Ectopic Pregnancy

Most ectopic pregnancies occur in the uterine fallopian tube, with most occurring in the ampullar section. Other sites include cervix, ovary and abdomen (Keenan-Linsay et al., 2022)

Implantation

sites

Hinkle, Cheever & Brunner, 2018).

Uncommon Sites

• Heterotopic pregnancy: one viable pregnancy intrauterine and the other implanted as an ectopic pregnancy
• Caesarean section scar: embryo implants on the surgical scar
• Interstitial ectopic pregnancy: fertilized ovum implants in the interstitial segment of the fallopian tube that lies with the muscular wall of the uterus (Ramanathan et al., 2018).

Uncommon sites

*Ectopic pregnancies result from an interruption in migration of the embryo through the fallopian tube. There is a 95% chance of an embryo being in the fallopian tube within the ampullar portion, a 0.5% chance in the ovary, a 1.5% chance in the abdominal cavity, and a 0.3% chance in the cervix

(Perry et al., 2022).

*Maternal age and ethnicity remain consistent for how frequent ectopic pregnancies occur

*The risk of ectopic pregnancies increases in women who use assisted reproductive therapy, who had tubal sterilization or reversal surgeries, surgical intervention for ectopic pregnancies, pelvic surgery, pelvic inflammatory disease, advanced age, smoking, and infertility

*10% to 25% of women who experienced an ectopic pregnancy will have another

(Perry et al., 2022).

*Ectopic pregnancies are constantly increasing with improved diagnostic testing as they are found early

*Point of care ultrasounds are used to detect intra-abdominal hemorrhages. Women with a moderate to a large amount of free fluid in the abdominal-pelvic area are 3 to 9 times more at risk for emergency ectopic pregnancies, while ultrasounds help to detect early to prevent emergency surgeries

(Stone et al., 2021).

*1.3% to 2% of all pregnancies result in an ectopic pregnancy

*1:7000 to 1:30,000 ectopic pregnancies occur from spontaneously conceived pregnancies

*9% of pregnancy deaths are related to ectopic pregnancies and is the leading cause of infertility (Karavani et al., 2021 & Perry et al., 2022).

Physical Exam

Lab Test

Ultrasound Exam

Early Signs and Symptoms of Ectopic Pregnancy

• Delayed menses
• Abnormal vaginal bleeding (spotting)
• Abdominal pain localized to one side
• Pain to lower back
• Dizziness
• Sweating
• Weakness
• Feeling faint
• Loss of appetite
• Nausea/vomiting

(Keenan-Lindsay et al., 2022)

(Bump2baby, 2021)

Signs and Symptoms of Ruptured Ectopic Pregnancy

• Shoulder pain
• Acute abdominal pain
• Severe lower back pain
• Hypotension
• Dizziness
• Drop in haematocrit
• Cullen's sign
• Hypovolemic Shock

(Zuin et al., 2021)

(Bump2baby., 2021)

Complications

Internal bleeding and hemorrhage

Rupture

Hypovolemic shock

Recurrent ectopic pregnancies

Death

Infertility and sterility

Medical Management

Medical

Management

Medical management includes:

• Methotrexate - an antimetabolite, folic acid antagonist and immunosuppressant given by IM. Dihydrofolic acid reductase enzyme’s action is decreased by destroying the rapidly acting cells
• Pre-treatment - Bloodwork (CBC, blood type and antibody screen, liver, and renal tests, B-hCG) and a transvaginal ultrasound

Post treatment lifestyle restrictions.

Education:

*Inform the patient to avoid taking analgesic stronger than acetaminophen to prevent masking tubal symptoms.

*Recommend the patient stop taking folic acid and alcoholic beverage consumption due to increased risk of adverse effects to methotrexate and ectopic rupture

*Avoid sun exposure to prevent increased photosensitivity

*Avoid gas forming foods

*Report vaginal bleeding, or abdominal pain

*Recommend the patient avoid intercourse and inserting tampons or douches into the vaginal canal

(Keenan-Lindsay et al., 2022).

Surgical Intervention

Surgical candidates include:

• Ruptured ectopic pregnancies
• Failed methotrexate trials
• Contraindications to expectant management and medical management

Types of surgeries

1.Salpingectomy; removal of the entire fallopian tube. 2.Salpingostomy; removal of fetal products from the fallopian tube. It is considered in women who want to pursue a pregnancy in the future.

(Keenan-Lindsay et al., 2022)

Pregnancy loss is a critical and traumatic event for women and men. Mourning and grieving can be painful after ectopic pregnancies. Negatively processing emotions and lack of support can cause anxiety, depression, and post-traumatic stress disorder.

Use distraction techniques to allow negative feelings to pass such as walking, exercise, listening to music, and forming new hobbies. Follow up with the family physician or gynecologist if feelings of anxiety or depression continue.

Supportive Care

Supportive Care

Discuss with the client and spouse the importance of rest after surgery and allowing the body to heal. Feelings can be overwhelming as the body returns to a nonpregnant state. The client may experience feelings of shock, disbelief, fear, upset, emptiness, relief, anger, sadness, guilt, jealousy, anxiety or worry. The relationship between the client and spouse may be affected.

Encourage the client and spouse to spend time with family and friends. Be open about negative feelings and encourage communication. Seek support services such as over the phone helplines, community support groups, and social services.

(Iwanowicz-Palus et al., 2021 & The Ectopic Pregnancy Trust., 2022)

Before the diagnosis

Before the diagnosis

• Obtain Data
• Monitor vital signs closely
• Monitor bleeding and initiate measures to prevent rupture and shock

(Silvestri, L. A., & Silvestri, A. E., 2020)

(Prezi., 2022)

Before the procedure

• Educate patient and family about ectopic pregnancies
• Explain and prepare patient for diagnostic and procedures
• Provide patient and family reassurance and support for the surgery

(Lewis et al., 2019)

Before

the

treatment

(Prezi, 2022)

During and after Treatment

(Prezi, 2022)

During and after Treatment

• Administer antibiotic, RH(D) globulin(for Rh-negative woman)
• Inform patient to notify MD as soon as pregnancy is suspected
• Assess the patient's emotional status
• Patient may be concerned about future ectopic pregnancies and have many inquiries about how this event will affect her fertility in the future
• Refer the patient and family to grief or infertility outreach programs

(Keenan-Lindsay et al., 2022, Lewis et al, 2019 & Silvestri et al., 2020).

References

American International Medical University. (2017, June 25). Ectopic pregnancy: Diagnosis, complications and managment. American International Medical University.

https://www.aimu.us/2017/06/25/ectopic-pregnancy-diagnosis-complications-and-managment/

Bump2baby (2021). Ectopic Pregnancy? Know about the Symptoms | Signs | Treatment | Complications. Retrieved from https://bump2babyscans.co.uk/ectopic-pregnancy-know-about-the-symptoms

signs-treatment-complications/

Healthwise. (2021, June 16). Ectopic Pregnancy. https://www.healthlinkbc.ca/health-topics/ectopic-pregnancy

Hendriks, Rosenberg, R., & Prine, L. (2020). Ectopic Pregnancy: Diagnosis and Management. American Family Physician, 101(10), 599–606.

Hinkle, J. L., Cheever, K. H., & Brunner, L. S. (2018). Brunner & Suddarth's textbook of Medical-Surgical Nursing. (14th Edition). Wolters Kluwer.

Hu, Paramboor, M. S., & Guo, T. (2021). Diagnosis and management of intramural ectopic pregnancy. Clinical and Experimental Obstetrics & Gynecology, 48(4), 974–979. https://doi.org/10.3108

3/j.ceog4804154

Iwanowicz-Palus, G., Mroz, M., Bien, A., & Krzysztof, J. (2021). Social support and subjective assessment of psychophysical condition, health, and satisfaction with quality of life among women

after pregnancy loss. BMC Pregnancy Childbirth, 21(750) https://doi-org.roxy.nipissingu.ca/10.1186/s12884-021-04093-w

​​

Karavani, Gutman-Ido, E., Herzberg, S., Chill, H. H., Cohen, A., & Dior, U. P. (2021). Recurrent Tubal Ectopic Pregnancy Management and the Risk of a Third Ectopic Pregnancy. Journal of

Minimally Invasive Gynecology, 28(8), 1497–1502.e1. https://doi.org/10.1016/j.jmig.2020.12.005

Keenan-Lindsay, L., Sams, C., O’Connor, C., Perry, S., Hockenberry, M., Low, D. (2022). Maternal Child Nursing Care in Canada: Pregnancy at Risk: Gestational Conditions

(3rd edition ). Elsevier Inc.

Kumari, S., Prasad, D., Sinha, A., & Parween, S. (2018). Retrospective study of ectopic pregnancy in tertiary care centre. IAIM, 5(1), 95-9. https://iaimjournal.com/wpcontent/uploads/2018/01/

iaim_2018_0501_13.pdf

References

Lewis, S. L., Buckner, L., Heitkemper, M. M., Harding, M. M., Barry, M. A., Lok, J., Tyerman, J. & Goldsworthy, S. (2019). Medical-surgical nursing in

Canada: Female Reproductive Problems.(4th edition). Elsevier Inc.

Medical Centric. (2021). Ectopic Pregnancy, Causes, Signs and Symptoms, Diagnosis and Treatment. [Video] YouTube. Retrieved June 22, 2022, from

https://www.youtube.com/watch?v=EBuqZr4Afw4.

Mummert, T., & Gnugnoli, D. M. (2022). Ectopic pregnancy. In StatPearls. StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/30969682/.b.

Ramanathan, S., Raghu, V., Ladumor, S. B., Nagadi, A. N., Palaniappan, Y., Dogra, V., & Schieda, N. (2018). Magnetic resonance imaging of common, uncommon, and rare

implantation sites in ectopic pregnancy. Abdominal Radiology, 43(12), 3425-3435. https://doi.org/10.1007/s00261-018-1604-2

Rubio, X. B., Kresak, J., Zona, M., Beal, S. G., & Ross, J. A. (2020). Educational Case: Ectopic Pregnancy. Academic pathology, 7, 2374289520911184.

https://doi.org/10.1177/2374289520911184

Silvestri, L. A., & Silvestri, A. E. (2020). Saunders comprehensive review for the NCLEX-RN examination. (8th edition.). St. Louis, Elsevier.

Stanica, Neacsu, A., Sima, R. M., & Ioan, R. G. (2021). Diagnosis and management of ectopic pregnancy. Practica Medicală (2006), 16(1), 73–78. https://

doi.org/10.37897/RJMP.2021.1.13

Stone, B. S., Muruganandan, K. M., Tonelli, M. M., Dugas, J. N., Verriet, I. E., & Pare, J. R. (2021). Impact of point-of-care ultrasound on treatment time

for ectopic pregnancy. American Journal of Emergency Medicine, 49, 226–232. https://doi-org.roxy.nipissingu.ca/10.1016/j.ajem.2021.05.071

The Ectopic Pregnancy Trust. (2022). Supporting you. https://ectopic.org.uk/Zuin, Zuliani, G., Rigatelli, G., & Roncon, L. (2021). Cullen’s sign associated

with ectopic pregnancy. QJM : Monthly Journal of the Association of Physicians, 114(6), 423–423. https://doi.org/10.\1093/qjmed/hcab040