Subject: Midwifery and Obstetrical Nursing. Topic: Ectopic pregnancy, Its types, various Implantation sites, Pathophysiology, Risk factors, Diagnosis, Various Managements and Recent Advancements.

1. MIDWIFERY & OBSTETRICAL NURSING
•ECTOPIC
PREGNANCY
SEMINAR BY : ALKA KUMARI
AIN/2018/495
BSC NURSING 4TH YEAR

2. INDEX
INTRODUCTION
DEFINITION
IMPLANTATION SITES
ACCORDING TO SITES OF IMPLANTATION:
ACCORDING TO CLINICAL FEATURES:
INCIDENCE & MORTALITY
RISK FACTOR
MORBID ANATOMY
TUBAL PREGNANCY
INTERSTITIAL PREGNANCY
OVARIAN PREGNANCY
ABDOMINAL PREGNANCY
CERVICAL PREGNANCY
CORNUAL PREGNANCY
CESAREAN SCAR PREGNANCY
HETEROTOPIC PREGNANCY
ACUTE (TUBAL RUPTURE OR ABORTION)
UNRUPTURED
SUBACUTE (CHRONIC OR OLD)

3. INDEX
 PATHOPHYSIOLOGY
 ETIOLOGY
 DIAGNOSIS
 MANAGEMENT:
 COMPLICATION
 INSTRUCTION TO PATIENT
 RECENT ADVANCEMENT
 SUMMARY & CONCLUSION
 BIBLIOGRAPHY
MEDICAL
SURGICAL
NURSING

4. INTRODUCTION

6. DEFINITION
“Any pregnancy where the fertilized ovum gets implanted & develops in a site other
than normal uterine cavity.”
Regarded as serious hazard to a woman’s health and reproductive potentials,
requiring prompt recognition and early aggressive intervention.
Ectopic pregnancy also known as eccyesis or tubal pregnancy, is a complication of
pregnancy in which the embryo attaches outside the uterus.
It occurs when the fertilized egg attaches itself in a place other than outside the
uterus.

7. INCIDENCE AND MORTALITY
One in 90 pregnancies is ectopic.
A combined intra-uterine and extra-uterine pregnancy is very rare and occurs in 1:40000 spontaneous
pregnancies and 1:1000 IVF (In-vitro fertilization) pregnancies.
Chances of ectopic pregnancy Increases in case of :
oPID (Pelvic Inflammatory Disease)
oIUCD (Intra-Uterine Contraceptive Devices)
oTubal surgeries, and
oAssisted Reproductive Techniques (ART)
Rate of ectopic pregnancy in India – 5.6/10000 deliveries.
In case of Late marriages and Late childbearing >2%
In case of ART >5%
Recurrence rate is 15% after 1st ectopic, 25% after 2nd ectopic.

8. RISK FACTORS OF ECTOPIC
PREGNANCY
Maternal age of 35 years or above.
History of pelvic surgery , abdominal surgery, or multiple abortions.
History of pelvic inflammatory disease.
History of endometriosis.
History of previous ectopic pregnancy.
Conception occurred despite tubal ligation or Intrauterine Device (IUD).
Smoking.
History of sexually transmitted disease (STDs) such as Gonorrhoea or Chlamydia..

9. MORBID ANATOMY
Two kind of changes are observed under morbid anatomy:
1. Changes in the Tube
2. Changes in the Uterus

10. PATHOPHYSIOLOGY
• In normal pregnancy, the egg is fertilized in the fallopian tube and the embryo is transported into the uterus.
• Any abnormality in the tubal morphology or function, it may lead to ectopic pregnancy that may be:
i. Mucosal Damage
ii. Dysfunction of Tubal Smooth Muscle
• Tubal pregnancy doesn’t develop beyond 8 weeks due to:
oPoor vascular supply
oThin wall
oNarrow Lumen
oLack of decidual reaction in the tube.
• Fertilized ovum borrows through the Epithelium.
• Zygote reaches the muscular wall.
• Trophoblastic cells at zygote periphery proliferate, invade and erode adjacent muscularis.
• Maternal blood vessels disrupted leading to hemorrhage.
oOUTCOME : Tubal abortion or rupture with hemorrhage.

11. ETIOLOGY
SALPINGITIS AND PELVIC INFLAMMATORY DISEASE (PID)
IATROGENIC: Illness caused by medical treatment or examination.
1. CONTRACEPTION FAILURES :
2. TUBAL SURGERIES
3. INTRAPELVIC ADHESIONS
4. ART
5. OTHERS :
A. IUD (INTRA-UTERINE DEVICES)
B. STERILISATION OPERATION
C. USE OF PROGESTERONE ONLY PILL
a. PREVIOUS ECTOPIC PREGNANCY
b. PRIOR INDUCED ABORTION
c. DEVELOPMENTAL DEFECTS OF THE TUBE
d. TRANSPERITONEAL MIGRATION OF THE OVUM

13. IMPLANTATION SITES
FLOWCHART: ECTOPIC PREGNANCY ACCORDING TO SITE OF IMPLANTATION
IMPLANTATION SITES
EXTRAUTERINE
TUBAL(97%)
AMPULLA(55%
)
ISTHMUS(25%)
INFUNDIBULUM(18%)
INTERSTITIAL(2%)
OVARIAN(0.5%) ABDOMINAL(1%)
PRIMARY
(RARE)
SECONDARY
INTRAPERITONEAL
(COMMON)
EXTRAPERITONEAL
BROAD LIGAMENT
(RARE)
UTERINE
CERVICAL(<1%)
ANGULAR
CORNUAL
CESAREAN

15. ECTOPICPREGNANCYACCORDINGTO
SITESOFIMPLANTATION:
ACCORDING TO SITES OF IMPLANTATION, THERE ARE 8
TYPES OF ECTOPIC PREGNANCIES:
1. TUBAL PREGNANCY
2. INTERSTITIAL PREGNANCY
3. OVARIAN PREGNANCY
4. ABDOMINAL PREGNANCY
5. CERVICAL PREGNANCY
6. CORNUAL PREGNANCY
7. CESAREAN PREGNANCY
8. HETEROTOPIC PREGNANCY

16. 1.
TUBAL
PREGNANCY
Commonest site of ectopic pregnancy (99%)
The ampulla is the most frequent location of implantation (64%).
SYMPTOMS :
o Onset occurs 7 weeks after LMP
o Abdominal Pain
oVaginal bleeding
SIGNS:
oAbdominal tenderness
o1st trimester bleeding (79%)
COMMON Associated FINDINGS :
o Amenorrhea
o Early pregnancy symptoms
o Cullen’s sign (Periumbilical bruising)
o Nausea, Vomiting
oDiarrhoea, Dizziness

17. 1. TUBAL PREGNANCY
MODE OF TERMINATION :
1. TUBAL MOLE AND PELVIC HEMATOMA : Gestation sac is retained in tube and surrounded by a blood clot.
2. TUBAL ABORTION : Occurs more if ovum have been implanted in the ampullary portion of the tube.
3. TUBAL RUPTURE : More common if implantation occurs in the narrower portion of the tube i.e., ISTHMUS.

18. 2. INTERSTITIAL PREGNANCY
It’s the rarest variety of tubal pregnancy.
 It’s associated with massive intraperitoneal hemorrhage due
to its combined vascularization by the uterine and ovarian
arteries.
 The diagnosis before rupture is very difficult.
MANAGEMENT:
a. EXPECTANT MANAGEMENT : Serum BHCG level : low or
falling.
b. MEDICAL MANAGEMENT : Patient hemodynamically stable,
methotrexate is used either systematic or local.
c. SURGICAL MANAGEMENT : Cornual resection (laparoscopy is
preferred over hysteroscopic resection). Hysterectomy is
commonly done.

19. HYSTERECTOMY

20. 3.
OVARIAN
PREGNANCY
Spiegelberg criteria for diagnosis of ovarian pregnancy:
o The gestational sac is in the region of the ovary.
o The ectopic pregnancy is attached to the uterus by the ovarian ligament.
o Ovarian tissue in the wall of the gestational sac is proved histologically.
o The tube on the affected side is intact.
TREATMENT:
o Laparotomy and inoculation of the ectopic pregnancy and reconstruction of the
ovary.
SURGICAL:
a. Laparoscopic Method
b. Oophorectomy (removal of one or both ovaries) is done when there’s –
(1) excessive bleeding; (2) Coexisting Ovarian pathology
MEDICAL:
o Systematic methotrexate can be used when –
i. Risk of surgery is high.
ii. Postoperatively, when there is persistent GTN (Gestational Trophoblastic
Neoplasia)
o In advanced pregnancy, rupture is an inevitable phenomenon and Salpingo-
oophorectomy is the definite surgery.

21. 4.
ABDOMINAL
PREGNANCY
Abdominal pregnancy is of two types:
oPRIMARY : Implantation occurs in the peritoneal cavity from the start.
oSECONDARY : Usually after tubal rupture or abortion. Intraligamentous
pregnancy is a type of abdominal pregnancy but it’s extraperitoneal
pregnancy. It develops between the anterior and posterior leaves of the
broad ligament after rupture of tubal pregnancy in the mesosalpingeal
border on the lateral rupture of intramural (in the myometrium) pregnancy.
SYMPTOMS :
o Disturbed tubal pregnancy during early months.
o Vaginal bleeding and lower abdominal pain present.
o Minor ailments of normal uterine pregnancy are often exaggerated such as
nausea, vomiting, constipation, pain abdomen and increased fetal
movement.
SIGNS :
o Braxton-Hicks contraction is absent in Abdominal Pregnancy.
o Fetal parts are felt easily and persistent abnormal attitude and position of
the foetus on repeated examination is quite common.

22. 4. ABDOMINAL PREGNANCY
DIAGNOSTIC CRITERIA :
oMRI (Magnetic Resonance Imaging)
oUSG (Ultra Sonography is used to plan surgery)
oPlain X-ray shows abnormal lie. in lateral view, the foetus overshadows the maternal spines.
MANAGEMENT :
a. Early Pregnancy – Laparoscopic removal is done. Systematic methotrexate with USG-guided feticide may be done.
b. In Advanced Pregnancy – Urgent laparotomy irrespective of period of gestation. The risk of continuation of pregnancy are:
i. Catastrophic Hemorrhage
ii. Fetal Death
iii. Increased fetal malformation
iv. Increased neonatal loss. (50%)
TREATMENT :
The condition should be terminated surgically through laparotomy once diagnosed.

23. 5.
CERVICAL
PREGNANCY
Implantation in the substance of the cervix below the level of uterine
vessels.
In this, the bleeding is painless, and the uterine body lies above the
distended cervix.
Cause severe bleeding.
CLINICAL DIAGNOSTIC CRITERIA :
a. Soft, enlarged cervix equal to or larger than the fundus.
b. Uterine bleeding following amenorrhea without cramping pain.
- Confirmation is done by histological evidence of the presence of villi
inside the cervical stroma.
MANAGEMENT :
oMedical Management : Systematic methotrexate, local injection with KCl.
oSurgical Management : When bleeding is life-threatening.
SURGICAL PROCEDURES USED :-
oHysterectomy
oHysteroscopic resection with (UAE)

24. 6. CORNUAL PREGNANCY
Pregnancy occurring in rudimentary horn of a bicornuate uterus is
called cornual pregnancy.
Prevalence is 1 in 76,000 pregnancies.
Termination by rupture is inevitable between 12 & 20 weeks with
massive intraperitoneal hemorrhage.
 The condition is commonly diagnosed as fulleroid or ovarian tumor
with pregnancy.
Position of the round ligament which is attached to the sac and the long
pedicle by which it’s attached to the uterus are the diagnostic point.
SURGICAL MANAGEMENT :
Include removal of the rudimentary horn by laparoscopy/laparotomy.

25. 7.
CESAREAN
SCAR
PREGNANCY
Defined as implantation into the myometrial defect in the site of the
previous uterine scar (for cesarean delivery).
Overall prevalence is 1 in 2500-3000 pregnancies.
DIAGNOSTIC FEATURES :
oCesarean scar pregnancy on MRI are similar to that of USG.
oSerum beta HCG level may be useful for management formulation.
TYPES :
oTYPE 1 [ENDOGENIC] – Growing towards the uterine cavity.
oTYPE 2 [EXOGENIC] – Growing outwards. Risk of rupture & hemorrhage
is high in exogenic type.
TREATMENT :
oMEDICAL TREATMENT : Methotrexate is administered by systematic
IM(intramuscular) or local injection into the gestation sac.
oSURGICAL TREATMENT : Evacuation or excision of pregnancy by open or
laparoscopic or hysteroscopic method.

26. 8.
HETEROTOPIC
PREGNANCY
It’s defined as the presence of multiple gestations with one being
present in the uterine cavity & the other outside the uterus, commonly
in fallopian tube and uncommonly in the cervix or ovary.
When two pregnancies are present simultaneously at different
implantation sites and only one located in the uterine cavity.
It’s more common following ART procedures.
MANAGEMENT :
A. Methotrexate can be given in case where -
Intrauterine pregnancy is nonviable.
Patient doesn’t wish to continue the pregnancy.
B. Local injection of potassium chloride or hyperosmolar glucose with
aspiration of the sac contents may be done.
i. SURGERY : Removal of ectopic pregnancy, if the patient is
hemodynamically unstable following simultaneous resuscitation.
ii. EXPECTANT MANAGEMENT : When heterotopic pregnancy is
nonviable, Rhesus D (RHD) negative women with ectopic pregnancy
should be given anti-D immunoglobin.

27. ECTOPICPREGNANCYACCORDING
TOCLINICALFEATURES:
ACCORDING TO CLINICAL FEATURES, THERE ARE 3 TYPES OF
ECTOPIC PREGNANCIES:
1. ACUTE PREGNANCY (TUBAL RUPTURE OR ABORTION)
2. UNRUPTURED PREGNANCY
3. SUBACUTE PREGNANCY (CHRONIC OR OLD)

28. 1.
ACUTE
PREGNANCY(TUBAL
RUPTUREORABORTION)
Less common (about 30%) associated with cases of tubal rupture or tubal abortion with massive intraperitoneal hemorrhage.
MODE OF ONSET : Acute.
SYMPTOMS: Classic triad of symptoms of disturbed tubal pregnancy are :
 Pain
 Amenorrhea, Abdominal Pain
 Vaginal bleeding, Feeling of nausea, vomiting, fainting attack, syncope attack (10%)
DIFFERENTIAL DIAGNOSIS :
 Rupture corpus luteum of pregnancy
 Twisted ovarian cyst
 Incomplete Abortion
 Acute Appendicitis
 Perforated peptic ulcer
 Renal colic
MANAGEMENT : Principles - Resuscitation and Laparotomy/Laparoscopy.
 Antishock Treatment
 Laparotomy
 Salpingectomy

29. 2.
UNRUPTURED
TUBAL
PREGNANCY
High degree of suspicion and ectopic conscious clinician can diagnose.
The physician should include ectopic pregnancy in the differential
diagnosis when a sexually active female has abnormal bleeding and
abdominal pain.
SYMPTOMS :
Presence of delayed period.
Uneasiness on one side of the flank which’s continuous.
SIGNS :
Uterus usually soft showing signs of early pregnancy.
A pulsatile small, well-circumscribed tender mass felt through one
fornix separated from uterus.
INVESTIGATION AND DIAGNOSIS:
Transvaginal sonography
Highly sensitive radioimmunoassay of Beta –hCG and laparoscopy.

30. UNRUPTURED TUBAL PREGNANCY
MANAGEMENT:
MEDICAL MANAGEMENT : Chemotherapeutic agents used either systematic or direct locally; (under sonographic or
laparoscopic guidance).
 Drugs commonly used for salpingocentesis are:
• Methotrexate
• Potassium Chloride
• Prostaglandin (PGF2X)
• Hyperosmolar Glucose or Actinomycin
 SURGICAL MANAGEMENT : surgery either done laparoscopically or by microsurgical laparotomy.
 Linear Salpingotomy
 Segmental Resection
 Fimbrial Expression
 Salpingectomy

31. 3.
SUBACUTE
PREGNANCY
(CHRONICOROLD)
ONSET: Insidious, previous attack of old pain.
SYMPTOMS :
 Amenorrhea
 Vaginal Bleeding with severe pain
 Bladder and Bowel complaints
INVESTIGATION :
 ABDOMINAL EXAMINATION :
Tenderness and muscle guard on the lower abdomen especially on the
affected side are a striking feature.
Cullen’s sign
 BIMANUAL EXAMINATION :
 Reveals vaginal mucosa pale
Normal or bulky uterus
Ill defined boggy tender mass felt in one of the fornix.

32. DIAGNOSIS
PHYSICAL EXAMINATION
BLOOD EXAMINATION
LAPAROTOMY/LAPAROSCOPY
ESTIMATION OF BETA-hCG.
CULDOCENTESIS
SONOGRAPHY – COLOUR DOPPLER SONOGRAPHY
SERUM PROGESTERONE
DILATATION AND CURETTAGE

33. ESTIMATION OF BETA-HCG CULDOCENTESIS COLOUR DOPPLER SONOGRAPHY

34. SERUM PROGESTERONE DILATATION AND CURETTAGE

35. MANAGEMEN
T
TYPES OF MANAGEMENT :
1. MEDICAL MANAGEMENT
2. SURGICAL MANAGEMENT
3. NURSING MANAGEMENT

36. MEDICAL MANAGEMENT
METHOTREXATE :
• TYPE OF MEDICINE THAT INTERFERES WITH DNA SYNTHESIS AND STOP CELLS
FROM DIVIDING OR MULTIPLYING.
oTREATMENT REGIMEN :
1. Day 1 : Give Methotrexate 50 mg/M².
2. Day 4 : Measure quantitative hCG levels (usually a rise in serum HCG levels
from day 1).
3. Day 7 : Measure quantitative hCG level.
• If decline of > or = 15% from day 4 level, Follow serum hCG levels weekly
until it is < 5 miu/ml.
• If no decline of > or = 15% from day 4 level, 2nd dose of methotrexate 50
mg/m² IM to be given.

37. SURGICAL MANAGEMENT
LAPAROSCOPIC APPROACH :
LAPAROTOMY :
Removing embryo.
Repairing internal damage if any.
SURGICAL LAPAROTOMY PROCEDURES :
1. SALPINGOTOMY (LINEAR)
2. SALPINGOSTOMY (LINEAR)
3. SALPINGECTOMY (ADVANCED)
LAPAROTOMY

38. SURGICAL MANAGEMENT
1. SALPINGOTOMY (LINEAR)
Longitudinal incision made on antimesenteric border
directly over site of ectopic pregnancy.
After product removal, incision kept open till heal.
Affected fallopian tube not removed.
Only pregnancy is removed.
Preserves the tube but risk of incomplete removal of
pregnancy tissue and repeat ectopic pregnancy in
same tube in future.
Tube closed by primary intention.
SALPINGOTOMY (LINEAR)

39. SURGICAL MANAGEMENT
2. SALPINGOSTOMY (LINEAR)
Contents of fallopian tubes removed by making an
opening.
Fallopian tubes allow travel of eggs from the ovaries to
the uterus.
Done when end of fallopian tube blocked by buildup of
fluid(hydrosalpinx).
Preserves the tube.
Tube allowed to close by secondary intention after
hemostasis achieved.
SALPINGOSTOMY

40. SURGICAL MANAGEMENT
SIMILARITIES & DIFFERENCES B/W
SALPINGOTOMY AND SALPINGOSTOMY :
SALPINGOSTOMY & SALPINGOTOMY
 Both surgeries come under minimal invasive
laparoscopic surgeries .
In both, only pregnancy is removed, and tube
is preserved.
The primary difference between a
salpingotomy and salpingostomy is that,
 In salpingotomy, fallopian tube closed by
primary intention.
 In salpingostomy, tube allowed to be closed
by secondary intention after hemostasis is
achieved.

41. SURGICAL MANAGEMENT
3. SALPINGECTOMY
One or both fallopian tubes removed along with
pregnancy.
This method is preferred over conservative
salpingotomy and salpingostomy.
It is performed to :
a) Treat certain conditions of fallopian tube and ectopic
pregnancies.
b) To prevent ovarian cancer in women of higher risks.
It is performed when :
a. Whole of affected tube damaged.
b. Contralateral tube is normal.
c. Future fertility not desired. SALPINGECTOMY

42. NURSING MANAGEMENT
DIAGNOSIS :
 Acute pain related to ruptured fallopian evidenced by patient’s verbalization.
 Risk of fluid volume deficit related to ruptured ectopic pregnancy.
 Powerlessness, related to early loss of pregnancy evidenced by fainting.
 Anxiety, related to fear of prognosis, evidenced by restlessness.
 Grief related to loss of pregnancy.
INTERVENTION :
 Administer analgesics as ordered by physician.
 Use of relaxational techniques and diversional activities to reduce the pain.
 Monitor and document vital signs every 15 mins.
 Make patient comfortable, lay her flat in bed.
 Ensure patient IV fluid and blood transfusion line.
 Obtain blood samples for laboratory workout as ordered.
 Maintain input output chart register routinely
 Encourage her by verbalization of feelings.
 Provide emotional support, include family and friends , try diversional therapy.

43. NURSING MANAGEMENT
PRE-OPERATIVE NURSING CARE :
1. PHYSIOLOGICAL CARE: Obtain & review laboratory/diagnostic investigation, blood report, health history.
2. PSYCHOLOGICAL CARE: Inform/enlighten patient of procedure and reassure them.
3. PHYSICAL CARE:-
 Monitor vital signs.
 Bowel bladder elimination should be checked.
 Jewellery removed, nails trimmed, surgical site prepared.
 Pre- medications served.
 All safety protocols (right patient, right folder, right surgery) and proper handling to theatre nurses.
 Obtain informed consent(signed by patient or relative).
 Ensure patient maintains nil per oral.

44. NURSING MANAGEMENT
POST-OPERATIVE NURSING CARE :
1. Evaluate patient’s IV lines, Tubes, Drains.
2. Maintain adequate fluid volumes, intake and output chart, urine bag.
3. Maintain respiratory function: deep breathing exercise.
4. Carry out orders by surgical team (npo medication, wound care, etc.) as prescribed.
5. Assisted bed bath, oral care and encourage early ambulation and post-op exercise.
6. Reassure patient and attend to her complains.
7. Keep repeating care until patient’s condition stable and fit for discharge.
8. Patient should be able to : Maintain urine output up to 30-60ml/hr.
Maintain normal blood pressure(100/70-120/80 mmhg) and normal pulse(70 bpm-80 bpm).
Free from complication during and after hospitalization.
Verbalize relief from pain.
No sign of abnormal bleeding and post-operative infections.

45. COMPLICATIONS

46. INSTRUCTIONS TO PATIENT

47. RECENT ADVANCEMENT
DIAGNOSIS AND TREATMENT OF ECTOPIC PREGNANCY
ISSUE : BCMJ, VOL 63. NO. 3, APRIL 2021
AUTHOR : SANYA RANCHAL, MD, FRCSC
ABSTRACT
Ectopic pregnancy refers to implantation of an embryo outside the endometrium. It is a medical emergency but associated
maternal mortality has significantly declined over the decades due to earlier diagnosis and treatment. Timely detection of ectopic
pregnancy is contingent on having a high index of suspicion in all women of reproductive age, identifying patient risk factors, and
then performing appropriate laboratory testing and imaging. Expectant management is less commonly used than medical
management, which is preferred for asymptomatic, vitally stable women who wish to avoid surgery. Minimally invasive surgery is
the gold standard for management of unstable or ruptured ectopic pregnancy. Recent data favor salpingectomy for women with a
healthy contralateral tube because it has higher treatment success and does not appear to reduce future fertility compared to
salpingotomy. However, salpingotomy is suggested for women with a dysfunctional or absent contralateral tube, or those who
elect to preserve both tubes and accept the increased risk of treatment failure. Knowledge of the risks and benefits of each
treatment option is critical for delivering patient-centered care.

48. SUMMARY & CONCLUSION
Incidence of ectopic pregnancy is rising while maternal mortality from it is falling.
Ectopic pregnancy can be diagnosed early before it ruptures with recent advancement in immunoassay to detect beta-hCG,
high resolution USG and diagnostic laparoscopy.
The choice today is laparoscopic treatment of unruptured ectopic pregnancy.
Carefully monitoring and proper counselling of patient is mandatory.
Risk for incorrect diagnosis are high as ectopic pregnancy can result in maternal insanguination and death.
Radiology trainees are on the frontline to provide early diagnosis for patient and guide them towards rapid treatment.
Ruptured ectopic should be unusual with compliant patient and appropriate medical care.

49. BIBLIOGRAPHY
BOOKS:
DC DUTTA'S "TEXTBOOK OF OBSTETRICS”, 8TH EDITION 2015,PUBLISHED BY JAYPEE
BROTHERS ( THE HEALTH SCIENCE PUBLISHERS NEW DELHI );PAGE NO 168-180.
KONAR HIRALAL, “TEXTBOOK OF OBSTETRICS”, 9TH EDITION, 2018; JP BROTHER’S
MEDICAL PUBLISHER PVT. LTD. ; PAGE NO: 161-165.
INTERNET:
http://www.slideshare.net/souravchowdhury313/ectopic-pregnancy-
64061537?from_m_app=android
https://nursestudy.net/ectopic-pregnancy-nursing-care-plans/

50. QUESTIONS?