EMILIO AGUINALDO COLLEGE

Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph

SCHOOL OF NURSING

NAME: ANDREA D. ABCEDE PROFESSOR: MRS. MARIBETH DOLOR

SECTION: BSN 2-2 B SUBJECT: RLE DUTY

ECTOPIC PREGNANCY
“Case Presentation”

INTRODUCTION

I. CASE STUDY
A 32-year-old Filipino patient, named Carlyn Nepomuceno, G3P2 - 1x miscarriage, 2 term
deliveries, presented to the emergency department on the 18th of April 2023, complaining of acute onset
of lower abdominal pain, with a pain level of 6/10, associated with Nausea, dizziness, and rapid breathing.
Upon assessment, the patient was visibly pale and lethargic, having:
▪ a blood pressure level of 80/55 mmHg
▪ respiratory rate: 23 bpm
▪ pulse rate: 110 bpm
▪ oxygen saturation: 97%
▪ Temperature: 36.6 C
The patient also reported intermenstrual bleeding recently, having 5 heavy pads used each for 2
days now, consecutively.

II. ETIOLOGY
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
assist in the transport of an oocyte and embryo. Damage to the fallopian tubes, usually secondary to
inflammation, induces tubal dysfunction which can result in an oocyte’s or embryo’s retention. This also
occurs when a fertilized egg implants in a location that can’t support its growth. An ectopic pregnancy
most often happens in your fallopian tube (a structure that connects your ovaries and uterus). Ectopic
pregnancies more rarely can occur in your ovary, abdominal cavity, or cervix. Pregnancies can’t continue
if they’re ectopic because only your uterus is meant to carry a pregnancy.
Ectopic pregnancies can become life-threatening, especially if your fallopian tube breaks
(ruptures). This is a ruptured ectopic pregnancy, and it can cause severe bleeding, infection, and worst,
death. This is a medical emergency. Healthcare providers must treat ectopic pregnancies immediately.
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 EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph

SCHOOL OF NURSING
III. CLINICAL FINDINGS & LABORATORY
• The definitive diagnosis is made on laparoscopic inspection of the fallopian tube.
• Algorithms have been developed that reduce the need for surgery, and include serial beta-HCG (human
chorionic gonadotropin) measurements and transvaginal ultrasound (TVUS).
• Although these algorithms are felt to be 97% sensitive and 95% specific, they may delay the diagnosis.
o ELISA (enzyme-linked immunosorbent assay) can detect beta-HCG as low as 1.0 IU/L. In a
normal pregnancy, this doubles every 2 days, whereas abnormal pregnancies (intrauterine or
ectopic) have impaired beta-HCG production and longer doubling times.
o An intrauterine gestation can generally be seen on TVUS when the beta-HCG is > 1500 IU/L
(generally ~ 5 – 6 weeks gestation).
o Absence of an intrauterine gestation with beta-HCG concentrations above this level is diagnostic
of an EP (100% sensitive and specific).
o The presence of an adnexal mass when the beta-HCG is > 1,000 IU/L has a sensitivity of 97%, a
specificity of 99%, and a PPV and NPV of 98%.
• Other algorithms use serum progesterone measurements and/or uterine curettage.
o If the serum progesterone is > 25 ng/ml, EP can be excluded (sensitivity of 97.5%).
o Curettage is done only after a non-viable pregnancy has been confirmed by either serum
progesterone < 5 ng/ml (100% sensitivity) or by the absence of a rise in beta-HCG after 2 days.
o If the progesterone is between 5 and 25 ng/ml a TVUS should be performed.
• A decrease in the beta-HCG of ≥ 15% 8 – 12 hours after curettage is diagnostic of complete abortion. If
the beta-HCG does not fall, EP is diagnosed.

VITAL SIGNS OF THE PATIENT UPON ASSESSMENT

NORMAL VALUES RESULT
Temperature 36.5 C to 37.5 C 36.6 C
Respiratory rate 16 to 20 bpm 23 bpm
Pulse Rate 60 to 100 bpm 110 bpm
Blood Pressure 120/80 mmHg 80/55 mmHg
Oxygen Saturation 95% to 100% 97%

▪ Potential Diagnosis
✓ Ruptured ectopic Pregnancy.

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Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph

SCHOOL OF NURSING
IV. MANIFESTATIONS, SIGNS, SYMPTOMS & RISK FACTORS
Most ectopic pregnancies are located in the fallopian tube, and any history of infection or surgery
that increases the risk of tubal adhesions or other abnormalities increases the risk of ectopic pregnancy.
Factors that particularly increase the risk of ectopic pregnancy include:
✓ Prior ectopic pregnancy
✓ Prior abdominal or pelvic surgery, particularly tubal surgery, including tubal ligation
✓ Tubal abnormalities
✓ Current intrauterine device (IUD) use
✓ In vitro fertilization in current pregnancy
Pregnancy is much less likely to occur after tubal ligation or IUD placement; however, when pregnancy
does occur, the risk of ectopic pregnancy is increased (eg, about 5% in current IUD users).
Other risk factors for ectopic pregnancy include:
✓ Current use of estrogen/progestin oral contraceptives
✓ History of pelvic inflammatory disease or sexually transmitted infections (particularly due
to Chlamydia trachomatis)
✓ Infertility
✓ Cigarette smoking
✓ Prior spontaneous or induced abortion
Early signs of an ectopic pregnancy include:
✓ Upset stomach and vomiting.
✓ Sharp belly cramps
✓ Pain on one side of your body
✓ Dizziness or weakness
✓ Pain in your shoulder, neck, or rectum
An ectopic pregnancy can cause your fallopian tube to burst, or rupture. Emergency
symptoms include major pain, with or without severe bleeding. Call your doctor immediately if you
have heavy vaginal bleeding, lightheadedness, fainting, shoulder pain, or severe belly pain, especially
on one side.

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Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph

SCHOOL OF NURSING
V. PATHOPHYSIOLOGY
An ectopic pregnancy is when the fertilized egg (zygote) attaches, or implants, and begins to
grow in an area other than the uterus. This most often occurs in the fallopian tube, but can be in other
areas like the cervix, ovary, or abdominal cavity. An embryo cannot grow and survive outside the uterus,
and parts like the fallopian tubes are unable to support such a pregnancy and must be treated immediately.
Often, a woman may not be aware that she is pregnant, and symptoms may be vague. Blood tests and
ultrasounds are the best ways to diagnose.

VI. STATISTICS
The estimated rate of ectopic pregnancy in the general population is 1 to 2% and 2 to 5% among
patients who utilized assisted reproductive technology. Ectopic pregnancies with implantation occurring
outside of the fallopian tube account for less than 10% of all ectopic pregnancies. Cesarean scar ectopic
pregnancies occur in 4% of all ectopic pregnancies and 1 in 500 pregnancies in women who underwent
at least one prior c-section. Interstitial ectopic pregnancies are reported in up to 4% of all ectopic
implantation sites and have morbidity with mortality rates up to 7 times higher than other ectopic
implantation sites. This increased morbidity and mortality are due to a high rate of hemorrhage in
interstitial ectopic pregnancies.
In summary, Ectopic pregnancy was responsible for 6450 deaths (95% UI 5500–7510) among
females ages 10 to 54, a 12·2% (-6·1 to 31·8) increase since 1990 here in the Philippines. There was a
total of 6·69 million (5·23–8·60) ectopic pregnancies globally in 2019, a 10·2% (4·0–15·9) decrease
since 1990.

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Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph

SCHOOL OF NURSING

VII. PROGNOSIS

Patients with a relatively low beta hCG level will likely have a better prognosis regarding treatment
success with single-dose methotrexate. The further the ectopic pregnancy has advanced; the less likely
single-dose methotrexate therapy will suffice. Patients in the extremities or with hemodynamic instability
have more risk of deterioration, such as hemorrhagic shock or other perioperative complications. The
prognosis will thus hinge on early recognition and timely intervention. Fertility outcomes with tubal
conservation surgeries remain debatable as some data suggest no significant difference in intrauterine
pregnancy rates when comparing salpingectomy versus conservative tubal management.

VIII. REFLECTION

Paramedics should consider ectopic pregnancy in all women of reproductive age who are
presenting with abdominal pain. Women using contraception (including emergency contraception) are at a
very low risk of pregnancy, however, if they do conceive, the probability of an ectopic pregnancy is high.
Mismanaging the care of women with ectopic pregnancies is easier than making the correct diagnosis,
partly because cases present infrequently, but mainly due to presentation not always being classical. A
systematic approach to history taking, including the use of both open-ended and direct questions is
important to allow for proper evaluation and patient management.
The entire process of doing this nursing care plan is a bit easy as I got lucky when I got the same
topic with our previous group presentation, so I got the chance to recall the mistake we made before and
made it right this time. However, it was a bit challenging on my part as I need to step up in this presentation
and use what I learned from our previous presentation. I am also happy and grateful because upon doing
this nursing care plan, I have noticed how I change and mature in creating nursing care plans, from a
beginner to a student nurse who puts my heart into every nursing action I give and plans for my patients.
One thing I have learned from this activity is that we made mistakes and there will be instances
that the things we do aren’t enough, but always remember that the most important part in life is that we
learn from that mistake and use that to strive harder to become better. And this activity will be our stepping-
stone to learn, explore, and grow so that we can be the best nurse in the making, every patient could ever
have.
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 EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph

SCHOOL OF NURSING

IX. NURSING CARE PLAN

CHIEF COMPLAINT: Acute Abdominal Pain

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Short Term: Independent: Short Term:

- “Namimilipit ako Acute After an hour of - Place the patient on To provide optimal comfort to the After an hour of
sa sobrang sakit ng abdominal effective nursing complete bed rest patient. effective nursing
tiyan ko” as pain related to intervention, the during severe episodes intervention, the
verbalized by the ruptured patient will be of pain. Perform non- patient was able to
patient. fallopian tube able to reduce the pharmacological pain reduce the pain
as evidenced pain intensity relief methods & intensity from a
- Pain scale level of by (+) facial from a pain scale relaxation techniques pain scale level of 6
6/10, as 10 is the grimace with level of 6 to 2 out such as deep breathing to 2 out of 10.
most painful. pain scale of 10. exercises, guided (GOAL MET)
level of 6/10. imagery, and provision
- Nausea Long Term: of distractions such as Long Term:
TV or radio.
- Dizziness After 2 days of After 2 days of
effective nursing - Monitor the To monitor the effectiveness of effective nursing
intervention, the patient’s vital signs medical treatment for the relief of intervention, the
patient will be and characteristics of abdominal pain. patient was able to
OBJECTIVE: able to learn pain at least 30 learn different pain
different pain minutes after management
- (+) Facial Grimace management administration of strategies and
strategies and medication. demonstrated the
- Lethargic demonstrates the use of appropriate
use of - Post-surgery: To reduce post-surgical pain and diversional
appropriate Advise the patient to allow full recovery and healing. activities and
diversional have no strenuous relaxation skills as
activities and activity for a few evidenced by: the
relaxation skills. weeks. Apply support patient was able to
on the abdomen when explain accurately
coughing, laughing, or what she learned
moving by placing a through health
pillow over the teaching.
abdominal area. (GOAL MET)

Dependent:

- Administer To alleviate the symptoms of

prescribed pain acute abdominal pain.
medications.

- Prepare the patient If the fallopian tube has ruptured,

for surgery. Maintain surgery to remove part or all the
NPO status. tubes may be the best option.
Surgery may be performed
laparoscopically, or a laparotomy
may be necessary.

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 EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph

SCHOOL OF NURSING

CHIEF COMPLAINT: Abnormal uterine bleeding

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Short Term: Independent: Short Term:

- “Hindi na normal Deficient fluid After 6 hours of - Monitor vital - Edema, headaches, low blood After 6 hours of
yung pagdurugo ko. volume related effective nursing signs, assess signs of pressure, and pain are associatedeffective nursing
Kung bibilangin, to abnormal interventions, the shock, and conduct with the patient’s blood loss.interventions, the
halos 5 heavy pads client will be physical examinations Assessment findings reveal client was able to
uterine
cardiovascular status, degree of
na nagagamit ko sa bleeding as able to re- hemorrhage, and the results of
re-establish a
isang araw” As evidenced by establish a continuous therapeutic adjustments functional body
verbalized by the reported usage functional body blood volume by
related to fluid replacement needs.
patient. of 5 heavy blood volume by controlling the
pads each day, controlling the - Elevate the head - Gently repositioning the patient amount of blood
OBJECTIVE: for 2 amount of blood of the bed and position from a supine to a Semi-fowler’s loss from heavy
consecutive loss, from heavy the patient in semi- position can reduce the risk of bleeding to light
- Lethargic days. bleeding to no Fowler’s. orthostatic BP changes and ensure bleeding, as
bleeding. adequate blood circulation. evidenced by: the
Vital Signs: patient reported
- Start input and output - To monitor circulatory blood reduced usage of
BP: 80/55mmHg monitoring volume. To ensure that the patient heavy pads, from 5
has adequate oral hydration or if to 2 each day.
PR: 110 bpm there is a need to commence IV (PARTIALLY
hydration therapy. MET)

- Discuss with the - To inform the patient and the

patient and family family about the importance of
about the need for the surgery and the urgency to
hospitalization for the immediately treat vaginal
treatment of serious bleeding.
hemorrhage and the
need for surgery.

Dependent:

- Prepare the patient - Placing the patient on “Nothing

for the surgical by Mouth” (NBM or NPO) is
intervention for necessary to prepare the patient
ectopic pregnancy. for emergent delivery.
Place the patient on a
nothing-by-mouth
(NBM or NPO) status.

- Prepare for blood - To increase blood volume.

transfusion as
required.

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 EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph

SCHOOL OF NURSING

CHIEF COMPLAINT:

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Short Term: Independent: Short Term:

Long Term: Dependent: Long Term:

OBJECTIVE:

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