Ectopic pregnancy is a pregnancy that implants outside the uterine cavity, most often in a fallopian tube. It cannot grow to term, and if the tube ruptures it can cause severe internal bleeding and shock. It is a medical diagnosis, not a nursing diagnosis; the nursing diagnoses used most often are Risk for Shock, Acute Pain, Anxiety, and Grieving. The nurse watches closely for signs of bleeding and rupture, prepares the client for medical or surgical treatment, manages pain, and supports her through the loss of the pregnancy.
At a glance
- What it is
- A fertilized egg that implants outside the uterus. More than 90% are in a fallopian tube; others occur in the cervix, ovary, abdomen, or a cesarean scar.
- Main risk factors
- A previous ectopic pregnancy, tubal surgery or sterilization, pelvic inflammatory disease (often from chlamydia or gonorrhea), smoking, assisted reproduction such as IVF, pregnancy with an IUD in place, and older maternal age.
- Key signs
- Missed period, positive pregnancy test, one-sided pelvic or lower abdominal pain, and vaginal spotting or bleeding. Many clients have few symptoms until the tube ruptures.
- Nursing focus
- Frequent vital signs, watching for bleeding and shock, IV access and blood work as ordered, preparing for methotrexate or surgery, pain control, and emotional support.
- Act now
- Sudden severe abdominal pain, shoulder-tip pain, dizziness or fainting, a rising heart rate, or falling blood pressure can mean rupture with internal bleeding — call the provider or rapid response team immediately.
Why ectopic pregnancy happens
After fertilization, the egg normally travels down the fallopian tube and implants in the uterine lining about a week later. Anything that damages the tube or slows that journey raises the risk that the egg implants in the tube instead. Scarring from pelvic infection, earlier tubal surgery, and smoking (which affects the tiny hair-like cilia that move the egg) are common causes. Many clients have no known risk factor.
The fallopian tube cannot stretch the way the uterus can. As the pregnancy grows, it erodes the tube wall and its blood vessels. Bleeding may start as a slow leak into the pelvis or as a sudden rupture with heavy internal bleeding. Blood in the abdomen irritates the peritoneum and the diaphragm, which is why pain can spread to the shoulder.
Young, healthy clients compensate well. The heart rate rises and the blood vessels tighten to hold the blood pressure up, so blood pressure may stay normal until a large amount of blood has been lost. A rising heart rate, dizziness when sitting up, pallor, and restlessness are earlier warnings than a low blood pressure.
Ruptured ectopic pregnancy is a leading cause of pregnancy-related death in the first trimester. Early diagnosis allows treatment before rupture, often with medicine instead of surgery, and gives the best chance of keeping the tube.
How ectopic pregnancy is diagnosed and treated
| Test or treatment | What it shows or does | Nursing point |
|---|---|---|
| Serum hCG (pregnancy hormone) | Confirms pregnancy. Repeat levels 48 hours apart show whether the pregnancy is growing normally; a slow rise, a plateau, or a fall raises concern | Draw at the times ordered; the trend matters more than one result |
| Transvaginal ultrasound | Shows whether the pregnancy is inside the uterus, an adnexal mass, and any free fluid (blood) in the pelvis | Explain the procedure; the provider interprets the scan together with the hCG level |
| CBC, blood type and Rh, type and screen or crossmatch | Baseline hemoglobin and hematocrit, readiness for transfusion, and Rh status | An Rh-negative client may need Rh(D) immune globulin per current guidelines and the provider’s order |
| Methotrexate | Stops the pregnancy cells from dividing so the body absorbs the tissue. Used for stable clients with an unruptured ectopic who can return for follow-up | The provider sets the dose; baseline kidney and liver function and CBC are checked first. Follow-up hCG levels are essential |
| Laparoscopic surgery | Salpingostomy (removing the pregnancy and keeping the tube) or salpingectomy (removing the tube) | Standard pre-op and post-op care; emergency surgery if she is unstable or the tube has ruptured |
Nursing assessment
Subjective data
- Date of last menstrual period and whether she knows she is pregnant
- Pain: location (often one side of the lower abdomen or pelvis), onset, severity, and any spread to the shoulder
- Vaginal spotting or bleeding: amount, color, and how many pads in what time
- Dizziness, lightheadedness, or fainting, especially when standing
- Rectal pressure or an urge to have a bowel movement (blood pooling behind the uterus)
- History of ectopic pregnancy, pelvic infection, tubal surgery or sterilization, IUD use, fertility treatment, and smoking
- Her feelings about the pregnancy, her support at home, and her understanding of what is happening
Objective data
- Heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature, trended over time and compared with her baseline
- Skin color, temperature, and capillary refill; restlessness or confusion
- Abdominal tenderness, guarding, rebound tenderness, or a rigid, distended abdomen
- Amount of vaginal bleeding (weigh or count pads if ordered)
- Urine output
- Serum hCG trend, hemoglobin and hematocrit, blood type and Rh status
- Ultrasound findings: no pregnancy in the uterus, an adnexal mass, or free fluid
Nursing diagnoses used with ectopic pregnancy
- Risk for Shock — possible bleeding into the abdomen from a leaking or ruptured tube
- Risk for Bleeding — a tubal pregnancy that is eroding blood vessels, and surgery
- Acute Pain — stretching of the tube and irritation of the peritoneum by blood
- Anxiety — sudden emergency, unfamiliar procedures, and worry about future fertility
- Grieving — loss of a pregnancy that may have been wanted
- Risk for Infection — surgical incisions and invasive procedures
Worked care plans
Four plans in the same ADPIE shape. The scenario is a 29-year-old woman, pregnant once before with one living child, who comes to the emergency department with sudden right-sided lower abdominal pain. Her last period was 7 weeks ago and she has had light spotting for two days. She was treated for chlamydia three years ago. Her hCG is positive, and the transvaginal ultrasound shows no pregnancy in the uterus, a right adnexal mass, and a small amount of free fluid in the pelvis. Heart rate is 104, blood pressure 108/68 (her clinic records show about 118/76), and hemoglobin 11.2 g/dL. The provider plans laparoscopic surgery today.
1. Risk for Shock
Risk diagnosis- Possible bleeding into the pelvis (free fluid on ultrasound) from a tubal pregnancy
- Risk of sudden tubal rupture before surgery
- Waiting time before surgery while tests and consent are completed
- Planned surgery with further blood loss possible
No “as evidenced by” — she is not in shock. She is alert, her blood pressure is close to her normal, her skin is warm, and she is making urine.
Risk for Shock related to possible intra-abdominal bleeding from a tubal ectopic pregnancy.
- Any sign of worsening bleeding or rupture is found and reported at once
- Heart rate and blood pressure stay within the limits the provider sets
- Client stays alert, with warm skin and adequate urine output, through surgery and recovery
- Check heart rate, blood pressure, respiratory rate, oxygen saturation, and level of consciousness at the frequency ordered, and compare each set with her baseline
- Report a rising heart rate, a falling blood pressure, new dizziness, pallor, restlessness, or new shoulder pain immediately
- Make sure large-bore IV access is in place and give IV fluids as ordered
- Send CBC, blood type and Rh, and type and screen or crossmatch as ordered; know where blood products will come from if needed
- Keep her NPO as ordered and on bed rest; help her up slowly and stay with her if she must stand
- Watch the abdomen for increasing tenderness, guarding, or distension, and count or weigh pads as ordered
- If she becomes hypotensive, keep her flat, call the rapid response team, and prepare for emergency surgery
- Complete the pre-op checklist and consent process quickly so surgery is not delayed
Vital signs stayed stable until surgery 3 hours later. She had a laparoscopic right salpingectomy for an unruptured tubal pregnancy. After surgery her heart rate was 84 and blood pressure 116/72, she was alert, and her urine output was adequate. Goal met; continue post-op monitoring.
2. Acute Pain
Problem-focusedSubjective: “It’s a sharp, stabbing pain on my right side. It started this morning and it’s getting worse.” Rates pain 7 out of 10.
Objective: Lying on her side with knees drawn up. Grimaces and guards the right lower abdomen when touched. Heart rate 104. No shoulder pain at this time.
Acute Pain related to stretching of the fallopian tube and peritoneal irritation, as evidenced by pain rated 7 out of 10, guarding of the right lower abdomen, grimacing, and a protective position.
- Client reports pain at or below her stated comfort goal within the time expected for the treatment given
- Any change in the pain pattern that suggests rupture is reported at once
- After surgery, client can turn, breathe deeply, and walk with pain controlled
- Assess pain location, character, severity, and spread at the frequency your facility requires and after each intervention
- Report pain that suddenly worsens, becomes generalized, or spreads to the shoulder; this can mean rupture
- Give analgesics as ordered, and check vital signs before and after opioid doses
- Help her into a position of comfort and keep the room calm and quiet
- After surgery, explain that shoulder pain from the gas used in laparoscopy is common and usually eases in a day or two, and encourage early walking
- Teach splinting of the incisions with a pillow when coughing or moving
Before surgery, pain fell to 4 out of 10 after analgesia with no change in its location. After surgery she rated incision and shoulder pain 3 out of 10, walked in the hallway that evening, and used a pillow to splint when coughing. Goal met; continue plan.
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3. Anxiety
Problem-focusedSubjective: “Is the baby going to be okay? Am I going to be able to get pregnant again?” Says she has never had surgery and is scared of being put to sleep.
Objective: Tearful, restless, and asks the same questions several times. Hands trembling. Partner is on the way from work.
Anxiety related to sudden emergency surgery and uncertainty about future fertility, as evidenced by restlessness, trembling, tearfulness, and repeated questions.
- Client states she understands what will happen before, during, and after surgery
- Client reports feeling calmer and shows fewer signs of anxiety before going to surgery
- Client has a support person with her as soon as possible
- Stay with her, speak calmly, and use short, simple explanations
- Explain each test and step before it happens, and why it is being done
- Answer honestly that the pregnancy cannot continue, in words she can understand, after the provider has explained the diagnosis
- Arrange for the provider or anesthesia team to answer her questions about surgery and fertility
- Help her contact her partner and allow the partner to stay with her as policy allows
- Teach slow breathing and offer comfort measures while she waits
After the provider explained the plan, she could describe the surgery in her own words. Her partner arrived before she went to surgery, and she was calmer and no longer trembling. She still worried about fertility. Goal partially met; continue plan.
4. Grieving
Problem-focusedSubjective: On post-op day 1: “We were so excited. I already told my daughter she was going to be a big sister.” Says she keeps wondering if she did something to cause it.
Objective: Crying at times, quiet, and not eating much. Partner at the bedside. Asks whether this will happen again.
Grieving related to loss of a wanted pregnancy, as evidenced by crying, expressions of sadness, self-blame, and decreased appetite.
- Client and partner express their feelings about the loss
- Client states that the ectopic pregnancy was not caused by anything she did
- Client knows where to find support after discharge
- Acknowledge the loss as a pregnancy loss, and use the words she uses to describe it
- Allow time to talk and to cry; sit with her rather than rushing through care
- Explain that ectopic pregnancy is not caused by anything she did, and that the pregnancy could not have survived
- Include the partner, who may also be grieving, and offer chaplain or social work support
- Give information about pregnancy loss support groups and counseling
- Arrange for the provider to discuss future pregnancy, the remaining tube, and the need for early care next time
- Watch for signs of depression after discharge and teach her when to seek help
She and her partner talked about the loss with the nurse and chaplain. She said, “I know now it wasn’t something I did.” She left with a list of local and online support groups and a follow-up visit booked. Goal met for this stay; grieving continues after discharge.
Interventions and rationales
Client and family teaching
- Ectopic pregnancy is not caused by anything you did, such as exercise, sex, or stress
- After methotrexate, keep every follow-up blood test until the hCG level is back to non-pregnant levels; this can take several weeks
- After methotrexate, avoid alcohol, folic acid supplements (including prenatal vitamins), and NSAIDs such as ibuprofen unless your provider says otherwise, and limit sun exposure
- Mild cramping a few days after methotrexate is common, but go to the emergency department for severe abdominal pain, shoulder pain, dizziness, fainting, or heavy bleeding
- Avoid sex and strenuous exercise until your provider says it is safe
- Ask your provider how long to wait before trying to conceive again; the advice is different after methotrexate than after surgery
- After surgery, keep the incisions clean and dry and report fever, redness, drainage, or increasing pain
- Your risk of another ectopic pregnancy is higher; take a pregnancy test as soon as you think you may be pregnant and call your provider early for an ultrasound
- Use condoms or other protection against sexually transmitted infections, and stop smoking, to protect your remaining tube
- Grief after an ectopic pregnancy is normal for both partners; ask about support groups and counseling
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A client at 7 weeks of pregnancy is waiting for an ultrasound to rule out an ectopic pregnancy. Which finding should the nurse report to the provider first?
Why C. Shoulder pain with dizziness suggests blood in the abdomen irritating the diaphragm and early hypovolemia from a ruptured tube, which needs immediate action. Light spotting, morning nausea, and stable, unchanged pain are expected findings that the nurse keeps monitoring. Prep also explains why each wrong option looks reasonable.
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Frequently asked questions
What is the nursing diagnosis for ectopic pregnancy?
Ectopic pregnancy is a medical diagnosis, so it goes in the “related to” or risk factor part. Common nursing diagnoses are Risk for Shock, Risk for Bleeding, Acute Pain, Anxiety, Grieving, and Risk for Infection.
What is the nursing priority for a client with a suspected ectopic pregnancy?
Circulation comes first: watch for signs of rupture and internal bleeding, such as a rising heart rate, dizziness, shoulder pain, or worsening abdominal pain, and make sure IV access and blood work are ready. Emotional support follows once she is stable.
What are the signs of a ruptured ectopic pregnancy?
Sudden, severe abdominal or pelvic pain, shoulder-tip pain, dizziness or fainting, a fast heart rate, low blood pressure, pallor, cool clammy skin, and a rigid or distended abdomen. Vaginal bleeding may be light even when internal bleeding is heavy.
Why can’t a client take folic acid after methotrexate?
Methotrexate works by blocking folic acid, which dividing cells need. Taking folic acid supplements can make the treatment less effective, so prenatal vitamins are usually held until the provider says to restart them.
Can a client get pregnant after an ectopic pregnancy?
Yes. Many clients go on to have a healthy pregnancy, even with one tube. The risk of another ectopic pregnancy is higher, so the client should contact her provider as soon as she has a positive pregnancy test.
Can an ectopic pregnancy be moved into the uterus?
No. There is no procedure that can move an ectopic pregnancy into the uterus. Treatment is watchful waiting in selected cases, methotrexate, or surgery.
References
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). NANDA International Nursing Diagnoses: Definitions and Classification, 2024–2026. Thieme.
- American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 193: Tubal ectopic pregnancy. Obstetrics & Gynecology, 2018;131(3):e91–e103.
- National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management (NG126). NICE, 2019, updated 2023.
- Mullany, K., Minneci, M., Monjazeb, R., & Coiado, O. C. Overview of ectopic pregnancy diagnosis, management, and innovation. Women’s Health, 2023;19:17455057231160349.
- Sivalingam, V. N., Duncan, W. C., Kirk, E., Shephard, L. A., & Horne, A. W. Diagnosis and management of ectopic pregnancy. Journal of Family Planning and Reproductive Health Care, 2011;37(4):231–240.
- Silvestri, L. A. Saunders Comprehensive Review for the NCLEX-RN Examination. Elsevier, 2023.
Vital sign frequency and escalation triggers, IV access and fluid orders, transfusion thresholds, Rh(D) immune globulin use, methotrexate eligibility, dosing, and follow-up schedules, activity limits, and how long to wait before the next pregnancy vary by client, by provider, and by facility. Follow the provider’s written orders and your own institution’s policies. This page supports study and does not replace course instruction or clinical judgment.
