Procrastinations essay
Scenario 9 – Ectopic pregnancy
Claire is a 26-year-old female who lives in Taradale with her 28-year-old partner. They have been trying to conceive for the past 12 months and they were delighted to finally have a positive home pregnancy test three weeks ago. She is fit and active, with no medical history.
This morning Claire experienced abdominal cramping and a very small amount of vaginal bleeding. This afternoon the pain became excruciating, extending to her left shoulder. Her partner has bought her into the Emergency Department, where they were informed she has an ectopic pregnancy.
Your discussion needs to include the following
Research this condition and using appropriate terms describe the aetiology of an ectopic pregnancy.
Describe the clinical manifestations (physical and/or mental health changes) seen in an acute presentation of a patient with an ectopic pregnancy.
Identify nursing strategies, supported by current peer reviewed literature, which you would implement to address Claire’s needs while caring for her in the ED.
Discuss treatment options (surgical and non-surgical) for patients with an ectopic pregnancy in New Zealand- including the risks and benefits of these
Discuss relevant New Zealand health determinants relating to Claire such as cultural, social, and economic factors in relation to ectopic pregnancy and miscarriage. What impact could an ectopic pregnancy have on Claire and her family?
On discharge, what local support services are available for Claire to access?
(1) Research this condition and using appropriate terms describe the aetiology of an ectopic pregnancy.
An ectopic pregnancy is where the fetilised egg implants outside the uterus (womb), most commonly in the fallopian tube (the tube that connect the ovary to the uterus) - Ectopic Pregnancy
Possible causes of an ectopic pregnancy: - Ectopic pregnancy
Tubal damage from pelvic infection, endometriosis or appendicitis
women who have had previous abdominal surgery (scar tissue and adhesions develop)
In most cases the cause of the pregnancy developing outside the uterus is never discovered
How is an EP confirmed? - Ectopic pregnancy
a urine test to confirm that you are pregnant
an ultrasound scan may confirm an EP. However, the scan may not be clear if the pregnancy is very early. A few days observation may be needed if symptoms are not severe. A repeat scan a few days later may clarify the site of the pregnancy
Blood tests that show changes in the pregnancy hormones
Laparoscopy is advised which is a procedure that has a look inside the abdomen using a special telescope
Ectopic pregnancy occurs when fetal tissue implants outside of the uterus or attaches to an abnormal or scarred portion of the uterus - StatPearls
Is the implantation of an embryo outside of the uterine cavity most commonly in the fallopian tube. Smooth muscle contraction and ciliary beat within the fallopian tubes to assist the transport of an oocyte and embryo. Damage to the fallopian tubes, usually secondary to inflammation, induces tubal dysfunction which can result in retention of an oocyte or embryo. - StatPearls
Ectopic implantation can occur in the cervix, uterine cornea, myometrium, ovaries, abdominal cavity, etc. Women with tubal ligation or other post-surgical alterations to their fallopian tubes are at risk for EP as the native function of the fallopian tube would be altered. The patient additionally can have an EP with a concurrent intrauterine pregnancy, known as a heterotopic pregnancy - StatPearls
(2) Describe the clinical manifestations (physical and/or mental health changes) seen in an acute presentation of a patient with an ectopic pregnancy.
Ectopic pregnancy
pain on one side of the lower abdomen. It may develop sharply, or may develop slowly get worse over several days. It can become severe
Vaginal bleeding often occurs, but not always. it is often different to the bleeding of a period. The blood may look darker.
Diarrhoea, feeling faint, or pain on passing faeces (stool)
Shoulder-tip pain may develop. This is due to some blood leaking into the abdomen and irritating the diaphragm (the muscle used to breath)
If the fallopian tube ruptures and causes internal bleeding, you may develop severe pain or ‘collapse’. This is an emergency as the bleeding is heavy
MFM
Amenorrhoea: many patients deny any amenorrhoea and some vaginal bleeding around the time a period is common (probably associated with low progestogen levels)
Minimal to severe abdominal tenderness, guarding or peritonism
stat-pearls
Evaluating of vital signs to assess for tachycardia and hypotension is pivotal in determining the patient’s hemodynamic stability.
When examining the abdomen and suprapubic regions, attention should focus on the location of tenderness as well as any exacerbating factors
If voluntary/involuntary guarding of the abdominal musculature is elicited on palpation, this should raise concern for possible free fluid or other cause of peritoneal signs
(3) Identify nursing strategies, supported by current peer reviewed literature, which you would implement to address Claire’s needs while caring for her in the ED.
Randomized trial
laparoscopic surgery is the first choice for the treatment of ectopic pregnancy. Its intraoperative vision is clear, which can help doctors quickly find the lesion and remove it in time
In addition, laparoscopic surgery is performed in an almost completely closed pelvic cavity, which can prevent the exposure of organs to the air and damage in an almost completely pelvic cavity, which can prevent the exposure of organs to the air and damage to tissues by gloves and gauze, and reduce the occurrence of pelvic and abdominal adhesions
Perioperative period refers to the period of time between the establishment of surgical treatment and the completion of the treatment related to the operation. In recent years, laparoscopic surgery has been widely used in the surgical treatment of ectopic pregnancy. With the continuous development of laparoscopic technology, perioperative nursing intervention carried out in conjunction with laparoscopic surgery has also progressed from a traditional single nursing model to a new type with strong comprehensiveness.
This nursing mode is helpful for promoting the recovery of patients and reducing the occurrence of complications
Basic perioperative nursing plan:
Perioperative care
after the patient was admitted to the hospital, the nurse assisted the doctor to ask for a detailed medical history, conduct a comprehensive physical examination, connect several parameter monitors, and determine the patient’s condition as soon as possible based on the degree of abdominal pain, complexion, pulse respiration, central venous pressure, urine output, severity, quick and accurate establishment to a venous channel, rapid fluid rehydration, blood transusion, and close observation of the patient’s vital signs.
Oxygen was inhaled at 4-6 L/min, and if necessary, the face mask was pressurized to maintain oxygen saturation above 95%
Absolute bed rest required, and the abdomen was not pressed.
The amount of vaginal bleeding was observed and recorded.
While fighting shock, all preoperative preparations were quickly completed, including instructing patients to abstain from eating and drinking indwelling urinary catheters, and preparing skin for the operation area.
Health education and psychological intervention
most patients lack disease and medical knowledge, and the prominent psychological response is anxiety and panic, especially in young patients. Before the operation, the procedure was patiently and carefully explained, and the patients were comforted to eliminate the patient’s worries. Relevant medical knowledge, successful cases of conservative treatment, and the pros and cons of surgical treatment were introduced if necessary to both the patients and their families, and the questions raised by patients and their families were answered patiently. Preoperative health education for patients and their families before surgery was carried out to inform them of the purpose of laparoscopic surgery, and increase patient’s understanding of laparoscopic surgery.
Discharge guidance:
nurses carefully taught patients about the precautions after discharge, and instructed patients not to engage in heavy physical labor within 2 weeks, strengthen nutrition, and try to eat high-calorie, high-protein, rich in vitamins, light, and easy-to-digest foods. Patients were told to keep warm daily and avoid catching a cold. The patients were also informed that human chorionic gonadotropin (HCG) hormone would be reviewed 1 week after surgery
A protocol
It has the potential to affect patients not only in the acute setting but also has lasting impacts on future fertility, with only 50% women successfully having a alive birth following an ectopic pregnancy
the main categories of treatment fall into expectant management, medical management with methotrexate, or surgical management with a salpingostomy or salpingectomy,.
The approach towards counselling women with ectopic pregnancies depends on the woman’s clinical states, her wishes and the level of compliance, but also her serum beta-hCG, ultrasonography findings and operator experience laparoscopically.
Clinically unstable patients with pain and bleeding may require immediate surgical management prior to formal ultrasonography
(4) Discuss treatment options (surgical and non-surgical) for patients with an ectopic pregnancy in New Zealand- including the risks and benefits of these
A protocol
the main categories of treatment fall into expectance management, medical management with methotrexate, or surgical management with a salpingostomy or salpingectomy
It has the potential to affect patients not only in the acute setting but also has lasting impacts on future fertility, with only 50% women successfully having a alive birth following an ectopic pregnancy
the main categories of treatment fall into expectant management, medical management with methotrexate, or surgical management with a salpingostomy or salpingectomy,.
The approach towards counselling women with ectopic pregnancies depends on the woman’s clinical states, her wishes and the level of compliance, but also her serum beta-hCG, ultrasonography findings and operator experience laparoscopically.
Clinically unstable patients with pain and bleeding may require immediate surgical management prior to formal ultrasonography
Ectopic pregnancy
Ruptured Ectopic pregnancy
emergency surgery is needed if a fallopian tube ruptures with heavy bleeding. The main aim is to stop the bleeding. The ruptured fallopian tube and remnant of the early pregnancy are then removed. The operation is often life-saving
Early ectopic pregnancy - surgery
a planned operation is the usual treatment. Removal of the tube and the ectopic pregnancy is the traditional treatment
Laparoscopy - insertion of scope (camera) into the abdomen through your navel (‘key hole surgery’)
Laparotomy - incision (open cut) into the abdominal cavity
Salpingectomy - removal of the fallopian tube
Salpingotomy - cutting open the tube and removing the ectopic pregnancy alone (preserving the tube)
Medical treatment
a medicine called methotrexate may be an option. it works by stopping the cells of the pregnancy growing in the fallopian tube. It is only advise if the pregnancy is very early. The advantage is that you do not need an operation. The disadvantage is that you will need close observation for several weeks with repeated blood tests to check it has worked. Also side-effects affect some women. if this treatment is not successful, further surgery to remove the tube may be necessary.
Expectant management (‘wait and see’)
some ectopic pregnancies that have not ruptured clear without treatment. The pregnancy often dies in a way similar to a miscarriage. A possible option is to ‘see how things go’ if you have mild or no symptoms. You can have treatment if symptoms become worse. However, a ‘wait and see’ approach is often not advised. This is because there is a chance of a sudden rupture of the fallopian tube. This will need emergency surgery. You will need close observation and repeated scans and blood tests to check on how things are developing.
You may experience some bleeding for few days after surgery/medical treatment, due to the fact that you have been pregnant and the lining of the womb has thickened.
MFM
Medical treatment of ectopic pregnancy
criteria for medical therapy
haemodynamically and clinically stable
normal blood count, liver enzymes, serum creatinine
no fetal heartbeat seen on ultrasound
desire for future fertility
drug used:
Methotrexate (a single intramuscular (IM) dose initially - repeated doses may be necessary
dose:
50 mg/m2 of patient body-surface are (typically 75 mg to 95 mg) calculated using nomogram
side effects:
Stomatitis
Gastritis, nausea
Leucopenia
Thrombocytopenia
Raised liver enzymes
Alopecia
Surgical treatment for ectopic pregnancy
Criteria for Laparoscopic salpingectomy
haemodynamically stable patients
future fertility is not desired
fallopian tube is significantly damaged, particularly the fimbrial end
fetal heart activity is seen on the scan
ruptured ectopic pregnancy
Criteria for laparoscopic salpingotomy
future fertility is desired
patient is haemodynamically stable
no fetal heartbeat seen on ultrasound
(5) Discuss relevant New Zealand health determinants relating to Claire such as cultural, social, and economic factors in relation to ectopic pregnancy and miscarriage. What impact could an ectopic pregnancy have on Claire and her family?
a protocol
It has the potential to affect patients not only in the acute setting but also has lasting impacts on future fertility, with only 50% women successfully having a alive birth following an ectopic pregnancy
STatpearls
Ectopic implantation can occur in the cervix, uterine cornea, myometrium, ovaries, abdominal cavity, etc. Women with tubal ligation or other post-surgical alterations to their fallopian tubes are at risk for EP as the native function of the fallopian tube would be altered. The patient additionally can have an EP with a concurrent intrauterine pregnancy, known as a heterotopic pregnancy - StatPearls
Ectopic pregnancy
Although you may want to try again, it is best to wait until you and your partner are ready, both physically and emotionally
It is advisable to wait until 4-6 weeks after surgery before resuming sexual intercourse. If you had medical treatment, your doctor will advise you accordingly
If one tube is removed, you will continue to ovulate as before, but your chances of conceiving may be reduced. This varies with each individual
One common question is “what is the chance of having a future normal pregnancy after an ectopic pregnancy?” Even if one fallopian tube is removed, you have about a 7 in 10 chance of having a future normal pregnancy. (The other fallopian tube will still usually work.). There is also a 1 in 10 chance of a repeat ectopic pregnancy. As soon as you suspect you are pregnant, You must contact your GP immediately and be monitored closely
Once an ectopic pregnancy has been excluded, the pregnancy would be anticipating to continue normally and no further close monitoring would be required
Returning to work or normal activities
you will need possibly upto 4-6 weeks to recuperate after surgery. It is advisable to build up your strength gradually. Having an ectopic pregnancy can be traumatic because you are dealing with loss of a pregnancy as well as trying to recover from emergency surgery
It is common to feel anxious or depressed for a while after treatment. Worries about possible future ectopic pregnancy, the effect of fertility, and sadness over the loss of the pregnancy are normal. Do talk with a doctor about these and any other concerns following treatment
MFM
patients are generally advised to delay another pregnancy until recovered both physically and emotionally from this pregnancy. The chance of another ectopic pregnancy should be explained. Patients are advised to have a pregnancy test on missing her menses and if pregnancy, a trans-vaginal ultrasound scan should be arranged to locate the pregnancy. Patients with bilateral tubal disease should be referred to discuss IVF if future fertility is desired
(6) On discharge, what local support services are available for Claire to access?