Case Study: Ectopic Pregnancy

• Implantation of a fertilized ovum outside the uterine cavity, most commonly in the fallopian tube.
• Good maternal prognosis with prompt diagnosis, appropriate surgical intervention, and control of bleeding.
• Poor fetal diagnosis (rare incidence of survival to term with abdominal implantation).
• About 33 % chance of giving birth to a live neonate in a subsequent pregnancy.
• Incidence: about 1 to 200 pregnancies in whites; about 1 of 120 pregnancies on nonwhites.
• Complications: rupture of fallopian tube, hemorrhage, shock, peritonitis, infertility, disseminated intravascular coagulation, and death.

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.

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

Assessment findings

• Amenorrhea
• Abnormal menses (after fallopian tube implantation)
• Slight vaginal bleeding
• Unilateral pelvic pain over the mass
• If fallopian tube ruptures, sharp lower abdominal pain, possibly radiating to the shoulders and neck.
• Possible extreme pain when cervix is moved and adnexa palpated.
• Boggy and tender urine
• Possible enlargement of adnexa

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

• Initially, in the event of pelvic-organ rupture, management of shock
• Diet determined by clinical status
• Activity determined by clinical status
• Transfusion with whole blood or packed red blood cells
• Broadspectrum I.V. antibiotics
• Methotrexate (Rheumatrex)
• Laparotomy and salpingectomy if culdocentesis shows blood in the peritoneum; possibly after laparoscopy to remove affected fallopian tube and control bleeding.
• Micro-surgical repair of the fallopian tube for patients who wish to have children.
• Oophorectomy for ovarian pregnancy
• Hysterectomy for interstitial pregnancy
• Laparotomy to remove the fetus for abdominal pregnancy.

Nursing Interventions

• 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.