INTRODUCTION

Definition of the Disease

Ectopic pregnancy is defined as the abnormal implantation of a fertilized ovum anywhere other
than the uterine cavity or the normal site of implantation. This is one of the most common pregnancy
complications during the first trimester. Because many cases were masked by misdiagnosis, there is no
exact statistic that represents ectopic pregnancy. Pregnancy is frequently thought to be normal during its
early stages due to the appearance of some signs indicating an ideal gestation. This is why ectopic pregnancy
is usually diagnosed late, or when the pain manifests as a sign of fallopian tube rupture (the most common
manifestation) and begins to develop more serious problems, such as hemorrhage.

The types of ectopic pregnancy is based on the site of implantation. The reason for the site of
implantation is still unclear, but, is/are associated with some forms of infections, anatomical abnormalities,
and some birth control methods.

1. Tubal ectopic pregnancy—the fertilized ovum was implanted anywhere within the fallopian
tube. This is the most common type of ectopic pregnancy. The usual site of implantation is on
the outer-third of the fallopian tube.
2. Cervical ectopic pregnancy—this is the abnormal implantation of a fertilized ovum near or on
the cervix. This occurs due to the inability of the uterus or not ideal set-up of the uterus for
implantation. Scar formation from previous uterine surgery (caesarean delivery-most common)
contributes to the incidence rate.
3. Abdominal ectopic pregnancy—this is the abnormal implantation of a fertilized ovum outside
the uterus, but, within the abdominal cavity.
4. Ovarian ectopic pregnancy—this is the abnormal implantation of a fertilized ovum within the
ovary. This is due to the non-progression of a matured ovum through the fallopian tube and got
fertilized by a sperm cell.

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 SIGNS AND SYMPTOMS

The clinical manifestations of ectopic pregnancy vary from its stage or state. These provide
information on its severity and serves as the basis of the treatment plan. Aside from the stage-specific signs
and symptoms, there are also some manifestations that help confirm the diagnosis of ectopic pregnancy.
Among these are:

 Positive pregnancy test

 A sharp and localized pain in the cervix upon palpation (vaginal examination)
 Shock and circulatory collapse from internal hemorrhage (latest and most indicative of severe
problem)
 Amenorrhea
 Uterine size is usually similar with what it would be in a normal pregnancy
 Abdominal tenderness on palpation
 Pelvic examination reveals a mass, either posterior or lateral to the uterus

Symptoms of Ruptured Ectopic Pregnancy

Patient may experience the same early pregnancy symptoms as a normal pregnancy if having an ectopic
pregnancy, such as nausea, tiredness, and breast tenderness. Additional signs of an ectopic pregnancy
usually appear six to eight weeks after the last normal menstrual period, but they can appear at any time
during the first trimester. These are some of the symptoms:

 Cramping or pain on one side, or in the lower abdomen

 Irregular vaginal bleeding or spotting
 Pain during intercourse
 Rapid heartbeat

Most ectopic pregnancies can be diagnosed before they rupture if these symptoms are recognized.
However, more than half of women who have ectopic pregnancies do not experience any of these symptoms
before the pregnancy ruptures. When an ectopic pregnancy ruptures, additional symptoms emerge. Any of
the following situations necessitates an immediate visit to the emergency room:

 Sudden, severe abdominal or pelvic pain

 Dizziness or fainting
 Pain in the lower back
 Pain in the shoulders (due to leakage of blood into the abdomen affecting the diaphragm)

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 ANATOMY AND PHYSIOLOGY

The human body is commonly regarded as a complex machine. The machine must have all of its
parts in order to operate, but each of these parts must also function optimally. Correspondingly, in order to
comprehend the disease process, Anatomy and Physiology provide the information needed about the proper
functioning of specific body parts, as well as their structure and function. The relationship between anatomy
and physiology is such that they will always directly relate. The study of the structures associated with the
human body is known as anatomy. The study of the function of each of these structures is known as
physiology.

The female reproductive system is the body parts that help women or people assigned female at
birth, as well as woman have sexual intercourse, reproduce and menstruate. The female reproductive system
provides several functions. Production of gametes, fertilization, development and nourishment of a new
individual. In addition to allowing a person to have sexual intercourse, it also helps a person reproduce. The
female reproductive anatomy includes both external and internal parts.

External Parts:

 Mons pubis: Also known as mons veneris, is a rounded eminence overlying the pubic bone (pubis).
It is considered to be the most anterior and superior part of the external female genitalia.
 Prepuce: The prepuce is a specialized, junctional mucocutaneous tissue which marks the boundary
between mucosa and skin; it is similar to the eyelids, labia minora, anus and lips.
 Clitoris: The glans clitoris sits at the top of the vulva, located where the inner lips meet. It is usually
around the size of a pea, though size varies from person to person. Only the tip of the clitoris is

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 visible, but it has two shafts that extend into the body by as much as 5 inches. The clitoris contains
many nerve endings that are very sensitive, especially during sexual stimulation.
 Labia majora: These are the fleshy outer lips on either side of the vaginal opening. The word
“labia” is Latin for “lips.” These outer lips usually grow pubic hair.
 Labia minora: These are the inner lips. They sit inside the outer lips but can be varying sizes. In
some females, for example, the inner lips extend beyond the outer lips.
 Urethra: The urethra is the tube through which urine passes from the bladder to the exterior of the
body. The female urethra is around 2 inches long and ends inferior to the clitoris and superior to
the vaginal opening.
 Vestibule: The labia minora enclose an area called the vestibule, which contains the urinary and
vaginal orifices along with the openings of the greater and lesser vestibular glands. The prepuce is
found at the anterior margin of the vestibule.
 Pudendal cleft: The cleft between the labia majora is called the pudendal cleft, or cleft of Venus,
and it contains and protects the other, more delicate structures of the vulva.
 Clinical perineum: The perineum is the part of the pelvis which contains the external genitalia and
anus. The skin and muscle of this region can tear during childbirth.
 Anus: The anus (AKA butthole) is below your vaginal opening. The anus is the opening to your
rectum. It has lots of sensitive nerve endings, so some people get sexual pleasure from anal
stimulation.

Internal Parts:

 Vagina: It is the female organ of copulation; it receives the penis during intercourse. The vagina is
a muscular canal that joins the cervix to the outside of the body. It can widen to oblige a child

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 during conveyance and afterward recoil back to hold something slender like a tampon. It's fixed
with mucous films that assist with keeping it damp.
 Uterus: Uterus is a hollow, pear-shaped organ that holds a fetus during pregnancy. It is divided
into two parts: the cervix and the corpus. Your corpus is the larger part of your uterus that expands
during pregnancy. The cervix is the lowest part of your uterus. A hole in the middle allows sperm
to enter and menstrual blood to exit. Cervix dilates to allow a baby to come out during a vaginal
childbirth
 Ovaries: Ovaries are small, oval-shaped glands that are located on either side of your uterus which
make females have two ovaries. Each ovary is a small organ suspended in the pelvic cavity by two
ligaments. Your ovaries produce eggs and hormones.
 Uterine tubes: This is so called fallopian tubes or oviduct and is associated with the ovary. These
are narrow tubes that are attached to the upper part of your uterus and serve as pathways for your
egg (ovum) to travel from your ovaries to your uterus. This is where fertilization of an egg by sperm
normally occurs.
 Mammary Glands: The mammary gland is a highly evolved and specialized organ present in pairs,
one on each side of the anterior chest wall. The organ's primary function is to secrete milk. Though
it is present in both sexes, it is well developed in females and rudimentary in males.
 Hymen: A thin mucous membrane that covers the vagina.

Ectopic pregnancy, in essence, is the implantation of an embryo outside of the uterine cavity most
commonly in the fallopian tube. Smooth muscle contraction and ciliary beat within the fallopian tubes to
assist the transport of an oocyte and embryo. An ectopic pregnancy usually happens because a fertilized
egg couldn't quickly move down the fallopian tube into the uterus. The tube can get blocked from an

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infection or inflammation. The tube can get blocked from: pelvic inflammatory disease. Almost all ectopic
pregnancies more than 90% occur in a fallopian tube. As the pregnancy grows, it can cause the tube to burst
(rupture). Reflecting this, most ectopic pregnancies are located in the fallopian tube; the most common site
is the ampullary portion of the tube, where over 80% of ectopic pregnancies occur. A rupture can cause
major internal bleeding.

Fallopian tubes containing an ectopic pregnancy demonstrate a marked reduction in the number of
ciliated cells in comparison with those of women with an intrauterine gestation. Marked deciliation is also
sometimes seen subsequent to an ectopic pregnancy and in biopsies from women undergoing tubal surgery
who later develop a tubal pregnancy. This effect suggests that pathological processes affecting the tubal
cilia may predispose to ectopic gestation.

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 PATHOPHYSIOLOGY

The major risk factors that contribute to Ectopic Pregnancy are previous ectopic pregnancy, prior
fallopian tube surgery, previous pelvic or abdominal surgery, pelvic inflammatory disease, and
endometriosis. Other factors that may increase a woman’s risk of ectopic pregnancy includes cigarette
smoking, age older than 35 years old, history of infertility, and use of assisted reproductive technology,
such as IVF or in vitro fertilization

Fertilization is the process wherein the ovum and the spermatozoa unite at the ampulla portion of
the fallopian tube, the usual site of fertilization, after the union, zygote begins to divide and grow. As an
ectopic pregnancy occurs the zygote cannot travel throughout the length of the tube due to an obstruction
by several risk factors.

The most common site of implant is the fallopian or uterine tube, other sites includes the abdomen
and ovaries. Structural factors that prevent or delay the passage of the fertilized ovum includes adhesions
of tube, salpingitis, congenital and developmental anomalies of fallopian tube or uterine tube, previous
ectopic pregnancy, current use of intrauterine device, and multiple induced abortions.

Functional factors may include menstrual reflux and decreased tubal motility.

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8
 MANAGEMENT

Management of an ectopic pregnancy is based on patient stability, characteristics of the ectopic

mass, desire for future fertility, and understanding of risks and benefits of each therapeutic option.
Possibilities include expectant management, medical management, and surgical management

Expectant Management

 Defined as observant waiting with no medical intervention. Cases qualifying for expectant
management are those whom are asymptomatic, have no adnexal mass on imaging, and show
signs of resolution, similar as a plateaued or decreasing βhCG. Cases’ βhCG must be trended to
observe a quantitative drop. Selective treatments must be enforced if cases come characteristic
or if βhCG situations rise.

Medical/Pharmacologic Treatment

 Methotrexate
With early resolution of an ectopic pregnancy, medical (non-surgical) treatment frequently
is possible with the medicine methotrexate. To be a candidate for methotrexate treatment, a
woman needs to be in stable condition with no testament of internal bleeding or severe pain.
She also needs to maintain communication with her physician during the treatment protocol
and be suitable to return for follow-up blood tests after treatment. Methotrexate is a
medicine that was originally used to treat certain types of cancers, some of which are
deduced from placental tissue. It's veritably effective in destroying ectopic pregnancy tissue
and allowing it to be reabsorbed by the body. It can also destroy normal pregnancy tissue.
These women may be considered aspirants for multiple- dosage methotrexate regimens or
surgical treatment. However, hCG levels should drop to zero over the coming 2 to 6 weeks,
if methotrexate is successful. However, methotrexate treatment may be repeated or the
pregnancy may be removed surgically, if the hCG situations don't fall. Side effects of in
taking this medication can cause nausea, vomiting, or both (for 24 hours) decreased appetite,
sores in the mouth, Headache, feeling tired, redness, swelling, or pain at the injection site,
having trouble sleeping, diarrhea.

 Leucovorin
Leucovorin is in a class of medications called folic acid analogs. It works by protecting
healthy cells from the effects of methotrexate or similar medications while allowing
methotrexate to enter and kill cancer cells. This medication is also used to treat people who

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 have accidentally received an overdose of methotrexate or similar medications. Side effects
of in taking this medication can cause diarrhea, Rash, hives, itching, difficulty breathing or
swallowing.

 Miferestone
An abortifacient, is also effective at causing sloughing of tubal implantation site. Side
effects of this medication can cause Chest pain or discomfort, cough or hoarseness, fast,
weak pulse, fever or chills, pain or discomfort in the arms, jaw, back, or neck, pale, cold, or
clammy skin, sudden increase in stomach or shoulder pain, unusual or large amount of
vaginal bleeding.

 Dactinomycin
Dactinomycin is one of the actinomycins, a group of antibiotics. In relation to antibacterial
activity are such as to preclude their use as antibiotics in the treatment of infectious diseases.
Because the actinomycins are cytotoxic, they have an antineoplastic effect and this cytotoxic
action is the basis for their use in the treatment of certain types of cancer. An ectopic
pregnancy implanted on the diaphragm resulted in spontaneous hemothorax due to
trophoblastic invasion into the pleura. Thoracoscopic excision followed by actinomycin D
chemotherapy provided successful resolution of the ectopic pregnancy. Side effects of this
drug when in taking can be Black, tarry stools, blood in the urine or stools, cough, diarrhea,
difficulty with swallowing, sores in the mouth and on the lips, stomach, pain, unusual
tiredness or weakness.

Surgical treatment

 Laparoscopy
In most surgeries for ectopic pregnancies are performed by laparoscopy. If the ectopic
pregnancy is diagnosed early, before the tube ruptures, a laparoscopic salpingostomy may be
performed. In this procedure, the fallopian tube is opened and the pregnancy tissue is
removed while leaving the tube in place. This may be treated by additional surgery to remove
the tube or by using methotrexate therapy. A partial salpingectomy (sometimes called a
segmental resection, to remove a middle segment of the tube may be performed when the
ends of the tubes (the fimbriae) appear healthy and the ectopic pregnancy is small. If only a
small portion of the tube is removed, the tube may be rejoined later using microsurgery. If
the fallopian tube is extremely damaged, the ectopic pregnancy is large, or the woman is

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 bleeding excessively, a total salpingectomy is performed. In rare cases when the ectopic
pregnancy involves the ovary, a portion of the ovary or the entire ovary may be removed.

 Laparotomy
Laparotomy usually is reserved for those ectopic pregnancies that have ruptured, causing
severe internal bleeding, or when there is extensive scar tissue inside the abdomen and pelvis.
Despite the advantages of laparoscopy, not all surgeries for ectopic pregnancy can be done
with this technique. Emergency situations with extensive internal bleeding or large amounts
of intra-abdominal adhesions may require immediate laparotomy.

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 NURSING CONSIDERATIONS

Nursing considerations are the implications of the interventions provided by a nurse. Nursing
concerns may take the form of assessments that must be completed prior to performing an intervention.

1. Assess the patient before taking medicine and nurse must explain adverse side effects/effects of
therapy.
2. Allow patients to express feelings about the loss of pregnancy, concerns of future pregnancy,
provide moral support and listen emphatically to the woman account of what has happened.

A. Medical Managements Considerations

Methotrexate

- This administered medication can’t be in taken when the tube already ruptured.
- Side effects of this drug may cause nausea and vomiting, increase abdominal pain, dizziness,
prolonged exposure to sunlight.
- It is also important to consider and ensure that patients taking methotrexate have no
complications such as:
o Patients with psoriasis or rheumatoid arthritis who have preexisting blood dyscrasias,
such as bone marrow hypoplasia, leukopenia, thrombocytopenia or significant anemia,
should not receive methotrexate.
o Patients with a known hypersensitivity to methotrexate should not receive the drug.
- Teaching patient the before and after taking the methotrexate, the patient is expected to mild to
moderate cramps or pain in the abdomen (belly), vaginal bleeding (like a period) and sexual
intercourse is prohibited this may increase the intra-abdominal pressure and could still have a
chance to rupture of tube or declining levels of hCG.

Mifepristone

- When administering this type of drugs to patient the expected side effects are well explained
to them such as weakness, nausea, vomiting, diarrhea, fever and 24 hours after taking
mifepristone vaginal bleeding, uterine cramping.
- Teach patient of long-term use of mifepristone to the body such as leading to asynchronous
endometrium, large fluid-filled glands with dilated, stratified nuclei, cells atypia, cells
metaplasia, and cells mitosis, abnormal blood vessels, including vascular dilatation, thin-
walled vessels, reticular capillary hyperplasia, etc.

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Leucovorin

- Before starting leucovorin treatment, make sure tell the physician about any other medications
that the patient is taking (including prescription, over the counter, vitamins, herbal remedies,
etc.).
- It can enhance the negative effects of fluorouracil. Fluorouracil may therefore remain in the
cancer cell longer and work against the cells. It usually causes symptoms like rashes, infection,
nausea, vomiting, diarrhea, constipation, and fatigue.
- Without first consulting your doctor, avoid breastfeeding while taking this medication since it
may be excreted.
- Leucovorin use may raise the risk of seizures in people who take medication for seizures. If
you observe any signs of a major allergic response, such as a rash, itching or swelling
(particularly of the face, tongue, or throat), severe dizziness, or difficulty breathing, tell the
patient to seek medical attention right once.
- It must be administered on schedule since missing or delayed doses might result in severe
immunosuppression and toxicity. Until further notice is indicated by laboratory testing, it
should be given every 6 hours.

Dactinomycin

- When taking dactinomycin, it can temporarily lower the number of white blood cells in your
blood increasing the chance of getting an infection. It can also lower the number of platelets,
which are necessary for proper blood clotting. If this occurs, there are certain precautions that
can take, especially when the blood count is low, to reduce the risk of infection or bleeding.
- Along with its needed effects, a medicine may cause some unwanted effects such as black,
tarry stools, blood in the urine or stools, cough, diarrhea, sores in the mouth and on the lips,
stomach pain and unusual tiredness or weakness. Nausea and vomiting can be severe. In some
cases, the doctor may prescribe medication to prevent or relieve nausea and vomiting. Eating
several small meals, not eating before treatment, or limiting activity may help lessen some of
these effects. If these effects persist or worsen, tell the doctor or pharmacist promptly.
- It should be administered only into a vein. However, it may leak into surrounding tissue causing
severe irritation or damage. The doctor or nurse will monitor the administration site for this
reaction.
- Female patients should use effective birth control during treatment with this medicine and for
at least 6 months after the last dose.

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B. Surgical Management Considerations

Laparoscopy

- Before undergoing surgery patient must be aware of the effects of the operation/therapy
especially adverse side effect these may include pain, fatigue, bleeding, and infection.
- Ensure if patient can take the operation and reconsider if complication and risk factors are
present such as: Skin irritation and bladder infection are common side effects of this procedure.
- More serious complications are rare. However, they include: damage to an abdominal blood
vessel, the bladder, the bowel, the uterus, and other pelvic structures.

Laparotomy

- Medical and surgical history and any lifestyle factors (such as current medications, or history
of smoking) that may affect your operation.
- Conduct tests like x-rays and blood tests.
- Before the operation expect shaving in the abdominal area.
- May be given a surgical scrub lotion to use in the shower and a theatre gown to wear and you
may be given an enema or some other form of bowel preparation to help empty your bowels.
- There are possible complications of laparotomy including: hemorrhage, infection, damage to
internal organs, formation of internal scar tissue (adhesions) and bowel blockages or abdominal
pain, which may be caused by adhesions. It may take an hour or several hours, depending on
the underlying condition.
- Patient will receive medication to help manage the pain and prevent infections and will likely
have a catheter to drain their urine. Depending on the site of the incision, patient may have a
drain to help get rid of excess fluids.

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 PREVALENCE

Ectopic pregnancy is a disease of short duration, immediately approached, hence difficult to

calculate its prevalence. Ectopic pregnancy remains an important cause of death among all pregnancies.
Around 1 in every 50 pregnancies in The United States are ectopic pregnancies. Worldwide, ectopic
pregnancies occur in 1-2% of all pregnancies. White females are more commonly affected, although,
mortality rate is higher in those of black race. In developing countries, the incidence of ectopic pregnancies
ranges between 0.4% of all pregnancies in places such as Middle East and India, and over 4% reported in
certain African countries, such as Ghana. In developed countries, such as The United States, the incidence
of ectopic pregnancy is 197 new cases per 100,000 persons. Ectopic pregnancies are thought to be high as
4% in pregnancies involving assisted reproductive technology. In Department of Obstetrics and
Gynecology, Ospital ng Maynila Medical Center, Manila, Philippines, abdominal pregnancy represents 1
to 1.4 percent of ectopic pregnancies.

One of the research said that in general characteristics, Of the 16,050 gynecological admissions
during the five-year period under study, 1273 EPs were observed, with a prevalence rate of 7.93% of all
gynecological admissions. There were still risk factors related in the presence of its signs and symptoms.
Alongside the complete diagnosis for all the patients admitted, three-fourths of the total percent receive the
proper treatment and appropriate management in handling such disease. Clinical research said that in one
specific area that have this case, the prevalence of EP was 7.93% among all gynecological admissions. The
majority of these patients were aged 25–34 y and had a past history of abortion (61%) and uterine cavity
surgery (38.6%), and a significant number were nulliparous (549, 43.1%). Bleeding accompanied by
abdominal pain were the most common presenting complaints (65.2%). Unilateral salpingectomy was
performed for most of these patients.

In recent years, with the prevalence of early sexual behavior and late childbearing among young
people, there has been a lack of correct guidance on healthy reproduction, and the incidence of EP has
increased year by year.10,11 The present study revealed that a significant proportion of nulliparous women
have an EP. Hence, the follow-up fertility problems facing these patients are worthy of attention. Over the
past five years, EP has resulted in notable morbidity. A previous history of abortion and uterine cavity
surgery were identified as the associated risk factors that limited the future reproductive potential of
nulliparous women. Therefore, targeted health education campaigns should be created to enlighten this
group of women and the public at large.

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 PROGNOSIS

Having had one ectopic pregnancy the risk of having another is 15%. If there are underlying risk
factors for ectopic pregnancy, the risk of recurrence may be higher. Another ectopic pregnancy is more
likely to occur. Some women do not become pregnant again.

The likelihood of a successful pregnancy after an ectopic pregnancy depends on:

 The woman's age

 Whether she has already had children
 Why the first ectopic pregnancy occurred

An ectopic pregnancy cannot move naturally or be moved to the uterus, it always requires treatment to
end the pregnancy. Otherwise, it could be life-threatening to the pregnant woman. Bleeding from ectopic
pregnancy causes 10% of all pregnancy-related deaths, and it's the leading cause of first-trimester maternal
death. If a woman does have trouble getting pregnant after an ectopic pregnancy, it may be due to problems
in the fallopian tubes or scarring in the pelvis; in these instances, fertility testing and treatment can improve
the chances of success.

The prognosis for future pregnancies depends on the extent of the surgery:

 If the Fallopian tube has been spared, the chance of a successful pregnancy is usually better than
50%. If a Fallopian tube has been removed, an egg can be fertilized in the other tube, and the chance
of a successful pregnancy drops somewhat below 50%.
 The intrauterine pregnancy rate following salpingectomy is 54-66%. Intrauterine pregnancy rate
after salpingotomy is higher at 60-89%, but the risk of recurrent ectopic is higher (18% versus 8%)
and there is a potential need for treatment for persistent pregnancy tissue.
 Expectant management in women with a pregnancy of unknown location will be successful in 67-
88%. Two thirds of these pregnancies will resolve spontaneously. Compliance with follow up in
the early pregnancy clinic is vital to reduce risks to the patient.

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 REFERENCE

1. When to Worry About a Ruptured Ectopic Pregnancy. (n.d.). Verywell Family.

https://www.verywellfamily.com/ruptured-ectopic-pregnancy-symptoms-and-signs-2371253
2. RNspeak. (2018). Ectopic Pregnancy Case Study. Rnspeak.com. https://rnspeak.com/ectopic-
pregnancy-case-study/
3. Strauch, I. (2014, October 30). What Is an Ectopic Pregnancy? EverydayHealth.com.
https://www.everydayhealth.com/ectopic-pregnancy/guide/
4. October 2016, D. P. W. on the 11. (n.d.). Clincal Review: Ectopic pregnancy. Www.gponline.com.
Retrieved March 3, 2023, from https://www.gponline.com/clincal-review-ectopic-
pregnancy/womens-health/womens-health/article/1058410#4
5. Medical Definition of Ectopic pregnancy. (n.d.). RxList. Retrieved March 3, 2023, from
https://www.rxlist.com/ectopic_pregnancy/definition.htm
6. Mayo Clinic. (2018). Ectopic pregnancy - Symptoms and causes. Mayo Clinic.
https://www.mayoclinic.org/diseases-conditions/ectopic-pregnancy/symptoms-causes/syc-
20372088
7. Better Health Channel. (2012). Laparotomy. Vic.gov.au.
https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/laparotomy

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