Station 1
Student Information
Mrs. XX is 33 years working at night club, G7P2+4, two of them were
ectopic pregnancies, and her both deliveries were surgical with an intra
uterine contraceptive device for the last 2 years. She is known to have
regular menstrual cycles, underwent a successful trial of In Vitro
fertilization. She presented to the emergency department with pain,
dizziness, heavy creamy vaginal discharge and vaginal spotting for the
last few hours. Vaginal ultrasound evaluation revealed marked
endometrial thickness with no definite intra uterine gestational sac. The
pregnancy hormone e is 647 m IU/ml.
The examiner will ask you sequent related questions about this
lady:
• What is the most likely diagnosis?
• Assume she diagnosed to have ectopic pregnancy. Mention the
risk factors in this lady to develop such condition.
• Mention the pathophysiology for this ectopic pregnancy condition.
• What are the main differential diagnosis?
• Mention the main lines of management for this lady and their
applications.
Station 1 Examiner information
What is the most likely diagnosis?
Ectopic Pregnancy: 1 marks [ ]
Assume she diagnosed to have ectopic pregnancy. Mention the risk factors in this lady
to develop such condition. Risk factors 5 marks (ANY 5)
1-previous history of ectopic pregnancy. The biggest R
• Damaged fallopian tube. 2- PID (STD) and infection (TB): most common cause in [ ]
developed countries. Due to -intratubal or peritubal
• Smoking adhesions -infection may destroy the cilia this will
suppress migration 3-previous tubal surgeries ex: tubal
[ ]
ligation 4-use of ART ex: IVF 5-use of contraceptive
• History of pelvic surgery. methods:POP,IUCD (m.c in developing countries [ ]
6- smoking
• History of ectopic pregnancy. 7-exposure to DES 8-congenital malformation of the [ ]
uterus
• Infertility treatments such as IVF, Use of fertility drugs. [ ]
• Having intra uterine contraceptive device. [ ]
Mention the pathophysiology for this ectopic pregnancy condition. 4 marks
• Damage of the tubal cilia by infection, →egg transport becomes disrupted. [ ]
• Formation of pocket like pools that engulf the fertilized eggs. [ ]
• Infection-related scarring and partial blockage of the Fallopian tubes. [ ]
• Bleeding-related scarring and partial blockage of the Fallopian tubes. [ ]
What are the main differential diagnosis? 6 marks
• Appendicitis. DDx for ectopic pregnancy: [ ]
A-normal IUP
• Salpingitis. B-spontaneous abortion C- [ ]
molar pregnancy , both b+c
• Ruptured corpus luteum cyst or ovarian follicle. have bleeding D-Ovarian [ ]
portion/ruptured ovarian cyst E-
• Spontaneous abortion or threatened abortion. PID/ acute appendicitis/ tube- [ ]
ovary abscess F-degenerating
• Ovarian torsion. fibroid , (D,E&F has abdominal [ ]
pain)
• Urinary tract disease. [ ]
Mention the main lines of management for this lady and their applications. 4 marks
• Observation; resolve on their own without the need for any intervention. [ ]
• Laparoscopy; for diagnosis and management. [ ]
• Laparotomy; urgent surgery if life-threatening bleeding happened. [ ]
• Medication (methotrexate); low hormonal level, stable condition. [ ]
TOTAL MARK: ………… EXAMINER NAME/SIGNATURE …………………….
Station # 4
Examiner information
The emergency department calls you to assess a 32
year old woman who presents with left lower quadrant
pain, some vaginal spotting and a positive pregnancy
test.
1. You agree to come and evaluate the patient. What
question would you ask before coming?
2. The patient is in no apparent distress and you
proceed with a history and physical exam. What
questions you want to ask and what relevant
physical examination you want to perform.
Name:________________________________________
Station # 4
Examiner information
The emergency department calls you to assess a 32 year old woman who
presents with left lower quadrant pain, some vaginal spotting and a
positive pregnancy test.
1. You agree to come and evaluate the patient. What question would you ask before
coming?
Is the patient hemodynamically stable? /1
2. The patient is in no apparent distress and you proceed with a history and physical
exam.
History:
G? P? A? 1 Tried of
LNMP 1 -Amenorrhea
-Abdominal pain: usually acute pain,
Pain 4 pelvic or lower abdominal pain radiating
- onset to the shoulder-ipsilateral (suspected
rupture).
- quality
-Vaginal bleeding: spotting, if ruptured
- duration then it’s intraperitoneal bleeding.
- relieving/aggravating factors
- associated back/ shoulder tip pain
Bleeding 2
– quantity
- passed tissue
Past history 4
menstrual hx
PMHx
PSurgHx
Meds
Allergies
Past Gyne Hx
Past OB Hx
Risk Factors 4
- IUD
- tubal OR
- abdominal OR
- STDs/PID
- previous ectopic
What relevant Physical Exam you want to perform 3
Vital Signs U/s , hemodynamic stability Abdominal
Abdo exam exam Bimanual exam /pv -palpate adrexial
Pelvic exam mass
-cervical tenderness
Total mark /20 Examiner:
bimanual exam is performed with two hands. The doctor
uses this two-handed exam to check the size and location of
a woman's pelvic organs (such as the uterus and ovaries).
This exam is routine in women's health care (gynaecology).
In urology, it is used to diagnose problems related to
urination, including cancer.
Station 5
Student Information
Mrs. Nabila is 32 years old married for the last 10 years,
تنسي% سؤال
Gravida 3, Para 0 + 2 ectopic, her LMP was on 15/7/2016. She
is working at coffee shop, known to have regular cycles every
28 days, presented to emergency room with nausea, abdominal
pain, vaginal spotting. Her ultrasound evaluation revealed thick
endometrium, left adnexal mass, with B-hCG of 871 IU/ml.
please discuss her condition with the examiner in sequence.
1. What are the most likely diagnosis and its incidence?
2. Mention 6 risk factors in this lady to develop ectopic
pregnancy?
3. Mention the signs that may suggest ruptured fallopian tube
ectopic.
4. Mention the lines of therapy with its indications.
Station 5
Examiner information
1. The most likely diagnosis is ectopic pregnancy: 1 mark
its incidence is 2%. : 1 mark
2. 6 risk factors in this lady to develop ectopic pregnancy: 6 marks
- Damaged fallopian tubes.
- History of pelvic inflammatory disease.
- Sexually-transmitted diseases.
- History of pelvic surgery.
- History of ectopic pregnancy.
- Use of fertility drugs.
- Smoking.
3. Signs that may suggest ruptured fallopian tube ectopic. 4 marks
- Sudden, severe, sharp pain,
- Feeling faint and dizzy,
- Hemorrhagic shock,
- Diarrhea.
- Shoulder tip pain
4. Mention the treatment options and their applications: 8 marks
A-expectant (observation) If stable, no significant bleeding, no significant pain, no rupture,
falling of HCG, ectopic in tube, size <4cm
• Observation; Stable vital signs, acceptable pain levels, β-hCG titers below 1000
mIU/mL
• Laparoscopy; for diagnosis and management;salpingictomy versus salpingistomy.
• Laparotomy; urgent surgery due to life-threatening bleeding.
• Medication; no fetal cardiac activity, β-hCG level less than 5000 mIU/mL, The
size of the GS should not exceed 4cm.
