ECTOPIC PREGNANC

Y
Prepared by: ENCINADA, MALINDOG
BACKGROUND
The classic clinical triad of ectopic pregnancy is pain, amenorrhea, and
vaginal bleeding; unfortunately, only about 50% of patients present with
all 3 symptoms. About 40-50% of patients with an ectopic pregnancy
present with vaginal bleeding, 50% have a palpable adnexal mass, and
75% may have abdominal tenderness. In one case series of ectopic
pregnancies, abdominal pain presented in 98.6% of patients,
amenorrhea in 74.1% of them, and irregular vaginal bleeding in 56.4%
of patients.
These symptoms overlap with those of spontaneous abortion; a
prospective, consecutive case series found no statistically significant
differences in the presenting symptoms of patients with unruptured
ectopic pregnancies versus those with intrauterine pregnancies.
Ectopic pregnancy causes major maternal morbidity and
mortality with pregnancy loss, and its incidence is
increasing worldwide. In northern Europe between 1976
and 1993, the incidence increased from 11.2 to 18.8 per
1,000 pregnancies, 2 and in 1989 the number of
admissions to US hospitals for ectopic pregnancy
increased from 17,800 in 1970 to 88,400.4 These
changes were greatest in women older than 35years. In
the United Kingdom, around 11,000 cases of ectopic
pregnancy occur per year (incidence, 11.5/1,000
pregnancies), with 4 deaths (a rate of
0.4/1,000ectopicpregnancies).
DEFINITION
Ectopic pregnancy refers to the implantation of
a fertilized egg in a location outside of the
uterine cavity, including the fallopian tubes
(approximately 97.7%), cervix, ovary, cornual
region of the uterus, and abdominal cavity. Of
tubal pregnancies, the ampulla is the most
common site of implantation (80%), followed by
the isthmus (12%), fimbria (5%), cornua (2%),
and interstitia (2-3%). (See the image below.)
ETIOLOGY
An ectopic pregnancy requires the occurrence of 2 events: fertilization of the o
vum and abnormal implantation. Many risk factors affect both events; for exam
ple, a history of major tubal infection decreases fertility and increases abnormal
implantation. Multiple factors contribute to the relative risk of ectopic pregnancy
. In theory, anything that hampers or delays the migration of the fertilized ovum
(blastocyst) to the endometrial cavity can predispose a woman to ectopic gesta
tion. The following risk factors have been linked to ectopic pregnancy:
Tubal damage - Which can be the result of infections such as pelvic inflammato
ry disease (PID) or salpingitis (whether documented or not) or can result from a
bdominal surgery or tubal ligation or from maternal in utero diethylstilbestrol (D
ES) exposure
SIGNS AND SYMPTOMS
Stabile (1996) points out that mortality and morbidity are a direct resul
t of the delay between presentation and treatment. It is essential that any woman
of childbearing age be investigated appropriately if any symptoms of this condition
are displayed. The most common are:
 Abdominal pain: this is usually one-sided, but not necessarily the side of the e
ctopic pregnancy;
 Bleeding that could be just spotting or abnormal bleeding. The blood is often d
arker than a normal period and can be described as watery or prune juice colo
ured
 Shoulder tip pain, which can be caused by irritation to the diaphragm caused
by internal bleeding, and is a classic sign of ruptured ectopic pregnancy
 Bladder and bowel problems: pain when going to the toilet and a feeling of pre
ssure in the bowels
 Dizziness, pallor and nausea
 Collapse
MANAGEMENT
It is vital to diagnose an ectopic pregnancy early to prevent further damage to the
tube and reduce the likelihood of morbidity as well as trying to preserve fertility.
If an ectopic pregnancy is suspected the woman should attend hospital. An ultras
ound scan and a pregnancy test should be performed. If the test is positive and th
e scan shows an empty uterus, an ectopic pregnancy is likely and needs to be rul
ed out (Tay et al, 2000). If the woman is well this can be done by serial blood tests
every 48 hours to check the level of the pregnancy hormone, beta-HCG. However
, Tay et al (2000) recommend caution as they found that this has a high failure rat
e. Ankum (2000) proposes laparoscopy as the preferred option.
If diagnosis is made early before the tube ruptures, keyhole surgery or drug treat
ments such as methotrexate can be offered. This promotes a quicker recovery tim
e and increases women’s chances of future fertility. This is the view expressed in t
he RCOG guidelines (2002), which suggest a laparoscopic approach is highly pre
ferable to undertaking a laparotomy because patients recover more quickly. It also
results in less morbidity, a shorter hospital stay and greatly reduced costs.
PREVENTION
There's no way to prevent an ectopic pregnancy, but here are some wa
ys to decrease your risk:
 Limit your number of sexual partners.
 Always use a condom during sex to help prevent sexually transmitte
d infections and reduce your risk of pelvic inflammatory disease.
 Don't smoke.
PREVALENCE
According to World Health Organization (2007), 5 percen
t of maternal deaths in developed countries are from ecto
pic pregnancy. These deaths declined markedly from 198
0-1992 due to improved diagnosis and management. In
a review of 206 cases of ectopic pregnancy in the Philipp
ines, the mortality was 7.28 percent. The main causes of
death were secondary anemia due to either preoperative
hemorrhage or both preoperative and postoperative hem
orrhage and infection.
PROGNOSIS

Ectopic pregnancy is fatal to the fetus, b

ut if treatment occurs before rupture, ma
ternal death is very rare. In the US, ecto
pic pregnancy probably accounts for 9%
of pregnancy-related maternal deaths.
NURSING CONSIDERATION
 Damage to the fallopian tube causing blockage or narrowing so the eggs cannot move into the ute
rus
 Previous pelvic infection
 Chlamydia. This infection is increasingly common in young women. It is crucial that school nurses,
midwives, health visitors and teachers warn young women of the problems that untreated sexually
transmitted infections (STIs) can cause to their health and future fertility
 Previous appendicitis
 Women with a history of infertility
 Caesarean section. With the rise in the Caesarean section rate in this country, this is an important
factor to consider when informing women of their choices;
 Women aged 35 or older
 Smoking.