04.07 Ectopic Pregnancy

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Overview

  1. When a fertilized egg (ovum) implants outside of the uterine cavity
    1. “Ectopic” means out of place
    2. It could be in multiple different locations, however most are in fallopian tubes
      1. Fallopian tube, cervix, abdominal cavity

Nursing Points

General

  1. Patient may have missed period/ presumptive signs of pregnancy, but do not know that it is ectopic without ultrasound or until it ruptures
  2. This can be an emergency, especially if the fallopian tube has ruptured

Assessment

  1. Classic signs are pregnancy symptoms (missed period, positive pregnancy test) followed by vaginal spotting and severe abdominal pain
  2. Signs of ruptured fallopian tube include severe pain on one side, signs of shock, and pain referring to the right shoulder
    1. Referred pain is due to blood in the abdomen

Therapeutic Management

  1. Goals are to prevent rupture, bleeding, and shock
  2. Surgical removal
    1. Laparoscopic
  3. Medical
    1. Methotrexate-inhibits cellular division of the embryo (aborts)
  4. Fallopian tube may be compromised and need to be removed
  5. Rh immune globulin if mom is Rh negative

Nursing Concepts

  1. Reproduction
  2. Comfort
  3. Coping

Patient Education

  1. Report severe pain, especially right shoulder pain
  2. Report vaginal bleeding
  3. Ectopic pregnancies cannot survive, the pregnancy will have to be terminated

Reference Links

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Video Transcript

In this lesson I will explain what an ectopic pregnancy is, how it occurs, and your role in caring for a patient with an ectopic pregnancy.

An ectopic pregnancy means a pregnancy that occurs outside of the uterus.So let’s get this straight we are talking about an embryo that attaches outside of the uterus. As you see in this picture these white eggs are showing the embryo in the normal place verses wrong places. This could be in the cervix, abdomen or most commonly in the fallopian tube. This is dangerous because the fallopian tubes are not very big so they are at risk to rupture because the embryonic cells are rapidly dividing causing growth. The patient will more then likely have a missed period and presumptive signs of pregnancy as well as a positive pregnancy test. She will not be aware that it is ectopic until later. This can be an emergency because it is usually not detected until there is a problem. What do I mean by problem? Well we have a fallopian tube and it is a small space. We have rapidly dividing cells in the fallopian tube growing bigger and bigger. Eventually something has to give and it is usually the rupture of the fallopian tube. The hope is that when the pain starts the female will seek medical help and they can preserve the tube and prevent the rupture.

The classic signs of an ectopic pregnancy start with just basic pregnancy symptoms. There is a missed period and a positive pregnancy test. This is followed by vaginal spotting, usually around 5-6 weeks, and severe abdominal pain. Remember it is in the wrong place! If it is not caught in time the fallopian tube could rupture. So what will that look like? This will cause severe pain on one side, the side that ruptured. This patient is bleeding into her abdomen so there will be signs of shock. She also might have referred pain. The referred pain is usually felt in the shoulder and is due to the blood in the abdomen. In this picture you can see the uterus marked with the blue arrows and in the left fallopian tube there is swelling and bleeding. You can see how much bigger the left tube is compared to the right. It really looks at risk to rupturing.

For therapeutic management our main goal is to prevent rupture of the fallopian tube from happening. We want to prevent or minimize bleeding to prevent shock from occurring. Management could include surgical removal. This could be laparoscopic which would not require a large incision or a laparotomy if the doctor needs a larger opening to remove contents or the ruptured tube. Medical management is with Methotrexate. This medication will inhibit cellular division. Remember an embryo is a ball of rapidly dividing cells. This will cause the body to abort the embryo and hopefully save the fallopian tube. It is very important that our management of this patient include rhogam for Rh immune globulin if mom is Rh negative. We need to give her this to protect any future pregnancies from her body attacking them because of the Rh factor.

What education does this patient need? She needs to report any severe pain, especially right shoulder pain. What was that a sign of? Right, a ruptured fallopian tube causing referred pain. Vaginal bleeding should also be reported because vaginal bleeding even spotting could be a sign of a problem such as an ectopic pregnancy. All ectopic pregnancies are not viable. This means they cannot survive so the pregnancy will have to be terminated. This is difficult for the patient to understand so we need to be aware of this and explain why it has to be terminated and what the options are.

Nursing concepts for the patient with ectopic pregnancy are reproduction because she has reproduced, comfort because we need to keep her comfortable during management for her care, and coping because this is a loss. She thought she was pregnancy and now has to cope with the loss.
Let’s look at the key points to bring it all together. Ectopic pregnancies are when the embryo attaches outside so it is not in the right place. The body recognizes that there is a pregnancy so there is a missed period and positive pregnancy test. Usually around 6 weeks the patient will begin to feel pain and experience some spotting. This is because it has started to grow and the body now realizes there is a problem. The pregnancy is not viable. A patient care not deliver an ectopic pregnancy. The goal is to terminate and save the fallopian tube, if that is where the pregnancy is. Termination will be either medically or surgically. Medically will be drugs such as methotrexate because that medication prevents cells from rapidly dividing. Think about it. An embryo is trying to develop there are a bunch of rapidly dividing cells so it will prevent this from occurring and the hope is that the body will terminate and remove on it’s own. Surgical termination will be trying to laparoscopically removing the embryo and trying their best to preserve the fallopian tube.

Make sure you check out the resources attached to this lesson. Now, go out and be your best selves today. And, as always, happy nursing.

Read more

  • Question 1 of 7

A 31-year-old patient is brought in to the emergency room after suffering an ectopic pregnancy. Based on the nurse’s understanding of this condition, the nurse knows to look for which signs or symptoms in this patient? Select all that apply.

  • Question 2 of 7

A nurse is caring for a client who will undergo medical management for an ectopic pregnancy. Which treatment would the nurse anticipate?

  • Question 3 of 7

A nurse is educating clients on the symptoms of ectopic pregnancy. Which of the following symptoms should be included in the education? Select all that apply.

  • Question 4 of 7

A nurse is caring for a client post-op for removal of an ectopic pregnancy. The client has A- blood type and reports receiving Rhogam with her last pregnancy. She asks if she needs to receive it again. What is the best response by the nurse?

  • Question 5 of 7

The nurse is working in an OB outpatient client. A client who is 10 weeks pregnant presents with abdominal pain, shoulder pain, and vaginal bleeding. The nurse promptly notifies the provider of these symptoms because it could be a medical emergency. Which condition does the nurse suspect?

  • Question 6 of 7

A female client presents to the emergency room with severe right sided abdominal pain and right shoulder pain. The urine pregnancy test is positive. What is the best next action by the nurse?

  • Question 7 of 7

A client who just learned she has an ectopic pregnancy in her fallopian tube wants to know if she can continue with the pregnancy. What is the best response by the nurse?

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