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Sure! Here’s a version of the pituitary gland notes without using tables:

🧬 1. Introduction Cells are the basic structural and functional units of life . All living organisms are made up of cells. Understanding cell structure and cell division is essential in nursing to comprehend how the human body grows, heals, and functions at the microscopic level. PART 1: CELL STRUCTURE 🔬 2. Definition of a Cell A cell is the smallest unit of life capable of performing all vital physiological functions.Human body has about 37.2 trillion cells , varying in size, shape, and function. 🧫 3. Types of Cells Type Description Prokaryotic Simple cells without a nucleus (e.g., bacteria) Eukaryotic Complex cells with a true nucleus and membrane-bound organelles (e.g., human cells) 🧠 Human cells are eukaryotic . 🧩 4. Structure of a Generalized Animal Cell Cell Organelle Function Cell membrane (Plasma membrane) Protects the cell, controls what enters and exits Cytoplasm Jelly-like fluid where organelles are suspended Nucleus Control center of the cell; contains DNA Nucleolus Produces ribosomes Endoplasmic Reticulum (ER) Rough ER : Protein synthesis (has ribosomes) Smooth ER : Lipid and hormone synthesis | Ribosomes  | Protein synthesis | Golgi Apparatus  | Packaging and transport of proteins | Mitochondria  | Powerhouse of the cell; produces ATP (energy) | Lysosomes  | Digests waste materials and worn-out cell parts | Centrioles  | Help in cell division | Vacuoles  | Storage of nutrients, waste | Cytoskeleton  | Maintains cell shape and allows movement 🌐 5. Cell Membrane Transport Mechanisms Type Description Example Diffusion Movement of molecules from high to low concentration O₂/CO₂ exchange in lungs Osmosis Movement of water through semi-permeable membrane Absorption in kidneys Active Transport Requires energy (ATP); moves substances against gradient Sodium-potassium pump PART 2: CELL DIVISION 🔄 6. Importance of Cell Division Growth and development Repair and regeneration Reproduction (in gametes) Maintenance of genetic information 🧪 7. Types of Cell Division Type Purpose Occurs In Result Mitosis Growth & repair Somatic (body) cells 2 identical diploid daughter cells Meiosis Reproduction Sex cells (gametes) 4 non-identical haploid cells 📚 8. Phases of Mitosis (PMAT) Mitosis = One division → 2 identical daughter cells (Diploid) Prophase Chromosomes condense Nuclear membrane breaks down Spindle fibers form Metaphase Chromosomes align at the cell’s equator Anaphase Sister chromatids separate and move to opposite poles Telophase New nuclear membranes form Chromosomes uncoil Cytokinesis Division of cytoplasm to form two cells 🧬 9. Meiosis Phases Meiosis = Two divisions → 4 unique daughter cells (Haploid) Occurs in sperm and egg  production Meiosis I:  Reduces chromosome number Meiosis II:  Similar to mitosis, separates chromatids Key features: Crossing over (genetic recombination) Variation in offspring 🧠 10. Differences Between Mitosis and Meiosis Feature Mitosis Meiosis Number of divisions 1 2 Number of daughter cells 2 4 Chromosome number Diploid (2n) Haploid (n) Genetic identity Identical Different Purpose Growth, repair Sexual reproduction Location Body cells Sex cells ✅ 11. Clinical Relevance in Nursing Cancer:  Uncontrolled mitosis leads to tumors. Genetic disorders:  Errors in meiosis can cause Down syndrome or Turner syndrome. Wound healing:  Depends on mitotic activity. Fertility treatment:  Understanding meiosis helps in managing reproductive health. 📝 12. Diagrams (Recommended for Study Material) Structure of a cell Mitosis phases (PMAT) Meiosis stages Difference chart (Mitosis vs Meiosis)

“Introduction to Anatomical Terms and Organization of the Human Body” — including anatomical terms, planes, and movements. 1. Introduction Anatomy is the study of the structure of the human body. Understanding anatomical terms, planes, and movements is essential for accurate communication among healthcare professionals and to understand the position and function of various body parts. 2. Anatomical Position and Terminology Standard Anatomical Position The body is upright, facing forward. Arms at the sides. Palms facing forward. Legs slightly apart, feet flat on the floor and pointing forward. This position serves as a reference point for describing body parts and their locations. 3. Anatomical Terms of Direction Term Meaning Example Superior (Cranial) Toward the head or upper part of the structure The head is superior to the chest. Inferior (Caudal) Away from the head or lower part The stomach is inferior to the heart. Anterior (Ventral) Toward the front The sternum is anterior to the spine. Posterior (Dorsal) Toward the back The heart is posterior to the breastbone. Medial Toward the midline of the body The nose is medial to the eyes. Lateral Away from the midline The ears are lateral to the nose. Proximal Closer to the point of attachment or origin The shoulder is proximal to the hand. Distal Farther from the point of attachment The fingers are distal to the elbow. Superficial Toward or on the surface The skin is superficial to the muscles. Deep Away from the surface The bones are deep to the skin. Ipsilateral On the same side The right arm and right leg are ipsilateral. Contralateral On the opposite side The right hand is contralateral to the left leg. https://en.wikipedia.org/wiki/File:Blausen_0019_AnatomicalDirectionalReferences.png https://en.wikipedia.org/wiki/File:Rostralcaudal.svg 4. Anatomical Planes of the Body Anatomical planes are imaginary lines that divide the body to help describe locations of structures. Plane Description Division Sagittal Plane Divides the body into left and right sections - Midsagittal: Equal halves- Parasagittal: Unequal parts Frontal (Coronal) Plane Divides the body into anterior (front) and posterior (back) parts Front and back halves Transverse (Horizontal) Plane Divides the body into superior (upper) and inferior (lower) parts Top and bottom halves Oblique Plane Cuts made diagonally between horizontal and vertical planes Angular division https://www.physio-pedia.com/File:Axes_of_the_human_body.jpg 5. Movements of the Human Body Movements occur at joints, and are based on anatomical position and planes. Types of Movements: Movement Description Plane Flexion Bending movement that decreases the angle between two parts Sagittal Extension Straightening movement that increases the angle Sagittal Abduction Movement away from the midline Frontal Adduction Movement toward the midline Frontal Rotation Turning around an axis Transverse Circumduction Circular movement combining flexion, extension, abduction, adduction Multiple Pronation Rotating the forearm so the palm faces downward Transverse Supination Rotating the forearm so the palm faces upward Transverse Inversion Turning the sole of the foot inward Frontal Eversion Turning the sole of the foot outward Frontal Dorsiflexion Bending the foot upward toward the shin Sagittal Plantarflexion Pointing the foot downward Sagittal Elevation Raising a body part (e.g., shoulders) Frontal Depression Lowering a body part Frontal Protraction Moving a part forward (e.g., jaw) Transverse Retraction Moving a part backward Transverse Movement in the sagittal plane about the frontal axis Movement in the frontal plane about the sagittal axis Movement in the transverse (horizontal) plane about the vertical axis 6. Levels of Structural Organization of the Human Body Chemical Level – Atoms and molecules (e.g., proteins, water) Cellular Level – Basic unit of life (e.g., nerve cell, muscle cell) Tissue Level – Groups of similar cells (e.g., epithelial tissue) Organ Level – Structures made of two or more tissue types (e.g., heart) System Level – Groups of organs working together (e.g., digestive system) Organism Level – All body systems functioning together as a whole The Levels of Organization 7. Importance in Nursing Practice Helps in describing injuries, procedures, or locations (e.g., giving injections in the deltoid muscle). Enhances understanding of physical assessment, surgeries, and radiological images. Supports safe and accurate documentation and communication in clinical settings. 8. Diagrams (For Reference in Notebook/Study Material) Anatomical position diagram Planes of the body illustration Body directional terms chart Joint movements illustration

Vital Signs Include: Blood Pressure Temperature Pulse (Heart Rate) Respiratory Rate Oxygen Saturation (Pulse Oximetry) Pain (Optional but commonly assessed) 1. BLOOD PRESSURE Definition: The force of blood pushing against the artery walls. Normal Range: 90/60 to 120/80 mmHg Steps: Ensure patient is relaxed, seated with back support, feet flat, legs uncrossed. Use correct cuff size—cuff should encircle 80% of the upper arm. Place cuff 1 inch above elbow over bare skin (avoid rolling tight sleeves). Locate brachial artery and place stethoscope over it. Inflate cuff to 180 mmHg, then deflate slowly. Listen: First sound = Systolic Disappearance of sound = Diastolic Remove cuff and document result. Precautions: Avoid caffeine, smoking, or activity before taking BP. Never use wrist/finger devices unless no alternative. Do not use on an arm with IV, cast, or surgery. Example: Patient Sunita: BP 138/88 mmHg, sitting, right arm. 2. TEMPERATURE Definition: Measurement of internal body heat. Normal Range: 97°F to 99°F (36.1°C to 37.2°C) Fever = >100.4°F (38°C) Hypothermia = <95°F (35°C) Steps: Ensure patient hasn’t eaten, drunk, or smoked in last 10 minutes. Choose route Oral (under tongue) Axillary (armpit): 0.5°F lower than oral Rectal: 0.5°F higher Place thermometer, wait for beep or time out. Remove and read. Clean and store thermometer. Precautions: Never force thermometer in mouth or rectum. Don’t use broken or old mercury thermometers. Example: Patient Ramesh: Temp 101.2°F, oral. Fever medication administered. 3. PULSE (Heart Rate) Definition: Number of heartbeats per minute. Normal Range: 60–90 bpm (beats per minute) Tachycardia = >100 bpm Bradycardia = <60 bpm Steps: Locate radial pulse (thumb side of wrist). Use index and middle finger (not thumb). Count for 30 sec × 2 or full 60 sec if irregular. Note rate, rhythm, and strength. Precautions: Resting rate should be taken, not after exertion. Report fast/slow or irregular pulse. Example: Patient Priya: Pulse 110 bpm, regular. Post-exercise. 4. RESPIRATION RATE Definition: Number of breaths per minute. Normal Range: 12–20 breaths/min Steps: Keep fingers on pulse to avoid alerting patient. Count chest rises for 60 seconds. Observe rhythm and depth. Precautions: Don’t tell the patient; it may alter breathing. Monitor for shallow, irregular, or labored breathing. Example: Patient Raj: RR 26/min, rapid breathing noted post-surgery. 5. PULSE OXIMETRY (SpO₂) Definition: Non-invasive measurement of oxygen saturation in blood. Normal Range: 95–100% 91–94%: Monitor closely Below 90%: Seek medical help Below 85%: Brain affected Steps: Place probe on clean, dry fingertip. Wait till reading stabilizes. Record reading and check for movement or errors. Precautions: Avoid use over nail polish or cold fingers. Remove dirt, avoid bright lighting, minimize patient movement. Example: Patient Meera: SpO₂ 88%, oxygen started at 2 L/min. 6. PAIN (Optional but important) Definition: Patient’s self-report of discomfort. Assessment: Use numeric scale (0–10) Ask about location, quality, duration, and intensity. Example: Patient: “Pain is 6/10, sharp, right lower abdomen.” 8. Symptoms to Report Immediately: BP >180/120 or <90/60 Temp >103°F Pulse <50 or >130 bpm RR <10 or >30/min SpO₂ <90% Chest pain, confusion, blue lips/skin Visual Guide & Video Links: Pulse Points Image: Vital Signs Assessment Video: RegisteredNurseRN – Full Vital Signs Check

Burns result from damage to skin & deeper tissues caused by external sources or substances.

✅ Introduction Nasogastric tube insertion is a common and essential nursing procedure used for feeding, medication administration, and gastric decompression. This guide provides a step-by-step breakdown with clear instructions, human interactions, precautions, equipment, site anatomy, documentation tips, and real-life examples. 🎯 Objectives To safely insert a nasogastric tube. To maintain patient comfort and dignity. To monitor and prevent complications. 📋 Indications Gastric decompression in bowel obstruction. Enteral feeding in patients unable to swallow. Administration of medications. Sampling of gastric contents. ⚠️ Contraindications Severe facial trauma Esophageal varices Recent nasal or esophageal surgery Coagulopathy or nasal obstruction 🧰 Articles Required Item Purpose NG tube (appropriate size) Main device Lubricating jelly (water-based) Smooth insertion Gloves and apron Infection control Towel or protective sheet Patient cleanliness Glass of water with straw Swallowing aid (if conscious) Syringe (50 ml, catheter tip) Aspirate gastric contents and confirm placement pH strip or litmus paper Confirm gastric placement Adhesive tape or NG fixation device Secure tube Kidney tray Collection of secretions Stethoscope Placement confirmation Penlight and tongue depressor Nasal and throat inspection Chart and pen Documentation 👩‍⚕️ Nurse-Patient Communication Knock  before entering. Greet  the patient politely: “Good morning, Mr. Patel! I’m Nurse Asha, here to assist with a procedure that will help you receive nutrition and medication.” Explain  the purpose and steps of the procedure in their preferred language. Gain consent  and answer any questions. Ensure privacy and comfort  using screens and drapes. Procedure Steps Steps Action 1 Apply lubricant to the tip of the NG tube 2 Gently insert tube into selected nostril, direct backward then downward 3 Ask patient to swallow sips of water (if conscious) as tube is advanced 4 Continue insertion until marked point is reached 5 Temporarily secure tube to cheek with tape 6 Confirm position: - Aspirate gastric contents and test pH (should be <5.5) - Optional: Air bolus (20–30 mL) and auscultate epigastric region 7 Once confirmed, permanently secure tube with fixation device 8 Connect tube to required system (e.g., feeding syringe, suction) 9 Document the procedure in patient’s record 📍 Sites of Insertion Primary: Nasal passage → Esophagus → Stomach Tube should never enter: Trachea (can cause coughing, aspiration) Lungs (can cause pneumothorax) 📌 Sites for Insertion Insert through nares  (preferred) into: Nasopharynx → Oropharynx → Esophagus → Stomach 🪜 Step-by-Step Procedure 1. Preparation Verify physician’s order. Wash hands and wear PPE. Position patient in high Fowler’s position  (60–90°). Drape a towel over the patient’s chest. Inspect nostrils for obstruction or injury. 2. Tube Measurement Measure from tip of nose → earlobe → xiphoid process . Mark length with tape or pen. 📍 Sites of Insertion Primary: Nasal passage → Esophagus → Stomach Tube should never enter: Trachea (can cause coughing, aspiration) Lungs (can cause pneumothorax) 3. Lubrication Lubricate 4–6 inches of the tube with water-soluble jelly . 4. Insertion Gently insert tube through selected nostril. Ask patient to swallow water  to assist movement. Advance gently with each swallow. Monitor for coughing, cyanosis, or distress (may indicate airway entry). 5. Confirm Placement Aspirate  stomach contents and test pH (should be 1–5). Inject air  and auscultate epigastrium (whooshing sound indicates gastric entry). X-ray  confirmation is gold standard (especially for initial placement). 6. Secure the Tube Fix with tape across nose  or NG tube holder. Leave free end capped  or connect to feeding system. 7. Documentation Date and time of insertion Size and type of tube Which nostril used Method of confirmation Patient’s response Any complications ⚠️ Precautions Never force the tube. Discontinue immediately if patient becomes cyanotic or coughs excessively. Avoid repeated attempts on the same side. Ensure proper hygiene and handwashing. ⚠️ Possible Complications / Abnormalities Abnormality Signs Response Misplacement into airway Coughing, choking, cyanosis Remove tube immediately Nasal bleeding or trauma Blood from nostril Stop, reassess, possibly use other nostril Aspiration Coughing, dyspnea Remove tube, monitor respiratory status Infection (sinusitis, otitis) Fever, discharge Monitor, report to physician 💡 Common Abnormalities and Responses Observation Possible Cause Nursing Action Coughing, gagging, cyanosis Tube entering trachea Withdraw immediately Nose bleeding Mucosal injury Pause, apply cold compress, reassess High pH in aspirate Non-gastric placement Do not use, re-confirm Coiling in mouth Incomplete advancement Reposition and retry 📝 Example Case Patient : Mr. Arun, 55-year-old male post-stroke Procedure : NG tube inserted via right nostril. Length measured 60 cm. Confirmed placement by pH (3) and air insufflation. Patient tolerated well. Feeding initiated. 📝 Record-Keeping Date and time of insertion Size and type of NG tube Side of nostril used Confirmation method (pH, auscultation) Patient’s tolerance Output (if for drainage) Signature and designation 👁️ Precautions Always confirm placement before any feeding or medication Check nostril daily for skin breakdown Label the tube with date of insertion Flush the tube regularly if used for feeding Keep head elevated during and 30 mins after feeding 🧠 Tips for Students Practice on models/manikins. Always prepare the patient and explain. Know your equipment thoroughly. Never skip confirmation. ✅ Summary Checklist ✔ Correct tube size ✔ Patient positioned upright ✔ Proper measurement and lubrication ✔ Gentle insertion with swallowing ✔ Confirmation by pH/stethoscope/x-ray ✔ Documentation

🔶 Objective To safely insert a Foley catheter for urinary drainage while maintaining aseptic technique and ensuring patient comfort. ✅ Indications Clinical Situation / indication Reason for Catheterization Urinary retention Inability to void voluntarily (e.g., post-surgery, BPH) Accurate urine output monitoring ICU, post-operative, septic shock, or during fluid management Surgical procedures During or after urological/gynecological surgeries Bladder irrigation For hematuria or clot retention (with 3-way catheter) Immobilized patients For pressure sore prevention in patients with incontinence Neurogenic bladder E.g., spinal cord injury Sterile sample collection For uncontaminated urine culture ❌ Contraindications Condition Reason to Avoid or Use with Caution Suspected or known urethral trauma Common in pelvic fracture – blood at meatus is a red flag Recent urethral surgery or stricture Increases risk of injury or misplacement Allergy to latex or catheter material Use silicone catheter instead Prostate enlargement with resistance May require specialized catheter (e.g., coude tip) Active urinary tract infection Consider alternatives unless absolutely necessary Severe urethral pain or bleeding during attempt Abort and notify physician 🧰 Articles Required and Use Timing Article Used At Step Purpose Sterile Gloves Step 2 Prevent contamination Foley Catheter (12–16 Fr) Step 5 Drain urine; size depends on patient condition Lubricating Jelly Step 4 Reduces trauma during insertion Antiseptic Solution Step 3 Cleans genitalia, reduces infection risk Syringe (10 mL, sterile water) Step 6 Inflates balloon after urine flow Urine Bag Step 5–7 Collects urine; always below bladder level Tape/Catheter Strap Step 8 Prevents dislodgement Mackintosh & Towel Step 1 Keeps bed clean Waste Disposal Bag/Sharp Bin Step 10 For biohazard disposal Documentation Sheet Step 11 Records date, catheter type, nurse's name, findings, etc. 👥 Human Response (Patient Greeting & Communication) “Hello [Mr./Ms.], I am [Your Name], a nursing student/nurse. Today, I will insert a catheter to help drain your bladder. I’ll ensure your privacy and comfort throughout. Do you have any questions before we begin?” 🛏️ Patient Positioning & Sites Sex Position Insertion Site Approx Length Female Dorsal recumbent Urethral meatus (between labia) 5–7 cm Male Supine Urethral opening at penis tip 17–22 cm ⚠️ Abnormal Findings & Action Finding Possible Cause What to Do Resistance during insertion Enlarged prostate or urethral stricture Stop, notify physician Catheter enters vagina (female) Poor visibility Leave in place, use new sterile one No urine output Not in bladder or blockage Reposition or flush Pain or bleeding Trauma Stop immediately, report Cloudy or foul-smelling urine UTI Monitor and report ✅ Step-by-Step Procedure with Details 1. Preparation & Patient Communication Articles Used: Mackintosh Towel PPE (gloves, apron, mask) Steps: Wash hands thoroughly. Introduce yourself to the patient. Verify identity using name, age, and wristband (if available). Explain the procedure: "This is a sterile procedure to help you empty your bladder. You might feel a little discomfort during insertion, but I’ll guide you through it." Gain informed consent  verbally. Provide privacy using curtains or screens. Position the patient: Female: Dorsal recumbent  (lying on back, knees bent and apart). Male: Supine  with legs slightly apart. Place mackintosh and towel  under the buttocks to protect bedding. 2. Set Up Sterile Field & Equipment Articles Used: Sterile catheterization kit Sterile gloves Sterile drape Sterile tray Pre-filled syringe with sterile water (10 mL) Steps: Open sterile tray and catheter pack on a clean surface. Don sterile gloves  using correct technique. Arrange all articles in sterile order (catheter, lubricating jelly, syringe, etc.). Place sterile drape  over perineal area. 3. Cleanse Genital Area (Aseptic Technique) Articles Used: Antiseptic solution (e.g., povidone-iodine or chlorhexidine) Sterile cotton balls/swabs Artery forceps Steps: Female: Separate labia with non-dominant hand. Clean one side of labia majora → minora (top to bottom). Repeat on other side with new swab. Final swab down the center over urethral opening. Male: Retract foreskin (if uncircumcised). Clean in a circular motion from the meatus outward. Hold penis perpendicular to body. ⚠️   Do not let your non-dominant hand touch anything sterile once you start. 4. Lubricate and Insert Catheter Articles Used: Foley catheter (12–16 Fr) Lubricating jelly Steps: Squeeze lubricating jelly  onto catheter tip (approx 5–7 cm). Insert catheter gently  into the urethra: Female: Insert 5–7 cm  or until urine appears. Male: Insert 17–22 cm  until urine appears. If resistance is felt: Never force. Ask patient to breathe deeply to relax pelvic muscles. Stop if resistance persists or bleeding occurs. 5. Confirm Placement and Inflate Balloon Articles Used: 10 mL syringe with sterile water Catheter balloon port Steps: Once urine flows, advance catheter 2–3 cm further  to ensure it is inside the bladder. Inflate balloon  with 10 mL sterile water  slowly. Gently pull catheter until resistance is felt – indicates balloon is seated. ⚠️  Never inflate balloon before  confirming urine flow – may injure urethra. 6. Connect Urine Bag & Secure Catheter Articles Used: Closed urinary drainage bag Catheter securement device or tape Steps: Attach catheter to urine bag tubing. Secure catheter  to thigh (female) or lower abdomen (male) to prevent pulling. Ensure urine bag hangs below bladder level  – not touching the floor. Loop tubing to prevent tension or backflow. 7. Clean Up & Dispose Articles Used: Gloves Waste disposal bags Sharps container (if applicable) Steps: Discard used items in appropriate bins (biohazard for contaminated items). Remove gloves, perform hand hygiene  thoroughly. 8. Documentation Record the following: Date and time of insertion Catheter type and size (e.g., Foley 14 Fr, 10 mL balloon) Volume of balloon inflation Characteristics of urine (color, odor, clarity, amount) Patient's tolerance and any abnormalities Signature and designation of performing nurse ✅ Sample of Documentation Field Example Date & Time 22/04/2025 – 10:45 AM Patient Name & ID Mr. Ramesh, 208954 Catheter Type & Size 14 Fr Foley, 2-way Balloon Volume 10 mL sterile water Route Urethral Urine Output Clear yellow, 120 mL Patient Response Cooperative, no discomfort Performed By S. Patel, 4th Year BSc Nursing Student 📌 Post-Procedure Care Observe for signs of infection, bleeding, or discomfort. Educate patient not to pull or tug catheter. Check urine output regularly. 🔍 Optional Notes for Ongoing Care: Monitor hourly urine output (if ordered). Keep bag below bladder level at all times. Check tubing for kinks or obstruction. Empty drainage bag when ¾ full. Perform catheter care per shift using aseptic technique. 📍 Sites of Insertion & Possible Abnormalities Site/Patient Notes Abnormalities Female urethra Shorter length; use care not to insert into vagina Vaginal misplacement, discomfort Male urethra Longer and may curve; consider coude tip if enlarged prostate Resistance, trauma Suprapubic (by MD only) Alternative for long-term use Redness, leaking, infection risk 🚩 Red Flags to Report Immediately No urine output within 30 min of insertion Bleeding from urethra Severe pain or resistance Balloon inflated without confirming placement Cloudy, foul-smelling urine or fever (possible UTI) 📚 Example Case Case : Female patient post-hysterectomy, unable to void. Procedure : Foley 14 Fr inserted; urine output 250 mL in first hour. Notes : No resistance; balloon inflated with 10 mL; catheter secured; documented in EMR.

Schizophrenia, a form of psychosis, is characterized by distortion to thinking and perception and inappropriate or blunted affect.

Introduction Ectopic pregnancies refer to any pregnancy that develops outside the endometrial cavity. 97% of ectopic pregnancies develop in the fallopian tube. The fallopian tubes are by far the most common site of ectopic pregnancy. Any pathology (infection, adhesions, iatrogenic injury) that damages the tubes leads to an increased risk. The ampulla of the tube is the most common site followed by the isthmus, but they may implant anywhere along the length of the structure. Risk factors A number of factors increase the risk of ectopic pregnancy, however, the majority of women have no identifiable risk factor. Previous ectopic pregnancy (risk is around 18.5%) IVF Fallopian tube damage (may be secondary to infection, surgery) Adhesions Smoking Intrauterine contraceptive device (overall the risk of ectopic pregnancy, and any pregnancy, is reduced, however, in the event of failure the proportion of pregnancies that are ectopic is increased) Progestogen-only pill (overall the risk of ectopic pregnancy, and any pregnancy, is reduced, however, in the event of failure the proportion of pregnancies that are ectopic is increased) Clinical features Features may be subtle and non-specific, patients with child-bearing potential must be offered a pregnancy test when presenting to hospital with an acute complaint. Symptoms Abdominal/pelvic pain Vaginal bleeding Amenorrhoea Shoulder tip pain (a sign of rupture and intra-abdominal bleeding, indicative of blood irritating the diaphragm) Urinary discomfort GI upset Signs Abdominal/pelvic tenderness Rebound tenderness, peritonism Abdominal distention Pallor Cervical motion tenderness (refers to pain on movement of the cervix during a bimanual examination, indicative of pelvic inflammation) Ruptured ectopic pregnancy A ruptured ectopic pregnancy is a gynaecological emergency. There can be significant intra-abdominal bleeding leading to collapse and haemodynamic instability. Vomiting, diarrhoea and shoulder tip pain may be present. Vaginal bleeding may be present but often misleads regarding the degree of blood loss as much will be intra-abdominal. Investigations Trans-vaginal USS is the investigation of choice in the diagnosis of ectopic pregnancy. Bedside Observations Urinary pregnancy test Urine dipstick Bloods FBC U&Es CRP LFTs Clotting screen Group and saves Serum B-hCG (see chapter below for detail) Imaging Trans-vaginal USS : the standard investigation. It provides good visualisation and identifies the majority of tubal ectopic pregnancies during the first assessment. A minority of cases won’t be identified and are termed ‘pregnancy of unknown location (PUL)’. This may be due to the location or how early in the process someone is scanned. Trans-abdominal USS : should generally only be used where the patient declines the transvaginal approach. You must explain the reduced sensitivity and specificity of this approach. MRI : may be used as a second-line investigation and can be of particular use in cervical scar or interstitial ectopic pregnancies. Serum B-HCG Serum beta-human chorionic gonadotropin (B-hCG) is used to help guide the management of ectopic pregnancy. Management Management of ectopic pregnancy falls into three main types; expectant, pharmacological and surgical. Expectant management This may be considered in carefully selected patients. They should be well, with only minor pain and low or declining B-hCG. Patients must also be willing and able to attend follow-up. NICE guidelines 126 advise the following women are offered expectant management: Clinically stable and pain-free and Unruptured tubal ectopic pregnancy measuring less than 35 mm with no visible heartbeat on transvaginal ultrasound scan and Serum B-hCG levels of 1,000 IU/L or less and Able to return for follow-up They also state it may be considered in women with serum B-hCG levels above 1,000 IU/L and below 1,500 IU/L. Serum B-hCG should be measured at days 2, 4 and 7 and then weekly. Levels should fall by 15% at each measurement, if they do not arrange senior review. Pharmacological management Single-dose methotrexate (though some may require subsequent doses) can be considered as an alternative to surgery. NICE guidelines 126 advise the following women are offered methotrexate: Have no significant pain and Have an unruptured tubal ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat and Have a serum B-hCG level less than 1,500 IU/litre and Do not have an intrauterine pregnancy (as confirmed on an ultrasound scan) and Able to return for follow-up Surgical management There are a number of indications for surgery, when indicated the laparoscopic approach should be used over open surgery when possible. There are two main terms to be aware of in the surgical management of tubal ectopics: Laparoscopic salpingectomy : laparoscopy refers to 'key-hole' surgery. Salpingectomy refers to the removal of a fallopian tube, in this case, the tube affected by the ectopic pregnancy. This is generally the preferred treatment. Laparoscopic salpingotomy : this refers to a procedure that aims to preserve the fallopian tube. The tube is opened and the ectopic is removed. It is generally considered if the contralateral tube is damaged or there are other fertility-based concerns. Anti-D rhesus prophylaxis Rhesus D (RhD) negative women may require anti-D rhesus prophylaxis. Rhesus (Rh) refers to a group of red cell antigens, the most important being RhD. Problems arise when RhD-negative mothers have RhD-positive foetuses. Feto-maternal haemorrhage (FMH) can expose the mother to RhD-positive blood. In response, a RhD-negative mother generates anti(D) antibodies. In subsequent pregnancies anti(D) antibodies can cross the placenta and lead to haemolytic disease of the newborn. Anti-D immunoglobulin is given to reduce the risk of maternal sensitisation in events where FMH is likely.