Ectopic Pregnancy

• Ectopic pregnancy  :
Ectopic means "out of place." In an ectopic pregnancy,
a fertilized egg has implanted outside the uterus. The
egg settles in the fallopian tubes in more than 95% of
ectopic pregnancies. This is why ectopic pregnancies
are commonly called "tubal pregnancies.

Pathophysiology :
 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 ,
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.

Risk Factors
Several factors could contribute to the occurrence
of an ectopic pregnancy, such as:
 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.
 Scars from a tubal surgery. These scars cause an
adhesion that would not let the fertilized egg travel
towards the uterus.
 Congenital malformations. Physical defects of the
reproductive system such as strictures in the fallopian
tube could cause ectopic pregnancy.
 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.
 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.
 Smoking. Women who frequently smoke have a
higher incidence of ectopic pregnancy than non-smoking
women.
 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.
 Previous ectopic pregnancy. Women who
underwent ectopic pregnancy are advised to avoid
getting pregnant for a year after the incident because
there is a 10% to 20% chance of a subsequent ectopic
pregnancy.

Signs and Symptoms :

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 unusual signs and symptoms at the time
of implantation, so it would be difficult to identify
them at first.
 Sharp abdominal pain. A pregnant woman with
possible ectopic pregnancy might move suddenly, and
as a result, the anterior uterine support might be pulled
and cause pain in the abdomen.
 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.
 Sharp, stabbing pain at the lower quadrant. This
is one of the symptoms which tell that the ectopic
pregnancy has already ruptured.
 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.

Diagnostic Tests
Tests to determine the possibility of ectopic
pregnancy must be performed first before the
diagnosis :

 Pelvic Ultrasound. An early pregnancy ultrasound

is the most common determinant of an ectopic
pregnancy.
 Magnetic Resonance Imaging. This is also
another way to detect the presence of ectopic
pregnancy and it is safer than undergoing a CT scan for
pregnant women.

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 . Methotrexate is
a chemotherapeutic agent that is a folic acid antagonist.
It destroys rapidly growing cells such as the trophoblast
and the zygote. This would be administered until a
negative hCg titer results have been produced.
 Administration of mifepristone. An abortifacient
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 performed
when the ectopic pregnancy has already ruptured to
restore intravascular volume due to bleeding.
 Withdrawing of blood sample. A large amount of
blood would be lost, so blood typing and cross 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
damaged fallopian tube.
 Salpingectomy. This intervention would be
performed if the fallopian tube is completely damaged.
 The affected tube would be removed and what would be
left would be sutured appropriately.

Nursing Management :

Nurses must also have their own function when it comes

to ectopic pregnancy, even without a direct order from the
physician.

Nursing Assessment
 No unusual symptoms are usually present at the
time of implantation of an ectopic pregnancy.
 The usual signs of pregnancy would occur, such as
a positive pregnancy test, nausea and vomiting, and
amenorrhea.
 At 6-12 weeks of pregnancy, the trophoblast would
be large enough to rupture the fallopian tube.
 Bleeding would follow, and it would depend on the
number and size of the affected blood vessels the
amount of bleeding that would occur.
 Sharp, stabbing pain in the lower quadrant is likely
to be felt by the woman once a rupture has occurred,
followed by scant vaginal bleeding.
 Upon arrival at the hospital, a woman who has a
ruptured ectopic pregnancy might present signs of shock
such as rapid, thread pulse, rapid respirations, and
decreased blood pressure.
 There would be a decreased hCg levels
or progesterone levels that would indicate that the
pregnancy has ended.
 Nursing Diagnosis :
 Risk for Deficient Fluid Volume : related to
bleeding from a ruptured ectopic pregnancy.
 Powerlessness  : related to early loss of pregnancy
secondary to ectopic pregnancy.

Nursing Interventions
 Upon arrival at the emergency room, place the
woman flat in bed.
 Assess the vital signs to establish baseline data and
determine if the patient is under shock.
 Maintain accurate intake and output to establish the
patient’s renal function.

Evaluation
 The goal of the evaluation is to ensure that maternal
blood loss is replaced and the bleeding would stop.
 The patient must maintain adequate fluid volume at
a functional level as evidenced by normal urine output at
30-60mL/hr and a normal specific gravity between the
ranges of 1.010 to 1.021.
 Vital signs, especially the blood pressure and pulse
rate, should be stable and within the normal range.
 Patient must exhibit moist mucous membranes,
good skin turgor , and adequate capillary refill.
Ectopic pregnancy is a menace for both the mother and
the zygote. However much we want to save the zygote,
it would be impossible because it has grown outside the
usual site of implantation. The only thing that we could
provide to the woman and their families is proper
education about ectopic pregnancy and ways on how to
prevent it from recurring.
 Hyperemesis gravidarum 
Description

 Hyperemesis gravidarum is severe and excessive

nausea and vomiting during pregnancy, which leads to
electrolyte, metabolic, and nutritional imbalances in the
absence of the medical problems.

Etiology :

 The etiology of hyperemesis gravidarum is

obscure; suggested causative factors include:
1. High levels of HCG in early pregnancy
2. Metabolic or nutritional deficiencies
3. More common in unmarried white women and
first pregnancies
4. Ambivalence toward the pregnancy or family-
related stress
5. Thyroid dysfunction

Pathophysiology :

1. Continued vomiting results in dehydration and

ultimately deceases the amount of blood and nutrients
circulated to the developing fetus.
2. Hospitalization may be required for severe
symptoms when the client needs intravenous hydration
and correction of metabolic imbalance.

Assessment Findings :

 Signs and symptoms occur during the first 16

weeks of pregnancy and are intractable.
 1. Clinical manifestations include:
 Unremitting nausea and vomiting.
 Vomitus initially containing undigested food, bile,
and mucus; later containing blood and material that
resembles coffee grounds
 Weight loss
2. Other common signs and symptoms include:
 Pale, dry skin
 Rapid pulse
 Fetid, fruity breath odor from acidosis
 Central nervous system effects, such as confusion,
delirium, headache, and lethargy, stupor, or coma.

Nursing Intervention for Hyperemesis Gravidarum :

1. Restrict oral intake until the vomiting stops.

Rationale: Maintaining a fluid electrolyte balance and prevent

further vomiting.

2. Give the anti-emetic drugs are prescribed.

Rationale: Preventing vomiting and maintain fluid and
electrolyte balance.

3. Maintain fluid therapy can be saved.

Rationale: Correction of hypovolemia and electrolyte balance.

4. Record intake and output.

Rationale: Determining hydration fluids, and spending
through vomiting.
5. Encourage to eat small meals but often
Rational: Can adequate intake of nutrients your body needs.

6. Advise to avoid fatty foods

Rational: fatty foods can stimulate nausea and vomiting.

7. Encourage to eat a snack such as crackers, bread and tea

(hot) warm before waking up at noon and before bed.
Rational: snack can reduce or prevent nausea, vomiting,
excessive excitatory.

8. Record intake, if oral intake cannot be given within a

certain period.
Rationale: To maintain a balance of nutrients.

9. Review oral hygiene and personal hygiene and the use of

oral cleaning fluid as often as possible.
Rationale: To maintain the integrity of the oral mucosa.

10. Urine Test against acetone, albumin and glucose ..

Rationale: Establish baseline data; done routinely to detect
potential high-risk situations such as inadequate intake of
carbohydrates.

Instructor : DR Marwa Rabee

St name : Shadi Jamel Amer Titi
St number : 21915045