9.6 Gynaecological Nursing: Ectopic Pregnancy, Abortion Care, Fibroids, PID & Cancer Screening
Key Takeaways
- A threatened miscarriage has slight bleeding with a closed cervical os, while an inevitable or incomplete miscarriage has an open os.
- A ruptured ectopic pregnancy causes sudden abdominal pain, shoulder-tip pain and shock and requires resuscitation and emergency laparotomy.
- Post-abortion care combines emergency treatment of complications with family planning counselling and links to STI, HIV and other services.
- Cervical cancer is caused by persistent high-risk HPV infection and is prevented by HPV vaccination and VIA or HPV screening.
- After mastectomy, avoid blood pressure measurement, injections and cannulation on the affected arm to reduce lymphoedema risk.
9.6 Gynaecological Nursing: Ectopic Pregnancy, Abortion Care, Fibroids, PID & Cancer Screening
Quick Answer: Gynaecology questions on the surgical paper centre on bleeding in early pregnancy and women's cancers. A ruptured ectopic pregnancy (amenorrhoea, sudden lower abdominal pain, shoulder-tip pain, shock) needs immediate resuscitation and emergency surgery. Classify miscarriage by the cervical os and products of conception: threatened (os closed, pregnancy continuing), inevitable (os open), incomplete (products partly passed) and complete. Offer post-abortion care without judgment. For prevention, promote cervical screening (visual inspection with acetic acid or HPV testing), HPV vaccination and breast awareness.
Gynaecological Assessment
Take a menstrual, obstetric, contraceptive and sexual history in private. Always offer a chaperone for pelvic examination, explain each step, and obtain consent. Before surgery, check haemoglobin (many gynaecological conditions cause anaemia), group and save or cross-match as ordered, and a pregnancy test in women of reproductive age.
Miscarriage (Spontaneous Abortion)
| Type | Bleeding and pain | Cervical os | Uterus / products | Management |
|---|---|---|---|---|
| Threatened | Slight bleeding, mild or no pain | Closed | Size matches dates; fetal heart present on scan | Reassure, observe, avoid strenuous activity; review if bleeding increases |
| Inevitable | Heavier bleeding, cramping | Open | Pregnancy cannot continue | Prepare for evacuation; resuscitate if needed |
| Incomplete | Heavy bleeding, cramps | Open | Some products passed, some retained | Uterine evacuation (manual vacuum aspiration) or misoprostol per protocol |
| Complete | Bleeding settling | Closed | All products passed; uterus smaller | Confirm, observe, counsel |
| Missed | Little or no bleeding; pregnancy symptoms fade | Closed | Non-viable pregnancy retained | Medical or surgical evacuation |
| Septic | Fever, offensive discharge, abdominal pain | Often open | Infected products | Resuscitate, IV antibiotics, evacuation; watch for septic shock |
Nursing care: monitor vital signs and blood loss (count or weigh pads), insert a large-bore cannula for heavy bleeding, keep products passed for inspection, give anti-D immunoglobulin to Rh-negative women as ordered, and offer emotional support—a miscarriage is a bereavement.
Post-Abortion Care (PAC)
Post-abortion care includes:
- Emergency treatment of complications (haemorrhage, sepsis, injury);
- Family planning counselling and services before discharge (fertility can return within about two weeks);
- Links to other services: STI and HIV testing, anaemia treatment, and community support.
Ghana's Criminal Offences Act (as amended in 1985) permits a registered medical practitioner to terminate a pregnancy in a registered facility on specified grounds, including pregnancy resulting from rape or incest, risk to the woman's life or physical or mental health, and a substantial risk of serious fetal abnormality. Unsafe abortion remains an important cause of maternal death, so nurses and midwives provide non-judgmental PAC to every woman who presents with complications.
Ectopic Pregnancy
Risk factors: previous pelvic inflammatory disease (PID), previous ectopic pregnancy or tubal surgery, pregnancy with an IUD in place, and assisted conception.
Presentation: a missed period, lower abdominal pain (often one-sided), light vaginal bleeding, and—when it ruptures—sudden severe pain, shoulder-tip pain (blood irritating the diaphragm), fainting, pallor, tachycardia and hypotension.
Diagnosis: urine or serum pregnancy test (β-hCG) and transvaginal ultrasound showing an empty uterus.
Management:
- Ruptured ectopic (shock): this is a surgical emergency—call for help, give oxygen, insert two large-bore IV cannulae, send blood for urgent grouping and cross-matching, start fluid resuscitation, keep the patient nil by mouth, obtain consent and prepare for emergency laparotomy (usually salpingectomy). The emergency-consent principles in section 2.2 apply if she cannot consent.
- Unruptured and stable: laparoscopy or medical treatment with methotrexate in selected patients, with β-hCG follow-up.
- Give anti-D to Rh-negative women and offer bereavement support and future-pregnancy counselling.
Molar Pregnancy (Hydatidiform Mole)
Suspect it with bleeding in early pregnancy, severe vomiting, a uterus larger than dates and very high β-hCG; ultrasound shows a "snowstorm" pattern. After evacuation, women need serial β-hCG follow-up and reliable contraception until follow-up is complete.
Uterine Fibroids (Leiomyomas)
Fibroids are benign smooth-muscle tumours and are common in women of African descent.
- Symptoms: heavy menstrual bleeding (causing iron-deficiency anaemia), pelvic pressure, urinary frequency, subfertility, or no symptoms;
- Treatment: iron and tranexamic acid for bleeding, hormonal treatment to shrink fibroids before surgery, myomectomy (removes fibroids, keeps the uterus) or hysterectomy;
- Nursing: correct anaemia before surgery, ensure blood is available (myomectomy can bleed heavily), and after hysterectomy monitor for vaginal bleeding, urinary retention, DVT and emotional reactions.
Pelvic Inflammatory Disease and STIs
PID causes lower abdominal pain, fever, abnormal vaginal discharge and pain during intercourse; complications include infertility, ectopic pregnancy and chronic pelvic pain. Primary care in Ghana often uses syndromic management of STIs—treating the syndrome (e.g., vaginal discharge, lower abdominal pain) according to national flowcharts—together with partner treatment, condom promotion and HIV testing.
Cervical and Breast Cancer
Cervical cancer is caused by persistent high-risk human papillomavirus (HPV) infection.
- Prevention: HPV vaccination (the Ghana Health Service schedule lists HPV vaccine at 9 years) and screening with visual inspection with acetic acid (VIA) or HPV testing, with treatment of precancerous lesions (e.g., thermal ablation or cryotherapy);
- Warning signs: bleeding after intercourse, between periods or after menopause, and offensive discharge.
Breast cancer often presents late in Ghana.
- Encourage breast awareness and clinical breast examination; refer any lump, skin dimpling, nipple retraction or discharge;
- After mastectomy: care for drains, elevate the arm on the operated side, begin arm exercises as ordered, avoid blood pressure measurement, injections and cannulation on that arm (lymphoedema risk), and support body image and psychological needs.
Obstetric Fistula (Vesicovaginal Fistula)
Prolonged obstructed labour can cause pressure necrosis between the bladder (or rectum) and vagina, leading to constant leakage of urine (or faeces). Women may be stigmatised and isolated. Care includes referral for surgical repair, catheter care after repair, and prevention through skilled birth attendance and partograph use (section 11.2).
Exam Traps at a Glance
- Os closed + fetal heart present + slight bleeding = threatened miscarriage.
- Shoulder-tip pain with shock in early pregnancy = ruptured ectopic until proved otherwise.
- After mastectomy: no BP cuff, injections or IV lines on the affected arm.
- Offer contraception as part of post-abortion care.
A woman at 10 weeks of gestation has slight vaginal bleeding and mild cramps. Speculum examination shows a closed cervical os, and ultrasound shows a live fetus. How should this be classified?
A 26-year-old woman whose period is three weeks late collapses with sudden lower abdominal pain and pain in the right shoulder tip. Her pulse is 124 bpm and BP 82/50 mmHg. What is the priority nursing action?
A patient is recovering from a left mastectomy with axillary node clearance. Which instruction should the nurse give to staff?