Ectopic Pregnancy

An ectopic pregnancy, or  eccysis, is a complication of pregnancy in which the

pregnancy implants outside the uterine cavity.  With rare exceptions, ectopic pregnancies are
not viable. Furthermore, they are dangerous for the mother, internal bleeding being a common
complication. Most ectopic pregnancies occur in the Fallopian tube (so-called tubal
pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen. An ectopic
pregnancy is a potential medical emergency, and, if not treated properly, can lead to death.

CLASSIFICATION OF ECTOPIC PREGNANCY

  Tubal pregnancy - the vast majority of ectopic pregnancies implant in the Fallopian
tube.
 Non Tubal Ectopic pregnancy - ectopic pregnancies occur in the ovary, cervix, or are
intraabdominal.
 Heterotopic pregnancy - in rare cases of ectopic pregnancy, there may be two fertilized
eggs, one outside the uterus and the other inside.
 Persistent ectopic pregnancy - refers to the continuation of trophoplastic growth after
a surgical intervention to remove an ectopic pregnancy.

CAUSES OF ECTOPIC PREGNANCY

An ectopic pregnancy is often caused by damage to the fallopian tubes. A fertilized egg
may have trouble passing through a damaged tube, causing the egg to implant and grow
in the tube. Things that make you more likely to have fallopian tube damage and an ectopic
pregnancy include:
 Smoking. The more you smoke, the higher your risk of an ectopic pregnancy.
 Pelvic inflammatory disease (PID). This is often the result of an infection such as
chlamydia or gonorrhea.
 Endometriosis, which can cause scar tissue in or around the fallopian tubes.
 Being exposed to the chemical DES before you were born.

Some medical treatments can increase your risk of ectopic pregnancy. These include:
 Surgery on the fallopian tubes or in the pelvic area.
 Fertility treatments such as in vitro fertilization.

The following may also increase the risk of ectopic pregnancy:

 Age over 35
 Having had many sexual partners
 In vitro fertilization

Other Causes:

 Congenital defects in the reproductive tract

 Diverticula
 Ectopic endometrial implants in the tubal mucosa
 Endosalpingitis
 Intrauterine device
 Previous surgery, such as tubal ligation or resection
 Sexually transmitted tubal infection
 Transmigration of the ovum
  Tumors pressing against the tube

SIGNS AND SYPMTOMS

Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy
occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8
weeks. Later presentations are more common in communities deprived of modern diagnostic
ability.

Early signs include:

 Pain in the lower abdomen, and inflammation (Pain may be confused with a strong
stomach pain, it may also feel like a strong cramp)
 Pain while urinating
 Pain and discomfort, usually mild. A corpus luteum on the ovary in a normal pregnancy
may give very similar symptoms.
 Vaginal bleeding, usually mild. An ectopic pregnancy is usually a failing pregnancy and
falling levels of progesterone from the corpus luteum on the ovary cause withdrawal
bleeding. This can be indistinguishable from an early miscarriage or the 'implantation
bleed' of a normal early pregnancy.
 Pain while having a bowel movement

Patients with a late ectopic pregnancy typically experience pain and bleeding. This bleeding will
be both vaginal and internal and has two discrete pathophysiologic mechanisms:

 External bleeding is due to the falling progesterone levels.

 Internal bleeding (hematoperitoneum) is due to hemorrhage from the affected tube.

The differential diagnosis at this point is between miscarriage, ectopic pregnancy, and early
normal pregnancy. The presence of a positive pregnancy test virtually rules out pelvic infection
as it is rare indeed to find pregnancy with an active Pelvic Inflammatory Disease (PID). The most
common misdiagnosis assigned to early ectopic pregnancy is PID.

More severe internal bleeding may cause:

 Lower back, abdominal, or pelvic pain.
 Shoulder pain. This is caused by free blood tracking up the abdominal cavity and
irritating the diaphragm, and is an ominous sign.
 There may be cramping or even tenderness on one side of the pelvis.
  The pain is of recent onset, meaning it must be differentiated from cyclical pelvic pain,
and is often getting worse.

Ectopic pregnancy can mimic symptoms of other diseases such as appendicitis, other
gastrointestinal disorder, problems of the urinary system, as well as pelvic inflammatory
disease and other gynaecologic problems.

PATHOPHYSIOLOGY

 Transport of a blastocyst to the uterus is delayed.

 The blastocyst implants at another available vascularized site, usually the fallopian tube
lining.
 Normal signs of pregnancy are initially present.
 Uterine enlargement occurs in about 25% cases.
 Human chorionic gonadotropin (hCG) hormonal levels are lower than in uterine
pregnancies.
 If not interrupted, internal hemorrhage occurs with rupture of the fallopian tube.

LABORATORY EXAMS AND TESTS

An ectopic pregnancy should be considered in any woman with abdominal pain or

vaginal bleeding who has a positive pregnancy test. An ultrasound showing a gestational
sac with fetal heart in the fallopian is clear evidence of ectopic pregnancy.

An abnormal rise in blood β-human chorionic gonadotropin (β-hCG) levels may indicate

an ectopic pregnancy. The threshold of discrimination of intrauterine pregnancy is around 1500
IU/ml of β-hCG. A high resolution, transvaginal ultrasound showing no intrauterine pregnancy is
presumptive evidence that an ectopic pregnancy is present if the threshold of discrimination for
β-hCG has been reached. An empty uterus with levels higher than 1500 IU/ml may be evidence
of an ectopic pregnancy, but may also be consistent with an intrauterine pregnancy which is
simply too small to be seen on ultrasound. If the diagnosis is uncertain, it may be necessary to
wait a few days and repeat the blood work. This can be done by measuring the β-hCG level
approximately 48hrs later and repeating the ultrasound. If the β-hCG falls on repeat
examination, this strongly suggests a spontaneous abortion or rupture.
 A laparoscopy or laparotomy can also be performed to visually confirm an ectopic
pregnancy. Often if a tubal abortion or tubal rupture has occurred, it is difficult to find the
pregnancy tissue. A laparoscopy in very early ectopic pregnancy rarely shows a normal
looking fallopian tube.

Culdocentesis, in which fluid is retrieved from the space separating the vagina and
rectum, is a less commonly performed test that may be used to look for internal bleeding. 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 may have been derived from a ruptured ectopic
pregnancy. Cullen's sign can indicate a ruptured ectopic pregnancy.

Other laboratory tests that may perform:

 Hematocrit
 Pregnancy test
 Quantitative HCG blood test
 Serum progesterone level
 White blood count

A rise in quantitative HCG levels may help tell a normal (intrauterine) pregnancy from an ectopic
pregnancy. Women with high levels should have a vaginal ultrasound to identify a normal
pregnancy.

Other tests may be used to confirm the diagnosis, such as:

 D and C
 Laparoscopy
 Laparotomy

TEST RESULTS

 Serum hCG is abnormally low; when repeated in

49 hours, the level remains lower than the levels
found in a normal intrauterine pregnancy.
 Ultrasonography may show an intrauterine
pregnancy or ovarian cyst.
 Culdocentesis shows free blood in the
peritoneum
 Laparoscopy may reveal a pregnancy outside the uterus.
TREATMENT

Ectopic pregnancies cannot continue to birth (term). The developing cells must be removed to
save the mother's life.
You will need emergency medical help if the area of the ectopic pregnancy breaks open
(ruptures). Rupture can lead to shock, an emergency condition. Treatment for shock may
include:

 Blood transfusion
 Fluids given through a vein
 Keeping warm
 Oxygen
 Raising the legs

Medical Treatment

Early treatment of an ectopic pregnancy with methotrexate is a viable alternative to

surgical treatment since at least 1993 If administered early in the pregnancy, methotrexate
terminates the growth of the developing embryo; this may cause an abortion, or the tissue may
then be either resorbed by the woman's body or pass with a menstrual period.

Surgical Management

If hemorrhage has already occurred, surgical intervention may be necessary. However,

whether to pursue surgical intervention is an often difficult decision in a stable patient with
minimal evidence of blood clot on ultrasound.

Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the
affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube
with the pregnancy (salpingectomy). The first successful surgery for an ectopic pregnancy was
performed by Robert Lawson Tait in 1883.

Other treatments may include:

 Initially, in the event of pelvic-organ rupture, management of shock
 Diet determined by clinical status
 Activity determined by clinical status
 Broadspectrum I.V. antibiotics
 Micro-surgical repair of the fallopian tube for patients who wish to have children.
 Oophorectomy for ovarian pregnancy
 Hysterectomy for interstitial pregnancy
NURSING MANAGEMENT:

 Determine the date and description of the patient’s last menstrual period.
 Monitor vital signs for changes.
 Assess vaginal bleeding, including amount and characteristics
  Assess pain level
 Monitor intake and output
 Assess for signs of hypovolemia and impending shock
 Prepare the patient with excessive blood loss for emergency surgery.
 Administer prescribed blood transfusions and analgesics.
 Provide emotional support.
 Administer Rh (D) immune globulin (RhoGAM), as ordered, if the patient is Rh negative.
 Provide a quiet, relaxing environment
 Encourage the patient to express feelings of fear, loss, and grief.
 Help the patient develop effective coping strategies.
 Refer the patient to a mental health professional, if necessary, prior to discharge.

Perioperative Interventions

 Check vital signs as indicated (depending on severity)

 Check amount of vaginal bleeding.
 Check for signs of shock such as tachycardia, drop in blood pressure, and coolclammy
skin. (During pregnancy, signs of shock are not manifested until there hasbeen at least a
40 % blood volume loss.
 Check state of mental acuity/level of consciousness.
 .Keep an accurate record of intake and output.
 Urinary output during pregnancy is the best noninvasive indicator of circulatory
volume.
 Diminished cardiac output causes a shunting of blood away from the skin, kidneys,
and skeletal muscles in order to ensure blood delivery to heart and brain.
 Start an intravenous infusion with an 18-gauge intracatheter and maintain as ordered.
 Fluid replacement may reverse impending shock by increasing capillary blood flow
and thereby cardiac output increases. (Normal saline or Ringer’
 Obtain blood as ordered for
 a complete blood count,
 prothrombin time,
 partial thromboplastin time,
 Rh antibody screen, and
 type and cross match for 2 to 4 units of blood.
 Administer oxygen at 8 to 10 L by mask as needed.
 Carry out such preoperative protocol as giving the patient
 nothing by mouth,
  giving no enemas or cathartics since they could stimulate a tubal ectopic
pregnancy to rupture,
 being prepared to insert a Foley catheter as ordered, and
 get the permit signed for surgery.

 Notify the attending physician of any changes in

 vital signs,
 decreasing urinary output,
 blood pressure that falls 10 mmHg or more, or
 a change in mental acuity.
 If the patient presents in shock, be prepared to assist with central line placement. The
internal jugular and subclavian veins are less likely to collapsed.
 Be prepared to administer blood replacement therapy if
 the hemoglobin level is below 7 g/dl or
 the patient is manifested signs of shock.

Postoperative Interventions

 Check blood pressure, pulse, and respiration

every 15 minutes, eight times;
every 30 minutes two times;
every hour, two times;
every 4 hours, two times; and then routinely.
 Assess vaginal bleeding by pad count.
 Check dressing
every hour four times and then
every shift for bleeding
 Refer to laboratory work, such as hemoglobin and hematocrit.
 Keep an accurate intake and output records.
 Assess for cyanosis.
 Reinforce or change dressing as needed.
 Carefully administer IV fluids as ordered.
 Once the gastrointestinal tract resumes normal function, instruct regarding the
importance of
a high protein,
  high-iron diet for body repair and replacement of blood loss.
 Notify physician if
blood pressure drops to less than 90 systolic,
pulse rises to greater than 120 bpm, or
anemia develops.