ECTOPIC PREGNANCY

• Implantation of the fertilized ovum outside

the uterine cavity
• Most occurs in fallopian tube (95%), other
sites include the cervix, ovary, or
abdominal cavity
• Second most common cause of vaginal
bleeding during pregnancy
• Significant cause of maternal death due to
hemorrhage
Ectopic Pregnancy
Ectopic Pregnancy
Ectopic Pregnancy
Pathophysiology:
Obstruction
↓
• Adhesion of the fallopian tube from a
previous infection (chronic salpingitis or PID)
• Congenital malformations
• Scars from tubal surgery
• Uterine tumor pressing on the proximal end
of the tube
↓
 ↓
.
Zygote cannot travel the length of the tube
↓
Lodges and implants at the strictured site
↓
Ectopic pregnancy
 Pathophysiology
Other factors:
• sexually transmitted tubal infections may
also be a factor as may the use of IUD →
causes irritation of the cellular lining of the
uterus and the fallopian tubes
 Assessment Findings
• normal pregnancy symptoms other that
mild abdominal pain
• amnorrhea or abnormal menses
• slight vaginal bleeding; unilateral pelvic
pain over the mass – due to tearing & destruction
(rupture) of bv
• abnormally low hCG
 Assessment Findings
• sudden, severe abdominal pain radiating
to the shoulder
• tender uterus
• Syncope - brief lapse of consciousness
• N/V
• shock with profuse bleeding → due to
internal bleeding
 S/S of Hypovolemic Shock
Assessment Significance
Increased PR Heart is attempting to circulate
decreased blood volume

Decreased BP Less peripheral resistance due to

decreased blood volume

Increased RR Increase gas exchange to better

oxygenate decreased RBC volume

Cold, clammy skin Vasoconstriction occurs to maintain

blood volume in central body core

Decreased urine output Inadequate blood is entering kidney

due to decreased blood volume

Dizziness or decreased LOC Inadequate blood is reaching

cerebrum due to decreased blood
volume
Decreased central venous Decreased blood is returning to heart
pressure (CVP) due to reduced blood volume
 DX TEST FINDINGS
• Serum pregnancy (hCG) test → shows an
abnormally low level of hCG, when
repeated in 48hrs, the level remains lower
than the levels found in a normal
intrauterine pregnancy
• Real-time ultrasonography →
determination of intrauterine pregnancy or
ovarian cyst (performed if serum
pregnancy test results are posititve)
 DX TEST FINDINGS
• Culdocentesis (aspiration of fluid
from the vaginal cul-de-sac) →
detects free blood in the peritoneum
(performed in ultrasonography
detects absence of gestational sac
in the uterus)
• Laparoscopy → reveal pregnancy
outside the uterus (performed if
culdocentesis is positive)
 Management
• Unruptured tube
– Methotrexate > attacks & destroys fast-
growing cells
– Leucovorin > counteracts the toxic effect of
methotrexate
❖ treated until negative hCG titer is achieved
- Mifepristone > an abortifacient, causing
sloughing of the tubal implantation site
Advantage: Tube is left intact; no surgical scarring
that could cause a second ectopic implantation
 Management
Ruptured tube > emergency situation
- Blood sample: hgb level, typing and cross-
matching, hCG level
- IVF, BT
• Laparoscopy - to ligate the bleeding
vessel; to remove or repair the damaged
fallopian tube
• Ovary – Oophorectomy
• Tube - Salpingectomy
 Management
Disadvantages:
• Rough suture line may lead to another
tubal pregnancy
• Tube is removed or sutured through
microsurgical technique
– Theoretically, woman is 50% fertile
– Not a reliable contraceptive measure >
translocation of ova from right ovary can pass
through the pelvic cavity to the left fallopian
tube and become fertilized, and vice versa.
 Nursing Intervention
• Ask the patient the date of her last menses
and obtain serum hCG levels as ordered
• Assess VS and monitor vaginal bleeding
for extent of fluid loss
• Check the amount, color and odor of
vaginal bleeding, monitor pad count
 Nursing Management
• NPO in anticipation of possible surgery;
prepare the patient for surgery, as indicated
• Assess the patient for signs and symptoms
of hypovolemic shock secondary to blood
loss from tubal rupture, and monitor urine
output closely for a decrease suggesting
fluid volume deficit
• Administer blood transfusions for
replacement as ordered and provide
emotional support
 Nursing Management
• Record the location and character of the
pain, and administer an analgesic as
ordered
• Determine if the patient is Rh-negative; if
she is, administer Rho (D) immune
globulin (RhoGAM) as ordered after
treatment or surgery
 Nursing Management
• Provide a quiet, relaxing environment,
offer the patient emotional support
-encourage her and her partner to express their
feelings of fear, loss, and grief
-Help her to develop effective coping strategies
-refer her to a mental health professional for
additional counseling, if necessary
 Nursing Management
• To prevent recurrent ectopic pregnancy,
urge the patient to have pelvic infections
treated promptly to prevent diseases of the
fallopian tube
• Inform patients who have undergone
surgery involving the fallopian tubes or
those with confirmed PID that they’re at
increased risk for another ectopic
pregnancy
 Possible Complications
• RUPTURE of the tube causes life-
threatening complications, including
hemorrhage, shock, and peritonitis
• Infertility results in the uterus or both
fallopian tubes or both ovaries are
removed.
 SPONTANEOUS ABORTION
• Spontaneous
expulsion of the
products of
conception from the
uterus before fetal
viability (fetal wt less
than 17 ½ oz or 500 g
and gestational age of
less than 20 wks)
• A.k.a. miscarriage
 Spontaneous Abortion
• Up to 15 % of all
pregnancies and
about 30% of first
pregnancies end in
spontaneous abortion
• At least 75% of
spontaneous abortion
occurs during the first
trimester
Types of Spontaneous Abortion
1.Complete – uterus passes ALL products
of conception.
➢Minimal bleeding usually accompanies
complete abortion because the uterus
contracts and compresses the maternal blood
vessels that fed the placenta
2. Habitual – spontaneous loss of three or
more consecutive pregnancies
Types of Spontaneous Abortion
3. Incomplete – uterus retains part or all of
the placenta.
➢Before 10 wks AOG, the fetus and placenta
are usually expelled together;
➢after 10th wk, they’re expelled separately.
Because part of the placenta may adhere to
the uterine wall, bleeding continues.
❖Hemorrhage is possible because the uterus
does not contract and seal the large vessels
that fed the placenta.
 Types of Spontaneous Abortion
4. Inevitable – membranes rupture and the cervix
dilates. As labor continues, the uterus expels
the products of conception
5. Missed abortion – uterus retains the product
of conception for 2 months or more after the
fetus has died.
➢Uterine growth ceases ; uterine size may even
seem to decrease.
➢Prolonged retention of the dead products of
conception may cause coagulation defects such as
DIC
Types of Spontaneous Abortion
6. Septic – infection accompanies abortion.
This may occur with spontaneous abortion
, but usually results from a lapse in sterile
technique during therapeutic abortion.
7. Threatened – bloody vaginal discharge
occurs during the 1st half of pregnancy.
About 20% of pregnant women have
vaginal spotting or actual bleeding early in
pregnancy. Of these, about 50% labor.
 Pathophysiology
• More than 50% are caused by
abnormalities in fetoplacental development
• Fetal factors usually cause such abortions
at 6 to 10 weeks’ gestation
-defective embryologic development from
abnormal chromosome division (the 2nd most
common cause of death)
-faulty implantation of fertilized ovum
-failure of the endometrium to accept the
fertilized ovum
 Pathophysiology
• Placental factors usually cause
spontaneous abortion around the 14th
week, when the placenta takes over the
hormone production necessary to maintain
the pregnancy
• -premature separation of the normally
implanted placenta
• -abnormal placental implantation
• -abnormal platelet function
 Pathophysiology
• Maternal factors usually cause
spontaneous abortion between 11 and 19
wks.
– -maternal infection
– -severe malnutrition
– -abnormalities of the reproductive organs
(especially incompetent cervix, in which the
cervix dilates painlessly and without blood in
the 2nd trimester)
 Pathophysiology
• Other maternal factors that can cause
spontaneous abortion
-endocrine problems, such as thyroid
dysfunction or lowered estriol secretion
-trauma, including any type of surgery that
necessitates manipulation of the pelvic organs
-blood group incompatibility and Rh
isoimmunization
-drug ingestion
 Assessment Findings
• -Symptom severity
depends on the
gestational age at the
time of spontaneous
abortion
• -S/S include uterine
cramping and vaginal
bleeding
 DX TEST FINDINGS
• Presence of hCG in the blood or urine
confirms pregnancy, with decreased hCG
levels suggesting spontaneous abortion
• Pelvic examination reveals size of the
uterus, which is inconsistent with the
length of pregnancy
 DX TEST FINDINGS
• Tissue cytology indicates
evidence of product of
conception
• Laboratory tests reflects
decreased hgb levels
and hematocrit from
blood loss
• Ultrasonography positive
for presence or absence
of fetal heartbeats or an
empty amniotic sac
 Management
• Threatened abortion - limitation of the pt’s
activities for 24 to 48 hrs
– Bed rest, pad count, restriction of coitus for
about 2 wks
• Complete abortion- rest, monitoring for
temperature elevation and bleeding, if the
uterus emptied on its own and the pt has
no signs of infection, no further
intervention is needed
 Nursing Management
• CBR without BRP, after bedpan use,
inspect contents for intrauterine material
• Note the amount, color and odor of vaginal
bleeding
• Save all pads the pt uses for evaluation
• Assess VS for 24 hrs or more frequently,
depending on the extent of bleeding
• Monitor urine output closely
 Nursing Management
• Provide good perineal
care
• Check the pt’s blood
type and administer
RhoGAM as ordered
• Provide emotional
support and
counseling during the
grieving process
• Encourage the pt and
her partner to express
their feelings
 Nursing Management
• Help the pt and her partner
to develop effective coping
strategies
• Explain all procedures and
treatments to the pt and
provide teaching about
aftercare and ff up
• -expect vaginal bleeding or
spotting to continue for
several days
 Nursing Management
• -immediately report bleeding that lasts
longer than 10days, is excessive, or
appears bright red
• -watch for signs of infections, such as
fever, (higher than 37.8 C) and foul-
smelling vaginal discharge
 Nursing Management
• -gradually increase your daily activities to
include whatever tasks you feel comfortable
doing as long as these activities don’t
increase vaginal bleeding or cause fatigue
• Use a contraceptive when you and your
partner resume intercourse
• Avoid the use of a tampon for 1 to 2 wks
• -Arrange for a ff up visit with your physician
in 2 to 4 wks