nursing

1. ECTOPICPREGNANCY
INTRODUCTION
Ectopic pregnancy ectopic pregnancy is one where implantation
occurs at a site other than the uterine cavity site can be in the
uterine tube ovary cervix and abdomenabout 1% of all
pregnancies are ectopic and the life threatening outcome of
this conditioncall for appropriatetreatment for the mother
Tubalpregnancy tubal pregnancy developwhen the transport
of the fertilized ovum into the uterine cavity is interfere with
implantation canoccur at any point along the tube the ampulla
is the common site . The isthmus next in frequency and the
interstitialperson least common
CAUSES
any alteration of the normal function of the uterine tube in
transporting the contributingto the risk of tubal pregnancy
Congenital abnormalities of the tube such as hypoplasia
tourtuosity E and tubaldiverticula
Acquired cause
 Previous infection such as post abortle sepsis sepsis
gonorrhea and tuberculosis. This may alter the ciliated
lining,or the static action of the tube. Infection can also
leave medicines both inside and surrounding the tube
restricting normal function.
 Iatrogenic cause
 Contraceptivefailure

2. A)IUD there is relative increase in tubal pregnancy (7 times
more) should pregnancy occur with IUD in situ copper T
380 and levonorgestrial device have got the lowest risk
.progestaserthas got the highest one
B) Sterilizationoperation there is 15 -20% chance of
ectopic pregnancy
C) Use of progestin only pillpost coital estrogen
preparationincrease the chance of tubal pregnancy
probablyby impaired tubalmotility.
 Tubalsurgery -tubal reconstructive surgery to improve
fertility, increase the Risk of tubal pregnancy, pre-existing
tubal pathologyimpaired tubalmotility, kinking of the tube .
 Intrapelvic adhesionsfollowing pelvic surgery.
 ART-tubal pregnancy is increased following ovulation
inductionand IVF -ET and GIFT procedure
 Others
Previous ectopic pregnancy
Prior inductionabortion
Developmentaldefects
Transperitonealmigration of the ovum
Factor facilitating nidation in the tube
 Early resumption of the trophoblastic activity is probably
due to premature degeneration of the zona pellucida.
 Increased decidual reaction
 Tubal endometriosis
MODE OF TERMINATION

3. Tubal mole-the formation of tubal mole is similar to that
formed in uterine pregnancy . repeated small hemorrhageoccur
in the choriocapsularspace , separating the vilai from their
attachment the fate of the mole is either complete absorption
and expulsion through the abdominal ostiumas tubal abortion
with a variableamount of internal hemorrhage the encysted
bloodcollected in the pouch of Douglasis called pelvic
hematocele.
Tubal abortion-thisis the common mode of terminationif
implantation occurin in the ampulla and infundibulum.
Muscularcontraction and enhanced separation and facilitate its
expulsion through the abdominalostium
Tubal rupture- tubalrupture is common isthmic and interstitial
implantation isthmicrupture usuallyoccur at 6 to 8 weeks the
ampullary8 to 12 week and the interstitial about4 months.
Dependingupon the site of rupture intraperitonealrupture and
extraperitonealrupture.
CLINICAL FEATURES
The clinicalfeatures are correlated with the more pathological
changes in the tube subsequent to implantation andthe
amount of intraperitonealbleeding.
Clinically three distinct types are described
Acute
Unruptured

4. Sub acute
Acute this is associated with case of tubal rupture for tubal
abortionwith massive intraperitonealhemorrhage
 Patient profile
1 the incidence is maximum between the age of 20 years and 30
years being the maximum period of fertility.
2 The prevalence is mostly limited to nulliparityfor followinglong
period of infertility
 Mode of onset the onset is acute the patient complain
unilateraluneasiness in about one third of cases before the acute
symptom appear.
 Symptoms
The classic triad of symptom pregnancy tubal pregnancy are
abdominalpainamenorrhea appearanceof vaginalbleeding
1 amenorrhea short period of 6 to 8 weeks there may be delayed
period history of spotting
2 abdominal painis the most constant feature it is acute
agonizing or colicky. Pain is located at lower abdomen unilateral
or bilateralaur maybe generalized shoulder tip painmaybe
present.
3 Vaginalslight for continuousexpulsion of deciduacast.
4 Vomiting fainting attack due to reflex in vasomotordisturbance
following territorial irritation
Sign

5.  General look the patientlie quiet and conscious perspired and
looked blanched.
 Pallor
 Features of shock pulse rapid and feeble, hypotension,
extremities cold and clammy.
 Abdominalexaminationabdomentense tumid tender no mass
is usually felt , shifting dullnesspresent , bowel may be distended.
 Pelvic examinationis less informative the findingsare : vaginal
mucosa blanchedwhite , uterus seems normal in size , extremely
tenderness on fornix palpationor on movement of the cervix ,no
mass is felt through the fornix
Investigations
 Blood should be done as routine for hemoglobin ABO and RH
incompatibility,totalwhite cell count and different count,
erythrocyte sedimentationrate
 Culdocentesissimple and safe , 18-20 gauze lumbar puncture
needle fitted with a syringe the posterior fornix is punctured to
gain exercise to pouch of Douglas.
 Estimation of beta HCG urine pregnancy test ELISA sensitive to
10-50m IU/mL
 Sonography
 Combinationof quantitive beta HCG valueand sonography
 Laparoscopy
 Dilatationandcurettage
 Serum progesterone less than 5 ng/ml
 laparotomy

6. MANAGMENT
Medicalmanagement primarily involves the use of methotrexate
(MTX), a folic-acidantagonist, which has been proned as a way to
avoid surgical risks. MTX management results in destruction of
the growing pregnancy but is comparativelyslow, often taking 4
to 6 weeks for complete resolution, thus risking rupture of the
ectopic pregnancy over this relatively long course of
management. Patients with an unrupturedEP measuring 4cm or
less on ultrasonographyare eligiblefor this treatment but those
with larger masses or evidence of rupture are ineligible. The
outcome of medical therapy now closely matches that of
laparoscopicsalpingostomy.
 Surgery allowsa rapid and usually definite resolutionof
the pregnancy and is the preferred treatment for ectopic
pregnancy when there is rupture, hypotension,anaemia,
diameter of the gestationalsac >4 cm on ultrasonographyor
persisting pain. Linearlaparoscopic,salpingostomy is
recommended in ampullaryectopic pregnancy, because the
nidationis located between the endosalpinxand the serosa, not
in the tuballumen .
 A longitudinal incisionismade by electrocautery, scissors,
or laser over the antimesenteric surface of the fallopiantube.
 suction or forceps -Products of conception are removed
with.After hemostasis has been achieved, the incisionis left to
heal by secondary intention.
 laparoscopicsalpingostomy -
 Salpingectomy is an alternative to salpingostomy
when there is extensive tubal damage, uncontrollable

7. bleeding, or recurrent ectopic pregnancy in the same tube,
and when the woman requests sterilization.