Ectopic Pregnancy

(1st Trimester Bleeding)

General Information:

Implantation of fertilized ovum in site other than endometrial lining of the uterus.

Usually occurs in the fallopian tubes where tissue is capable of the growth needed to accommodate pregnancy , so rupture of the site occurs before 12 weeks.

Pregnancy caused by high levels of progesterone , which can alter the mobility of egg cells within the uterine cavity.

Sites Of Implantation :o F - allopian tube (Ampullar ) – implant grow and may extrude into abdominal cavity ; most common site of ectopic pregnancy o F - imbrial (80 %)o O – varian (5%)o C - ervical os (internal ; 0.2%) o A – bdominal viscera (1.4 %)o I - sthmic - tube ruptures after 4 – 5 weeks growth of embryo (12 %)o I – nterstitial / Cornual – the most dangerous part for ectopic pregnancy ( 2 %)o I – ntraligamentous o I – nfudibular o I - ntramural

Predisposing Factor Of Ectopic Pregnancy :

Recall CAUSE HIPS

• C – ongenital anatomic irregularity e.g. malformed fallopian tube • A – dvanced maternal age • U – se of ovulation inducing drugs (hormonal factors)

e.g. Clomid , Gonad F • S – alpingectomy (removal of fallopian tube ) ; S alphingitis ( infection and inflammation ) of the oviducts)• E – ndometrious ( the growth of endometrial cells in areas

outside the uterus )• H - igh levels of progesterone which can alter the mobility of the egg in the fallopian tube e.g. tubal atony relaxation • I – nfertility ( ovulation induction with clomiphene citrate

or injectable gonadotropin therapy ) ; In – vitro fertilization (IVF)• P – elvic Inflammatory disease ; P – revious tubal or pelvic

surgery ; P – resence of IUD• S – moking (includes altered tubal and uterine motility or

altered immunity and delayed ovulation)

Assessment Findings : A – menorrhea or abnormal menses (after fallopian tube implantation) A – bdomen , tender and rigid B – bleeding , minimal vaginal bleeding (scant vaginal spotting ) , if severe lead to shock or hemorrhage ; often requires blood transfusion and fluid replacement B – lood pressure ; fall / dropped H – emoglobin (hgb) and hematocrit (hct) ; progesterone low / fall (tubal ruptures indicators of shock ) N – nausea , vomiting ,and faintness P - ain extreme with movement of the cervix during pelvic examination ; right or left colicky abdominal pain P – ulse ; rapid (sign of impending shock ) P – elvic mass abnormal sometimes R – ectal pressure or distention of posterior fonix if blood collects in

Douglas cul de - sac R – espirations ; rapid (sign of impending shock) R – upture of fallopian tube (Pain) : localized ,severe , stabbing

abdominal pain , radiating to the shoulder and neck as abdomen fills with blood ; sudden knifelike , one sided (unilateral ) lower quadrant abdominal pain S - yncope ( a sudden fall of blood pressure or failure of cardiac systole ) T - emperature ; normal low U - uterus : boggy and tender U - mbilicus : bluish tinge discoloration (Cullen’s sign) W - eakness Y - awning

Complications : recall HIPS

H - emorrhage I – infection P – ain S - hock

PATIENT PROBLEM / NURSING DIAGNOSIS

• Hypovolemic shock due to effects of painful tubal rupture and blood loss .• Fluid volume deficit related to blood loss• Pain related to abdominal bleeding secondary to tubal rupture • Anxiety related to uncertainty about condition and potential loss of childbearing capacity • Infection related to surgical excision • Anticipatory grieving related to the loss of

pregnancy

DIAGNOSTIC TESTS :

Endovaginal ultrasonography – pelvic ultrasonography using a probe inserted into the vagina .

Laparoscropy reveals pregnancy outside the uterus

Culdocentesis – aspiration of fluid from the Culdesac Of Douglas

Beta hCG - a pregnancy hormone produced by the cells of the implanting egg and can be produced in the absence of an embryo , can be detected in maternal plasma or urine by the 8 to 9 days after ovulation

Culdoscopy – introduction of the endoscope through the posterior vaginal wall to view rectovaginal pouch and pelvic viscera .

MEDICAL TREATMENT

1 . Non – surgical treatment A. Start IV / blood transfusion as

prescribed .

B. Drugs to be used like :

a. Methotrexate – anti – cancer drug ; chemotherapeutic agent that attacks and destroys fast growing cells indicated for women who desires for future pregnancy .

b. Mifepristoner - an abortificient which is effective at causing sloughing the tubal implantation site .

c. Leucovorin – is an active form of folic acid that is used to “rescue ” normal cells from the adverse effect of methotrexate therapy in the treatment of oesteosarcoma given intravenously or orally

d. Dactinomycin – anti – neoplastic antibiotic , part of combination drug regimen in the treatment of a variety of sarcomas and carcinomas.

2. SURGERY

a. Salpingotomy - incision into the fallopian tube

b. Salpingostomy – establishment of an artificial opening in a fallopian tube in which the fimbracted extremity has been closed .

c. Laparoscopic Salpingectomy – incision of the fallopian tube and remove only the pregnancy

d. Abnominal incision if the women is in shock

e. Oopherectomy – removal of ovary

f. Suturing of fallopian tube

NURSING MANAGEMENT : Ask the patient to date her menstruation and obtain serum hCG levels as ordered Prevent shock by monitoring vital signs , monitor vaginal bleeding for extent of fluid loss and urine output. Check the amount , color , and odor of vaginal bleeding ; monitor pad count prevent infection by hand washing and personal hygine Withhold oral food or fluid ; maintain nothing by mouth (NPO) status in anticipation of possible surgery Replace fluid loss by maintaining ongoing IV intake Locate character of pain and reduce pain by administering analgesic as prescribed .

locate character of pain and reduce pain by

adminestering analgesic as prescribed In case of emergency , blood sample is withdrawn for

hemoglobin , typing and cross matching and Hcg level for immediate pregnancy testing.

Prepare client for laparascopic removal of fallopian tube (salpingectomy) surgery ; or ovary (oophorectomy )

Supportive treatment , e.g. blood transfusion with whole blood or packed RBC’s to replace excessive blood loss ; administration of supplemental iron ( I.M.) administration broad spectrum I.V. . Antibiotic for sepsis ; and institution of high protein diet ,

Determine if patient is RH – negative ; if she is , administer Rho (D) immune globulin (RhoGAM) as ordered after treatment or surgery

Allow patient to express feelings about loss of pregnancy and concerns about future pregnancies .

Listen empathetically to the woman’s account of what has happened . Explain to her the future of child bearing potential.