00:01
Now, let's talk about
an ectopic pregnancy.
00:04
So an ectopic pregnancy describes
when the pregnancy
has implanted somewhere
that it is not supposed to be.
00:11
It is outside the uterine cavity.
00:14
This occurs about
0.5% to 2% of all pregnancies.
00:19
So normally, the embryo is going
to implant into the uterine wall.
00:24
Hopefully around
the area of the fundus,
but on the side of the
uterus is usually okay.
00:29
When we're describing
an ectopic pregnancy,
this means that the conceptus
has invaded something else
besides the endometrial wall.
00:39
So, it could be the tube,
could be the ovary.
00:41
Let's look at some of those spaces.
00:43
So this is an
interstitial implantation.
00:46
That means that the products
of conception have made its way
really inside the muscle structure,
not just in the endometrial lining.
00:53
The implantation
could also be Tubal.
00:56
So sometimes you'll hear someone
describe a tubal pregnancy.
01:00
This is a type of
ectopic pregnancy.
01:02
So if the pregnancy
implants in the tubes,
as you can see,
once the products of conception
start to grow,
and the fetus gets bigger,
there's no room,
so this is part of the problem.
01:14
We can also have implantation
in the ovary itself.
01:17
So after ovulation,
the egg doesn't move anywhere,
the sperm comes to the egg inside
the ovary and they get stuck.
01:23
So again, there's no space
for the fetus to grow.
01:28
The implantation can also happen
in the area of the cervix,
so all the way down.
01:33
So yes, that's still
technically the uterus,
but again,
there's no room for expansion.
01:39
Now, sometimes the pregnancy
can actually implant itself
into the pelvic cavity
and completely away from
the reproductive organs.
01:47
That's rare, but it can happen too.
01:49
All of those describe
an ectopic pregnancy.
01:53
Let's talk about risk factors
for ectopic pregnancy,
Sexually transmitted diseases or
sexually transmitted infections
can cause an ectopic pregnancy.
02:03
Now, it's not the infection itself.
02:05
It's a sequelae or the consequences
because STDs and STIs can lead to
pelvic inflammatory infections.
02:12
And what that does is it can
create scar tissue in the tubes.
02:17
It can also create scar tissue
in the abdominal structures
so that the tubes are
no longer straight.
02:23
Scar tissue is sticky like
tape and it can cause adhesions
that are going to pull the
tubes in very strange places.
02:30
And so when the egg and sperm
get together,
then the highway is not straight,
it's crooked,
and then when the egg
cannot get through,
then we can have an ectopic.
02:41
Any kind of tubal surgery
or really any procedure
that might lead to tubal scarring
can also play someone at risk
for an ectopic pregnancy.
02:50
And finally, infertility.
02:52
It's not the infertility itself,
it's the procedures that we may do
to resolve the infertility,
that can actually
lead to the ectopic.
03:00
So when we get into <inaudible>,
or any of those in vitro
fertilization procedures,
then we can increase
the risk of an ectopic.
03:10
Let's talk about assessing
for an ectopic pregnancy.
03:15
Now one of the major
concepts we need to grasp
is what happens with hCG?
So hCG, remember,
that's human chorionic gonadotropin
doubles about every 48 hours
until about 10 weeks.
03:28
So that's in a normal pregnancy.
03:31
And an ectopic pregnancy, we
will find that it doesn't double.
03:34
Sometimes it only goes
up by maybe a fourth,
or maybe it doesn't go up at all,
or maybe it begins to drop.
03:42
This may be a way.
03:43
And sometimes the only way that
we're able to diagnose an ectopic.
03:48
Now, let's look at
some other symptoms
that the client might
experience along with
the changes in their HCG.
03:54
Unilateral stabbing pain.
03:57
A client may come in and say,
"I'm experiencing
a lot of pain in my abdomen
on the right side or the left side."
Sometimes they know
they're pregnant.
04:05
Sometimes I have no idea.
04:07
So anybody of childbearing age
that has unilateral stabbing pain,
you should suspect an ectopic
until proven otherwise.
04:14
Their period may be different.
04:16
So they may have a period.
04:19
It might be really light,
or it might be late.
04:22
So this would be a reason to suspect
a possible ectopic pregnancy.
04:27
Obviously, there's bleeding
because it's in this unit,
but let's think about
the characteristics.
04:31
Typically the bleeding
is going to be dark red.
04:35
They may also have
referred shoulder pain.
04:38
Anytime there's a
buildup of pressure
inside the abdominal cavity,
often there'll be pain that's
referred to the left shoulder.
04:46
It has to do with
displacement of the diaphragm
from the buildup of fluid.
04:49
Typically, when the client
presents with shoulder pain,
that means there's been an ectopic
that has actually ruptured.
04:57
If they haven't a
rupture of an ectopic
then they may exhibit signs of shock
from the blood loss.
05:03
So again, if you have a client
that is of childbearing age
that shows up in the
emergency department,
and they're in shock.
05:10
One of the tests
that usually will be done
is a pregnancy test
to rule out an ectopic.
05:16
And finally Cullen' sign.
05:18
So again, once we have
a rupture of an ectopic,
you can see on this graphic
that we have sort of a bruising
around the umbilicus.
05:25
And so that is what this may cause.
05:28
I haven't seen very
many cases of this,
but this is definitely
a tell-tale sign
of some sort of bleeding
inside the abdomen if you see it.
05:37
Let's talk about
medical management.
05:39
So in addition to the HCG,
which we'll do first,
we will also get an ultrasound.
05:45
What are we doing?
What are we looking for?
We're looking for an
intrauterine pregnancy.
05:49
So if we don't see one,
then that's highly suspicious that
the egg is implanted somewhere else.
05:56
Now, I say that
with one small caveat.
05:58
The HCG has to be high enough
for us to expect
to even see anything.
06:04
So when you get the HCG back,
if the level is less than 1500,
even if it was a normal pregnancy
and everything was fine,
you wouldn't be able to see
anything anyway, it's too small.
06:14
So we'll get the HCG first
and then we'll look
at the ultrasound and compare.
06:18
So for example,
if your HCG is 5000,
and you don't see anything
inside the uterine cavity,
then that is pretty much going
to be diagnostic of an ectopic.
06:28
Next we will do a cervical exam.
06:31
We do a cervical exam to see
if the cervix has opened or
we can look at the bleeding
and see what that looks like.
06:37
If it's decided that the
pregnancy is in fact an ectopic
and we want to make sure that the
entire uterine cavity is clear,
then a dilation and curettage
may be ordered.
06:47
Or we may do a
dilation and evacuation
and use a suction device to help
empty the contents of the uterus.
06:54
Methotrexate is a medication that's
also used in ectopic pregnancy.
06:58
Now maybe you're
thinking to yourself,
"Hey, I've heard of that medication
before, but it wasn't in maternity."
And you'd be right.
07:05
Methotrexate was originally used
to treat arthritis.
07:09
And so what they found when
they had clients who had both
a pregnancy and arthritis
that when they were
taking the methotrexate,
it dissolved the pregnancy.
07:17
So why would we use
it for an ectopic?
So think about it.
07:21
One of the risk factors for causing
an ectopic is tubal surgery.
07:25
And that's actually going to be
our last intervention
I'll talk about in just a second.
07:28
But if we do any sort of
manipulation to the tubes,
we can actually increase the
risk of further ectopic later.
07:35
And anytime we can avoid surgery,
it's always a good thing.
07:38
So, we can use methotrexate
to dissolve an ectopic
that is somewhere outside
of the endometrial cavity.
07:45
We can only use it however,
if the ectopic hasn't ruptured,
so it hasn't broken through,
or if there's no cardiac activity,
because once there's
cardiac activity,
the fetus is too large for
us to use this as a strategy.
08:00
And finally,
a surgical intervention.
08:02
So, we can actually
go into the abdomen
and actually remove
the tube section,
or find the conceptus
where it may be
in the abdomen
and physically remove it.
08:15
Let's talk about what
the nurse is doing.
08:17
So, the nurse may be
obtaining the pregnancy tests.
08:20
In this case, remember that
it is a quantitative HCG,
because we need the numbers.
08:26
We may also assist with
those medical procedures
that I talked about.
08:29
So the dilation and curettage,
or evacuation,
the nurse may help
to gather the equipment
and help prepare the patient.
08:37
We want to offer
support and education,
Both about the topic and
what to expect post procedure.
08:43
This is going to be
really important.
08:44
And even if the nurse doesn't
perform the education,
making sure that it's done
and making sure that the client
really understands what happened.
08:51
That's definitely
within our purview.
08:54
And finally,
we want to make sure
that we're monitoring
for signs of complications.
08:58
So we might be monitoring
the blood loss or vital signs
or sending any tissue that
might be collected to pathology.