ANGELES UNIVERSITY FOUNDATION COLLEGE OF NURSING NURSING CARE MANAGEMENT 106-RLE

CASE REPORT:
Ectopic Pregnancy and Incompetent Cervix
SUBMITTED BY: MAGTOTO, ROSE ANNE BSN 4 5/ GROUP 18 SUBMITTED TO: GUADA KRISTINE S. MEDINA, R. N., M. N. SUBMITTED ON: JULY 24, 2012

ECTOPIC PREGNANCY - It came from the Greek word ektopos which means out of place; therefore, this is an implantation which occurs outside the uterine cavity. The most common site is on a fallopian tube {ampulla (80%), isthmus (12%), and interstitial/ fimbrial (8%)}. RISK FACTORS History of Pelvic Inflammatory Disease (tubal scarring e.g., salphingitis) In-Vitro Fertilization Women with IUD (may slow transport of zygote leading to tubal or ovarian implantation) Women who smoke Women who douche (risk of introducing an infection) Age over 35 Past infection in the fallopian tube Having many sexual partners Previous ectopic pregnancy Past abdominal surgery Narrow birth spacing

SIGNS & SYMPTOMS No unusual symptoms at the time of implantation o No menstrual flow o Nausea and vomiting of early pregnancy o Pregnancy test for hCG will be positive Weeks 6 12 of pregnancy (possible rupture of fallopian tube) o Sharp [one of the round ligaments is pulled with sudden movements], stabbing pain in one of the lower abdominal quadrants flowed by scant vaginal spotting o Bleeding [size and number of ruptured vessels]/ severe intra-peritoneal bleeding [if bleeding is within the interstitial portion] o Lightheadedness and rapid pulse (shock) [if internal bleeding progresses to acute hemorrhage] o Rapid, thread pulse; rapid respirations; and falling BP (severe shock) o Leukocytosis (not from infection but from trauma) o Temperature is usually normal o Cullens sign [if blood is slowly seeping and accumulating into the peritoneal cavity, the umbilicus may develop a bluish tinge where in pain due to irritation of the phrenic nerve radiates from the abdomen to back and shoulders]

DIAGNOSTIC & LABORATORY PROCEDURES Transvaginal sonogram demonstrates the ruptured tube and blood collecting in the peritoneum

Insertion of a needle through the post-vaginal fornix into the cul-de-sac under sterile conditions this is being performed by a physician to assess whether blood can be aspirated Laparoscopy or culdoscopy can be used to visualize the fallopian tube if the symptoms alone do not reveal a clear picture of what has happened Hgb & Hct level Blood typing & cross-matching hCG level [if pregnancy has been confirmed earlier in sonography]

MEDICAL-SURGICAL MANAGEMENT Unrupured tube Methotrexate (folic acid antagonist, chemotherapeutic agent) o Administer if the size is 3cm in ultrasound, 3 weeks from LMP, 300IU hCG o Attacks & destroys fact-growing cells o Followed by leucovorin to prevent normal cells from being destroyed Mifepristone (abortifacient) o Sloughing of the tubal implantation site Hysterosalphingogram or sonogram o usually performed after the chemotherapy to assess whether the tube is fully patent Tube is left intact & no surgical scarring Women are treated until a negative hCG titer is achieved Ruptured tube IVF infusion using large-gauge catheter Ligation of bleeding vessels and removal or repair of damaged fallopian tube through laparoscopy When a tube is removed, patient is just 50% fertile because when she ovulates every month, from the ovary next to the removed tube, sperm cant reach the ovum on that side. In case of a miscarriage Women with Rh-negative blood should receive Rh D immune globulin (RhIG) after an ectopic pregnancy within 72 hours (protection against isoimmunization in future childbearing)

NURSING MANAGEMENT 1. Encourage patient to verbalize her concerns about her ectopic pregnancy and future child bearing. 2. Assess patients need fro counseling.

PREMATURE CERVICAL DILATATION (INCOMPETENT CERVIX) - A cervix that dilates prematurely and cannot hold the fetus until term - Commonly occurs at approximately 20 weeks of pregnancy RISK FACTORS Increased maternal age Congenital structural defect Trauma to cervix (cone biopsy/ repeated D&C)

SIGNS & SYMPTOMS - Bloody show - Pelvic pressure - Rupture of the membranes SURGICAL MANAGEMENT Cervical Cerclage o done at approximately 12 to 14 weeks o purse-string sutures are placed in the cervix by the vaginal route under regional anesthesia o strengthen the cervix & prevent it from dilating o sutures may be removed at 37-38 weeks so the fetus may be delivered vaginally o sutures may be placed transabdominally, then Cesarean birth is performed A. McDonald Procedure o Nylon sutures are placed horizontally and vertically across the cervix and pulled tightly to reduced the cervix xanal to a few millimeters in diameter o Removal of sutures within 37-38 weeks of pregnancy (temporary) B. Shirodkar Technique o Sterile tape is threaded in a purse-string manner under the submucous layer of the cervix and sutured in place to achieve a closed cervix (more permanent solution) NURSING MANAGEMENT 1. After cerclage, the woman should remain on bed rest in a slight or modified Trendelenburg position to reduce pressure of the pelvic area and to promote proper healing. 2. Inform the woman that sexual relation may be resumed after rest periods.