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Ectopic pregnancy is the abnormal implantation of a fertilized ovum anywhere outside the uterine cavity or normal site of implantation. This is one of the most common complications of pregnancy during the first trimester. There is no exact statistic that would represent ectopic pregnancy because many cases were masked by misdiagnosis. Oftentimes, pregnancy is believed to be normal during its early phase due to the presentation of some signs indicative of an ideal gestation. This is the reason why ectopic pregnancy is usually diagnosed late, or when pain starts to be manifested as sign of rupture of the fallopian tube (most common manifestation) and begins to develop more serious problems such as hemorrhage.

TYPES

The types of ectopic pregnancy is based on the site of implantation. The reason for the site of implantation is still unclear, but, is/are associated with some forms of infections, anatomical abnormalities, and some birth control methods.

  1. Tubal ectopic pregnancy—the fertilized ovum was implanted anywhere within the fallopian tube. This is the most common type of ectopic pregnancy. The usual site of implantation is on the outer-third of the fallopian tube.
  2. Cervical ectopic pregnancy—this is the abnormal implantation of a fertilized ovum near or on the cervix. This occurs due to the inability of the uterus or not ideal set-up of the uterus for implantation. Scar formation from previous uterine surgery (caesarean delivery-most common) contributes to the incidence rate.
  3. Abdominal ectopic pregnancy—this is the abnormal implantation of a fertilized ovum outside the uterus, but, within the abdominal cavity.

Ovarian ectopic pregnancy—this is the abnormal implantation of a fertilized ovum within the ovary. This is due to the non-progression of a matured ovum through the fallopian tube and got fertilized b a sperm cell.

NORMAL ANATOMY AND PHYSIOLOGY

Anatomy

  1. Ovaries—these are considered the gonads (primary sex organs) of the female reproductive system. Normally, there are two ovaries in a female body; measuring approximately 3.5 centimeters long, 2.5 centimeters wide, and 1 centimeter in thickness; making an ovoid shape. These are located on each side (shallow depression) of the wall of the pelvic cavity (ovarian fossa), held in place by various ligaments (broad ligament-largest). The tissues of the ovaries are composed of two indistinct regions known as inner medulla (loose connective tissues with numerous blood vessels, lymphatic vessels, and nerve fibers) and ovarian cortex (compact tissues with ovarian follicles). Its primary function is to produce egg cells.
  2. Fallopian tubes—these are otherwise known as oviducts or uterine tubes. There is a pair of fallopian tubes in a normal female body. These are about 10 centimeters long and 0.7 centimeters in diameter. They are held in place by by portions of the broad ligament. Each fallopian tube has an opening near each ovary and connected to the uterus on its other end. The wall of the fallopian tube is composed of inner mucosal layer, middle muscular layer, and an outer covering of the peritoneum. The primary function of these organs is to aid in the transport of egg cells towards the uterus.
  3.  Uterus—the uterus is a hallow, muscular organ with a shape of n inverted pear. This is highly flexible that is about 7 centimeters long, 5 centimeters wide, and 2.5 centimeters in diameter on its broadest point during a pre-pregnat state. This is held in place by the broad ligament within the anterior portion of the pelvic cavity, above the vagina, and is bent forward over the urinary bladder. The upper 2/3 of the uterus is called the fundus and the lower 1/3 is called the cervix. It is composed of three layers namely: 1. Endometrium(inner layer), 2. Myometrium (muscle layer), and 3. Perimetrium (outer covering). The normal uterus can hold and sustain implantation and pregnancy. Its vascular nature has all what is needed for gestation.

Vagina—this is a fibromuscular tube approximately 9 centimeters in length. This connects the uterus to the outer female reproductive organs. It has 3 main functions: 1. Convey uterine secretions, 2. Receives the penis during intercourse, and 3. Transports the fetus during delivery.

Physiology

CAUSES AND INCIDENCE

            The exact cause of ectopic pregnancy is unknown, however, with the following risk factors; the incidence of this complication of pregnancy is increased.

Health experts are unanimously convinced that any structural anomaly within the fallopian tube causes the delay or prevents the movement of a fertilized ovum unto the normal site of implantation, is the major contributor in the occurrence of ectopic pregnancy. Among these contributory factors are tubal adhesions and salphingitis (inflammation of the fallopian tube/s). Also, congenital and developmental anomalies of the fallopian tubes; use od intrauterine device (IUD), history of previous ectopic pregnancy and multiple induced abortions heightened its occurrence.

Aside from the anatomical causes, physiological factors are also of great impact in the development of ectopic pregnancy. Some of these are menstrual reflux and decreased tubal motility.

Previous surgeries such as tubal surgery and inflammatory diseases such as endometriosis and PID (pelvic inflammatory disease) are also great contributory factors.

Sexually-transmitted diseases (STD) cause 43% of all ectopic pregnancy cases. Along with this, 25% of all the cases are from chlamidial infections.

PATHOPHYSIOLOGY

SIGNS AND SYMPTOMS

The clinical manifestations of ectopic pregnancy vary from its stage or state. These provides information on its severity and serves as the basis of the treatment plan.

Aside from the stage –specific signs and symptoms, there are also some manifestations that helps confirm the diagnosis of ectopic pregnancy. Among these are:

  1.  Positive pregnancy test
  2.  Sharp and localized pain in the cervix upon palpation (vaginal examination)
  3. Shock and circulatory collapse from internal hemorrhage (latest and most indicative of severe problem)
  4. Amenorrhea
  5. Uterine size is usually similar with what it would be in a normal pregnancy
  6. Abdominal tenderness on palpation
  7. Pelvic examination reveals a mass, either posterior or lateral to the uterus
STAGEMANIFESTATIONS
Early signs1. Abnormal menstrual period (after a missed period)2. Spotting3. Positive for some signs of pregnancy (first trimester)

4. Dull pain on affected side in some cases

 

Impending or post-tubal rupture1. Sudden acute lower abdominal pain2. Nausea and vomiting3. Kehr’s sign (referred pain)

4. Neck pain (if blood is present in the peritoneal cavity)

5. Rectal pressure (if blood is present in the cul-de-sac)

6. Some signs of shock like elevated pulse rate, respiratory rate and blood pressure during its early stage and then drops

7. Vaginal bleeding (scanty and dark)

COMPLICATIONS

There could only be one definite complication of ectopic pregnancy, and that is the cessation of pregnancy to prevent maternal tendencies. This is the absolute way to free the mother or woman of further complications, besides, the implantation in on undesired environment for growth and development. To do this, the mother is expected to undergo a voluntary surgery to evacuate the growing products of conception before it inflicts unwanted effects like the rupturing of the tube.

Other possible complications of ectopic pregnancy include:

  1. Hypovolemia
  2. Shock
  3. Hormonal problems
  4. Infertility
  5. Another/future ectopic pregnancy/ies

DIAGNOSTIC EVALUATIONS

  1. Ultrasonography—may determine tubal mass and the absence of gestational sac within the uterus.
  2. Serum β-HCG (Human Chorionic Gonadotropin)—when done serially, shows extrauterine pregnancy
  3. Laparoscopy—to visualize tubal pregnancy
  4. Culdocentesis—may indicate intraperitoneal bleeding
  5. Laparotomy—to have direct visualization of the abnormal implantation

NURSING DIAGNOSES

  1. Fear related to abdominal pain and pregnancy status.
  2. Grief related to loss of pregnancy.
  3. Anxiety related to unfamiliarity of the health/pregnancy condition.
  4. Risk for fluid volume deficit related to blood loss secondary to ruptured tube.
  5. Acute pain related to growing products of conception against the site of implantation. 

MANAGEMENT

               The overall goal of management of ectopic pregnancy is to preserve the life of the mother. This is only achieved through terminating the pregnancy and to reconstruct the organ where the implantation took place.

The termination of ectopic pregnancy can be done either pharmacologically or surgically. The pharmacological treatment is through the use of methotrexate, a folic acid antagonist which inhibits cell division. With this action, it retards the growth and development of the products of conception, leading to its death and detachment. This is primarily indicated for early stages of ectopic pregnancies. On the other hand, the surgical approach is done for later stages, especially, if there are indications of rupture. Surgeons may choose one of the following, depending on the extent of damage:

  1. Removal of ectopic pregnancy with tubal resection
  2. Salphingostomy
  3. Salphingectomy
  4. Salphingo-oophorectomy

NURSING MANAGEMENT

Since the termination of pregnancy is inevitable, the overall goal of nursing management is the provision of supportive care and health teachings towards the loss of pregnancy. For cases indicative of surgery, providing preoperative and postoperative care are the major concerns.

A. Assessment

 Monitor the following for it indicates the severity of the case, leading to the precise diagnosis and plan of care:

  1. Vital signs
  2. Vaginal bleeding
  3. Characteristics and location of pain
  4. Abdominal tenderness
  5. Last menstrual period (LMP)
  6.  Pregnancy test results

B. Interventions

1. Fluid volume

    • Ensure a patent IVF and blood transfusion line
    • Obtain blood samples for laboratory workouts as ordered (CBC and typing)
    • Monitor vital signs
    • Monitor I&O

2. Grief

    • Encourage verbalization of feelings
    •  Be available to provide emotional support at all times
    • Include family and significant others in the therapy
    • Suggest referrals if necessary (clergy, psychiatrists, work groups)

3. Pain

    • Administer analgesics as ordered
    • Use of relaxation techniques and diversional activities

C. Educative

    1. Teach on facts and chances of having another ectopic pregnancy. Try incorporating the signs such as abnormal vaginal bleeding, abdominal pain and irregularity of menstruation.
    2. Teach on signs of postoperative infections such as fever and malodorous vaginal discharges, and report them promptly.
    3. Discuss on other forms of contraception available.

EVALUATION

  1. Stable vital signs
  2. No signs of postoperative infections
  3. Client and significant others have gone through a successful grieving process and now shows acceptance and willingness to move-on.
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A Registered Nurse with Master of Arts in Nursing, Major in Medical-Surgical Nursing. Worked as a Clinical Instructor for 5 years.