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 type 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.
Tubal ectopic pregnancythe 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.
Cervical ectopic pregnancythis 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.
Abdominal ectopic pregnancythis is the abnormal implantation of a fertilized ovum outside the
uterus, but, within the abdominal cavity.
Ovarian ectopic pregnancythis 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.
ANATOMY
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.
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.

Uterusthe 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),
3.Perimetrium (outer covering).
The normal uterus can hold and sustain implantation and pregnancy. Its vascular nature has all what is needed
for gestation.
Vaginathis 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.

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.

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:

POSITIVE PREGNANCY TEST

-Sharp and localized pain in the cervix upon palpation (vaginal examination)
-Shock and circulatory collapse from internal hemorrhage (latest and most indicative of severe problem)
-Amenorrhea
-Uterine size is usually similar with what it would be in a normal pregnancy
-Abdominal tenderness on palpation
-Pelvic examination reveals a mass, either posterior or lateral to the uterus

STAGE
Early signs MANIFESTATIONS
1. 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 rupture 1. Sudden acute lower abdominal pain2. Nausea and vomiting3.Kehrs
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:
Hypovolemia
Shock
Hormonal problems
Infertility
Another/future ectopic pregnancy/ies
DIAGNOSTIC EVALUATIONS
Ultrasonographymay determine tubal mass and the absence of gestational sac within the uterus.
Serum -HCG (Human Chorionic Gonadotropin)when done serially, shows extrauterine pregnancy
Laparoscopyto visualize tubal pregnancy
Culdocentesismay indicate intraperitoneal bleeding
Laparotomyto have direct visualization of the abnormal implantation
NURSING DIAGNOSES
Fear related to abdominal pain and pregnancy status.
Grief related to loss of pregnancy.
Anxiety related to unfamiliarity of the health/pregnancy condition.
Risk for fluid volume deficit related to blood loss secondary to ruptured tube.
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:
-Removal of ectopic pregnancy with tubal resection
-Salphingostomy
-Salphingectomy
-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:
Vital signs
Vaginal bleeding
Characteristics and location of pain
Abdominal tenderness
Last menstrual period (LMP)
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

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.
Teach on signs of postoperative infections such as fever and malodorous vaginal discharges, and report them
promptly.
Discuss on other forms of contraception available.

EVALUATION
-Stable vital signs
-No signs of postoperative infections
-Client and significant others have gone through a successful grieving process and now shows acceptance and
willingness to move-on.