ECTOPIC PREGNANCY

Marino M. Abogado Jr.BSN II - Pure

Objectives of the discussion To know the definition of ectopic pregnancy

and its manifestation. To have an idea with its clinical symptoms. To know the illness’ etiology and

pathophysiology. To determine what is the appropriate medical

and nursing management

DefinitionPregnancy in which the fertilized egg or embryo implants on any

tissue other than the endometrial lining of the uterus.

Etiology Pelvic inflammatory disease History of prior ectopic pregnancy History of tubal surgery and

conception after tubal ligation Use of fertility drugs or assisted

reproductive technology Use of an intrauterine device

Increasing age Smoking Salpingitis isthmica nodosum T-shaped uterus Prior abdominal surgery, failure with

progestin-only contraception ruptured appendix.

Common Ectopic Sites1. Ampullary (mid) portion of the fallopian tube (80-90%), 2. Isthmic (area closer to the uterus) portion of the fallopian

tube (5-10%), 3. Fimbrial (distal end away from the uterus) portion of the

fallopian tube (about 5%), 4. Cornual (within the uterine muscle) portion of the fallopian

tube (1-2%), 5. Abdomen (1-2%), 6. Ovary (less than 1%), or 7. Cervix (less than 1%).

Incidence and Impact Occurs in 1 in 50 pregnancies Is becoming increasingly more common Is the second leading cause of maternal

mortality overall, and primary mortality factor in first trimester pregnancies

May lead to impairment or loss of fertility

Clinical Signs and Symptoms Amenorrhea Vaginal bleeding(40-50%) Nausea Breast fullness Fatigue Pain

Low abdominal pain Heavy cramping Pelvic tenderness (75%) Enlarged uterus Adnexal mass(50%) Shoulder pain Recent dyspareunia

Diagnosis History and physical

any woman presenting with pain and vaginal bleeding should be considered to have an ectopic pregnancy until otherwise ruled out

Laboratory markersBeta-HCG(measured in mIU/mL) --lack of

doubling signals only impending failure, not indicative of location;absolute value only helpful in correlation with ultrasound

Progesterone--also only indicates impending loss, not location

Ultrasound--transvaginal is most sensitive at this stage of pregnancy.

Correlation with the quantitative serum hormone levels is suggested to increase your sensitivity –if intrauterine gestational sac is seen and b-

HCG is 1,000-2,000, normal pregnancy is virtually certain.

If b-HCG is <1,000 and there is an empty uterus, ectopic pregnancy is very likely

Culdocentesis In this test, a needle is inserted into the

space at the very top of the vagina, behind the uterus and in front of the rectum. Any blood or fluid found there likely comes from a ruptured ectopic pregnancy.

Cullen's sign can indicate a ruptured ectopic pregnancy.

Medication Methotrexate 1 mg/kg body weight is

an antimetabolite which inhibits the reduction of folic acid to tetrahydrofolate. This interferes with DNA synthesis and cell multiplication. Ideal for disrupting trophoblastic tissue proliferation.

SurgeryTube sparing salpingotomy--used when

gestational sac is <2cm and in distal tube; lateral incision made and gestational sac removed.

Tube sacrificing salpingectomy

Effects of Ectopic Pregnancy

The muscle wall of the tube has not the capacity of uterine muscles for hypertrophy and distention and tubal pregnancy nearly always end in rupture and the death of the ovum.

Tubal abortion – usually in ampullary about 8 weeks – forming pelvic haematocele

Rupture into the peritoneal cavity○ Occur mainly from the narrow isthmus before 8

weeks or later from the interstitial portion of the tube. Haemorrhage is likely to be severe.

○ Sometimes rupture is extraperitoneal between the leaves of the broad ligament – Broad ligament haematoma. Haemorrhage is likely to be controlled

Tubal pregnancy – effect on uterus

The uterus enlarge in first 3 months as if the implantation were normal, reach the size of a gravid uterus of the same maturity.

Uterine decidua grows abundantly and when the embryo dies bleeding occurs as the decidua degenerates due to effect of oestrogen withdrawal.

Nursing Diagnosis: Powerlessness related to early loss of pregnancy secondary to ectopic pregnancy

Outcome Evaluation: Client states she feels sad at pregnancy loss but is able to deal with situation; has returned to previous level of activities and has forward-thinking plans.

Uterus outlined in red, uterine lining in green, tubal ectopic pregnancy yellow. Fluid in uterus at blue circle - sometimes called a "pseudosac" - looks like an early pregnancy sac, but is not (usually a small blood collection).

Citations Chambers, H. M., & Chan, F. Y. (2009). Support for women/families after

perinatal death. Cochrane Database of Systematic Reviews, 2009(1), (CD000452).

Chhabra, S., Dargan, R., & Nasare, M. (2007). Antepartum transabdominalamnioinfusion. International Journal of Gynaecology and Obstetrics,97(2), 9599. Chauhan, S. P., et al. (2007). Intrauterine growth restriction and

oligohydramnios among high-risk patients. American Journal of Perinatology, 24(4), 215–221.

Clark, E. A. S., Silver, R. M., & Branch, D. W. (2007). Do antiphospholipidantibodies cause preeclampsia and HELLP syndrome? Current Rheumatology

Reports, 9(3), 219–225. Crombleholme, W. R. (2009). Obstetrics. In S. J. McPhee & M. A. Papadakis

(Eds.). Current medical diagnosis and treatment. Columbus, OH: McGraw-Hill.

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