Gynaecology — MCQs
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What is the primary mechanism by which ectopic pregnancy most commonly occurs in the fallopian tube?
A 37-year-old woman with adenomyosis presents with heavy menstrual bleeding that has failed to respond adequately to tranexamic acid and mefenamic acid. She has had a levonorgestrel intrauterine system in situ for 18 months but continues to experience heavy bleeding and dysmenorrhoea affecting her work. She has two children and her family is complete. Examination reveals a tender, bulky uterus. What is the most appropriate next management step?
A 26-year-old woman with confirmed left tubal ectopic pregnancy receives intramuscular methotrexate. Her initial beta-hCG is 2400 IU/L. On day 4 post-injection, she reports increased left-sided abdominal pain but remains haemodynamically stable. Repeat beta-hCG is 2800 IU/L. What is the most likely explanation for these findings?
A 48-year-old woman presents with a 10-month history of increasingly heavy and unpredictable menstrual bleeding. Her periods occur every 21-35 days and last 7-10 days. Pelvic examination is unremarkable. Transvaginal ultrasound shows a normal-sized uterus with 9 mm endometrium and normal ovaries. FSH level is 42 IU/L. Endometrial biopsy shows proliferative endometrium with no atypia. What is the most appropriate initial management?
A 31-year-old woman with 6 weeks amenorrhoea presents with minimal vaginal spotting. She is asymptomatic otherwise. Transvaginal ultrasound shows an empty uterus with no adnexal masses. Her serum beta-hCG is 1800 IU/L. A repeat beta-hCG after 48 hours is 2100 IU/L. What is the most appropriate classification of this clinical scenario?
A 45-year-old woman with type 2 diabetes mellitus and body mass index of 32 kg/m² presents with heavy menstrual bleeding of 11 months duration. Her periods occur regularly every 28 days but last 8 days with flooding and clots. Pelvic examination is normal. Transvaginal ultrasound shows a uniformly thickened endometrium measuring 14 mm with no focal lesions. Full blood count shows haemoglobin 98 g/L. What is the most appropriate next step in management?
A 34-year-old woman presents to the emergency department with 7 weeks amenorrhoea and moderate left-sided abdominal pain. She has a copper intrauterine device in situ. Transvaginal ultrasound shows an empty uterus with a 25 mm left adnexal mass and moderate free fluid in the pelvis. Her serum beta-hCG is 4200 IU/L and haemoglobin is 102 g/L. She is haemodynamically stable with blood pressure 118/75 mmHg and pulse 88 bpm. What is the most appropriate immediate management?
A 33-year-old nulliparous woman undergoes laparoscopy for a suspected ectopic pregnancy. At surgery, a 2.2cm unruptured ampullary ectopic pregnancy is identified in the right fallopian tube with surrounding oedema. The left fallopian tube appears healthy with no abnormalities. There is no haemoperitoneum. The patient has previously expressed strong desire to preserve her fertility and had declined salpingectomy in pre-operative discussions. The surgeon performs right salpingotomy and achieves complete removal of ectopic tissue with haemostasis. What is the most important aspect of post-operative follow-up for this patient?
A 40-year-old woman presents with heavy menstrual bleeding affecting her daily activities. She reports soaking through ultra-absorbent pads every 1-2 hours on her heaviest days and passing large clots. Her periods last 9 days and occur regularly every 26 days. She has tried tranexamic acid without significant benefit. She has three children and does not wish for more. Pelvic examination reveals a bulky, slightly irregular uterus. Which investigation would be most appropriate to guide further management?
A 28-year-old woman is being monitored following single-dose intramuscular methotrexate for an unruptured tubal ectopic pregnancy. Her initial beta-hCG was 2,100 IU/L. On day 4, her beta-hCG is 2,450 IU/L, and on day 7, it is 1,890 IU/L. She remains clinically stable with minimal symptoms. What is the most appropriate management at this stage?
Gynaecology UK Medical PG Practice Questions and MCQs
Question 61: What is the primary mechanism by which ectopic pregnancy most commonly occurs in the fallopian tube?
- A. Impaired tubal motility preventing embryo transport to the uterus (Correct Answer)
- B. Premature activation of trophoblast adhesion molecules
- C. Reduced progesterone receptor expression in tubal epithelium
- D. Abnormal embryonic development causing delayed implantation
- E. Increased tubal blood flow promoting ectopic implantation
Explanation: ***Impaired tubal motility preventing embryo transport to the uterus*** - The primary mechanism of **tubal ectopic pregnancy** is the delay or arrest of the fertilized egg's transport to the uterus, often due to **impaired tubal motility** or **ciliary dysfunction**. - Factors like **pelvic inflammatory disease** (PID) causing **scarring** or congenital tubal abnormalities can disrupt the coordinated movements necessary for embryo transit. *Premature activation of trophoblast adhesion molecules* - While **trophoblast adhesion** is essential for implantation, its premature activation is typically a *consequence* of the embryo being retained in the tube, rather than the primary cause of its initial entrapment. - The fundamental issue leading to ectopic implantation is the embryo's inability to reach the **endometrium**, which is usually due to tubal transport problems. *Reduced progesterone receptor expression in tubal epithelium* - Progesterone is crucial for maintaining pregnancy and influencing tubal physiology, but a primary reduction in **progesterone receptor expression** in the tubal epithelium is not an established main cause of ectopic pregnancy. - Hormonal imbalances might play a role in tubal function, but **mechanical obstruction** or **motility defects** are more central to ectopic implantation. *Abnormal embryonic development causing delayed implantation* - Most embryos in ectopic pregnancies are **genetically normal**; hence, abnormal embryonic development is generally not the primary cause of the ectopic location. - If an embryo's development is significantly abnormal, it is more likely to result in **non-implantation** or early **pregnancy loss**, rather than successful implantation in an ectopic site. *Increased tubal blood flow promoting ectopic implantation* - **Increased tubal blood flow** is a physiological response to implantation (angiogenesis) to support the developing embryo, not the initial factor that causes the embryo to implant in the tube. - The ectopic location is determined by factors that prevent the embryo from reaching the uterus, such as **tubal damage** or **dysfunction**, before vascular changes occur.
Question 62: A 37-year-old woman with adenomyosis presents with heavy menstrual bleeding that has failed to respond adequately to tranexamic acid and mefenamic acid. She has had a levonorgestrel intrauterine system in situ for 18 months but continues to experience heavy bleeding and dysmenorrhoea affecting her work. She has two children and her family is complete. Examination reveals a tender, bulky uterus. What is the most appropriate next management step?
- A. Trial of GnRH analogue for 6 months to assess response
- B. Remove LNG-IUS and commence combined hormonal contraceptive
- C. Refer for endometrial ablation procedure
- D. Discuss hysterectomy as definitive treatment option (Correct Answer)
- E. Increase dose by inserting second levonorgestrel intrauterine system
Explanation: ***Discuss hysterectomy as definitive treatment option***- The patient has **completed her family** and has **failed multiple medical therapies** including NSAIDs, tranexamic acid, and 18 months of **LNG-IUS**, for her adenomyosis-related heavy bleeding and dysmenorrhea.- **Hysterectomy** is the **definitive cure** for adenomyosis, as it removes the entire uterus which contains the ectopic endometrial tissue within the myometrium.*Trial of GnRH analogue for 6 months to assess response*- **GnRH analogues** induce a **temporary menopause**, which can alleviate symptoms, but are typically used for **short-term management** due to side effects like **bone mineral density loss**.- Symptoms almost always **recur upon cessation** of GnRH analogues, making it an unsuitable long-term solution for a patient seeking definitive management.*Remove LNG-IUS and commence combined hormonal contraceptive*- The **LNG-IUS** delivers **progesterone directly to the uterus** and is generally more effective for managing adenomyosis-related bleeding and pain than systemic combined hormonal contraceptives.- Given the failure of the **LNG-IUS** after an adequate trial, it is unlikely that a less potent systemic **combined hormonal contraceptive** would provide better symptom control.*Refer for endometrial ablation procedure*- **Endometrial ablation** targets the superficial endometrium and is generally **ineffective for adenomyosis** because the disease involves endometrial glands deep within the **myometrium**.- Ablation in adenomyosis can potentially lead to **trapped blood** within the myometrium, worsening pain and dysmenorrhea.*Increase dose by inserting second levonorgestrel intrauterine system*- Inserting **two LNG-IUS devices** is **not a standard or evidence-based practice** for increasing hormonal dosage or efficacy in managing adenomyosis.- If a single **LNG-IUS** has failed after a sufficient trial (18 months), the appropriate next step is to consider **alternative treatment modalities**, not simply to double the existing one.
Question 63: A 26-year-old woman with confirmed left tubal ectopic pregnancy receives intramuscular methotrexate. Her initial beta-hCG is 2400 IU/L. On day 4 post-injection, she reports increased left-sided abdominal pain but remains haemodynamically stable. Repeat beta-hCG is 2800 IU/L. What is the most likely explanation for these findings?
- A. Treatment failure requiring immediate surgical intervention
- B. Separation pain from tubal abortion, which is expected with methotrexate (Correct Answer)
- C. Ruptured ectopic pregnancy requiring emergency laparoscopy
- D. Inadequate methotrexate dose requiring second injection
- E. Persistent ectopic pregnancy requiring repeat methotrexate on day 7
Explanation: ***Separation pain from tubal abortion, which is expected with methotrexate*** - **Separation pain** occurs in up to 80% of patients 3–7 days after **methotrexate** administration as the pregnancy detaches from the tubal wall. - An initial rise in **beta-hCG** between Day 1 and Day 4 is a normal physiological response and does not indicate **treatment failure** provided the patient is **haemodynamically stable**. *Treatment failure requiring immediate surgical intervention* - **Treatment failure** is not determined on Day 4; it is defined by a <15% fall in **hCG levels** between Day 4 and Day 7. - **Surgical intervention** is reserved for patients who are clinically deteriorating or show definitive signs of **tubal rupture**. *Ruptured ectopic pregnancy requiring emergency laparoscopy* - While pain is a symptom, **haemodynamic stability** (normal BP and heart rate) makes **acute rupture** less likely than expected separation pain. - Rupture typically presents with **peritoneal signs**, shoulder tip pain, or clinical evidence of **intra-abdominal hemorrhage**. *Inadequate methotrexate dose requiring second injection* - The decision to administer a **second dose** can only be made after comparing Day 4 and Day 7 **hCG levels**. - A single dose of **methotrexate** is often sufficient if the levels drop by 15% later in the first week. *Persistent ectopic pregnancy requiring repeat methotrexate on day 7* - Persistence is assessed on Day 7; if the **hCG decline** is less than 15% from the Day 4 value, a repeat dose is then considered. - Assessing persistence on Day 4 is premature because the **hCG** frequently plateaus or rises initially following the injection.
Question 64: A 48-year-old woman presents with a 10-month history of increasingly heavy and unpredictable menstrual bleeding. Her periods occur every 21-35 days and last 7-10 days. Pelvic examination is unremarkable. Transvaginal ultrasound shows a normal-sized uterus with 9 mm endometrium and normal ovaries. FSH level is 42 IU/L. Endometrial biopsy shows proliferative endometrium with no atypia. What is the most appropriate initial management?
- A. Levonorgestrel intrauterine system insertion (Correct Answer)
- B. Tranexamic acid for symptomatic relief
- C. Cyclical progestogen therapy days 15-26 of cycle
- D. Combined hormonal contraceptive pill
- E. Total hysterectomy with bilateral salpingo-oophorectomy
Explanation: ***Levonorgestrel intrauterine system insertion*** - The **LNG-IUS** is the first-line treatment for **heavy menstrual bleeding (HMB)** as it provides both symptom control and **endometrial protection** by thinning the uterine lining. - For this patient in the **perimenopause** (suggested by elevated **FSH**), it offers the highest reduction in blood loss and can remain in situ for up to 5 years. *Tranexamic acid for symptomatic relief* - This is a **non-hormonal** option that reduces fibrinolysis; however, it does not regulate the cycle or address the underlying **proliferative endometrium**. - It is less effective at reducing total blood loss compared to the **LNG-IUS** and provides no **contraceptive** benefit. *Cyclical progestogen therapy days 15-26 of cycle* - While it can help regulate the cycle, it is significantly **less effective** than the LNG-IUS or the combined pill in reducing menstrual blood flow. - It does not consistently provide **contraception** and often has lower patient compliance due to the need for daily dosing. *Combined hormonal contraceptive pill* - The **COCP** is an effective treatment for HMB, but it carries an increased risk of **venous thromboembolism (VTE)** in women over 35, especially those who smoke or have cardiovascular risk factors. - Given the high **FSH of 42 IU/L**, the patient is nearing menopause, and systemic estrogens may not be the ideal initial choice compared to **local delivery** systems. *Total hysterectomy with bilateral salpingo-oophorectomy* - This is an **invasive surgical** option that should only be considered after medical management (like the **LNG-IUS**) has failed or is contraindicated. - Given her **normal biopsy** (no atypia) and normal imaging, initial management must prioritize conservative, **medical therapies**.
Question 65: A 31-year-old woman with 6 weeks amenorrhoea presents with minimal vaginal spotting. She is asymptomatic otherwise. Transvaginal ultrasound shows an empty uterus with no adnexal masses. Her serum beta-hCG is 1800 IU/L. A repeat beta-hCG after 48 hours is 2100 IU/L. What is the most appropriate classification of this clinical scenario?
- A. Failing intrauterine pregnancy requiring evacuation
- B. Pregnancy of unknown location requiring further monitoring (Correct Answer)
- C. Ectopic pregnancy requiring immediate methotrexate treatment
- D. Complete miscarriage with resolving beta-hCG levels
- E. Normal early intrauterine pregnancy below discriminatory zone
Explanation: ***Pregnancy of unknown location requiring further monitoring*** - A **Pregnancy of Unknown Location (PUL)** is diagnosed when the woman has a positive pregnancy test but the **transvaginal ultrasound** does not identify an intrauterine or extrauterine pregnancy. - The **hCG rise of only 17%** (from 1800 to 2100 IU/L) over 48 hours is suboptimal, but because the patient is **asymptomatic**, further monitoring with serial hCG and repeat imaging is required before definitive intervention. *Failing intrauterine pregnancy requiring evacuation* - An **intrauterine pregnancy** has not yet been visualized on ultrasound; therefore, it cannot be classified as failing within the uterus. - **Surgical evacuation** is inappropriate unless a non-viable intrauterine pregnancy is confirmed or the patient becomes hemodynamically unstable. *Ectopic pregnancy requiring immediate methotrexate treatment* - While the suboptimal hCG rise increases the suspicion of an **ectopic pregnancy**, immediate treatment is not indicated as the location is still **unconfirmed** and the patient is stable. - **Methotrexate** should only be administered once the diagnosis of ectopic pregnancy is confirmed or a PUL persists with rising hCG levels below the **discriminatory zone**. *Complete miscarriage with resolving beta-hCG levels* - A **complete miscarriage** would typically show a significant drop in **beta-hCG levels** (at least 50%) rather than an increase. - In this case, the hCG is **rising**, which is inconsistent with the resolution of a pregnancy through miscarriage. *Normal early intrauterine pregnancy below discriminatory zone* - The **discriminatory zone** is the hCG level (usually 1500–2000 IU/L) at which a viable **intrauterine sac** should be visible; this patient is at 1800–2100 IU/L with an empty uterus. - A normal pregnancy should show a **minimal hCG increase of 53–63%** over 48 hours; a 17% rise is highly suggestive of an abnormal pregnancy (ectopic or failing).
Question 66: A 45-year-old woman with type 2 diabetes mellitus and body mass index of 32 kg/m² presents with heavy menstrual bleeding of 11 months duration. Her periods occur regularly every 28 days but last 8 days with flooding and clots. Pelvic examination is normal. Transvaginal ultrasound shows a uniformly thickened endometrium measuring 14 mm with no focal lesions. Full blood count shows haemoglobin 98 g/L. What is the most appropriate next step in management?
- A. Insert levonorgestrel intrauterine system and review in 6 months
- B. Perform endometrial biopsy before initiating treatment (Correct Answer)
- C. Commence tranexamic acid therapy and monitor response
- D. Arrange hysteroscopy and endometrial ablation
- E. Start combined hormonal contraceptive pill
Explanation: ***Perform endometrial biopsy before initiating treatment*** - This patient requires **endometrial sampling** due to her age (≥45 years) and persistent **abnormal uterine bleeding (AUB)**, combined with risk factors like **obesity (BMI 32)** and **type 2 diabetes**, and a significantly **thickened endometrium (14 mm)**. - It is crucial to exclude **endometrial hyperplasia** or **carcinoma** via biopsy before initiating any hormonal or symptomatic treatment that might delay diagnosis. *Insert levonorgestrel intrauterine system and review in 6 months* - The **levonorgestrel intrauterine system (LNG-IUS)** is a treatment for heavy menstrual bleeding, but it is contraindicated as an initial step in a patient with risk factors for **endometrial cancer** until **histological sampling** has ruled out malignancy. - Initiating hormonal treatment without biopsy risks masking a potential **endometrial carcinoma** or **atypical hyperplasia**, critically delaying diagnosis and appropriate management. *Commence tranexamic acid therapy and monitor response* - **Tranexamic acid** provides symptomatic relief for heavy menstrual bleeding by reducing fibrinolysis, but it does not investigate or treat the underlying cause of the bleeding. - Using it in a high-risk patient without an **endometrial biopsy** would delay the diagnosis of a potentially serious **endometrial pathology**, such as hyperplasia or carcinoma. *Arrange hysteroscopy and endometrial ablation* - **Endometrial ablation** is a definitive treatment for heavy menstrual bleeding, but it is **contraindicated** until **endometrial cancer** and **atypical hyperplasia** have been conclusively excluded by histological examination. - Performing ablation without a prior biopsy could destroy malignant tissue, making future diagnosis or staging difficult, and would be an inappropriate first-line intervention in a high-risk patient. *Start combined hormonal contraceptive pill* - Starting a **combined hormonal contraceptive pill** (COCP) in this patient is inappropriate without an **endometrial biopsy** to rule out malignancy, as it could mask symptoms. - Furthermore, a 45-year-old woman with **obesity** and **type 2 diabetes** has increased risks for **thromboembolic events**, making COCP a less ideal choice without careful consideration and screening.
Question 67: A 34-year-old woman presents to the emergency department with 7 weeks amenorrhoea and moderate left-sided abdominal pain. She has a copper intrauterine device in situ. Transvaginal ultrasound shows an empty uterus with a 25 mm left adnexal mass and moderate free fluid in the pelvis. Her serum beta-hCG is 4200 IU/L and haemoglobin is 102 g/L. She is haemodynamically stable with blood pressure 118/75 mmHg and pulse 88 bpm. What is the most appropriate immediate management?
- A. Administer intramuscular methotrexate and arrange follow-up in 48 hours
- B. Arrange urgent laparoscopy for surgical management (Correct Answer)
- C. Remove the intrauterine device and commence expectant management
- D. Admit for observation with serial beta-hCG measurements
- E. Perform endometrial sampling to exclude intrauterine pregnancy
Explanation: ***Arrange urgent laparoscopy for surgical management*** - The presence of **moderate free fluid** in the pelvis and a slightly low **haemoglobin** (102 g/L) are strong indicators of **intra-abdominal bleeding** from a ruptured or leaking ectopic pregnancy. - Despite current **haemodynamic stability**, the risk of rapid clinical deterioration is high, necessitating urgent **laparoscopy** for definitive surgical management, such as **salpingectomy** or **salpingotomy**. *Administer intramuscular methotrexate and arrange follow-up in 48 hours* - **Methotrexate** is contraindicated due to the high **beta-hCG** level (4200 IU/L) and clear signs of rupture (**moderate free fluid**), which increase the risk of treatment failure and complications. - Medical management is reserved for patients who are asymptomatic, haemodynamically stable, have smaller ectopic pregnancies, and lower **beta-hCG** levels without signs of haemorrhage. *Remove the intrauterine device and commence expectant management* - **Expectant management** is only appropriate for highly selected patients with very low and declining **beta-hCG** levels and no signs of rupture or significant pain. - While the **copper IUD** increases the risk of ectopic pregnancy, simply removing it does not treat the existing and potentially life-threatening **extrauterine gestation**. *Admit for observation with serial beta-hCG measurements* - Serial **beta-hCG** monitoring is primarily for pregnancies of **unknown location (PUL)** or very early, stable ectopic pregnancies without evidence of rupture. - Given the ultrasound findings of an **adnexal mass** and **free fluid**, observation would dangerously delay definitive treatment for a condition with a high risk of **hypovolemic shock**. *Perform endometrial sampling to exclude intrauterine pregnancy* - **Endometrial sampling** is unnecessary because the transvaginal ultrasound already clearly demonstrates an **empty uterus** and a definitive **adnexal mass**, indicating an ectopic pregnancy. - Pursuing such an invasive and time-consuming procedure would lead to a critical delay in the required **surgical intervention** for the ruptured ectopic pregnancy.
Question 68: A 33-year-old nulliparous woman undergoes laparoscopy for a suspected ectopic pregnancy. At surgery, a 2.2cm unruptured ampullary ectopic pregnancy is identified in the right fallopian tube with surrounding oedema. The left fallopian tube appears healthy with no abnormalities. There is no haemoperitoneum. The patient has previously expressed strong desire to preserve her fertility and had declined salpingectomy in pre-operative discussions. The surgeon performs right salpingotomy and achieves complete removal of ectopic tissue with haemostasis. What is the most important aspect of post-operative follow-up for this patient?
- A. Serial beta-hCG measurements until levels fall to <5 IU/L (Correct Answer)
- B. Hysterosalpingography at 3 months to assess tubal patency
- C. Prophylactic intramuscular methotrexate to prevent persistent trophoblast
- D. Repeat laparoscopy at 6 weeks to assess tubal healing
- E. Serum progesterone measurement to confirm return of ovulation
Explanation: ***Serial beta-hCG measurements until levels fall to <5 IU/L*** - Salpingotomy carries a 4–8% risk of **persistent trophoblast**, requiring serial **beta-hCG monitoring** to ensure all pregnancy tissue has been successfully removed. - Monitoring is typically performed weekly until the level reaches the laboratory's threshold for a **non-pregnant state**, as plateauing or rising levels indicate the need for **methotrexate** or repeat surgery. *Hysterosalpingography at 3 months to assess tubal patency* - While tubal patency is a concern for future fertility, **hysterosalpingography (HSG)** is not a routine part of immediate post-operative care following an ectopic pregnancy. - An HSG may be considered later if the patient struggles with **subfertility**, but it does not address the acute risk of persistent trophoblastic tissue. *Prophylactic intramuscular methotrexate to prevent persistent trophoblast* - **Prophylactic methotrexate** is not routinely recommended after salpingotomy as the majority of cases resolve spontaneously without further intervention. - Medical management is reserved for patients where beta-hCG levels actually **plateau or rise** during the post-operative surveillance period. *Repeat laparoscopy at 6 weeks to assess tubal healing* - **Repeat laparoscopy** is an invasive procedure and is not indicated for routine follow-up of a standard, uncomplicated salpingotomy. - Healing is monitored through clinical symptoms and **biochemical markers** rather than direct visual inspection unless complications like hemorrhage or infection occur. *Serum progesterone measurement to confirm return of ovulation* - **Serum progesterone** levels are used to confirm ovulation in specialized fertility workups, but they have no role in the management of post-ectopic recovery. - The primary safety concern post-salpingotomy is the resolution of the **ectopic pregnancy**, for which beta-hCG is the only reliable marker.
Question 69: A 40-year-old woman presents with heavy menstrual bleeding affecting her daily activities. She reports soaking through ultra-absorbent pads every 1-2 hours on her heaviest days and passing large clots. Her periods last 9 days and occur regularly every 26 days. She has tried tranexamic acid without significant benefit. She has three children and does not wish for more. Pelvic examination reveals a bulky, slightly irregular uterus. Which investigation would be most appropriate to guide further management?
- A. Transvaginal ultrasound scan (Correct Answer)
- B. Full blood count and serum ferritin
- C. Hysteroscopy with endometrial biopsy
- D. Serum thyroid function tests
- E. MRI pelvis with contrast
Explanation: ***Transvaginal ultrasound scan***- This is the first-line imaging modality for **heavy menstrual bleeding (HMB)** when physical examination reveals a **bulky or irregular uterus**, suggesting structural pathology like **fibroids** or **adenomyosis**.- It guides management by detailing the size, location, and number of fibroids, which is essential since the patient has already failed **tranexamic acid** and may require surgical intervention.*Full blood count and serum ferritin*- These tests are necessary to diagnose **iron-deficiency anemia** resulting from chronic HMB but do not identify the **underlying etiology** or guide structural management.- While important for supportive care, they cannot distinguish between causes like **leiomyoma** or **polyps** indicated by the bulky uterus.*Hysteroscopy with endometrial biopsy*- Usually reserved as a second-line investigation or when **ultrasound** is inconclusive or suggests **endometrial polyps** or submucosal fibroids.- While biopsy is important to rule out **endometrial hyperplasia** or malignancy in specific risk groups, ultrasound is the more appropriate initial step for a bulky, irregular uterus.*Serum thyroid function tests*- Thyroid dysfunction can cause menstrual irregularities, but it is not indicated as a routine investigation for HMB unless **symptoms of hypothyroidism** are present.- In this case, the **physical finding** of an irregular uterus points strongly toward a primary pelvic structural cause rather than systemic endocrine disease.*MRI pelvis with contrast*- **MRI** provides high resolution for preoperative mapping of complex fibroids but is not the first-line diagnostic investigation due to high cost and lower accessibility.- It is generally reserved for cases where **ultrasound** findings are indeterminate or when distinguishing between **adenomyosis** and multiple fibroids is critical for specific surgical planning.
Question 70: A 28-year-old woman is being monitored following single-dose intramuscular methotrexate for an unruptured tubal ectopic pregnancy. Her initial beta-hCG was 2,100 IU/L. On day 4, her beta-hCG is 2,450 IU/L, and on day 7, it is 1,890 IU/L. She remains clinically stable with minimal symptoms. What is the most appropriate management at this stage?
- A. Continue expectant monitoring with repeat beta-hCG on day 14 (Correct Answer)
- B. Administer second dose of methotrexate 50mg/m² immediately
- C. Arrange urgent laparoscopy for surgical management
- D. Measure beta-hCG on day 11 to assess ongoing decline
- E. Change to multi-dose methotrexate regimen with folinic acid rescue
Explanation: ***Continue expectant monitoring with repeat beta-hCG on day 14*** - In the **single-dose methotrexate protocol**, a successful response is defined by a **decrease in beta-hCG of ≥15%** between Day 4 and Day 7. - The patient's beta-hCG dropped from 2,450 IU/L on Day 4 to 1,890 IU/L on Day 7, which represents a **~22.8% reduction**, confirming the treatment is effective. Expectant monitoring with the next beta-hCG on Day 14 is the appropriate next step until levels are **<5 IU/L**. *Administer second dose of methotrexate 50mg/m² immediately* - A second dose of methotrexate is indicated only if the **beta-hCG decline is less than 15%** between Day 4 and Day 7, or if there is clinical deterioration. - Since a sufficient decline was observed, administering an additional dose now would be premature and increase the risk of **methotrexate-related side effects** without clinical benefit. *Arrange urgent laparoscopy for surgical management* - **Surgical intervention** is reserved for patients who are **hemodynamically unstable**, show signs of **tubal rupture**, or fail medical management. - This patient is **clinically stable** and has shown a biochemical response to methotrexate, making surgical management inappropriate at this stage. *Measure beta-hCG on day 11 to assess ongoing decline* - Standard follow-up after a successful Day 7 beta-hCG decline in single-dose methotrexate protocols involves **weekly monitoring**, meaning the next measurement would typically be on **Day 14**, not Day 11. - Deviation from established **monitoring protocols** can lead to suboptimal management and does not align with evidence-based guidelines. *Change to multi-dose methotrexate regimen with folinic acid rescue* - The **multi-dose regimen** is a distinct protocol or an alternative initial treatment strategy, not typically a switch or rescue for a successfully responding single-dose case. - Since the patient has already achieved the target **15% reduction** in beta-hCG, changing to a more intensive regimen is unnecessary and could lead to increased **toxicity**.
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