Topics today

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Topics today

• Normal puerperium
• Diseases of puerperium
• Gestational trophoblastic diseases,GTD

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Normal puerperium(Postpartum care)
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Puerperium

• 6 weeks periods after birth
• the reproductive tract return to its normal,
  non-pregnancy state
• the initial postpartum visit is scheduled at
  42th days

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Physiology of the puerperium

• Involution of the uterus
• return to the pelvis by about 2 weeks
• be at normal size by 6 weeks
• the weight changes of uterus
• 1000g immediately after birth
• 500g 1 weeks after birth
• 300g 2 weeks after birth
• 50g 6 weeks after birth

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• Cervix
• It has reformed within several hours of
• delivery
• it usually admits only one finger by 1 weeks
  
• the external os is fish-mouth-shaped
• it return to its normal state at 4 weeks after
  birth

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• Ovarian function
• the time of ovulation is 3 months in non-
• breast -feeding women
• Cardiovascular system
• return to normal after 2-3 weeks

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• Clinical manifestaion of puerperium
• T is less than 38ºc
• Involution of uterus
• After-pains
• occuring at 1-2 days and maintant
• 2-3days

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• lochia
• discharge comes from the placental site and
  maintants for 4-6 weeks
• Lochia rubra
• be red in color for the first 3-4 days
• Lochia serosa
• maintants for 2 weeks
• Lochia alba
• maintants for 2-3 weeks

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Management of the puerperium

• Maternal -infant bonding
• rooming in
• Uterine complications
• postpartum hemorrhage, infection,
• the amount of lochia
• Bowel movement
• Urination
• Care of the perineum

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• Management of breast
• Breast-feeding
• the benefits of breast-feeding
• increase the conversation
• decrease the cost
• improve infant nutrition and protect
• against infection and allergic reaction
• uterus contraction

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Differential diagnosis of engorgement, mastitis
and plugged duct
Finding Engorgement Mastitis Plugged duct
Onset Gradual Sudden Gradual
Location Bilateral Unilateral Unilateral
Swelling Generalized Localized Localized
Pain Generalized Intense, localized Localized
Systemic symptoms Feels well Feels ill Feels well
Fever No Yes No
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• Diseases of puerperium
• Puerperal infection
• Late puerperal hemorrhage
• Postpartum depression
• puerperal heat stroke

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• Puerperal infection
• Puerperal infection
• Genital infected by pathogenic
• microorganism during labor and puerperal
• period
• The incidence is about 1-7.2
• It is one of the four kinds of causes which
• result in maternal mortality

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• Puerperal morbidity
• T of maternal more than 38ºc occurs twice
• within 24h-10 days after birth
• It may be caused by pueperal infection,
• urogenital infection et al.

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• Induction factors of puerperal infection
• General asthenia, Dystrophy
• Anemia ,Sexual intercourse
• PROM, Infection of amnotic cavity
• Obstetric operation
• Hemorrhage pre and postpartum

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• The kinds of pathogen
• Bata-hemolytic streptococcus
• Anaerobic streptococcus
• Anaerobic bacillus
• Staphylococcus
• Bacillus coli

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• Pathology and clinical manifestation
• Acute vulvitis, vaginitis,cervicitis
• Acute endometritis, myometritis
• Acute inflammation of pelvic connective
• tissure, Salpingitis, Peritonitis
• Thrombophlebitis
• Pyemia and hematosepsis

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• Diagnosis and treatment
• supporting treatment
• Delete the induction factors
• Broad-spectrun antibiotic
• Expectant treatment

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• Late puerperal hemorrhage
• Excessive bleeding in puerperal period
• after 24h delivery
• It can occur sudden and profuse
• It can occur slowly but prolonged and
• persistent

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• Etiology and clinical manifestation
• Retained placenta and membrane
• Lochia rubra prolonged
• Blood loss repeated or bleeding excessive
  suddendly
• Sabinvolution of urerus
• Relax of cervix
• Placenta tissure can be palpable

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• Retained decidua
• Infection of the placenta attachment
• area
• Sabinvolution of uterus
• Fissuration of uterine insision
• postcesarean
• Trophoblastic tumor postpartum
• Submucus myoma

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• Diagnosis and treatment
• supporting treatment
• Delete the etiologic factors
• Broad-spectrun antibiotic
• Expectant treatment

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• Gestational trophoblastic diseases(GTD)
• Molar pregnancy(hydatidiform
• mole)
• Invisave mole
• Choriocarcinoma
• Placentalsite trophoblastic
• tumor(PSTT)

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• Molar pregnancy
• Classification
• Complete molar pregnancy
• Partial molar pregnancy

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• Epidemiology
• The incidence varies among different national
• and ethnic groups
• The highest occurring among Asian women(up
• to 1 in 500-600)
• The lowest incidence occurring in white
• women of western European and U.S ( 1 in
• 1500-2000)

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• Etiology
• Unknown?
• Associated with
• age
• Dietary deficiencies
• Economic status, et al

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• Genetic constitution
• Complete molar pregnancy
• Fertilization of an empty egg
• dispermy
• Karyotype is 46,XX (most common,90) or 46,XY
• Partial molar pregancy
• Triploid
• Most common being 69,XXY
• 69,XXX

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• Histologic features
• Trophoblast proliferation
• Villi interstitial edema
• Fetal origin Capillary disappearance
• Luteinizing cyst

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• Clinical presentation
• Bleeding postamenorrhea(most common)
• Uterus usually large than expected
• Uterine date/size discrepancy in two thirds of
  patients
• Luteinizing cyst
• Severe nausea and vomiting
• Pregnancy induced hypertension
• Clinical hyperthyroidism

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• Diagnosis
• Clinical presentation
• Ascertain the level of HCG
• Ultrasoundsnowstorm appearance
• Histology

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• Treatment
• Remove the intrauterine contents promply
• Hysterectomy
• in the older reproductive group who have no
  interest in further childbearing
• Management of luteinizing cyst

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• Preventive chemotherapy
• Age more than 40
• Level of serum HCG increased significantaly(more
  than
• 100KIU/L)
• Titer of HCG has not returned to normal after 12
  weeks
• postevacuation
• Re-elevated HCG level
• Uterus larger than expected
• Diameter of luteinizing cyst more than 6cm
• Trophoblast hyperproliferation still after second
  curettage
• Has no condition to follow-up

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• Follow-up
• Pelvic examination, ultrasound examination
• Assessment of HCG
• Serum quantitative HCG level every 1 week until
  normal
• Every 1 week(three month)
• Every 2 weeks(three month)
• Every 1 month( half year)
• Every half year(one year)
• Contraception for 1-2 years

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• Invasive mole
• Is a complete mole invading the myometrium or
  vascular
• Most common occuring within 6 months after
  curretage of a complete mole following
  evaluation for HCG levels that do not fall
  appropriately

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• Histology
• Type I
• amount of mole
• Invading myometrium or vascular
• Hemorrhage or necrosis rarely

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• Type II
• Moderate of mole
• Trophoblast proliferation moderate
• partial trophoblast undifferentiated
• Hemorrhage and necrosis

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• Type III
• Amount of Hemorrhage or necrosis tissue
• Trophoblast hyperproliferation and
• undifferentiated
• The histology is very same as choriocarcinoma

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• Clinical presentation
• Presentation of primary disease
• Vaginal bleeding irregular
• Involution of uterus prolonged
• If the uterus perforation occuring
• Abdominal pain
• Presentation of intraperitoneal hemorrhage

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• Presentation of metastasis
• Lung is the most common metastatic
• location
• The second is vagina, side of uterus and
• brain

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• Diagnosis
• History and presentation
• presentation occuring within 6 months of mole
  curretage
• Assessmant of HCG
• Persistant high level 8 weeks after curretage
• Or the titer of HCG evaluated fast after it
  returned
• to normal
• Deplete retained mole, luteinizing cyst and
• pregnancy again

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• Ultrasound examination
• Histologic diagnosis
• Treatment and follow-up
• Same as to choriocarconoma

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• Choriocarcinoma
• Hyper-malignant tumor
• 50 of patients follow molar pregnancy
• 25 of patients follow abortion
• 25 of patients follow term pregnancy
• few of patient follow ectopic pregnancy

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• Histology
• Only found
• hyperproliferative trophoblast
• Hemorrhage, Necrosis
• No
• Interstial cell
• Fixed vascular
• Chorionic Villi

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• Clinical presentation
• Vaginal bleeding
• Abdominal pain
• Pelvic mass
• Presentation of metastasis
• Lung, vagina, brain, liver et al

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• Diagnosis
• Clinical presentation
• If the symptom and sign follow abortion, term
  birth and ectopic pregnancy companing HCG level
  increased, the diagnosis can be considered
• Assessment of HCG titer
• Ultrasound and doppler examination
• Histology

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• Treatment
• Chemotherapy
• Operation
• Follow-up
• Every 1 month first year
• Every 3 months 2 years
• Every 1 year 2 years
• Then every 2 yeas