308 Ectopic Pregnancy history of tubular damage as a result of infections or endometriosis. They may also have had tubal surgeries. Often, patients describe a history of using an IUD, and some may report a history of infertility. Question the patient about her last menstrual period to determine the onset, duration, amount of bleeding, and whether it was a "normal" period for her. This description is important because although amenorrhea may be present in many cases of ectopic pregnancy, uterine bleeding that occurs with ectopic pregnancy may be mistaken for a menstrual period. In addition to amenorrhea, the patient may exhibit other signs of pregnancy, such as breast tenderness, nausea, and fatigue.

PHYSICAL EXAMINATION. Assess vaginal bleeding for the amount, color, and odor; if none is noted, bleeding may be concealed. Bleeding can occur as vaginal spotting, as a "slow leak," or as a massive hemorrhage, depending on the gestational age and whether the tube has ruptured. Usually, the bleeding is slow, and the abdomen can become rigid and tender. Sometimes, vaginal bleeding is present with the death of the embryo. If internal hemorrhage is profuse, the woman experiences signs and symptoms of hypovolemic shock (restlessness, agitation, confusion, cold and clammy skin, increased respirations and heart rate, delayed capillary blanching, hypotension).

Evaluate the patient's pain; it can range from a feeling of fullness in the rectal area and abdominal cramping to excruciating pain. Often, the pain is one-sided and increases when the cervix is moved during a vaginal exam. Some women do not feel any pain until the tube is about to rupture, usually at the 3-month period of gestation. If the tube ruptures, the woman experiences sharp, one-sided, lower abdominal pain and syncope. The pain may radiate to the shoulders and neck and is aggravated by situations that cause increased abdominal pressure, such as lifting or having a bowel movement.

PSYCHOSOCIAL. Often, the patient experiences anger, grief, guilt, and self-blame over the loss of the fetus. She may also be anxious about her ability to conceive in the future. Since much of her anxiety may stem from lack of information about her condition, assess her learning needs. Determine the ability of the father and other family members to cope and support the patient.

Diagnostic Highlights

General Comments: Diagnosis is based on a positive pregnancy and inability to

visualize the embryo in the uterus.

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