Ectopic Pregnancy

Ectopic Pregnancy Nursing Diagnosis Interventions and Care Plans

Ectopic Pregnancy NCLEX Review Care Plans

Nursing Study Guide on Ectopic Pregnancy

Ectopic pregnancy is a medical condition wherein the zygote fails to attach to the uterus and will either be on the fallopian tubes, the cervix, or any other part of the female reproductive system.

Due to the nature of placement, the embryo cannot fully mature and this will eventually lead to death.

In a healthy pregnancy, the fertilized egg attaches to the inner uterine wall. Without timely diagnosis, ectopic pregnancy poses a great threat to the mother’s life.  

Signs and Symptoms of Ectopic Pregnancy

50% of patients present with all 3 symptoms of the classic triad of ectopic pregnancy and they are:

  1. Abdominal pain 
  2. Amenorrhea
  3. Vaginal bleeding

Other associated clinical signs and symptoms common to early pregnancy that can be found in ectopic pregnancy are:

  1. Nausea and vomiting
  2. Breast fullness
  3. Fatigue
  4. Heavy cramping
  5. Shoulder pain – may be suggestive of peritoneal inflammation
  6. Dizziness or weakness
  7. Flu-like symptoms 
  8. Syncope
  9. Painful fetal movements (for advanced abdominal pregnancy)

The following are clinical manifestations that would warrant emergency surgical management and they are:

  1. Abdominal rigidity
  2. Involuntary guarding
  3. Severe tenderness
  4. Evidence of severe low blood pressure (Hypovolemic shock) – orthostatic blood pressure changes, tachycardia

Causes and Risk Factors of Ectopic Pregnancy

A tubal pregnancy, wherein the implantation happens at the fallopian tubes, is considered the most common type of ectopic pregnancy.

This occurs when the fallopian tubes are damaged or erratic in shape. Imbalances in hormones and abnormal development of the zygote may also play a role in ectopic pregnancy.

The following are proven to increase the risk for its development:

  1. Previous ectopic pregnancy. Scarring of the structures brought about by previous ectopic pregnancies contributes to future episodes.
  2. Inflammation or infection. Pelvic inflammatory disease (PID) brought about by infections like chlamydia and gonorrhea alters the normal structures by blocking the passage of the fertilized egg
  3. Fertility treatments. Artificial induction of ovulation through injectable gonadotropin therapy has been linked to a 4-fold increased risk, therefore suggesting that multiple egg cells and high hormone levels plays a major role in ectopic pregnancy.
  4. Tubal surgery. Alterations and scarring of the structures contribute to the improper implantation of the fertilized egg
  5. Choice of birth control. Use of progestin-only oral contraceptives or progestin-only implants (IUD) may put a woman at risk for ectopic pregnancy.
  6. Smoking. Studies have shown that an elevated risk of 1.6 to 3.5 times is more common for smokers than non-smokers to develop ectopic pregnancies.

Complications of Ectopic Pregnancy

Complications of ectopic pregnancy can be due to incorrect or late diagnosis, or faulty treatment regimen.

Failure to address the diagnosis of ectopic pregnancy correctly and promptly will result to rupture depending on the implantation site, therefore leading to massive bleeding, shock, disseminated intravascular coagulopathy (DIC), and death.

Diagnosis of Ectopic Pregnancy

  • Physical examination – a pelvic examination may show these findings:
  • Uterus is slightly soft and enlarged
  • Uterine or cervical motion tenderness – suggestive of peritoneal inflammation
  • Upon palpation, an adnexal mass may be assessed. However, this mass is usually difficult to differentiate from the ipsilateral ovary.
  • Serum B-HCG levels – serum Beta Human Chorionic Gonadotropin (B-HCG) levels are elevated, but not as much as with normal pregnancy. This test is necessary to differentiate between normal and abnormal pregnancies. This is also crucial to monitor the therapeutic effect of treatment once therapy is initiated. An elevated serum B-HCG level and the absence of uterine pregnancy is highly suggestive of an ectopic pregnancy or abortion.
  • Progesterone levels – They are helpful in aiding with diagnosis as progesterone is:
    • Not gestational age dependent
    • Remaining relatively constant during the first trimester of normal and ectopic pregnancy
    • Independent and not correlated with B-HCG levels
    • If initially abnormal, progesterone levels do not return to reference range
  • Ultrasonography – used as the most important tool for diagnosing extra-uterine pregnancy. It involves the utilization of sound waves in assessing the intra uterine and abdominal structures.
  • Laparoscopy –used as the gold standard in diagnosing ectopic pregnancy for patients who are in pain or hemodynamically unstable.

Treatment for Ectopic Pregnancy

Treatment management for unruptured ectopic pregnancy involves medical and surgical therapies and they are:

  1. Antimetabolite therapy/ Folic acid antagonist. In antimetabolite therapy, the patient is given a single dose or multiple sessions of chemotherapeutic agent through the intramuscular route.  The effectiveness of this regimen to trophoblastic has been well established due to its original indication for use against hydatidiform moles and choriocarcinomas.
  2. Salpingostomy and Salpingectomy. Salpingostomy is the surgical removal of the unruptured ectopic pregnancy from the fallopian tube utilizing laparoscopic technique. Salpingectomy is the surgical resection of the unruptured ectopic pregnancy and the involved fallopian tube through laparoscopy.

Medications. Other supportive medical treatments for the management of ectopic pregnancy are:

  • Folic acid analogs – used with Antimetabolite therapy to limit its nephrotoxic and hepatotoxic effects while allowing its action against trophoblastic tissue.
  • Vitamin D – used to correct depressed folic acid levels brought about by antimetabolite treatment
  • Vasopressors – used to minimize bleeding during surgery by acting on the alpha1 and beta1 receptors, thereby stimulating vasoconstriction

Nursing Care Plans for Ectopic Pregnancy

Nursing Care Plan 1

Nursing Diagnosis: Deficient Fluid Volume related to active blood loss secondary to ectopic pregnancy, as evidenced by an average blood pressure level of 85/50, body weakness, decreased urinary output, and pale, clammy skin

Desired Outcome: The patient will re-establish a functional body fluid volume and a balanced input and output status.

InterventionRationale
Assess vital signs, conduct physical examination, and commence daily weight monitoring.Edema, headaches, low blood pressure, and pain are associated with the patient’s blood loss. Fluid retention may be evident if the patient has an unexplained weight gain.
Start input and output monitoring.To monitor circulatory blood volume. To ensure that the patient has adequate oral hydration or if there is a need to commence IV hydration therapy.  
Speak to the patient and family about the need for hospitalization for the treatment of serious hemorrhage and the need for surgery.To treat the vaginal bleeding and deficient fluid volume related to ectopic pregnancy in the appropriate setting.
Prepare the patient for the surgical intervention for ectopic pregnancy. Place the patient on a nothing by mouth (NBM or NPO) status.Salpingostomy is the surgical removal of the unruptured ectopic pregnancy from the fallopian tube utilizing laparoscopic technique. Salpingectomy is the surgical resection of the unruptured ectopic pregnancy and the involved fallopian tube through laparoscopy.  Placing the patient on “Nothing By Mouth” (NBM or NPO) is necessary to prepare the patient for emergent delivery.
Prepare for blood transfusion as required.To increase blood volume.  
Encourage the patient to have a low salt intake.Consuming salt between 2 to 4 g per day is ideal as a very low salt intake may increase dehydration.

Nursing Care Plan 2

Nursing Diagnosis: Risk for Maternal Injury

Desired Outcome: The patient will maintain safety and participate in measures that will protect self during the treatment.

          Interventions                       Rationale
Assess the patient’s mental status. Ectopic pregnancy may cause the patient to have low mood, depression, or negative emotional state, which puts her at risk for maternal injury.
Monitor the patient’s level of consciousness using AVPU.  Heavy vaginal bleeding may result to hypotension and lower level of consciousness. Using AVPU scale (i.e.  Alert, Voice, Pain stimuli, or Unresponsive/unconscious) can help determine the urgency of surgical treatment and increased risk for maternal injury.
Prepare the patient for immediate surgical intervention for the removal of the ectopic pregnancy.Ectopic pregnancy is the leading cause of maternal death during the first trimester due to internal bleeding, therefore an urgent surgery to remove it is needed.
Place the patient in complete bed rest if there is evidence of severe bleeding.To reduce pain and keep the patient safe

Nursing Care Plan 3

Nursing Diagnosis: Acute Pain related to ectopic pregnancy as evidenced by pain score of 10 out of 10, verbalization of abdominal pain, abdominal rigidity, and restlessness

Desired Outcome: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and absence of restlessness.

InterventionsRationale
Administer prescribed pain medications.To alleviate the symptoms of acute abdominal pain.
Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication.  To monitor effectiveness of medical treatment for the relief of abdominal pain. The time of monitoring of vital signs may depend on the peak time of the drug administered.  
Elevate the head of the bed and position the patient in semi Fowler’s.To increase the oxygen level by allowing optimal lung expansion.
Place the patient in complete bed rest during severe episodes of pain. Perform non-pharmacological pain relief methods such as relaxation techniques such as deep breathing exercises, guided imagery, and provision of distractions such as TV or radio.To provide optimal comfort to the patient.
Prepare the patient for surgery.Salpingostomy is the surgical removal of the unruptured ectopic pregnancy from the fallopian tube utilizing laparoscopic technique. Salpingectomy is the surgical resection of the unruptured ectopic pregnancy and the involved fallopian tube through laparoscopy. 
Post-surgery, advise the patient to: Have no strenuous activity for a few weeks.Apply support on the abdomen when coughing, laughing, or moving by placing a pillow over the abdominal areaInform the healthcare team if the pain medications are not workingTo reduce post-surgical pain and allow full recovery and healing.

Other Nursing Diagnoses:

  • Risk for Shock
  • Powerlessness related to early loss of pregnancy

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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