Ectopic Pregnancy

ECTOPIC PREGNANCY

Q. 1

The commonest complication of pregnancy after complete treatment of genital tuberculosis is :

 A

Abortion

 B

Ectopic pregnancy

 C

Malpresentation

 D

Intra uterine death

Q. 1

The commonest complication of pregnancy after complete treatment of genital tuberculosis is :

 A

Abortion

 B

Ectopic pregnancy

 C

Malpresentation

 D

Intra uterine death

Ans. B

Explanation:

Ectopic pregnancy


Q. 2

Which of the folowing statements about calen­dar method (Rhythm method) is false :

 A

Abstinence is needed for only a few days in a month

 B

It is associated with no costs

 C

Safe period can also be observed using tempera­ture rhythm or mucous method

 D

Ectopic pregnancy is a reported complication of calendar method

Q. 2

Which of the folowing statements about calen­dar method (Rhythm method) is false :

 A

Abstinence is needed for only a few days in a month

 B

It is associated with no costs

 C

Safe period can also be observed using tempera­ture rhythm or mucous method

 D

Ectopic pregnancy is a reported complication of calendar method

Ans. A

Explanation:

Ans. is a i.e Abstinence is needed for only a few days in the month

Calendar method or Rhythm method

  • Basis – avoidance of sexual intercourse around ovulation
  • In a 28 days cycle ovulation normally occurs on the 14″ day of cycle, but may occur at anytime between the 12″ and 16′h day.
  • Spermatozoa deposited in female genital tract survive for 24 hours.
  • The ovum may live for 12-24 hours so that intercourse between 11′h and 17″ day may result in a pregnancy.
  • The safe period is calculated from ls‘ day of the menstrual period until the 10th day of the cycle and from 18’h to 28″ day.
  • Or safe period can be calculated as

shortest cycle minus () 18 gives first day of fertile period and longest cycle minus (–) 10 gives last day of fertile period

  • An alternative method is to calculate the risk period, which is from 3 days before ovulation to 3 days after ovulation.
  • Hark 19,e, p vvr-Ire such ;..:aiL,Lliatiur is are IRA posibie, the couple is advised to avoid intercourse from the 8th day to 22h” day of the menstrual cycle, counting from the 151 day of the menstrual period. (i.e. first and last 7 days are safe).

Thus, long periods of compulsory abstinence for nearly one half of every month may be required.

Advantages :

  • Low cost

Lack of side effects.

Dra Jacks :

  • Difficult to predict the safe period if cycles are irregular
  • Can only be used by educated and responsible couples with a high degree of motivation and co-operation.
  • Compulsary abstinence of sexual intercourse for nearly half month called as Programmed sex.
  • Not applicable during postnatal period.
  • High failure rate – 9/100 WY.

Medical complications :

  • Ectopic pregnancy
  • Embryonic abnormalities due to conception involving either over aged sperm or egg.

Other methods which can be observed to calculate the safe period :

Temperature rhythm : female notes her basal bodytemperature before getting up from bed and abstinence is advised until the third day of rise of temperature.

Mucus method /Billing method : Abstinence is advised on all days of noticeable mucus and for four days thereafter.

Symptothermic method : It combines BBt + cervical mucus + calender technique.


Q. 3

IUCD with highest incidence of ectopic pregnancy is :

 A

Lippe’s loop

 B

Copper T

 C

Progestasert

 D

All have equal incidence

Q. 3

IUCD with highest incidence of ectopic pregnancy is :

 A

Lippe’s loop

 B

Copper T

 C

Progestasert

 D

All have equal incidence

Ans. C

Explanation:

Progestasert


Q. 4

Which of the following has the least risk of ectopic pregnancy?

 A Tubectomy
 B

OC pills

 C Copper T
 D

Condoms

Q. 4

Which of the following has the least risk of ectopic pregnancy?

 A Tubectomy
 B

OC pills

 C Copper T
 D

Condoms

Ans. D

Explanation:

Condoms REF: Dutta obs 6th e p. 179-180

Condoms and diaphragms are protective for Ectopic pregnancy

Risk factors for ectopic pregnancy

  • Pelvic infections/present salphingitis
  • Contraceptives: progestasert > copper t
  • IVF/ ovulation inducers
  • Previous ectopic
  • Endometriosis
  • Fibroids
  • Developmental defects of the tube
  • Transperitoneal ovum migration
  • Salphingits icthmica nodosum
  • Cigarette smoking > 20 / day
  • Multiple partners
  • Intercourse before 18 yrs
  • In utero DES exposure
  • Age> 40 yrs
  • Tubal surgeries
  • Tubal sterilization (greatest risk within 2 yrs.)
    (Condoms and diaphragms are protective)

Q. 5 In comparing laparoscopic salpingostomy vs. laparotomy with salpingectomy for the treatment of ectopic pregnancy, laparoscopic therapy results in
 A Decreased hospital stays
 B Lower fertility rate
 C Lower repeat ectopic pregnancy rate
 D Comparable persistent ectopic tissue rate
Q. 5 In comparing laparoscopic salpingostomy vs. laparotomy with salpingectomy for the treatment of ectopic pregnancy, laparoscopic therapy results in
 A Decreased hospital stays
 B Lower fertility rate
 C Lower repeat ectopic pregnancy rate
 D Comparable persistent ectopic tissue rate
Ans. A

Explanation:

Conservative laparoscopic treatment of ectopic pregnancy is now commonplace, although not yet universal. With increasing sophistication of techniques and fiberoptics, many microsurgical procedures can be done through the laparoscope Recent studies uggest that the fertility rates for laparoscopy and laparo- tomy are comparable, as are the implications of repeat ectopic pregnancies. Certainly laparoscopy, because of its small incision, results in fewer break- downs and shorter hospital stays, but the incidence of complications due to retained ectopic tissue is higher.


Q. 6 A 27-year-old has just had an ectopic pregnancy. Which of the following events would be most likely to predispose to ectopic pregnancy? 
 A Previous tubal surgery
 B Pelvic inflammatory disease (PID)
 C Use of a contraceptive uterine device (IUD)
 D Induction of ovulation
Q. 6 A 27-year-old has just had an ectopic pregnancy. Which of the following events would be most likely to predispose to ectopic pregnancy? 
 A Previous tubal surgery
 B Pelvic inflammatory disease (PID)
 C Use of a contraceptive uterine device (IUD)
 D Induction of ovulation
Ans. B

Explanation:

Mishell, 3/e, pp 452–457.) Any factor delaying transit of the ovum through the fallopian tube may predispose a patient to ectopic pregnancy. The major predisposing factor in the development of ectopic pregnancy is pelvic inflammatory  disease.   However,  any  operative procedure on the fallopian tubes may increase a patient’s  risk.  It  appears  that  tubal  sterilizations with laparoscopic fulguration have a higher rate of ectopic pregnancy than tubal ligations performed with clips or rings. Women who have had one ectopic pregnancy are at increased risk of having a second. DES exposure, induction of ovulation, and IUD use increase the possibility of ectopic pregnancy.The best choice is B PID.


Q. 7

Most sensitive diagnosis test for ectopic pregnancy

 A

Transvaginal USG

 B

Culdocentesis

 C

MRI

 D

Serial monitoring of (-HCG

Q. 7

Most sensitive diagnosis test for ectopic pregnancy

 A

Transvaginal USG

 B

Culdocentesis

 C

MRI

 D

Serial monitoring of (-HCG

Ans. A

Explanation:

Transvaginal ultrasound [Ref: Williams obst. 21Ve p 892, Dutta 6h/e p 185]

Diagnosis of Ectopic pregnancy

  • Pregnancy is definitely diagnosed by demonstrating intrauterine sac.

– A normal intrauterine sac appears regular and well defined on ultrasound.

  • So ectopic pregnancy can be diagnosed by demonstrating the absence of the intrauterine sac.
  • In a woman in whom ectopic pregnancy is suspected because of pain, bleeding and positive pregnancy test, performance of vaginal sonography is the logical first step.
  • If the sonography demonstrates live intrauterine fetus then ectopic pregnancy is extremely unlikely.
  • Alternatively if the uterus is empty, an ectopic pregnancy can be diagnosed based on the visualization of an adnexal mass separate from the ovaries.
  • 3-hCG hormones also play an important role in the diagnosis of pregnancy. fi HCG is a hormone secreted during pregnancy.
  • It is positive in virtually 100% of ectopic pregnancies. However, a positive test only confirms pregnancy and does not indicate whether it is intrauterine or extrauterine.
  • In normal pregnancy pHCG should double up every 2 days but in ectopic pregnancy the rate of increase of fl hCG is slow.
  • 13 hCG litres and ultrasound complement one another in detecting ectopic pregnancy and have led to earlier detection. By correlating fl hCG titres with ultrasound .findings an ectopic pregnancy can often be differentiated.from intrauterine pregnancy.
  • An intrauterine sac should be visible by transvaginal ultrasound when the p hCG is approximately 1000 ml
    p/m1 and by transabdominal ultrasound approximately 1 week later when the fi hCG is 1800-3600 ?nip/int.
  • Thus when an empty uterine cavity is seen with a 13 hCG litre above this threshold, the patient is likely to have an ectopic pregnancy. An empty cavity is less of a concern when a fihCG below this threshold is obtained. Serum progesterone measuremen
  • A single measurement of serum progesterone may sometimes clarify the diagnosis when ectopic pregnancy is suspected, but
  • Its accuracy is crude and the customary thresholds are < 5 ng/m and > 25 ‘tend. i.e.a value exceeding 25 ng/m1 excludes ectopic pregnancy with 97.5% sensitivity, value below 5 ng/ml occur in only .3 percent of normal regnancies. So normal pregnancies can be excluded if the progesterone level is below 5%.

Surgical diagnosis of ectopic pregnancy :-

Laparoscopy

  • Direct visualization of the ,fallopian tubes and pelvis by diagnostic laparoscopy offers a reliable diagnosis in most cases of suspected ectopic pregnancy and a ready transition to definitive operative therapy.
  • At times, identification of an early unruptured tubal pregnancy may be difficult even if the tube is .fully visualized.
  • Inspite of the low morbidity and quick recovery time, laparoscopy usually is performed when, on the basis of noninvasive test or curettage results, the diagnosis of ectopic pregnancy is fairly certain and medical therapy is not planned. In these cases laporoscopy is used both for therapeutic and diagnostic purpose.

Laparotomy

  • Open abdominal surgery is preferred when the woman is hemodynamically unstable or when laparoscopy is not feasible.
  • Laparotomy should not be delayed while laparoscopy is performed in a woman with obvious abdominal hemorrhage that required immediate definitive treatment.

Culdocentesis

  • Culdocentesis is the transvaginal passage of a needle into the posterior cul-de-sac in order to determine whether free blood is present in the abdomen.
  • This procedure is useful in the diagnosis of intraperitoneal bleeding.
  • This procedure will reveal nonclotting blood if intra-abdominal bleeding has occurred.
  • If culdocentesis is positive, laparoscopy or laparotomy should be performed immediately.
  • Indeed, some argue that the main purpose of culdocentesis is, not in diagnosis but to better prioritize patients so that those with positive culdocentensis are taken immediately to the operating room.

More on imaging procedures used in the diagnosis of ectopic pregnancy

Vaginal sonography

  • There has been much improvement in the early diagnosis of ectopic pregnancy using vaginal sonography.
  • Its use results in earlier and more specific diagnosis of uterine pregnancy than abdominal sonography and it has become the imaging method of choice in early pregnancy.

Abdominal sonography:-

  • Id entification of pregnancy products in the fallopian tube.

Q. 8

The cause of fetal death in ectopic pregnancy is postulated as:

 A

Vascular accident

 B

Nutritional adequancy

 C

Endocrine insufficiency

 D

Immune response of mother

Q. 8

The cause of fetal death in ectopic pregnancy is postulated as:

 A

Vascular accident

 B

Nutritional adequancy

 C

Endocrine insufficiency

 D

Immune response of mother

Ans. A

Explanation:

Vascular accident [Ref. Internet reference]

  • In a normal pregnancy, the fertilized egg enters the uterus and settles into the uterine lining (endometrium) where it has plenty of room to divide and grow.
  • The uterine endomentrium is adequately developed to sustain pregnancy.
  • In a typical ectopic pregnancy, the embryo does not reach the uterus, but instead adheres to the lining of the fallopian tube. The follopian tube cannot sustain the pregnancy.
  • The implanted embryo burrows actively into the tubal lining seeking nourishment.
  • This boring in activity of the embryo causes invasion of the vessels of the tubal wall and the muscular layer too.
  • This leads to bleeding.
  • This bleeding expels the implantation out of the tubal end as tubal abortion.

Q. 9

Hormone responsible for decidual reaction and Arias stella reaction in ectopic pregnancy is :

 A

Oestrogen

 B

Progesterone

 C

HCG

 D

HPL

Q. 9

Hormone responsible for decidual reaction and Arias stella reaction in ectopic pregnancy is :

 A

Oestrogen

 B

Progesterone

 C

HCG

 D

HPL

Ans. B

Explanation:

Ans. is b i.e. Progesterone

Arias stella reaction

  • Arias stella reaction is characterized by adenomatous change of the endometrial glands.
  • Cells loose their polarity, have hyperchromatic nucleus, vacuolated cytoplasm and occasional mitosis.
  • The reaction is seen in ectopic pregnancy (in 10-15% cases) and indicates blightening of conceptus be it intrauterine or extrauterine. (therfore it is not specific for ectopic pregnancy)
  • It occurs under the influence of progesterone.°

Decidual reaction

  • Under the hormonal effect of ectopic pregnancy (i.e. oestrogen, progesterone and chorionic gonadotrophin) the endometrium hypertrophies and is converted to decidua similar to normal uterine pregnancy.
  • The decidua has all the characteristics of intrauterine pregnancy except it does not have chorionic villi.°
  • The decidual reaction occurs under the influence of estrogen, progesterone and HCG.°

So, hormone which is common to both Arias stella reaction and decidual reaction is progesterone which is our answer of choice.



Q. 10

Medical treatment of ectopic pregnancy should be offered to those patients whose hCG level is less than:

 A

10,000 I Ll and the size of the mass is less than 4 cms

 B

5,000 ILI and the size of the mass is less than 5 cm

 C

7,500 ILJ and the size of the mass is less than 7.5 cm

 D

2,000 ItJ and the size of the mass is less than 3 cm

Q. 10

Medical treatment of ectopic pregnancy should be offered to those patients whose hCG level is less than:

 A

10,000 I Ll and the size of the mass is less than 4 cms

 B

5,000 ILI and the size of the mass is less than 5 cm

 C

7,500 ILJ and the size of the mass is less than 7.5 cm

 D

2,000 ItJ and the size of the mass is less than 3 cm

Ans. A

Explanation:

10,000 I Ll and the size of the mass is less than 4 cms


Q. 11

Basanti, a 28 yrs aged female with a history of 6 weeks of amenorrhoea presents with pain in abdomen; USG shows fluid In pouch of douglas. Aspiration yields dark color blood that fails to clot. Most probable diagnosis is :

 A

Ruptured ovarian cyst

 B

Ruptured ectopic pregnancy

 C

Red degeneration of fibroid

 D

Pelvic abscess

Q. 11

Basanti, a 28 yrs aged female with a history of 6 weeks of amenorrhoea presents with pain in abdomen; USG shows fluid In pouch of douglas. Aspiration yields dark color blood that fails to clot. Most probable diagnosis is :

 A

Ruptured ovarian cyst

 B

Ruptured ectopic pregnancy

 C

Red degeneration of fibroid

 D

Pelvic abscess

Ans. B

Explanation:

Ans. is b i.e. Ruptured ectopic pregnancy

The picture given in the question classically represents a case of ruptured ectopics pregnancy.

Symptom           In Ectopic pregnancy triad of :

  • Amenorrhea (seen in 75% cases) followed by :
  • Abdominal pain (seen in 100% cases, it is the most consistent symptom of ectopic pregnancy).
  • Appearance of vaginal bleeding are seen :

The above triad may be accompanied by nausea, vomiting, fainting attacks or syncope.

  • Patient may present in shock with pallor, tachycardia, hypotension and cold clammy extremities.

Examination

  • General examination : — P/R T

—       Pallor +nt

—       BP .1,

—       Slight intermittent pyrexia due to absorption of products of degeneration.

  • Per Abdomen – Abdomen is tense, tender and distended.

—          Shifting dullness may be present (depending on the amount of hemorrhage).

—          Rigidity / muscle guarding +/—,

—          Cullen’s sign – bluish discolouration around the umbilicus may be present.

  • On Bimanual examination

—           Vaginal mucosa appears blanched.°

—           Uterus : normal size / slightly bulky.

—           Extreme tenderness on cervical movement

—          Fornices – tender. (Remember – tenderness in pelvis is the most constant sign of Ectopic pregnancy).

—          U/L adnexal mass : is palpable in one third to half of patient.

Culdocesitt:si

  • It is a simple technique used to identify hemoperitoneum.
  • Fluid is aspirated from cul-de-sac via posterior fornix with the help of a needle.
  • If non clotting blood is obtained, it is indicative of an intraperitoneal bleed and probably a ruptured ectopic.

Note :  If the aspirated blood clots, it may have been obtained from an adjacent blood vessel rather than from bleeding ectopic pregnancy.

The women in the question is presenting with amenorrhea of 6 weeks and pain in abdomen.

On USG – fluid is seen in POD and aspiration of dark coloured blood which fails to clot – all these features leave no doubt of ectopic pregnancy.

“Sonographic absence of uterine pregnancy, a positive pregnancy test ($ -HCG), fluid in cul-de-sac and an abnormal pelvic mass. ectopic pregnancy is almost certain.”


Q. 12

Young lady presents with acute abdominal pain and history of 11/2 months amenorrhoea, on USG examination there is collection of fluid in the pouch of douglas and empty gestational sac. Diagnosis is

 A

Ectopic pregnancy

 B

Pelvic hematocele

 C

Threatened abortion

 D

Twisted ovarian cyst

Q. 12

Young lady presents with acute abdominal pain and history of 11/2 months amenorrhoea, on USG examination there is collection of fluid in the pouch of douglas and empty gestational sac. Diagnosis is

 A

Ectopic pregnancy

 B

Pelvic hematocele

 C

Threatened abortion

 D

Twisted ovarian cyst

Ans. A

Explanation:

Ans. is a i.e. Ectopic pregnancy


Q. 13

Ectopic pregnancy is most commonly sociated with:

 A

Endometriosis

 B

Congenital tubal anomalies

 C

Tuberculosis

 D

Tubal inflammatory diseases

Q. 13

Ectopic pregnancy is most commonly sociated with:

 A

Endometriosis

 B

Congenital tubal anomalies

 C

Tuberculosis

 D

Tubal inflammatory diseases

Ans. D

Explanation:

Ans. is d i.e. Tubal inflammatory disease

Read the question carefully, it says ectopic pregnancy is most commonly associated with : “Pelvic inflammatory disease (RD) increases the risk of ectopic pregnancy by 6-10 fold.”

“The most common cause (of ectopic pregnancy) is previous salpingitis due to sexually transmitted disease such as gonococcal and chlamydial infection or salpingitis that follows septic abortion and puerperal sepsis. –

  • After one episode of PID                  13%
  • After two episode of PID         – 35%
  • After three episode of PID       – 75%

Note : M/C cause of ectopic pregnancy is PID, Maximum risk of ectopic pregnany is after tubal damage, either due to previous ectopic pregnancy or tubal surgery.

Incidence of ectopic pregnancy :



Q. 14

Most common manifestation of ectopic pregnancy is :

 A

Vomiting

 B

Bleeding

 C

Pain abdomen

 D

Shock

Q. 14

Most common manifestation of ectopic pregnancy is :

 A

Vomiting

 B

Bleeding

 C

Pain abdomen

 D

Shock

Ans. C

Explanation:

Ans. is c i.e. Pain in abdomen

  • Most common and the most consistent symptom of ectopic pregnancy (undisturbed) is Abdominal pain.
  • It is seen in 95-100% cases.
  • Pain is located in the lower abdomen / pelvic region.
  • It can be unilateral or bilateral.
  • In case of ruptured ectopic pregnancy : when internal hemorrhage floods the peritoneal cavity and irritates the undersurface of diaphragm and phrenic nerve, the patient complains of shoulder tip and epigastric pain.
  • Classical triad of symptoms in disturbed tuba! pregnancy is . Amenorrhea (75%) followed by abdominal pain (95-100%) and lastly – vaginal bleeding (70%).

Vaginal bleeding is almost always small but persistent and consists of dark altered fluid blood or dark coagulated blood.


Q. 15

In which part of fallopian tube ectopic pregnancy will have longest survival:

 A

Isthmus

 B

Ampulla

 C

Cornua

 D

Interstitum

Q. 15

In which part of fallopian tube ectopic pregnancy will have longest survival:

 A

Isthmus

 B

Ampulla

 C

Cornua

 D

Interstitum

Ans. D

Explanation:

Ans, is d i.e. Interstitium


Q. 16

True about ectopic pregnancy :

 A

Transvaginal USG-first imaging test of choice

 B

Associated with decidual reaction

 C

In ectopic interstitial ring sign is seen

 D

All

Q. 16

True about ectopic pregnancy :

 A

Transvaginal USG-first imaging test of choice

 B

Associated with decidual reaction

 C

In ectopic interstitial ring sign is seen

 D

All

Ans. D

Explanation:

Ans. is a, b and c i.e. Transvaginal USG first imaging of choice; Associated with decidual reaction and In ectopic interstitial ring sign seen

  • In ectopic pregnancy under the influence of estrogen, progesterone and chorionic gonadotrophin. there is varying amount of enlargement of the uterus with increased vascularity. Decidua develops all the characteristics of intra-uterine pregnancy except that it contains no evidence of chorionic This is k/a decidual reaction (i.e. option b is correct)
  • Transvaginal USG (TVS) detects uterine gestational sac 1 week earlier than transabdominal probe (TAS), and gives a clear image because of its proximity to the pelvic organs. As discussed earlier not only it is the first imaging test which should be done but is also the imaging modality of choice (option a is correct).
  • Color Doppler sonography can identify the placental shape (ring of fire pattern) and blood flow pattern outside the urine cavity. It is used to diagnose those cases of ectopic pregnancy which cannot be identified by TVS (i.e. option c is incorrect).
  • USG findings in ectopic pregnnacy include demosntration of an extra uterine gestational sac appearing as fluid containing structure with an echogenic ring, “the tubal ring sign” (i.e. option d is correct:
  • A single estimation of fihCG level either in serum or in urine confirms pregnacy but can not determine its location (i.e. option e is incorrect). When the (3hCG value is greater than 1500m1U/m1 and there is an empty uterine cavity, ectopic pergnancy is more likely. Failure to double the value by 48 hours along with an empty uterus is very much suggestive.

Q. 17

Which of the following drug is not used for medi­cal management of ectopic pregnancy

 A

Potassium Chloride

 B

Methotrexate

 C

Actinomycin D

 D

Misoprostol

Q. 17

Which of the following drug is not used for medi­cal management of ectopic pregnancy

 A

Potassium Chloride

 B

Methotrexate

 C

Actinomycin D

 D

Misoprostol

Ans. D

Explanation:

Ans. is d i.e. Misoprostol

A number of chemotherapeutic drugs have been used either systemically or directly (surgically administered medical management – SAM under sonographic or laparoscopic guidance) for the medical management of ectopic pregnancy.

Drugs commonly used for medical management :

Mnemonic

Surgically administered medical nagement       –

Systemic

Most                        – Methotrexate° (20%)                                                             – Methotrexate (+ leucoverin)

Post                         – Prostaglandins° (PGF 2ct)

Graduate                  -Hyperosmolar Glucose°

Males                       -Mifepristone (RU486)

Are                           – Actinomycin D°

Very                         – Vasopressin°

Knowledgeable         KCI (Potassium Chloride)


Q. 18

In which of the following conditions, the medical treatment of Ectopic pregnancy is contraindicated:

 A

Sac size is 3 cm

 B

Blood in pelvis is 70 ml

 C

Presence of fetal heart activity

 D

Previous ectopic pregnancy

Q. 18

In which of the following conditions, the medical treatment of Ectopic pregnancy is contraindicated:

 A

Sac size is 3 cm

 B

Blood in pelvis is 70 ml

 C

Presence of fetal heart activity

 D

Previous ectopic pregnancy

Ans. C

Explanation:

Ans. is c i.e. Presence of fetal heart activity

Many questions are asked on Medical management of ectopic pregnancy. This particular question is one of the most controversial question. To clear all your doubts I am summarizing important points on medical management of ectopic pregnancy.

Medical management of ectopic pregnancy

  • Drug most commonly used : Methotrexate°

Methotrexate : It is a folic acid analogue which inhibits dehydrofolate reductase° and prevents synthesis of DNA.°

Candidates for methotrexate :

Absolute requirements

  • Hemodynamic stability°
  • No evidence of acute intra-abdominal bleeding°
  • Reliable commitment to comply with required follow-up care°
  • No contraindications to treatment viz woman should not be breast feeding / renal / hepatic dysfunction.

Preferable requirements

  • Absent or mild pain
  • Serum beta HCG level less than 10.000 I WI_ (best results seen with HCG < 2000 IU/L)°. It is the single best prognostic indicator of treatment success.
  • Absent embryonic heart activity°
  • Ectopic gestational mass less than 4 cms in diameter°

(or Less than < 3.5 according to William Obs 23/ed)

Friends, there is no doubt on this issue that presence of cardiac activity is a relative contraindication according to books like Williams Obs 23/e, Williams Gynae 1/ed and Leon Speroff 7/ed.

“Fetal based cardiac on limited activity evidence. – Although this is a relative contraindication to medical therapy, the admention Is

“The presence of embryonic heart activity is not an absolute contraindication for medical management but the likelihood of failure and the risk (If tuba/ rupture are substantially increased (therefore it is a relative contraindication).”

As far as fluid in cul-de-sac is concerned : Earlier. it was also considered a relative contraindication to medical treatment, but studies have shown that free peritoneal fluid can be seen in almost 40% of women with early unruptured ectopic pregnancy and so it’s presence and absence does not accurately predict the success or failure of medical treatment.

Contraindications to methotrexate treatment:

  • Breast feeding°
  • Immunodeficiency states°
  • Alcoholism or evidence of chronic liver disease (elevated transaminases)°
  • Renal disease (elevated serum creatinine)°
  • Hematological abnormalities (severe anemia, leukopenia or thrombocytopenia)a
  • Known sensitivity to methotrexate°
  • Active pulmonary disease°
  • Peptic ulcer disease.°

Also Know

Surgically administered medical management

  • Methotrexate can also be administered by direct local injection (lmg/kg) into an ectopic gestation sac under laparoscopic or ultrasonographic guidance.
  • The method delivers a high concentration of the drug to the site of implantation
  • Results with this therapy are inconsistent.
  • Direct local injection is ‘-nn0                                          more costly, and requires greater technical skills.
  • With the above disadvantages, and no clear advantages, systemic methotrexate treatment is the more logical choice.

Q. 19

Which of the following treatment is not done in ectopic pregnancy :

 A

Salpingectomy

 B

Salpingo-oophorectomy

 C

Salpingostomy

 D

Resection of involved segment

Q. 19

Which of the following treatment is not done in ectopic pregnancy :

 A

Salpingectomy

 B

Salpingo-oophorectomy

 C

Salpingostomy

 D

Resection of involved segment

Ans. B

Explanation:

Ans. is b i.e. Salpingo Oophorectomy

Surgiclt management of Ectopic pregnancy (laparoscopv nr lannrotomy)

Conservative surgery                                                                Radical surgery

 

Salpingostomy :

  • It is the procedure of choice when the patient is hemodynamcially stable and

wishes to retain her future fertility

  • Done to remove a small pregnancy less than 2 cm in length and located in the distal third of the fallopian tube- (William 22/e, p 261, 23/e, p 246)
  • The recommended surgical procedure for ampullary ectopic pregnancy.

Salpingotomy :

  • Seldom done now-a-days

Segmental resection and anastomosis :

  • It is done in case of isthmic pregnancy. Fimbrial expression of the ectopic pregnancy :
  • Risk of recurrence of ectopic pregnancy are
    high therefore not commonly performed.

 

Salpingectomy

Indications

  • The patient has completed her family,
  • The tubes are grossly damaged
  • Ectopic pregnancy has recurred in a
    tube already treated conservatively.
  • Uncontrolled bleeding

Salpingo-oophorectomy i.e. removal of tubes along with the ovaries is not recommended in young patients

“Presently salpingo-oophorectomy is never recommended unless the ovary itself is grossly diseased or damaged”.

“The ipsilateral ovary and its vascular supply is preserved. Oophorectomy is done only if the ovary is damaged beyond salvage or is pathological”.

Extra Edge :

Following surgical I medical management :

  • Estimation of J3HCG should be done weekly till the values become less than 5mlU/ml.
  • Additional monitoring by TVS is preferred.

This is done to rule out persistent ectopic pregnancy due to incomplete removal of trophoblast (in such a case single dose methotrexate 1 mg/kg should be given).


Q. 20

In a nulliparous woman, the treatment of choice in ruptured ectopic pregnancy is :

 A

Salpingectomy and end to end anastomosis

 B

Salpingo-oophorectomy

 C

Wait and watch

 D

Linear salpingostomy

Q. 20

In a nulliparous woman, the treatment of choice in ruptured ectopic pregnancy is :

 A

Salpingectomy and end to end anastomosis

 B

Salpingo-oophorectomy

 C

Wait and watch

 D

Linear salpingostomy

Ans. D

Explanation:

Ans. is d i.e. Linear salpingostomy

In the question the patient is presenting with ruptured ectopic pregnancy therefore surgical management is a must (option “c” ruled out)

Since, the patient is a nulliparous woman so we will avoid radical surgery in the form of salpingectomy or salpingo-oophorectomy as far as possible.

Now the only option of conservative surgery given in the options is—Linear salpingostomy, so we will go with it.

“The woman who is hemodynamically stable and strongly desires to preserve fertility is an appropriate candidate for salpingostomy.”


Q. 21

Ectopic pregnancy differs from threatened abortion by :

 A

Minimal vaginal bleeding

 B

Pain follows bleeding

 C

Uterine size corresponds to gestational age

 D

Manifests at an early age

Q. 21

Ectopic pregnancy differs from threatened abortion by :

 A

Minimal vaginal bleeding

 B

Pain follows bleeding

 C

Uterine size corresponds to gestational age

 D

Manifests at an early age

Ans. D

Explanation:

Ans. is d i.e. Manifests at an early age

This is a tough one : as it is quite difficult to differentiate between Ectopic pregnancy and threatened abortion on the clinical grounds.

 

Ectopic pregnancy                                       Vs

  1. Manifests at an early age
  2. Symptom-chronology :

Abdominal pain is followed by bleeding. Pain is the main symptom.

  1. Fainting attacks seen.

Abortion (Threatened)                   AIM

The initial period of amenorrhea tends to be longer Uterine bleeding precedes abdominal pain.

Bleeding is the main symptom and overshadows pain. Fainting attack absent.

 

In ectopic pregnancy as well as threatened absorption – amount of bleeding is slight.


Q. 22

Commonest cause of ectopic pregnancy is :

 A

Endometriosis

 B

Previous salpingitis

 C

Anemia

 D

Cervicitis

Q. 22

Commonest cause of ectopic pregnancy is :

 A

Endometriosis

 B

Previous salpingitis

 C

Anemia

 D

Cervicitis

Ans. B

Explanation:

Previous salpingitis


Q. 23

Most common cause of ectopic pregnancy is :

 A

Progestasert

 B

Cu-T

 C

OCP

 D

Minipill

Q. 23

Most common cause of ectopic pregnancy is :

 A

Progestasert

 B

Cu-T

 C

OCP

 D

Minipill

Ans. A

Explanation:

Progestasert


Q. 24

Causes of ectopic pregnancy includes :

 A

IUCD

 B

Tubal ciliary damage

 C

Late fertilisation

 D

a and b

Q. 24

Causes of ectopic pregnancy includes :

 A

IUCD

 B

Tubal ciliary damage

 C

Late fertilisation

 D

a and b

Ans. D

Explanation:

a and b both


Q. 25

Ectopic pregnancy is common in :

 A

Tuboplasty

 B

Endometriosis

 C

Copper T users

 D

All

Q. 25

Ectopic pregnancy is common in :

 A

Tuboplasty

 B

Endometriosis

 C

Copper T users

 D

All

Ans. D

Explanation:

All


Q. 26

Ectopic pregnancy is associated with all except :

 A

Salpingitis

 B

IUCD

 C

Plastic procedure on the tube

 D

None

Q. 26

Ectopic pregnancy is associated with all except :

 A

Salpingitis

 B

IUCD

 C

Plastic procedure on the tube

 D

None

Ans. D

Explanation:

None


Q. 27

Commonest site of ectopic pregnancy is :

 A

Uterus

 B

Cervix -WE

 C

Abdomen

 D

Tubes

Q. 27

Commonest site of ectopic pregnancy is :

 A

Uterus

 B

Cervix -WE

 C

Abdomen

 D

Tubes

Ans. D

Explanation:

Tubes


Q. 28

Commonest type of ectopic pregnancy with rupture is:

 A

Isthmic

 B

Ampulla

 C

Interstitial

 D

Intundibula

Q. 28

Commonest type of ectopic pregnancy with rupture is:

 A

Isthmic

 B

Ampulla

 C

Interstitial

 D

Intundibula

Ans. A

Explanation:

Isthmic


Q. 29

In a young patient with abdominal pain and fea­ture most suggestive of ectopic pregnancy is :

 A

Amenorrhea

 B

Vomiting

 C

Palpation of tender adnexal mass

 D

Increase beta HCG in urine

Q. 29

In a young patient with abdominal pain and fea­ture most suggestive of ectopic pregnancy is :

 A

Amenorrhea

 B

Vomiting

 C

Palpation of tender adnexal mass

 D

Increase beta HCG in urine

Ans. D

Explanation:

Increase beta HCG in urine


Q. 30

The most consistent sign in disturbed ectopic pregnancy is:

 A

Pain

 B

Vaginal bleeding

 C

Fainting

 D

Vomiting

Q. 30

The most consistent sign in disturbed ectopic pregnancy is:

 A

Pain

 B

Vaginal bleeding

 C

Fainting

 D

Vomiting

Ans. B

Explanation:

Vaginal bleeding


Q. 31

The expelled products in ectopic pregnancy originate from :

 A

Decidua basalis

 B

Decidua vera

 C

Chorionic villi

 D

Decidua Capsularis

Q. 31

The expelled products in ectopic pregnancy originate from :

 A

Decidua basalis

 B

Decidua vera

 C

Chorionic villi

 D

Decidua Capsularis

Ans. B

Explanation:

Decidua vera


Q. 32

Pathognomonic of ectopic pregnancy is :

 A

Purple hemorrhagic pregnancy in lower vagina

 B

Decidual casts

 C

Chadwick sign

 D

Postcoital hemorrhage

Q. 32

Pathognomonic of ectopic pregnancy is :

 A

Purple hemorrhagic pregnancy in lower vagina

 B

Decidual casts

 C

Chadwick sign

 D

Postcoital hemorrhage

Ans. B

Explanation:

Decidual casts


Q. 33

Best endometrial reaction In ectopic pregnancy is :

 A

Arias stella reaction

 B

Secretory phase

 C

Decidual reaction without chorionic villi

 D

Decidual reaction with chorionic villi

Q. 33

Best endometrial reaction In ectopic pregnancy is :

 A

Arias stella reaction

 B

Secretory phase

 C

Decidual reaction without chorionic villi

 D

Decidual reaction with chorionic villi

Ans. C

Explanation:

Decidual reaction without chorionic villi


Q. 34

Medical treatment of ectopic pregnancy is :

 A

Methotrexate

 B

Progesterone

 C

Oestrogen

 D

Adriamycin

Q. 34

Medical treatment of ectopic pregnancy is :

 A

Methotrexate

 B

Progesterone

 C

Oestrogen

 D

Adriamycin

Ans. A

Explanation:

Methotrexate


Q. 35

A 32 year old woamn with two live children was brought to emergency with the history of missed period for 15 dyas, spotting since 7 days and pain abdomen since 6hrs. Her pulse was 120/min, pal­lor ++, systolic BP BOmmHg. There was fullness and ternderness on per abdomen examination. Cu-T thread was seen through external os on P/S ex­amination On PN examination, cervical move­ments were tender, uterus was bulky and soft. There was fullness in pouch of Douglas. She is most likely suffering from :

 A

Pelvic inflammatory disease

 B

Missed aboriton with infectkion

 C

Rupture ectopic pregnancy

 D

Threatened aboriton

Q. 35

A 32 year old woamn with two live children was brought to emergency with the history of missed period for 15 dyas, spotting since 7 days and pain abdomen since 6hrs. Her pulse was 120/min, pal­lor ++, systolic BP BOmmHg. There was fullness and ternderness on per abdomen examination. Cu-T thread was seen through external os on P/S ex­amination On PN examination, cervical move­ments were tender, uterus was bulky and soft. There was fullness in pouch of Douglas. She is most likely suffering from :

 A

Pelvic inflammatory disease

 B

Missed aboriton with infectkion

 C

Rupture ectopic pregnancy

 D

Threatened aboriton

Ans. C

Explanation:

Rupture ectopic pregnancy


Q. 36

Absolute contraindication to intra-uterine device is:

 A

Anaemia

 B

History of ectopic pregnancy

 C

History of pelvic inflammatory disease

 D

None of the above

Q. 36

Absolute contraindication to intra-uterine device is:

 A

Anaemia

 B

History of ectopic pregnancy

 C

History of pelvic inflammatory disease

 D

None of the above

Ans. B

Explanation:

Absolute contraindications to intra uterine devices are:
  • History of ectopic pregnancy
  • Suspected pregnancy
  • Pelvic inflammatory disease
  • Vaginal bleeding of unknown etiology
  • Cancer of cervix, uterus, adnexa and other pelvic tumours
Ref: Park, 22nd edition pg: 449;Park 21st Ed Page 460.

Q. 37

A female patient is found to have an ectopic pregnancy. In order to gain access to the peritoneal cavity endoscopically to remove the embryo, the instrument can be passed into the vagina and through the?

 A

Anterior fornix

 B

Cervix

 C

Posterior fornix

 D

Retropubic space

Q. 37

A female patient is found to have an ectopic pregnancy. In order to gain access to the peritoneal cavity endoscopically to remove the embryo, the instrument can be passed into the vagina and through the?

 A

Anterior fornix

 B

Cervix

 C

Posterior fornix

 D

Retropubic space

Ans. C

Explanation:

In females, the rectouterine pouch is a peritoneal fold reflecting from the rectum to the posterior fornix of the vagina.
This means that an incision made through the posterior fornix of the vagina will allow a surgeon to enter the rectouterine pouch of the peritoneal cavity and remove the embryo.
Entering the anterior fornix of the vagina would not allow a surgeon to enter the peritoneal cavity.
In fact, one might pierce through into the bladder.
The cervix is the inferior portion of the uterus which connects the uterus to the vagina.
Passing through the cervix would allow the surgeon to enter the uterus, but not the peritoneal cavity.
 
Ref:Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 2. Maternal Anatomy. In F.G. Cunningham, K.J. Leveno, S.L. Bloom, J.C. Hauth, D.J. Rouse, C.Y. Spong (Eds), Williams Obstetrics, 23e.

Q. 38

A 31-year-old woman presents to the emergency department because of two days of abdominal pain without vaginal bleeding. Pelvic examination reveals a closed cervical os and right adnexal pain. The serum beta hCG level is 9,000 mIU/mL. An endovaginal ultrasound demonstrates no intrauterine gestational sac. Which of the following is the most likely diagnosis?

 A

Ectopic pregnancy

 B

Incomplete abortion

 C

Ovarian torsion

 D

Ruptured ovarian cyst

Q. 38

A 31-year-old woman presents to the emergency department because of two days of abdominal pain without vaginal bleeding. Pelvic examination reveals a closed cervical os and right adnexal pain. The serum beta hCG level is 9,000 mIU/mL. An endovaginal ultrasound demonstrates no intrauterine gestational sac. Which of the following is the most likely diagnosis?

 A

Ectopic pregnancy

 B

Incomplete abortion

 C

Ovarian torsion

 D

Ruptured ovarian cyst

Ans. A

Explanation:

The primary use of pelvic ultrasonography in women with lower abdominal pain, vaginal bleeding, and a positive pregnancy test is to establish the diagnosis of intrauterine pregnancy (IUP).

Transvaginal ultrasound should visualize an IUP when the serum beta hCG level is more than 1,200 mIU/mL.

If an IUP is not present, then the pregnancy lies outside of the uterine cavity, the patient has just had a miscarriage, or the pregnancy is less developed than menstrual dates indicate.

The absence of vaginal bleeding and the closed cervical os suggest that an incomplete abortion is unlikely, but place this patient at high risk for ectopic pregnancy.
 
Ref: Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 10. Ectopic Pregnancy. In F.G. Cunningham, K.J. Leveno, S.L. Bloom, J.C. Hauth, D.J. Rouse, C.Y. Spong (Eds), Williams Obstetrics, 23e. 

Q. 39

Mallika, 21 year old married female brought to ER with abdominal pain and slight vaginal bleeding. Her urine pregnancy test was positive two days ago. For ruling out ectopic pregnancy, the test that CANNOT be used is:

 A

Pelvic examination

 B

USG

 C

HCG levels

 D

Hysterosalpingography

Q. 39

Mallika, 21 year old married female brought to ER with abdominal pain and slight vaginal bleeding. Her urine pregnancy test was positive two days ago. For ruling out ectopic pregnancy, the test that CANNOT be used is:

 A

Pelvic examination

 B

USG

 C

HCG levels

 D

Hysterosalpingography

Ans. D

Explanation:

Ectopic pregnancies are identified with the combined use of clinical findings along with,

  • Transvaginal sonography
  • Serum beta-hCG level—both the initial level and the pattern of subsequent rise or decline
  • Serum progesterone level
  • Uterine curettage
  • Laparoscopy and occasionally, laparotomy
The hysterosalpingography (HSG) has been considered the gold standard for imaging the uterine corpus for benign disorders (submucous myomas, submucous polyps, localization of tubal occlusion, and evaluation of müllerian fusion defects) and malignant disease (endometrial carcinoma).
 
Ref: Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 10. Ectopic Pregnancy. In F.G. Cunningham, K.J. Leveno, S.L. Bloom, J.C. Hauth, D.J. Rouse, C.Y. Spong (Eds), Williams Obstetrics, 23e.

Q. 40

The following drug is not helpful in the treatment of ectopic pregnancy:

 A

Methotrexate

 B

Misoprostol

 C

Actinomycin-D

 D

RU486

Q. 40

The following drug is not helpful in the treatment of ectopic pregnancy:

 A

Methotrexate

 B

Misoprostol

 C

Actinomycin-D

 D

RU486

Ans. B

Explanation:

Misoprostol (PGE1) has been used for cervical ripening which is used for induction of labour.

It doesn’t have any role in management of ectopic pregnancy.

Ref:Text Book of Obstetrics By Dutta, 6th Edition, Pages 175, 189, 505


Q. 41

A hemodynamically stable nulliparous patient with ectopic pregnancy has adnexal mass of 2.5 x 3 cms and beta hCG titer of 1500 mIU/ml. There is no foetal cardiac activity. Which of the following modality of treat­ment is suitable for her?

 A

Laparotomy

 B

Laparoscopic surgery

 C

Medical management

 D

Conservative management

Q. 41

A hemodynamically stable nulliparous patient with ectopic pregnancy has adnexal mass of 2.5 x 3 cms and beta hCG titer of 1500 mIU/ml. There is no foetal cardiac activity. Which of the following modality of treat­ment is suitable for her?

 A

Laparotomy

 B

Laparoscopic surgery

 C

Medical management

 D

Conservative management

Ans. C

Explanation:

The patient in the question is suffering from unruptured tubal pregnancy.

Medical management is suitable for her as she meets the criteria for medical management. 

The best candidate for medical therapy is the woman who is asymptomatic, motivated, and compliant and with the following conditions: 
 
Initial serum Beta-hCG level: This is the single best prognostic indicator of successful treatment with single-dose methotrexate.

Reported failure rates of 1.5 percent if the initial serum hCG concentration was
 
Ectopic pregnancy size: Lipscomb and colleagues (1998) reported a 93-percent success rate with single-dose methotrexate when the ectopic mass was 3.5 cm.
 
Fetal cardiac activity: Most studies report increased failure rates if there is cardiac activity, Lipscomb and colleagues (1998) reported an 87-percent success rates in such cases.
 
A single dose of methotrexate 50mg/m2 is given I.M
 
Ref: Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 10. Ectopic Pregnancy. In F.G. Cunningham, K.J. Leveno, S.L. Bloom, J.C. Hauth, D.J. Rouse, C.Y. Spong (Eds), Williams Obstetrics, 23e. ; Textbook of Obstetrics By D.C. Dutta 6th, Edition, Page 189

 


Q. 42

Best for unruptured ectopic pregnancy is:

 A

Per abdominal US

 B

HCG

 C

Trans vaginal US

 D

Amniocentesis

Q. 42

Best for unruptured ectopic pregnancy is:

 A

Per abdominal US

 B

HCG

 C

Trans vaginal US

 D

Amniocentesis

Ans. C

Explanation:

C i.e. Tranvaginal US


Q. 43

All are signs /features of ectopic pregnancy on USG except

 A

Pseudo sac

 B

Hyprechoic ring

 C

Adenexal mass

 D

Echogenic mass with multicystic spaces within endometrial cavity

Q. 43

All are signs /features of ectopic pregnancy on USG except

 A

Pseudo sac

 B

Hyprechoic ring

 C

Adenexal mass

 D

Echogenic mass with multicystic spaces within endometrial cavity

Ans. D

Explanation:

D i.e. Echogenic mass with multicystic spaces within endometrial cavity


Q. 44

Most common site of ectopic pregnancy in fallopian tube:      

March 2005

 A

Infundibulum

 B

Ampulla

 C

Isthmus

 D

Interstitium

Q. 44

Most common site of ectopic pregnancy in fallopian tube:      

March 2005

 A

Infundibulum

 B

Ampulla

 C

Isthmus

 D

Interstitium

Ans. B

Explanation:

Ans. B: Ampulla

The vast majority of ectopic pregnancies implant in the Fallopian tube.

Pregnancies can grow in the infundibulum (18% of all ectopics), the ampullary section (55%), the isthmus (25%), and the interstitial part of the tube (20%).

Mortality of a tubal pregnancy at the isthmus or within the uterus (interstitial pregnancy) is higher as there is increased vascularity that may result more likely in sudden major internal hemorrhage.


Q. 45

Ectopic pregnancy can be ruled out on ultrasound by:

 A

Finding foetus in uterus

 B

Normal adenexa

 C

Uterus size proportional to foetal size

 D

Clinical examination

Q. 45

Ectopic pregnancy can be ruled out on ultrasound by:

 A

Finding foetus in uterus

 B

Normal adenexa

 C

Uterus size proportional to foetal size

 D

Clinical examination

Ans. A

Explanation:

Ans. Finding foetus in uterus



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