Tubal
pregnancy accounts for 95% cases among ectopic pregnancies. It is
a potentially fatal condition and remains a leading cause of pregnancy
related deaths in the first trimester. It constitutes 2% births
with recurence in more than 20% patients and permanent sterility
in 20-60% of cases.
Mrs. P, 35 years old G3 pI LI A I came to the hospital on 8-3- 03
with history of polymenorhoea since two cycles with chronic colicky
lower abdominal pain with discomfort while on mobility. Attacks
were relieved by taking rest.
Her menstrual periods were irregular - 3-4/45-60 days. With dysmenorrhoea.
Her past obstetical history revealed that she had 6 year old male
child who was deivered by forceps application. 2nd pregnancy was
evacuated due to blighted ovum. Her general conition was stable,
mild tenderness over abdomen. On speculum ex- amination cervical
erosion was noticed. On PV examination ex- pressed pain on movement
of cer- vix and nodularity of uterus was appreciated. It was diagnosed
as PID and she was kept on following medications i.e. T. Doxycyclin
200mg od 7 days, T. Ibugesic I BD 7 dyas, T. Metrogyl 300 mg tid
7 days. But symptoms were not relieved. Lower abdominal pain inreased
and bleeding continued.
Transvaginal
sonography advised when she came for recheck up on 15-3-03. This
test was delayed till 20-3-03 due to personal problems of the motner.
TVS was done on 20-3-0. TVS showed mixed echogenic sol , suggestive
of ectopic gestation and it was diagnosd as chronic left unruptured
ectopic pregnancy, with right ovarian cyst.
Pap smear was sent on the same day which showed moderately inflammatory
smear.
Urine test for pregcolor was done. It was found to be negative.
Serum sent for Bh CG. Mrs. P BhCG levels are 70 iu/ml (nor- mal
10 iulml).
Explained to the mother about the risk and signs and symptoms of
rupture of ectopic pregnancy. Immediately the mother was posted
for surgery but it was delayed for one week due to personal problems
of the mother.
Sent
the necessary investigations: HB: 12.8gltl, urine analysis: NAD,
RBS; 104mg, blood group B+VE,HBSAG-VE,HIV-VE. Mrs P was readmitted
on 23-3-03. Op- erative laparoscopy under general anaesthesia was
done on 24-03- 03. As tubal mass was big and extensively damaged
and intlammed left salpigectomy preformed. Dye test was done to
assess the patency of right tube. Partial block was noticed. Block
was cleared by repeated pushing under pressure cystectomy of right
ovary was done.
Preoperative
Nursing Care
Observed
for signs & symptoms of tubal rupture i.e severe abdominal pain,
syncope, shock distension of ab domen, haemorr-hages no bleeding
during preoperative period. Explained about the surgical procedure
that is either conservation of tube or resection of tube depending
on the tubal involvement provided emotional support.
Administered preoperative medications: administered tab. Diazepam
2hs & at 6 a.m.
Post
Operative Management
No
bleeding observed during postoperative period vital signs stable.
Surgical dressing was clean & healthy. Wound drainage was observed
tor bleeding only 20 ml fluid was collected. It was removed on 2nd
postoperative day. Patient was kept on NBM 011 operative day. Administered
intravenous fluids.
Oral fluids given on j'irst postoperative day after listening to
bowel sounds.
Strict
aseptic principles maintained while doing allY proedure.
Administered Inj Metrogyl 500mg Q8t11 days, Inj. Cetextrime 500mg
bd 3 days. Mrs. P developed fever 101 F during second post operative
day. After the cold compress application administered Inj Crocin2ml
lM. Plenty of oral fluids administered. Fever reduced on third post
operative day.
Maintained
intake and out- put chart. Mother ambulated on first post operative
day.
Counselled
the Couple about Future Pregnancy
Encouraged
the women to plan for early pregnancy. Couple informed regarding
subsequent fertility chances and even recurrence of ectopic pregnancy.
Mrs P was given ovulation induction drugs and she was followed for
conception.
Discharge
Advice
Educated
regarding signs of post operative infection that is fever, abdominal
pain, increased or malodorous vaginal discharge and to report to
if it appears. Rest for 15 days.
Restriction of activities for One week.
Reinforce the chances ofanother ectopic pregnancy are increased.
And that subsequent potential fertility may be decreased.
Advised follow up after one week.
Educated about sig.ns of ectopic pregnancy i.e amenorrhoea, vaginal
bleeding, adominal pain and to report immediately. Informed the
need for tests or procedures to evaluate the future reproductive
status.
Conclusion
Incidence
of ectopic pregnancy has increased over the last few years due to
increased prevalcnce of risk factors. In recent years due to increased
public awareness and in:lproved diagnostic techniques, about 76%
women now present with unruptured ectopic pregnancies in haemodynam-ically
stable conditions and classical presentation of shocked patients
had become uncommon.
Women who experience tubal pregnancy often experience manifestations
of pam, physiological shock due to hemorrhage and grief simultaneously.
Patient may also express feelings of self blame and concern for
her child bearing capacity. In addition to provid- ing high quality
physical care to patient, nurse must be sensitive to the sense of
loss and grief. With modern methods of diagnosis and treatment prognosis
from this pregnancy related complication has markedly improved.
RFERENCES
1.
Malik Mehamood Rahana, Jalil Gulfreen, Malik Mahamood Addullah (2003).
Current trends in management of ectopic pregnancy journal of obs
& gynae to day. Vol VIII (2) pp 74-80.
2. Kotia Namita (2001) Ruptured Tubal Twin Pregnancy, A Rare Case
Report Journal of Obs & Gynae to day vol VI(I),PP.28.
3. Mukherjee, Soma, Jain Meenakshi (2002). Fertility Outcome Following
Ectopic pregnancy journal of Obs & Gynae t09ay Volll (5) pp 249-
251.
4. Nattina M. Sandra (2000). Lippincott mahual of Nursing Practice
(Seventh Edition): Newyork, Lippincot publish- ers, Ch 39; pp 1179-1180.
