Ectopic_Pregnancy_Investigation_and_Management_Flashcards

Question 1

Where are stable women typically investigated and managed for ectopic pregnancy?

Answer 1

In an early pregnancy assessment unit.

Question 2

Where should unstable women with suspected ectopic pregnancy be referred?

Answer 2

To the emergency department.

Question 3

What is the result of a pregnancy test in cases of ectopic pregnancy?

Answer 3

A pregnancy test will be positive.

Question 4

What is the investigation of choice for ectopic pregnancy?

Answer 4

A transvaginal ultrasound.

Question 5

What are the criteria for expectant management of ectopic pregnancy?

Answer 5

Size <35mm, unruptured, asymptomatic, no fetal heartbeat, hCG <1,000IU/L, compatible if another intrauterine pregnancy.

Question 6

What are the criteria for medical management of ectopic pregnancy?

Answer 6

Size <35mm, unruptured, no significant pain, no fetal heartbeat, hCG <1,500IU/L, not suitable if intrauterine pregnancy.

Question 7

What are the criteria for surgical management of ectopic pregnancy?

Answer 7

Size >35mm, can be ruptured, pain, visible fetal heartbeat, hCG >5,000IU/L, compatible with another intrauterine pregnancy.

Question 8

What does expectant management of ectopic pregnancy involve?

Answer 8

Closely monitoring the patient over 48 hours and intervening if B-hCG levels rise again or symptoms manifest.

Question 9

What does medical management of ectopic pregnancy involve?

Answer 9

Giving the patient methotrexate and ensuring the patient is willing to attend follow-up.

Question 10

What does surgical management of ectopic pregnancy involve?

Answer 10

Surgical management can involve salpingectomy or salpingotomy.

Question 11

What is the first-line surgical management for women with no other risk factors for infertility?

Answer 11

Salpingectomy.

Question 12

When should salpingotomy be considered for ectopic pregnancy?

Answer 12

Salpingotomy should be considered for women with risk factors for infertility such as contralateral tube damage. Around 1 in 5 women who undergo a salpingotomy require further treatment (methotrexate and/or a salpingectomy).

Question 13

summarise ectopic pregnancy: investigations and management

Answer 13

Ectopic pregnancy: investigation and management

Women who are stable are typically investigated and managed in an early pregnancy assessment unit. If a woman is unstable then she should be referred to the emergency department.

Investigation

A pregnancy test will be positive.

The investigation of choice for ectopic pregnancy is a transvaginal ultrasound.

Question 14

An 18-year-old woman is assessed in the urgent gynaecology clinic due to concerns about her period being 3 weeks overdue. She has been experiencing mild abdominal cramping but no other symptoms.

A transvaginal ultrasound is performed and shows an adnexal mass of 28mm with no visible heartbeat, consistent with an extrauterine pregnancy.

How should this patient be managed?

Laparoscopic salpingectomy
Laparoscopic salpingotomy
Methotrexate
Mifepristone and misoprostol
Misoprostol

Answer 14

Methotrexate

Methotrexate is the drug of choice for medical management of ectopic pregnancy

Methotrexate is correct. This patient has an ultrasound-proven ectopic pregnancy which needs urgent management. As the adnexal mass is < 35mm, has no detectable heartbeat and has not ruptured, this patient can be managed medically according to NICE, as the pain they are experiencing is not severe. Methotrexate is the drug of choice to manage an ectopic pregnancy - it is highly teratogenic, so a single dose of IM methotrexate can induce spontaneous termination. It is important to discuss that methotrexate can be teratogenic up until 3 months after the treatment.

Laparoscopic salpingectomy is the choice for surgical management of an ectopic pregnancy. As this patient is currently stable and suitable for medical management, an invasive approach can be avoided. This patient is also 18 years old, therefore salvaging the fallopian tube is the most favourable outcome.

Laparoscopic salpingotomy is not the procedure of choice, even for surgical management - it is usually only reserved for patients who have had a previous salpingectomy or have significant adhesions, therefore the tube is preserved. Again, it is not indicated in this case, as medical management is more appropriate for this patient.

Mifepristone and misoprostol is incorrect. This combination of drugs is given to terminate a pregnancy, and although an ectopic pregnancy must be terminated, those are not the appropriate drugs to use. Mifepristone blocks the action of progesterone, halts the growth of pregnancy and relaxes the cervix - although stopping the growth of the pregnancy is beneficial, as the pregnancy is extrauterine it would not help with expelling it.

Misoprostol is incorrect. It is a prostaglandin analogue which stimulates uterine contractions and is used alongside mifepristone to terminate a pregnancy. As this pregnancy is extrauterine, inducing uterine contractions would not suffice in managing it.

Question 15

A 27-year-old woman has been referred to Early Pregnancy Unit, with pregnancy of unknown gestation and with some per vaginal bleeding.

She denies pain and is haemodynamically stable. This is her first pregnancy.

Ultrasound demonstrates a tubal pregnancy, with a visible foetal heartbeat and an unruptured adnexal mass of 40mm. beta-hCG is 5,200 IU/L.

What management would be first-line for this patient?

Surgical - open salpingectomy
Expectant
Medical
Reassure and do nothing
Surgical - laparoscopic salpingectomy

Answer 15

Surgical - laparoscopic salpingectomy

All ectopic pregnancies >35 mm in size or with a serum B-hCG >5,000IU/L should be managed surgically

The correct answer is:

Surgical - laparoscopic salpingectomy. Surgical management is indicated if an ectopic pregnancy is confirmed on ultrasound with an adnexal mass of 35mm or larger. In this case, the adnexal mass is 40mm. The beta-hCG is also >5,000 IU/L here. In most cases, surgery is done via laparoscopy.

The incorrect answers are:

Surgical - open salpingectomy. Laparotomy is reserved for emergency cases where there is rupture of the Fallopian tube and with haemodynamic instability. Here the patient is haemodynamically stable without rupture, so laparotomy is not required at present.

Medical. The adnexal mass is >35mm and BHCG >1500 so medical management would be inappropriate here.

Expectant. The adnexal mass is >35mm and BHCG is >1500 so medical management would be inappropriate here.

Reassure and do nothing. This is inappropriate as this patient’s ectopic pregnancy requires treatment.

Question 16

A 35-year-old woman presents to the emergency department with sudden abdominal pain and vaginal bleeding. She has a past medical history of complicated pelvic inflammatory disease resulting in scarring of the right fallopian tube. Her last period was 6 weeks ago.

Her heart rate is 93 bpm, and her blood pressure is 136/76 mmHg. Palpation of the left iliac fossa elicits pain. A urinary pregnancy test is positive and further investigations are performed:

Serum b-hCG 5200 IU/L
Ultrasound 45 mm left adnexal mass present, no heartbeat seen

What is the most appropriate step in her management?

Expectant management and monitoring
Laparoscopic salpingectomy and monitoring
Laparoscopic salpingotomy and monitoring
Methotrexate and monitoring
Vaginal misoprostol and monitoring

Answer 16

Laparoscopic salpingotomy and monitoring

Ectopic pregnancy requiring surgical management: Salpingotomy (rather than salpingectomy) should be considered for women with risk factors for infertility such as contralateral tube damage

Laparoscopic salpingotomy and monitoring is correct. This patient has acute-onset abdominal pain and vaginal bleeding after 6-8 weeks following her last period which should raise suspicion of an ectopic pregnancy. The positive pregnancy tests and ultrasound findings confirm this diagnosis. Given that the size of the ectopic pregnancy is greater than 35 mm, and the beta-hCG levels are higher than 5000 IU/L, the most appropriate step in this patient’s management is surgical, either via a laparoscopic salpingectomy (removal of the affected tube) or salpingotomy (removal of the ectopic pregnancy material and retaining the tube). The preferred method depends on the status of the other tube and the woman’s desire for future fertility. Given that she has pelvic inflammatory disease (PID) requiring hospitalisation that has led to scarring of the contralateral tube, the ideal method of choice would be a salpingotomy. This preserves the affected tube and means that her fertility is preserved.

Expectant management and monitoring is incorrect. This would be an appropriate option if the size of the ectopic pregnancy was less than 35 mm, the beta-hCG levels were less than 1000 IU/L, no foetal heartbeat was present, and the patient was asymptomatic. Except for the absence of a foetal heartbeat, these do not apply to this patient, therefore making expectant management less appropriate.

Laparoscopic salpingectomy and monitoring is incorrect. Although this is another option for surgery in the management of ectopic pregnancy, it would be less appropriate to remove the affected tube in its entirety as this patient has a history of PID requiring hospitalisation and subsequent contralateral fallopian tube scarring. A salpingotomy means that the affected tube is preserved, and means that her fertility is preserved.

Methotrexate and monitoring is incorrect. This would be appropriate if the patient had no significant pain, the size of the ectopic pregnancy was <35 mm, the beta-hCG was less than 1500 IU/L, and no foetal heartbeat was present. Except for the absence of a foetal heartbeat, these do not apply to this patient, therefore making medical management with methotrexate inappropriate.

Vaginal misoprostol and monitoring is incorrect. This is used in the medical management of a miscarriage. Misoprostol is used to expedite the miscarriage. Misoprostol plays no role in the management of an ectopic pregnancy as the pregnancy tissue is not present in the uterus.

Question 17

buzz words

Answer 17

period overdue
mild abdominal cramping
adnexal mass
no visible heartbeat
extrauterine pregnancy.
pregnancy of unknown gestation
per vaginal bleeding.
very high beta-hCG
emergency department
sudden abdominal pain
vaginal bleeding
past medical history of complicated pelvic inflammatory disease resulting in scarring of the fallopian tube.
tachycardia
High BP
iliac fossa elicits pain

Question 18

salpingotomy vs salpingectomy

Answer 18

Salpingotomy: Incision and removal of an ectopic pregnancy/blockage from the fallopian tube without removing the tube; aims to preserve fertility.
Salpingectomy: Removal of one or both fallopian tubes; often done to prevent recurrence of ectopic pregnancies, for sterilization, or to reduce cancer risk; results in reduced fertility or permanent infertility if both tubes are removed.

Question 19

A 30-year-old woman presents to the Emergency Department with lower abdominal pain and vaginal bleeding. Her last menstrual period was six weeks ago. She describes the pain as sharp and localized on the right side of her abdomen. On physical examination, she appears pale but vital signs are stable. Pelvic examination reveals cervical motion tenderness.

What would be the most diagnostic investigation for this patient?

Full blood count
Serum beta-human chorionic gonadotropin (β-hCG) level
Transabdominal ultrasound
Transvaginal ultrasound
Urine pregnancy test

Answer 19

Transvaginal ultrasound

The investigation of choice for ectopic pregnancy is a transvaginal ultrasound

The answer is a transvaginal ultrasound

In a patient with suspected ectopic pregnancy, the investigation of choice is a transvaginal ultrasound. Ectopic pregnancy is a potentially life-threatening condition where the fertilised egg implants outside the uterus, most commonly in the fallopian tube. Transvaginal ultrasound offers better visualisation and sensitivity in detecting early ectopic pregnancies compared to transabdominal ultrasound. It allows for direct visualisation of the pelvic organs, including the uterus and fallopian tubes, which can help identify an ectopic pregnancy, visualise the adnexal mass, and assess for signs of rupture or internal bleeding.

A full blood count (FBC), is a routine laboratory test that can provide information about red blood cell count, haemoglobin, and white blood cell count. While an FBC may be useful in assessing for anaemia or infection, it is not the primary investigation for evaluating a suspected ectopic pregnancy.

Measuring the serum beta-human chorionic gonadotropin (β-hCG) level is an important diagnostic test in the evaluation of pregnancy. In the context of suspected ectopic pregnancy, a rising or plateauing β-hCG level can indicate an abnormal pregnancy. However, the initial imaging modality to confirm the diagnosis and determine the location of the pregnancy is a transvaginal ultrasound.

A transabdominal ultrasound involves placing an ultrasound probe on the abdomen to obtain images of the pelvic organs. While transabdominal ultrasound can provide some information about the uterus and adnexal structures, it is less sensitive in detecting early ectopic pregnancies compared to transvaginal ultrasound. In this scenario, where there is a high suspicion of ectopic pregnancy, transvaginal ultrasound is the preferred initial imaging modality.

A urine pregnancy test, is a simple and convenient test for detecting the presence of human chorionic gonadotropin (hCG) in the urine, indicating pregnancy. However, it is not the investigation of choice for evaluating a suspected ectopic pregnancy. In this scenario, where there is a clinical suspicion of ectopic pregnancy based on the patient’s symptoms, physical examination findings, and adnexal mass, a transvaginal ultrasound is necessary for confirming the diagnosis.

Question 20

A 37-year-old woman presents to the emergency department with lower abdominal pain. She states that she had a positive pregnancy test two weeks prior. She states that this is her first pregnancy and that she hopes to become a parent. She has no prior gynaecological history.

A transvaginal ultrasound scan is performed, which shows the following:

Transvaginal ultrasound No intrauterine pregnancy was visualised. An adnexal mass size of 46mm. Visible foetal heartbeat.

What is the most appropriate management option?

Expectant management
Methotrexate
Misoprostol
Salpingectomy
Salpingotomy

Answer 20

Salpingectomy

All ectopic pregnancies >35 mm in size or with a serum B-hCG >5,000IU/L should be managed surgically

Salpingectomy is correct. In this example, surgical management is required as the patient is in pain, has an adnexal mass > 35 mm and has a visible foetal heat beat on transvaginal ultrasound. In this case, despite the patient wanting to preserve her fertility, it is most appropriate to remove the fallopian tube as keeping the fallopian tube risks future ectopic pregnancies. Preservation of the fallopian tube is only indicated when there is contralateral fallopian tube disease/blockage. In this example, there is no evidence of previous gynaecological disease so salpingectomy is the most appropriate management.

Expectant management is incorrect. In this example, the patient is in pain and has findings on the ultrasound scan (a visible foetal heartbeat and adnexal mass > 35mm) which makes expectant management inappropriate for this patient. Expectant management should only be performed in patients with an ectopic pregnancy who are pain-free and clinically stable - this is because there is a low risk of rupture in these patients.

Salpingotomy is incorrect. Salpingotomy is a surgical procedure which can be performed for ectopic pregnancy in those who have risk factors for infertility (such as a contralateral tube disease/blockage) as this procedure aims to preserve the fallopian tube. Whilst the patient intends to preserve her fertility, a tube removal is still indicated as there is no evidence that the is any pathology in the contralateral tube.

Methotrexate is incorrect. Medical management is not appropriate in this patient because the adnexal mass in this example is > 35mm and also there is a foetal heartbeat present on the scan. Surgical management is indicated in this patient because there is a risk of rupture which can lead to generalised peritonitis of the abdomen.

Misoprostol is incorrect. This is synthetic prostaglandin which can be used to induce termination of pregnancy or induce labour by causing contraction of the uterus. Misoprostol is not routinely used to treat an ectopic pregnancy as the embryo has been implanted outside the uterus.

Question 21

A 25-year-old woman presents to the emergency department complaining of vaginal bleeding. The patient states that the bleeding is minimal, likely around a teaspoon of blood and that her last menstrual period was 6 weeks ago. The patient denies any other symptoms, has no relevant past medical history and is haemodynamically stable.

Examination reveals a soft, non-tender abdomen and a small amount of vaginal bleeding. Ultrasound reveals a 40mm mass in the right fallopian tube and no other abnormalities. Serum β-hCG is shown below:

β-HCG 6000 IU/L

What is the most appropriate management?

Expectant management
Exploratory laparotomy
Laparoscopic salpingectomy
Laparoscopic salpingotomy
Methotrexate

Answer 21

Laparoscopic salpingectomy

Ectopic pregnancy requiring surgical management: salpingectomy is first-line (rather than salpingotomy) for women with no other risk factors for infertility

The correct answer is a laparoscopic salpingectomy. This patient is presenting with vaginal bleeding and a missed menstrual period. Imaging confirms the presence of a 40mm ectopic pregnancy. Her B-hCG is 6000. Due to the size of the ectopic and the level of serum B-hCG, surgical management is the best option. As this patient has no risk factors for infertility, a salpingectomy (removal of the fallopian tube) is most appropriate.

Expectant management is incorrect. This patient is presenting with an ectopic pregnancy. Expectant management can be considered in patients with no pain, a <35mm ectopic and a low (<1000) B-hCG level. This patient has a large ectopic and a high B-hCG so surgical management is indicated.

Exploratory laparotomy is incorrect. The patient is presenting with a classic clinical picture of an ectopic pregnancy, confirmed by ultrasound imaging. Therefore an exploratory laparotomy would be excessive.

Laparoscopic salpingotomy is incorrect. This patient is presenting with an ectopic pregnancy. A salpingotomy (removal of the ectopic pregnancy whilst preserving the fallopian tube) is a good option for patients who have risk factors for infertility. However, as this is not the case in this patient, a salpingectomy is indicated as it has a lower risk of complications.

Methotrexate is incorrect. This patient is presenting with an ectopic pregnancy. Methotrexate is used in the medical management of ectopic pregnancy, as it is highly teratogenic. However, to qualify for medical management, a patient needs to have an ectopic <35mm and a B-hCG <1500. As this is not the case surgical management is indicated.

Question 22

A 25-year-old woman presents to the emergency department with acute-onset abdominal pain and vaginal bleeding. Her last period was 7 weeks ago. She is sexually active, does not use any hormonal contraception, and has no other past medical history.

Her heart rate is 85 bpm, and her blood pressure is 126/76 mmHg. Palpation of the right iliac fossa elicits pain. A urinary pregnancy test is positive and further investigations are performed:

Serum b-hCG 5200 IU/L
Ultrasound 38 mm right adnexal mass present, no heartbeat present

What is the most appropriate step in her management?

Expectant management and monitoring
Laparoscopic salpingectomy and monitoring
Laparoscopic salpingotomy and monitoring
Methotrexate and monitoring
Vaginal misoprostol and monitoring

Answer 22

Laparoscopic salpingectomy and monitoring

Ectopic pregnancy requiring surgical management: salpingectomy is first-line (rather than salpingotomy) for women with no other risk factors for infertility

Laparoscopic salpingectomy and monitoring is correct. This patient has acute-onset abdominal pain and vaginal bleeding after 6-8 weeks following her last period which should raise suspicion of an ectopic pregnancy. The positive pregnancy tests and ultrasound findings confirm this diagnosis. Given that the size of the ectopic pregnancy is greater than 35 mm, and the beta-hCG levels are higher than 5000 IU/L, the most appropriate step in this patient’s management is surgical, either via a laparoscopic salpingectomy (removal of the affected tube) or salpingotomy (removal of the ectopic pregnancy material and retaining the tube). The preferred method depends on the status of the other tube and the woman’s desire for future fertility. Given that there is nothing to suggest the contralateral tube is affected, the ideal choice in management would be a salpingectomy, as a salpingotomy may require further treatment with methotrexate and may not remove the ectopic pregnancy entirely. There is no evidence to suggest that a salpingotomy is better than a salpingectomy if the contralateral tube is normal, therefore it would be more appropriate to perform a salpingectomy.

Expectant management and monitoring is incorrect. This would be an appropriate option if the size of the ectopic pregnancy was less than 35 mm, the beta-hCG levels were less than 1000 IU/L, no foetal heartbeat was present, and the patient was asymptomatic. Except for the absence of a foetal heartbeat, these do not apply to this patient, therefore making expectant management less appropriate.

Laparoscopic salpingotomy and monitoring is incorrect. This would be appropriate if this patient had a past medical history of a condition affecting the contralateral tube or reducing her fertility, such as a previous salpingectomy or pelvic inflammatory disease. The reason for this is that this would preserve future fertility if desired. Since this patient has none of these present in her history, the most appropriate step would be a salpingectomy, as a salpingotomy may not entirely remove all the tissue and further treatment with additional methotrexate may be necessary.

Methotrexate and monitoring is incorrect. This would be appropriate if the patient had no significant pain, the size of the ectopic pregnancy was <35 mm, the beta-hCG was less than 1500 IU/L, and no foetal heartbeat was present. Except for the absence of a foetal heartbeat, these do not apply to this patient, therefore making medical management with methotrexate inappropriate.

Vaginal misoprostol and monitoring is incorrect. This is used in the medical management of a miscarriage. Misoprostol is used to expedite the miscarriage. Misoprostol plays no role in the management of an ectopic pregnancy as the pregnancy tissue is not present in the uterus.

Question 23

A 34-year-old woman presents to the emergency department with some spotting and occasional very mild abdominal discomfort which started this morning. She had one of her ovaries removed 3 years ago due to ovarian torsion and she found the post-op recovery very unpleasant.

Her observations are:
Heart rate 87/min.
Respiratory rate 16/min.
Blood pressure 102/79mmHg.

Her transvaginal ultrasound showed free fluid in the uterus and a pregnancy in the right ovarian duct of 30mm in size and no visible heartbeat. The β-hCG is 1,100iu/L. She is willing to attend follow-up if needed.

What is the next most appropriate step?

Perform surgical salpingectomy
Perform surgical salpingotomy
Prescribe methotrexate
Prescribe mifepristone
Prescribe ulipristal

Answer 23

Prescribe methotrexate

Methotrexate is the drug of choice for medical management of ectopic pregnancy

Prescribe methotrexate is the correct answer. This patient has presented with an ectopic pregnancy that has been confirmed on transvaginal ultrasound, with very mild abdominal discomfort and spotting. According to RCOG, she is a good candidate for medical management as she has minimal symptoms, unruptured confirmed ectopic pregnancy, and a serum β-hCG of less than 1,500iu/L, she is haemodynamically stable and is also willing to come back for a follow-up to check if another methotrexate dose is needed.

Since the patient found the post-op recovery of her previous surgery unpleasant it would be sensible to avoid surgery at the moment. Methotrexate 50mg is the recommended medication for medical management of ectopic pregnancy.

Perform surgical salpingectomy is incorrect. Since the patient found the post-op recovery of her previous surgery unpleasant it would be sensible to avoid surgery at the moment for her ectopic pregnancy. It would also not be indicated as she has a past medical history of removal of one of her ovaries.

Perform surgical salpingotomy is incorrect. This patient has presented with an ectopic pregnancy. It would be preferred to a salpingectomy as she has a past medical history of removal of one of her ovaries, however, since the patient found the post-op recovery of her previous surgery unpleasant it would be sensible to avoid surgery at the moment.

Prescribe mifepristone is incorrect. This patient has presented with an ectopic pregnancy. According to RCOG, she is a good candidate for medical management as she has minimal symptoms, unruptured confirmed ectopic pregnancy, and a serum β-hCG of less than 1,500iu/L, she is haemodynamically stable and is also willing to come back for follow-up to check if another methotrexate dose is needed. Mifepristone is used for termination of pregnancy as it relaxes the cervix, sensitises myometrium to prostaglandins and stops pregnancy but is not part of the RCOG guidelines for ectopic pregnancy. Methotrexate is the medication of choice.

Prescribe ulipristal is incorrect. This patient has presented with an ectopic pregnancy. According to RCOG, she is a good candidate for medical management. She has minimal symptoms, unruptured confirmed ectopic pregnancy, and a serum β-hCG of less than 1,500iu/L but can be higher than that, she is haemodynamically stable and is also willing to come back for follow-up to check if another methotrexate dose is needed. Ulipristal is used for emergency contraception and is not indicated in this case. Methotrexate would be the first line in this case.

Question 24

A 32-year-old nulliparous woman presents to the emergency department with a 6-hour history of diarrhoea, mild abdominal discomfort, and a positive home pregnancy test.

Her last menstrual period was 8 weeks ago and she takes no regular contraception. She has a past medical history of pelvic inflammatory disease.

Transvaginal ultrasound reveals a 40mm foetal sac at the ampulla of the fallopian tube with no visible heartbeat, and serum B-HCG is 1200IU/L.

Given this information, what is the definitive indication for surgical management in this patient?

Foetal heartbeat not detected
Foetal sac size
History of pelvic inflammatory disease
Septate uterus
Serum HCG concentration

Answer 24

Foetal sac size

All ectopic pregnancies >35 mm in size or with a serum B-hCG >5,000IU/L should be managed surgically

The correct answer is 40mm foetal sac, as according to NICE guidelines on the management of ectopic pregnancy, foetal sacs larger than 35mm require surgical management. Large foetal sacs >35mm are at higher risk of spontaneous rupture, and as such these patients are unsuitable for expectant or medical management. The diameter of the foetal sac is measured by transvaginal ultrasound.

Foetal heartbeat not detected is incorrect, as this would support medical or expectant management. If a foetal heartbeat is detected on transvaginal ultrasound urgent surgical management.

History of pelvic inflammatory disease is incorrect, as this is not an indication for surgical management of ectopic pregnancy. Pelvic inflammatory disease is a risk factor for ectopic pregnancy, and salpingotomy may be carried out rather than salpingectomy to preserve fertility, though this is not an indicator for surgical management.

Serum HCG of 1200IU/L is incorrect, as this alone is not an indication for surgical management. NICE guidelines on the management of ectopic pregnancy state that serum HCGs between 1,500IU/L and 5,000IU/L may be managed medically, as long as the patient is able to return for follow-up and has no significant abdominal pain or haemodynamic instability.

Septate uterus is incorrect, as this is not an indication for surgical management of ectopic pregnancy. Septate uterus refers to a congenital abnormality in which a longitudinal septum divides the uterine cavity, and is thought to increase the risk of miscarriage rather than ectopic pregnancy.