Bleeding and pain in early pregnancy — KFP-style written assessment

KFP 1 (10 marks)

A 31-year-old woman presents with six weeks amenorrhoea and right iliac fossa discomfort. Urinary hCG positive; serum hCG 1400 IU/L. TVS: empty uterus, no adnexal mass, no free fluid. She is haemodynamically stable. ^[2]

1. Label her situation using correct terminology. (2) ^[2]
2. Outline the next 48 hours. (3) ^[2]
3. Her repeat hCG rises to 2100 IU/L at 48 hours; rescan still shows empty uterus. What now? (3) ^[1]
4. Which single factor most predicts failure of conservative management? (2) ^[2]

Model answers

1. Pregnancy of unknown location (PUL) — a positive pregnancy test without ultrasound confirmation of location. ^[2]
2. Serial hCG at 48 hours plus repeat transvaginal scan; safety-net for sudden pain, bleeding or shoulder tip; early pregnancy unit contact numbers. A viable intrauterine pregnancy usually shows roughly a doubling by 48 hours. ^[2]
3. An empty uterus above the discriminatory zone (~1500–2000 IU/L) is treated as ectopic until proven otherwise — same-day gynaecology review for medical management criteria (methotrexate) if unruptured, stable, no cardiac activity, mass below 3.5 cm. ^[1][2]
4. Initial serum beta-hCG level — in the placebo-controlled trial it was the only covariate significantly associated with outcome. ^[2]