Ectopic Pregnancy Nursing Guide

This course is intended as a Quick Reference for ectopic pregnancy and will cover an overview as well as nursing considerations utilizing the nursing process.

Ectopic Pregnancy Etiology and Epidemiology 

Ectopic pregnancy is the occurrence of a fertilized ovum implanting outside of the uterine lining. Ectopic pregnancies are medical emergencies that can be life-threatening. Out of all reported pregnancies, 1 to 2% are ectopic pregnancies (Conrad-Stöppler, 2021). Any pregnant woman in the first trimester who presents with vaginal bleeding should be evaluated for the existence of an ectopic pregnancy. This is critical to prevent the rupture of the structure where the embryo has been implanted and prevent negative, and possibly fatal, outcomes. Ectopic pregnancies can rupture as early as 6 weeks and as late as 16 weeks gestation (Dulay, 2020). 

The abnormal implantation of an embryo may occur in several locations, including (Dulay, 2020): 

• Fallopian tubes (known as tubal pregnancy and accounts for most ectopic pregnancies) 
• Uterine cornua (horns) 
• Ovary 
• Cervix 
• Abdominal/pelvic cavity 

Once an ovum is fertilized, it travels through the fallopian tubes to implant into the nutrient, blood-enriched endometrium lining of the uterus. However, when en route to the uterus, the embryo may become blocked or trapped in the fallopian tube and forced to implant there. This may occur due to several risk factors, including (Conrad-Stöppler, 2021): 

• Age: 35 to 44 is the age group with the highest incidence of ectopic pregnancies 
• Fallopian tube defects: Tumors or congenital abnormalities 
• History of tubal ligation and/or tubal ligation reversal 
• Infections: Pelvic inflammatory disease (PID), chlamydia, or gonorrhea 
• Scarring: Ruptured appendix, c-sections, reproductive organ surgeries, and infections 
• Gynecological conditions: Endometriosis, pelvic adhesions, fibroid tumors, or lesions 
• Intrauterine devices (IUDs) 
• Cigarette smoking 
• Multiple sex partners: Increases the risk of pelvic infections 

A history of a previous ectopic pregnancy will increase the risk of recurrence by 10 to 25%, which is the most significant risk factor (Dulay, 2020). Infertility may also increase risk due to the use of assisted reproductive techniques (in vitro fertilization and gamete intrafallopian tube transfer) to achieve pregnancy (Dulay, 2020). 

Complications of ectopic pregnancies for the fetuses are fatal. This is due to most ectopic pregnancies ending spontaneously (implanted structure ruptures if not treated) by the 16th week of gestation, which is too early for a fetus to survive on its own. Complications for the mother can be severe with delayed or no treatment; 9% of all maternal pregnancy-related deaths are attributed to ectopic pregnancies (Dulay, 2020). 

Complications may include (Dulay, 2020): 

• Rupture of implanted structure 
• Internal bleeding 
• Rapid hemorrhaging 
• Hemorrhagic shock 
• Peritonitis 
• Infertility (hysterectomy) 
• Death 

Rapid identification and intervention of an ectopic pregnancy are important to ensure the best outcome for each circumstance. 

Ectopic Pregnancy Diagnosis 

A definitive diagnosis of ectopic pregnancy can be obtained from diagnostic procedures that include (Conrad-Stöppler, 2021): 

• Pregnancy test (that detect human chorionic gonadotropin [hCG] levels) 
• Pelvic ultrasonography 
• Transvaginal ultrasonography 
• Laparoscopy 

Ectopic Pregnancy Management 

Management and treatments are focused on the survival of the mother and the least invasive to maintain childbearing possibilities. Management of ectopic pregnancy depends on the acuity of the case. 

 For ectopic pregnancies that are detected early, unruptured, and small (less than 3 centimeters in diameter), a methotrexate injection may be given (Dunlay, 2020). However, the treatment must be closely monitored for efficacy, and surgery may be needed or a second dose of methotrexate if the first dose is not effective (Dunlay, 2020). 

 The usual treatment is surgical removal of the ectopic pregnancy. The surgical procedure used may include (Dunlay, 2020): 

• Laparoscopic surgery 
• Laparotomy 
• Salpingotomy 

Ectopic Pregnancy Nursing Care Plan

Nursing Considerations 

Use the nursing process to develop a plan of care for individuals. The nursing assessment (with common findings listed), diagnoses, interventions, expected outcomes, and education for ectopic pregnancy are listed below. 

Assessment 

A thorough history should be taken that includes: 

• Past and present health conditions 
• Current symptomology (symptoms most likely started 6 weeks since last menstrual cycle) 
• Menstruation history (especially within the past 3 months) 
• Reproductive history (past pregnancies, infertility, miscarriages, ectopic pregnancies) 
• Sexual history and practices (if time permits) 
• Smoking history 

Upon physical assessment, the following findings may be noted: 

• Low blood pressure 
• Increased respirations 
• Shallow breathing 
• Rapid pulse 
• Altered levels of consciousness 
• Confusion 
• Excessive sweating 
• Pale skin 
• Tenderness in the pelvic region (unilateral or bilateral) 
• Swelling/bloating (abdominal, pelvic) 
• Vaginal exam (Dulay, 2020): 
  • Cervical tenderness when moved 
  • Adnexal tenderness 
  • Adnexal mass 
  • Uterus slightly enlarged 

The individual may report: 

• Pelvic pain (possibly one-sided) 
• Rectal pain/pressure 
• Cramping (abdomen, pelvic) 
• Shoulder pain 
• Missed or irregular periods 
• Vaginal bleeding 
• Dizziness 
• Fainting 
• Nausea 
• Vomiting 

Nursing Diagnosis/Risk For 

The individual experiencing an ectopic pregnancy may exhibit physical, emotional, and psychological symptoms. To care for the individual appropriately and understand the depth of the issues that arise is important. It is imperative to recognize some of the many complications that the individual may be at risk of, including but not limited to: 

• Acute confusion 
• Acute pain 
• Deficient fluid volume 
• Bleeding 
• Infection 
• Fatigue 
• Shock 
• Maternal injury 
• Disturbed maternal-fetal dyad 
• Ineffective coping 
• Grieving 
• Fear 
• Hopelessness 

Interventions 

Interventions should reflect the individualized needs of the person. The degree of acute illness (physical and psychological) must be considered to create interventions. Interventions should include: 

• Monitor vital signs. 
• Increase comfort. 
• Discuss procedures. 
• Surgical or pharmacological 
• Expectations and outcomes 
• Post-surgical care and monitoring 
• Post-injection care and monitoring 
• Monitor input and output. 
• Monitor activities if bed rest is ordered. 
• Refer/connect with grief support counselor/groups. 

 If shock occurs, maintain comfort and prescribe treatments which may include (Martinez, 2020): 

• Monitor closely 
• Maintain warmth 
• Elevate legs 
• Provide oxygen 
• Provide intravenous (IV) fluids 
• Provide blood transfusion 

Expected Outcomes 

Outcomes will reflect successful symptom management by: 

• Cease bleeding/hemorrhaging 
• Decrease in pain/discomfort 
• Maintain childbearing ability 
• Vital signs within a normal clinical range 
• Decrease in depression and/or guilt 

Individual/Caregiver Education 

• Risk of ectopic pregnancy reoccurrence (signs and symptoms to be aware of) 
• Decrease preventable ectopic pregnancy risk factors by (Martinez, 2020): 
  • Smoking cessation 
  • Safe sex practices 
  • Early treatment for sexually transmitted infections (STIs) 
• Self-care measures 
  • Quiet space 
  • Relaxation techniques 
  • Deep breathing 
  • Centering techniques 
• Importance of family/friend support 
• Future childbearing outlook 
• Grief and loss 

Content Release Date

4/1/2022

Content Expiration

12/31/2025

Course Contributor 

The content for this course was created by Tameka N. Warren, MSN, RN, CLC. 

Tameka N. Warren, MSN, RN, CLC, earned her Bachelor and Master of Science in Nursing degrees from Indiana University School of Nursing at IUPUI, and her Associate of Science in Nursing from Ivy Tech College. She has over 16 years of nursing experience in public health, regulation, home health, education, maternal child community health, and long-term care environments. Tameka served as a Public Health Nurse Surveyor (Home Health & Hospice) certified by the Centers for Medicare & Medicaid Services, or CMS, a maternal and infant mortality advocate, an ALPP Certified Lactation Counselor, and an Adjunct Clinical Professor. Tameka’s passion is to serve the most vulnerable populations affected by health disparities and to inspire a new generation of nurses to do the same successfully. 

Resource 

• March of Dimes https://www.marchofdimes.org/complications/ectopic-pregnancy.aspx 

References 

• Conrad-Stöppler, M. (2021). Ectopic pregnancy (Tubal pregnancy). https://www.medicinenet.com/ectopic_pregnancy/article.htm 
• Dulay, A. T. (2020). Ectopic pregnancy. https://www.merckmanuals.com/home/women-s-health- issues/complications-of-pregnancy/ectopic-pregnancy 
•  Martinez, L. (2020). Ectopic pregnancy. https://medlineplus.gov/ency/article/000895.htm