Ectopic Pregnancy

Pregnancy is an occasion worth celebrating. The formation of a new life inside of a woman is a miracle to behold and should be experienced by women who want to seek the fulfillment you have always wanted. However, no matter how you handle a pregnancy with care there are still instances that it is compromised. Nurses promote life and well-being, so it is a must for us to educate our clients with regards to the complications they could experience during pregnancy.

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Definition

  • Ectopic pregnancy happens when the implantation of the fertilized egg occurs outside the uterine cavity.
  • The implantation can either occur on the surface of the ovary, in the cervix, in the abdomen and most commonly in the fallopian tube.

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 (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.

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 crossmatching 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.

Ectopic Pregnancy

Pregnancy is an occasion worth celebrating. The formation of a new life inside of a woman is a miracle to behold and should be experienced by women who want to seek the fulfillment you have always wanted. However, no matter how you handle a pregnancy with care there are still instances that it is compromised. Nurses promote life and well-being, so it is a must for us to educate our clients with regards to the complications they could experience during pregnancy.

Definition

  • Ectopic pregnancy happens when the implantation of the fertilized egg occurs outside the uterine cavity.
  • The implantation can either occur on the surface of the ovary, in the cervix, in the abdomen and most commonly in the fallopian tube.

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 (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.

Risk Factors

Several factors could contribute to the occurrence of an ectopic pregnancy, such as:

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  • 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.

What causes an ectopic pregnancy?

The cause of an ectopic pregnancy isn’t always clear. In some cases, the following conditions have been linked with an ectopic pregnancy:

  • Inflammation and scarring of the fallopian tubes from a previous medical condition, infection, or surgery
  • Hormonal factors
  • Genetic abnormalities
  • Birth defects
  • Medical conditions that affect the shape and condition of the fallopian tubes and reproductive organs

Your doctor may be able to give you more specific information about your condition.

Who is at risk for an ectopic pregnancy?

All sexually active women are at some risk for an ectopic pregnancy. Risk factors increase with any of the following:

  • Maternal age of 35 years or older
  • History of pelvic surgery, abdominal surgery, or multiple abortions
  • History of pelvic inflammatory disease (PID)
  • History of endometriosis
  • Conception occurred despite tubal ligation or intrauterine device (IUD)
  • Conception aided by fertility drugs or procedures
  • Smoking
  • History of ectopic pregnancy
  • History of sexually transmitted diseases (STDs), such as gonorrhea or chlamydia
  • Having structural abnormalities in the fallopian tubes that make it hard for the egg to travel

If you have any of the above risk factors, talk to your doctor. You can work with your doctor or a fertility specialist to minimize the risks for future ectopic pregnancies.

What are the symptoms of an ectopic pregnancy?

Nausea and breast soreness are common symptoms in both ectopic and uterine pregnancies. The following symptoms are more common in an ectopic pregnancy and can indicate a medical emergency:

  • Sharp waves of pain in the abdomen, pelvis, shoulder, or neck
  • Severe pain that occurs on one side of the abdomen
  • Light to heavy vaginal spotting or bleeding
  • Dizziness or fainting
  • Rectal pressure

You should contact your doctor or seek immediate treatment if you know that you’re pregnant and have any of these symptoms.

Diagnosing an ectopic pregnancy

If you suspect you may have an ectopic pregnancy, see your doctor immediately. Ectopic pregnancies can’t be diagnosed from a physical exam. However, your doctor may still perform one to rule out other factors.

Another step to diagnosis is a transvaginal ultrasound. This involves inserting a special wand-like instrument into your vagina so that your doctor can see if a gestational sac is in the uterus.

Your doctor may also use a blood test to determine your levels of hCG and progesterone. These are hormones that are present during pregnancy. If these hormone levels start to decrease or stay the same over the course of a few days and a gestational sac isn’t present in an ultrasound, the pregnancy is likely ectopic.

If you’re having severe symptoms, such as significant pain or bleeding, there may not be enough time to complete all these steps. The fallopian tube could rupture in extreme cases, causing severe internal bleeding. Your doctor will then perform an emergency surgery to provide immediate treatment.

Treating ectopic pregnancy

Ectopic pregnancies aren’t safe for the mother. Also, the embryo won’t be able to develop to term. It’s necessary to remove the embryo as soon as possible for the mother’s immediate health and long-term fertility. Treatment options vary depending on the location of the ectopic pregnancy and its development.

Medication

Your doctor may decide that immediate complications are unlikely. In this case, your doctor can prescribe several medications that could keep the ectopic mass from bursting. According to the AAFP, one common medication for this is methotrexate (Rheumatrex).

Methotrexate is a drug that stops the growth of rapidly dividing cells, such as the cells of the ectopic mass. If you take this medication, your doctor will give it to you as an injection. You should also get regular blood tests to ensure that the drug is effective. When effective, the medication will cause symptoms that are similar to that of a miscarriage. These include:

  • Cramping
  • Bleeding
  • The passing of tissue

Further surgery is rarely required after this occurs. Methotrexate doesn’t carry the same risks of fallopian tube damage that come with surgery. You won’t be able to get pregnant for several months after taking this medication, however.

Surgery

Many surgeons suggest removing the embryo and repairing any internal damage. This procedure is called a laparotomy. Your doctor will insert a small camera through a small incision to make sure they can see their work. The surgeon then removes the embryo and repairs any damage to the fallopian tube.

If the surgery is unsuccessful, the surgeon may repeat a laparotomy, this time through a larger incision. Your doctor may also need to remove the fallopian tube during surgery if it’s damaged.

Home care

Your doctor will give you specific instructions regarding the care of your incisions after surgery. The chief goals are to keep your incisions clean and dry while they heal. Check them daily for infection signs, which could include:

  • Bleeding that won’t stop
  • Excessive bleeding
  • Foul-smelling drainage from the site
  • Hot to the touch
  • Redness
  • Swelling

You can expect some light vaginal bleeding and small blood clots after surgery. This can occur up to six weeks after your procedure. Other self-care measures you can take include:

  • Don’t lift anything heavier than 10 pounds
  • Drink plenty of fluids to prevent constipation
  • Pelvic rest, which means refraining from sexual intercourse, tampon use, and douching
  • Rest as much as possible the first week post-surgery, and then increase activity in the next weeks as tolerated
  • Always notify your doctor if your pain increases or you feel something is out of the ordinary.

Prevention

Prediction and prevention aren’t possible in every case. You may be able to reduce your risk through good reproductive health maintenance. Have your partner wear a condom during sex and limit your number of sexual partners. This reduces your risk for STDs, which can cause PID, a condition that can cause inflammation in the fallopian tubes.

Maintain regular visits with your doctor, including regular gynecological exams and regular STD screenings. Taking steps to improve your personal health, such as quitting smoking, is also a good preventive strategy.

What’s the long-term outlook?

The long-term outlook after an ectopic pregnancy depends on whether it caused any physical damage. Most people who have ectopic pregnancies go on to have healthy pregnancies. If both fallopian tubes are still intact, or even just one, the egg can be fertilized as normal. However, if you have a preexisting reproductive problem, that can affect your future fertility and increase your risk of future ectopic pregnancy. This is especially the case if the preexisting reproductive problem has previously led to an ectopic pregnancy.

Surgery may scar the fallopian tubes, and it can make future ectopic pregnancies more likely. If the removal of one or both fallopian tubes is necessary, speak to your doctor about possible fertility treatments. An example is in vitro fertilization that involves implanting a fertilized egg into the uterus.

Pregnancy loss, no matter how early, can be devastating. You can ask your doctor if there are available support groups in the area to provide further support after loss. Take care of yourself after this loss through rest, eating healthy foods, and exercising when possible. Give yourself time to grieve.

Remember that many women go on to have healthy pregnancies and babies. When you’re ready, talk to your doctor about ways you can ensure that your future pregnancy is a healthy one.

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.

  • ltrasound 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 crossmatching 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

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.