Ectopic Pregnancy: Diagnosis and Risk Factors

Ectopic Pregnancy (1st Trimester)

• Condition where a pregnancy develops outside the uterine cavity

Predisposing Factors

• Fallopian Tube narrowing
• PID (pelvic inflammatory disease)
• Prior Tubal pregnancy or surgeries
• Puerperal and postpartal sepsis
• Surgery of the fallopian tubes
• Congenital anomalies of the fallopian tubes
• Adhesions, spasms, and tumors
• IUD usage prevents normal implantation
• Age is a factor

Diagnosis

• Low Hemoglobin and Human Chorionic Gonadotropin levels
• Elevated White Blood Cell count

Ultrasonography

• Transabdominal ultrasound is less invasive
• Endovaginal ultrasonography is more invasive

β-human Chorionic Gonadotropin monitoring

• Tracks levels of the pregnancy hormone hCG in blood or urine
• Can help confirm and monitor pregnancy and diagnose certain cancers

Laparoscopy

• Requires direct visualization and is not common

Serial Testing

• Serial testing of the hCG beta subunit offers 100% accurate test result
• Used to differentiate normal from abnormal pregnancies and to detect or exclude an ectopic pregnancy

Hemogram (CBC)

• It is a fast and effective initial screening to detect ectopic pregnancy
• May show a slightly elevated WBC count, a sign of inflammation due to the body's response to the ectopic implantation site

Treatment

• Salpingectomy involves the surgical removal of a ruptured tube
• Blood replacement and Antibiotics are required
• Methotrexate (MTX) blocks enzymes that maintain the pregnancy, stopping tissue growth to prevent rupturing

Contraindications

• Ruptured tube is a contraindication
• Do not use if Breastfeeding
• Do not use if Intrauterine pregnancy is present
• Peptic Ulcer is a contraindication
• Do not use if Immunodeficiency is present
• Hepatic, renal dysfunction are contraindications

Types of Ectopic Pregnancy

• Depends on the site of implantation

Tubal Ectopic Pregnancy

• The most common type, found in 90-95% cases
• Tubal rupture typically occurs before 12 weeks
• Associated with high maternal morbidity and mortality when ruptured

Cervical Ectopic Pregnancy

• A rare pregnancy where a fertilized egg implants in the lining of the endocervical canal

Abdominal Pregnancy

• A rare pregnancy that occurs outside of the uterus

Ovarian Pregnancy

• A rare pregnancy where a fertilized egg implants on the ovary

Signs and Symptoms of Ectopic Pregnancy

• Amenorrhea/Abnormal menstrual period/spotting occurs, the most common sign
• Sudden, Acute low abdominal pain radiates to the shoulder
• Kehr’s sign refers to shoulder pain or neck pain
• Nausea and vomiting
• Bluish Navel (Cullen’s Sign) indicates blood in the peritoneal cavity
• Rectal pressure occurs because of blood cul-de-sac
• Sharp, localized pain occurs when the cervix is touched
• Signs of shock/circulatory collapse emerge

Complications

• Hemorrhage and Infection
• RH Sensitization occurs when a mother has Rh-negative blood and the fetus has Rh-positive blood
• The mother's body creates antibodies that attack the fetus' Red Blood Cells (RBCs)

Management

• RhoGAM is a shot given IM at buttocks, prevents Rh incompatibility in pregnant people who are Rh-negative with negative
• Coomb’s test is given to prevent the mother's body from making antibodies that could harm the baby's blood

Hydatidiform Mole (H-Mole) - 2nd Trimester

• Benign neoplasm of the chorion
• The chorion fails to develop into a full term placenta and instead degenerates into fluid-filled vesicles
• Cause is unknown

Risk Factors

• Increased or decreased maternal age
• Low socioeconomic status and low protein diet are factors
• History of abortion and Clomiphene/Clomid Therapy are risk factors

Signs & Symptoms

• Brownish/reddish intermittent or profuse vaginal bleeding by 12 weeks occurs
• Spontaneous expulsion of molar cyst typically emerges between the 16th and 18th weeks of pregnancy
• Rapid uterine enlargement occurs
• Symptoms of Pregnancy Induced Hypertension (PIH) before 20 weeks will emerge
• Excessive nausea and vomiting along with excessive hCG (1-2 million IU/24 hrs) occurs
• A Positive Pregnancy Test will result
• No Fetal Signs, of heart tones or movements
• Abdominal pain

Treatments

• Evacuation is performed by D&C or hysterectomy if there is no spontaneous evacuation
• Hysterectomy is performed if above 45 years old and no future pregnancy is desired or with increased chorionic gonadotropin levels after D&C
• HCG titer monitoring is required for one year
• Medical replacement includes blood, fluid, and plasma
• Chemotherapy is used for malignancy, methotrexate is the drug of choice
• Chest X-ray is used to detect early lung metastasis

Complications

• Choriocarcinoma is the most dreaded complication
• Hemorrhage and Uterine perforation
• Infection

Nursing Management

• Advise bedrest
• Monitor vital signs, blood loss, molar/tissue passage, and Intake and Output
• Maintain fluid and electrolyte balance, plasma, and blood volume through replacement as ordered
• Prepare for D&C and hysterectomy as indicated
• Provide psychological support

Incompetent Cervix

• Mechanical defect in the cervix causes cervical effacement, dilation, and expulsion of products of conception in the mid-trimester of pregnancy
• Shortens or opens too soon during early pregnancy, which can cause preterm labor

Risk Factors

• Congenital defect of the cervix (short)
• Trauma to the cervix as in forceful dilatation, curettage, and difficult delivery
• Cervical lacerations procedures like conization or cauterization

Assessment Findings

• Painless contractions resulting in the delivery of a dead or non-viable fetus
• History of Abortions
• Finding of relax cervical OS on pelvic examination

Treatment

• Cervical cerclage procedure during the 4th to 6th week of gestation or prior to next pregnancy

Shirodkar Procedure

• Permanent Suturing of the cervix
• Subsequent deliveries are done by CS

McDonald Procedure

• Temporary purse-string suturing of the cervix
• Suture is removed at term in preparation for vaginal delivery

Nursing Implementations

• Provide psychological support to the patient
• Have bedrest while lying on the left side for the next few days
• Advise limitation of physical activities within 2 weeks after treatment
• Drink plenty of fluids and void regularly

Perineal Hygiene

• No douches or tampons
• Report Danger Signs, such as fever and chills, general aches, saturating one pad in less than 3-4 hours, and foul smelling or thick yellow discharge
• Maternal and fetal growth monitoring, with routine prenatal care
• Instruct the patient to promptly report signs of labor
• Assess signs of labor, infection, or PROM
• Prepare stitch removal sets in labor