Ectopic Pregnancy – fetus is outside the uterus

Ectopic preganancy risk factors

• Advanaced maternal age
• PID (pelvic Inflammatory Disease)
• Prior ectopic pregnancy
• Hx pelvic surgery or tubal ligation
• IUD
• In vitro fertilization
Signs and Symptoms of Ectopic Pregnancy
• Symptoms of bleeding
• Bleeding int the uterine cavity
• Sharp one sided abdominal pain – example in the fetus is in right quadrant so the pain is in one
sides abdominal pain
• Syncope
• Referred shoulder pain -– example in the fetus is in right quadrant so the pain will radiate from
the chest to the shoulders
• Lower abdominal pain
• Vaginal bleeding
• Abdominal tenderness – example naglalabor
• Low HCG hormone

Ectopic Pregnancy Symptoms:

- There are symptoms that help in deducing the ectopic pregnancy. Although it is also not necessary that
all these pregnancy symptoms will be seen.

- Lower abdominal pain, which increases over a period of time, accompanied by lower back pain

- Shoulder pain, which occurs, as the fetus draws blood for its growth, hampers the functions of
diaphragm.

- Vaginal bleeding, which is different from normal can be heavier or lighter and the blood is dark color

-Nausea and vomiting

-Weakness and pale skin, followed by fainting (c..natabunan because of bleeding)

- Low blood pressure when the bleeding is heavy

Fallopian tube – most

common site, not sure ko
dri kay nag putol si maam

Interstitial - layer of the

uterus
Diagnostic examinations of ectopic pregnancy
• Transvaginal ultrasound – visualize the presence of embryo or trophoblast cell
• Physical examination
• Pregnancy test
• HCG
• Pelvic examinations

Management of ectopic pregnancy

• Methotrexate – if wala pa nag rupture
- MOA: to alter the DNA,
• Salphingostomy via laparoscope- opening the uterus via laparoscopic manner
• Laparoscopic salphingectomy – removal of the uterus
Fallopian tube- is a very thin hollow organ that compose of many blood vessel
MANAGEMENT OF ECTOPIC
PRINCIPLE: Resuscitation and Laparotomy/Laparoscopy
ANTI SHOCK TREATEMENT: - to prevent the pt. from hypovolemic shock

-IV line made patent, crystalloid is started

-Blood sample for Hb, blood grouping & cross matching, BT, CT

-Folley's catheterization done

-Colloids for volume replacement

LAPAROTOMY:
Principle is 'Quick in and Quick out'

-Rapid exploration of abdominal cavity is done – when you already found the site cut and ligate

-Salpingectomy is the definitive surgery (sent for HP study)-

-Blood transfusion to be given- more than 1000c

-Autotransfusion only when donated blood not available.

Nursing Interventions with Ectopic Pregnancy

• Prepare patient for surgery. – because it is considered an emergency
• Institute measures to control bleeding/treat shock if hemorrhage severe and continue to
monitor postoperatively
• May be given methotrexate instead of surgery – if there is no rupture
• Allow patient to express feelings about loss of pregnancy and concerns about future
pregnancies.

Ectopic Pregnancy: Nursing Care

•Assess the appearance and amount of vaginal bleeding

•Monitor vital signs

•Assess the woman's emotional status and coping abilities

•Evaluate the couple's informational needs

•Provide post-operative care

Preterm Labor
- Labor that occurs between 28th week to the end of the thirty-seventh week of gestation. It occurs
approximately 9%· 11% of pregnancies.

-Any woman having persistent uterine contractions (4 very 20 min) should be considered to be in labor.

- A woman is documented as being in actual labor rather than having false labor contractions if she is
having uterine contractions that cause cervical effacement over 80% and dilation over 1cm

- Preterm labor Is always serious because if it results in infant's birth, the infant may be immature

Assessment
During tocolytoc therapy, assess the following:

•Fetal status by electronic fetal monitoring

•Uterine activity pattern – interval and intensity
•Respiratory status -RR, hypoventilation
•Muscular tremors-
•Palpitations
•Dizziness - isoxsuprine
•Lightheadedness
•Urinary output
•Patient education to S/Sx of PTL
•Patient education to S/Sx of infection

Risk factors:
• Race: African-American women
• Age: adolescent – lack of knowledge and no prenatal check up
• Those with inadequate prenatal care
• Those who continue to work at strenuous jobs during pregnancy
• Those who have shift works that leads to extreme fatigue
 Premature onset of physiologic initiators – or early giving of oxytocin

In fetal fibronectin – the blood vessel will leak that cause:

1. Susceptibility to environmental toxins like smoking, substances, alcohol the there is premature
rupture of membrane that will release Proteases that will lead to opening of the cervix
2. Uterotonins- chemical substances that facilitates the uterine contraction

Signs and Symptoms

• Persistent, dull, low backache
• Vaginal spotting
• A feeling of pelvic pressure (abdominal tightening)
• Menstrual-like cramping
• Vaginal discharges
• Uterine contractions -duration, interval, frequency, intensity
• Intestinal cramping
• Feeling that baby is “pushing down” or that “something” is in the vagina – if there is aonly
rupture bag of water

Medical management
1. Antibiotics (amoxicillin, ampicillin)
2. Tocolytics:
Ex: Isoxsuprine HCI ( Duvadillan) it relaxes uterine smooth muscles - two effects sa smooth
muscle and sa blood vessel
3. Prostaglandin inhibitors - prostaglandin E- for uterine contraction
Ex: Indomethacin (Indocin) inhibits prostaglandin thereby decreasing uterine contractions
4. Calcium Channel blockers ( blocks calcium reducing uterine contractions) – for muscle
contraction while magnesium is relaxation of muscle, partner sa calcium is sodium kay outside
sa cell
Ex: Nifepidine (Procardia) – ginabigay ito sa hindi pa term together with duvadilan. Usually -20-
30 or 3 ampules , SUBLINGUAL
5. Corticosteroids: hasten fetal lung maturity
Ex: Betamethazone 12 mg IM q 24 hrs 2 doses
Ex Dexamethazone 6 mg IM q 12 hrs 4 doses
Suppresses neutrophil migration
Decreases the production of inflammatory mediator
Reverses increase capillary permeability
Explanation :
- si neutrophils mag release ug cytokines that may amplify in inflammation reaction, if ang
neutrophil mag migrate mag cause siya sang inflammation
- inflammatory mediator- mag act as blood vessel messenger that cause inflammatory
response
 - Reverses increase capillary permeability – if mag increase mag enter ang fluid sa
surrounding tissue then the fluid is high protein that cause swelling
- surfactant – substance necessary to prevent lung collapse

6. Magnesium sulfate ( inhibits acetylcholine promoting uterine relaxation

- as vasodilator for dilation because mayroong uterine contraction
7. Beta- sympathomimetic drugs: dilates smooth muscles
Ex: Ritodrine hydrochloride ( yutopar)
Terbutaline (brethine)

Surgical management
• Caesarean section

Nursing Management
• Hydration (Oral or IV)

• Bedrest (Home or Hospital), usually left side lying

• Tocolytics : Duvadilan

• Medications to stop labor {Magnesium sulfate, brethine, terbutaline, etc.)

• Antibiotics for RBOW

• Evaluation of the baby: BPS, non-stress or stress tests – to check the heart tone, contraction, CR,
reflexes, muscle tone, amniotic fluid index

• Dexamethasone: hasten fetal lung development

Preconception Care
i. Baseline assessment of health and risks for Preterm labor

ii. Pregnancy planning and identification of barriers to care.

iii. Adjustment of prescribed and OTC that may pose a threat to the developing fetus.

iv. Advise to improve maternal nutrition.

v. Screening for and treatment of diseases.

vi. Genetic counseling for those with a history of genetic disease/ a previously affected pregnancy
Antepartum Mgt
• Educate mother regarding S/Sx of PTL.
• No smoking, daily walking, eat nutritious food
• Bed rest in a left lateral position with - to prevent pressure for ascending aorta
• Monitor for uterine contractions
• Monitor for fetal heart beat Hook to EFM
• Hydration
• l&O
• Trendelenburg Position ( shock, block) – head down, elevate foot
• CBR without BRP
• No frequent abdominal manipulation

PIH
Gestational hypertension- when you get pregnant your BP is high but no other disease

Preeclampsia- if the gestational hypertension is not management and there is an edema

Eclampsia- if hypertension, edema, and proteinuria plus seizure

Risk factors
• First pregnancy
• Multiple gestation
• Polyhydramnios
• Hydatidiform mole
• Malnutrition
• Family history
• Vascular disease

Types of Pregnancy Induced Hypertension

• Gestational hypertension
• Preeclampsia
• Eclampsia
• Eclampsia
• Chronic hypertension
- superimposed preeclampsia
 Gestational Hypertension
*increased blood pressure
-systolic pressure of more than 130mm/Hg or +30mmHg from baseline
- diastolic pressure of more than 90mmHg
or +l5mmHg from baseline
* edema- not present

MILD PREECLAMPSIA
•HYPERTENSION (140/90}

•PROTEINURIA>300mg/24 hrs

•MILD EDEMA,signaled by wt gain

(>2 lb/week or >6 lb/month)

•URINE OUTPUT>500ml/24hrs

Severe Preeclampsia
• Any of the following symptoms:
• BP>160/110 (2x,6 hrs apart, bedrest)
• Proteinuria .5g/24hours ( 3+ or 4+ dipstick)
• Massive edema
• Oliguria <400ml/24 hrs
• IUGR in fetus
• Systemic symptoms
Systemic symptoms
• Pulmonary edema
• Headache
• Visual changes
• RUQ pain
• Increase liver enzymes
• Thrombocytopenia

Eclampsia
• Hypertension
• Proteinuria
• Edema
• Seizure

Chronic hypertension superimposed preeclampsia

• Hypertensive disorders before pregnancy that progresses to preeclampsia

The arteries is vein become narrow,

Narrow blood vessel

Slow oxygen content

These two will result to poor placental perfusion

There is a increase blood volume and will release angiotensinogen because there is damage in
endothelial cells then converted to angiotensin I then go to the lungs which will release an enzyme –
angiotensin working enzyme to convert angiotensin II which is harmful because it can cause
vasoconstriction

Thromboxane- is a clotting factor

Nitric oxide -release during endothelial damage

Decrease oxygen supply because of vasoconstriction that will lead to decrease renal perfusion follow
decrease GFR that will cause glomerular damage that will allow protein to stay that will result
proteinuria in the urine then decreased oncotic pressure because protein is essential for homeostasis
that serve as a pulling force

There is a cerebral vasospasm that causes rupture of small vessels that will cause changes in intracranial
pressure that cause nervous system irritation . that cause seizure
The baby does not receive enough oxygen that will result to fetal perfusion

HELLP syndrome- all blood vessel have clots

Signs & Symptoms
• Hypertension
• Edema
• Proteinuria
• Headache
• Dizziness
• Seizure
• Decrease urine output
• Decrease Platelet count
• Bleeding
• Increase AST/ALT
• Tachycardia
• Tachypnea
• Metabolic acidosis
• Blurring of vision

FETAL EFFECTS:
Fetal tachycardia

•Fetal distress

•Intrauterine Growth restriction

•Fetal death in utero

•Abruptio placenta
Laboratory studies
• CBC – hypoprothrombinemia- normal is 150-450 thousand
• Serum electrolytes
• BUN
• Serum Creatine
• Liver function studies : ALT/AST
• Blood typing, crossmatching
• 24hr urine
• HELLP syndrome
- hemolysis
- elevated liver function tests
- low platelet count

Complications

• Eclamptic seizures
• HELLP syndrome
• Hepatic rupture
• DIC
• pulmonary edema
• renal failure
• placental abruption
• cerebral hemorrhage
• fetal demise

What is HELLP syndrome?

- is a life threating pregnancy complication usually considered to be a variant of preeclampsia
It sands for
H- (hemolysis, which is the breaking of red blood cells)
EL ( elevated liver enzymes)
LP ( Low platelet count)

Both condition usually occur during the later stages of pregnancy or sometimes after childbirth

MANAGEMENT OF PIH
• bed rest with or without BRP
• BP monitoring
• weight and urine checks
• NST's early
• USO for IUGR
• IVF
• Check for reflexes
 Antihypertensive drugs:
• Anticonvulsant drugs
• Steroids
• Delivery of the baby

Nursing Care for PIH

• Monitor VS, especially BP
• Monitor uterine contractions, ( duration, intensity, intervals & frequency)
• Monitor for FHT
• Monitor for progress of labor ( IE)
• Monitor for DTR every 4 hours while on MgS04
• Monitor for I & 0
• Monitor for Proteinuria
• Implement seizure precaution at all times

Seizure Precautions
• Keep side rails up at all times
• Minimize Noise
• Keep environment free of sharp objects
• Place pads on side of bed
• Dim lights
• Prepare rolled cloth at bed side ( for mouth)
• Time the duration of Seizure
• Stay with the client during seizure
• Position client's head on left after seizure
• Start Oxygen after Seizure – 2 liters per minute

- Magnesium Sulfate- It blocks the release of acetylcholine making the muscle to relax
Laxative – allows shifting of water in poops

Anti Hypertensive

• Methyldopa 250 mg/ tab ( Alpha adrenergic antagonist)

• Hydralazine 5 mg IVTT PRN for BP> 180/100
Hydralazine is a potent Vasodilator
Nifedipine ( Calcium Channel Blocker)
Anti Seizure: Magnesium Sulfate as side drip to mainline
Steroids: for Preterm with Pl H: Dexamethasone