Ectopic Pregnancy – Early Pregnancy Bleeding (Nursing)

by Jacquelyn McMillian-Bohler, PhD, CNM

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      Slides Ectopic Pregnancy Early Pregnancy Bleeding Nursing.pdf
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      Reference List Maternity Nursing Care of the Childbearing Family.pdf
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    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.

    About the Lecture

    The lecture Ectopic Pregnancy – Early Pregnancy Bleeding (Nursing) by Jacquelyn McMillian-Bohler, PhD, CNM is from the course Bleeding in Pregnancy (Nursing).

    Included Quiz Questions

    1. Tubal
    2. Ovarian
    3. Cervical
    4. Urethra
    5. Uterine
    1. hCG levels drop
    2. hCG levels increase over 24 hours
    3. hCG levels double in 48 hours
    4. hCG levels triple in 72 hours
    1. Tubal surgery
    2. In vitro fertilization procedures
    3. Sexually transmitted diseases
    4. Birth control pills
    5. Multiple pregnancies
    1. Unilateral stabbing pain
    2. Dark red bleeding
    3. Cullen sign
    4. No pain
    5. hCG levels that double in 48 hours

    Author of lecture Ectopic Pregnancy – Early Pregnancy Bleeding (Nursing)

     Jacquelyn McMillian-Bohler, PhD, CNM

    Jacquelyn McMillian-Bohler, PhD, CNM

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