ECTOPIC PREGNANCY

An ectopic pregnancy is commonly referred to as tubal pregnancy because 95 percent occur in a

fallopian tube. An ectopic pregnancy needs to be treated immediately to avoid fallopian tube damage or
life threatening blood loss. When identified early, ectopic pregnancies are treatable with medication that
stops the pregnancy. If the pregnancy is further along, laparoscopy is usually performed to remove the
ectopic tissue and repair the fallopian tube. Currently, laparotomy is the preferred technique when the
patient is hemodynamically unstable, the surgeon has not been trained in laparoscopy, physical facilities
and supplies to perform laparoscopic surgery are lacking or technical barriers to laparoscopy are present.

An ectopic pregnancy is often caused by a condition that blocks or slows the movement of a
fertilized egg through the fallopian tube to the uterus. This may be caused by a physical blockage in the
tube by hormonal factors and by other factors, such as smoking.

Most cases of scarring are caused by:

 Past ectopic pregnancy

 Past infection in the fallopian tubes
 Surgery of the fallopian tubes

Ectopic pregnancy is gestation located outside the uterine cavity. The fertilized ovum implants outside of
the uterus, usually in the fallopian tube. Predisposing factors  include adhesions of the tube, salpingitis,
congenital and  developmental anomalies of the fallopian tube, previous ectopic pregnancy, use of
an  intrauterine device for more than 2 years, multiple induced abortions, menstrual reflux, and decreased
tubal motility.

If the ectopic pregnancy has ruptured or bleeding persists, salpingectomy is a very common
option. This procedure involves excision of segment of the Fallopian tube involved in the ectopic
pregnancy. The tubal segment to be removed is coagulated and cut off with bipolar forceps.

CAUSES OF ECTOPIC PREGNANCY

An ectopic pregnancy is often caused by damage to the fallopian tubes. A fertilized egg may have
trouble passing through a damaged tube, causing the egg to implant and grow in the tube.
Things that make you more likely to have fallopian tube damage and an ectopic pregnancy include:

 Smoking. The more you smoke, the higher your risk of an ectopic pregnancy.
 Pelvic inflammatory disease (PID). This is often the result of an infection such as
chlamydia or gonorrhea.
 Endometriosis, which can cause scar tissue in or around the fallopian tubes.
 Being exposed to the chemical DES before you were born.

Some medical treatments can increase your risk of ectopic pregnancy. These include:

 Surgery on the fallopian tubes or in the pelvic area.

 Fertility treatments such as in vitro fertilization.

The major cause of ectopic pregnancy is salpingitis, accounting for about half of first time ectopic
pregnancies.

Salpingitis can fuse together the folds in the Fallopian tube. These folds are naturally found lining
the inside of the tube. This narrows the inside of the tube such that sperms can travel normally through it,
but the embryo cannot. Secondly, the embryo can be trapped in blind pockets formed by adhesions inside
the tube (adhesions are abnormal joining between organ parts, which usually form after damage to
organs). 

SYMPTOMS OF ECTOPIC PREGNANCY

If a woman has an ectopic pregnancy, she may experience the typical early pregnancy
symptoms, including nausea and breast tenderness. Or, she may have no early symptoms at all and may
not even realize that she is pregnant. About a week after the first missed menstrual period, one may
notice:

 Slight vaginal bleeding that is usually brown in color. Women often mistake this bleeding for a
normal menstrual period.
 Pain in the lower abdomen, felt mainly on one side.

Without treatment, the symptoms of the ectopic pregnancy will worsen over several days or weeks. They
include:

 Severe pelvic pain

 Shoulder pain caused by blood from a ruptured ectopic pregnancy pressing on the diaphragm,
the large muscle that separates the abdominal and chest cavities
 Faintness or dizziness caused by blood loss
 Nausea
 Vomiting
 Low blood pressure
 Lower back pain

DIAGNOSIS

A urine test can show if you are pregnant. To find out if you have an ectopic pregnancy, your
doctor will likely do:

 A pelvic exam to check the size of your uterus and feel for growths or tenderness in your belly.
 A blood test that checks the level of the pregnancy hormone (hCG). This test is repeated 2 days
later. During early pregnancy, the level of this hormone doubles every 2 days. Low levels suggest
a problem, such as ectopic pregnancy.
 An ultrasound. This test can show pictures of what is inside your belly. With ultrasound, a doctor
can usually see a pregnancy in the uterus 6 weeks after your last menstrual period.

NURSING MANAGEMENT

1. Ensure that appropriate physical needs are addressed and monitor for complications. Assess
vital signs, bleeding, and pain.

2. Provide client and family teaching to relieve anxiety.

 Explain the condition and expected outcome.
 Material prognosis is good with early diagnosis and prompt treatment, such as
laparotomy, to ligate bleeding vessels and repair or remove the damaged fallopian tube.
  Pharmacologic agents, such as methotrexate followed by leucovorin, may be
given orally when ectopic pregnancy is diagnosed by routine sonogram before the tube has
ruptured. A hystesolpingogram usually follows this therapy to confirm tubal patency.
 Rh-negative women must receive RhoGAM to provide protection from
immunization for future pregnancies.
 Describe self-care measures, which depend on the treatment.

3. Address emotional and psychosocial needs.

NURSING INTERVENTIONS

 Determine the date and description of the patient’s last menstrual period.

 Monitor vital signs for changes.
 Assess vaginal bleeding, including amount and characteristics
 Assess pain level
 Monitor intake and output
 Assess for signs of hypovolemia and impending shock
 Prepare the patient with excessive blood loss for emergency surgery.
 Administer prescribed blood transfusions and analgesics.
 Provide emotional support.
 Administer Rh (D) immune globulin (RhoGAM), as ordered, if the patient is Rh negative.
 Provide a quiet, relaxing environment
 Encourage the patient to express feelings of fear, loss, and grief.
 Help the patient develop effective coping strategies.
 Refer the patient to a mental health professional, if necessary, prior to discharge.

BREAST CANCER
 Is the leading type of cancer in women.Most breast cancer begins in the lining of the milk ducts, sometimes
the lobule.
 The cancer grows through the wall of the duct and into the fatty tissue.
 Breast cancer metastasizes most commonly to auxiliary nodes, lung, bone, liver, and the brain.
 The most significant risk factors for breast cancer are gender (being a woman) and age (growing older).
 Other probable factors include nulliparity, first child after age 30, late menopause, early menarche, long
term estrogen replacement therapy, and benign breast disease.
 Controversial risk factors include oral contraceptive use, alcohol use, obesity, and increased dietary fat
intake.
 About 90% of breast cancers are due not to heredity, but to genetic abnormalities that happen as a result of
the aging process and life in general.
 A woman’s risk of breast cancer approximately doubles if she has a first-degree relative (mother, sister,
daughter) who has been diagnosed with breast cancer. About 20-30% of women diagnosed with breast cancer
have a family history of breast cancer.

STAGES OF BREAST CANCER

STAGE DEFINITION
Stage 0 Cancer cells remain inside the breast duct, without
invasion into normal adjacent breast tissue.
Stage I Cancer is 2 centimeters or less and is confined to the
breast (lymph nodes are clear).
Stage IIA No tumor can be found in the breast, but cancer cells
are found in the axillary lymph nodes (the lymph nodes
under the arm)
OR
the tumor measures 2 centimeters or smaller and has
spread to the axillary lymph nodes
OR
the tumor is larger than 2 but no larger than 5
centimeters and has not spread to the axillary lymph
nodes.
Stage IIB The tumor is larger than 2 but no larger than 5
centimeters and has spread to the axillary lymph nodes
OR
the tumor is larger than 5 centimeters but has not
spread to the axillary lymph nodes.
Stage IIIA No tumor is found in the breast. Cancer is found in
axillary lymph nodes that are sticking together or to
other structures, or cancer may be found in lymph nodes
near the breastbone
OR
the tumor is any size. Cancer has spread to the axillary
lymph nodes, which are sticking together or to other
structures, or cancer may be found in lymph nodes near
the breastbone.
Stage IIIB The tumor may be any size and has spread to the chest
wall and/or skin of the breast
AND
may have spread to axillary lymph nodes that are
clumped together or sticking to other structures, or
cancer may have spread to lymph nodes near the
breastbone.
Inflammatory breast cancer is considered at least stage
 IIIB.
Stage IIIC There may either be no sign of cancer in the breast or a
tumor may be any size and may have spread to the
chest wall and/or the skin of the breast
AND
the cancer has spread to lymph nodes either above or
below the collarbone
AND
the cancer may have spread to axillary lymph nodes or
to lymph nodes near the breastbone.
Stage IV The cancer has spread — or metastasized — to other
parts of the body.

ASSESSMENT

 A firm lump or thickness in breast, usually painless; 50% are located in the upper outer quadrant
of the breast.
 Spontaneous nipple discharge; may be bloody, clear or serous.
 Asymmetry of the breast may be noted as the woman changes positions; compare one breast
with the other.
 Nipple retraction or scalliness, especially in Paget’s disease.
 Enlargement of auxiliary or supraclavicular lymph nodes may indicate metastasis

NURSING INTERVENTIONS

1. Monitor for adverse effects of radiation therapy such as fatigue, sore throat, dry cough, nausea,
anorexia.
2. Monitor for adverse effects of chemotherapy; bone marrow suppression, nausea and vomiting,
alopecia, weight gain or loss, fatigue, stomatitis, anxiety, and depression.
3. Realize that a diagnosis of breast cancer is a devastating emotional shock to the woman. Provide
psychological support to the patient throughout the diagnostic and treatment process.
4. Involve the patient in planning and treatment.
5. Describe surgical procedures to alleviate fear.
6. Prepare the patient for the effects of chemotherapy, and plan ahead for alopecia, fatigue.
7. Administer antiemetics prophylactically, as directed, for patients receiving chemotherapy.
8. Administer I.V. fluids and hyper alimentation as indicated.
9. Help patient identify and use support persons or family or community.
10. Suggest to the patient the psychological interventions may be necessary for anxiety, depression,
or sexual problems.
11. Teach all women the recommended cancer-screening procedures.