ECTOPIC

PREGNANCY
What is Ectopic pregnancy?

Ectopic means ”out of place.” In an

ectopic pregnancy, a fertilized egg has
implanted outside the uterus. The egg
settles in the fallopian
2
tubes in more
than 95% of ectopic pregnancies. This
is why ectopic pregnancies are
commonly called”tubal pregnancies.”
Causes:
• An ectopic pregnancy is usually caused by a
condition that blocks or slows the movement of a
fertilized egg through the fallopian tube to the
uterus. This may be caused by a physical blockage
in the tube.
Most cases are a result of
scarring caused by:

Past ectopic pregnancy

Past infection in the fallopian tubes
Surgery of the fallopian tubes
Signs and Symptoms:
• abdominal and pelvic pain
• vaginal “spotting” or light bleeding
Anatomy and
Physiology
 Vagina
• The vagina is a canal that joins the cervix (the
lower part of uterus) to the outside of the body. It
also is known as the birth canal.
Uterus (womb)
• is a hollow, pear-shaped organ that is the home to a
developing fetus. The uterus is divided into two
parts: the cervix, which is the lower part that opens
into the vagina, and the main body of the uterus,
called the corpus. The corpus can easily expand to
hold a developing baby. A channel through the
cervix allows sperm to enter and menstrual blood to
exit.
Ovaries
• The ovaries are small, oval-shaped glands that are
located on either side of the uterus. The ovaries
produce eggs and hormones.
 Fallopian tubes
• These are narrow tubes that are attached to the
upper part of the uterus and serve as tunnels for the
ova (egg cells) to travel from the ovaries to the
uterus. Conception, the fertilization of an egg by a
sperm, normally occurs in the fallopian tubes. The
fertilized egg then moves to the uterus, where it
implants into the lining of the uterine wall.
Broad Ligaments
• Two wing-like structures that extend from the
lateral margins of the uterus to the pelvic walls
and divide the pelvic cavity into an anterior and a
posterior compartment.
Fimbriae
• Fringes; especially the finger-like ends of the
fallopian tube.
Endometrium
• - is the mucosal layer lining the cavity of the uterus.
 Myometrium
• is the middle layer of the uterine wall consisting of
smooth muscle cells and supporting stromal and
vascular tissue.
Perimetrium
• is the outer serosa layer of the uterus, equivalent to
peritoneum.
Mesovarium
• is the portion of the broad ligament of the uterus
that covers the ovaries.
Round Ligament
• of the uterus originates at the uterine horns, in the
parametrium.
• It leaves the pelvis via the deep inguinal ring,
passes through the inguinal canal and continues on
to the labia majora where its fibers spread and mix
with the tissue of the mons pubis.
Uterine Cavity
• The Cavity of the Body in the uterus is a mere slit,
flattened antero-posteriorly.
Ovarian Ligament
• (also called the utero-ovarian ligament or proper
ovarian ligament) - is a fibrous ligament that
connects the ovary to the lateral surface of the
uterus.
Infundibulum
• (Latin for funnel; plural, infundibula) - is a
funnel-shape cavity or organ.
Fundus of the Uterus -
• is the top portion, opposite from the cervix.
• Fundal height, measured from the top of the pubic
bone, is routinely measured in pregnancy to
determine growth rates.
Uterine Artery
• - is an artery in females that supplies blood to the
uterus.
Labia majora
• The labia majora enclose and protect the other
external reproductive organs. Literally translated as
"large lips," the labia majora are relatively large and
fleshy, and are comparable to the scrotum in males.
The labia majora contain sweat and oil-secreting
glands. After puberty, the labia majora are covered
with hair.
Labia minora
• Literally translated as "small lips," the labia minora
can be very small or up to 2 inches wide. They lie
just inside the labia majora, and surround the
openings to the vagina (the canal that joins the
lower part of the uterus to the outside of the body)
and urethra (the tube that carries urine from the
bladder to the outside of the body).
 Bartholin's glands
• These glands are located beside the vaginal opening
and produce a fluid (mucus) secretion.
Clitoris
• The two labia minora meet at the clitoris, a small,
sensitive protrusion that is comparable to the penis
in males. The clitoris is skin, called the prepuce,
which is similar to the foreskin at the end of the
penis. Like the penis, the clitoris is very sensitive to
stimulation and can become erect.
PATHOPHYSIOLOGY
Predisposing Precipitating Factor:
factors: •History o pelvic
•Age inflammatory
•lifestyle disease
•Uterine curettage
Dysfunction of the cilia w/c •Previous tubal surgery
normally propels the •Endometriosis
fertilized ovum through
the tube into the uterine cavity.

Disruption of the scarring

of the fallopian tube
 Blocks or slows the movement of a
fertilized egg though the
fallopian tube to the uterus.

Fertilized ovum implants Painless

outside the uterus. bleeding

Tubal ectopic pregnancy

 Blastocyst burrows into the epithelium of the
tubal wall (usually in the distal / ampullary
two or thirds of the fallopian tube.

1. Decrease
resistance
of the invading Tapping of Before
trophobalstic blood vessels Rupture
tissue by the in the tube. 1. Abdominal
fallopian tube. pain
2. Decreased 2. Abdominal
muscle vaginal
mass lining bleeding.
of the 3. Abdominal
fallopian tube. tenderness.
3. Decreased
HCG.
 Abortion, spontaneous During
Embryonic regression Rupture:
death or rupture Exacerbation
(depends on gestational age of pain.
and location of implantation

After Rupture:
Faintness/dizziness
Abdominal pain
Sign of shock
 Excessive
Maternal hemorrhage
bleeding occurs.

Maternal Death
VITAL SIGNS
Vital signs upon admission
Temp =
Pulse = 91 bpm
RR = 20 bpm
BP = 130/100
December 14-15,2009
Time BP PR RR Temp.
11:00p 120/70 85 23
m
11:15 120/70 83 20
11:30 120/70 88 21
11:45 110/80 80 22
12:00m 110/70 78 20 36.8
n
12:15 110/80 75 23
12:30 110/70 76 18
12:45a 120/80 81 20
m
1:00am 110/80 80 23
1:30am 110/70 83 24
2:00am 110/70 79 21
2:30am 110/70 81 23
3:00am 120/80 78 20
4:00am 110/80 80 22 36.5
5:00am 120/70 83 21
6:00am 120/70 80 20
7:00am 120/80 85 19
Dec. 15, 2009

Time BP PR RR Temp.
8am 120/60 84 22 36.8
9am 120/70 82 20 37
10am 120/70 80 21 37
11am 120/70 81 20 36.7
12nn 120/70 82 20 37
1pm 120/70 84 22 37.1
2pm 120/70 82 21 37
3pm 110/70 - - -
4pm 110/70 80 20 37.1
5pm 110/70 - - -
6pm - - - -
7pm 110/70 - - 37
8pm 110/70 80 -20 37
9pm 110/70 - - -
10pm 110/80 - - -
11pm 110/80 - - -
12mn 120/70 78 19 37.5
Dec. 16,2009

time BP PR RR Temp
1am 110/80 - - -
2am 110/80 - - -
3am Asleep - - -
4am Asleep - - -
5am Asleep - - -
6am 110/80 80 19 37.5
7am 110/80 - - -
8am - - - -
HEALTH
ASSESSMENT
OPERATIVE RECORD
Address: Tiguma, Pagadian City

Surgeon: Dra.Rexie Ramirez

Anesthesiologist: Dr.Jeke Rocabo
Sterile Nurse: Whela Sabuero RN
Assistant: Dane Sandalo RN
Anesthesia used: SAB ( Sensorcaine + Morpeine )
Time of induction: 9:41pm
Time of Operation started: 9:47pm
Time of operation ended: 10:45pm
Operation: Pelvic lap, salphingectomy
Pre-operative Diagnosis: Ruptured ectopic pregnancy
Admitting Diagnose: Ectopic Pregnancy
Chief Complaint: Abdominal pain
Reason for admission: For treatment
Brief History of present illness:
Sudden onset of colicly abdominalpain three days
pta associated of vaginal bleeding. G2P1 A0.
Activity Of Daily
Living
 Mrs. X woke up early in the morning at
4:00am, then she prepare her self and the
things needed that are useful in her store.
At 5:00am she goes in her store located at
the Agora and arrange all the things that
needs to be arranged and ready for selling.
She manage her store and her co workers
as well, someone will brings lunch for her
and to her co workers. At 12:30 they ate
their lunch. Around 4:00pm she goes
around the market and buy something for
their dinner at 5:00pm she prepare in
leaving her store and let her co-workers
take good care of it, because she will go
home, she prepare their dinner, and mostly
they sleep at around 9:00pm.
Laboratory
Results
 Result Unit Nomal Significanc
e
WBC 11.2 10 3/mm3 5.0 /10.0 Increased
levels are
associated
with
infection,
inflammatio
n,
autoimmune
disorders &
leukemia.

RBC 4.30 10 6/mm3 4.00 /6.00 normal

HGB 13.0 a/dl 12.0 /17.0 normal

HCT 37.0 % 37.0 /50.0 normal

MCV 86 um3 80 /100 normal

MCH 30.3 Pa 26.0 / normal

34.0

MCHC 34.9 a/dl 31.0/ normal

35.0

RDW 12.5 % 10.0 / normal

20.0

PLT 309 10 150 /450 normal

3/mm3
MPV 7.2 um3 6.0 /10.0 normal

PCT 0.221 % 0.200 / normal

0.500

PDW 10.3 % 8.0 /18.0 normal

LYM % 17.6 1.96 25.0 / normal
50.0
1.00/5.00
EOS % 0.9 0.10 0.0/5.0 normal
0.00/0.40

BAS % 1.7 0.03 0.0/2.0 normal

0.00/0.20

ALY % 1.5 0.05 0.0/2.0 normal

0.00/0.20

HC % 1.1 0.13 0.0/2.0 normal

0.00/0.20
Ultrasound
ULTRASOUND
No.:20091214
Date: Dec. 14,2009
Examination TVS
TRANSVAGINAL ULTRASOUND
The anteverted uterus is normal in size andectotexture. The
uterus measure 5.9 x 5.1 x 4.8 cm. There is a heterogeneous
solid focus at the left fundal aspect of the uterus meaning
3.88 x 3.7 x 2.71 cm. The endometrium is thin. The cervix is
normal in size with closed cervical OS.
The right ovary was not identified, instead, a complex mass is
noted in the right lateral aspect of the uterus measuring 4.30
x 3.17 x 2.33 cm. There is what appears to be a small
gestational sac in the posterior aspect of this complex mass.
The left ovary measures 3.02 x 1.74 cm. There no fluid in the
posterior cul-de-sac.
IMPRESSION:
Consider ectopic pregnancy – please correlate clinically
andwith pregnancy test (+)
MYOMA UTERI
Sonographically normal left ovary
Intravenous Fluid
DATE SHIFT NO. OF NAME TIME
BOTTLE STARTED

Decembe 7am- 1 D5LR 1L 8pm

r 14, 7pm @ 30
2009 gtts/min
Decembe 7am- 2 D5LR 1L 1am
r 15, 7pm @ 30
2009 gtts/min
Decembe 7am- 3 D5LR 1L 2pm
r 15, 7pm @ 30
2009 gtts/min
Decembe 7am- 4 D5LR 1L 1am
r 16, 7pm @ 30
2009 gtts/min
INPUT and OUTPUT

DEC 14,2010
12-PS=8
1AMP.Tramadol IV given

Dec Oral IVF IV Meds TOTAL URINE

15,09
NPO 130cc 10cc 140cc 50cc
NPO 140cc 140cc 80cc
NPO 140cc 140cc 30cc
NPO 100cc 100cc 40cc
 NPO 130cc 1cc 131cc 100cc
60cc 130cc 10cc 140cc
100cc 100cc
140cc
120cc 100cc 220cc
120cc 10cc 130cc 490cc
240cc 100cc 340cc
120cc 140cc 1cc 261cc
140cc 140cc
TOTAL 540cc 1470c 22cc 2032c 790cc
c c
Drug Study
Medication Classification Indication

Generic name: Analgesic; Antipyretic -Short term

Ketorolac management of pain.
tromethamine
Brand name:
Foradol -Short term relief of
Generic name: Non-steroidal anti mild to moderate pain
Mefenamic acid inflammatory drugs including primary
dysmenorrheal.
Brand name:
-Relieves nausea and
Dolfenal vomiting caused by
Generic name: Antiemetic chemotherapy and
Metoclopramide drug related
Brand name: postoperative factors.
Clopra
Generic name: Analgesic -Management of acute
Celecoxib pain
Brand name:
Clebrex
Generic name: Analgesic, centrally -Relief moderate severe
Tramadol hydrochloride acting pain.
Brand name:
Ultram
Generic name: Phenothiazine -Treatment and
prevention of motion
Promethazine Dopaminergic blocker
sickness;prevention and
hydrochloride Antihistamine control of nausea and
Brand name: Antiemetic vomiting associated with
Phenadoz, phenergan Anti-motion-sickness anesthesia and surgery
drug Preoperative,
Sedative or hyphotic postoperative, or
obstetric sedation.
Adjunct to analgesic to
control postoperative.
generic name: antibiotic As for the other
cefuroxime cephalosporins, although
brand name: as a second-generation it
is less susceptible to
zinnat antibiotic
Beta-lactamase and so
may have greater activity
against Haemophilus
influenzae, Neisseria
gonorrhoeae and Lyme
disease.

Relieve constipation and

prepare the bowel for
generic name:bisacodyl laxatives diagnostic or surgical
brand name: dulcolax procedures requiring the
bowel to be empty.
generic Antagonist Duodenal and
name:zantac gastric ulcer
Brand name: (short term
Ranitidine treatment;
hypersecretory
conditions such
as Zollinger-
Ellison
syndrome.
generic name: Non-opioid
paracetamol analgesic pain reliever
brand name:
biogesic
generic name: Opioid agonist- relief of
nalbuphine antagonist moderate to
brand name: analgesic severe pain
Nubain
generic name:
cataflam Anti- Used commonly to
inflammatory treat mild to
brand name: moderate post-
dicloenac operative or post-
traumatic pain,
particularly when
inflammation is
also present, and
is effective against
menstrual pain
and endometriosis
generic name: Vitamins &/or Prevention &
Minerals treatment of vit &
termin-C mineral deficiency.
brand name: As an adjuvant in the
terramedic therapy of infections,
in pre- & post-op
conditions,
pregnancy, lactation,
degenerative &
cardiac diseases.
Local inflammation,
pruritic & allergic
conditions of the skin
& mucosa.
generic name: Topical
aplosyn Corticosteroids
brand name:
zuellig
PHYSICIANS ORDER SHEET
Time/Date Order
Dec.14,09 Please admit under Dra. Ramirez
8:00am TPR q4h npo
CBC – blood typing
Hooked with D5LR 1L 30gtts/min
A-prep
Secure consent
For pelvic lap ectopic
Pre of meds – Ramirez
Inform OR personnel
Ranitidine 1amp. IVTT
Metoclopamide 1amp.IVTT
Ceferoxine 750mg IVTT q8h anst
Inform Dra. Sicad
8:15pm PRE-OP
Promethazine 25g IM
Nalbuphine 5mg IM
Preload plain LR
POST ORDER
To her room
Flat on bed 4am turn side to side q2h
NPO
Monitor v/s q15 mins. For the first
2hours
Next 30mins,the next 4hours qh
O2 inhalation 3L/mins until alert and
stable (1-2 hrs)
IVF to follow
D5LR 1L @30-35GTTS/MIN
D5LR 1L @30-35GTTS/MIN
D5LR 1L @ 30-35GTTS/MIN
Physicians Order Sheet
TIME/DATE ORDERS
Dec.15,2009 -Site up on bed
11:35 am advice deep breathing exercise
clean liquids
12:15 am -may give open liquid with crackers this
afternoon
continue IVTT
5:30 pm continue IV medications
-soft diet morning
dolculax 1 cap. Rectum in morning
ranitidine to consume
continue IV medication cap. 2X a day
binder to start in the morning
 Physicians Order Sheet
Time/Date Orders
Dec. DAT this afternoon
16,2009 terminate IV when consume
10:25 am IV meds. Continue
Zinnat 500mg 1 cap. 3X a day

5:15 pm MGH anytime for patient request

continue home meds.
NURSING CARE PLAN
Subjective: · Acute pain Short term: Independent: · Provides ·at the end
“sakit akong related to 1. Follow ·Evaluate information of 1 week
tahi sa tiyan” disruption of prescribed pain regularly about need for nursing
as verbalized pharmacological intervention
skin, tissue, noting
by patient. regimen.
and muscle characteristics, s, the
2.Verbalize
Objective: Or effectiveness patient pain
integrity Nonpharmacolog location, intensity
· Facial mask of i (0-10 scale). of interventions. was
pain. cal methods that relieved
· Identify specific
· Guarding provide relief. or
activity
behavior. 3.Demonstrate · Prevents undue controlled
use of relaxation limitations.
· Narrowed strain on with the
skills and · Recommend pain scale
focus. diversional planned or operative site.
of 0 from 6.
Pain scale-6 activities, as progressive · Promotes
· V/S taken as indicated, for return of normal
exercise.
follows: individual function and
T: 37.3 situation. enhances
P: 80 Long term: feelings of
At the end of 1
R: 18 week nsg. general well
Bp: 110/90 Intervention, the being.
patient ·
pain will be
relieved or
Controlled with a
pain scale of 0
from 6.
periods. Conserves energy for
healing.
· Review importance of · Provides elements
nutritious diets necessary for tissue
and adequate regeneration or
fluid intake. healing.
. May relieve pain and
· Reposition as Enhance circulation.
indicated.
· Provide additional · Improves circulation,
comfortmeasures like reduces muscle tension
back rub. and anxiety
· associated with pain.
Encourage use of · Relieves muscle and
Relaxation technique emotional
like tension.
deep breathing
exercises.
Collaborative:
· To relieve mild
· Administer
or moderate
analgesics or non
pain.
steroidal anti-
inflammatory
drugs as prescribed.
 Cues Nursing Dx Nursing Nursing rationale evaluation
objectives intervention
Subjective:“Na Grieving r/t Short term: Independent: Goal is met
guol gyud ko anticipatory After 8 hours · provide open · promotes a because the
ug loss/death of environment free discussion patient had
of nursing
nasayangan a significant and trusting of feeling and accepted that
kay others interventions concerns. the fetus baby
relationship.
namatayan , the patient · enhances was lost/
napod ko ug will be able to: sense of trust death
anak” as · be honest and nurse-
Identify and when answering client
verbalizedby express questions, relationship
patient.Objecti feelings
ve:Facial providing
effectively. information.
expression of
feeling Acknowledge · identify · indicators of
sadBlaming impact/effect problems with severity of
herself of not of the grieving eating, activity feelings client is
process and experiencing
knowing that level, sexual and need for
she’s seek desire, role specific
pregnant· V/S appropriate performance. interventions to
taken help. address these
.
asfollows:T: Participate in tissues.
36.9P: 80R: work and self-
20Bp: 110/80 care/ ADL’s as
able.
Long term: Collaborative:
After nsg. · refer to · to meet on
Interventions, additional going needs
patient will be resources, and facilitate
able to long such as grief work.
toward a plan pastoral care,
for future one counseling/ps
day at a time. ychotherapy,
community
organized
support
groups, as
indicated for
both client and
family/SO.
Discharge Plan
MEDICATION
nstruct pt to take medication within prescribed
ime and dosage
religiously to maintain health improvement.
Home meds:
. zinnat 500mg 3x a day
. termin – C 1 capsule once a day
. cataflam 3x a day
. aplosyn apply 3x a day
EXERCISE
ncourage pt to exercise as tolerated. Educate pt
n the benefits
f exercise towards health
particularly to improvement of tolerance activities.
DIET
A high-protein, high-calorie
diet is recommended for the
patient
as well as iron-rich foods.
Patient should also avoid
foods that are high in sodium.
HEALTH TEACHING
Educate the pt on the nature of
Ectopic pregnancy.
SCHEDULE OF NEXT VISIT
Instruct pt to return 1 week after
discharge for follow up check-up.
Emphasize importance of follow up
check ups.
SPIRITUAL
Encourage pt to continue trusting
God, to pray. Explain to pt that
everything happens for a reason
and they’re still alternatives to
having children.
LIFESTYLE
Encourage pt to take adequate rest
and take proper meals. Socializing with
people and having a healthy
relationship with friend may help
divert patient’s attention from his
vices, and restore her love for life.
Reuniting with her family may also
help her psychological condition.
REFERRAL
Refer to a female reproductive
specialist such as obstetrician or
gynecologist for further consultation or
go to a nearest health center or
EVALUATION
EVALUATION
Patient x was our patient, accompanied by her
husband; she was last December 14, 2009 at 8:00
m at PCMC Hospital with the admitting diagnosis of
ectopic pregnancy. Her chief complaint is abdominal
pain. During the interview, the patient was
cooperative and responsive. The frequent
interaction in the patient and SO have greatly
helped the feeling and relaxed.
The patient was confined in the hospital for three
days. After series of medical treatment and nursing
interventions, patient condition improved and
successfully treats. The patient was discharged last
December 16, 2009 at 5:15 pm with home
medication to continue.
SPECIAL
THANKS
TO:
Ms. Rexie Ramirez
Mr. Jeekee Rocabo
Ms. Whela Sabuero
Ms. Dane Sandalo
Ms. Grace Sicad