ED Charge Nurse
Dixie Regional Medical Center
St. George, Utah
ACCOMPANIED BY HER HUSBAND, Tiffany Blackmore, 31, arrives at your ED complaining of severe lower abdominal and right shoulder pain. She tells you that the pain started suddenly 2 hours ago, and she also noticed some vaginal spotting this morning. Mrs. Blackmore says she feels dizzy and lightheaded; she's pale and diaphoretic.
What's the situation?
While obtaining Mrs. Blackmore's health history, you learn that she was treated for endometriosis about 5 years ago. She also tells you that she and her husband have been trying to conceive their first baby for the last 6 months. You take her vital signs: BP, 82/44; heart rate, 116; respirations, 22; and SpO2, 95% on room air. Her last menstrual period was 6 weeks ago. You perform a point-of-care pregnancy test; it's positive. She rates her pain as 8 on a 0–10 pain intensity rating scale. During your physical assessment, you note abdominal tenderness and guarding.
What's your assessment?
Based on Mrs. Blackmore's history and clinical status, you suspect a ruptured ectopic pregnancy. You immediately inform the ED physician, who confirms your assessment findings.
An ectopic pregnancy occurs when a fertilized ovum is implanted outside the uterus, typically in a fallopian tube. A ruptured ectopic pregnancy and resulting hemorrhage is one of the leading causes of maternal death in the first trimester.
Signs and symptoms of ectopic pregnancy typically include abdominal pain, amenorrhea, and abnormal vaginal bleeding. Shoulder pain, as in Mrs. Blackmore's case, may indicate peritoneal irritation. If the ectopic pregnancy has ruptured and hemorrhage has occurred, the patient may have signs and symptoms of hypovolemic shock. These include hypotension, tachycardia, pale, cool skin, near-syncope, and syncope.
What must you do immediately?
Continuously assess and support Mrs. Blackmore's airway, breathing, and circulation. Administer supplemental oxygen via a nonrebreather mask, establish vascular access with two large-bore I.V. devices, and place her on a cardiac monitor. Position Mrs. Blackmore supine with her legs elevated 6 to 8 inches to treat for shock. Keep Mrs. Blackmore N.P.O., provide analgesia as prescribed, and continue to monitor her vital signs at least every 15 minutes. Obtain blood specimens for a complete blood cell count, comprehensive metabolic panel, serum lactate level, beta-human chorionic gonadatropin level, and type and crossmatch, including Rh factor. Obtain a urine specimen for urinalysis. Administer a 1-L bolus of warmed 0.9% sodium chloride solution and call for a stat bedside transabdominal and transvaginal ultrasound, as prescribed. Call for a stat OB/GYN consult.
Ultrasonography confirms a ruptured ectopic pregnancy, so you prepare Mrs. Blackmore for immediate surgery. Without prompt, appropriate treatment, she's at risk for hypovolemic shock and death.
Continue to assess her response to I.V. fluids and be prepared to transfuse blood products, as indicated. Mrs. Blackmore's clinical status improves after the fluid challenge. Provide emotional support to the Blackmores during this difficult time.
What should be done later?
After surgery, Mrs. Blackmore is admitted to the gynecologic floor, where she's monitored for postoperative complications. Mrs. Blackmore has an uneventful recovery and is discharged from the hospital later that day. Teach her about activity restrictions, care of the surgical wound, signs and symptoms to report to her healthcare provider (including pain, bleeding, fever, or chills), and when to follow up with her obstetrician/gynecologist. Because of her ectopic pregnancy and history of endometriosis, she's at risk for future ectopic pregnancies, so educate her about this risk.
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