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128 Obstetrics & Gynaecology

Questions

261. Which of the following regarding Ectopic pregnancy is /aretrue: (PGI 2004)

a. Occurs in about 10% of pregnanciesb. The risk is increased in those with a history of PIDc. Usually presents between 2 and 4 months of gestationd. Patients usually have a negative pregnancy teste. If patient is in shock, early laparotomy is essential

262. In a case of ectopic pregnancy, medical treatment is contraindic-ated if: (KAR 2005)

a. Sac size is 3.0 cmb. Serum HCG levels > 1500 miu / mlc. Significant hemoperitoneum is presentd. Absent fetal activity

263. In which of the following conditions the medical treatment ofEctopic Pregnancy is contraindicated? (AIIMS 2004 may)

a. Sac size is 3cmb. Blood in pelvis is 70 mlc. Presence of fetal heart activityd. Previous ectopic pregnancy

264. Most common cause of ectopic pregnancy is: (AI 96)a. IUCDb. Previous tubal diseasec. Endometriosisd. Mini pills

265. Ectopic pregnancy is seen maximum with: (JIPMER 98)a. IUCDb. OC pillsc. Barrier methodd. Tubal insertion

Ectopic Pregnancy

128

Ectopic Pregnancy 129

266. Commonest cause of ectopic gestation: (Kerala 96)a. Previous salpingitisb. Dysfunction of ciliac. Uterine abnormalitiesd. Delayed fertilization of ovume. Hydrosalphynx

267. Which one of the following drug is not used for medical managem-ent of ectopic pregnancy? (AIIMS 2003)

a. Kclb. Methotrexatec. Actinomycin Dd. Misoprostol

268. Medical treatment of ectopic pregnancy is: (AIIMS 96)a. Methotrexateb. Progesteronec. Oestrogend. Adriamycin

269. Medical treatment of ectopic pregnancy includes all of thefollowing drugs except: (Kar 94)

a. Prostaglandinsb. Methotrexatec. RU 486d. Dexamethasone

270. The following drug is not useful in treatment of ectopic pregnancy:(AI 2005)

a. Methotrexateb. Misoprostolc. Actinomycin-Dd. RU-486

271. Diagnostic criteria for primary abdominal pregnancy: (Orissa 99)a. Spigelberg criteriab. Rubin’s criteriac. Studdiford criteriad. Wrigly criteria

272. Rupture of ampullary ectopic pregnancy occurs during: (AP 99)a. 8 weeksb. 12 weeksc. 16 weeksd. 20 weeks


273. Ectopic pregnancy is more common in: (PGI 90)a. Tuboplastyb. Endometriosisc. CuT usersd. All of the above

274. The commonest site of ectopic gestation: (TN 2006)a. Ovaryb. Broad ligamentc. Fallopian tubed. All of the above

275. Which is the normal site of fertilization?a. Infundibulumb. Isthmusc. Ampullad. Cornu

276. In which part of fallopian tube does ectopic pregnancy occursmost frequently: (Kar 93)

a. Ampullab. Isthmusc. Fimbriad. Cornu

277. The hormone responsible for the decidual and Arias Stellareaction of the ectopic pregnancy: (Kerala 2001)

a. HCGb. Progesteronec. Estrogend. HPL

278. Most common cause of ectopic pregnancy is: (AIIMS 96)a. Progestasertb. Cu-Tc. OC pillsd. Minipill

279. Third generation oral contraceptive pills containing norgestreland gestodene along with estrogens: (DNB 2006)

a. Are more lipid friendlyb. Decrease the risk of venous thromboembolismc. Increase the risk of break through bleedingd. Are not used for emergency contraception


280. Which one of the following hormonal contraceptives CANNOT beused during lactation?

a. Mini-pillb. Norplantc. DMPAd. Combined oral contraceptives

281. Match List I (Type of Pill) with List II (Effect) and select the correctanswer using the codes given below the Lists:

List I List IIA. Triphasic 1. Prevention of ovarian tumorsB. DMPA 2. Good for women having hypomenorrhoeaC. Biphasic pill 3. Amenorrhoea is commonD. Progestin 4. Beneficial effect on HDLcontaining IUD

5. Chance of ectopic pregnancy

Codes:a. A B C D

4 3 1 5b. A B C D

4 1 3 5c. A B C D

5 4 2 1d. A B C D

5 3 4 2

282. A primipara with a cardiac lesion (MI) has come on the 40th day ofdelivery asking for contraception. The contraceptive of choice is

a. Condom with spermicidal jellyb. Oral contraceptive pillc. Intrauterine contraceptive deviced. Laparoscopic sterilization

283. Which one of the following intrauterine contraceptive deviceshas the lowest pregnancy rate?

a. Lippes loopb. Cu-7c. Cu T-200d. Levonorgestrel IUD

284. Which one of the following is the most common problemassociated with the use of condom?

a. Increased monilial infection of vaginab. Premature ejaculationc. Contact dermatitisd. Retention of urine


Answers261. Ans. b and e

Ectopic pregnancyOccur in about 1% of pregnanciesIt usually presents at between 6 and 8 weeks gestation A sensitivebeta-HCG test is usually positiveOccurs in 1% of pregnanciesMortality is less than 1%Commonest site is in the tubal ampullaUsually presents at 6-8 weeks amenorrhoeaClinical presentation:o Clinically patient has lower abdominal pain and slight vaginal

bleedingo Cardiovascular collapse and shoulder tip pain suggest large

intraperitoneal bleedo Examination will often shown abdominal and adnexal tendernessManagement:o Patient invariably has positive urinary pregnancy testo In cases of doubt sensitive serum beta-HCG is helpfulo Ultrasound shows empty uterus and may identify ectopico An intrauterine pregnancy on USG almost invariably excludes an

ectopico If no evidence of cardiovascular compromise laparoscopy is

investigation of choiceo If patient is shocked immediate laparotomy is essentialo Fetus can then be removed by salpingotomy or salpingectomy

262. Ans. c (Significant hemoperitoneum is present)(Ref. Textbook of obstetrics D C Dutta 6th ed. 191)EXPECTANT MANAGEMENT of ECTOPIC PREGNANCYPregnancy of unknown location• Serum HCG levels are below the discriminatory zone (level at

which it is assumed that a viable intra-uterine pregnancy wouldbe visualised on trans-vaginal scan: 1000 – 2000 iu/l)

• If no pregnancy is detectable on scan, the pregnancy is of unknownlocation

• Discriminatory zone dependent on quality of ultrasoundequipment, experience of the sonographer, prior knowledge ofthe woman’s risks and symptoms and the presence of factorssuch as fibroids and multiple pregnancy

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132


• Women with minimal / no symptoms can be managed expectantlywith 48-72h follow-up and active management if symptomatic,HCG levels rise above discriminatory zone or levels plateau

• Intervention may be required in 23-29% of cases• Monitor serum HCG until below 20iu/l• Provide clear written information on the importance of compliance

with follow-up and should have easy access to the hospitalExpectant management - Ectopic pregnancyCriteria• Asymptomatic and haemodynamically stable• HCG low and falling (<1000iu/l)• < 100ml blood in pouch of Douglas• gestation sac < 5cm with no FH on scan• Low and rapidly falling HCG levels indicate high likelihood of

successful expectant management• Perform twice weekly serum HCG levels and weekly transvaginal

scans to ensure levels falling rapidly and size of ectopic massdecreasing. Thereafter, weekly HCG and scans until HCG <20iu/l

• Provide clear written information on the importance of compliancewith follow-up and should have easy access to the hospital

• Rupture may still occur under these circumstances.

263. Ans: b (Blood in pelvis is 70 ml)(Ref. Textbook of obstetrics D C Dutta 6th ed. 191)MANAGEMENT OF TUBAL PREGNANCYLaparotomy Viz LaparoscopyIn a haemodynamically stable woman, laparoscopy is preferableto laparotomy.Laparoscopy associated with:• Lower blood loss• Lower analgesic requirement• Shorter hospital stay• Quicker post-op recovery• Lower cost• No significant difference in subsequent intra-uterine pregnancy

rates• A trend towards a lower repeat ectopic pregnancy rate• Higher rate of persistent trophoblastic tissue (12.2% v 1.7%) if

salpingotomy performed• Lower risk of adhesion formation

IF THE WOMAN IS HAEMODYNAMICALLY UNSTABLE• Management should be by the most expedient method and in

most cases, this would be by laparotomy


SALPINGECTOMY Vs SALPINGOTOMY• Both tubes present – there does not appear to be a difference in

subsequent intra-uterine pregnancy rate (46 v 44%)• Recurrent ectopic pregnancy rate appears to be higher after

salpingotomy although data are conflicting• Risk of persistent trophoblastic tissue higher after salpingotomy

– monitor HCG levels; risk of tubal bleeding in the immediatepost-op period. These risks should be discussed and documen-ted if salpingotomy is being considered or is requested

• In women with one tube only or contra-lateral tubal disease –tubal conservation associated with a 54% intra-uterine pregnancyrate but a 20.5% recurrent ectopic pregnancy rate – appropriatepre-op counselling required. This is however, cost effective whenthe requirement for IVF is considered.

264. Ans. b (Previous tubal disease)(Ref. Textbook of obstetrics D C Dutta 6th ed. 191)Risk factors for ectopic pregnancy include:1.Previous PID2. Infertility3.Tubal surgery4. Intrauterine contraceptive device5.Previous ectopic6.PID increases risk of ectopic seven fold

265. Ans. a (IUCD)(Ref. Textbook of obstetrics D C Dutta 6th ed. 191)Risk factors for ectopic pregnancy include:1.Previous PID2. Infertility3.Tubal surgery4. Intrauterine contraceptive device (maximum risk)5.Previous ectopic6.PID increases risk of ectopic seven fold

266. Ans. a (Previous salpingitis)(Ref. Textbook of obstetrics D C Dutta 6th ed. 191)Ectopic Pregnancy• Incidence in UK 11.1 per 1000 pregnancies• Account for ~10% of all direct maternal deaths• Caused 13 maternal deaths in 1997-99• Mortality has decreased 4 –fold in the last 20 years• Diagnostic laparoscopy has a false positive rate of 5% and a

false negative rate of 3-4%• There is some debate on the level of HCG at which a viable intra-

uterine gestation sac should be detectable on trans-vaginalultrasound scan but most would accept a level of >1500miu/l


• A rise in serum HCG of <50% in 48h is almost always associatedwith a non-viable pregnancy, ectopic or otherwise

RISK FACTORS• PID• IUCD• Sterilisation• Tubal surgery• Previous ectopic• Assisted reproduction• Mini-pill• All current contraceptive users, including IUCD are less likely to

have an ectopic pregnancy than sexually active women not usingcontraception

• IUCD users (except MIRENA) are 3 times more likely to have anectopic pregnancy than users of other contraceptives

• Use of depot medroxyprogesterone acetate is associated with alower risk of ectopic pregnancy than the mini-pill but higher thanthe Combined OC Pills.

267. Ans. c (Actinomycin D)(Ref. Textbook of obstetrics D C Dutta 6th ed. 202)MEDICAL TREATMENT• This should be offered to suitable women and units should have

treatment and follow-up protocolsCriteria for medical treatment1) Ectopic mass <3.5cm – the presence of fetal cardiac activity is a

contra-indication to medical treatment2) No fetal cardiac activity3) Initial HCG <3000iu/l• Success rates of 85-94% following single dose treatment – less

expensive, fewer side-effects, requires less intensive monitoringand does not require folinic acid supplementation when compar-ed to multiple dose regimens

• Increase in abdominal pain is reported by 59% of women followingmethotrexate administration

• A transient increase in beta-HCG may occur in up to 86% ofwomen between days 1 and 4 of treatment. Serum beta-HCGshould be measured on days 4 and 7. A further dose ofmethotrexate should be considered if HCG levels fall by lessthan 15% between days 4 and 7.

• If medical treatment is offered, women should be given clearwritten information about the possible need for further treatmentand potential complications. Women should be able to returneasily for assessment at any time during follow-up

• 7% of women experience tubal rupture during follow-up


• About 75% of women will experience abdominal pain followingtreatment

• Women should be advised to avoid sexual intercourse duringtreatment, maintain ample fluid intake and use reliablecontraception for 3 months after treatment because of the possibleteratogenic effects of methotrexate

• Ipsilateral tubal patency rates following treatment are ~80%• Among women trying to become pregnant, intra-uterine pregnancy

rate = 54% and recurrent ectopic rates = 8-10% - comparable tothose following laparoscopic salpingostomy

• Intra-muscular methotrexate (50mg/square m)COMPLICATIONS:• Stomatitis, alopecia, hematosalpinx, neutropenia, pneumonitis,

multiple ovarian cysts, failed therapy.

268. Ans. a (Methotrexate)(Ref. Textbook of obstetrics D C Dutta 6th ed. 202)Treatment of ectopic pregnancyMedical management includes use of:1.KCL,2.Anti-HCG abs,3.Ru486 and4.Methotrexate.Criteria for medical management-1. Sac size < 3.5cm2. Stable patient3. No jaundice4. HB > 10gm%Laparoscopic management is the preferred treatment option in allbut the haemodynamically compromised or in those with a largeectopic pregnancy (e.g., >5).Conversation of the tube by linear salpingostomy using unipolarneedlepoint diathermy is effective, and the tube is left to closespontaneously.Salpingectomy can be carried out using a pre-tied loop or withexcision using coagulation diathermy or by laparotomy where, inaddition, the pregnancy may be milked through the fimbrial end ofthe tube.Non-surgical conservative technique is salphingcentsis whichinvolves injecting 50% dextrose or methotrexate in the saclaparoscopically. If the tube is conserved it is essential to ensurethat the hCG is falling; if not there is likely to be residual trophoblast.The hCG should fall to 25% of the pre-treatment level within 4 daysof surgery.


269. Ans. d (Dexamethasone)(Ref. Textbook of obstetrics D C Dutta 6th ed. 202)The drugs commonly used in management of ectopic pregnancyare: methotrexate, Kcl, PGs, hyperosmolar glucose, or Mifepristone(RU486). A single dose of methotrexate 50 mg/M2 is given intramusc-ularly.

270. Ans: c (Actinomycin-D)(Ref. Shaw’s textbook of Gynacology-13th Edn-275)Criteria for medical management of ectopic pregnancy:The gestational sac is not more than 3.5cm.Serum HCG level net > 10,000 mIU/ml.Fetal cardiac activity absent.Patient can be followed up.

Drugs used in treatment are:Methotrexate ± leucovorumProstaglandin F2 α (Misoprostol)RU 486RCIHyperosmolar glucose

271. Ans. c (Studdiford criteria)(Ref. Textbook of obstetrics D C Dutta 6th ed. 204)Criteria laid down by Studdiford to diagnose primary abdominalpregnancy are:1.Both tubes and ovaries are normal without evidence of recent

pregnancy.2.Absence of uteroperitoneal fistula3.Presence of pregnancy related exclusively to the peritoneal surface

and young enough to eliminate the possibility of secondaryimplantation following primary radiation in the tube.

272. Ans. b (12 weeks)(Ref. Textbook of obstetrics D C Dutta 6th ed. 194)Tubal rupture is predominantly common in isthmic and interstitialimplantation. Isthmic rupture usually occurs at 6-8weeks, theampullary one at 8-12weeks and the interstitial one at about 4months.

273. Ans. d (All of the above)(Ref. Textbook of obstetrics D C Dutta 6th ed. 191)Sites of Ectopic Pregnancy• 0.5% - ovarian• 0.1% intra-abdominal


Tubal Pregnancy• 2% cornual• 55% ampulla• 17% fimbrial end• 25% isthmus

274. Ans. c (Fallopian tube)(Ref. Textbook of obstetrics D C Dutta 6th ed. 191, flowchart)Sites of Ectopic Pregnancy• 0.5% - ovarian• 0.1% intra-abdominalTubal Pregnancy• 2% cornual• 55% ampulla• 17% fimbrial end• 25% isthmus

275. Ans. c (Ampulla)Usually fertilization occurs in AMPULLA.

276. Ans. a (Ampulla)(Ref. Textbook of obstetrics D C Dutta 6th ed. 191, flowchart)

277. Ans. a, b(Ref. Textbook of obstetrics D C Dutta 6th ed. 195)Arias Stella reaction is characterized by a typical adenomatouschange of endometrial glands. Intraluminal budding together witha typical cell changes (loss of polarity of cells, hyperchromatic nuclei,vacuolated cytoplasm and occasional mitosis) are collectively

Ectopic Pregnancy

� � �Cervical

Extrauterine Uterine �Angular

�Cornual

� � �

Tubal Ovarian Abdominal (Commonest 95%)

� � � � � �

Ampulla Isthmus Infundibulum Interstitial Primary Secondary(55%) (25%) (18%) (2%) (rare)

� �

Intraperitoneal Extraperitoneal(Broad ligament)(Rare)


referred as Arias Stella reaction. This is strikingly due to progesteroneinfluence.

278. Ans. a (Progestasert)(Ref. Textbook of obstetrics D C Dutta 6th ed. 191)The etiology of ectopic pregnancy include:Pelvic inflammatory diseaseIatrogenica.Contraceptive failure

IUCDUse of progestin only pillsSterilization operation

b.Tubal surgeryc. Intrapelvic adhesions

Previous ectopic pregnancyPrior induced abortionDevelopmental defects of the tubeDistortion of the tube (fibroid or broad ligament cyst)Trans-peritoneal migration of the ovumTubal spasmEarly resumption of trophoblastic activityIncreased decidual reactionTubal endometriosis

279. Ans: a (Are more lipid friendly)A new device levonova contains 60 mg of levonorgestrel andreleases hormone in very low doses (20 mg/ day). Incidences ofectopic pregnancies with its use is 6 fold higher in women whodo become pregnant as compared to failure amongst cu- T users.However they are more lipid friendly.

280. Ans: d (Combined oral contraceptives )

281. Ans: aBiphasic pill � Prevention of ovarian tumorsTriphasic � Beneficial effect on HDLDMPA � Amenorrhoea is commonProgestin containing IUD � Chance of ectopic pregnancy

282. Ans: a (Condom with spermicidal jelly)Condom with spermicidal jelly is best contraceptive measure for apostpartum female with heart disease.


283. Ans: d (Levonorgestrel IUD)Contraceptive failure:Cu T 380A and Levonorgestrel have got lowest rate, whereasprogestasert has got highest rate of ectopic pregnancy.——————————————————————————————Generation Coil Failure rate Lasts for (Years)——————————————————————————————First Cu7 (200) >2/100 3–5

CuT (200) >2/100Second Multiload Cu 250 1–2 /100 3–5

NovaT 1–2 /100 1–2/100Third Multiload Cu 375 0.5–1.1/100 5+

Cu 380 0.3–1/100Hormone Progestasert 1releasing LNG-IUCD 0.5/100 at 1 yr 5

(Levenorgestrel 0.7/100 at 3 yrImpregnated) 1/100 at 5 yr

——————————————————————————————

284. Ans: c (Contact dermatitis)Contact dermatitis is the most common problem associated withthe use of condom.

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