A 31-year-old woman conceived by IVF presents at 7 weeks with mild right iliac fossa pain. Transvaginal ultrasound shows a live intrauterine gestational sac with yolk sac, and separately a 2 cm right adnexal ring with free fluid in the pouch of Douglas. Serum beta-hCG is 18,000 mIU/mL. What is the appropriate next step?
- A Reassure and repeat ultrasound in 2 weeks, attributing pain to ovarian hyperstimulation
- B Suction evacuation of the intrauterine pregnancy
- C Surgical management of the adnexal mass, preferably laparoscopic salpingectomy ✓
- D Intramuscular methotrexate 50 mg/m2 single dose
Correct answer: C. Surgical management of the adnexal mass, preferably laparoscopic salpingectomy
Explanation
This is a heterotopic pregnancy, an intrauterine and extrauterine gestation coexisting. Its incidence rises from roughly 1 in 30,000 spontaneous conceptions to about 1 in 100 after assisted reproduction, so a demonstrated intrauterine sac never excludes an ectopic in an ART patient. With haemoperitoneum and an adnexal ring, surgical removal of the ectopic while conserving the intrauterine pregnancy is indicated. Methotrexate is absolutely contraindicated because it is embryotoxic to the viable intrauterine gestation.
Reference: Williams Obstetrics, 26th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.