PONTIFICAL AND ROYAL

UNIVERSITY OF SANTO TOMAS

THE CATHOLIC UNIVERSITY OF THE PHILIPPINES

COLLEGE OF NURSING
A.Y. 2019 - 2020

CASE ANALYSIS IN OBSTETRICS

(NUR81014)
Submitted to:
Trinidad S. Ignacio, RN, MAN
Submitted by:
SANCHEZ, Joseph Matthew B.
SANTOS, Camille Ann L.
SANTOS, Dana Angeli M.
SANTOS, Ryan Maxwell M.
SARINGAN, Shannen Raiza B.
SARTAGUDA, Fatima R.
SAYONG, John Lyndon C.
SCHWARZKOPF, Sophia Marie T.
SERRANO, Rackelle Andrea P.
SEVILLA, Denise Anne G.

2NUR7 RLE 3

April 2020
CASE SCENARIO

Mrs. Sakura, a 27 year old G4P3 with a chief complaint of abnormal menstruation without a period of amenorrhea was diagnosed to have left tubal ectopic pregnancy
after vaginal examination and abdominal ultrasonography. The case shows the need for careful history taking and the need for considering ectopic pregnancy in
women in the reproductive age group, who have abnormal menstruation even if they are on contraception.

CASE REPORT

A 27 year-old Para 3 whose last child was delivered 2 year ago, presented on 4 th of January 2020 a complaint of heavy prolonged menstruation. Her last normal
menstrual period was on the 7th of November 2019. Her menstrual cycle has always been regular with normal flow. The current menstrual flow started on the 7 th of
December 2019 and prolonged until the date of first consultation at the hospital. On further questioning, she admitted that she initially taken treatment from another
clinic to “increase” flow of her menstruation when she experience scanty flow during the first 3 days of this cycle. Upon treatment her menstruation became heavy and
prolonged and hence she sought a second opinion. There were no other complaints and the patient denied any pain or discomfort in the abdomen.

She has been married for 9 years and had 3 spontaneous vaginal deliveries. She was on combined oral contraceptive pills started a year ago and claimed to be
complaint with medication taken during the last menstrual cycle. There were no significant past medical, surgical or gynaecological problems.

On physical examination, there were no sign of anemia. Her blood pressure was 125/70 mmHg with a pulse rate of 85/min. abdominal examination revealed mild
tenderness over the lower abdomen. Vaginal examination excluded local causes of vaginal bleeding. On digital examination, there as tenderness at the posterior
fornix. Urine pregnancy test was positive. This was complemented by an empty uterine cavity with the presence of fluid in the pouch of Douglas.

The possibility of ectopic pregnancy was explained to her and she was transported immediately to the nearby hospital as she could collapse as a result of
hemoperitoneum. The patient underwent diagnostic laparoscopy the same evening. There was hemoperitoneum and leaking left tubal pregnancy at the ampullary
region. Both ovaries and the right tube were normal. Left salphingectomy and peritoneal lavage was done laparoscoppically and patient was discharge well the
following evening

LABORATORY TEST – Santos, Ryan Maxwell

Laboratory Tests with Analysis

The fetus rarely survives longer than a few weeks because tissues outside the uterus do not provide the necessary blood supply and structural support to promote
placental growth and circulation to the developing fetus. If it's not diagnosed in time, generally between 6 and 16 weeks, the fallopian tube will rupture.
Pregnancy Tests

If ectopic pregnancy is suspected, the first thing to do is to have a pregnancy test to check if there is HCG in the urine.

1. Urine β-hCG test (Immunoassays)

 An order of urine test can determine if there is presence of human chorionic gonadotrophin in the urine. An increase of this hormone means that the patient is
pregnant. This hormone interacts with the receptor of the ovary that promotes the maintenance of the corpus luteum during the beginning of pregnancy. This allows
the corpus luteum to secrete the hormone progesterone during the first trimester. (Normal pregnancy)
 Because of the lower levels of hCG being secreted by an ectopic implanted placenta related to poor vascularization, the pregnancy test must be highly sensitive for
beta-human chorionic gonadotropin (beta-hCG) to confirm if an ectopic pregnancy is suspected.
 The most common urine pregnancy tests such as the latex agglutination inhibition slide test are only 50% to 60% accurate in confirming a pregnancy that is ectopic.

2. β-hCG Radioimmunoassay tests

 Because of the morbidity and mortality associated with unrecognized ectopic pregnancy, the need for an accurate, rapid, sensitive, and specific method for measuring
low levels of human chorionic gonadotropin (hCG) is apparent.
 The beta subunit HCG radioimmunoassay is the most sensitive test available. It uses antisera against the isolated polypeptide chains of HCG to obtain maximum
specificity. Other pituitary hormones do not interfere with this assay.
 Because of its specificity and great sensitivity (5 mU/ml), the beta subunit assay is rapid method for confirming the diagnosis of ectopic pregnancy as well as for
managing all phases of trophoblastic disease.

 At present, the most promising pregnancy tests are the enzyme-linked immunoassays and new monoclonal antibody pregnancy tests such as:

1. The enzyme-linked immunosorbent assay (ELISA) and

2. The immunofluorometric assay (IFMA) are specific for the beta-hCG submit and therefore are 95% to 99% accurate. It takes only minutes to run these tests.

These are qualitative tests are readily adaptable to most clinic and office settings and may be run on either serum or urine specimens. Advantages include its ready availability,
simplicity, sensitivity, and specificity for the beta subunit of hCG. 

Blood Testing

If two negative results showed in the pregnancy test and you think you are pregnant or the doctor suspects you to be pregnant, you can do a blood test to measure the
pregnancy hormone (HCG) for more accurate results.

1. Blood Beta-HCG level test - An order of blood test measures the amount of HCG in the blood. This is more accurate than the urine test for it determines the exact
value of HCG. Under normal circumstances, the level of HCG doubles approximately every 48 hours, in the first trimester. Make sure to be tested twice with an
interval of 48 to 72 hours and compare the results. A more quantitative hCG tests help diagnose or rule out an ectopic pregnancy.
2. Complete Blood Count - This is to determine if the woman is suffering from blood loss or having anemia.
 3. Blood typing - To identify the blood type of the woman in case the mother needs blood transfusion.

DIAGNOSTIC TEST – Sayong, John Lyndon

● Early diagnosis before extrauterine rupture or abortion can decrease maternal mortality from hemorrhage and simplify the management of an ectopic pregnancy.

Ultrasound:

The usefulness of ultrasound in the diagnosis of an ectopic pregnancy is improving continuously.

➢ With the more sophisticated real-time equipment and an expert technician, characteristic changes of an ectopic pregnancy can be picked up with pelvic ultrasound.
➢ With transvaginal ultrasound, the location of the gestational sac of an early ectopic pregnancy can be visualized with 82% to 84% accuracy
➢ Therefore, transvaginal ultrasound is becoming an important diagnostic tool in an ectopic pregnancy before rupture because the probe can be placed closer to the pelvic
structures.

Culdocentesis

Culdocentesis can be used to diagnose an intraperitoneal bleeding if a rupture ectopic pregnancy is suspected.

➢ The procedure involves passing a needle through the cul-de-sac of Douglas to aspirate fluid from the peritoneal cavity

Laparoscopy

If any question remains, an endoscope may be inserted through a small abdominal incision to visualize the peritoneal cavity for an ectopic implanted pregnancy.
Laparoscopy is a surgical procedure where a small in the abdomen for the purpose of viewing or performing surgery on the organs of the pelvis or abdomen. Salpingostomy and
salpingectomy are two laparoscopic surgeries used to treat some ectopic pregnancies. In these procedures, a small incision is made in the abdomen, near or in the navel. Next,
your doctor uses a thin tube equipped with a camera lens and light (laparoscope) to view the tubal area. In a salpingostomy, the ectopic pregnancy is removed and the tube left
to heal on its own. In a salpingectomy, the ectopic pregnancy and the tube are both removed. Which procedure you have depends on the amount of bleeding and damage and
whether the tube has ruptured. Also, a factor is whether your other fallopian tube is normal or shows signs of prior damage.

Emergency Surgery

If the ectopic pregnancy is causing heavy bleeding, you might need emergency surgery. This can be done laparoscopically or through an abdominal incision
(laparotomy). In some cases, the fallopian tube can be saved. Typically, however, a ruptured tube must be removed.

Pelvic Examination
 To check the size of the uterus and feel for growth or tenderness in the abdomen..

NURSING MANAGEMENT, RESPONSIBILITIES AND INTERVENTIONS – Santos, Maxwell and Sayong, John Lyndon

NURSING MANAGEMENT and INTERVENTIONS:

1. Assess family’s anxiety over maternal well-being because of 10-time greater risk of mortality as compared to normal childbirth.

o Assess family’s level of guilt such as their feeling as to what they did to cause this to happen

3. Assess family’s coping strategies and resources.

4. Explain all treatment modalities and reasons for each in understandable terms.

5. Prepare the patient for transvaginal ultrasound, if this diagnostic procedure is ordered, by having the patient empty her bladder before the procedure.

6. Prepare a patient for Culdocentesis, if this diagnostic procedure is ordered, by explaining the procedure.

7. Ensure that appropriate physical needs are addressed and monitor for complications. Assess vital signs, bleeding, and pain.

8. Provide client and family teaching to relieve anxiety.

9. Explain the condition and expected outcome

o Material prognosis is good with early diagnosis and prompt treatment, such as laparotomy, to ligate bleeding vessels and repair or remove the damaged
fallopian tube.
o Pharmacologic agents, such as methotrexate followed by leucovorin, may be given orally when ectopic pregnancy is diagnosed by routine sonogram
before the tube has ruptured.
o A hysterosalpingogram usually follows this therapy to confirm tubal patency.
o Rh-negative women must receive RhoGAM to provide protection from immunization for future pregnancies
o Describe self-care measures, which depend on the treatment.
o Address emotional and psychosocial needs.

NURSING RESPONSIBILITIES

1. Pretest
● Assessment of the patient to assist in determining precautions.
● Preparation of the equipment and supplies needed.
 ● Preparation of a consent form, if required.
● Providing information and answering client questions about the procedure.
2. Intratest
● Use of standard precautions or sterile technique if necessary.
● Providing emotional support to the patient and monitoring the patient’s response during the procedure.
● Ensuring the correct labeling, storage, and transportation of the specimen.
3. Post-test
● Compare the previous and current test results, if available.
● Reporting of the results to the appropriate members of the healthcare team.
● Provide proper health teaching

ANATOMY OF THE FEMALE REPRODUCTIVE SYSTEM – Sanchez, Joseph

The reproductive system is vital for the survival of the human species. However, unlike other organ systems, it is not necessary for the survival of an individual. The male
and female reproductive systems both exhibit striking differences and similarities, but we are going to focus more on the female’s.

The normal anatomy of the said system is composed of the vagina, cervix, uterus, and two ovaries, one on each end of the fallopian tube. The functions of the female
reproductive system include the production of gametes, fertilization, development and nourishment of a new individual, and production of reproductive hormones.

Figure 1. Female Reproductive System

Source: Female Reproductive System (labelled), illustration - Stock Image - C043/4903. (n.d.). Retrieved from https://www.sciencephoto.com/media/995607/view/female-reproductive-system-labelled-illustration
The following table explains the function of each organ in the female reproductive system.

ORGAN FUNCTION

Ovaries A pair of tiny glands in the female pelvic cavity which produce female sex hormones such as estrogen and
progesterone to control reproduction and the female gametes that are fertilized to form embryos.

PHYSIOLOGY
Uterus Also commonly known as the womb; a muscular organ responsible for the development of the embryo and fetus OF THE
during pregnancy FEMALE

Vagina An elastic muscular tube that connects the cervix of the uterus to the vulva. It serves as the passageway of the
sperm to enable fertilization.

Cervix Serves as the narrow connection between the larger body of the uterus above the vagina below. It has a vital
role in controlling the movement into and out of the uterus, protecting the fetus during pregnancy and delivering
the fetus during childbirth.

Fallopian tubes A pair of muscular tubes that extend from the left and right superior corners of the uterus to the edge of the
ovaries. They are responsible for connecting the ovaries to the uterus. Egg cells are carried to the uterus through
the fallopian tubes following ovulation.

REPRODUCTIVE SYSTEM – Sanchez, Joseph

The Reproductive Cycle

The female reproductive cycle is the process of ovum production and preparing the uterus to receive an ovum that has been fertilized to begin pregnancy. If an ovum is
produced but has not been fertilized and implanted in the uterus, the cycle will reset through menstruation. On average, this cycle takes about 28 days but it may also take
between 24 (minimum) to 36 (maximum) days for some women.
 Figure 2. Female Reproductive Cycle

Source: Bicpuc. (2016, July 4). Menstrual cycle - An important process of Human Reproduction. Retrieved from https://medium.com/@bicspuc/menstrual-cycle-an-important-process-of-human-reproduction-
e22a4abce2e2

Oogenesis and Ovulation

Under the influence of follicle stimulating hormone (FSH), and luteinizing hormone (LH), the ovaries produce a
mature ovum in a process called ovulation. By about 14 days into the reproductive cycle, an oocyte matures and
is released as an ovum. Although the ovaries begin
to mature many oocytes each month, usually only
one ovum per cycle is released.
 Figure 3. Oogenesis
Source: Oogenesis. (2020, March 14). Retrieved from https://en.wikipedia.org/wiki/Oogenesis

Figure 4. Ovulation Cycle

Source:How to Know Your Fertile Days Naturally & Precisely 2019. (n.d.). Retrieved from https://naturalcontra.com/safe-days/fertile-days/

The process of ovulation is as follows:

PHASE DESCRIPTION

Follicular
A large number of primordial follicles begin the process of maturation into primary follicles. A layer of cells around
the ovum begins to mucify, or become more like mucus, and expand and the uterus lining begins to thicken.
Ovulatory
Occurs at about day 14 of a typical 28-day cycle. Estrogen levels rise as a result of increasing estrogen production
by hormonally active cells within the follicle. Enzymes are secreted and form a hole, or stigma. The ovum and its
network of cells use the stigma to move into the fallopian tube. This is the period of fertility and usually lasts from
24 to 48 hours.

Luteal
LH is secreted and a fertilized egg will be implanted into the womb, while an unfertilized egg slowly stops producing
hormones and dissolves within 24 hours. FSH and LH stimulate what remains of the mature follicle after ovulation
to become the corpus luteum. If fertilization does not occur, progesterone and estrogen levels fall, and the corpus
luteum dies.

Hormones involved in ovulation include:

HORMONE FUNCTION

Gonadotropin-releasing hormone (GnRH) A tropic peptide hormone made and secreted by the hypothalamus which stimulates the release of FSH and LH
from the anterior pituitary gland. Low-frequency GnRH pulses are responsible for FSH secretion whereas high-
frequency pulses are responsible for LH secretion.

Follicle-Stimulating Hormone (FSH) A gonadotropin synthesized and secreted from the anterior pituitary gland in response to GnRH. It is involved in
reproductive processes of both males and females. FSH stimulates the growth and maturation of immature oocytes
into mature (Graafian) follicles before ovulation.
Luteinizing Hormone (LH) Secreted by the anterior pituitary gland in response to GnRH. When follicle maturation is complete, an LH surge
triggers ovulation.

Progesterone Hormone that is responsible for preparing the endometrium for uterine implantation of the fertilized egg. If a
fertilized egg implants, the corpus luteum secretes progesterone in early pregnancy until the placenta develops and
takes over progesterone production for the remainder of the pregnancy.

Estrogen Responsible for the growth and regulation of the female reproductive system and secondary sex characteristics
produced by the granulosa cells of the developing follicle and exerts negative feedback on LH production in the
early part of the menstrual cycle.

Fertilization

The fimbriae catch the egg and direct it down the fallopian tube to the uterus once the mature egg is released from the ovary. It takes about 1 week for the egg to travel to
the uterus. If the sperm can reach and penetrate the egg, the egg is fertilized and becomes a zygote that contains a full complement of DNA. After 2 weeks of cell division, the
zygote now forms an embryo. This embryo will then implant itself into the uterine wall and continuously develop there during pregnancy.
 Figure 5. Fertilization Process

Source: What Are the Steps of Fertilization in Humans? (2019, December 3). Retrieved from https://www.invitra.com/en/human-fertilization/

Pregnancy

If the egg is fertilized by a sperm, the embryo will implant itself into the endometrium and begins to form an amniotic cavity, placenta, and umbilical cord. In the first 8
weeks, almost all of the tissues and organs present in the adult will be developed by the embryo before entering the fetal period of development during weeks 9-38. During the
fetal period, the fetus grows bigger and more complex development is seen until it is ready to be born. In the case of Mrs. Sakura, her reproductive system is affected
particularly the left fallopian tube where the ovum was implanted during the event of an ectopic pregnancy.

PATHOPHYSIOLOGY OF ECTOPIC PREGNANCY – Santos, Camille and Serrano, Rackelle

General Pathophysiology

Ectopic pregnancy is a complication of pregnancy in which the embryo attached outside normal uterine cavity. It a result of a flaw in human reproductive physiology that
allows that conceptus to implant and mature outside the endometrial cavity, which ultimately puts the mother and the baby at risk. Ectopic pregnancy refers to the implantation
of a fertilized egg in a location outside of the uterine cavity, including the fallopian tube with approximately 97.7% of the case, cervix, ovary and abdominal cavity in some cases.
In this case of abnormal pregnancy, the gestation grows and draws its blood supply form the site of abnormal implantation/fertilization. As the gestation progresses, it creates
the potential for organ rupture, because only the uterine cavity is designed to expand and accommodate fetal development unlike if the implantation in the fallopian tube –
chances are the tubes will rupture when the embryo grows beyond its’ capacity.

I. Signs and Symptoms

The clinical triad symptoms of ectopic pregnancy are:

- Abdominal pain
- Amenorrhea
- Vaginal bleeding

Only 50% of the patient with ectopic pregnancy present with all 3 symptoms. Patient may present other common signs and symptoms of early pregnancy like nausea, vomiting
and breast fullness – just like any other common pregnancies.

Upon pelvic examination, the uterus may be slightly enlarged and soft. Uterine or cervical motion tenderness may suggest peritoneal inflammation. An adnexal mass may be
palpated but is usually difficult to differentiate form the ipselateral ovary.

The presence of the following symptoms are of a medical emergencies:

- Abdominal rigidity
- Involuntary guarding
- Severe tenderness
- Evidence of hypovolemic shock (tachycardia, fluctuation in orthostatic blood pressure)

II. Etiology

An ectopic pregnancy requires the occurrence of 2 events: the fertilization of the ovum and abnormal implantation. Many cases of ectopic pregnancy are due to an obstruction in
the way of the ovum for normal implantation and decreased peristalsis in the fallopian tube. All of these are factors to be considered when an ectopic pregnancy is suspected.
 III. Predisposing, Precipitating and Contributory Factors

One of the predisposing factor of ectopic pregnancy is tubal damage - which can be the result of infections (vaginal infections) which if not treated can lead to pelvic
inflammatory disease (PID). The most common cause of PID is an antecedent infection caused by Chlamydia trachomatis. Another predisposing factor of tubal damage is a
previous abdominal surgery – which can cause adhesion of the tissue which makes normal implantation difficult.

History of previous ectopic pregnancy are scientifically proven to increase the risk of second ectopic pregnancy because of the possibility of tubal scarring as a result of the D&C
done on the prior ectopic pregnancy.

Cigarette smoking is a factor in about 1/3 of reported ectopic pregnancies; smoking may contribute to the decreased tubal peristalsis and vasoconstriction. Altered tubal motility
can also be a result of contraceptives... Progesterone-only contraceptives and intrauterine devices have been associated with an increased risk of ectopic pregnancy.

Infertility is another thing to consider – women using assisted reproduction seem to have a doubled risk of ectopic pregnancy, mostly due to the underlying infertility problem. On
the other hand, having a history of multiple sexual partners is also a risk factor.

Specific Pathophysiology
The case of the Mrs. Sakura, a 27 y/o G4P3 with a medical diagnosis of left tubal ectopic pregnancy and a chief complaint of abnormal menstruation without a period of
amenorrhea. She was under contraceptive pills before the detection of the ectopic pregnancy. Ectopic pregnancy is potentially fatal emergency condition if early diagnosis is
missed. As shown in this case, the absence of the clinical triad symptoms of ectopic pregnancy can lead to a missed diagnosis. The patient is only presenting with vaginal
bleeding, the abnormal menstruation referred to even though the patient is on contraceptive. Failed contraceptives especially progesterone-only pills increase the chances of
ectopic pregnancy. Progesterone-only pills reduce the activity of cilia in the fallopian tube and reduce tubal contractility or tubal peristalsis. This will slow the rate of zygote
transport and eventually, the zygote will develop and will be implanted in the fallopian tube hence, it will result in ectopic pregnancy. This tubal implantation is a medical
emergency especially when it rupture. The uterus is the only organ designed to stretch and keep the fetus viable with the sufficient blood supply needed. Implantation other than
the normal uterine cavity puts the mother in a danger of possible rupture hence leading to hypovolemic shock if not treated immediately.

UTERINE
ECTOPIC PREGNANCY
1. Cervical Any pregnancy where the fertilized
2. Angular Implantation
3. Caesarean
ovum gets implanted and develops in
Site
4. Cornual a site other than normal uterine
 Precipitating
Predisposing Factors
1. Ampulla Factors
2. Isthmus
Primary Secondary
3. Interstitial
4. Infundibular Others

Congenital
-Use of IUD
-Infertility
-Multiple Sex Partners
Tubal Lesion
1. Tubal Hypoplasia
2. Tortuosity -Cigarette Smoking
3. Congenital Diverticuli -Prior Induced Abortion
4. Accessory Ostia Acquired -Prior ectopic pregnancy
37 5. Partial Stenosis -Prior abdominal surgery
Lifestyle and Occupation 6. Elongation 1. Pelvic Inflammatory -Prior tubal surgery / tubal
7. Intramural Polyp Disease / Vaginal ligation
8. Entrap the ovum on its way Infection -Endometriosis
9. Obstruction - Chlamydia trachomatis
2. Contraceptive Failure

ECTOPIC PREGNANCY

Ectopic preganncy can be due to several risk factors. But the general pathophysiology as to why EPs occur is that
there is obstruction in the pathway of the implantation or there is reduced fallopian peristalsis brought about by
several factors like vasoconstriction/ vasospasm.
 Uterine
(1) Cervical – has implanted in Extrauterine
the uterine endocervix. Such
a pregnancy typically aborts within the first
trimester, however, if it is implanted closer to
(1) Ampulla –  the commonest type of tubal
the uterine cavity – a so-called cervico-
isthmic pregnancy – it may continue longer. ectopic pregnancy and accounts for
~70% of such cases
(2) Angular – implantation occurs eccentrically (2) Isthmus – 12. 0 %
along the fundus of the endometrial cavity, (3) Interstitial – 2-3 %
along with the lateral upper angle or (4) Infundibular - 11. 1%
cornua of the uterus. In contrast to interstitial (1) Implantation
tubal pregnancy, angular pregnancies have
- Implantation of the blastocyst normally occurs
a more medial location and are considered an
in the body of the uterus. Ectopic Abdominal Extrauterine Implantation
intrauterine implantation.
implantation can occur at number of sites In primary abdominal pregnancy, which is the
(3) Caesearean – Cesarean scar pregnancy is a outside the uterine body rarest type of ectopic gestation, the conceptus
type of ectopic pregnancy where the fertilized implants on the peritoneal surface.
egg is implanted in the muscle or fibrous
tissue of the scar after a
previous cesarean section Secondary abdominal pregnancy is a condition
where the embryo or fetus continues to grow in
(4) Corneal - Cornual pregnancy is a rare form the abdominal cavity after its expulsion from the
of fallopian tube or other seat of its primary
ectopic pregnancy where implantation occur development
s in the cavity of a rudimentary horn of the
uterus, which may or may not be
communicating with the uterine cavity.
[1] Cornual pregnancy represents 2–4% of
all tubal pregnancies and occurs once in
Contributory Factor Predisposing Factor Precipitating Factor

Previous infection such as salpingitis or pelvic inflammatory Use of IUD. The irritation of the fallopian tubes caused by
Race disease. Women who experience infection of the reproductive
the presence of the IUD in the uterine cavity may
system increase the incidences of having ectopic pregnancy
- African American women face higher rates of because the scar from these infections could cause adhesion in the prevent the egg from going into the uterus. IUDs are
BEFORE ADMISSION
 ADMISSION
Early diagnosis
The patient will undergo different diagnostic procedures like
laparoscopy, culdoscopy, and transvaginal ultrasound, etc.
These procedures and imaging tests are used to visualize the
condition inside the patient's body. Due to early diagnosis, the
patient can be medically treated because the fallopian tube is still
intact. In this way, she will be given intramuscular or oral
methotrexate which is a drug that stops cells from dividing. It will
not be stopped until the hCG titer turns into negative. After, the
patient needs to be assessed by hysterosalpingogram or
ultrasound to make sure that the pregnancy ended.
Nursing responsibilities for methotrexate:

 Administer antiemetic as ordered by the physician.

 Arrange leucovorin as soon as the patient started
methotrexate. It serves as an antidote for large doses of
methotrexate
 The patient should receive adequate hydration during
therapy to avoid hyperuricemia
 Mouth care should be advise to the patient to avoid
infection and provide comfort
 Observe GI tract and adverse effect.
 Advise the patient and family member to report
immediately abnormal symptom
Late diagnosis
The zygote grew to the point that the fallopian tube ruptured.
Blood and products of conception usually go to the pelvic cavity
which result to vaginal spotting because it does not usually reach
the vagina. Placenta dislodge in the same time the progesterone
will stop producing and will result to sloughing of uterine decidua
that will cause of additional bleeding. In the case of the patient,
she went to the hospital because she believed that she’s having
abnormal menstruation which we think is manifestation of ectopic
pregnancy.
NURSING CARE PLANS

Sartaguda, Fatiima

ASSESSMENT NURSING ANALYSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS

Subjective Risk for fluid The common sites In 24 hours: Independent: Independent: After 24 hours:
Data: volume deficit where ectopic
related to pregnancy often 1. Monitor and  Hypotension and
“Parang blood loss occur in the document vital signs tachycardia is
nanghihina Goal: including blood The risk for deficient
fallopian tube are caused by
buong pressure and heart fluid volume is reduced
ampullar, isthmus For the patient decreased
katawan ko.” rate. and has demonstrated
and interstitial/ to attain and circulation of blood
as verbalized stable and balanced
fimbrial. However, maintain volume. Changes
by the patient. level of fluid volume in
the most common sufficient in vital signs may
2. Assess and the body with a
site is the ampullar amount of fluid be used for rough
maintain the accurate reflection of stable vital
which likely causes volume in the estimate of blood
intake and urine signs, good capillary
Objective Data: chronic bleeding body loss and baseline
output; report output refill and individually
since it only data.
● Unable to rise less than 30 ml/hr for 2 adequate urine output
involves small  To observe
on bed/shows consecutive hours. and specific gravity
vessels; blood Objectives: guidelines for fluid
signs of replacement and to
weakness doesn’t really
● Blood 3. Measure diapers establish the
● Poor or cause discomfort
pressure, or sanitary pads if patient’s renal
decreased for the woman
pulse, and necessary. function.
skin turgor because it just
body  This will assess the
● There is an pools somewhere
temperature amount of blood
evident in the ampullar or 4. Assess skin turgor
all within loss every day.
increase in near another organ and oral mucous
normal limits.  Signs of
pulse rate, near the original membranes for signs
● Will manifest dehydration which
decrease in site. Anyhow, if the of dehydration.
stable is the main
blood products of
amount of manifestation of a
pressure, and conception coming
fluid volume 5. Advise patient to deficient fluid
decrease in from the site get
● Will have an take adequate rest and volume are
volume or expelled into the
alternative to have more amount detected through
pulse pelvic cavity, it will
pressure. cause possible compensatio of water. the skin.
hypovolemic n for possible  Activity increases
shock, hence a blood loss intra abdominal
deficient fluid from the pressure which can
volume. rupture result in further
● Demonstrate bleeding; oral fluid
Pillitteri, Adele. good skin replacement is a
(2007) Maternal & turgor, cost-effective
child health mucous method for
nursing :care of the membranes replacement
childbearing & moist, no treatment.
childrearing family excessive
Philadelphia, PA : thirst.
Lippincott Williams
& Wilkins,
Sevilla, Denise Anne

ASSESSMENT NURSING ANALYSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS

Subjective Data: Anticipatory Grieving is a normal, In 6 months Independent: After 6 months

grieving complex process that
 “Di ko alam related to early includes emotional,  Assess the client and  Client and the
mararamadaman loss of physical, spiritual, significant other’s partner may present to
ko. Natutulala na Goal: response to the the hospital in any  Was able to express
pregnancy social, and her feelings of loss, guilt,
lang ako pregnancy loss, such as phase of the grief
secondary to intellectual responses Patient will express fear or sadness
pagkatapos denial, bargaining, process. Client may
ectopic and behaviors by feeling about her
malulungkot pati depressions and so. move in and out of
minsan wala rin pregnancy which individuals or loss to her stages of grieving.
ako gana families incorporate significant other,  Was able to maintain
bumangon sa an actual, support person, or  Provide support healthy patterns of sleep,
kama o kumain ng anticipated, or healthcare without offering false ADL, and eating
pagkain” perceived loss into providers. hopes. If in denial, tell
their daily lives. patient/couple that being
in denial and that the  Use healthy coping
 Coping mechanism and social
Objective Data:  delays in grieving is a
Client and family mechanisms assist the support system
normal coping
 Verbal are able to share client to gradually face
mechanism and part of
expression of their grief with each the loss. Also, to
the process
distress, loss, guilt other. eliminate negative self-  Began planning for
 Alteration in talk in order to respond future
eating habits or    Provide an open, well to behavioral
sleep pattern non-judgmental therapy
Objectives: environment and  Appropriate move
 Crying
consider individual nature through stages of
 Detached from  Identify
of movement through the grieving
environment healthy ways to
stages of grief (e.g. the
deal with and
mother has a longer
express
attachment to pregnancy  Grieving is an
pregnancy loss
than the father) individual process. A
place for opening up or
 Recognize discussion to facilitate
 Provide opportunity communication
the impact and
to ask questions and regarding the loss may
effect of the
encourage patient to aid comfort and
grieving
verbalize or express promote acceptance
process like
feelings
eating and
sleeping
 Able to  Include partner in
participate in planning of care to
self-care reinforce discussion of  Sharing feelings
activities of concerns with healthcare provider
daily living as may help the patient in
well as having finding the importance
an open of the experience of
communication loss
with other
family members  Provide clear  Partnership in the
explanations and decision making and
information regarding the planning may let the
 Look
grieving process partner be seen
toward plans
and future, one individually
day at a time.  Strengthen the
Paying patient’s efforts to go on
attention to  Information assist
with her life and normal client to understand
welfare of the routine by providing
family feelings that may be
means of healthy coping overwhelming
with grief such as
cooking for the family,
bonding with the other
kids
 Allow the patient
and family to feel what
Collaborative: they are feeling, but still
continue to go on by
 Refer patient and partner supporting each other.
to a grief support group This enable to review
role changes and help
plan to deal with loss

 Support groups
may help client and
partner to cope with the
pregnancy loss
Santos, Dana Angeli

NURSING
DIAGNOSIS
ASSESSMENT ANALYSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective Data: Chronic Ectopic Goal: To prevent Independent  Patient verbalized

bleeding pregnancy is a further bleeding understanding of her
- “Nagdudugo condition and the
related to gestation in and maintain the
parin ako  Monitor vital signs surgical intervention
ruptured which well-being of the  To establsih baseline
kahit tapos done to her
na yung ampulla of implantation mother data. Also, if the tube
 Patient maintains
period ko. the fallopian occurred outside is ruptured, the
stable vital signs
Bukod pa tube (pg. the uterine patient may go into
 Patient demonstrate
doon, 534) cavity. The most Short Term shock and will have
improved blood/ fluid
masakit yung common site of Objectives rapid heart rate, rapid
volume
bandang implantation is breathing and low
 Patient demonstrates
kaliwa ng the fallopian In 24 hours, blood pressure.
good skin turgor
tiyan ko pati tube, specifically,
yung balikat  Patient
in the ampulla. It
ko” as understands
usually happens
verbalized by her present  To assess the blood
because a
the patient condition and loss and to see
fertilized egg
the surgical whether the patient is
wasn't able
intervention not in shock
Objective Data:  to move down
the fallopian tube that will be  Assess the amount of
- Vital signs into the uterus. performed to bleeding regularly and
taken as stop further check laboratory
follows: values such hematocrit
bleeding
-BP: 110/70 (Hct) and hemoglobin
As the ectopic  Patient’s (Hgb)
-Temp: 36.4 pregnancy blood lost will
°C progresses and the be replaced
tube ruptures,  Patient’s vital  To check for renal
-PR: 85
bleeding results signs (BP, RR function. Heavy
-RR: 20 due to destruction and PR) are bleeding reduces
of blood vessels. stable  Monitor the input and blood flow to organs
- Vaginal Unlike in interstitial output of the patient such as the kidneys.
bleeding/  Patient Therefore, the
portion where
spotting manifest kidneys cannot make
evident severe
improved urine without this
- Rigid intraperitoneal intravascular blood flow
abdomen bleeding may volume
- Pale skin and occur, less  Demonstrate
lips bleeding will good skin
- Weakness happen when the turgor and no
implantation site is signs of
in the ampulla.
dehydration
Hence, profuse
hemorrhage is less
likely to happen Long Term  If the tube is
because of its Objectives ruptured,
small blood laparoscopic surgery
vessels. However, is done to ligate the
less bleeding may bleeding vessels and
 After a 2-3 Prepare the patient for remove/ repair the
lead to chronic
weeks, the surgery: damaged fallopian
bleeding. Constant
patient will tube
and continued
show no signs
bleeding may result
to loss of large of pain and  Explain the surgical  It is very important to
amount of blood. bleeding intervention have an empty
Also, there may be  The patient (laparoscopic surgery) stomach before
will maintain to be performed to stop surgery that requires
compression of the
further bleeding anesthesia to prevent
phrenic nerves. stable vital
Hence, signs (her nausea andd keep
any food or liquid
compression of normal blood from getting into the
these will lead to pressure, RR lungs
shoulder pain.  & HR)
 The patient
will remain
free of
complications  Maintain NPO status

 To treat bleeding and

Flagg, J. & prevent complications
Pillitteri, A.
(2018).
Maternal
and Child  To replace fluid loss
Health and optimize cardiac
Nursing: output needed for
Care of the tissue perfusion
Childbearing
&
Childrearing Dependent
 To replace the blood
Family (8th
 Administer medications that was loss
Edition).
prescribed by the
Philadelphia: physician
Wolters
Kluwer

Hirsch, L. (2015).  Infuse IV solutions

Ectopic Pregnancy. ordered
Retrieved from
https://kidshealth.or
g/en/parents/ectopi
c.html  Anticipate the need for
blood transfusion
REHABILITATION / HEALTH PROMOTION – Saringan, Shannen and Schwarzkopf, Sophia

Medical Interventions

 Methotrexate is one of the treatment options for ectopic pregnancy. It prevents cell growth and dissolves existing cells, such as fetal, embryonic, and early placental cells. This will
eventually stop the pregnancy as evidenced by a decline in human chorionic gonadotropin in a span of 2 to 4 days. It can be administered intramuscularly, or orally.

Nursing interventions:

o Inform the patient about the therapeutic action of methotrexate.

o Advise the patient to avoid taking folic acid, alcohol, and antibiotics.
o Teach the side effects of methotrexate, such as abdominal cramps, vaginal bleeding, nausea and vomiting, decreased appetite, headache, mouth sores and swelling in the
injection site.
o Advise the patient to sip clear fluids like ginger broth or chicken soup broth.
o Instruct the patient to eat small, frequent feeding.
o Advise the client to gently brush her teeth at least two times a day with a soft-bristled brush to prevent mouth sores. Also, rinsing mouth at least 4 times a day to 
o Instruct the patient to avoid hot or spicy food that may aggravate mouth sores.
o Advise the client to put a warm compress to relieve abdominal cramps.
o Administer acetaminophen as ordered.
o Instruct the patient to report unusual symptoms such as heavy vaginal bleeding, facial edema, and difficulty breathing.
o Inform the patient to avoid intercourse during and after the therapy until the doctor tells you the treatment worked.

Surgical Interventions

 Salpingostomy
- This is considered to be a more conservative type of surgery wherein the fallopian tube is cut open to remove the pregnancy and leave the tube to heal. However, there is a risk of
developing another ectopic pregnancy and persistent trophoblast. 
 Salpingectomy
- This procedure involves the removal of the affected fallopian tube which provides assurance or non-repetitive ectopic pregnancy but only one tube is functional for future reproduction.

Nursing responsibilities:

o Upon the patient's arrival at the hospital, assess the vital signs and frequently monitor fluid intake & output. 
o Maintain NPO status and Insert indwelling catheter

o Prior to surgery, make sure that the patient is aware of the procedure to be done and informed consent has been established.
o Evaluate the patient’s vital signs, blood pressure, and heart rate to ensure that it goes back to normal. 
o Assess the incision site and look for signs of bleeding, infection, or other problems.
o Instruct the patient and her family regarding post-operative care to be done at home. 
Coping and Support

 Let the patient have some time to grief and talk about her feelings and experiences fully. Encourage her to verbalize her concerns regarding pregnancy loss and her possibly reduced
potential for future childbearing.
 Encourage the family members, loved ones, or friends of the patient to give support to the patient. The patient may also seek help from support groups, grief counselors, or other mental
health providers. 
 Explain to the patient that future healthy pregnancies may still be possible, certain safety measures should be considered. If one of the fallopian tubes is damaged or removed, the union
of the egg and sperm is still possible which can also travel to the uterus. 
 Suggest alternatives, such as in vitro fertilization (IVF), if both fallopian tubes are damaged or removed. 
 Explain that fertility rates after either medical or surgical management are similar in patients with no history of subfertility or tubal pathology 

Pharmacological

 Instruct patient to avoid vitamins and folic acid until Hcg level is back to zero
 Avoid antiinflammatory medicines such as Ibuprofen, diclofenac, and aspirin one week after treatment.
 Women undergoing medical management should avoid alcoholic beverages, NSAIDs, vitamins containing folic acid, sexual intercourse, sun exposure due to risk of Methotrexate
dermatitis, and ultrasound and pelvic examinations during Methotrexate therapy surveillance

Activities

 Avoid coitus until Hcg level becomes normal, and bleeding and pain stops, usually for two to three weeks.
 Instruct patient to avoid lifting, until the doctor tells you it's safe to resume normal activities
REFERENCES

Bicpuc. (2016, July 4). Menstrual cycle - An important process of Human Reproduction. Retrieved from https://medium.com/@bicspuc/menstrual-cycle-an-important-process-of-
human-reproduction-e22a4abce2e2

Chowdhury, S. (2016, July 15). Ectopic pregnancy. Retrieved from https://www.slideshare.net/souravchowdhury313/ectopic-pregnancy-64061537

Clark, J. F., Verly, G. P., & Johnson, H. D. (1982, August). Pathogenesis of tubal pregnancy. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2552970/?page=2

Dulay, A. T., By, Dulay, A. T., & Last full review/revision Jun 2019| Content last modified Jun 2019. (n.d.). Ectopic Pregnancy - Gynecology and Obstetrics. Retrieved from
https://www.msdmanuals.com/professional/gynecology-and-obstetrics/abnormalities-of-pregnancy/ectopic-pregnancy#v1074103

Ectopic pregnancy. (2018). Retrieved from https://www.mayoclinic.org/diseases-conditions/ectopic-pregnancy/diagnosis-treatment/drc-20372093

Female Reproductive System - Anatomy Pictures and Information. (n.d.). Retrieved from https://www.innerbody.com/image/repfov.html?
fbclid=IwAR13R766budRa0KiE_jBhWBKsXYW9nD1HsVLUopIn7PNjqwAnZ_L9v7Squ0

Female Reproductive System (labelled), illustration - Stock Image - C043/4903. (n.d.). Retrieved from https://www.sciencephoto.com/media/995607/view/female-reproductive-
system-labelled-illustration

Flagg, J. & Pillitteri, A. (2018). Maternal and Child Health Nursing: Care of the Childbearing & Childrearing Family (8th Edition). Philadelphia: Wolters Kluwer
Hirsch, L. (2015). Ectopic Pregnancy. Retrieved from https://kidshealth.org/en/parents/ectopic.html

Harris, N. (2019). Ectopic Pregnancy Pain, Explained. Retrieved from https://www.parents.com/pregnancy/complications/ectopic-pregnancy-pain-explained/

Hirsch, L. (2015). Ectopic Pregnancy. Retrieved from https://kidshealth.org/en/parents/ectopic.html

How to Know Your Fertile Days Naturally & Precisely 2019. (n.d.). Retrieved from https://naturalcontra.com/safe-days/fertile-days/

Oogenesis. (2020, March 14). Retrieved from https://en.wikipedia.org/wiki/Oogenesis

What Are the Steps of Fertilization in Humans? (2019, December 3). Retrieved from https://www.invitra.com/en/human-fertilization/