Ectopic Pregnancy

Ectopic pregnancy | definition of ectopic pregnancy by Medical dictionary

Early complaints are consistent with those of a normal pregnancy (i.e., amenorrhea, breast tenderness, nausea). Pregnancy test results are positive owing to the presence of human chorionic gonadotropin (hCG) in blood and urine. Signs and symptoms arise as the growing embryo distends the fallopian tube; associated complaints include intermittent, unilateral, colicky abdominal pain. Complaints associated with tubal rupture include sharp unilateral pelvic or lower abdominal pain; orthostatic dizziness and vertigo or syncope; and referred shoulder pain related to peritoneal irritation from abdominal bleeding (hemoperitoneum). Signs of hypovolemic shock may indicate extensive abdominal bleeding. Vaginal bleeding, typically occurring after the onset of pain, is the result of decidual sloughing.Locations

Abdominal: The incidence of pregnancy in the abdominal cavity with the conceptus attached to an abdominal organ is between 1:3000 and 1:4000 births. Ovarian: Conception and implantation within the ovary itself occurs in approximately 1 in 7,000 to 1 in 50,000 pregnancies. Tubal: Ninety to 95% of ectopic pregnancies occur in the fallopian tube; of these, 78% become implanted in the uterine ampulla, 12% in the isthmus, and 2% to 3% in the interstices.Diagnosis

Transabdominal or transvaginal pelvic ultrasonography is used to identify the location of the pregnancy. It has also largely replaced culdocentesis for confirmation of hemoperitoneum.Treatment

An operative approach is most common. Laparoscopy and linear laser salpingostomy can be used to excise early ectopic implantations; healing is by secondary intention. Segmental resection allows salvage and later reconstruction of the affected tube. Salpingectomy is reserved for cases in which tubal damage is so extensive that reanastomosis is not possible. Methotrexate has been used successfully to induce dissolution of unruptured tubal masses less than 3.5 cm. Posttreatment monitoring includes serial quantitative b-hCG levels, to be certain that the pregnancy has ended.Patient care

Preoperative: The patient is assessed for pain and shock. Vital signs are monitored and oxygen administration by nonrebreather mask is started. An IV fluid infusion via a large-bore cannula is started and blood is drawn to type and cross (including Rh-compatibility) for potential transfusion. Medications (including RhoGAM if the patient is Rh negative) may be prescribed and administered and the patient's response evaluated. The patient's and family's wishes regarding religious rites for the products of conception are determined. Both patient and family are encouraged to express their feelings of fear, loss, and grief. Information regarding the condition and the need for surgical intervention is clarified.

Postoperative: Vital signs are monitored until stable, incisional dressings are inspected, vaginal bleeding is assessed, and the patient's physical and emotional reactions to the surgery are evaluated. Prescribed analgesics and other medications are administered, and the patient evaluated for desired and adverse effects. The grieving process is anticipated, and both the patient and family are referred for further counseling as needed.See also: pregnancyectopic pregnancy A dangerous complication of pregnancy in which the fertilized egg (ovum) becomes implanted in an abnormal site, such as the FALLOPIAN TUBE or in the pelvis or abdomen, instead of in the womb lining. The great danger is severe, and sometimes life-threatening, bleeding (haemorrhage). Treatment is by urgent operation to remove the growing embryo. This is now mainly done by laparoscopic surgery.Ectopic PregnancyDRG Category:777Mean LOS:2.3 daysDescription:MEDICAL: Ectopic Pregnancy

An ectopic pregnancy is an implantation of the blastocyst (a solid mass of cells formed by rapid mitotic division of the zygote that eventually form the embryo) in a site other than the endometrial lining of the uterus. It is the leading cause of maternal death in the first trimester of pregnancy. In more than 95% of ectopic pregnancies, this implantation occurs somewhere in the fallopian tubes, hence the term tubal pregnancy. The fallopian tube lacks a submucosal layer, which allows the ovum to burrow through the epithelium. Fertilization occurs, and the zygote lies within the muscular wall of the tube, drawing its blood supply from maternal vessels. The ampullary portion of the tube is the most common site (80%), followed by the isthmic portion (12%) and the fimbria (5%). The cornual and interstitial regions of the tube have lower (2%) prevalence but a higher risk of mortality. Nontubal sites are more rare and include abdominal, ovarian, and cervical locations.

After the blastocyst implants in the tube, it begins to grow and can cause bleeding into the abdominal cavity. Eventually, the ovum becomes too large and the tube can rupture, causing further bleeding that can lead to shock and maternal death. Ectopic pregnancies occur in approximately 25 per 1,000 pregnancies, and non-European Americans have a 1.4 times increased risk over European Americans. Heterotopic pregnancies, in which there is an ectopic and a uterine pregnancy at the same time, occur at a rate of 1:10,000. The frequency of ectopic pregnancy has increased four-fold since 1970, owing to the increase in sexually transmitted infections (STIs), better diagnostic techniques, increased use of artificial reproductive technology, and increased use of tubal surgeries to treat infertility. Ectopic pregnancy accounts for 3% to 4% of all pregnancy-related deaths and reduces a woman s chance of future pregnancy because of tubal damage; approximately one-third of women who experience an ectopic pregnancy subsequently give birth to a live infant. Hemorrhage, peritonitis, and infertility are the main complications.Causes

The major cause of ectopic pregnancy is tubal damage, which can result from pelvic inflammatory disease, previous pelvic or tubal surgery, or endometriosis. Other causes may be hormonal factors that impede ovum transport and mechanically stop the forward movement of the egg in the tube, congenital anomalies of the tube, and a blighted ovum. Pelvic infections and STIs, specifically chlamydia and gonorrhea, are often involved. Other risk factors include smoking, diethylbestrol exposure, T-shaped uterus, certain intrauterine devices (IUDs), and a ruptured appendix.Genetic considerations

No clear genetic contributions to susceptibility have been defined.Gender, ethnic/racial, and life span considerations

In the United States, ectopic pregnancy is most often seen in non-European American women over age 35. Women of all ancestries over 40 have three times the likelihood of ectopic pregnancy as compared to their younger counterparts. Aging may result in progressive loss of myoelectrical activity responsible for moving the egg through the fallopian tube. Also, ectopic pregnancy often occurs in teens who have engaged in high-risk sexual practices that have resulted in frequent pelvic infections. African American teenagers and teenagers of other minority races have a mortality rate almost five times higher from ectopic pregnancy than white teenagers.Global health considerations

In developing countries, deaths from ectopic pregnancy are 10 times higher than those reported in developed countries. Several reasons may contribute to this disparity, including increased prevalence due to untreated sexual transmitted infections and lack of prompt identification and intervention when an ectopic pregnancy occurs.AssessmentHistory

Women in their childbearing years, including teens, should be evaluated for an ectopic pregnancy any time they are evaluated for abdominal pain, cramping, or vaginal bleeding. Elicit a history about the onset of menses, gynecological disorders, pattern of sexual practices and birth control, and past pregnancies. Patients with an ectopic pregnancy often have some history of tubular damage as a result of infections or endometriosis. They may also have had tubal surgeries. Often, patients describe a history of using an IUD, and some may report a history of infertility. Question the patient about her last menstrual period to determine the onset, duration, amount of bleeding, and whether it was a normal period for her. This description is important because although amenorrhea may be present in many cases of ectopic pregnancy, uterine bleeding that occurs with ectopic pregnancy may be mistaken for a menstrual period. In addition to amenorrhea, the patient may exhibit other signs of pregnancy, such as breast tenderness, nausea, and fatigue.Physical examination

The most common symptoms include abdominal pain, amenorrhea, and vaginal bleeding. An undocumented ectopic pregnancy is a life-threatening emergency. Assess vaginal bleeding for the amount, color, and odor; if none is noted, bleeding may be concealed. Bleeding can occur as vaginal spotting, as a slow leak, or as a massive hemorrhage depending on the gestational age and whether the tube has ruptured. Usually, the bleeding is slow, and the abdomen can become rigid and tender. Sometimes, vaginal bleeding is present with the death of the embryo. If internal hemorrhage is profuse, the woman experiences signs and symptoms of hypovolemic shock (restlessness, agitation, confusion, cold and clammy skin, increased respirations and heart rate, delayed capillary blanching, hypotension).

Evaluate the patient s pain; it can range from a feeling of fullness in the rectal area and abdominal cramping to excruciating pain. Often, the pain is one-sided and increases when the cervix is moved during a vaginal examination. Some women do not feel any pain until the tube is about to rupture, usually at the third month of gestation. If the tube ruptures, the woman experiences sharp, one-sided, lower abdominal pain and syncope. The pain may radiate to the shoulders and neck and is aggravated by situations that cause increased abdominal pressure, such as lifting or having a bowel movement.Psychosocial

Often, the patient experiences anger, grief, guilt, and self-blame over the loss of the fetus. She may also be anxious about her ability to conceive in the future. Because much of her anxiety may stem from lack of information about her condition, assess her learning needs. Determine the ability of the father and other family members to cope and support the patient.Diagnostic highlights

General Comments: Diagnosis is based on a positive pregnancy and inability to visualize the embryo in the uterus. Have a high index of suspicion for any female patient in her reproductive years who reports abdominal pain, cramping, or vaginal bleeding. All these females should be screened for ectopic pregnancy.TestNormal ResultAbnormality With ConditionExplanationTransvaginal ultrasonographyIntrauterine gestational sac is visualizedUnable to visualize intrauterine sacThis result, combined with a positive pregnancy test (elevated hCG), confirms the diagnosisHuman chorionic gonadotropin (hCG)Normally is not present in nonpregnant womenThe level is above the discriminatory zone of 1,500 mIUhCG doubles every 2 days during the first 40 days of pregnancy; failure to do so is evidence of abnormalityProgesterone level (not accurate if fertility drugs were used) 25 ng/L 5 ng/L (values between 5 and 25 are inconclusive)Progesterone increases with normal pregnancy

Other Tests: Laparoscopic examination of the abdominal cavity (used only in confusing cases), color flow Doppler ultrasound (used in cases when the gestational sac is questionably empty), Rh antibody screen and blood type, complete blood count and coagulation studies, culdocentesisPrimary nursing diagnosisDiagnosisAnticipatory grieving related to the loss of a pregnancyOutcomesCoping; Family coping; Grief resolutionInterventionsGrief work facilitation; Perinatal death; Active listening; PresencePlanning and implementationCollaborative

medical. Medical management of a tubal pregnancy depends on the patient s condition, fetus s gestational age and size, and whether the fallopian tube has ruptured. If the tube is intact, the gestation is less than 6 weeks, the fertilized mass is less than 3.5 cm in diameter, and the patient is hemodynamically stable with normal liver and renal function, methotrexate, a chemotherapeutic agent that inhibits cell division, may be ordered. The patient must also be committed to coming in for follow-up appointments, which are critical to maternal well-being and assessing the effectiveness of treatment. Human chorionic gonadotropin (hCG) levels and fetal cardiac activity are monitored with methotrexate therapy; success of treatment is based on these two assessments (hCG should decrease 15% by day 4, and fetal cardiac activity should cease by day 7). If the tube is damaged or ruptured, surgical management is indicated immediately.

surgical. Laparoscopic laser surgery is usually performed, but if the tube has already ruptured, a laparotomy may be indicated. A salpingectomy (removal of the tube), salpingostomy (incision and evacuation of tubal contents), salpingotomy (incision and closure of the tube), or segmental resection and anastomosis can be performed. The goal is to salvage the tube, especially in women who desire future pregnancy.

Postoperative care includes monitoring vital signs and observing for other signs of shock. Monitor the fluid intake and output as well and note the color and amount of vaginal bleeding. Observe the incision for any signs and symptoms of infection. Administer analgesics and assess the patient s level of pain relief from the medication.Pharmacologic highlightsMedication or Drug ClassDosageDescriptionRationaleMethotrexate sodium (Folex) (leucovorin is also given with methotrexate if given over 4 days)50 mg/m2 IM or 1 mg/kg IM days 1, 3, 5, 7Antineoplastic, acts a folic acid antagonistInhibits the growth of the pregnancy by interfering with DNA, RNA, and protein synthesisAnalgesicsVaries by drugNarcotics, NSAIDs; drug used depends on the level of painRelieve painRhoD immunoglobulin (RhoGAM)120 300 g IM one timeImmune serumGiven only if mother is Rh-negative and father is Rh-positive; prevents the antigen-antibody response leading to Rh isoimmunization in future pregnanciesIndependent

Provide emotional support, using therapeutic communication techniques to relieve the patient s anxiety. Emotional support of this patient is important because the termination of any pregnancy causes a host of psychological and physiological changes. Inform the patient of perinatal grief support groups.

The patient may be concerned about infertility. Provide information and clarify the physician s explanations if needed. If necessary, provide a referral for a clinical nurse specialist or counselor.Evidence-Based Practice and Health Policy

Karhus, L.L., Egerup, P., Skovlund, C.W., Lidegaard, O. (2013). Long-term reproductive outcomes in women whose first pregnancy is ectopic: A national controlled follow-up study. Human Reproduction, 28(1), 241 246.Future fertility may be compromised in women who have ectopic pregnancies.Investigators conducted a retrospective study among a sample of 2,917 women whose first pregnancies were ectopic and compared them to a cohort of age-matched women who had first pregnancies within the same year. Findings revealed that women with ectopic pregnancies had a lower long-term rate of successful delivery (69 per 100 pregnancies) over a mean follow-up period of 23.2 years.Women whose first pregnancy was ectopic were 4.7 times more likely (95% CI, 3.8 to 5.8) to have future ectopic pregnancies and 45% less likely (95% CI, 0.52 to 0.58) to deliver future pregnancies successfully than the comparison cohort.Documentation guidelinesPhysical responses: Amount and character of blood loss, vital signs, abdominal assessment (presence and description of pain, response to analgesics)Serial laboratory values: Hemoglobin and hematocrit, coagulation profile, white blood cell count; results of Rh testResponse to treatments: Surgery, laparoscopy, fluid or blood replacement, medicationsEmotional status and coping abilities, partner s responsePresence of complications: Hemorrhage, hypovolemic shock, infectionDischarge and home healthcare guidelines

patient teaching. If the patient is receiving methotrexate on an outpatient basis, teach her that more severe pain may indicate treatment failure and that she needs to notify the physician. She should not drink alcohol or take vitamins containing folic acid. She may experience anorexia, nausea and vomiting, mouth ulcers, and sensitivity to sunlight as side effects of methotrexate. She also needs to follow up with scheduled hCG testing.

If a salpingectomy was done, explain to the patient that becoming pregnant again may be difficult. Fertilization takes place only on the side of the remaining tube after ovulation of the ovary on the same side. If a tubal repair was done, the patient is at a higher risk for a subsequent ectopic pregnancy as well as infertility. Educate the patient to recognize the signs and symptoms of ectopic pregnancy and to notify the doctor immediately if these should occur.

To prevent recurrence, advise the patient to engage in safe sexual practices. Teach her strategies to avoid STIs and pelvic infections that could cause further damage to the fallopian tubes.

postoperative instructions. Give the patient the following instructions: Limit activity and get plenty of rest. Increase fluid intake. Keep the incision clean. Refrain from sexual intercourse for 2 weeks until the follow-up appointment with the physician occurs. Delay pregnancy for at least 3 months to allow for tubal healing. Determine that she has a method of birth control prior to leaving the hospital.

referral. If the patient is having difficulty dealing with the perinatal loss, referring her to a support group is appropriate. Often, follow-up by the hospital perinatal grief counselor is done. Referral to a fertility specialist is indicated if she is having difficulty conceiving for 6 months after tubal surgery.Patient discussion about ectopic pregnancy

Q. What is an Ectopic Pregnancy? I've heard that an ectopic pregnancy can be very dangerous. What is exactly an ectopic pregnancy?A. Thanks Ridings and Conger..for easier understanding, ectopic pregnancy means a pregnancy that occurs not in the normal place (uterus/womb). It talks about the implantation of the zygote (embryo). If it is implanted in uterus wall then it is normal, if it is not in uterus wall (endometrium) then it is called ectopic pregnancy.So ectopic pregnancy includes :- extra-uterine pregnancy (including tuba, abdomen, ovarium)- abnormal intra-uterine pregnancy (some doctors include : cervix, muscular wall of uterine)

Q. Do doctors normally do ultrasounds to prove you have mis carried?? 2 weeks ago i found out i was pregnant, i started spottion so we went to the hospital where they toldl me i miscarried, but they did not do any alternative tests to prove it not even check my Hcg levels. Im wandering if i should get a second opinion to make sure.A. Congratulations on the new pregnancy - that's wonderful news!More discussions about ectopic pregnancy Want to thank TFD for its existence? Tell a friend about us, add a link to this page, or visit the webmaster's page for free fun content. Link to this page: a href= ectopic pregnancy /a Facebook Twitter Feedback My bookmarks ? Please log in or register to use bookmarks. You can also log in with FacebookTwitterGoogle+Yahoo + Add current page to bookmarks TheFreeDictionary presents: Write what you mean clearly and correctly. Mentioned in ? abdominal crisisabdominal gestationabdominal pregnancyacute abdomenadnexal painampullar pregnancyantepartum hemorrhageArias-Stella reactionassisted reproductionbigeminal pregnancyblue bellycervical pregnancychlamydial vaginitisclinical pregnancycombined pregnancycompound pregnancycornual pregnancycortical implantationCullen sign References in periodicals archive ? Based on intra-operative findings, most of patients had ampullary ectopic pregnancy.A rare case of bilateral ectopic pregnancy and differential diagnosis of gestational trophoblastic diseaseReproductive outcomes after medical and surgical management of ectopic pregnancy.Retrospective review of the medical management of ectopic pregnancies with methotrexate at a South African tertiary hospitalThe gestational sac in a cervical ectopic pregnancy must be distinguished from a gestational sac passing through the cervix during an abortion in progress.Imaging of vaginal bleeding in early pregnancyThe study also showed that women in the ectopic pregnancy group were less likely to have a subsequent miscarriage or an induced abortion - a 54 percent and 28 percent reduced risk respectively - when compared with women whose first pregnancy ended in miscarriage.Women whose first pregnancy was ectopic have fewer kidsIs the difficulty in diagnosing ectopic pregnancy adding substantial financial burden to the healthcare system, and would a new biomarker improve this?Ectopic pregnancyThe plan was a diagnostic laparoscopy with possible oopherectomy or salpingectomy to identify and remove the presumed ectopic pregnancy.Ectopic production of HCG by a benign ovarian mature cystic teratoma simulating an extra-uterine pregnancy: a case reportThe study group included 88 women from population of ectopic pregnancy who were admitted with signs and symptoms of ectopic pregnancy.Is serum creatine kinase a reliable indicator for early diagnosis of ectopic pregnancy?Prior to the ectopic pregnancy, the woman had given birth three times, and had had six abortions.Bulgarian Roma Besiege Hospital over Pregnant Womana[euro][TM]s DeathMark's wife, Suzanne, suffered an ectopic pregnancy and he will run to raise funds for the trust.Marathon man runs in memory of his lost babyThe pair carried out their fundraiser at the Novotel Hotel, Cardiff, after Ceri nearly died from a misdiagnoses of an ectopic pregnancy in 2008.Mum's health scare inspires charity effortAn ectopic pregnancy occurs when a fertilized egg does not reach the uterus and starts growing outside the uterus.Health Watch Ectopic pregnancyThere are chapters on pregnancy loss, ectopic pregnancy, gestational trophoblastic disease, and multi-fetal pregnancy reduction.Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care Medical browser ? ▲ectopic ACTH syndromeectopic beatectopic boneectopic calcificationectopic corticotropin productionectopic Cushing syndromeectopic deciduaectopic eruptionectopic expressionectopic eyelashectopic fatectopic focusectopic gestationectopic hamartomatous thymomaectopic heart beatectopic hormoneectopic hormone productionectopic hormone secretionectopic impulseectopic kidneyectopic lymph nodeectopic myelopoiesisectopic pacemakerEctopic parathyroid tissueectopic pinealomaectopic pregnancyectopic rhythmectopic schistosomiasisectopic tachycardiaectopic teratismectopic teratosisectopic testisectopic ureterectopic ureteroceleectoplacentalectoplacental coneectoplasmectoplasmaticectopotomyectopterygoidectopyectoretinaectosarcectoscopyectostealectostosisectothermectothermicectothermyectothrixEctothrix species▼ Full browser ? ▲ectopic lymph node ectopic lymph node ectopic lymph node ectopic lymph node ectopic mineralization ectopic mineralization ectopic mineralization ectopic mineralization ectopic myelopoiesis ectopic myelopoiesis ectopic myelopoiesis, extramedullary myelopoiesis ectopic myelopoiesis, extramedullary myelopoiesis ectopic oral calcification ectopic oral calcification ectopic oral calcification ectopic oral calcification ectopic ossification ectopic ossification ectopic ossification ectopic pacemaker ectopic pacemaker ectopic pacemaker ectopic pacemaker ectopic pairing Ectopic parathyroid tissue ectopic pinealoma Ectopic pregnancies Ectopic pregnancies Ectopic pregnancies Ectopic pregnancies ectopic pregnancyEctopic Pregnancy 2 Ectopic Pregnancy Trust ectopic pregnancy, extrauterine pregnancy ectopic pregnancy, extrauterine pregnancy ectopic pregnancy, extrauterine pregnancy ectopic pregnancy, extrauterine pregnancy ectopic rhythm ectopic rhythm ectopic rhythm ectopic rhythm ectopic schistosomiasis ectopic sesamoid bone ectopic sesamoid bone ectopic tachycardia ectopic tachycardia ectopic tachycardia ectopic teeth ectopic teeth ectopic teeth ectopic teratism ectopic teratism ectopic teratosis ectopic testis ectopic testis ectopic testis ectopic testis ectopic thyroid ectopic thyroid ectopic thyroid ectopic ureter ▼ Facebook Share Twitter Google+ CITE Site: Follow: Facebook Twitter Google+ Rss Mail Share: Facebook Twitter LinkedIn Mail Open / Close More from Medical Dictionary Mobile Apps Apple Android Kindle Windows Windows Phone Free Tools For surfers: Free toolbar 2003-2016 Farlex, Inc Disclaimer

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