NURSING MANAGEMENT OF THE PATIENT WITH AN ECTOPIC PREGNANCY
By T. Norris: RN, RM, RPN, RCHN, Assessor.
This article reviews the care of a patient who presents with an ectopic pregnancy and the nursing management that is necessary to attend to her. Ectopic pregnancies are obstetric and surgical emergencies and can cause death if the patient is not adequately treated. By applying general basic nursing principles, nurses can recognize this emergency and be prepared for it.
Ectopic pregnancies are on the increase primarily because of the rise in pelvic inflammatory disease. It leads to pregnancy related death in the first trimester of pregnancy and can lead to infertility.
An ectopic pregnancy occurs when the fertilized ovum fails to reach the uterus and becomes implanted elsewhere. It is also known as an extra uterine pregnancy (1).
This means that the fertilized ovum can be implanted in the uterine tubes, the ovary, the abdomen or the cervix (2).
Any factor that slows the passage of the ovum along the tube to the uterus can result in an ectopic pregnancy (3).
The ovum only implants when the zona pellucida [the thick transparent membrane surrounding the ovum (1)] is shed partially or completely. If the ovum dies, it is either reabsorbed, forms a tubal mole, or is aborted into the abdominal cavity. If the ovum survives, the trophoblast [a layer of ectodermal tissue that serves to attach the ovum to the wall of the uterus and supply nourishment to the embryo (1)] enlarges and erodes into the tissues of the uterine tube. The endometrium thickens, the uterus enlarges, the muscles of the tubes thicken and the ovarian and uterine arteries become tortuous (3).
The tube stretches as the ovum develops and enlarges and as a result there are repeated bleeding episodes. Eventually the uterine tube can stretch no further and the tube ruptures (3).
Sites of implantation include the fimbriate (3) or infundibular (2) ends of the uterine tube (3), the ampulla or widened area of the tube (1) (3), the isthmus of the uterine tubes (3), the interstitial portion of the uterine tubes (3), the ovary (3), the abdominal cavity (3) and the cervix which is rare (2).
Figure 1 Sites of ectopic pregnancy (7).
Causes of Ectopic Pregnancy
Pelvic inflammatory disease due to multiple infections appears to be a major factor for ectopic pregnancy (2). Other causes include congenital narrowed uterine tubes (3), salphingitis or inflammation of the uterine tubes (acute or chronic), endometriosis or the presence of functioning endometrium in abnormal places within and without the uterus (1, 3), tuberculosis (3), tubal surgery (3), tumors that distort the tube (2), use of intra-uterine devices (2), and multiple previous induced abortions (2).
Improved antibiotic therapy may prevent tubal closure, but may leave a stricture or narrowing of the tube (2). Progesterone-only contraceptives may also be a causative factor in ectopic pregnancy (2, 3).
The history of the patient is important. The woman may initially have a history of amenorrhoea followed by slight bleeding or ‘spotting’ (2). This is often construed as an abnormal period (2). A slight brownish, continuous discharge may be present (3). There is pain on the affected side due to tubal distention (2). This is usually sharp and colicky (2) and can sometimes be persistent (3). The patient may also present with nausea, vomiting, dizziness and lightheadedness, fainting (2, 3). Backache is common (3).
Once rupture occurs the signs of shock appear: Air hunger, rapid thready pulse, decreased blood pressure, subnormal temperature, pallour, restlessness, sweating, extreme pain radiating to the shoulder and neck due to accumulated intraperitioneal blood that irritates the diaphragm (2).
Treatment and diagnostic criteria
Transvaginal ultrasound appears to be very accurate to establish...
References: 1. Blackwell’s dictionary of nursing. 2003. Juta Educational Press: Cape Town. Pp. 226 - 739
3. Sellers, P. 1997. Midwifery, a textbook and reference book for Midwives in Southern Africa. Volume 2. Juta Educational Press: Cape Town. Pp 1014 - 1016.
4. Odendal, H; Schaetzing, A; Kruger, T F. 2002. Clinical gynaecology. Second edition. Juta Educational Press: Cape Town. Pp. 178 - 186.
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