High Risk Pregnancy

-Bleeding Disorders-
Prepared by:
Yvette M. Batar, RN, MAN, DM
 Ectopic Pregnancy
■ EP is implantation of the zygote outside the
uterine cavity or in an abnormal location
inside the uterus.
Causes of EP:
1. Mechanical Factors (that delay the passage of ovum)
2. Functional Factors
3. Assisted Reproduction
4. Failed Contraception
 TYPES OF ECTOPIC PREGNANCY
1. Tubal - Most common site (95%) of implantation
- Ampulla 55%; Isthmic 25%; Fimbrial 17%

2. Ovarian - s/s are like tubal pregnancy or bleeding

corpus luteum.
- Management is cystectomy or oophorectomy
3. Abdominal - Occurs 1/15,000 pregnancies
❖ Primary
❖ Secondary

4. Cervical ✓ Often due to IVF & embryo transfer

✓ Signs:
❖ Hour glass sign
❖ Thin-walled cervix
❖ Painless vaginal bleeding
❖ Seldom goes beyond 20 weeks gestation
 TYPES OF ECTOPIC PREGNANCY
5. Heterotypic ❖A tubal pregnancy accompanied by
intrauterine pregnancy
Pregnancy
6. Tubo - ❖ Results from the gradual extension into
the uterine cavity of products of
uterine conception that originally implanted in
the interstitial portion of the tube.
7. Tubo - ❖ A zygote that originally implanted in the
fimbriated end of the fallopian tube
Abdominal gradually extends into the peritoneal
cavity.
8. Tubo - ❖A zygote that is partly implanted in the
tube & partly in the ovary
ovarian
 Ectopic Pregnancy

Signs & Symptoms:

✓ Most Common Symptoms:
❖ Missed period of 2 weeks duration
❖ Unilateral lower abdominal pain
❖ Irregular bleeding
 Ectopic Pregnancy
Signs & Symptoms:
1. Normal signs of pregnancy appear during the
1st weeks after fertilization.
2. Before the rupture:
❖ Brief amenorrhea
❖ Pelvic & abdominal pain on the side
❖ “ Arias-Stella reaction
 Ectopic Pregnancy
Signs & Symptoms:
3. Ruptured ectopic pregnancy
a. Pain (sudden, severe, knife-like)
b. Spotting or bleeding
c. Cullen’s sign
d. Hard or board-like abdomen
e. Signs of shock - if internal bleeding
progresses to acute hemorrhage
 ECTOPIC PREGNANCY: DIAGNOSIS
A. Transvaginal Can reveal an extrauterine
Ultrasound (TVUS) pregnancy.
B. Serial HCG In normal pregnancy, the
determination HCG titer doubles every
48-72 hours, in ET its lower.
C. Pregnancy Usually negative coz HCG
Test present in the urine &
serum level is not enough
to be detected by
pregnancy test.
D. Culdocentesis Aspiration of bloody fluid
from cul-de-sac of Douglas
& HCG testing from this
area.
 ECTOPIC PREGNANCY: DIAGNOSIS

E. Serum ❖ Greater than 25ng/ml normal

Progesterone viable preg
Levels ❖ Less than 5ng/ml often
associated w/ non-viable preg
(EP & abortion) – does not
distinguish b/n non-viable & EP
❖ If serum levels are between
5-25ng/ml, an ultrasound is
necessary
F. Uterine Currettage If intrauterine pregnancy is
not visualized w/ TVUS, when
HCG is at least 1,500 mIU/ml,
then uterine currettage may
be performed to distinguish
b/n non-viable & EP.
 ECTOPIC PREGNANCY: DIAGNOSIS

G. Colpotomy Direct visualization of the

oviducts & ovaries.

H. Laparoscopy Visualization of the pelvis

using a fiber optic glass

I. CBC The rate of a falling

hematocrit can discriminate
slow internal bleeding from
the sudden hemorrhage of a
ruptured tube.
J. Elevation in May help to aid in correct
WBC Levels diagnosis because PID or
appendicitis may have the
same manifestations as EP
 Ectopic Pregnancy
Management:
1. For unruptured EP – therapeutic abortion is
performed by:
A. Methotrexate
Rule of threes:
❖ Less than 3 weeks from expected menses (7 week
from LMP)
❖ HCG level less than 3000 mIU/ml
❖ Ectopic size less than 3 cm
❖ -- has 95% chance of success w/ methotrexate
 Ectopic Pregnancy
Management:
Criteria for Methotrexate therapy: women
eligible are:
❖ Unruptured EP less than 3 cm (3.5) on
ultrasound
❖ No FHT
❖ No renal or hepatic disease
❖ Normal CBC

B. Mifepristone
 Ectopic Pregnancy
Nursing Interventions:
1. If w/significant anemia (very low hgb & hct),
notify AP, methotrexate therapy is not warranted.
2. Methotrexate has been associated w/ stomatitis,
gastritis, hepatic enzyme elevation, pneumonitis,
& hematologic toxicity, careful monitoring &
evaluation throughout treatment is very
important.
 Ectopic Pregnancy
Nursing Interventions:
3. Baseline HCG level is determined before & after.
4. Blood type & RH factor are determined.
❖ Rhogam is administered if the patient is Rh (-)
5. IM leucovorin (similar to folic acid) is given on
alternate days to decrease hematologic toxicity of
methotrexate.
 Ectopic Pregnancy
Nursing Interventions:
6. Patient Instructions:
❖ Tell
patient that she may have some cramping or
discomfort on the side of EP as pregnancy is aborted
& the HCG declines, these symptoms are usually
mild & tolerable
❖ Bleeding is expected & will mimic a usual menstrual
flow.
❖ Instruct
patient to increase fluid intake to avoid
some of the adverse effects of methotrexate
 Ectopic Pregnancy
Management:
B. Other medical records involve the use of local
transabdominal, transvaginal, & transuterine
injections of compound, such as prostaglandins,
methotrexate, & hyperosmolar glucose to cause
abortion.
C. Surgical Management
 Ectopic Pregnancy
Management: Ruptured EP
Salphingectomy Indicated in uncontrollable hemorrhage
& severely damage tube.

Hysterectomy Often for ruptured interstitial or

cervical pregnancy.

Oophorectomy In ovarian pregnancy but is not

required where tubal removal is
required.
Note:
Depending on whether the tube will be removed or repaired,
the products of conception must be removed completely
otherwise secondary implantation & regrowth of trophoblastic
tissue may occur.
 Ectopic Pregnancy
Nursing Intervention:
1. Prevent & treat hemorrhage (main
danger of EP)
2. Patient w/ EP are often in extreme pain
❖ Provide assistance w/ positioning
during pelvic exam, ultrasonography &
other procedures
❖ Coach in breathing techniques
❖ Administer analgesics as ordered
 Ectopic Pregnancy
Nursing Intervention:
3. Post operative interventions
4. Meet emotional needs of patient (pregnancy
loss)
5. Prevention:
❖Safe sex practices – use condoms to
prevent STI & PID that causes EP
❖Importance of routine gynecological exams
(including chlamydia)
Thank you!