1. A CASE STUDY ON: “ ECTOPIC PREGNANCY” Alhambra, Julianne Miral Anking, Lamies Ibrahim Atok, Methusela Ondin Bastareche, Diana Martin Belmonte, Erika Jean Pandoy Cadungog, Catherine Mae Villar

2. OBJECTIVES General Objective General Objective  Manage ectopic pregnancy cases in any clinical setting with the use of acceptable notions, skills, and outlooks Specific objectives Specific objectives  To identify the different anatomical structures of female reproductive organs and understand its functions.  To understand the pathophysiology of ectopic pregnancy and to differentiate deviations from normal.  To identify and describe the different signs and symptoms of ectopic pregnancy.  To apply nursing care plan effectively for the management of ectopic pregnancy.

3. INTRODUCTION  Ectopic pregnancy, in essence, is the implantation of an embryo outside of the uterine cavity most commonly in the fallopian tube.  Damage to the fallopian tubes, usually secondary inflammation, induces tubal dysfunction which can result in retention of an oocyte or embryo.  There is up-regulation of pro-inflammatory cytokines following tubal damage; this subsequently promotes embryo implantation, invasion, and angiogenesis within the fallopian tube.  Chlamydia trachomatis infection results in the production of interleukin 1 by tubal epithelial cells.  Ectopic implantation can occur in the cervix, uterine cornea, myometrium, ovaries, abdominal cavity, etc,.

4. DEFINITION OF TERMS Amenorrhea ─ is the absence of menstruation, often defined as missing one or more menstrual periods. Amenorrhea ─ is the absence of menstruation, often defined as missing one or more menstrual periods. Ampulla ─ widest section of the uterine tubes where fertilization usually occurs. Ampulla ─ widest section of the uterine tubes where fertilization usually occurs. Antineoplastics ─ blocking the formation of neoplasms (growth that become cancer). Antineoplastic drugs are medications used to treat cancer. It is also called anticancer, chemotherapy, chemo, cytotoxic, or hazardous drugs. These drugs come in many forms, some are liquids that are injected into the patient and some are pills that patients take. Antineoplastics ─ blocking the formation of neoplasms (growth that become cancer). Antineoplastic drugs are medications used to treat cancer. It is also called anticancer, chemotherapy, chemo, cytotoxic, or hazardous drugs. These drugs come in many forms, some are liquids that are injected into the patient and some are pills that patients take. Dysmenorrheal (dysmenorrhea) ─ medical term for painful menstrual periods which are caused by uterine contractions. Primary dysmenorrhea refers to recurrent pain, while secondary dysmenorrhea results from reproductive system disorders. Dysmenorrheal (dysmenorrhea) ─ medical term for painful menstrual periods which are caused by uterine contractions. Primary dysmenorrhea refers to recurrent pain, while secondary dysmenorrhea results from reproductive system disorders. Ectopic Pregnancy- implantation of embryo outside of the uterine cavity. Ectopic Pregnancy- implantation of embryo outside of the uterine cavity. Ectopic implantation (other term for ectopic pregnancy)- refers to abnormal implantation of the blastocyst. Ectopic implantation (other term for ectopic pregnancy)- refers to abnormal implantation of the blastocyst.

5. Full blood count (FBC) – a test looks for abnormalities in your blood, such as unusually high or low numbers of blood cells. This common blood test can help to diagnose a wide range of illnesses, infections and diseases. Full blood count (FBC) – a test looks for abnormalities in your blood, such as unusually high or low numbers of blood cells. This common blood test can help to diagnose a wide range of illnesses, infections and diseases. Hemogram - a systematic report of the findings from a blood examination. Hemogram - a systematic report of the findings from a blood examination. Human chronic gonadotropin (hCG) – this hormone is produced by the placenta. Its detection is the basis of most pregnancy test. Human chronic gonadotropin (hCG) – this hormone is produced by the placenta. Its detection is the basis of most pregnancy test. Isthmica nodosa (SIN) - sometimes also referred to as diverticulosis of the fallopian tube, refers to nodular scarring of the fallopian tubes. Isthmica nodosa (SIN) - sometimes also referred to as diverticulosis of the fallopian tube, refers to nodular scarring of the fallopian tubes. Methotrexate – a medication that destroys pregnancy-related tissue and hastens reabsorption of this tissue in a woman with an ectopic pregnancy. Methotrexate – a medication that destroys pregnancy-related tissue and hastens reabsorption of this tissue in a woman with an ectopic pregnancy. Miscarriage – the naturally occurring expulsion of a nonviable fetus and placenta from the uterus, also known as spontaneous abortion or pregnancy loss. Miscarriage – the naturally occurring expulsion of a nonviable fetus and placenta from the uterus, also known as spontaneous abortion or pregnancy loss. Salpingectomy – an operation which one or both of the fallopian tubes are removed. Salpingectomy – an operation which one or both of the fallopian tubes are removed. Salpingitis - inflammation of the fallopian tubes. Salpingitis - inflammation of the fallopian tubes. Salpingostomy - is the creation of an opening into the fallopian tube, but the tube itself is not removed in this procedure. Salpingostomy - is the creation of an opening into the fallopian tube, but the tube itself is not removed in this procedure.

6. REVIEW OF SYSTEM/PHYSICAL ASSESSMENT SystemAssessment Skin Skin is pale colored and clammy. Presence of mole on the left cheek and visible wrinkles in the forehead. Hair is thick, short and straight without parasites or flakes. Scalp is mobile and non-tender. HeadNo tenderness or masses. EyesVisual fields normal. No visual impairment. Ears No masses, redness, swelling, lesions, present in the external ear. The skin is smooth with no lesions, lumps, or nodules. The canal walls is pink and smooth and without nodules. Tympanic membrane intact. Nose and sinuses Nasal structure is smooth, no tenderness. The patient is able to sniff. No nasal flaring. Outward expansion of the abdomen and lower ribs on inspiration and return to resting position in expansion. Dark pink, moist, no exudate, nasal septum is intact. Mouth/ ThroatLips is smooth and moist without lesions and swelling. 32 ivory colored teeth. Dental carry noted at the upper left canine. Buccal mucosa is pink, tissue is smooth and moist without lesions. Tongue is pink, moist, moderate size with papillae, without lesion. Posterior pharyngeal wall is pink without exudate or lesions.

7. NeckStiffness and limitation in motion is not evident. RespiratoryRapid respirations upon arrival on the health care facility. CardiovascularPresence of chest pains. Rapid pulse. GastrointestinalPatient is experiencing nausea and vomiting. GenitourinaryPresence of reddish vaginal spotting. ReproductivePatient is dysmennorheal. Nervous system The patient is conscious. Experiencing headache and weakness. Extremities Patient is experiencing body weakness. Patient is pale and experiencing cold and clammy extremities. Endocrine SystemSlow rising hCG

8. ANATOMY AND PHYSIOLOGY (FEMALE REPRODUCTIVE SYSTEM) The female reproductive system performs the following functions: a)Production of female sex cells. b)Reception of sperm cells from the males. c)Nurturing the development of and providing nourishment for the new individual. d)Production of female sex hormones.

9. STRUCTURE AND FUNCTION OF THE FEMALE REPRODUCTIVE SYSTEM

11. LABORATORY RESULT Investigation: Hemogram Result: first reading shows slight reduction but eventually decreases. Normal values: Haemoglobin─ 12.0-15.5 grams per decilitre Haematocrit─ 36%-48% Clinical Significance: after an acute haemorrhage, a decrease in haemoglobin or haematocrit level over several hours is a more valuable index of blood loss than the initial reading. Invetigation: Serum B- hCG Result: slow rising hCG Normal Value: double every 48-72 hours until it reaches 10,000-20,000 mIU/mL Clinical significance: Slow rising hCG level may indicate ectopic pregnancy. Slow rising hCG might also indicate that a pregnancy is not viable.

12. Investigation: FBC (full blood count) test Result: monocyte counts are higher Normal Values: Red blood cell count: 3.92-5.13 trillion cells/L Hemoglobin: 11.6-15 grams/dL Hematocrit: 35.5-44.9 percent White blood cell count: 3.4-9.6 billion cells/L Platelet count: 157-371 billion/L Clinical significance: monocyte activation in the pathophysiology of EP could be effective in the formation of tubal motility and microenvironment regulation. Investigation: Pelvic exam Result: uterine size not enlarged Normal values: In normal pregnancy, uterus enlarged as the baby grow Clinical Significance: pelvic exam detects tenderness in the uterus or fallopian tube, less enlargement of the uterus than expected for a pregnancy, or a mass in the pelvic area.

13. PATHOPHYSIOLOGY

14. DRUG STUDY DRUG (GENERIC NAME AND BRAND NAME) INDICATION ACTION CONTRAINDICATION Methotrexate (Trexall) Therapeutic class: Antineoplastics Pharmacologic class: Folate antagonist Ectopic pregnancy  50 mg/m² IM; measure serum hCG levels on days 4 and 7; may repeat dose on day 7 if necessary.  If hCG levels decrease <15% between days 4 and 7, administer methotrexate 50 mg/m² IM; if hCG ≥15% between days 4 and 7, discontinue treatment and measure hCG weekly until reaching nonpregnant levels.  Reversibly binds to dihydrofolate reductase, blocking reduction of folic acid to tetrahydrofolate, a cofactor necessary for purine, protein, and DNA synthesis.  Contraindicated in patients hypersensitive to drug and in those with psoriasis or RA who also have alcoholism, alcoholic liver, chronic liver disease, immunodeficiency syndrome, or blood dyscariasis.  Use cautiously in very young, elderly, or debilitated patients and in those with infection, peptic ulcerations, or ulcerative colitis.  Contraindicated during pregnancy. Don’t use in women of childbearing potential unless benefits outweigh risk.  Contraindicated in breastfeeding women.  If either partner is receiving methotrexate, they should avoid conception during and for a minimum of 3 months after therapy for males, and during and for at least one ovulatory cycle after therapy for females.  Drug has been reported to cause impaired fertility, oligospermia, and menstrual dysfunction during and for a short period after therapy ends.

15. SIDE EFFECTS ADVERSE REACTION NURSING RESPONSIBILITIES  Dizziness, drowsiness, headache, swollen, tender gums, decreased appetite, reddened eyes, hair loss Serious side effects and needs to refer to a physician immediately:  Blurred vision or sudden loss of vision, seizures, confusion, weakness or difficulty moving one or both sides of the body, or loss of consciousness. CNS: arachnoiditis within hours of intrathecal use, subacute neurotoxicity possibly beginning a few weeks later, demyelination, malaise, fatigue, dizziness, aphasia, hemiparesis, fever. CV: thromboembolic events, chest pain, hypotension, pericardial effusion, pericarditis. EENT: pharyngitis, blurred vision. GI: gingivitis, stomatitis, diarrhea, GI ulceration, GI bleeding, enteritis, nausea, vomiting. GU: nephropathy, tubular necrosis, renal failure, menstrual dysfunction, abortion, cystitis. Hematologic: leukopenia, thrombocytopenia. Hepatic: acute toxicity, chronic toxicity, including cirrhosis, hepatic fibrosis. Metabolic: diabetes, hyperuricemia. Musculoskeletal: arthralgia, myagalia, osteopporosis in children on long-term therapy. Respiratory: pulmonary interstitial infiltrates, pneumonitis. Skin: urticaria, pruritus, hyperpigmentation, erythematous rashes, ecchymoses, rash, photosensitivity reactions, alopecia, acne, psoriatic lesions, aggravated by exposure to sun. Others: chills, reduced resistance to infection, septicaemia, sudden death.  Methotrexate should be used only by health care providers whose knowledge and experience include the use of antimetabolite therapy.  Drug can cause severe and fatal toxicities. Modify dosage or discontinue drug for bone marrow suppression, infection, and renal, GI pulmonary, and dermatologic toxicities or hypersensitivity.  Methotrexate-induced lung disease, including acute or chronic interstitial pneumonitis, is a potentially dangerous lesion that may occur at any time during therapy. It isn’t always fully reversible. Pulmonary symptoms (especially a dry, non-productive cough) may require interruption of treatment and careful investigation.  Diarrhea and ulcerative stomatitis require interruption of therapy; hemorrhagic enteritis and death from intestinal perforation may occur.  Malignant lymphomas may occur in patients receiving low-dose methotrexate and may regress upon discontinuing drug.  Methotrexate may induce TLS in patients with rapidly growing tumors.  Severe, occasionally fatal skin reactions have been reported following single or multiple doses of methotrexate. Reactions have occurred within days of methotrexate administration. Recovery has been reported with discontinuation of therapy.  Potentially fatal opportunistic infections especially pneumocystis jiroveci pneumonia, may occur with methotrexate therapy.

16. NURSING CARE PLAN NO. 1 Assessment: Subjective data: Patient verbalizes experiencing vaginal bleeding which is usually scanty and dark. Objective data: lowered blood pressure; body weakness, decreased urinary output, pale and clammy skin. Nursing Diagnosis: Deficient fluid volume related to active blood loss secondary to ectopic pregnancy. Planning: The patient will re-establish a functional body fluid volume and a balanced input and output status. InterventionsRationale Assess vital signs, conduct physical examination, and commence daily weight monitoring. Edema, headaches, low blood pressure, and pain are associated with the patient's blood loss. Fluid retention may be evident if the patient has an unexplained weight gain. Start input and output monitoring To monitor circulatory blood volume. To ensure that the patient has adequate oral hydration or if there is a need to commence IV hydration therapy. Speak to the patient and family about the need for hospitalization for the treatment of serious hemorrhage and the need for surgery. To treat vaginal bleeding and deficient fluid volume related to ectopic pregnancy in appropriate setting. Prepare the patient for the surgical Intervention for ectopic pregnancy. Place the patient on a nothing by mouth (NBM or NPO) status. Salphigostomy is the surgical removal of the unruptured ectopic pregnancy from the fallopian tube utilizing laparoscopic technique. Salphingectomy is the surgical resection of the unruptured ectopic and the involved fallopian tube through laparoscopy. Placing the patient on "Nothing by mouth" (NBM or NPO) is necessary to prepare the patient for emergent delivery Prepare for blood transfusion as required.To increase blood volume Encourage the patient to have a low salt intake. Consuming salt between 2 to 4 g per day is ideal as a very low salt intake may increase dehydration. Evaluation: After 8 hours of nursing intervention, the patient’s fluid volume will be re-established. NURSING CARE PLAN 1

17. NURSING CARE PLAN NO. 2 Assessment: Subjective data: Patient is restless and disoriented. Objective data: rapid respirations and lowered blood pressure. Nursing Diagnosis: Risk for Maternal Injury Planning: The patient will maintain safety and participate in the measures that will protect self during the treatment. InterventionsRationale Assesss the patient's mental status. Ectopic pregnancy may cause the patient to have low mood, depression, or negative emotional status, which puts her at risk for maternal injury. Monitor the patient's level of consciousness using AVPU. Heavy vaginal bleeding may result to hypotension and lower level of consciousness. Using AVPU scale (i.e. Alert, Voice, Pain stimuli or Unresponsive/unconsciousness) can help determine the urgency of surgical treatment and increased risk for maternal injury. Prepare the patient immediate surgical Intervention for the removal of the ectopic pregnancy. Ectopic pregnancy is the leading cause of maternal death during the first trimester due to internal bleeding, therefore an urgent surgery to remove it is needed. Place the patient in complete bed rest of there is evidence of severe bleeding. To reduce pain and keep the patient safe. Evaluation: After 8 hours of nursing intervention, the patient will maintain safety and has participated with the given measures.

18. NURSING CARE PLAN NO. 3 Assessment: Subjective data: Abdominal or pelvic pain. Objective data: Facial mask of pain. Guarding behaviour. Abnormal tenderness on palpation. Nursing Diagnosis: Acute pain related to ectopic pregnancy as evidenced by a pain score of 10 out of 10, verbalization of abdominal pain, abdominal rigidity and restlessness. Planning: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs and absence of restlessness. InterventionsRationale Administer prescribed pain medications.To alleviate the symptoms of acute abdominal pain. Assess the patient's characteristics of pain at least 30 mins after administration of medication. To monitor effectiveness of medical treatment for the relief of abdominal pain. The tine of monitoring of vital signs may depend on the peak time of the drug administered. Elevate the head of the bed and position the patient in semi Fowler's.To increase the oxygen level by allowing optimal lung expansion. Place the patient in complete bed rest during severe episodes of pain. Perform non-pharmacological pain relief methods such as relaxation techniques: deep breathing, guided imagery and provision of distraction such as TV or radio. To provide optimal comfort to the patient. Prepare the patient for surgery. Salpingostomy is the surgical removal of the unruptured ectopic pregnancy from the fallopian tube utilizing laparoscopic technique. Salpingectomy is the surgical resection of the unruptured ectopic pregnancy and the involved fallopian tube through laparoscopy. Post-surgery, advise the patient to: Have no strenuous activity for a few weeks. Apply support on the abdomen when coughing, laughing, or moving by placing a pillow over the abdominal area, inform the healthcare tean if the pain medications are not working. To reduce post-surgical pain and allow full recovery and healing. Evaluation: After 8 hours of nursing interventions, the patient was relieved or controlled.

19. NURSING CARE PLAN NO. 4 Assessment: Subjective data: Patient verbalizes concern and grief over loss and verbalizes that she cannot believe this happened to her. Objective data: Mood is dysphoric and tearful at times, but client is responsive and cooperative. Nursing Diagnosis: Anticipatory grieving related to loss of pregnancy Desired Outcomes: Progress through the phase of grief as evidenced by verbalization of grief, use resources support appropriately and discuss concerns and feelings openly with each other. InterventionRationale Promote feelings of self-worth through one on one session.Promote trust relationship. Encourage verbalization of fears, concerns and questions regarding the condition, treatment and future implications. An increase knowledge base decreases anxiety and dispels misconceptions. Promote family cohensiveness.Frequent contacts reduce feelings of fear and isolation. Encourage vebtilation of negative feelings including projected anger and hostility within acceptance limits. This allows for emotional expression without loss of self-esteem. Allow for periods of crying and expressions of sadness.These are necessary for separation and detachment to occur. Give spiritual support.This facilitates the grief process and spiritual care. Evaluation: After 8 hours of nursing interventions, the patient was able to verbalize grief, use resources support appropriately and discuss concerns and feelings openly with each other.

20. NURSING CARE PLAN NO. 5 Assessment: Subjective data: Patient verbalizes feeling sad due to of pregnancy loss. Objective data: received patient with grimace face. Nursing Diagnosis: Powerlessness related to loss of pregnancy secondary to ectopic pregnancy. Desired Outcomes: Client should be able to create support system and sense of control. InterventionsRationale Encourage verbalization of feelings, thoughts, and concerns about making decisions.This approach creates a supportive environment and sends a message of caring. Encourage patient to identify strengths.This will aid patient to recognize inner strengths. Discuss with the patient concerning her (treatment options, convenience of visits). Allowing the patient to participate in discussions will increase her sense of independence or autonomy. Encourage an increased responsibility for self. The perception of Powerlessness may negate the patients attention to areas in which self-care is attainable; however the patient may require significant support systems and resources to accomplish goals. Help patient in reexamining negative perceptions of the situation.The patient may have her own perceptions that are unrealistic for the situation. Eliminate the unpredictability of events by allowing adequate preparation for test or procedures. Information in advance of a procedure can provide the patient with a sense of control. Give the patient control over her environment.This approach enhances patient's independence. Aid the patient in recognizing the importance of culture, religion, race, gender and age on her sense of powerlessness. Patient may develop powerlessness especially in a hospital environment when they don't speak the dominant language, food is unusual and customs are different. Support in planning and creating a time table to manage increased responsibility in the future. Use of realistic short-term goals for resuming aspects of self-care foster confidence in one's abilities. Avoid using coercive power when approaching the patient. This approach may increase the patient’s feelings of powerlessness and result in decreased self-esteem. Render positive feedback for making decisions and engaging in self-care. Success promotes confidence in abilities and sense of control. Recognition and positive reinforcement for self-care are great motivators for heightening self-esteem and feelings of self-governance. Evaluation: After hours of nursing intervention, the patient was able to create support system and sense of control over the situation.

21. PROGNOSIS DataImplication Onset of illness Pain on the lower abdomen or pelvic region with light vaginal bleeding POOR PROGNOSIS Age 36 years oldPOOR PROGNOSIS Gender FemalePOOR PROGNOSIS Complicati on History of previous ectopic pregnancy POOR PROGNOSIS attitude Mother shows cooperation towards the treatment plan GOOD PROGNOSIS Prognosis: 4/5 Since the mother shows cooperation on the treatment, there is a big possibility of recovery.

22. DISCHARGE PLANNING Medicine The patient will take her prescribed drug unfailingly. Environment The patient will live in an environment conducive to faster recovery and health maintenance. Health Teaching The patient will learn about ectopic pregnancy and will follow certain measures to avoid further complications while on treatment. Out Patient Follow Up The patient will recognize any signs of deviations from normal and will communicate with her health care provider within the course of treatment. Diet The patient will identify due diet for faster recovery. Support System The patient will identify due diet for faster recovery.