Confirmed tubal ectopic — structured oral station (12 minutes)

Opening prompt — "What does this scan show, and how certain are you?"

Model response — give the label, the certainty and the one qualifier. ^[1]

• "This is a tubal ectopic pregnancy — diagnostic, not just probable, because there is an adnexal mass moving separately from the ovary that contains a yolk sac. A yolk sac, pole or heartbeat outside the uterus makes it diagnostic."^[1]
• "She is stable, the mass is small and her hCG is moderate, so I have time to be systematic rather than to rush her to theatre."^[1]
• "I would confirm her baseline bloods — full blood count, renal and liver function, group and antibody screen — and assess her for methotrexate, because in this stable woman medical management is my first choice."^[1]

Examiner is listening for: the diagnostic (not merely probable) certainty, recognition that stability buys time, and a named plan rather than a list of possibilities. ^[1]

Probe 1 — "Why methotrexate rather than surgery?"

• "She is haemodynamically stable, the ectopic is unruptured, the mass is small at 2.2 cm and her hCG is moderate. Those are the features that favour medical management."^[1][2]
• "The dominant predictor of methotrexate failure is a high presenting hCG, followed by cardiac activity and mass size. At 1800 IU/L with a small mass her chance of success is high — in the Lipscomb series single-dose methotrexate succeeded in about 90% overall."^[4][3]
• "I would exclude the contraindications first: renal or hepatic impairment, cytopenia, active peptic ulcer, pulmonary disease, breastfeeding, and any reason she could not return for follow-up."^[1]

Probe 2 — "Walk me through the protocol."

• "Single dose: methotrexate 50 mg per metre squared intramuscularly, with the day of injection as day 1. Then serum hCG on days 1, 4 and 7, and weekly after that until the hCG is negative."^[1][3][8]
• "The decision is between day 4 and day 7. A fall of 15% or more over those three days means it is working — continue weekly. Less than 15% means reassess, and usually a second dose, with another hCG on day 7 after that dose."^[1][7][8]
• "A rise between day 1 and day 4 is common and does not by itself mean failure — the comparison that matters is day 4 to day 7."^[1]

Probe 3 — "Day 7 her hCG has fallen only 9% from day 4. She has new right-sided pain. What now?"

• "Two red flags at once: an inadequate response and new pain. I reassess her now — observations, abdomen for peritonism, repeat transvaginal ultrasound looking for increasing or echogenic free fluid, and I crossmatch and involve the consultant."^[1]
• "If she is stable and the scan shows no rupture, a second dose of methotrexate is reasonable. If she becomes unstable, or the scan shows rupture, she goes to theatre — laparoscopic salpingotomy if she wants the tube spared and it is feasible, salpingectomy if the tube is badly damaged or she is unstable."^[1][5]
• "I would not keep observing a woman with new pain and a failing methotrexate course, because the failure mode is rupture."^[1]

Probe 4 — "She asks you to explain it to her. She is frightened of the injection and of losing the pregnancy."

This is a scored domain. Demonstrate it in plain words. ^[1][6]

• Sit down and use her name. "I know this is not the news you came for. Let me explain exactly what we have found and what I am recommending."
• "The pregnancy is growing in your fallopian tube rather than in your womb, and a tube cannot safely hold a pregnancy. It would eventually rupture and cause dangerous bleeding, so we treat it rather than wait."
• "A single injection of a medicine called methotrexate stops the pregnancy cells growing, and your body then absorbs them over a few weeks. Most women in your situation do not need an operation. You will need blood tests on day 4 and day 7 to check it is working, and weekly after that until the hormone is gone."
• "You can call the unit at any time, and I want you to come straight back if you get new or one-sided pain, shoulder-tip pain, dizziness or heavy bleeding."
• Acknowledge the loss and offer written information and support. Around three in ten women (29%) met post-traumatic stress criteria one month after an early pregnancy loss, and how this conversation goes is part of preventing that.^[6]

Examiner is listening for: plain language, no jargon, a concrete monitoring plan, explicit safety-netting, and an offer of support without being asked. ^[6]

Probe 5 — "She asks whether she will be able to have a baby afterwards."

• "Yes, in most cases. After an ectopic the chance of a future intrauterine pregnancy is good. If she needed surgery, the ESEP trial showed similar future pregnancy rates whether the tube is removed or preserved, provided the other tube is healthy."^[5]
• "Her risk of another ectopic is substantially raised, so in her next pregnancy I would offer her an early scan to locate the pregnancy early."^[1]
• "After methotrexate she should delay attempts to conceive for 3 months — the guideline washout period, while the manufacturer advises 6 months."^[7][9]

Probe 6 — "Your colleague says methotrexate is being overused and ruptures are missed. Is that fair?"

• "It is a fair caution. The modern pitfall is not failing to find an ectopic — it is treating a pregnancy that was never properly located, or a woman who could not comply with monitoring. Methotrexate given to a wanted intrauterine pregnancy terminates it."^[1]
• "So the safeguards are: confirm the diagnosis on ultrasound, exclude contraindications, ensure follow-up is booked before the dose is given, and safety-net for rupture even while the hCG is falling. Methotrexate is safe when it is protocolised; it is dangerous when it is casual."^[1]