A 38-year-old woman comes to the emergency department for lower abdominal pain. The patient has had some mild, cramping abdominal pain for the past few days, but today it became constant. She has also had intermittent vaginal bleeding. The patient has a history of irregular menses, and her last menstrual period was 8 weeks ago. Physical examination shows a left adnexal mass. The patient undergoes surgery and the resected specimen is shown in the image below: Which of the following risk factors is most strongly associated with this patient's condition?

Question

A 38-year-old woman comes to the emergency department for lower abdominal pain.  The patient has had some mild, cramping abdominal pain for the past few days, but today it became constant.  She has also had intermittent vaginal bleeding.  The patient has a history of irregular menses, and her last menstrual period was 8 weeks ago.  Physical examination shows a left adnexal mass.  The patient undergoes surgery and the resected specimen is shown in the image below:  Which of the following risk factors is most strongly associated with this patient's condition?

Quizplus · Accepted Answer

11ec160b_391c_e982_9249_e51d5bfdeb52_MD0001_00 This patient with lower abdominal cramping, vaginal bleeding, and a palpable adnexal mass has an ectopic pregnancy (ie, embryo implantation in an extrauterine location [most commonly the fallopian tube]). The surgical specimen above reveals products of conception (eg, embryo) surrounded by the fallopian tube wall, which is grossly intact but edematous with evidence of hemorrhage (ie, blood clots) due to tubal injury. The fallopian tube, specifically the ampulla, is the most common site of ectopic pregnancy due to high rates of tubal scarring among reproductive-aged women. Tubal scarring impedes the migration of the embryo past the abnormally scarred segment and promotes tubal rather than uterine implantation. Risk factors associated with tubal scarring include prior ectopic pregnancy, pelvic inflammatory disease, and prior pelvic surgery (eg, tubal ligation). Other risk factors for ectopic pregnancy include tobacco use (due to decreased tubal motility) and in vitro fertilization. (Choice A) Family history of ovarian cancer due to an inherited mutation (eg, BRCA) can increase the risk of ovarian cancer but does not affect the risk of ectopic pregnancy. (Choice B) Müllerian anomalies typically cause agenesis or hypoplasia of the fallopian tubes, uterus, cervix, or vagina. Therefore, patients are at increased risk for infertility and spontaneous abortion rather than ectopic pregnancy. (Choice D) Progestin-only oral contraceptives decrease, not increase, the risk for ectopic pregnancy by preventing ovulation and thickening the cervical mucus to prevent sperm entry. (Choice E) Recent anticoagulant use is a risk factor for hemorrhagic ovarian cysts, which develop due to bleeding into a physiologic ovarian cyst and can cause severe abdominal pain with cyst rupture. Hemorrhagic cysts are typically thin-walled and filled with blood or clot; there are no associated products of conception. Educational objective: Ectopic pregnancy occurs when the embryo implants in an extrauterine location, most commonly the fallopian tube. Risk factors for ectopic pregnancy include tubal scarring (eg, prior pelvic surgery, pelvic inflammatory disease), tobacco use, and in vitro fertilization. __________ References: Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review. (http://www.ncbi.nlm.nih.gov/pubmed/28620520)

A 38-Year-Old Woman Comes to the Emergency Department for Lower