Ectopic Pregnancy Nursing Implications

An ectopic pregnancy occurs when a fertilized egg develops but implants somewhere other than the endometrium of the uterus. Ectopic pregnancies occur in about two percent of all pregnancies. It is important to note that pregnancies that occur outside the uterus cannot progress to produce a viable fetus.

Types of ectopic pregnancy

There are several types of ectopic pregnancy:

• Tubal –  In most cases, the egg implants in a fallopian tube due to getting stuck on its way to the uterus. This can occur when the fallopian tube is misshapen in some way or inflamed.
• Interstitial – The egg implants in the area of the fallopian tube that is in the uterus (about 5% of ectopic pregnancies).
• Cervical – The fertilized egg implants in the lining of the endocervical canal (less than 1% of ectopic pregnancies).
• Cesarean scar – A cesarean scar ectopic pregnancy occurs when the fertilized egg implants in the location of the uterine incision. In some cases, the pregnancy grows outward toward the bladder and in other cases, the pregnancy can grow into the uterine cavity and potentially be viable (though with potential serious complications). Cesarean scar ectopic pregnancy is the most rare type.
• Abdominal – In this rare form of ectopic pregnancy, the fertilized egg implants within the peritoneal cavity.
• Ovarian – An ovarian ectopic pregnancy occurs when the fertilized egg implants in the surface of the ovary (about 3% of ectopic pregnancies).
• Heterotopic – Heterotopic ectopic pregnancy is a rare condition in which extrauterine and intrauterine pregnancies occur simultaneously. In most cases the extrauterine pregnancy is located in the fallopian tube, though it can occur in the ovary or cervix.

Who is most at risk for ectopic pregnancy?

There are several risk factors for ectopic pregnancy, though it can occur without any risk factors present. These include: 

• History of infertility or treatment with IVF
• Previous ectopic pregnancy
• History of pelvic inflammatory disease, STIs, or endometriosis
• Use of hormonal birth control or the presence of an IUD at the time of conception
• History of fallopian tube surgery, such as tubal ligation
• Smoking
• Age over 35 years
• Frequent vaginal douching, which one study showed can increase the risk of ectopic pregnancy by 76 percent

Complications of tubal ectopic pregnancy

Ectopic pregnancy accounts for 2.7 percent of all pregnancy related deaths in the United States and is considered a medical emergency. As the implanted fertilized egg develops, it places excess pressure on the delicate fallopian tube which can ultimately burst, leading to internal hemorrhage and death.

 L: How does the patient LOOK? What are the signs and symptoms of ectopic pregnancy?

The most common signs and symptoms of ectopic pregnancy are abdominal pain and vaginal bleeding in the first trimester. The patient may also experience low back pain, cramping on the side of the pregnancy, and weakness. When the fallopian tube bursts this causes a sudden, sharp and intense pain in the lower abdomen. This leads to internal bleeding which can cause significant hypotension and loss of consciousness. The buildup of blood in the peritoneal cavity can irritate nerves causing the patient to feel discomfort in other areas such as the shoulder or rectum. A ruptured tube is a medical emergency that requires prompt treatment.

A: How do you ASSESS a patient with ectopic pregnancy? 

Key nursing assessments for ectopic pregnancy include monitoring for bleeding, assessing pain, and looking for signs of tubal rupture. 

• Monitor for bleeding – Assess for vaginal bleeding, signs of hypovolemia and poor perfusion (tachycardia, hypotension, delayed capillary refill)
• Assess pain – Ask the patient to rate and describe their pain. Prior to rupture, ectopic pregnancy causes abdominal pain that may be more pronounced on the affected side. Pain may also be generalized to the abdomen or felt in the lower back.
• Look for signs of tubal rupture – Tubal rupture causes sudden abdominal pain that is sharp in nature and severe in intensity. Other signs include hypotension and hemodynamic instability, tachycardia, decreased LOC or dizziness. As blood collects in the peritoneal space, the patient can also experience pain in other parts of the body such as the shoulder.

T: What TESTS will be utilized to evaluate ectopic pregnancy?

Tests utilized to evaluate ectopic pregnancy include a pregnancy test, pelvic exam, ultrasound and blood tests.

Pregnancy test – An individual showing signs of ectopic pregnancy will have undergo a pregnancy test, which will show as positive even though the pregnancy is not in the uterus.

Pelvic exam – A standard pelvic exam can assess for areas of pain or tenderness and may enable the physician to identify a mass on the ovary or fallopian tube. An ectopic pregnancy cannot be diagnosed with a pelvic exam all on its own, though it is an important part of the overall evaluation. 

Ultrasound – A transvaginal ultrasound is utilized to confirm the presence of an ectopic pregnancy. A transabdominal ultrasound may be utilized to assess for internal hemorrhage.

Blood tests – Serum hCG usually rises less in an ectopic pregnancy when compared to a healthy pregnancy. Other blood tests include CBC (to assess for blood loss), Rh blood type (Rh-negative patients will need treatment to prevent complications with future pregnancies), and progesterone (levels above 25 ng/mL is strongly associated with ectopic pregnancy).

T: What is the TREATMENT for ectopic pregnancy?

In all cases of ectopic pregnancy, the non-viable pregnancy must be terminated to save the life of the patient. Some patients may be treated medically while those with rupture or impending rupture will require surgery. 

Medical treatment for ectopic pregnancy

The medical treatment for ectopic pregnancy is methotrexate, which in most cases can be administered as a single dose in an outpatient setting. It is only indicated when the patient is hemodynamically stable, the serum hCG is less than or equal to 5,000 mIU/ml, the mass is smaller than 3 to 4 cm, and there is no fetal cardiac activity noted on transvaginal ultrasound. Patients must also be willing to stay near medical services in case a rupture does occur. Specific contraindications for methotrexate include signs of rupture, immunodeficiency, breastfeeding, thrombocytopenia and liver disease.

Methotrexate works by interfering with folic acid metabolism to inhibit DNA synthesis and cell reproduction. The result is that it stops the cells from growing, thus ending the ectopic pregnancy. The body is then able to reabsorb the tissue. 

Side effects of methotrexate include nausea, vomiting, diarrhea, abdominal cramping, and fatigue. More serious effects include hepatic impairment, alopecia, pneumonitis and pleuritis. After methotrexate treatment, the patient must undergo serial hCG testing until values return to pre-pregnancy levels.

Surgical treatment for ectopic pregnancy

Surgical treatment is required in those who do not meet the criteria for methotrexate and in those experiencing a ruptured fallopian tube. Two procedures are utilized – salpingostomy and salpingectomy. In a salpingostomy an incision is made in the affected tube and the ectopic mass is removed. A key benefit of this procedure is that fallopian tube function is preserved. A salpingectomy is necessary when the tube has ruptured. This procedure involves removal of the fallopian tube, which greatly affects future fertility.

E: How do you EDUCATE the patient?

For patients undergoing medical management with methotrexate, it’s vital they know the signs of rupture and to seek emergency medical treatment. They should also avoid alcohol and gas-producing foods as these can mask the pain associated with rupture. Other things to teach your patient receiving methotrexate are:

• Folic acid supplements and NSAIDs can decrease efficacy so they should be avoided.
• Methotrexate can cause fetal death or serious birth defects if taken with a viable intrauterine pregnancy. This is why IU pregnancy must be ruled out prior to methotrexate therapy.
• Sun exposure can cause a rash, so patients should wear protective clothing and SPF 30 or above.
• Avoid sexual activity or vigorous exercise until the ectopic pregnancy has been treated.
• A future viable pregnancy is possible, though they should wait at least three months before attempting to conceive.

Teaching after surgical intervention involves basic post-op teaching, infection prevention tactics, and how to recognize post-op infection. Signs of post-op infection include fever, redness/warmth at the surgical site, and purulent drainage. It’s also important to ensure the patient understands that they are still capable of becoming pregnant after salpingostomy or salpingectomy. If both tubes have been removed, then IVF may be an option for future family planning.

Ensure all patients with ectopic pregnancy know their risk of having another one is higher than average and that they should receive early prenatal care with any future pregnancy. With that, it is also important they know the signs of ectopic pregnancy and to seek prompt medical treatment.

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Review ectopic pregnancy while you study for NCLEX and exams on the go with episode 365 of the Straight A Nursing podcast.

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References:

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Last Updated on September 27, 2024 by Maureen Osuna, MSN, RN