1. 16 y/o female with no PMH presents to the ED with sharp abd pain and vaginal bleeding for the past 12 hrs. The patient believes her LMP was approximately 8 wks ago, is sexually active and uses protection inconsistently. What combination of diagnostic tests will permit a definitive diagnosis is most cases?

2. A. TVUS & serum hCG B. TVUS & urine hCG C. TAUS & serum hCG D. Serum hCG & progesterone

4. Classic triad of symptoms – 1 Abd pain (99%) Amenorrhea (74%) Vaginal bleeding (56%) TVUS is most useful test for location identification If nondiagnostic, may be too early -> follow serial hCG hCG doubles every 1.4-2 days until 6-7 wks hCG detected in urine and serum as early as 8 days Serum hCG levels of >1500 IU/L should show intrauterine sac detected on TVUS but require >6000 IU/L if TAUS (C) hCG>1500 + no intrauterine sac = ectopic pregnancy 2 (D) Progesterone higher in viable preg, only 75% sensitive, variable predictive value

5. 14 y/o female presents with LLQ abd pain, vaginal bleeding, and a positive pregnancy test to the ED. Her vital signs are stable and you confirm your diagnosis by TVUS and serum hGC. Indications for surgical treatment include all of the following EXCEPT:

6. A. Impending or ongoing mass rupture B. Hemodynamic stability C. Non-compliance with medical therapy post-tx f/u D. Failed medical therapy

8. Virtually all women undergo medical or surgical treatment due to the high morbidity/mortality of rupture 3 2 options shown to be equally comparable Laparoscopic salpingostomy Systemic methotrexate Expectant management is significantly less successful than surgery or medical management

9. References 1 Interventions for Tubal Ectopic Pregnancy. Petra J Hajenius, Femke Mol, Ben Willem J Mol, Patrick MM Bossuyt, Willem M Ankum and Fulco Van der Veen. January 2009 2 UpToDate – Clinical manifestations, diagnosis, and management of ectopic pregnancy 3 Does this woman have an ectopic pregnancy? The rational clinical examination systematic review. Crochet JR, Bastian LA, Chireau MV.JAMA. 2013 Apr 24;309(16):1722-9.