An ectopic pregnancy is an implantation of the blastocyst (a solid mass of cells, formed by rapid mitotic division of the zygote, that eventually form the embryo) in a site other than the endometrial lining of the uterus. In more than 95% of ectopic pregnancies, this implantation occurs somewhere in the fallopian tubes, hence the term “tubal pregnancy.” The ampullary portion of the tube is the most common site (80%), followed by the isthmic portion (12%) and the fimbria (5%). The fallopian tube lacks a submucosal layer, which allows the ovum to burrow through the epithelium. Fertilization occurs and the zygote lies within the muscular wall of the tube, drawing its blood supply from maternal vessels. Other sites of potential implantation are the cervix, ovary, abdomen, and interstitial tissue of the uterus. After the blastocyst implants in the tube, it begins to grow and can cause bleeding into the abdominal cavity. Eventually, the ovum becomes too large, and the tube can rupture, thus causing further bleeding that can lead to shock and maternal death. ectopic pregnancy occur in approximately 2 in 100 pregnancies and non–European Americans have a 1.4 times increased risk over European Americans. The frequency of ectopic pregnancy has increased fourfold since 1970, owing to the increase in sexually transmitted infections, better diagnostic techniques, increased use of artificial reproductive technology, and the increased use of tubal surgeries to treat infertility. Ectopic pregnancy accounts for 10% of all pregnancy-related deaths and reduces a woman’s chance of future pregnancy because of tubal damage; approximately one-third of women who experience an ectopic pregnancy subsequently give birth to a live infant. Hemorrhage, peritonitis and infertility are the main complications.
The major cause of ectopic pregnancy is tubal damage, which can result from pelvic inflammatory disease, previous pelvic or tubal surgery, or endometriosis. Other causes may be hormonal factors that impede ovum transport and mechanically stop the forward movement of the egg in the tube, congenital anomalies of the tube, and a blighted ovum. Pelvic infections and sexually transmitted diseases (STDs), specifically chlamydia and gonorrhea, are often involved. Other risk factors include: smoking, diethylbestrol exposure, T-shaped uterus, certain intrauterine devices (IUDs), and a ruptured appendix.
Nursing care plan assessment and physical examination
Elicit a history about the onset of menses, gynecologic disorders, pattern of sexual practices and birth control, and past pregnancies. Patients with an ectopic pregnancy often have some history of tubular damage as a result of infections or endometriosis. They may also have had tubal surgeries. Often, patients describe a history of using an IUD, and some may report a history of infertility. Question the patient about her last menstrual period to determine the onset, duration, amount of bleeding, and whether it was a “normal” period for her. This description is important because although amenorrhea may be present in many cases of ectopic pregnancy, uterine bleeding that occurs with ectopic pregnancymay be mistaken for a menstrual period. In addition to amenorrhea, the patient may exhibit other signs of pregnancy, such as breast tenderness, nausea, and fatigue.
Assess vaginal bleeding for the amount, color, and odor; if none is noted, bleeding may be concealed. Bleeding can occur as vaginal spotting, as a “slow leak,” or as a massive hemorrhage, depending on the gestational age and whether the tube has ruptured. Usually, the bleeding is slow, and the abdomen can become rigid and tender. Sometimes, vaginal bleeding is present with the death of the embryo. If internal hemorrhage is profuse, the woman experiences signs and symptoms of hypovolemic shock (restlessness, agitation, confusion, cold and clammy skin, increased respirations and heart rate, delayed capillary blanching, hypotension). Evaluate the patient’s pain; it can range from a feeling of fullness in the rectal area and abdominal cramping to excruciating pain. Often, the pain is one-sided and increases when the cervix is moved during a vaginal exam. Some women do not feel any pain until the tube is about to rupture, usually at the 3-month period of gestation. If the tube ruptures, the woman experiences sharp, one-sided, lower abdominal pain and syncope. The pain may radiate to the shoulders and neck and is aggravated by situations that cause increased abdominal pressure, such as lifting or having a bowel movement.
Often, the patient experiences anger, grief, guilt, and self-blame over the loss of the fetus. She may also be anxious about her ability to conceive in the future. Since much of her anxiety may stem from lack of information about her condition, assess her learning needs. Determine the ability of the father and other family members to cope and support the patient.
Nursing care plan primary nursing diagnosis: Anticipatory grieving related to the loss of a pregnancy.
Nursing care plan intervention and treatment
Medical management of a tubal pregnancy depends on the patient’s condition, gestational age and size, whether the tube has ruptured. If the tube is intact, the gestation is less than 6 weeks, and the fertilized mass is less than 3.5 cm in diameter, methotrexate, a chemotherapeutic agent that inhibits cell division, may be ordered. The patient must also be committed to coming in for follow-up appointments, as this is critical to maternal well-being and assessing the effectiveness of treatment. Human chorionic gonadotropin (hCG) levels and fetal cardiac activity are monitored with methotrexate therapy; success of treatment is based on these two assessments (hCG should decrease 15% by day 4 and fetal cardiac activity should cease by day 7). If the tube is damaged or ruptured, surgical management is indicated immediately.
Laparoscopic laser surgery is usually performed, but if the tube has already ruptured, a laparotomy may be indicated. A salpingectomy (removal of the tube), salpingostomy (incision and evacuation of tubal contents), salpingotomy (incision and closure of the tube), or segmental resection and anastomosis can be performed. The goal is to salvage the tube, especially in women who desire future pregnancy. Postoperative care includes monitoring vital signs and observing for other signs of shock. Monitor the fluid intake and output as well, and note the color and amount of vaginal bleeding. Observe the incision for any signs and symptoms of infection. Administer analgesics and assess the patient’s level of pain relief from the medication.
Provide emotional support, using therapeutic communication techniques to relieve the patient’s anxiety. Emotional support of this patient is important because the termination of any pregnancy causes a host of psychological and physiological changes. Inform the patient of perinatal grief support groups. The patient may be concerned about infertility. Provide information, and clarify the physician’s explanations if needed. If necessary, provide a referral for a clinical nurse specialist or counselor.
Nursing care plan discharge and home health care guidelines
If the patient is receiving methotrexate on an outpatient basis, teach her that more severe pain may indicate treatment failure and that she needs to notify the physician. She should not drink alcohol or take vitamins containing folic acid. She may experience anorexia, nausea and vomiting, mouth ulcers, and sensitivity to sunlight as side effects of methotrexate. She also needs to follow up with scheduled hCG testing. If a salpingectomy was done, explain to the patient that becoming pregnant again may be difficult. Fertilization takes place only on the side of the remaining tube after ovulation of the ovary on the same side. If a tubal repair was done, the patient is at a higher risk for a subsequent ectopic pregnancy, as well as infertility. Educate the patient to recognize the signs and symptoms of ectopic pregnancy and to notify the doctor immediately if these should occur. To prevent recurrence, advise the patient to engage in safe sexual practices. Teach her strategies to avoid STDs and pelvic infections that could cause further damage to the fallopian tubes.
Give the patient the following instructions: Limit activity and get plenty of rest. Increase fluid intake. Keep the incision clean. Refrain from sexual intercourse for 2 weeks until the follow-up appointment with the physician occurs. Delay pregnancy for at least 3 months to allow for tubal healing. Determine that she has a method of birth control prior to leaving the hospital.
If the patient is having difficulty dealing with the perinatal loss, referring her to a support group is appropriate. Often, follow-up by the hospital perinatal grief counselor is done. Referral to a fertility specialist is indicated if she is having difficulty conceiving for 6 months after tubal surgery.