ECTOPIC PREGNANCY

ECTOPIC PREGNANCY
1. DEFINITION

What is an ectopic pregnancy?

From fertilization to delivery, pregnancy requires a number of steps in a woman’s body. One of these steps

is when a fertilized egg travels to the uterus to attach itself. In the case of an ectopic pregnancy, the ferti-

lized egg doesn’t attach to the uterus. Instead, it may attach to the fallopian tube, abdominal cavity, or cer-

vix.

While a pregnancy test may reveal a woman is pregnant, a fertilized egg can’t properly grow anywhere oth-

er than the uterus.

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2. ASSESSMENT AND DIAGNOSIS

Doctors suspect an ectopic pregnancy in women who are of childbearing age and who have lower ab-

dominal pain or vaginal bleeding, faint, or go into shock. In such women, a pregnancy test is done.

1. Transvaginal ultrasonography

If the pregnancy test is positive, ultrasonography is done using a handheld device inserted into the vagi-

na (called transvaginal ultrasonography). If ultrasonography detects a fetus in a location other than its

usual place in the uterus, the diagnosis is confirmed. If ultrasonography does not detect a fetus anywhere,

ectopic pregnancy is still possible, or the pregnancy may be in the uterus but be so early that it cannot be

seen.

2. Serum β-hCG concentrations

Doctors also do blood tests to measure a hormone produced by the placenta early in pregnancy called hu-

man chorionic gonadotropin (hCG). This test can help doctors determine whether the pregnancy is too early

for the fetus to be visible in the uterus or is an ectopic pregnancy.

3. Diagnostic laparoscopy

If needed to confirm the diagnosis, doctors may use a viewing tube called a laparoscope, inserted through

a small incision just below the navel. This procedure enables them to view an ectopic pregnancy directly.

4. Endometrial biopsy

In selected cases of PUL, an endometrial biopsy may be taken and analysed for the presence or absence of

chorionic villi. Their absence in the presence of a static β-hCG is suggestive of an ectopic pregnancy. A

dilatation and curettage may be useful when performed in association with a ‘negative’ diagnostic laparos-

copy for a suspected ectopic pregnancy. The clinician should be certain that the pregnancy, if intrauterine,

is non-viable and appropriate consent obtained, as this procedure could potentially interrupt a continuing

pregnancy.
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3. PREDISPOSING FACTORS

Some things that make you more likely to have an ectopic pregnancy are:

1. Previous ectopic pregnancy. If you've had this type of pregnancy before, you're more likely to have

another.

2. Inflammation or infection. Sexually transmitted infections, such as gonorrhea or chlamydia, can cause

inflammation in the tubes and other nearby organs, and increase your risk of an ectopic pregnancy.

3. Fertility treatments. Some research suggests that women who have in vitro fertilization (IVF) or similar

treatments are more likely to have an ectopic pregnancy. Infertility itself may also raise your risk.

4. Choice of birth control. The chance of getting pregnant while using an intrauterine device (IUD) is rare.

However, if you do get pregnant with an IUD in place, it's more likely to be ectopic. Tubal ligation, a per-

manent method of birth control commonly known as "having your tubes tied," also raises your risk, if you

become pregnant after this procedure.

5. Smoking. Cigarette. smoking just befor e you get pr egnant can incr ease the r isk of an ectopic pr eg-

nancy. The more you smoke, the greater the risk.

6. A recent in vitro fertilization. Following an in vitro fertilization, a zygote may have slower transportation

and lead to an increased incidence of tubal or ovarian implantation.

7. Previous infection such as salpingitis or pelvic inflammatory disease. Women who experience infection

of the reproductive system increase the incidences of having ectopic pregnancy because the scar from these

infections could cause adhesion in the fallopian tube.

8. Scars from a tubal surgery. These scars cause an adhesion that would not let the fertilized egg travel

towards the uterus.

9. Congenital malformations. Physical defects of the reproductive system such as strictures in the fallopi-

an tube could cause ectopic pregnancy.

10. Uterine tumors. A tumor might be pressing at the proximal end of the tubes, which would not allow

access of the fertilized egg into the uterus.

11. Use of intrauterine device. IUDs are contraceptive devices shaped like an inverted T and inserted into

the uterus of a woman. It may impede the traveling fertilized egg to reach the ideal place of implantation if

it is inserted after conception.

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4. SIGNS AND SYMPTOPMS

It is important for both the pregnant woman and the health care provider to identify any signs and symptoms

of an ectopic pregnancy before rupture occurs. However, most ectopic pregnancy does not show any unusu-

al signs and symptoms at the time of implantation, so it would be difficult to identify them at first.

1. Sharp abdominal pain.

A pregnant woman with possible ectopic pregnancy might move suddenly, and as a result, the anterior uter-

ine support might be pulled and cause pain in the abdomen.

2. Vaginal spotting.

This would rarely occur in conjunction with the pain, but this may be a sign that the ectopic pregnancy is

nearing its rupture.

3. Sharp, stabbing pain at the lower quadrant.

This is one of the symptoms which tell that the ectopic pregnancy has already ruptured.

4. Vaginal bleeding. Bleeding

occurs after the ectopic pregnancy has ruptured. Tearing of the blood vessels and its destruction is the cause

of the bleeding, and the amount would not be determined fully because some products of conception and

blood might be expelled into the pelvic cavity.

Early warning of ectopic pregnancy

Often, the first warning signs of an ectopic pregnancy are light vaginal bleeding and pelvic pain.

If blood leaks from the fallopian tube, you may feel shoulder pain or an urge to have a bowel movement.

Your specific symptoms depend on where the blood collects and which nerves are irritated.

Emergency symptoms

If the fertilized egg continues to grow in the fallopian tube, it can cause the tube to rupture. Heavy bleeding

inside the abdomen is likely. Symptoms of this life-threatening event include extreme lightheadedness,

fainting and shock.

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5. PATHOPHYSIOLOGY

The most common site of ectopic implantation is a fallopian tube, followed by the uterine cornua. Preg-

nancies in the cervix, a cesarean delivery scar, an ovary, the abdomen, or fallopian tube interstitium are

rare.

Heterotopic pregnancy (simultaneous ectopic and intrauterine pregnancies) occurs in only 1/10,000 to

30,000 pregnancies but may be more common among women who have had ovulation induction or used

assisted reproductive techniques such as in vitro fertilization and gamete intrafallopian tube transfer

(GIFT); in these women, the overall reported ectopic pregnancy rate is ≤ 1%.

The structure containing the fetus usually ruptures after about 6 to 16 weeks. Rupture results in bleed-

ing that can be gradual or rapid enough to cause hemorrhagic shock. Intraperitoneal blood irritates the peri-

toneum. The later the rupture, the more rapidly blood is lost and the higher the risk of death.

 Fertilization occurs at the usual distal third of the fallopian tube.

 After the union, zygote begins to divide and grow.

 However, due to an obstruction by several factors (see Risk Factors), the zygote cannot travel through

the length of the tube.

 It lodges on that constricted part and implantation takes place at that area instead of the uterus.
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6. MANAGEMENT

Medical Interventions

The medical management of a woman with an ectopic pregnancy should be initiated the moment she is

brought to the emergency room. Just a few moments of interval for action would cause a big difference in the

safety of the patient.

 Administration of methotrexate. Methotr exate is a chemother apeutic agent that is a folic acid an-

tagonist. It destroys rapidly growing cells such as the trophoblast and the zygote. This would be adminis-

tered until a negative hCg titer results have been produced.

 Administration of mifepristone. An abor tifacient that causes sloughing off of the tubal implantation

site. Both of these therapies would leave the tube intact and no surgical scarring.

 Intravenous therapy. This would be per for med when the ectopic pr egnancy has alr eady r uptur ed

to restore intravascular volume due to bleeding.

 Withdrawing of blood sample. A lar ge amount of blood would be lost, so blood typing and cr oss-

matching must be done in anticipation of a blood transfusion. The blood sample would also be used to

determine the hemoglobin levels of the pregnant woman.

Surgical Interventions

Surgical interventions would be performed after the rupture of the ectopic pregnancy to ensure that the

reproductive system would still be functional and no complications would arise.

 Laparoscopy. This will be performed to ligate the bleeding blood vessels and repair or remove the dam-

aged fallopian tube.

 Salpingectomy. This inter vention would be per for med if the fallopian tube is completely damaged.

The affected tube would be removed and what would be left would be sutured appropriately.
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6. MANAGEMENT

Ectopic pregnancy may be managed surgically, medically or expectantly. Clear documentation of diagnostic

and management strategies with clinical, sonographic and biochemical assessment of the patient is therefore

important. Which management is most appropriate depends on ongoing assessment and on numerous clinical

factors. Management is tailored to individual patients, based on their presentation and on the severity of their

condition, suitability of treatment options and patient preference. The figure demonstrates a suggested diagno-

sis and management pathway.

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7. NURSING RESPONSIBILITIES
NURSING RESPONSIBILITIES RATIONALE
1. Assess vital signs: If an ectopic pregnancy occurs in the fallopian tube that ruptures,

Blood pressure, Heart rate, Respirations, the patient may go into shock and will have rapid heart rate, rap-

Temperature id breathing and low blood pressure.

2. Assess for signs of dehydration; skin Excessive blood loss and vomiting may cause hypovolemia and

turgor, mucous membranes, cap refill dehydration.

3. Position patient for comfort and assist Patient should be positioned lying flat on the bed to reduce

with movement as needed movement, stabilize vitals and promote comfort.

4. Assess for abdominal pain and tender- Pain may vary, but is usually a sign that an ectopic pregnancy, or

ness fallopian tube, has ruptured.

Patients will report stabbing or sharp pain in the lower abdomen

with fluctuating intensity.

5. Monitor blood loss and administer Vaginal bleeding may range from spotting to heavier than a nor-

blood products as necessary mal menstrual cycle

6. Monitor intake and output; administer To maintain renal function, especially in the case of shock.

fluids as appropriate

7. Administer medications as appropriate Methotrexate may be given to absorb the pregnancy tissue and

and monitor for adverse reactions save the fallopian tube.

Anti-nausea and analgesic medications may be given to manage

symptoms
8. Prepare patient for surgery: If the fallopian tube has ruptured, surgery to remove part or all

1. Maintain NPO status 2. Insert indwelling of the tube may be the best option. Surgery may be performed

catheter 3. Establish and maintain IV access laparoscopically or a laparotomy may be necessary.

and fluids

9. Provide patient education of ways to Educate patient of risk factors and lifestyle changes to avoid fu-

prevent future ectopic pregnancies ture ectopic pregnancies:

Stop smoking . Multiple sex partners increase risk of pelvic in-

fections and ectopic pregnancies

TO: TO:
MAAM ELIZABETH C. BRILLO-AGUSTIN MAAM MERCEDES ANICAS
OFFICE OF THE VICE PRESIDENT COLLEGE OF NURSING

FROM: FROM:
PRINCESS MELANIE R. BALLO PRINCESS MELANIE R. BALLO
BSN 2D BSN 2D

TO: TO:
MRS. MARJORIE JOVEN MRS. MARJORIE JOVEN
COLLEGE OF NURSING COLLEGE OF NURSING

FROM: FROM:
PRINCESS MELANIE R. BALLO PRINCESS MELANIE R. BALLO
BSN 2D BSN 2D