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Unruptured tubal ectopic pregnancy — MRCEM SBA MCQ

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HardObstetric and gynaecological emergenciesUnruptured tubal ectopic pregnancyMRCEM SBA

A 30-year-old woman at 9+2 weeks’ gestation attends the emergency department with mild left iliac fossa pain. Her pulse is 84/min and blood pressure 122/76 mmHg. Specialist transvaginal ultrasonography confirms an unruptured 38 mm left tubal ectopic pregnancy without a visible heartbeat or significant free fluid; there is no intrauterine pregnancy. Serum hCG is 3,800 IU/L. She is RhD negative and has no red-cell antibodies. A previous right salpingectomy left her without a contralateral tube. She wishes to preserve the possibility of natural conception and, after counselling, prefers tubal conservation if feasible. The gynaecology team considers laparoscopic salpingotomy technically feasible. Which treatment and follow-up plan is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Laparoscopic salpingotomy; omit anti-D; measure serum hCG on day 7 and weekly thereafter.

The confirmed tubal ectopic pregnancy measures 38 mm. NICE recommends surgery as first-line treatment when the adnexal mass is **35 mm or larger**, even if the patient is stable, has little pain and has an hCG below 5,000 IU/L. Her absent contralateral tube is a substantial fertility risk, so salpingotomy is an appropriate alternative to the usual salpingectomy, consistent with her informed preference. Following salpingotomy, persistent trophoblastic tissue remains possible: serum hCG should be measured at day 7 and then weekly until negative. Under NICE’s June 2026 update, anti-D is not offered for an ectopic pregnancy at or before 11+6 weeks, including when surgery is performed. ([nice.org.uk](https://www.nice.org.uk/guidance/NG126/chapter/management-of-tubal-ectopic-pregnancy)) **B** uses the usual operation and its appropriate follow-up, but removes her remaining tube despite feasible, preferred conservation. **C** is tempting because she is stable and her hCG is below 5,000 IU/L; the 38 mm mass nevertheless meets the first-line surgical criterion. **D** reflects the previous recommendation to give anti-D after surgical management, which the June 2026 update replaced for this gestation. **E** substitutes the three-week urine test advised after salpingectomy for the serial serum measurements required after salpingotomy. ([nice.org.uk](https://www.nice.org.uk/guidance/NG126/chapter/management-of-tubal-ectopic-pregnancy))

Reference: NICE NG126: Management of tubal ectopic pregnancy (17 June 2026) — https://www.nice.org.uk/guidance/NG126/chapter/management-of-tubal-ectopic-pregnancy NICE NG126: Resource impact statement, anti-D immunoglobulin prophylaxis update (June 2026 update) — https://www.nice.org.uk/guidance/ng126/resources/resource-impact-statement-pdf-8779033659589