ECTOPIC PREGNANCY

What is Ectopic pregnancy? Ectopic means out of place. In an ectopic pregnancy, a fertilized egg has implanted outside the uterus. The egg 2 settles in the fallopian tubes in more than 95% of ectopic pregnancies. This is why ectopic pregnancies are commonly calledtubal pregnancies.

Causes: An ectopic pregnancy is usually caused by a condition that blocks or slows the movement of a fertilized egg through the fallopian tube to the uterus. This may be caused by a physical blockage in the tube.

Most cases are a result of scarring caused by: Past ectopic pregnancy Past infection in the fallopian tubes Surgery of the fallopian tubes

Signs and Symptoms: abdominal and pelvic pain vaginal spotting or light bleeding

Anatomy and Physiology

Vagina The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal.

Uterus (womb) is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit.

Ovaries The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones.

Fallopian tubes These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants into the lining of the uterine wall.

Broad Ligaments Two wing-like structures that extend from the lateral margins of the uterus to the pelvic walls and divide the pelvic cavity into an anterior and a posterior compartment.

Fimbriae Fringes; especially the finger-like ends of the fallopian tube.

Endometrium - is the mucosal layer lining the cavity of the uterus.

Myometrium is the middle layer of the uterine wall consisting of smooth muscle cells and supporting stromal and vascular tissue.

Perimetrium is the outer serosa layer of the uterus, equivalent to peritoneum.

Mesovarium is the portion of the broad ligament of the uterus that covers the ovaries.

Round Ligament of the uterus originates at the uterine horns, in the parametrium. It leaves the pelvis via the deep inguinal ring, passes through the inguinal canal and continues on to the labia majora where its fibers spread and mix with the tissue of the mons pubis.

Uterine Cavity The Cavity of the Body in the uterus is a mere slit, flattened antero-posteriorly.

Ovarian Ligament (also called the utero-ovarian ligament or proper ovarian ligament) - is a fibrous ligament that connects the ovary to the lateral surface of the uterus.

Infundibulum (Latin for funnel; plural, infundibula) - is a funnel-shape cavity or organ.

Fundus of the Uterus is the top portion, opposite from the cervix. Fundal height, measured from the top of the pubic bone, is routinely measured in pregnancy to determine growth rates.

Uterine Artery - is an artery in females that supplies blood to the uterus.

Labia majora The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting glands. After puberty, the labia majora are covered with hair.

Labia minora Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body).

Bartholin's glands These glands are located beside the vaginal opening and produce a fluid (mucus) secretion.

Clitoris The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect.

PATHOPHYSIOLOGY

Predisposing factors: Age lifestyle

Precipitating Factor: History o pelvic inflammatory disease Uterine curettage Dysfunction of the cilia w/c Previous tubal surgery Endometriosis normally propels the fertilized ovum through the tube into the uterine cavity.

Disruption of the scarring of the fallopian tube

Blocks or slows the movement of a fertilized egg though the fallopian tube to the uterus.

Fertilized ovum implants outside the uterus.

Painless bleeding

Tubal ectopic pregnancy

Blastocyst burrows into the epithelium of the tubal wall (usually in the distal / ampullary two or thirds of the fallopian tube. 1. Decrease resistance of the invading trophobalstic tissue by the fallopian tube. 2. Decreased muscle mass lining of the fallopian tube. 3. Decreased HCG.

Tapping of blood vessels in the tube.

Before Rupture 1. Abdominal pain 2. Abdominal vaginal bleeding. 3. Abdominal tenderness.

Embryonic death

Abortion, spontaneous regression or rupture (depends on gestational age and location of implantation

During Rupture: Exacerbation of pain.

After Rupture: Faintness/dizziness Abdominal pain Sign of shock

Maternal hemorrhage

Excessive bleeding occurs.

Maternal Death

VITAL SIGNS

Vital signs upon admission Temp = Pulse = 91 bpm RR = 20 bpm BP = 130/100

December 14-15,2009Time 11:00p m 11:15 11:30 11:45 12:00m n 12:15 12:30 BP 120/70 120/70 120/70 110/80 110/70 110/80 110/70 PR 85 83 88 80 78 75 76 RR 23 20 21 22 20 23 18 Temp.

36.8

12:45a 120/80 m 1:00am 110/80 1:30am 110/70 2:00am 110/70 2:30am 110/70 3:00am 120/80 4:00am 110/80 5:00am 120/70 6:00am 120/70 7:00am 120/80

81 80 83 79 81 78 80 83 80 85

20 23 24 21 23 20 22 21 20 19 36.5

Dec. 15, 2009Time 8am 9am 10am 11am 12nn 1pm 2pm 3pm BP 120/60 120/70 120/70 120/70 120/70 120/70 120/70 110/70 PR 84 82 80 81 82 84 82 RR 22 20 21 20 20 22 21 Temp. 36.8 37 37 36.7 37 37.1 37 -

4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12mn

110/70 80 110/70 -

20 -20 19

37.1 37 37 37.5

110/70 110/70 80 110/70 110/80 110/80 120/70 78

Dec. 16,2009time 1am 2am 3am 4am 5am 6am 7am 8am BP 110/80 110/80 Asleep Asleep Asleep 110/80 110/80 PR 80 RR 19 Temp 37.5 -

HEALTH ASSESSMENT

OPERATIVE RECORD Address:

Tiguma, Pagadian City

Surgeon: Dra.Rexie Ramirez Anesthesiologist: Dr.Jeke Rocabo Sterile Nurse: Whela Sabuero RN Assistant: Dane Sandalo RN Anesthesia used: SAB ( Sensorcaine + Morpeine ) Time of induction: 9:41pm Time of Operation started: 9:47pm Time of operation ended: 10:45pm Operation: Pelvic lap, salphingectomy Pre-operative Diagnosis: Ruptured ectopic pregnancy Admitting Diagnose: Ectopic Pregnancy Chief Complaint: Abdominal pain Reason for admission: For treatment Brief History of present illness: Sudden onset of colicly abdominalpain three days pta associated of vaginal bleeding. G2P1 A0.

Activity Of Daily Living

Mrs. X woke up early in the morning at 4:00am, then she prepare her self and the things needed that are useful in her store. At 5:00am she goes in her store located at the Agora and arrange all the things that needs to be arranged and ready for selling. She manage her store and her co workers as well, someone will brings lunch for her and to her co workers. At 12:30 they ate their lunch. Around 4:00pm she goes around the market and buy something for their dinner at 5:00pm she prepare in leaving her store and let her co-workers take good care of it, because she will go home, she prepare their dinner, and mostly they sleep at around 9:00pm.

Laboratory Results

Result WBC 11.2

Unit 10 3/mm3

Nomal 5.0 /10.0

Significanc e Increased levels are associated with infection, inflammatio n, autoimmune disorders & leukemia.

RBC

4.30

10 6/mm3

4.00 /6.00

normal

HGB

13.0

a/dl

12.0 /17.0

normal

HCT

37.0

%

37.0 /50.0

normal

MCV

86

um3

80 /100

normal

MCH

30.3

Pa

26.0 / 34.0 31.0/ 35.0 10.0 / 20.0 150 /450

normal

MCHC

34.9

a/dl

normal

RDW

12.5

%

normal

PLT

309

10 3/mm3

normal

MPV

7.2

um3

6.0 /10.0

normal

PCT

0.221

%

0.200 / 0.500

normal

PDW

10.3

%

8.0 /18.0

normal

LYM %

17.6

1.96

25.0 / 50.0 1.00/5.00 0.0/5.0 0.00/0.40 0.0/2.0 0.00/0.20 0.0/2.0 0.00/0.20 0.0/2.0 0.00/0.20

normal

EOS %

0.9

0.10

normal

BAS %

1.7

0.03

normal

ALY %

1.5

0.05

normal

HC %

1.1

0.13

normal

Ultrasound

ULTRASOUND No.:20091214 Date: Dec. 14,2009 Examination TVS TRANSVAGINAL ULTRASOUND The anteverted uterus is normal in size andectotexture. The uterus measure 5.9 x 5.1 x 4.8 cm. There is a heterogeneous solid focus at the left fundal aspect of the uterus meaning 3.88 x 3.7 x 2.71 cm. The endometrium is thin. The cervix is normal in size with closed cervical OS. The right ovary was not identified, instead, a complex mass is noted in the right lateral aspect of the uterus measuring 4.30 x 3.17 x 2.33 cm. There is what appears to be a small gestational sac in the posterior aspect of this complex mass. The left ovary measures 3.02 x 1.74 cm. There no fluid in the posterior cul-de-sac. IMPRESSION: Consider ectopic pregnancy please correlate clinically andwith pregnancy test (+) MYOMA UTERI Sonographically normal left ovary

Intravenous Fluid

DATE

SHIFT

NO. OF BOTTLE

NAME

TIME STARTED

Decembe 7amr 14, 7pm 2009 Decembe 7amr 15, 7pm 2009 Decembe 7amr 15, 7pm 2009 Decembe 7amr 16, 7pm 2009

1

D5LR 1L @ 30 gtts/min D5LR 1L @ 30 gtts/min D5LR 1L @ 30 gtts/min D5LR 1L @ 30 gtts/min

8pm

2

1am

3

2pm

4

1am

INPUT and OUTPUTDEC 14,2010 12-PS=8 1AMP.Tramadol IV given Dec 15,09 Oral IVF IV Meds TOTAL URINE

NPO NPO NPO NPO

130cc 140cc 140cc 100cc

10cc

140cc 140cc 140cc 100cc

50cc 80cc 30cc 40cc

NPO 60cc

130cc 1cc 130cc 10cc 100cc

131cc 100cc 140cc 100cc 140cc

120cc 100cc 120cc 10cc 240cc 100cc 120cc 140cc 1cc 140cc TOTAL 540cc 1470c 22cc c

220cc 130cc 490cc 340cc 261cc 140cc 2032c 790cc c

Drug Study

Medication Generic name: Ketorolac tromethamine Brand name: Foradol Generic name: Mefenamic acid Brand name: Dolfenal Generic name: Metoclopramide Brand name: Clopra

Classification Analgesic; Antipyretic

Indication -Short term management of pain.

Non-steroidal anti inflammatory drugs

Antiemetic

-Short term relief of mild to moderate pain including primary dysmenorrheal. -Relieves nausea and vomiting caused by chemotherapy and drug related postoperative factors.

Generic name: Celecoxib Brand name: Clebrex Generic name: Tramadol hydrochloride Brand name: Ultram Generic name: Promethazine hydrochloride Brand name: Phenadoz, phenergan

Analgesic

-Management of acute pain

Analgesic, centrally acting

-Relief moderate severe pain.

Phenothiazine Dopaminergic blocker Antihistamine Antiemetic Anti-motion-sickness drug Sedative or hyphotic

-Treatment and prevention of motion sickness;prevention and control of nausea and vomiting associated with anesthesia and surgery Preoperative, postoperative, or obstetric sedation. Adjunct to analgesic to control postoperative.

generic name: cefuroxime brand name: zinnat antibiotic

antibiotic

As for the other cephalosporins, although as a second-generation it is less susceptible to Beta-lactamase and so may have greater activity against Haemophilus influenzae, Neisseria gonorrhoeae and Lyme disease. Relieve constipation and prepare the bowel for diagnostic or surgical procedures requiring the bowel to be empty.

generic name:bisacodyl brand name: dulcolax

laxatives

generic name:zantac Brand name: Ranitidine

Antagonist

Duodenal and gastric ulcer (short term treatment; hypersecretory conditions such as ZollingerEllison syndrome. pain reliever

generic name: Non-opioid paracetamol analgesic brand name: biogesic

generic name: nalbuphine brand name: Nubain generic name: cataflam brand name: dicloenac

Opioid agonist- relief of antagonist moderate to analgesic severe pain

Antiinflammatory

Used commonly to treat mild to moderate postoperative or posttraumatic pain, particularly when inflammation is also present, and is effective against menstrual pain and endometriosis

generic name: termin-C brand name: terramedic

Vitamins &/or Minerals

generic name: aplosyn brand name: zuellig

Topical Corticosteroids

Prevention & treatment of vit & mineral deficiency. As an adjuvant in the therapy of infections, in pre- & post-op conditions, pregnancy, lactation, degenerative & cardiac diseases. Local inflammation, pruritic & allergic conditions of the skin & mucosa.

PHYSICIANS ORDER SHEET

Time/Date Dec.14,09 8:00am

Order Please admit under Dra. Ramirez TPR q4h npo CBC blood typing Hooked with D5LR 1L 30gtts/min A-prep Secure consent For pelvic lap ectopic Pre of meds Ramirez Inform OR personnel Ranitidine 1amp. IVTT Metoclopamide 1amp.IVTT Ceferoxine 750mg IVTT q8h anst Inform Dra. Sicad

8:15pm

PRE-OP Promethazine 25g IM Nalbuphine 5mg IM Preload plain LR POST ORDER To her room Flat on bed 4am turn side to side q2h NPO Monitor v/s q15 mins. For the first 2hours Next 30mins,the next 4hours qh O2 inhalation 3L/mins until alert and stable (1-2 hrs) IVF to follow D5LR 1L @30-35GTTS/MIN D5LR 1L @30-35GTTS/MIN D5LR 1L @ 30-35GTTS/MIN

Physicians Order SheetTIME/DATE Dec.15,2009 11:35 am 12:15 am ORDERS -Site up on bed advice deep breathing exercise clean liquids -may give open liquid with crackers this afternoon continue IVTT continue IV medications -soft diet morning dolculax 1 cap. Rectum in morning ranitidine to consume continue IV medication cap. 2X a day binder to start in the morning

5:30 pm

Physicians Order SheetTime/Date Dec. 16,2009 10:25 am Orders DAT this afternoon terminate IV when consume IV meds. Continue Zinnat 500mg 1 cap. 3X a day MGH anytime for patient request continue home meds.

5:15 pm

NURSING CARE PLAN

Subjective: sakit akong tahi sa tiyan as verbalized by patient. Objective: Facial mask of pain. Guarding behavior. Narrowed focus. Pain scale-6 V/S taken as follows: T: 37.3 P: 80 R: 18 Bp: 110/90

Acute pain related to disruption of skin, tissue, and muscle integrity

Short term:1. Follow prescribed pharmacological regimen. 2.Verbalize Nonpharmacolog i cal methods that provide relief. 3.Demonstrate use of relaxation skills and diversional activities, as indicated, for individual situation.

Independent: Evaluate pain regularly noting characteristics, location, intensity (0-10 scale). Identify specific activity limitations. Recommend planned or progressive exercise.

Provides information about need for Or effectiveness of interventions.

Long term:At the end of 1 week nsg. Intervention, the patient pain will be relieved or Controlled with a pain scale of 0 from 6.

Prevents undue strain on operative site. Promotes return of normal function and enhances feelings of general well being.

at the end of 1 week nursing intervention s, the patient pain was relieved or controlled with the pain scale of 0 from 6.

periods. Review importance of nutritious diets and adequate fluid intake. Reposition as indicated. Provide additional comfortmeasures like back rub. Encourage use of Relaxation technique like deep breathing exercises. Collaborative: Administer analgesics or non steroidal antiinflammatory drugs as prescribed.

Conserves energy for healing. Provides elements necessary for tissue regeneration or healing. . May relieve pain and Enhance circulation. Improves circulation, reduces muscle tension and anxiety associated with pain. Relieves muscle and emotional tension.

To relieve mild or moderate pain.

Cues Subjective:Na guol gyud ko ug nasayangan kay namatayan napod ko ug anak as verbalizedby patient.Objecti ve:Facial expression of feeling sadBlaming herself of not knowing that shes pregnant V/S taken asfollows:T: 36.9P: 80R: 20Bp: 110/80

Nursing Dx Grieving r/t anticipatory loss/death of a significant others

Nursing objectives Short term: After 8 hours of nursing interventions , the patient will be able to: Identify and express feelings effectively. Acknowledge impact/effect of the grieving process and seek appropriate help. Participate in work and selfcare/ ADLs as able.

Nursing intervention Independent: provide open environment and trusting relationship. be honest when answering questions, providing information. identify problems with eating, activity level, sexual desire, role performance. .

rationale

evaluation Goal is met because the patient had accepted that the fetus baby was lost/ death

promotes afree discussion of feeling and concerns. enhances sense of trust and nurseclient relationship

indicators of severity of feelings client is experiencing and need for specific interventions to address these tissues.

Long term: After nsg. Interventions, patient will be able to long toward a plan for future one day at a time.

Collaborative: refer to additional resources, such as pastoral care, counseling/ps ychotherapy, community organized support groups, as indicated for both client and family/SO.

to meet on going needs and facilitate grief work.

Discharge Plan

MEDICATION nstruct pt to take medication within prescribed ime and dosage religiously to maintain health improvement. Home meds: . zinnat 500mg 3x a day . termin C 1 capsule once a day . cataflam 3x a day . aplosyn apply 3x a day EXERCISE ncourage pt to exercise as tolerated. Educate pt n the benefits f exercise towards health particularly to improvement of tolerance activities.

DIET A high-protein, high-calorie diet is recommended for the patient as well as iron-rich foods. Patient should also avoid foods that are high in sodium. HEALTH TEACHING Educate the pt on the nature of Ectopic pregnancy.

SCHEDULE OF NEXT VISIT Instruct pt to return 1 week after discharge for follow up check-up. Emphasize importance of follow up check ups. SPIRITUAL Encourage pt to continue trusting God, to pray. Explain to pt that everything happens for a reason and theyre still alternatives to having children.

LIFESTYLE Encourage pt to take adequate rest and take proper meals. Socializing with people and having a healthy relationship with friend may help divert patients attention from his vices, and restore her love for life. Reuniting with her family may also help her psychological condition. REFERRAL Refer to a female reproductive specialist such as obstetrician or gynecologist for further consultation or go to a nearest health center or

EVALUATION

EVALUATIONPatient x was our patient, accompanied by her husband; she was last December 14, 2009 at 8:00 m at PCMC Hospital with the admitting diagnosis of ectopic pregnancy. Her chief complaint is abdominal pain. During the interview, the patient was cooperative and responsive. The frequent interaction in the patient and SO have greatly helped the feeling and relaxed. The patient was confined in the hospital for three days. After series of medical treatment and nursing interventions, patient condition improved and successfully treats. The patient was discharged last December 16, 2009 at 5:15 pm with home medication to continue.

SPECIAL THANKS TO:Ms. Mr. Ms. Ms. Ms. Rexie Ramirez Jeekee Rocabo Whela Sabuero Dane Sandalo Grace Sicad