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Ectopic Pregnancy -  Overview (pathophysiology, signs and symptoms, treatment, investigations)

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A 31 year old woman comes to the clinic because of a 3 day history of vaginal bleeding and lower abdominal cramping. Her last menstrual period was 7 weeks ago. She is sexually active with one male partner, and she explains that he always uses condoms for contraception. She has no notable past medical history, does not take any medications, and has no allergies. Her pulse is 89/min, blood pressure is 100/60 mm Hg, and respiration rate is 16/min. Her abdomen is soft, and there is lower abdominal tenderness. A genital exam reveals moderate vaginal bleeding and a closed cervical os. A pregnancy test is performed and is positive. Transvaginal ultrasound show a fluid filled cavity with no gestational sac. Her beta hCG value is 2400 mIU/mL. 48 hours later a second measurement of beta hCG is 2800.

What is the most likely diagnosis?

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A 44-year-old G3P2 woman presents with cramping, vaginal bleeding and right lower quadrant pain for six days that has been progressively worsening. Her last normal menstrual period occurred eight weeks ago. Her surgical history is notable for a bilateral tubal ligation following her last delivery 10 years ago. On physical exam, vital signs are a blood pressure of 112/80 mm Hg, a pulse 80/min, respirations 17/min, and a temperature of 99.2°F. On abdominal exam, she has right lower quadrant tenderness, with rebound tenderness and guarding. On pelvic exam, she has scant old blood in the vagina and a unremarkable cervix. Her uterus is normal sized and slightly tender. She has cervical motion tenderness, and marked tenderness during the rectal examination. Her quantitative Beta-hCG is 4100 mIU/ml, hematocrit is 35%, and WBC count is 15,500. The transvaginal ultrasound shows an empty uterus with endometrial thickening, a mass in right ovary that is 4.0 x 2 cm, and a small amount of free fluid in the pelvis.

What is the most likely diagnosis?

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A 20 year old G1P0 woman notes vaginal spotting and comes into the emergency room concerned. Her last normal menstrual period occurred six weeks ago. She began having spotting early this morning. She has no pain and denies other any other symptoms. Her medical history is unremarkable. Vital signs are all within normal limits. On pelvic exam, her cervix is unremarkable, her uterus is small and nontender, and no masses are palpable. Initial labs show a quantitative Beta-hCG of 2000 mIU/ml and a hematocrit of 38%. A repeat Beta-hCG level 48 hours later is 2100 mIU/ml. A transvaginal ultrasound shows an empty uterus with a thin endometrial stripe and no adnexal masses.

What is the likely diagnosis in this patient?

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A woman presents with a short history of vaginal spotting and cramping abdominal pain after 7 weeks of amenorrhoea. A few days earlier she had a positive result on a home pregnancy test. The cervix is closed on examination. An ultrasound scan shows an intrauterine gestational sac. A fetal pole with cardiac activity is seen.
What is the most likely diagnosis?
A. Complete miscarriage
B. Incomplete miscarriage
C. Inevitable miscarriage
D. Septic miscarriage
E. Threatened miscarriage

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A 34 year woman comes to the emergency department with complains of abdominal pain and nausea that began 2 days earlier. She explains that they have become increasingly more severe in the past 3 hours. She has passed several blood clots vaginally for the last hour. She has a history of irregular menstrual cycles, and is not sure when her last menstrual period was. She was diagnosed with a “heart shaped uterus” about 2 years ago. Her BMI is 29 kg/m². Blood pressure is 94/55 mm Hg, and pulse is 125/min. Her abdominal exam shows guarding and she is noted to have decreased bowel sounds. Examination with the speculum reveals moderate vaignal bleeding with the presence of clots. A urine pregnancy test is positive. Transvaginal ultrasound shows a gestational sac at the upper right uterine cornu, and the presence of free fluid in the posterior cul-de-sac.
What is the diagnosis in this patient?

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A 30 year old woman is brought to the emergency department after she experiences a syncopal episode after getting off of the couch. Yesterday she developed right sided abdominal pain which has spread across the lower abdomen. She has also noted a blood stain on her underwear after the syncopal episode. The patient was diagnosed with ulcerative colitis 4 years ago, and has been in remission with oral mesalamine therapy. She does not take any other medications, and has no allergies. Her last menstrual period was 9 weeks ago. The patient uses condoms intermittently as a means of birth control. Her temperature is 98.2°F, blood pressure is 90/60 mm Hg, and her pulse is 120/min. She has diffuse lower abdominal tenderness, and rebound tenderness and guarding is also present. Gynecological examination shows cervical motion tenderness, and right sided adnexal tenderness, although no masses are palpated.

What is the likely diagnosis in this patient?

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A 24-year-old presents at 27 weeks into her second pregnancy feeling unwell, with backache, fever and rigors. She has a temperature of 39.5°C. Urinalysis shows leucocytes and protein +++. Her blood pressure is 80/50. Which action is most appropriate?

A. Admit to ICU/HDU for intravenous antibiotics and supportive care
B. Arrange ultrasound of renal tract
C. Commence 7-day course of oral antibiotics
D. Give intramuscular steroids to promote fetal lung maturity
E. Make referral for physicians to review

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A 22 year old woman comes to the clinic because of right lower abdominal pain. She also comments that she has been noticing bloody vaginal discharge since the symptoms began the morning. She believes her symptoms are worsening. She is sexually active with on male partner, and they use condoms occasionally. She is unsure if her partner is monogamous or not. She as treated for a “infection in her vagina” a few years ago but does not remember what the condition was called. She takes no medications, and has no other notable past medical history. Her last menstrual period was 5 weeks ago, and she has never been pregnant. Her blood pressure is 114/72 mm Hg while supine, and 93/58 mm Hg standing. Her heart rate is 120/min, and she seems ill appearing. Her laboratory results are listed below:
Hemoglobin: 11.9 g/dL
Mean corpuscular volume: 83 fL
Platelets: 205,000/mm³
Leukocytes: 9,100/mm³
Urine beta-hCG: positive*

What is the likely diagnosis?

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A 18-year-old G2P0 female has severe right lower quadrant pain. Her last menstrual period was seven weeks ago. She explains that last night she began having lower abdominal pain that radiated to her right lower quadrant. She denies  vaginal bleeding, nausea or vomiting. The patient’s history is notable for two first trimester elective abortions and a history of chlamydia that was treated successfully twice. Vital signs are a blood pressure 90/60 mm Hg, pulse 97/min, respirations 23/min and a temperature of 98.4°F. On physical exam, the patient is notably uncomfortable and is unable to move. She has rebound tenderness and voluntary guarding when her abdomen is examined. She has cervical motion tenderness and rectal tenderness. Her Beta-hCG level is 2600 mIU/ml, hematocrit is 25%, and a urinalysis is unremarkable. Ultrasound shows no intrauterine pregnancy, a right adnexal mass that measures 6 x 3 cm, and a moderate amount of free fluid in the cul de sac.

What is the likely diagnosis in this patient?

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A 34 year old G5P3 woman presents with left-sided abdominal pain. Her last menstrual period was eight weeks ago. She noticed pain this morning and it has been getting more severe as the day has gone on. She denies nausea, vomiting, or vaginal bleeding. Her gynecological history is notable for a right-sided ectopic pregnancy five years ago. At that time, she had a right salpingectomy and a left tubal ligation. On physical examination her blood pressure is 90/55 mm Hg, pulse is 110/min, respirations are 22/min, and her temperature is 98.6°F. On abdominal examination, she has rebound and guarding throughout the abdomen. A pelvic exam reveals a uterus that is very tender and there is left adnexal fullness. Urine pregnancy test is positive. A transvaginal ultrasound shows a thickened endometrium as well as a left pelvic mass with a gestational sac and fetal pole, and a large amount of free fluid in the pelvis. Her hematocrit is 25%.

What is the diagnosis?

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A 21 year old woman presents at 7 weeks’ gestation with vaginal bleeding and left iliac fossa pain. She was treated for an asymptomatic chlamydial infection two years previously. Examination reveals tenderness in the left adnexum and her serum beta-hCG level is 6,000 mIU/ML.  A pelvic ultrasound scan shows an empty uterus.
Choose one of the following Answers:

A Choriocarcinoma
B Complete miscarriage
C Ectopic pregnancy
D Heterotopic pregnancy
E Incomplete miscarriage
F Inevitable miscarriage
G Missed miscarriage
H Molar pregnancy
I Ruptured ectopic pregnancy
J Threatened miscarriage
K Tubal pregnancy

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What is the management of a 36 year old woman who is pregnant after primary fertility. She is referring to you for spotting and hypogastric pain, beta HCG is 1500 mu/l and ultrasound of uterus and ovaries are normal.
a) Laparotomy
b) Laparascopy
c) Repeat vaginal sonography several days later
d) Progesterone measurement

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A 24 years old G2 P1 A0 had last menstrual period 9 weeks ago. She presents with bleeding and passage of tissues per-vaginum. Bleeding is associated with lower abdominal pain. The most likely diagnosis is:
a) Threatened miscarriage
b) Inevitable miscarriage
c) Incomplete miscarriage
d) Twin pregnancy
e) Ectopic pregnancy

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What is your management for a woman with HR = 120
BP = 80/60 mmHg, T = 37.5 uterine size = 8 weeks, beta HCG = 2500 mIU/mL and no intrauterine pregnancy on sonography?
a) Laparotomy
b) Laparascopy
C) D&C
d) Serum progesterone

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a) Threatened miscarriage  b) Inevitable miscarriage
c) Missed miscarriage  d) Stillbirth e) complete miscarriage f) chorioamnionitis
g) Urinary tract infection h)None of the above

For each description below, choose the SINGLE most appropriate answer from the above list of options. Each option may be used once, more than once, or not at all.

1) A 23-year-old woman presents at 21/40. She is complaining of low backache and suprapubic discomfort. Routine examination of the patient’s abdomen reveals that there is suprapubic tenderness. Examination of her vital signs reveals pyrexia of 37.7°C and a tachycardia of 90 beats per minute. Internal examination reveals that the cervix is closed. Urine dipstick demonstrates leukocytes and nitrites.

2) A 23-year-old woman presents at 23/40 in her second pregnancy. The first pregnancy had unfortunately ended at 19 weeks with a miscarriage after premature rupture of the fetal membranes. She is complaining of low backache, feeling hot and a slight vaginal loss. She has pyrexia of 38°C and a pulse of 98 beats per minute. Routine examination of the patient’s abdomen reveals that there is tenderness suprapubically. Speculum examination reveals a slightly open cervix and fluid draining.

3) A 23-year-old woman presents at 21/40. She is complaining of vaginal bleeding, low backache and supra- pubic discomfort. Routine examination of the patient’s abdomen reveals that there is suprapubic tenderness. Examination of her vital signs demonstrates that she is apyrexial. Internal examination reveals that the cervix is closed. Urine dipstick is unremarkable.

4) A 32-year-old woman presents in her first pregnancy at 20 weeks of amenorrhoea. She is complaining of minor discomfort in the lower abdomen. Her pulse and blood pressure are within the normal range and she is apyrexial. Abdominal examination is unremarkable. However, speculum examination reveals a slightly open cervix. A transvaginal ultrasound scan demonstrates the cervical canal to be 2 cm long and funnelling of the membranes is present.

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Second trimester miscarriage:
a)  Is typically painless.
b)  Occurs between 12 and 24 weeks’ gestation.
c)  Can be associated with rupture of the fetal membranes.
d)  May be associated with haemorrhage, infection and multiple pregnancy.
e)  Antibiotic prophylaxis is usually given.

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Which statement is most accurate regarding cervical cerclage?
a)  In a high risk patient it should be performed as soon as practical after confirmation of intrauterine pregnancy.
b)  Is a suitable procedure in any woman with a history of delivery between 20 and 26 weeks.
c)  Should be performed using an absorbable suture material.
d)  May be placed using a transvaginal approach.
e)  Requires a second anaesthetic procedure for removal when delivery is imminent.

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Which of the following medical abortion regimens is the most effective if available? (95-99% efficacy)

a) Mifepristone + misoprostol to 9+ weeks
b) Methotrexate + misoprostol to 7 weeks
c) Misoprostol alone to 9+ weeks
d) Methotrexate alone to 9+ weeks