CASE PRESENTATION:

I. CASE INTRODUCTION
Presenting the case of patient TBB, 37 years old, G4P2, with 7 weeks AOG from Roxas
City with a chief complaint of sudden onset of right lower quadrant tenderness along
with some vaginal spotting and a possible diagnosis of ectopic pregnancy right,
unruptured.
II. PAST MEDICAL AND FAMILY HX
History of asthma on maternal side, renal failure on paternal side and diabetes mellitus
on both sides.
Patient has a history of chlamydia.

III. PERSONAL SOCIAL HX

Pt is a smoker who smokes 2 packs of cigarettes per month. She is not an alcoholic
beverage drinker, and denies illicit drug use. She is a college graduate, a housewife and
is currently unemployed. The pt. had her first coitus at age 21 with 1 promiscuous sexual
partner. There is no Hx of OCP or IUD. Pt had chlamydia at age 29.

IV. MENSTRUAL HX
The pt. had her menarche at age 14 with subsequent periods occurring at 28 days,
lasting for 5 days, having 3 fully soaked pads per day. Patient usually experience
dysmenorrhea on her first day. LMP was March 1, 2022.

V. OBSTETRIC HX

The pt. is a G4P2 T2P0A1L2M0. This is her 4th pregnancy.

The first pregnancy was an uncomplicated pregnancy last 2010, delivered via normal
spontaneous vaginal delivery (NSVD) by a doctor in a local hospital. Live baby boy, and
has a weight of 3.0 kg Appropriate for Gestational Age (AGA), w/o any complications.

The same goes for the second pregnancy last 2014. Live baby boy, and has a weight of
2.8 kg, Appropriate for Gestational Age (AGA), w/o any complications.

The third pregnancy last 2017 resulted in spontaneous abortion at 10 weeks AOG,
dilatation and curettage done at PGH.

VI. CLINICAL PRESENTATION

 The patient presented to the Emergency room with chief complaint of _.
The patient presented to the Emergency room with chief complaints of sudden
onset of right lower quadrant tenderness along with some vaginal spotting.
  Describe General appearance of Pt.
The patient appears to be grimacing in pain while walking towards the examiner
with a slumped posture and with her hands holding her lower abdomen. The
patient appears to be pale, anxious, and uncomfortable as well as she always
changes position every 2- minutes.

 Signs noticed by the examiner

Abdomen is soft, mild tenderness on the right hypogastrium. Speculum

examination: cervix is healthy, os closed, slight bleeding. No cervical motion
tenderness noted. On pelvic examination, uterus is slightly enlarged and a solid,
mobile, tender, and unilateral adnexal mass about 3cm is observed on the right
adnexa. Bagel’s sign was found during pelvic ultrasonography.

 Initial Assessment by Nurse

Patient’s vital signs were taken as follows: PR 88 bpm, BP 110/70 mmHg, RR

18bpm, T 36.5 °C and a pain scale of 8/10. Upon history taking, it was found out that
she had a history of chlamydia. On physical examination, she appears pale, anxious, and
uncomfortable as she always changes position every 2 minutes. Abdomen is soft, with a
mild tenderness on the right hypogastrium. Adnexa was palpated and a solid, mobile,
tender, and unilateral adnexal mass about 3cm is observed on the right adnexa. Uterus
is slightly enlarged. Patient has a closed cervix and a scant blood in the vaginal vault.

 Admitting Diagnosis
Ectopic pregnancy (unruptured)

 Differential Diagnoses
UTI
Abortion 
Pelvic inflammatory disease
Appendicitis

VII. TEXTBOOK DISCUSSION

 Description
An ectopic pregnancy is one in which implantation occurred outside the uterine cavity.
With ectopic pregnancy, fertilization occurs as usual in the distal third of the fallopian tube.
Unfortunately, because an obstruction is present, the zygote cannot travel the length of the
tube. It lodges at a structured site along the tube and implants there instead of in the uterus.
  Risk Factors (Modifiable, Non-Modifiable)
Modifiable: 
 Smoking 

Non-Modifiable:
 Previous Ectopic Pregnancy 
 G4
 Adhesion of the fallopian tube from a previous infection such as chronic
salpingitis or pelvic inflammatory disease)
 Congenital malformations such as webbing (fibrous bands) that block a
fallopian tube
 Scars from tubal surgery
 Uterine tumor pressing on the proximal end of the tube

 Signs and Symptoms

TEXTBOOK RATIONALE EVIDENT IN PATIENT

Positive pregnancy test HCG

Amenorrhea There are no unusual

Nausea and vomiting
Severe sharp knife pain in the
right lower quadrant that
radiates to the right shoulder
Positive Cullen’s sign
symptoms at the time of
implantation. The corpus
luteum of the ovary continues
to function as if the
implantation were in the
uterus so no menstrual flow
occurs.
A woman begins to experience
the usual signs of nausea and
vomiting of early pregnancy.
Rupture of the fallopian tube
produces sharp lower
abdominal pain, which may
radiate to the shoulders and
neck and become extreme
with cervical or adnexal
palpation
ecchymosis around the
umbilicus associated with
severe intraperitoneal
bleeding. Blood travels from a

Signs of hypovolemic schock;
Tachycharida, Tachyonea and
Hypotension
 Diagnostics
Pregnancy Test for HCG
Transvaginal Ultrasound
Laparoscopy or culdoscopy
retroperitoneal organ or
structure to the periumbilical
area, where it diffuses through
subcutaneous tissues. It’s seen
with ruptured ectopic pregnan
The woman becomes
hypotensive from blood loss,
she will experience light-
headedness and a rapid pulse,
signs of hypovolemic shock.
Positive
will demonstrate the tube has
already ruptured and if the
blood is already collecting in
the peritoneum
can also be used to visualize
the fallopian tube if the
symptoms alone do not reveal
a clear picture of what has
happened.
(A fold of peritoneum behind
the uterus is the posterior
ligament. This forms a pouch
(Douglas cul-de-sac) between
the rectum and uterus.
Because this is the lowest
point of the pelvis, any fluid
(such as blood) released from
a condition, such as a ruptured
tubal (ectopic) pregnancy,
tends to collect in this space.
The space can be examined for
the presence of fluid or blood
to help in diagnosis by
inserting a culdoscope through
 the posterior vaginal wall
(culdoscopy) or a laparoscope
through the abdominal wall
(laparoscopy)

 Medical Management
Oral administration of methotrexate. The advantage of this therapy is that the
tube is left intact, with no surgical scarring that could cause a second ectopic
implantation. Women are treated until a negative hCG titer is achieved. A
hysterosalpingogram or ultrasound is usually performed after this to assess that
the pregnancy is no longer present and also whether the tube appears fully patent.

 Nursing Management

VIII. PHYSICAL EXAM

 The Pt. has stable vital signs. Was taken : PR 88 bpm, BP 110/70 mmHg, RR
18bpm, T 36.5 °C
 Essentially Normal Systemic Physical Examination except for the following
systems:

GI SYSTEM Abdomen is soft, with a mild

tenderness on the right
hypogastrium. Adnexa was palpated
and a solid, mobile, tender, and
unilateral adnexal mass about 3cm is
observed on the right adnexa.

REPRODUCTIVE SYSTEM Uterus is slightly enlarged. Pt has a

scant blood in the vaginal vault.

 Uterine pregnancy at 7 weeks AOG by LMP. Fetal presentation cannot be identified as

well as the fundic height and fetal heart tone.

IX. SHORT TERM PLAN

 Tests to be ordered

Blood grouping B+
CBC Normal
.
 LFT Normal
KFT Normal
Pelvic Ultrasonography This will confirm shows an empty
ectopic pregnancy uterus, no gestational
and will rule out sac and no cardiac
appendicitis since activity was seen and a
it will detect an 3 x 3 complex adnexal
inflamed mass in the location of
appendix. the right adnexa with
ring of fire sign.
Urine test This will rule out UTI. Normal. Presence of
Presence of nitrates is nitrates were not
highly specific for a detected.
patient with UTI.
Serum beta HCG

 Differential Diagnoses to rule out

UTI
Abortion 
Pelvic inflammatory disease
Appendicitis

 STAT concerns that need TX

Abdominal pain
Hemorrhage
Hypovolemia

X. LONG TERM PLAN

 Medical Management

Methotrexate Therapy – to eliminate pregnancy and to decrease levels of HCG.

Multi Dose MTX Therapy – Methotrexate is given by weight and the therapy spans for 8 days.
The regimen involves administration of Methotrexate as 1mg/kg on days 1,3,5,and 7 followed
by 4 doses of Leucovorin as 0.1mg/kg on days 2,4,6,8

 Surgical Management PRN

Surgical management should be performed if:
  the ectopic pregnancy has ruptured and if the patient is hemodynamically
unstable
 patient is not suitable for medical management and
 medical therapy has failed.
The most effective surgical management for ectopic pregnancy is the salpingectomy.

XI. NURSING CARE PLAN

 Nursing Management
Manage bleeding and pain
Maintain and monitor temperature
Prevent shock and sepsis
Offer Psychological Support
 Prioritization of Nursing Problems
Abdominal Pain
Sepsis
Hemorrhage
Hypovolemic Shock

 Nursing Responsibility
Monitor vital sign
Assess patient pain scale
Provide hot compress
Provide psychological support
Patient Education

 Health Education PRN

Importance of follow up
Educate the woman about common side effects
Educate the woman about the danger signs
Refrain from vigorous activity and sexual intercourse
Avoid narcotic analgesics

Springhouse-Lippincott Manual of Nursing Practice Series_ Alarming Signs and Symptoms-LWW

(2006).pdf