A Case Study on

ECTOPIC PREGNANCY

In Partial Fulfilment of
the Requirements of NCM 209 – RLE
OB/GYN NURSING ROTATION

Submitted to:
RODELIZA FAITH B. GUILLERMO, RN, MN
Clinical Instructor

JOSEPHINE B. MAGNO, RN, MN

Clinical Instructor

Submitted by:

SHEINA GILIAN P. BATAO, ST.N.

KATE JANNINE S. DELA CRUZ, ST.N.
NICOLE O. JAVIER, ST.N.
HAGEE MAE S. MARCOJOS, ST.N.
CHEYENNE MARI B. RODRIGUEZ, ST.N.
AIRA LEA M. ROMARATE, ST.N.
NELVIN JONES A. TEMAN, ST.N.

BSN 2C - Group 1, Subgroup 3

March 14, 2022

1
 TABLE OF CONTENTS

I. INTRODUCTION AND OBJECTIVES…………………………………………... 3

II. PATHOPHYSIOLOGY……………………………………………………………. 7

A. ETIOLOGY……………………………………………………………........ 7

B. SYMPTOMATOLOGY……………………………………………………. 12

C. DISEASE PROCESS……………………………………………………... 14

D. DIAGNOSTIC/LABORATORY CONFIRMATORY TESTS…………… 17

E. MANAGEMENT……………………………………………………………. 18

F. PROGNOSIS………………………………………………………………. 37

III. DISCHARGE PLANNING……………………………………………………....... 38

IV. NURSING THEORY………………………………………………………………. 40

V. REVIEW OF RELATED LITERATURE / STUDIES…………………………… 42

VI. REFERENCES…………………………………………………………………….. 44

2
 I. INTRODUCTION AND OBJECTIVES

Motherhood is indeed an unending, universal, and intrinsic dream that every

woman possesses. However, it is not always pleasant, and sometimes the dream leads
to nightmares. Ectopic pregnancy is one of them, and it is a potentially fatal pregnancy.
According to Obstetrics & Gynecology (2018), ectopic pregnancy occurs when
pregnancy occurs outside the uterus, typically in the fallopian tube. In rare cases, it can
develop on an ovary or in the abdominal cavity.

Classic presenting symptoms include lower quadrant abdominal pain, vaginal

bleeding, and amenorrhea. Other potential symptoms include syncope, vomiting,
diarrhea, shoulder pain, lower urinary tract symptoms, rectal pressure, or pain with
defecation. However, about half of patients present atypically and may be asymptomatic
at earlier gestations (Gauvin et al., 2018). The nature, location, and severity of pain
vary, beginning as a colicky abdominal or pelvic pain that is localized to one side as the
pregnancy distends the fallopian tube. The pain may become more generalized once
the tube ruptures and hemoperitoneum develops. Ectopic pregnancy occurs in
approximately 1–2% of pregnancies, being one of the top leading causes of maternal
mortality in the first trimester and accounts for 10–15% of all maternal deaths worldwide
(Gerema, et.al, 2021). As stated in the case study by Suarez and Soccoro (2020) in the
Philippines, from the Ospital ng Maynila Medical Center, the incidence of ovarian
ectopic pregnancy is one in 7000 to 40 000, but most rupture in the first trimester and
only a few survive to term.

Diagnosis of ectopic pregnancy relies on serum human chorionic gonadotropin

(hCG) measurements combined with pelvic ultrasonography. In the emergency setting,
patients presenting with acute-onset abdominal pain and/or hemodynamic instability
must be quickly screened for ruptured ectopic pregnancy with (1) a serum or urine test
to confirm pregnancy and (2) a focused assessment with sonography for trauma (FAST)
scan, to detect hemoperitoneum (Paula Brady, 2017).

3
 Conferring with Hendriks et al. (2020), clients with suspected or confirmed
ectopic pregnancy who exhibit signs and symptoms of ruptured ectopic pregnancy
should be emergently transferred for surgical intervention. Meanwhile, if ectopic
pregnancy has been diagnosed, and the patient is deemed clinically stable, treatment
options include medical management with intramuscular methotrexate or surgical
management with salpingostomy or salpingectomy.

The aim of this nursing case study is to achieve a concrete understanding of

clinical concepts surrounding ectopic pregnancy to render a quality and holistic care to
clients sharing the same diagnostic predicament. Moreover, through the avenue
provided in this research the improvement of nursing implications will be warranted.
Enhancement of the student-nurse’s clinical eye shall be practiced as the signs and
symptoms of ectopic pregnancy and other pertinent responsibilities under the umbrella
of nursing education are ventured. This study will serve as a reliable academic
reference for researchers and hopefully aid them in developing new clinical solutions to
increase the probability of clients in attaining a better health outcome. The medical
inputs revolving medical managements, nursing responsibilities and other interventions
in the scope of patient health care will significantly improve our nursing practice,
something some of pioneering clients were deprived of.

4
Patient Information

The subject of nursing case study was asked for her consent and was given with
an initials W.M.Z to observe patient’s rights and confidentiality. Client W.M.Z is a
37-year-old female, gravida 2, para 1, presenting to the emergency room of San Pedro
Hospital with a chief complaint of right abdominal pain and fever for 2 days. The client
has been compliant with her antenatal visits on a healthcare facility and has a normal
result of antenatal examinations. Two days prior to admission, the patient experienced
right lower quadrant pain associated with low grade fever and opted to have rest which
gave her relief as claimed. As the days went by the patient continually suffered from
abdominal pain that was increasing in intensity (intense, sharp, stabbing pain), with mild
fever, and this time around accompanied with moderate to heavy vaginal bleeding, and
shoulder pain which compelled the client to confinement.

General Objectives

At the end of the 3-week Obstetrics and Gynecology Nursing Rotation, the
student nurses from BSN - 2C Group 1 Subgroup 3 will be able to understand Ectopic
Pregnancy based on research-based information, which will enhance their knowledge to
provide efficient nursing care and management to patients within the range of
responsibility.

Specific Objectives

In order to achieve the general objectives, the group specifically aims to:
● Present an introduction that outlines the disease, relevant statistics, and nursing
implications of the study;
● Compose objectives that are specific, measurable, attainable, realistic, and time
bounded;
● Identify the etiology of ectopic pregnancy based on its predisposing and
precipitating factors;
● Determine all the possible signs and symptoms of ectopic pregnancy;

5
● Create a schematic diagram and a supporting narrative that explains the disease
process of ectopic pregnancy;
● Discuss the pharmacological, surgical, and nursing management applicable to
the case;
● Analyze and interpret the prognosis;
● Address the client’s discharge plans;
● Specify the nursing theories relevant to the disease;
● Relate a review of related literature relevant to the case study; and
● Cite reliable books, journals, scientific articles, up-to-date researches, and other
references used as sources in an American Psychological Association (APA)
format.

6
 II. PATHOPHYSIOLOGY

A. Etiology

Predisposing Factors

FACTORS RATIONALE

Maternal Age Advanced maternal age is associated with

increased risk of ectopic pregnancy
(Attali and Yogev, 2021). Babies born to
older mothers are more likely to have
birth defects caused by genetic illnesses
or chromosomal abnormalities (Texas
Children's Hospital, 2019). Aged fallopian
tubes may have decreased function,
causing delay of oocyte transport.
Hosseini et al. (2017) stated that the
current evidence regarding the effect of
advanced maternal age on the risk of
ectopic pregnancy is inconclusive.

Genetics According to Costa (2021), the risk of

ectopic pregnancy may be impacted by
the regulation of a certain gene.
Interleukin (IL) I is a vital indicator for
embryo implantation in the
endometrium. It is involved in the
downstream neutrophil recruitment,
contributing to fallopian tubal damage
(Mummert & Gnugnoli, 2021). Elevated
Vascular Endothelial Growth Factor A
(VEGFA) in fallopian implantation site

7
 enhances oxygen supply to embryo,
inducing ectopic pregnancy. IL-6 and IL-8,
as induced by fallopian inflammation,
sends signals to the embryo and
promotes tubal implantation. Epidermal
growth factor receptor (EGFR) is
prevalent in the ectopic implantation site,
making it a possible target for treatment.

Immunity The fallopian tubes inflammatory

environment can disrupt ciliary activity
and muscle contractility, affecting the
embryo-tubal transport. TNF- α and IL-6
are pro-inflammatory cytokines that
amplify the inflammation and destruction
in the fallopian tube. B cell activation
factor (BAFF) is a homeostatic and
proinflammatory cytokine that is
prevalent in decidua and trophoblast
during pregnancy. BAFF is elevated in
patients with salpingitis and tubal
pregnancy, which affects the environment
for fertilization and inflammation in the
fallopian tube (Xu et.al, 2019).

Race Pacific Islander and Asian women have

less risk for ectopic pregnancy than white
women, as smoking is prevalent in the
reproductive age of the latter (Stulberg et
al., 2017). Chlamydia rates are greater in
black and Hispanic women. Compounded

8
 by an increased risk of delayed treatment,
pelvic inflammatory disease, and
consequent tubal damage, contribute to
the population-wide racial discrepancy in
ectopic pregnancy.

Precipitating Factors

FACTORS RATIONALE

Tubal Surgery An ectopic pregnancy can occur as a

result of surgery to repair a closed or
damaged fallopian tube (Mayo Clinic,
n.d.). As stated by Jacob, et al (2017),
women with tubal damage were 2.5 to 3
times more likely to be affected by ectopic
pregnancy. This is caused by adhesions
formed during surgery which may lead to
the blocking of fallopian tubes.

Pelvic Inflammatory Disease Untreated PID can cause scar tissue to

develop in the fallopian tubes, thus
contributing to ectopic pregnancy. The
scar tissue disrupts the passage of the
fertilized egg in the fallopian tube to
implant in the uterus. Instead, the egg
implants itself in the fallopian tube
(Pelvic Inflammatory Disease (PID),
2020).

9
History of Ectopic Pregnancy According to Jacob et al. (2017), previous
occurrences of ectopic pregnancy make a
pregnant woman more susceptible to
develop subsequent ectopic pregnancy.
This is because recurrent ectopic
pregnancies may trigger pathology and
dysfunction of the fallopian tubes. A
history of EP may damage the
surrounding tissue thus, may make it
more likely for an egg to get stuck in the
future (Abduljabbar, 2017).

Smoking Ectopic pregnancies are caused by

chemical reactions caused by cigarette
smoke. Studies have found that PROKR1,
a protein, increases the risk of an egg
implanting outside the womb (Edinburgh
Scientists, 2022). It has been shown that
maternal smoke can cause damage to the
fetal tissue, especially in the lungs and
brain, along with some evidence that
maternal smoking is associated with a
cleft lip (CDC, 2022).

Assisted Reproductive Techniques Technologies such as in-vitro fertilization

(IVF) increases the risk for developing
ectopic pregnancy with combined
concurrent heterotypic pregnancy in 1
out of 100 women or 1% to 3% of
pregnancies. Embryos implanted into the
uterine cavity can possibly return back

10
 into the fallopian tubes due to the
negative pressure in the abdomen,
causing ectopic pregnancy (Infertility and
Reproductive Endocrinology, n.d.).

Use of Intrauterine Devices Pregnancy with an IUD is more often an

ectopic one than a pregnancy with no
IUD. IUDs are contraceptive devices
shaped like an inverted T. When inserted
into the uterus of a woman, IUDs may
impede the transport of fertilized egg to
the endometrial lining of the uterus
where it should be implanted if it is
inserted after conception (Belleza, 2017).

11
 B. Symptomatology

SIGNS AND SYMPTOMS RATIONALE

Lower Abdominal or Pelvic Pain In some cases, women with ectopic

pregnancy may experience mild to severe
unilateral pain in the lower abdomen or
pelvic area. Ruptured ectopic pregnancy
may cause blood to build up in and it
irritates certain nerves in the affected area.
(Belleza, 2017).

Vaginal Bleeding Spotty and intermittent vaginal bleeding

may be experienced by some women with
ectopic pregnancy due to the tearing and
destruction of blood vessels (Belleza,
2017). Decidua breaks down in the uterine
cavity and is passed as a prune-colored
discharge as a result of suboptimal B-hCG
levels. In ruptured ectopic pregnancy,
bleeding is intra-abdominal rather than
vaginal.

Shoulder Pain A ruptured fallopian tube can occur later in

the pregnancy. Internal blood pools
beneath the diaphragm, irritating the
nerves which innervate the shoulder tip.
This frequently results in shoulder and
neck pain (Harris, 2019). The
supraclavicular nerves and diaphragm
both share the C3 to C5 dermatomes.

12
Syncope Fainting is attributed to sudden
hypotension which is caused by significant
bleeding from ruptured ectopic pregnancy.
Blood volume loss causes a drop in blood
pressure, which then reduces blood
circulation to the brain, leading to loss of
consciousness (DerSarkissian, 2021).
Syncope can be a sign of an impending
hemorrhagic shock.

Hemodynamic Instability The continuous extensive bleeding due to

ruptured pregnancy causes the patient to
be hemodynamically unstable. This is
manifested by hypotension, pallor,
tachycardia, and increased capillary refill
time (Pazhaniappan, n.d.).

Peritonitis Peritonitis can be attributed to infection

caused by ruptured fallopian tube or
ovarian cyst. Vaginal bleeding allows the
entry of bacteria into the uterus and then
into the fallopian tubes, causing pelvic
infection. It is manifested by abdominal
rebound tenderness and guarding
(Pazhaniappan, n.d.).

C. Disease Process

13
14
 The exact etiology for ectopic pregnancy is still unknown. It Is only affected by
factors such as maternal age, smoking, genetics, sexually transmitted disease, pelvic
inflammatory disease, tubal surgery, previous ectopic pregnancy, and intrauterine
device.

15
 In In-vitro fertilization (IVF) there is a negative pressure in the abdomen causing
the embryo to return to the fallopian tube. Advanced maternal age cause susceptibility
to other risk factors, reducing the function of the fallopian tube and delaying ovum
transfer, causing extrauterine implantation. Unhealthy lifestyle specifically smoking
leads to inhalation of cigarette smoke which impairs fallopian tube function by affecting
the cilia, resulting in decreased tubal motility, causing the mature egg cell to move
slower than normal and resulting in stasis. Genetics accounts for congenital anomalies
including problems with the natural structure of the reproductive organ. While sexually
transmitted diseases and pelvic inflammatory diseases are due to bacteria, both can
cause infection to the woman’s reproductive organ, resulting in salphingitis. These three
could result in the narrowing of the tubal diameter which leads to stasis. Additionally,
tubal surgery and previous ectopic pregnancy both damage the fallopian tube by
forming scars and adhesions which narrows its tubal diameter. While an intrauterine
device in the uterine cavity may impede the transport of fertilized egg to the endometrial
lining of the uterus where it should be implanted if it is inserted after conception
resulting in stasis.

Once the matured egg on stasis is fertilized by the sperm, this causes
implantation outside the uterus, inducing ectopic pregnancy. If left untreated it could
rupture the maternal tissue on the implantation site due to the increasing fetal size. The
ruptured tissue may cause excessive bleeding which could result in hypovolemic shock,
and in a far worse scenario, to an untimely death, which is a poor prognosis.
Meanwhile, if health-seeking behavior is exercised, diagnostic tests are done to
anticipate and prevent possible complications. Furthermore, medical management to be
rendered includes medication administration and appropriate surgical management.
Nursing interventions that need to be observed include monitoring the presence and
amount of vaginal bleeding and increased pain, monitoring CBC, encouraging complete
bed rest, and addressing the emotional and psychological needs of the patient. These
will help in preventing further complications to occur; all of which ultimately translates to
a desirable prognosis.

D. Diagnostic / Laboratory Confirmatory Tests

16
Ultrasonography
This can be used in the first 3 to 5 weeks after conception and the first marker to
determine an extrauterine pregnancy, especially if the ß-hCG levels are above the
normal values. Transvaginal ultrasonography is most preferred due to its greater
sensitivity and resolution. It provides visualization of the definite indicator of ectopic
pregnancy which is a fetal heartbeat detected outside the uterine cavity. Other findings
include a thick echogenic ring-like structure outside the uterus, with a gestational sac
containing fetal pole and yolk sac or a complex adnexal mass (Sepilian, 2017).

Beta Human Chorionic Gonadotropin Levels

It is one of the main investigations as it differentiates normal and ectopic
pregnancies as well as it is the main target of monitoring during medical therapy. ß-hCG
levels doubles every 48 to 72 hours in normal pregnancy until reaching 10000 to 20000
mlU/ml, whereas the levels increase less in ectopic pregnancies. When the ß-hCG level
is above the discriminatory zone of 1500mlU/mL and no intrauterine pregnancy is
detected during transvaginal ultrasound, it most possibly indicates an ectopic
pregnancy, until proven otherwise (Sepilian, 2017).

Dilation and Curettage

This is a rapid and cost-effective procedure differentiating ectopic and
intrauterine pregnancies. It is employed if the blood hormone levels and ultrasound
results indicate an impending miscarriage or nonviable gestation but its location was not
determined by ultrasound. The scraped uterine lining undergoes histological
examination. The findings which indicate an ectopic pregnancy are the absence of
chorionic villi in the tissue and unchanging ß-hCG levels after the evacuation of uterine
contents (Sepilian, 2017).
Laparoscopy
It is employed when radiologic imaging fails to confirm the presence of an ectopic
pregnancy. It involves inserting a laparoscope into the abdominal cavity through a small
incision. It assesses the size and location of the ectopic pregnancy and pelvic
structures. However, it can miss 4% of early ectopic pregnancies as it cannot identify

17
small ectopic gestations or cervical pregnancies. Its routine use can also lead to risks,
costs, and morbidity (Mummert & Gnugnoli, 2021).

E. Management

1. Pharmacological Management

Generic Name: Methotrexate

Brand Name: Metoject, Nordimet, Otrexup, Rasuvo, Reditrex, Trexall, Xatmep

Classification: Pharmacologic: Antimetabolites

Therapeutic: Immunosuppressants, Antineoplastics
Pregnancy Category: X

Mode of Action: Methotrexate competes with enzymes necessary to reduce folic

acid to tetrahydrofolic acid, inhibiting cell proliferation by
destroying rapidly dividing cells, preventing the tissue from
growing larger and from rupturing.

Suggested Dose Adults IM (Ectopic Pregnancy): 50 mg/m^2; measure serum

and Route: hCG levels on days 4 and 7; repeat dose on day 7 if necessary.
If hCG levels decrease less than 15% between days 4 and 7,
administer methotrexate 50 mg/m^2 IM. If hCG is 15% or more
between days 4 and 7, discontinue treatment and monitor hCG
weekly.
Adults PO/IM (Choriocarcinoma hydatidiform mole):
15-30 mg daily, then off 1 week; may repeat, maximum of 5
courses

Indications: Methotrexate is indicated in ectopic pregnancy; gestational

choriocarcinoma, chorioadenoma destruens, and hydatidiform
mole; severe, recalcitrant, disabling psoriasis; and management
of selected adults with severe, active, rheumatoid arthritis.

18
Contraindications: Patients with severe renal or hepatic impairment, pre-existing
profound bone marrow suppression in psoriasis or rheumatoid
arthritis, alcoholic liver disease, AIDS, pre-existing blood
dyscrasias, pregnancy (in patients with psoriasis or rheumatoid
arthritis), and breast-feeding.

Side Effects: Nausea, vomiting, diarrhea, dizziness, vaginal spotting, and

mouth ulcers.

Adverse Effects: CNS: blurred vision, aphasia, hemiparesis; arachnoiditis,

convulsions (after intrathecal administration); mental confusion,
tremors, ataxia, coma.
GI: Hepatotoxicity, GI ulcerations and hemorrhage, ulcerative
stomatitis, glossitis, gingivitis, pharyngitis, diarrhea, hepatic
cirrhosis. 
Urogenital: Defective oogenesis or spermatogenesis,
nephropathy, hematuria, menstrual dysfunction, infertility,
abortion, fetal defects.
Hematologic: Leukopenia, thrombocytopenia, anemia, marked
myelosuppression, aplastic bone marrow, telangiectasis,
thrombophlebitis at intraarterial catheter site,
hypogammaglobulinemia, hyperuricemia, septicemia
Dermatologic: Erythematous rashes, pruritus, urticaria,
folliculitis, vasculitis, photosensitivity, depigmentation,
hyperpigmentation, alopecia.
Respiratory: pneumonitis, pulmonary fibrosis
Immune System: decreased resistance to infection
Musculoskeletal: osteoporosis
Others: systemic toxicity, metabolic changes precipitating
diabetes, sudden death

Drug Interactions: Drug-Drug: Azathioprine and Sulfasalazine increase risk of

hepatotoxicity; Chloramphenicol, Etretinate, Salicylates,
NSAIDs, Sulfonamides, Sulfonylureas, Phenylbutazone,
Phenytoin, Tetracyclines, PABA, Penicillin, and Probenecid may
increase methotrexate levels with increased toxicity; Folic acid
may alter response to methotrexate; and cholestyramine
enhances methotrexate clearance.
Drug-Herbs: Echinacea may increase risk of hepatotoxicity. 
Drug-Vaccine: It may may potentiate virus replication, increase
vaccine side effects, and decrease patient’s antibody response
to vaccine;
Drug-Food: Alcohol may increase the risk for hepatotoxicity.

Nursing 1. Monitor pulmonary functions like lung volumes, breath

Responsibilities: sounds, and respiratory rates periodically.

19
R: Pulmonary fibrosis or pneumonitis manifest as dry cough,
dyspnea, shortness of breath, and cyanosis.

2. Monitor any unusual weakness and fatigue.

R: These can indicate aplastic anemia and other blood
dyscrasias like leukopenia and thrombocytopenia.

3. Arrange to have leucovorin readily available as antidote for

methotrexate overdose or when large doses are used.
R: Generally, leucovorin doses should be equal or higher than
methotrexate doses and should be given within the first hour. Up
to 75 mg IV within 12 hr, followed by 12 mg IM q 6 hr for four
doses. For average doses of methotrexate that cause adverse
effects, give 6–12 mg leucovorin IM, q 6 hr for four doses or 10
mg/m2 PO followed by 10 mg/m2 q 6 hr for 72 hr.

4. Observe carefully the gait, balance, and coordination.

R: Balance problems and functional limitations increases risk for
injury or falls.

5. Increase the fluid intake 2 to 3 liters daily.

R: Diarrhea and vomiting due to the drug causes dehydration.
Methotrexate can also cause kidney damage.

6. Instruct patient not to take NSAIDS.

R: NSAIDS with methotrexate cause brief and mild increase in
blood problems (low platelet count) in people with rheumatoid
arthritis.

7. Advise patient to avoid intake of alcohol, narcotics, and

gas-producing food.
R: Alcohol during drug therapy causes incoordination, nausea,
and fainting. It also poses risk for internal bleeding and difficulty
in breathing.

8. Instruct patients to avoid sun exposure and use protective

clothing.
R: The drug may make the skin sensitive to real or artificial
sunlight.

9. Remind the patient not to self-medicate with vitamins.

R: Some OTC compounds may include folic acid (or its
derivatives), which alters methotrexate response.

10. Educate patient on fastidious mouth care.

20
 R: To prevent infection, provide comfort, and maintain adequate
nutritional status.

Generic Name: Leucovorin calcium

Brand Name: Wellcovorin, Folinic acid

Classification: Pharmacologic: Folic acid derivative

Therapeutic: Methotrexate rescue agent
Pregnancy Category: C

Mode of Action: Leucovorin actively competes with methotrexate for same

transport processes into cells, displaces methotrexate from
intracellular binding sites, and restores active folate stores
necessary for DNA/RNA synthesis. Therapeutically, it reverses
toxic effects of folic acid antagonists and folic acid deficiency.

Suggested Dose Adults PO, IV, IM (Rescue in High-Dose Methotrexate

and Route: Therapy): 15 mg or 10 mg/m2 started 24 hours after starting
methotrexate infusion; continue every 6 hours for 10 doses, until
methotrexate level is less than 0.05 micromole/L. Additional
dose adjusted based on methotrexate levels.
Adults PO (Folic Acid Antagonist Overdose): 5-15mg/day
Adults IV (Colon Cancer): Combined with 5-fluorouracil, 200
mg/m2 daily for 5 days. Repeat course at 4-week intervals for 2
courses, then 4- to 5-week intervals or 20 mg/m2 daily for 5
days. Repeat course at 4-week intervals for 2 courses, then 4-
to 5-week intervals.

Indications: Treatment of megaloblastic anemias when folate-deficient,

advanced colon cancer (with fluorouracil), IV rescue therapy
after high-dose methotrexate for osteosarcoma or orally to
diminish toxicity and impaired methotrexate elimination.

21
Contraindications: Hypersensitivity to leucovorin. Pernicious anemia, other
megaloblastic anemias secondary to vitamin B12 deficiency.
renal impairment.

Side Effects: Diarrhea, stomatitis, nausea, vomiting, lethargy, malaise, fatigue,

alopecia, anorexia (when combined with chemotherapeutic
agents).

Adverse Effects: Dermatologic: urticaria, dermatitis

Immune System: Anaphylaxis
Hematologic: thrombocytopenia.
Gastrointestinal: Anorexia,
CNS: seizures, syncope

Drug Interactions: Drug-Drug: May decrease effects of trimethoprim and

anticonvulsants. May increase 5-fluorouracil toxicity/effects
when taken in combination.
Drug-Laboratory Values: May decrease platelets, WBCs (when
used in combination with 5-fluorouracil).

Nursing 1. Obtain CBC, LFT, and assess renal function.

Responsibilities: R: To obtain baseline data.
2. Determine laboratory test on creatinine levels.
R: To detect the onset of kidney function impairment.

3. Check the infusion rates and intervals carefully.

R: The drug must be started 24 hours after methotrexate is
given so the latter can exert its anti-cancer effects.

4. Monitor the patient’s response carefully.

R: To observe and prevent potential adverse and side effects.

5. Observe patient for occurrence of vomiting.

R: To obtain intake and output data and prevent fluid volume
deficit.

6. Monitor neurologic status periodically.

R: Leucovorin can cause hematological remission while allowing
already present neurologic damage to progress.

7. Maintain proper fluid intake and hydration.

R: The drug may cause dehydration. Fluid intake of 2 to 3 liters
per day to prevent constipation.

8. Explain to the patient that the drug may cause an allergic

reaction.

22
 R: To let patients know what to expect and can call for
immediate help if such reactions occur.
9. Take the medication with food.
R: To avoid gastrointestinal upset.

10. Do not breast feed while taking this drug without consulting
physician.
R: Leucovorin can be excreted in breast milk which can be
harmful to the infant.

Generic Name: Midazolam

Brand Name: Versed

Classification: Pharmacologic: Benzodiazepines

Therapeutic: Sedatives, Antianxiety agents
Pregnancy Category: D

Mode of Action: Midazolam enhances the action of gamma-aminobutyric acid

(GABA), one of the major inhibitory neurotransmitters in the
brain. Therapeutically, it produces anxiolytic, hypnotic,
anticonvulsant, muscle relaxant, amnestic effects.

Suggested Dose Adults IV: For pre-surgery medication, administer 1mg to 2mg
and Route: given 5 to 30 minutes before surgery. Repeat if necessary. For
sedation in critical care, loading dose of 0.03-0.3 mg/kg given in
1-2.5mg increments injected slowly for 20 to 30 seconds,
allowing 2 minutes between each dose. Maintenance of 0.03-0.2
mg/kg/hr. For sedation in combined anesthesia, 0.03-0.1
mg/kg/hr and repeat as required.

23
Indications: Intravenously, it promotes preoperative sedation, anxiolysis,
anesthesia induction, or amnesia. Intramuscularly, it is the
treatment of status epilepticus in adults. Nasally, it is indicated
for the acute treatment of intermittent, stereotypic episodes of
frequent seizure activity (i.e., seizure clusters, acute repetitive
seizures) that are distinct from a patient’s usual seizure pattern
in patients with epilepsy 12 years of age and older.

Contraindications: Patients with hypersensitivity to midazolam, acute narrow-angle

glaucoma, concurrent use of protease inhibitors (e.g.,
atazanavir, darunavir), renal/hepatic/pulmonary impairment,
impaired gag reflex, HF, obesity, taking concurrent CNS
depressants, alcohol dependency, elderly, and debilitated.

Side Effects: Frequent (10%–4%): Decreased respiratory rate, tenderness at

injection site, pain during injection, oxygen desaturation,
hiccups. Occasional (3%– 2%): Hypotension, paradoxical CNS
reaction. Rare (less than 2%): Nausea, vomiting, headache,
coughing.

Adverse Effects: Respiratory: laryngospasm, respiratory depression,

bronchospasm, apnea
Cardiovascular; cardiac arrest, arrhythmia
CNS: cerebral hypoxia, hyperactivity
Neuromuscular: involuntary movements, combativeness
Dermatologic: rashes
Local: phlebitis at IV site

Drug Interactions: Drug-drug: Midazolam may interact with H2 blockers,

fluconazole, theophylline, aminophylline, erythromycin, or drugs
that make you drowsy, such as: narcotics, psychiatric medicines,
anti-anxiety drugs, anti-seizure drugs, antihistamines, muscle
relaxants, sleeping pills, or sedatives.
Drug-Herb: Herbals with sedative properties (e.g., chamomile,
kava kava, valerian) may increase CNS depression. St. John’s
wort may decrease concentration.
Drug-Food: Grapefruit products increase oral absorption,
systemic availability.

Nursing 1. Obtain patient history of alcohol consumption and current

Responsibilities: medications especially blood pressure and antibiotics including
over-the-counter drugs.
R: Alcohol has an increased effect when consumed with
benzodiazepines. Caution should be exercised on simultaneous
ingestion of alcohol during benzodiazepine treatment.

2. Observe the injection site closely upon administration.

24
R: To prevent extravasation and phlebitis as manifested by pain,
swelling, and inflammation.

3. Prepare oxygen and resuscitation equipment upon

administration.
R: To immediately control cases of severe respiratory
depression.

4. Monitor respiratory rate, oxygen saturation continuously

during parenteral administration for underventilation, and apnea.
R: To prevent developing respiratory depression as manifested
by decreased respiration, cyanosis, and dyspnea.

5. Monitor heart rate, ECG, and heart sounds periodically.

R: Rhythm disturbances or arrhythmias are adverse effects as
manifested by palpitations, shortness of breath, and chest
discomfort.

6. Monitor blood pressure, pulse, respirations during

administration.
R: These provide baseline information in identifying
complications during infusion.

7. Monitor the patient’s response to medication carefully.

R: To observe and prevent potential adverse and side effects.

8. Assess level of consciousness periodically.

R: To determine the effectiveness of the drug and prevent
prolonged sedation which can cause delirium and cognitive
dysfunction.

9. Be aware of overdose symptoms including somnolence,

confusion, sedation, diminished reflexes, coma, and untoward
effects on vital signs.
R: An overdose is a medical emergency that requires immediate
medical attention.

10. Prepare Romazicon (Flumazenil) as antidote should

overdose occur.
R: Flumazenil is a selective competitive antagonist of the
gamma-aminobutyric acid (GABA) receptor and is the only
available specific antidote for benzodiazepine (BZD) toxicity. It
will reverse the effects of BZDs but must be used with caution.

25
Generic Name: Tramadol

Brand Name: Ultram

Classification: Pharmacologic: Opioid agonist

Therapeutic: Centrally-acting analgesics
Pregnancy Category: C

Mode of Action: Tramadol binds to mu-opioid receptors and inhibits reuptake of

serotonin and norepinephrine in the central nervous system,
causing decreased pain.

Suggested Dose Adults IV: For postoperative pain, initially 100mg via slow
and Route: intravenous route followed by 50mg every 10 to 20 minutes up
to a total of 250 mg in the first hour. Subsequent doses of 50mg
or 100mg 4 to 6 hours hourly may be given as long as it will not
exceed 600mg daily. For moderate to severe pain, 50mg to
100mg 4 to 6 hourly via slow IV over 2 to 3 minutes, with a
maximum of 600mg daily.
Adults Oral: For moderate to severe pain, 50mg to 100mg
tablet 4 to 6 hourly with a maximum of 400mg daily. Adjust dose
according to pain severity and sensitivity.

Indications: Tramadol is indicated for moderate to moderately severe pain in

adults when alternative therapies are inadequate. It is also for
moderate to severe chronic pain in patients requiring continuous
treatment for an extended period of time.

Contraindications: Patients with a history of epilepsy, hepatic impairment, opioid

dependence, increased intracranial pressure, pregnancy, use of
CNS depressants, and hypersensitivity to tramadol or any of its
excipients.

26
Side Effects: Dizziness, somnolence, headache, diaphoresis, constipation,
urinary retention/frequency, flatulence, vomiting.

Adverse Effects: CNS: seizures, coordination disturbance, central sleep apnea,

serotonin syndrome
Optical: Visual disturbances
Gastrointestinal: anorexia, dyspepsia, diarrhea
Genitourinary: menopausal symptoms
Dermatologic: pruritus
Neuromuscular: hypertonia

Drug Interactions: Drug-Drug: increased risk of convulsions with antipsychotics,

SSRIS, SNRIs, and other seizure-threshold lowering agents.
Mixed agonist/antagonist analgesics like buprenorphine,
nalbuphine, and pentazocine diminishes analgesic effect in
prolonged tramadol therapy. CNS depressants or
benzodiazepines may cause sedation, respiratory depression,
and coma.
Drug-Food: Tramadol potentiates the CNS depressant effects of
alcohol. St. John’s wort can increase risk for serotonin syndrome

Nursing 1. Employ appropriate pain scales on the duration of the drug

Responsibilities: therapy.
R: To document the effectiveness of the drug and manage the
pain.

2. Observe for any coordination problems and check the muscle

tone.
R: Incoordination and hypertonia are adverse effects that
impairs function and increase the risk for falls.

3. Monitor for increased seizure activity especially at the onset of

treatment.
R: Seizures are an adverse effect of tramadol.

4. Ensure the security of the bed and implement fall-prevention

strategies.
R: Side effects like sedation, dizziness, and blurred vision may
cause falls and trauma.

5. Monitor emotional or behavioral changes in the patient.

R: Euphoria, confusion, nervousness, and anxiety are adverse
effects of the drug.

6. Emphasize the need for consistency and compliance to the

drug therapy.

27
 R: Following the proper dosing schedule avoids the occurrence
of drug overdose and adverse effects.

7. Implement manual therapy techniques and therapeutic

exercise.
R: To reduce pain and wean patient off the analgesics

8. Demonstrate to the patient relaxation techniques such as

deep breathing.
R: Nonpharmacologic methods help reduce chronic pain without
exacerbating the effects of the drug.

9. Advise the patient to avoid intake of alcohol and other CNS

depressants.
R: These increase the risk of sedation and decrease CNS
function.

10. Advise the patient to increase the fluid intake.

R: To alleviate urinary retention which is a side effect of the drug.

Generic Name: Metronidazole

Brand Name: Flagyl

Classification: Pharmacologic: Nitroimidazole derivatives

Therapeutic: anti-infectives, antiprotozoals, antiulcer agents
Pregnancy Category: B

28
Mode of Action: Metronidazole interacts with the microbial DNA, blocking nucleic
acid synthesis, causing strand breakage and loss of DNA
structure, inhibiting protein synthesis and eventually causing
degradation and cell death. Therapeutically it has bactericidal,
antiprotozoal, anti-inflammatory, and immunosuppressive
effects.

Suggested Dose Adults IV: For postoperative pain, initially 100mg via slow
and Route: intravenous route followed by 50mg every 10 to 20 minutes up
to a total of 250 mg in the first hour. Subsequent doses of 50mg
or 100mg 4 to 6 hours hourly may be given as long as it will not
exceed 600mg daily. For moderate to severe pain, 50mg to
100mg 4 to 6 hourly via slow IV over 2 to 3 minutes, with a
maximum of 600mg daily.
Adults Oral: For moderate to severe pain, 50mg to 100mg
tablet 4 to 6 hourly with a maximum of 400mg daily. Adjust dose
according to pain severity and sensitivity.

Indications: Metronidazole is indicated for anaerobic infections

(intraabdominal, gynecologic, blood, respiratory tract, and skin
structures), perioperative prophylactic agent post-surgery, and
parasitic infections.

Contraindications: Patients taking disulfiram within the past 14 days and alcohol
during therapy, patients with hematological disease, renal
impairment, ethanol intoxication, first trimester pregnancy,
breastfeeding, and hypersensitivity to metronidazole and its
excipients.

Side Effects: Nausea, dry mouth, metallic taste, uterine pain, abdominal
cramps (frequent), diarrhea, dizziness. Transient erythema, skin
irritation (occasional), transient leukopenia, thrombophlebitis
(rare).

Adverse Effects: Cardiovascular: leucopenia, neutropenia, syncope

Ocular: nystagmus, optic neuropathy
Metabolism: anorexia
Musculoskeletal; myalgia
Psychiatric; confusion, hallucination
Genitourinary: genital pruritus
CNS: ataxia, vertigo, convulsive seizure, encephalopathy 
Dermatologic: urticaria, erythematous rash, toxic epidermal
necrolysis

29
Drug Interactions: Drug-Drug; Disulfiram may increase risk of toxicity and acute
psychosis; potentiates anticoagulant effect of anticoagulants;
phenobarbital or phenytoin decreases serum concentration, and
cyclosporin and busulfan increases serum concentration.
Drug-Food: Alcohol causes disulfiram-like reactions (nausea,
vomiting, psychotic episodes, abdominal cramps). Food delays
absorption of conventional tablets and increases absorption of
extended-release tablets.
Drug-Laboratory Test: Metronidazole interferes with AST, ALT,
glucose hexokinase, triglycerides, and LDH testing.

Nursing 1. Observe the injection site upon administration

Responsibilities: R: To prevent occurrence of phlebitis as manifested by pain,
swelling, and irritation

2. Monitor closely the mental status of the patient.

R: Mental alterations like confusion, agitation, and headache are
adverse effects of the drug.

3. Monitor signs of disulfiram-like reaction.

R: Alcohol intake during drug therapy may cause difficulty
breathing, chest pain, tachycardia, syncope, and vertigo.

4. Assess gait, balance, and functional activities.

R: Side effects like dizziness and incoordination may cause
injury and trauma.

5. Monitor vital signs periodically.

R: To provide baseline data in identifying complications early.

6. Observe for any seizure activity and peripheral neuropathy.

R: These are symptoms of CNS toxicity as manifested by
numbness and paresthesia.

7. Observe for any occurrence of edema.

R: Metronidazole contains sodium ions which can lead to
sodium retention.

8. Emphasize the need for consistency and adherence to the

drug regimen.
R: To ensure drug effectiveness and avoid adverse effects.

9. Advise patient not to take alcohol or alcohol-containing

preparations (cough syrups, elixirs) during therapy.
R: This may induce disulfiram-reaction.

30
 10. Remind patient to avoid activities requiring alertness.
R: The drug may cause dizziness and light-headedness which
disrupts alertness.

Generic Name: Paracetamol,

Acetaminophen

Brand Name: Ofirmev (IV), Abenol, Acephen, Fortolin, Pediatrix, Taminol,

Tempra, Tylenol (Oral, Rectal)

Classification: Pharmacologic: para-aminophenol derivative

Therapeutic: Antipyretics, nonopioid analgesics
Pregnancy Category: B

Mode of Action: Paracetamol Inhibits synthesis of prostaglandins that may serve

as mediators of pain and fever, primarily in the CNS. Has no
significant anti-inflammatory properties or GI toxicity.
Therapeutically, it causes antipyresis and produces analgesic
effect.

Suggested Dose Adults PO: 325-650mg every 6 hours or 1g 3 to 4 times daily or

and Route: 1300 mg every 8 hours. Must not exceed 3 g or 2 g per 24 hours
in patients with hepatic/renal impairment.

Adults IV: 1000mg every 6 hours or 650mg every 4 hours with

maximum of 1000 mg/dose, 4 g/day [by all routes], and less
than 4 hours dosing interval.

Indications: Paracetamol is indicated for mild pain and fever orally and
rectally; intravenously, it is for mild to moderate pain or moderate
to severe pain with opioid analgesics and fever.

31
Contraindications: Patients taking alcohol, aspartame, tartrazine; have severe
hepatic impairment, active liver disease, chronic malnutrition,
severe hypovolemia, lactation in pregnancy, and hypersensitivity
to paracetamol and its excipients.

Side Effects: Stomach pain, loss of appetite, low fever, nausea, vomiting,
sweating, dark urine.

Adverse Effects: Gastrointestinal: hepatic failure, hepatotoxicity

Genitourinary: renal failure
Hematologic: neutropenia, leukopenia, pancytopenia,
thrombocytopenia
Dermatologic: rash, urticaria

Drug Interactions: Drug-Drug; Hepatotoxic medications like phenytoin and enzyme

inducers like rifampin may increase risk of hepatotoxicity with
prolonged high dose or single toxic dose. Dasatinib and
probenecid increase concentration and effect.
Drug-Food: Chronic alcohol use may pose risk of hepatoxicity.
Food may decrease rate of absorption.
Drug-Herb: Feverfew and gingko biloba may increase risk of
bleeding. Red clover can enhance anticoagulation. Watercress
inhibits drug oxidative metabolism
Drug-Laboratory Test: May increase serum ALT, AST, bilirubin;
prothrombin levels (may indicate hepatotoxicity). Drug can also
decrease hemoglobin, WBC, RBC, and platelet counts.

1. Assess overall health status and alcohol usage before

administration.
R: Patients who are malnourished or chronically abuse alcohol
are at higher risk for hepatotoxicity with chronic use of drug.

2. If given for analgesia, assess onset, type, location, duration of

pain.
R: Effect of medication is reduced if full pain response recurs
prior to next dose.

3. Assess pain, range of motion, and muscle strength.

R: To determine effectivity of drug on decreasing pain and
impairments.

4. Note for rash, blisters, anorexia and diaphoresis, vomiting,

right upper quadrant tenderness, elevated LFTs within 48 to 72
hours after ingestion.
R: These are signs of acetaminophen toxicity; may also trigger
Stevens-Johnson syndrome.

32
5. Assess fever and note presence of associated signs
(diaphoresis, tachycardia, and malaise).
R: Severe/recurrent pain or high/ continuous fever may indicate
serious illness.

6. Observe for unusual weakness, fatigue, and excessive

bleeding.
R: These are signs of anemia, leukopenia, or neutropenia.

7. Monitor serum bilirubin, LDH, AST, ALT, and prothrombin

time.
R: Elevation of these values may indicate hepatotoxicity.

8. Implement nonpharmacologic methods like relaxation

techniques and exercise.
R: To reduce chronic pain without the risk for side effects of the
drug.

9. Caution patient to check labels on all OTC products if it

contains acetaminophen
R: Taking more than one product with acetaminophen all at once
increases risk of hepatotoxicity as many nonprescription
combination products contain acetaminophen.

10. Advise patient to reduce alcohol intake.

R: Alcohol increases the risk of liver toxicity.

33
2. Surgical Management

Laparoscopic Salpingectomy
It remains as the cornerstone of surgical treatment for tubal ectopic pregnancy. It
involves removal of the entire single fallopian tube, called unilateral salpingectomy, or
both fallopian tubes, called bilateral salpingectomy. Laparoscopy is employed to reduce
recovery time. This procedure is indicated for ruptured ectopic pregnancy, reconstructed
tubes, and persisting hemorrhage after salpingostomy (Dulay, 2020). It poses
decreased risk for tubal bleeding in the immediate postoperative period and recurrence
of ectopic pregnancy. However, it only leaves one fallopian tube for reproductive
capacity (American Society for Reproductive Medicine, n.d.).

Laparoscopic Salpingostomy
It is performed when the ectopic pregnancy has early diagnosis well before the
fallopian tube ruptures. It involves removing the pregnancy tissue through a tubal
incision while leaving the tube in situ, allowing it to heal on its own. As the tube is still
intact and preserved, it has a better fertility prognosis. However, the ectopic tissue may
remain and may continue to grow in 5% to 15% of the cases, calling for an additional
salpingectomy (American Society for Reproductive Medicine, n.d.).

Laparotomy
Before the preference for laparoscopy, laparotomy was employed in all
reproductive, gynecologic, and tubal operations. It involves opening the abdomen by
surgical incision to remove the ectopic pregnancy tissues. It is usually performed today
only in emergency situations when the fallopian tubes have severely ruptured which
causes extensive internal bleeding or when an extensive scar tissue is present inside
the abdomen, called intra-abdominal adhesions, or inside the pelvis (American Society
for Reproductive Medicine, n.d.).

34
3. Nursing Management

1. Administer medications as ordered.

R: To manage the signs and symptoms. Methotrexate is the drug of choice for
ending ectopic pregnancy by ceasing cell growth.

2. Monitor the patient’s response to medications appropriately.

R: To observe and avoid potential adverse and side effects including drowsiness,
vomiting, diarrhea, and malaise.

3. Monitor maternal vital signs periodically.

R: To establish baseline data and to assess the occurrence of hypotension and
tachycardia as a result of rupture or hemorrhage.

4. Observe for the presence and amount of vaginal bleeding.

R: To further assess the present situation as it indicates hemorrhage.

5. Observe for increased pain and abdominal distention.

R: Increased abdominal pain and distention are signs of a rupture and potential
abdominal bleeding.

6. Monitor the complete blood count (CBC).

R: To help determine the amount of blood loss.

7. Encourage the patient in increasing their oral fluid intake.

R: To replenish the fluid level in the body lost from bleeding and prevent drying of
oral mucosa.

8. Address the patient’s emotional and psychosocial needs.

R: Acknowledgement of needs improves patient’s coping and well-being in
adverse situations.

35
 9. Assess the patient’s nutritional ingestion for adequate energy sources and
metabolic demands.
R: Drowsiness can be an indication of protein-calorie, vitamin, or iron deficiency.
10. Advise the patient to maintain complete bed rest and activity restrictions.
R: To expedite post-surgery recovery and alleviate vaginal bleeding.

11. Provide comfort measures such as therapeutic massage and breathing

exercises.
R: To promote relaxation and potentially improve the patient's ability to cope by
redirecting attention.

12. Evaluate the patient's perspective on fatigue relief, the willingness to participate
in drowsiness-reducing approaches, and the patient's level of family and social
support.
R: These encourage active participation in the planning, implementation, and
evaluation of fatigue-relieving therapeutic management. Social support assists
patient in implementing adjustments that will reduce drowsiness.

F. Prognosis

Ectopic pregnancy is generally fatal to the fetus. A woman who previously

experienced ectopic pregnancy has a decreased chance of conception and has a 10%
to 20% chance of developing it again in the future. There is also a 64% to 76% chance
of developing subsequent intrauterine pregnancy. A patient with recurrent ectopic
pregnancies can develop tubal disease, which may be opted with artificial pregnancy
methods such as in-vitro fertilization.

However, this can have a good prognosis if treatment has occurred before tubal
rupture, mitigating the incidence of maternal death. The accurate determination of low
Hcg concentrations and ultrasound allowed for the diagnosis of more than 85% of

36
women before tubal rupture, potentiating for future fertility (Willacy, 2021). Patients with
low beta hCG level have better prognosis when managed with methotrexate therapy.
Generally, prognosis of ectopic pregnancy depends on early diagnosis and timely
interventions (Mummert & Gnugnoli, 2021).
III. DISCHARGE PLANNING

METHOD INTERVENTIONS

Medication ● Discuss the proper intake of prescribed medications such as

Methotrexate with their appropriate dosages and intervals.
● Accentuate the significance of medication intake as prescribed
and discuss the drug's purpose, action, side effects, and adverse
effects.
● Remind the patient to seek a physician if adverse side effects
occur.

Exercise ● Encourage the patient to engage in light physical activity to

alleviate backaches, weariness, stress, and to redirect attention.
● Remind the patient to avoid strenuous exercise to avoid injury
and overfatigue.
● Encourage maintenance of activity restrictions, especially when
experiencing abdominal pain to alleviate discomfort.
● Advise not to lift more than 10 pounds to avoid straining the
incisions.

Treatment ● Explain that special intervention is only required when

pharmacological treatments fail and when extremely rare
complications arise, such as pneumonia and decreased platelet
production.
● Advise the patient to take follow-up blood tests to monitor the
pregnancy hormone levels.
● Remind that patient may undergo further ultrasound

37
 examinations to monitor reproductive integrity and observe for
possible complications.

Health ● Advise the patient to take adequate rest especially for around 2
Teachings weeks post-surgery.
● Demonstrate the proper wound care technique and discuss the
appropriate times to do so.
● When taking Methotrexate, avoid the intake of vitamins with folic
acid, penicillin, and pain relievers such as ibuprofen and
naproxen for 24 hours.
● Advise to avoid taking vices such as alcohol drinking and
cigarette smoking.
● Encourage the patient to allow time for emotional recovery for her
and her partner. Encourage communication with relations or a
counselor as part of coping management.
● Discuss the safe time to resume sexual activities, such as once
the bleeding and discharge cease 2 to 3 weeks after surgery or
hormone levels have normalized after medication therapy.

Outpatient ● Remind the patient to see respective surgeon 1 week

post-surgery to observe for incision sites and monitor for
complications.
● Direct the patient to seek medical attention immediately if
complications emerge such as swelling, heat, or drainage in the
incision site; heavy vaginal bleeding, fainting, and fever of 38C or
higher.
● Remind the patient to visit for regular check-ups to enhance
health and maintain a stable level of well-being.

Diet ● Emphasize the intake of 6 to 8 glasses of water to prevent

constipation.
● Remind the patient to eat slowly.

38
 ● Avoid foods that can induce constipation like highly processed
food, sweets, and red meat.
● Encourage consumption of bland & light food like toast, crackers,
and broth to alleviate nausea after surgery.

IV. NURSING THEORY

Dorothea Orem “Theory of Self-care Deficit”

Dorothea Orem developed the Self-Care Deficit Nursing Theory, also known as
the Orem Model of Nursing, between 1959 to 2001. This is considered as a broad
nursing theory since it contains a wide range of principles that may be applied to all
fields of nursing. It stresses the ability of each individual to practice self-care, which is
defined as "the practice of activities that individuals initiate and perform on their own
behalf in maintaining life, health, and well-being" (Gonzalo, 2021). The Self-Care Deficit
Nursing Theory can be readily adapted to a variety of contexts because of the
universality of its concepts and through this theory nurses and patients may collaborate
with each other to obtain the best possible treatment and have the chance to care for
themselves. (American Sentinel College of Nursing & Health Sciences, 2020).

This theory applies to ectopic pregnancy since self-care is essential after

discharge. The nurse can highlight the significance of self-care by relaying instructions
such as, "avoid alcohol and vitamin preparations containing folic acid until your
pregnancy hormone level is back to zero" and "after your ectopic pregnancy is treated,
you should expect some heavy period-like bleeding for a week or so." While the
bleeding occurs, it is advisable to use sanitary pads rather than tampons to avoid the
risk of infection. Baths or showers are available to be taken as needed." (Mater Mothers’
Hospital, 2020). Along with this, it is recognized how important it is to take good care of
oneself in order to keep one's health. Since this idea emphasizes the need of self-care,
people would be self-sufficient and accountable for their own well-being. Finally, the
theory can assist the nurses decide which areas of patient care to emphasize in a
particular scenario.

39
The Neuman Systems Model Theory

Betty Neuman developed the Neuman Systems Model which was published in
1982. It is based on stress and the patient’s reaction to the stressor. In this theory,
Neuman considers any internal and external factors that affect the patient as stressors.
She established the 5 factors that cause stress to an individual; physiological stressors,
psychological stressors, socio-cultural stressors, developmental stressors, and spiritual
stressors (Reddy, 2017).

The significance of this theory to Ectopic pregnancy is how it can aid the patient
in avoiding and coping with stress. Ectopic pregnancy usually starts with uncomfortable
and painful symptoms and ends with the termination of pregnancy resulting in the death
of the fetus; however, it could be difficult for the patient to accept the outcome, not only
affecting her physical health but as well as her mental health. So, in order to help the
patient how to cope with stress, as nurses, we must enhance patient wellbeing by stress
reduction and prevention to make them more bearable to the patient. This could be done
by encouraging the patient to do stress-relieving activities and educating the patient’s
family to show appropriate emotional responses towards the patient to avoid inflicting
further stress on the patient. The main goal of nursing is to identify the proper action in
stress-related circumstances or address the patient's reaction to stress. Nursing
management aims to guide the patient to adapt or adjust, as well as to protect, restore,
or maintain some degree of stability between client system variables and external
stressors. This theory not only applies to the patient but also to the patient’s family as
well. This is important in order to prevent depression and other mental health illnesses
from occurring. Also, to help the patient for better recuperation.

40
V. REVIEW OF RELATED LITERATURE AND STUDIES

An ectopic pregnancy occurs when a fertilized egg implants and grows outside
the uterus with the fallopian tube as the most common site of implantation. It is the
leading cause of maternal death and morbidity during the first trimester. The patient who
experiences ectopic pregnancy can be subjected to grieving, manifest sadness, guilt,
anger, and anxiety in regarding future pregnancies and pregnancy loss (Tarek, 2018).

The study “Ectopic pregnancy: a single-center experience over ten years” by Al

Naimi, et.al (2021) investigated the factors related to ectopic pregnancy that may be
used to predict morbidity or mortality. The incidence of ectopic pregnancy is 1.05% or
30,247 pregnancies over a ten-year period. There are 87.9% of pregnant women
presented with lower abdominal pain and tenfold increase in the risk of suffering
discomfort. There was a detectable fetal heartbeat in 5.1% of patients and 18.15 % had
one or more risk indicators for ectopic pregnancy. Most ectopic pregnancies were tubal
and 2% were ovarian. Ectopic pregnancy is a common disease affecting 1% of all
pregnancies.

Studies have determined whether women are at risk of developing psychiatric

symptoms following pregnancy loss, the impact of early pregnancy loss on partners, and
the optimal sort of therapies and how to provide treatments. According to Ian Lush, CEO
of Imperial Health Charity, they support pioneering research leading to actual advances
in patient care through their yearly research fellowships program. This study indicates
that a miscarriage or ectopic pregnancy have substantial and long-term effects on
women's psychological health, and they endeavor to see how this vital research might
be turned into improved treatment for patients and family members in the future
(Wighton, 2020).
41
 According to Andola, et al. (2021), the study “study of risk and treatment
modalities of ectopic pregnancy” with 42 patients diagnosed with ectopic pregnancy
reveals that the incidence rate of ectopic pregnancy was 10.7/1000 deliveries or 1 in 325
deliveries. 89.9% of the subjects had risk factors associated with ectopic pregnancy. The
most common risk factor was history WDPV which was seen in 47.62% of patients.
Ectopic pregnancy and its treatments continue to be a common source of morbidity in
women and can have an impact on long-term reproductive success (Ranchal, Dunne
2021).
Both acute appendicitis and ectopic pregnancy have similar clinical presentations,
causing diagnostic problems to patients presenting with right lower abdominal pain in
the first trimester. The patient of the group’s case coincided with the case study of Seak,
et.al (2019), where the diagnosis of extremely rare unilateral live spontaneous twin tubal
ectopic pregnancy is complicated due to her unremarkable medical history which
prompted two differential diagnoses: ectopic pregnancy and appendicitis.

42
NURSING CARE PLAN

43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
VI. REFERENCES

Advanced Maternal Age. (2017). Pavilion for Women.

https://women.texaschildrens.org/program/high-risk-pregnancy-care/conditions/ad

vanced-maternal-age

Al Naimi, A., Moore, P., Brüggmann, D. et al. (2021) Ectopic pregnancy: a single-center

experience over ten years. Retrieved 9 March 2022 from

https://doi.org/10.1186/s12958-021-00761-w

Americansentinel.edu Find all latest health. (2020).

https://www.healthgolds.com/sites/americansentinel.edu/.

Attali, E., & Yogev, Y. (2021). The impact of advanced maternal age on pregnancy

outcome. Best Practice & Research Clinical Obstetrics & Gynaecology, 70, 2-9.

Belleza, M. (2017). Ectopic Pregnancy: Implantation Outside the Uterine Cavity.

Nurseslabs. Retrieved 7 March 2022, from

https://nurseslabs.com/ectopic-pregnancy/.

Brady, P. C. (2017). New Evidence to Guide Ectopic Pregnancy Diagnosis and

Management. Obstetrical & Gynecological Survey, 72(10), 618–625.

https://doi.org/10.1097/OGX.0000000000000492

Costa, B. (2021). Gene that guides egg points to cause of ectopic pregnancy - BioNews.

Gene That Guides Egg Points to Cause of Ectopic Pregnancy.

59
 https://www.bionews.org.uk/page_155017#:%7E:text=The%20risk%20of%20ecto

pic%20pregnancy,the%20causes%20are%20poorly%20understood.

DerSarkissian, C. (2021). Understanding fainting—the basics. WebMD. Retrieved online

from https://www.webmd.com/brain/understanding-fainting-basics

Ectopic pregnancy - Symptoms and causes. Mayo Clinic, n.d.). Retrieved 7 March 2022,

from

https://www.mayoclinic.org/diseases-conditions/ectopic-pregnancy/symptoms-cau

ses/syc-20372088#:~:text=Surgery%20to%20correct%20a%20closed,more%20li

kely%20to%20be%20ectopic.

Ectopic pregnancy. Mater Patient Information. (2020).

http://brochures.mater.org.au/brochures/mater-mothers-hospital/ectopic-pregnanc

#:~:text=Therefore%20after%20your%20ectopic%20pregnancy,can%20be%20ta

k en%20as%20required.

Gari, R., Abdulgager, R., Abdulqader O. (2020). A Live 13 Weeks Ruptured Ectopic

Pregnancy: A Case Report. Retrieved March 10, 2022 from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7667717/pdf/cureus-0012-000000

10993.pdf

Gauvin, C., Amberger, M., Louie, K., & Argeros, O. (2019). Previously asymptomatic

ruptured tubal ectopic pregnancy at over 10 weeks’ gestation: Two case reports.

Case Reports in Women’s Health, 21, e00089.

https://doi.org/10.1016/j.crwh.2018.e00089

60
Gerema, U., Alemayehu, T., Chane, G., Desta, D., & Diriba, A. (2021). Determinants of

ectopic pregnancy among pregnant women attending referral hospitals in

southwestern part of Oromia regional state, Southwest Ethiopia: a multi-center

case control study. BMC Pregnancy and Childbirth, 21(1).

https://doi.org/10.1186/s12884-021-03618-7

Gonzalo, A. (2021) Dorothea Orem: Self Care Deficit Theory Study Guide. Nurseslabs.

Retrieved from https://nurseslabs.com/dorothea-orems-self-care-theory/ on March

7, 2022.

‌Hendriks, E., Rosenberg, R., & Prine, L. (2020). Ectopic Pregnancy: Diagnosis and

Management. American Family Physician, 101(10), 599–606.

https://pubmed.ncbi.nlm.nih.gov/32412215/

Hirsch, L. (2021). Ectopic Pregnancy (for Parents) - Nemours KidsHealth.

Kidshealth.org. Retrieved 7 March 2022, from

https://kidshealth.org/en/parents/ectopic.html.

Infertility and Reproductive Endocrinology (n.d.). Ectopic pregnancy. Retrieved online

from https://laivfclinic.com/ectopicpregnancy/

Khalife, T. (2018). Ectopic pregnancy: Signs, treatment and future fertility. Retrieved

March 09, 2022 from

https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/ect

o pic-pregnancy-signs-treatment-and-future-fertility

Kzior, R. K., & Hodgson, B. B. (2021). Saunders Nursing Drug Handbook 2022.

Retrieved 10 March 2022

61
Lingamchetty TN, Hosseini SA, Saadabadi A. Midazolam. [Updated 2021 Aug 6]. In:

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

Available from: https://www.ncbi.nlm.nih.gov/books/NBK537321/

Maternal Fetal Health Case Reports. (2020). Journal of Obstetrics and Gynaecology

Research, 46(S1), 42–46. https://doi.org/10.1111/jog.14285

Midazolam: Uses, Interactions, Mechanism of Action | DrugBank Online.

Go.drugbank.com. (2022). Retrieved 10 March 2022, from

https://go.drugbank.com/drugs/DB00683.

Moini, A., Hosseini, R., Jahangiri, N., Shiva, M., & Akhoond, M. R. (2018). Risk factors

for ectopic pregnancy: A case–control study. Journal of research in medical

sciences: the official journal of Isfahan University of Medical Sciences, 19(9), 844.

Mummert, T. & Gnugnoli, D.M. (2021). Ectopic Pregnancy. StatPearls. Retrieved online

from https://www.ncbi.nlm.nih.gov/books/NBK539860/#article-27633.s10

Pazhaniappan, N. (n.d.). Ectopic Pregnancy. TeachMe ObGyn. Retrieved online from

https://teachmeobgyn.com/pregnancy/early/ectopic-pregnancy/

Pelvic inflammatory disease (PID) - Symptoms and causes. Mayo Clinic. (2022).

Retrieved 7 March 2022, from

https://www.mayoclinic.org/diseases-conditions/pelvic-inflammatory-disease/symp

toms-causes/syc-20352594#:~:text=Untreated%20PID%20can%20cause%20sca

r,of%20the%20female%20reproductive%20organs.

Reddy, S. (2017). Neuman's theory- nursing theories. Retrieved from:

https://www.slideshare.net/sivanandareddy52/neumans-theory-nursing-theories

62
Rxlist.com. (2022). Retrieved 10 March 2022, from

https://www.rxlist.com/midazolam-injection-side-effects-drug-center.htm#professio

nal.

Seak, C. J., Goh, Z. N. L., Wong, A. C., Seak, J. C. Y., & Seak, C. K. (2019). Unilateral

live twin tubal ectopic pregnancy presenting at 12 weeks of gestation: A case

report. Medicine, 98(38).

Shiel, W. (2019). Medicinenet.com. Retrieved 7 March 2022, from

https://www.medicinenet.com/abdominal_pain/symptoms.htm.

Smoking link to ectopic pregnancy. BBC News. (2022). Retrieved 7 March 2022, from

https://www.bbc.com/news/uk-scotland-edinburgh-east-fife-11418432#:~:text=A%

20chemical%20in%20cigarette%20smoke,protein%20in%20the%20Fallopian%2

0tubes.

Stulberg, D. (2017). Ectopic pregnancy rates in the Medicaid population. Ectopic

Pregnancy Rates. https://secure.jbs.elsevierhealth.com/action/cookieAbsent

Wighton, K. (2020). Miscarriage and ectopic pregnancy may trigger post-traumatic

stress disorder. Retrieved March 09, 2021 from

https://www.imperial.ac.uk/news/175666/

miscarriage-ectopic-pregnancy-trigger-post-traumatic-stress/

Willacy, H. (2021). Ectopic Pregnancy. PatientInfo. Retrieved online from

https://patient.info/doctor/ectopic-pregnancy-pro#nav-8

Xu, J., Luo, X., Qu, S., Yang, G., & Shen, N. (2019). B cell activation factor (BAFF)

induces inflammation in the human fallopian tube leading to tubal pregnancy.

BioMedCentral. Retrieved online from

63
https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-019-2

324-5#citeas

64