ECTOPIC PREGNANCY Ectopic Pregnancy is gestation located outside the uterine cavity.

The fertilized ovumimplants outside the uterus, usually in the fallopian tube.Predisposing factors include adhesions of the tube, salpingitis, congenital anddevelopmental anomalies of the fallopian tube, previous ectopic pregnancy, use of anintrauterine device for more than 2 years, multiple induced abortions, menstrual reflux,and decreased tubal motility. Causes An ectopic pregnancy is often caused by damage to the fallopian tubes. A fertilized eggmay have trouble passing through a damaged tube, causing the egg to implant and growin the tube.Things that make you more likely to have fallopian tube damage and an ectopicpregnancy include:

Smoking. The more you smoke, the higher your risk of an ectopic pregnancy.

Pelvic inflammatory disease (PID). This is often the result of an infection such aschlamydiaor gonorrhea.

Endometriosis, which can cause scar tissue in or around the fallopian tubes.

Being exposed to the chemicalDESbefore you were born.Some medical treatments can increase your risk of ectopic pregnancy. These include:

Surgery on the fallopian tubes or in the pelvic area.

Fertility treatments such asin vitro fertilization. Signs and Symptoms Before Rupture

Abdominal Pain

Amenorrhea

Abnormal Vaginal Bleeding

Abdominal Tenderness

Palpable Pelvic Mass Rupture

Exacerbation of the pain occurs during rupture in an ectopic pregnancy.

After Rupture

Faintness / Dizziness

Abdominal Pain

Referred Shoulder Pain Signs of Shock

Shock is related to the severity of the bleeding into the abdomen. Medical Diagnosis

Pregnancy Tests

Ultrasound

Culdocentesis

Laparoscopy Pathophysiology The uterus is the only organ capable of containing and sustaining a pregnancy. Whenfertilized ovum implants in other location, the body is unable to maintain the pregnancy.Nursing Management1. Ensure that appropriate physical needs are addressed and monitor for complications.Assess vital signs,bleeding, and pain.2. Provide client and family teaching to relieve anxiety. o Explain the condition and expected outcome

Material prognosis is good with early diagnosis and p r o m p t treatment, such asl a p a r o t o m y , t o l i g a t e b l e e d i n g v e s s e l s a n d r e p a i r o r r e m o v e t h e damagedfallopian tube.

Pharmacologic agents, such as methotrexate followed by leucovorin,may be givenorally when ectopic pregnancy is diagnosed by routine sonogrambefore the tube hasruptured. A hystesolpinogram usually follows this therapy to confirmtubal patency.

Rh-negative women must receive RhoGAM to provide protection from immunizationFor future pregnancies. o Describe self-care measures, which depend on the treatment.3. Address emotional and psychosocial needs. Nursing Process

Prevention Because an ectopic pregnancy is closely associated with a previous pelvic infection education regarding the importance of treating a vaginal or pelvic infection early would also decrease the incidence. Since there is a correlation between cigarette smoking and an increased risk of anectopic pregnancy, women during their childbearing years should be encouraged to avoid smoking. If an elective abortion is desired it should always be carried out only by medically prepared professionals.These measures can decreased the chance of tubal d efects and thereby decrease theincidence of an ectopic pregnancy.Because of the increasing incidence of ectopic pregnancy, health professionals shouldc o n s i d e r t h e p o s s i b i l i t y i n a n y w o m a n w h o p r e s e n t s w i t h a n y t y p e o f a b d o m i n a l discomfort during her childbearing years.AssessmentB e c a u s e o f t h e h i g h m a t e r n a l m o r t a l i t y a s s o c i a t e d w i t h a n u n d i a g n o s e d e c t o p i c pregnancy until after rupture or tubal abortion, it is very important for nurses to be alert tosigns and symptoms of this complication of pregnancy.Therefore any woman during her childbearing years who experiences irregular vaginalspotting associated with a dull, aching pelvic pain, with or without signs of pregnancy, should be evaluated for a possible ectopic pregnancy. Risk Factors A history of any pelvic inflammatory disease, previous ectopic pregnancies, elective abortions, or prior infertility disorders should be determined; they can increase the patients riskfor a tubal defect. Pain If an ectopic pregnancy is suspected, a detailed history should include questionsr e g a r d i n g t h e t y p e o f a b d o m i n a l p a i n . T h e p a i n c a u s e d b y a n u n r u p t u r e d e c t o p i c pregnancy can be a unilateral, cramplike pain related to tubal distension by

the enlargingembryo or fetus.At the time of tubal rupture many patients experience a sudden, sharp, stabbing pain inthe lower abdomen. Vaginal Bleeding Assess for the presence of vaginal bleeding, and obtain a menstrual history. Vaginalbleeding is usually related to the sloughing of the endometrial lining related to decreasingprogesterone and estrogen levels and can present as continuous or intermittent vaginalbleeding in small or large quantities. It is usually different from the patients normal period.Pad Counts should be kept to determine the amount and type of vaginal bleeding. Syncope Assess for the presence of any signs of syncope.When an ectopic pregnancy ruptures or aborts, blood is lost into the peritoneal cavity.A t t h i s t i m e t h e p a t i e n t c a n e x p e r i e n c e a f e e l i n g o f faintness or weakness related to An ectopic pregnancy develops as the result of the blastocyst implanting somewhereother than in the endometrium of the uterus. Sites of an ectopic pregnancy are 1 the fallopian tube, 2 ovary, 3 cervix, 4 or abdominal cavityT h e m a j o r i t y o f e c t o p i c p r e g n a n c i e s ( 9 5 % ) a r e l o c a t e d i n t h e f a l l o p i a n t u b e , w i t h 1 % located on an ovary, less than 1 % on the cervix, and 3% to 4% in the abdominal cavity,Of all tubal pregnancies, more than half are located in the ampulla , or largest portion of the tube. The next most common site in the isthmus, or the narrow part of the tube thatconnects the interstitial to the ampullar portion. Three percent are located in the interstitialor muscular portion of the tube adjacent to the uterine cavity. Rarely does the ectopicpregnancy locate in the fimbria or terminal end of the tube. The outcome and gestationallength of the ectopic pregnancy will be influenced by its location in the fallopian tube. Incidence

The incidence of ectopic pregnancy is approximately 1 out of every 60 pregnancies, or 2 % w i t h t h e number increasing each year worldwide . Women over 35 years o l d , nonwhites, or those who have a history of infertility are at a greater risk of experiencingan of ectopic pregnancy. Etiology 1 Previous Tubal Infections Previous pelvic infections caused by certain sexually transmitted diseases, such as chlamydia and gonorrhea, postpartum endometritis and postabortal uterine infections canp r e d i s p o s e t o a t u b a l i n f e c t i o n . A t u b a l infection can cause damage to the mucosalsurface of the fallopian tube, c a u s i n g i n t r a l u m i n a l a d h e s i o n s t h a t i n t e r f e r e w i t h t h e transportation of the fertilized ovum to the uterine cavity. 2 Previous Tubal or Pelvic Surgery During surgery, if blood is allowed to enter the fallopian tubes, tubal adhesions can resultfrom the irritation of the mucosal surface. Salpingectomy, for previous ectopic pregnancyor for treatment of an inflammatory process, and salpingoplasty, for infert ility are thesurgeries that most frequently cause tubal adhesions. Occasionally irritation results froman appendectomy. 3 Hormonal Factors Altered estrogen/progesterone levels or inappropriate levels of prostaglandines c a n interfere with normal tubal motility of the fertilized ovum. 4 Contraceptive Failure Ectopic pregnancies occur with the use of an intrauterine device (IUD) in approximately 2per 1000 users each year. The cause is unknown but may be related to altered tubalmotility or a tubal infection. There is increased risk for an ectopic pregnancy with the progestin-only oral contraceptive because of the decreased motility - induced effect of progesterone. 5 Stimulation of Ovulation

There is a 3% increased incidence of an ectopic pregnancy associated with ovulation stimulating drugs such as human menopausal gonadotropin and clomiphene citrate. These drugs alter the estrogen/progesterone level, which can affect tubal motility. 6 Infertility Treatment There is an increased risk of an ectopic pregnancy with in vitro fertilization ( I V F ) o r gamete intrafallopian transfer (GIFT) since underlying tubal damage is frequently one of the causative factors predisposing one to this type of infertility treatment. 7 Environmental Effect Maternal cigarette smoking at the time of conception was found in a case c o n t r o l l e d study, to be associated with an increased risk of an ectopic pregnancy. 8 Transmigration of Ovum Migration of the ovum from one ovar y to the opposite fallopian tube can occur b y a n extrauterine or intrauterine route. This can cause a potential delay in transportation of thefertilized ovum to the uterus. Then trophoblastic tissue is present on the blastocyst beforeit reaches the uterine cavity, and therefore the trophoblastic tissue implants itself on thewall of the fallopian tube. 9 Endometriosis The presence of endometrial tissue located outside the uterine cavity increases thereceptivity of the fertilized ovum to an ectopic implantation. Normal Physiology The fallopian tube is very muscular and narrow and contains very few ciliated cells atthe interstitial area. In the ampullar area the fallopian tube becomes less muscular, the luminal size increases, and the ciliated cells are more abundant.The fimbriated end of the fallopian tube has the unique function of moving the ovuma n d s p e r m i n o p p o s i t e d i r e c t i o n s a l m o s t s i m u l t a n e o u s l y b y p e r i s t a l t i c ( m u s c u l a r contraction) and ciliated activity. This tubal activity is initiated by two or more adjacentp a c e m a k e r s i n t h e a m p u l l a r a n d i s t h m i c a r e a s o f t h e f a l l o p i a n t u b e b y s e n d i n g o u t myoelectrical activity is in either direction. The net directional movement in the fallopian tubes will vary during the menstrual cycle. During menstruation the net directional force istoward the uterus starting from the ampullar area to prevent menstrual blood reflux intothe tube. This is stimulated primarily by estrogen induced prostglandins. Just before o v u l a t i o n , t h e d i r e c t i o n a l f o r c e f r o m t h e a m p u l l a r a r e a i s i n w a r d i n o r d e r t o p i c k t h e released ovum from the ovary and moved it into

the ampullar area of the fallopian tube. Atthe same time the directional force from the uterine area is just the opposite in order tofacilitate sperm motility toward the ovum. This is influenced by estrogen primarily. After fertilization the directional force varies in the ampullar area, which delays ovum transport.Approximately 5 days after ovulation, the net directional force from the middle of theampullar area is inward through the isthmus in order to transport the ovum to the uterus.This is influenced by increasing progesterone and prostaglandin E 2 (PGE). Approximately7 days after ovulation, the myoelectrical activity become variable again, moving in bothdirections from each of the pacemakers. The fertilized ovum should reach the uterine cavity in 6 to 7 days, just about the timethe trophoblast cells begin to secrete the proteolytic enzyme and start to develop the threadlike projections called chorionic villi that initiate the implantation process.The uterus is normally prepared by estrogen and progesterone to accept the fertilizedovum, now called a blastocyst . As the chorionic villi invade the endometrium, the villiare held in check by a fibrinoid zone. The uterus is also supplied with an increased bloodsupply capable of nourishing the products of conception. PathophysiologyTubal Ectopic Pregnancy Because most ectopic pregnancies initially implant in a f a l l o p i a n t u b e , t h e pathophysiology will focus on tubal ectopic pregnancies. The blastocyst burrows into thee p i t h e l i u m o f t h e t u b a l w a l l , t a p p i n g b l o o d v e s s e l s , b y t h e s a m e p r o c e s s a s n o r m a l implantation into the uterine endometrium. However, the environment of the tube is quitedifferent because of the following factors:1.1. There is a decreased resistance to the invading trophoblastic tissue by the fallopian tube.2.2. There is a decreased muscle mass lining the fallopian tubes; therefore their dispensability3.3. The blood pressure is much higher in the tubal arteries than in the uterine arteries is greatly limited.4.4. There is limited decidual reaction; therefore human chorionic gonadotropin (hCG) is decreased and the signs and symptoms of pregnancy are limited.It is because of these characteristic factors the termination of a tubal pregnancy occursgestationally early by an abortion, spontaneous regression, or rupture, depending on thegestational age and the location of the implantation. If the embryo dies early in gestation,spontaneous regression often occurs. If spontaneous regression fails to occur,

thenusually an ampullar or fimbriated tubal pregnancy ends in an abortion and an isthmic or interstitial pregnancy ends in a rupture A tubal abortion primarily occurs because of separation of all or part of the placenta.This separation is caused by the pressure exerted by the tapped blood vessels or tubal contractions.With complete separation, T h e p r o d u c t s o f c o n c e p t i o n a r e e x p e l l e d i n t o t h e abdominal cavity by way of the fimbriated end of the fallopian tube.With an incomplete separation, bleeding continues until complete separation takes place, and the blood flows into the abdominal cavity collecting in the rectouterine cul-de-sac of Douglas. Tubal rupture results from the uninterrupted invasion of the trophoblastic tissue or tearing of the extremely stretched tissue. In either case the products of conception are completely or incompletely expelled into the abdominal cavity or between the folds of thebroad ligaments by way of the torn tube.The duration of the tubal pregnancy depends on the location of the implanted embryoo r fetus and the distensibility of that part of the fallopian tube. For i n s t a n c e , i f t h e implantation is located in the narrow isthmic portion of the tube, it will rupture very early, within 6 to 8 weeks; the distensible interstitial portion may be able to retain the pregnancyup to 14 weeks of gestation. Abdominal Ectopic Pregnancy An abdominal pregnancy almost always results from an implantation secon dary to atubal rupture or abortion through the fimbriated end of the fallopian tube. In these casest h e p l a c e n t a l c o n t i n u e s t o g r o w f o l l o w i n g a t t a c h m e n t t o s o m e a b d o m i n a l s t r u c t u r e , usually the surface of the uterus, broad ligaments, or ovaries. However, it can be anya b d o m i n a l structure including the liver, spleen, or intestines. Because the i n v a d i n g trophoblastic tissue is not held in check, it can erode major blood vessels at any becausethey are not cushioned by the myometrium. Cervical Ectopic Pregnancy In very rare cases the fertilized ovum bypasses the uterine endometrium and implantsi t s e l f i n t h e c e r v i c a l m u c u s . P a i n l e s s b l e e d i n g b e g i n s s h o r t l y a f t e r i m p l a n t a t i o n , a n d surgical termination is usually required before the fourteenth week of gestation. Signs and Symptoms Before Rupture

 Abdominal Pain Abdominal pain occurs close to 100% of the time. It is usually first manifested by a dullpain caused by tubal stretching following by a sharp colicky tubal pain caused by further tubal stretching and stimulated contractions. It is diffuse and is bilateral or unilateral. Amenorrhea A history of a late period for approximately 2 weeks or a higher than usual or irregular period is reported by 75 % to 90 % of the patients Abnormal Vaginal Bleeding Mild to intermittent dark red or brown vaginal discharge occurs in 50 % to *0 % of thecases related to uterine decidual shedding secondary to decreased hormones. Absence of Common Signs of pregnancy Absence of common signs of pregnancy is secondary to decreased pregnancy hormonesand occurs 75 % of the time. Abdominal Tenderness Abdominal Tenderness occurs in approximately 95 % of the cases. Palpable Pelvic Mass Referred Shoulder Pain approximately 50 % of the cases. It may be in the oppositeabdominal quadrant from the ectopic growth related to a corpus luteum cyst. Rupture Exacerbation of the pain occurs during rupture in an ectopic pregnancy. After Rupture Faintness / Dizziness

Faintness and dizziness occur in the presence of significant bleeding Generalized, Unilateral, or Deep Lower Quadrant Acute Abdominal Pain Pain is caused by blood irritating the peritoneum Referred Shoulder Pain Referred shoulder painis related to diaphragmatic irritation from blood in the peritoneal cavity Signs of Shock Shock is related to the severity of the bleeding into the abdomen. Maternal Effects Ectopic pregnancies account for approximately 10% of all maternal deaths. They are the fourth leading cause of maternal mortality, but they are the number one cause of maternal mortality in the first trimester of pregnancy. Hemorrhage is the cause of death in 85 % to 89 % of the cases and occurs more frequently with an interstitial or abdominal ectopic pregnancy. The greater risk of mortality related to an ectopic pregnancy is associated with anabdominal ectopic growth, which has a 7.7 times greater risk when compared to other types of ectopic pregnancies. Fetal and Neonatal Effects Death is almost certain for the fetus in an ectopic pregnancy. From 5 % to 25 % of abdominal ectopic pregnancies will reach viability. However, it is not recommended toc o n t i n u e a n a b d o m i n a l p r e g n a n c y i f d i a g n o s e d e a r l y b e c a u s e o f t h e e x t r e m e r i s k o f hemorrhage at any time during the pregnancy. The risk of fetal deformity is also high; 20% t o 40 % of the fetuses that live beyond 20 weeks of gestation will

h a v e s u c h deformities as facial asymmetry, severe neck webbing, joint deformities, and hypoplasticlimbs These are pressure deformities caused by oligohydramnios. Medical Diagnosis Early diagnosis before extrauterine rupture or abortion can decrease maternal mortalityfrom hemorrhage and simplify the management of an ectopic pregnancy. Pregnancy Tests Because of the lower levels of hCG being secreted by an ectopic implanted placentarelated to poor vascularization, the pregnancy test must be highly sensitive for beta -human chorionic gonadotropin (beta- hCG) to confirm a if an ectopic pregnancy issuspected. The most common urine pregnancy tests such as the latex agglutination inhibition slide test are only 50 % to 60 % accurate in confirming a pregnancy that is ectopic Radioimmunoassay tests are able to detect minute amounts of hCG (5 to 10 mIU/mI)a n d h a v e p r o v e n t o b e a l m o s t 1 0 0 % a c c u r a t e i n d e t e c t i n g a n e c t o p i c p r e g n a n c y . However, they take several hours to run. The new monoclonal antibody pregnancy tests such as the enzyme-linked immunosorbent assay (ELISA) and the immunofluorometric assay (IFMA) are specific for the beta-hCG submit andtherefore are 95 % to 99 % accurate. It takes only minutes to run these tests. Ultrasound The usefulness of ultrasound in the diagnosis of an ectopic pregnancy is improvingcontinuously. With the more sophisticated real-time equipment and an expert technician,characteristic changes of an ectopic pregnancy can be p i c k e d u p w i t h p e l v i c ultrasound.

 With transvaginal ultrasound, the location of the gestational sac of an early ectopicpregnancy can be visualized with 82 % to 84 % accuracy Therefore transvaginal ultrasound is becoming an important diagnostic tool in an ectopic pregnancy before rupture because the probe can be placed closer to the pelvicstructures. Culdocentesis Culdocentesis can be used to diagnose intraperitoneal bleeding if a rupture ectopicpregnancy is suspected. The procedure involves passing a needle through the cul -de-sac of Douglas t o aspirate fluid from the peritoneal cavity. Laparoscopy If any question remains, an endoscope may be inserted through a small abdominal incision to visualize the peritoneal cavity for an ectopic implanted pregnancy Medical treatment Tubal Ectopic Pregnancy Before Rupture Surgical treatment The type of surgical management depends on the location depends on the location and cause of the ectopic pregnancy, the extent of tissue involvement, and the patients wishes for future fertility.The choice of treatment for an unruptured ampullar or fimbriated tubal pregnancy is asalpingostomy , in which a longitudinal incision is made over the pregnancy site and theproducts of conception are gently removed, being very careful to prevent or control the bleeding.

Segmental resection and subsequent end -to-end anastomosis after the swelling andinfection have subside may be necessary if the ectopic pregnancy was located in theproximal isthmus portion of the tube. Nonsurgical Treatment A methotrexate type of chemotherapy has been successfully used as an alternative tos u r g e r y . Provided there are no signs of bleeding, a dose of 1 ml/kg can be g i v e n intramuscularly every other day for 4 days. In clinical studies a single dose of 12.5mg hasb e e n proven effective when locally injected into the ectopic site. This cytotoxic d r u g causes dissolution of the ectopic mass. Tubal ectopic pregnancy After Rupture Following a ruptured tubal pregnancy, a salpingectomy (removal of the affectedf a l l o p i a n t u b e ) i s t h e m o s t c o m m o n s u r g i c a l t r e a t m e n t . O c c a s i o n a l l y a salpingooophorectomy (removal of the affected fallopian tube and adjacent ovary) isperformed if the blood supply to the ovary is affected or the ectopic pregnancy involved the ovary. Otherwise, preservation of the ovary is recommended. If the couple does notwish to have more children, then a hysterectomy may be done if the womans condition isstable. Abdominal Ectopic Pregnancy For an abdominal pregnancy, hemorrhage is a serious possibility because the placentacan separate from its attachment site at any time.A b d o m i n a l s u r g e r y t o r e m o v e t h e e m b r y o o r f e t u s i s usually done as soon as anabdominal pregnancy is diagnosed. Unless the p l a c e n t a i s a t t a c h e d t o a b d o m i n a l structures that can be removed, such as the ovary or exterior of the uterus, or the bloodvessels that supply blood the placenta can be ligated, the placenta is left without beingdisturbed.If the placenta is removed, large blood vessels would be opened and there would notbe a constricting muscle such as the uterus to apply a sealing pressure. If left intact, thep l a c e n t a i s u s u a l l y a b s o r b e d b y t h e b o d y , b u t u n f o r t u n a t e l y i t m a y c a u s e s u c h complications as infection, abscesses, adhesions, intestinal obstruction, paralytic ileus,p o s t p a r t u m p r e e c l a m p s i a , a n d w o u n d d e h i s c e n c e . T h e s e c o m p l i c a t i o n s a r e l e s s threatening than the hemorrhage that could result, if removed. Cervical Ectopic Pregnancy In the case of a cervical pregnancy, the risk of hemorrhage is great as any other typeof ectopic pregnancy.A vaginal delivery should be attempted if the gestational age is less than 12 weeks andthe couple desires to have more children. T he cervical branch of the uterine artery is ligated and the cervix is then packed or a Foley catheter balloon inflated in an attempt tocurtail the bleeding from opened blood vessels after the removal of the placenta. If this does not stop the bleeding, amputation of the cervix or a hysterectomy must bedone. If the couple does not wish to have any more children, an abdominal hysterectomy isgenerally the method of treatment.

Nursing Process Prevention Because an ectopic pregnancy is closely associated with a previous pelvic infection education regarding the importance of treating a vaginal or pelvic infection early wouldalso decrease the incidence. Since there is a correlation between cigarette smoking and an increased risk of anectopic pregnancy, women during their childbearing years should be encouraged to avoid smoking. If an elective abortion is desired it should always be carried out only by medically prepared professionals.These measures can decreased the chance of tubal defects and thereby decrease theincidence of an ectopic pregnancy.Because of the increasing incidence of ectopic pregnancy, health professionals shouldc o n s i d e r t h e p o s s i b i l i t y i n a n y w o m a n w h o p r e s e n t s w i t h a n y t y p e o f a b d o m i n a l discomfort during her childbearing years. Assessment Because of the high maternal mortality associated with an undiagnosed e c t o p i c pregnancy until after rupture or tubal abortion, it is very important for nurses to be alert tosigns and symptoms of this complication of pregnancy.Therefore any woman during her childbearing years who experiences irregular vaginalspotting associated with a dull, aching pelvic pain, with or without signs of pregnancy,should be evaluated for a possible ectopic pregnancy. Risk Factors A history of any pelvic inflammatory disease, previous ectopic pregnancies, elective abortions, or prior infertility disorders should be determined; they can increase the patients risk for a tubal defect.

Pain If an ectopic pregnancy is suspected, a detailed history should include questionsr e g a r d i n g t h e t y p e o f a b d o m i n a l p a i n . T h e p a i n c a u s e d b y a n u n r u p t u r e d e c t o p i c pregnancy can be a unilateral, cramplike pain related to tubal distension by the enlargingembryo or fetus.At the time of tubal rupture many patients experience a sudden, sharp, stabbing pain inthe lower abdomen. Vaginal Bleeding

Assess for the presence of vaginal bleeding, and obtain a menstrual history. Vaginalbleeding is usually related to the sloughing of the endometrial lining related to decreasingprogesterone and estrogen levels and can present as continuous or intermittent vaginalbleeding in small or large quantities. It is usually different from the patients normal period.Pad Counts should be kept to determine the amount and type of vaginal bleeding. Syncope Assess for the presence of any signs of syncope.When an ectopic pregnancy ruptures or aborts, blood is lost into the peritoneal cavity.A t t h i s t i m e t h e p a t i e n t c a n e x p e r i e n c e a f e e l i n g o f f a i n t n e s s o r w e a k n e s s r e l a t e d t o hypovolemia. If the bleeding is not continuous, the depleted blood volume is restored tonear normal in 1 or 2 days by hemodilution and the faint or week feeling subsides. If thebleeding is profuse, the patient can go into should quickly. Vital signs To assess the amount of intraperitoneal blood loss, the patients vital signs should bechecked as frequently as the situation indicates. Nursing Diagnosis/Collaborative Problems and Interventions Fear related risk of mortality and possible treatment alternatives.Desired Outcome: The patient and her family will be able to communicate their fearsand concerns openly. Interventions 1. Assess familys anxiety over maternal well-being because of 10 times greater risk of mortality as compared to normal childbirth.2 . A s s e s s f a m i l y s l e v e l o f g u i l t s u c h a s t h e i r f e e l i n g a s t o w h a t t h e y d i d t o c a u s e t h i s happen.3.Assess familys coping strategies and resources.4.Explain all treatment modalities and reasons for each in understandable terms.5.Prepare patient for transvaginal ultrasound, if this diagnostic procedure is ordered,

byhaving patient empty her bladder before the procedure.6 . P r e p a r e p a t i e n t f o r a c u l d o c e n t e s i s , i f t h i s d i a g n o s t i c p r o c e d u r e i s o r d e r e d , b y explaining the procedure. (A sterile speculum is inserted into the vagina, the c e r v i x i s s t e a d i e d w i t h a tenaculum , and a 16- to 18- gauge needle is inserted into the cul-de-sac so any fluidthat is present can be aspirated for evaluation.)P o s i t i o n p a t i e n t i n a semi-Fowlers position t o a l l o w a n y i n t r a p e r i t o n e a l b l o o d , i f present, to pool in cul-de-sac. Just before the procedure prepare the external genitalia with p o v i d o n e - i o d i n e (Betadine).7.Prepare the patient for the medical procedure. Pain related to stretching of the tube, severe abdominal bleeding secondary to tubal rupture,

or surgical treatment. Desired Outcome:

t h e p a t i e n t w i l l v e r b a l l y a n d n o n v e r b a l l y e x p r e s s r e a s o n a b l e comfort. Interventions 1.Assess the type and location of pain.2.Maintain position of comfort.3.Limit movement, and support patient. 4 . P r o v i d e r e a s s u r a n c e . 5.Instruct regarding t h e u s e o f r e l a x a t i o n a n d b r e a t h i n g t e c h n i q u e s t o r e d u c e p a i n i f medication cannot be administered.6.Administer pain medication as ordered if needed. 7 . N o t i f y p h y s i c i a n regarding any change in the amount or type of pain the p a t i e n t experiences. Potential Complication: Hemorrhage caused by ectopic rupture/abortion or surgicaltreatment. Desired Outcome: The signs and symptoms of hemorrhage will be minimized/managedas measured by stable vital signs, urinary output of 30 ml/hr or greater, absence of signs of shock, and hematocrit maintained between 30 % and 45 %. Preoperative Interventions 1.Check vital signs as indicated (depending on severity). 2 . C h e c k a m o u n t o f v a g i n a l bleeding.3 . C h e c k f o r s i g n s o f s h o c k s u c h a s t a c h y c a r d i a , d r o p i n b l o o d p r e s s u r e , a n d c o o l clammy skin. (During pregnancy, signs of shock are not manifested until there hasbeen at least a 40 % blood volume loss.4.Check state of mental acuity/level of consciousness.5.Keep an accurate record of intake and output . Urinary output during pregnancy is the best noninvasive indicator of c i r c u l a t o r y volume.

 Diminished cardiac output causes a shunting of blood away from the skin, kidneys, and skeletal muscles in order to ensure blood delivery to heart and brain.6.Start an intravenous infusion with an 18-gauge intracatheter and maintain as ordered. Fluid replacement may reverse impending shock by increasing capillary blood flow and thereby cardiac output increases. (Normal saline or Ringer7 . O b t a i n b l o o d a s o r d e r e d f o r a complete blood count, prothrombin time, partial thromboplastin time, Rh antibody screen, and type and cross match for 2 to 4 units of blood.8.Administer oxygen at 8 to 10 L by mask as needed.9.Carry out such preoperative protocol as giving the patient