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OVERVIEW
This page is dedicated to organizing various examples of standardized exam questions whose answer is ectopic pregnancy. While this may seem a odd practice, it is useful to see multiple examples of how ectopic pregnancy will be characterized on standardized exams (namely the boards and the shelf exams). This page is not meant to be used as a tradition question bank (as all of the answers will be the same), however seeing the classic “test” characterization for a disease is quite valuable.
KEY CHARACTERISTICS OF THIS CONDITION (ON EXAMS)
When it comes to standardized exams, each condition has its own “code” marked by key buzzwords, lab findings, clues, etc. If you are well versed in this code you will be able to more quickly identify the condition that is being discussed, and get the right answer on the exam you are taking. Below is the “code” for ectopic pregnancy.
Chief Complaints:
- Abdominal pain: often times on the lower abdomen. Can be very severe in cases of rupture.
- Vaginal bleeding: can be very heavy in the setting of rupture.
Patient History:
- Likely pregnancy: can be in the setting of a last menstrual period (LMP) many weeks ago.
- Inconsistent birth control usage can also hint at likely pregnancy in the patient.
Clinical Workup:
- Positive pregnancy test: can be either urine or serum beta-hCG
- Empty uterus on ultrasound
- Mass/lesion/gestational sack outside uterus on ultrasound.
Features Suggesting Rupture:
- Hemodynamic instability: orthostatic hypotension, tachycardia
- Surgical abdomen: guarding, rebound tenderness, diffuse abdominal tenderness
- Free fluid seen on ultrasound
STABLE ECTOPIC PREGNANCY
Question # 1
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?
Explanation #1
Slow rising beta hCG + no gestational sac in the uterus = ectopic pregnancy
Question # 2
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 in this patient?
Explanation #2
Abdominal pain + positive beta-hCG + no intrauterine pregnancy + ovarian mass with free fluid = ectopic pregnancy (can occur even in the setting of a patient who has a tubal ligation)
Question # 3
A 25 year old G1P0 woman presents with cramping, vaginal bleeding and right lower quadrant pain. Her last normal menstrual period occurred seven weeks ago. Her vital signs are a blood pressure of 110/75 mm Hg, a pulse of 85/min, respirations of 18/min and a temperature of 98.4°F. Her abdominal exam is notable for very mild right lower quadrant tenderness. On pelvic exam, she has scant old blood in the vagina and a normal appearing cervix. Her uterus is normal size and slightly tender. On bimanual exam, there is no cervical motion tenderness, and she has slight tenderness in the right lower quadrant. Quantitative Beta-hCG is 2600 mIU/ml and her hematocrit 36%. The transvaginal ultrasound shows an empty uterus with endometrial thickening, as well as a mass in the right ovary measuring 3.5 x 2.5 cm with a small amount of free fluid in the pelvis. What is the likely diagnosis?
Explanation #3
Abdominal pain + positive beta-hCG + no intrauterine pregnancy + ovarian mass with free fluid = ectopic pregnancy
Question # 4
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?
Explanation #4:
Abdominal pain + positive beta-hCG + no intrauterine pregnancy + beta-hCG not increasing as expected = ectopic pregnancy
RUPTURED ECTOPIC PREGNANCY
Question # 1
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?
Explanation #1
Abdominal pain (recently more severe)+ passing blood vaginally + positive urine pregnancy test + gestational sac outside the uterus + free fluid present = ectopic pregnancy.(likely ruptured)
Question # 2
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?
Explanation #2
Abdominal pain + likely pregnancy (LMP 9 weeks ago/intermittent condom usage) + surgical abdomen = ectopic pregnancy (likely ruptured)
Question # 3
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?
Explanation #3
Abodminla pain + past history of (likely) PID + hemodynamic instability + positive beta-hCG = ectopic pregnancy (most likely ruptured)
Question # 4
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?
Explanation #4
Abodminla pain + past history of (likely) PID + hemodynamic instability + positive beta-hCG + no intrauterine pregnancy + adnexal mass with free fluid = ectopic pregnancy (most likely ruptured)
Question # 5
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?
Explanation #5
Abdominal pain + positive pregnancy test + no intrauterine pregnancy + hemodynamic instability + pelvic mass with gestational sac and fetal pole = ectopic pregnancy (very likely ruptured)
Question # 6
A 30 year old female who is G2P2 comes to the emergency department with severe right lower quadrant abdominal pain. She also complains of heavy vaginal bleeding, and is soaking 1 large pad every 3 hours. Her last menstrual period was 7 weeks ago. The patient’s past medical history is notable for a bilateral tubal ligation. A urine pregnancy test is performed and is positive. Ultrasound reveals a 3 cm mass in the right adnexa next to the ovary. The uterus is found to have a thickened endometrial stripe on ultrasound. What is the likely diagnosis in this patient?
Explanation #6
Severe lower abdominal pain + heavy vaginal bleeding + adnexal mass + empty uterus = ectopic pregnancy (very likely ruptured)
Question # 7
A 25 year old woman comes to the clinic with lower abdominal pain. She complains that she has also been having bloody vaginal discharge. She initially noticed these symptoms early this morning, and feels that they have progressively been worsening. She says that she and her boyfriend use condoms “sometimes”. Her past medical history is notable for pelvic inflammatory disorder, but is otherwise unremarkable. She is G0P0 and her last menstrual period was 6 weeks ago. Her vitals reveal orthostatic hypotension and she is tachycardic. Lab results reveal a positive urine beta-hCG. What is a possible diagnosis in this patient?
Explanation #7
Lower abdominal pain + vaginal bleeding + likely pregnancy (inconsistent condom usage/LMP 6 weeks ago) + hemodynamic instability (orthostasis/tachycardia) + positive urine pregnancy test = ectopic pregnancy (very likely ruptured)
Question # 8
A 34 year old female who is G1P0 is at 7 weeks gestation. She comes to the emergency department with severe abodminal pain and vaginal bleeding. She feels that her abodminal pain has recently worsened significantly. An abodminla exam reveals tenderness in the left lower quadrant, and there is rebound tenderness and guarding present. A serum beta-hCG concentration is 6200 mIU/mL. An abodminal and transvaginal ultrasound reveal an empty uterus. What is the likely diagnosis int his patient?
Explanation #8
Severe abodminal pain + vaginal bleeding + surgical abdomen (rebound tenderness and guarding) + positive pregnancy test + empty uterus on ultrasound = ectopic pregnancy (very likely ruptured)
TESTABLE FACTS ABOUT THIS CONDITION (BEYOND ITS IDENTIFICATION)
Many questions on standardized exams go beyond simply recognizing the underlying condition. Often there are specific testable facts regarding some aspect of the disease’s pathophysiology/management/clincial implications that are commonly asked. Some of these are listed below:
Other:
- Most common site of ectopic pregnancy: ampullae of fallopian tube
- Risk factors: Pelvic inflammatory disorder (tubal scarring)
Page Updated: 10.09.2016