Topics today

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Topics today

• Normal puerperium
• Diseases of puerperium
• Ectopic pregnancy
• Abortion
• Zhao Aimin MD.PhD.

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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 38? Involution of uterus
After-pains onsets 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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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 38 ? 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
• Dys-involution of tuerus
• Relax of cervix
• Placenta tissure can be palpable

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• Retained decidua
• Infection of the placenta attachment
• area
• Dys-involution of uterus
• Fissuration of utrine 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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Ectopic pregnancy Definition Implantation outside
of the uterine cavity is termed ectopic
pregnancy It is a condition that significantly
jeopardizes the mother because catastrophic
bleeding may occur when the implanting pregnancy
erodes blood vessels or ruptures of the tubal wall
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• Implant locations
• Tubal 95 (80 ampullary portion)
• Ovarian lt1
• Abdominal 1-2
• Cervical 0.15
• Cornual 2

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Etiology Salpingitis have 6-fold increase the
risk of ectopic
pregnancy Operation of tubal IUD(intrauterine
device) Dysfunction of tubal Orther
endometriosis
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Outcomes of ectopic pregnancy Tubal abortion
8-12 Weeks ampullary portion Rupture of tubal
pregnancy 5 weeks isthmic portion Tubal
abortion with subsequent implantation on an
intraperitoneal structure for example liver
pregnancy
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Clinical manifestation of ectopic
pregnancy Amenorrhea 70-80 6-8 weeks Abdominal
and pelvic pain the most common symptom,which
is present in nealy all patients. Pain is a
result of distented of tubal and irritation of
peritoneum by blood Irregular vaginal bleeding
results from the sloughing of the decidua Shock
result from amount of blood loss Abdominal mass
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• Physical findings in tubal pregnancy
• General findings
• Anemic or pale face
• pulse increased
• BP decreased
• Tlt 38 degree

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• Abdominal examination
• distention and tenderness with or without rebound
• Decreased bowel sound
• Shifting dullness positive
• mass

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• Pelvic examination
• Slightly open cervix with bleeding
• Cervical motion tenderness
• Adnexal tenderness
• Adnexal mass
• The uterus size may be normal or enlarged

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Diagnostic procedures Typical cases can be
determined easy Early ectopic pregnancy or
unrupture type difficulty It is nessesary to need
assistant examination
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• HCG test 80-100 positive
• Urinary HCG level
• Blood HCG level
• If HCG negative,ectopic pregnancy does not be
  rule out
• Type B Utrasound
• Culdocentesis
• Aid in the identification of peritoneum bleeding
• Positive (noncloting blood)
• ectopic pregnancy may be confirmed
• Negative ectopic pregnancy does not be depletion

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• Laproscopy
• It is a direct visualization and accurte method
  to diagnosis ectopic pregnancy
• Even laproscopy,however,carries 2-5 misdiagnosis
  rate, because an extremely early tubal pregnancy
  gestation may not be identified

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• Pothology of endometriun
• Curettage of the uterine cavity can also help
  rule out ectopic pregnancy
• Identification of chorionic villi in curetting
  may identify an intrauterine pregnancy

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• Differential diagnosis
• Abortion
• Acute salpingitis
• Acute appendicitis
• Rupture of corpus luteum
• Torsion of ovarian cyst

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• Treatment of ectopic pregnancy
• Surgical treatment
• Salpingectomy
• Conservative operation
• Salpinggostomy
• Segmantal resection and tubal reanatomosis

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• Nonsurgical therapy
• Chinese traditional medicine
• Chemical therapy
• DrugMTX
• Indication
• The diameter of the mass lt3cm
• Unrupture
• Not significantly bleeding
• HCG level lt2000U/L

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Abortion
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• Definition
• Abortion is the termination of a pregnancy before
  28 weeks from the first day of the last menstrual
  period and the fetus weight lt1000g

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• Classification
• Early abortion lt12W
• Late abortion 12-28W
• Spontaneous abortion
• Artificial abortion

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• Etiology
• Genetic factors
• Maternal factors
• Infection
• systemic factors heart disease sever anemia
  endocrine
• Reproductive tract abnormality
• Immunologic factors
• Enviromental factors Toxin Radiation smoking
  alohol

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Pathology 1.Haemorrhage occurs in the decidua
basalis leading to local necrosis and
inflammation.
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2. The ovum, partly or wholly detached, acts as a
foreign body and irritates uterine contractions.
The cervix begins to dilate.
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3. Expulsion complete, The decidua is shed during
the next few days in the lochial flow.
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Clinical manifestation

• Haemorrhage is usually the first sign and may be
  significantly if placental separation is
  incomplete.
• Pain is usually intermittent, like a small
  labrur. It ceases when the abortion is complete.

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Threatened abortion
Low abdominal Pain company vaginal
bleeding Cervix is closed unrupture of
membrane Embryo survive
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Inevitable abortion
Bleeding increased Pain development Ruputure of
membrane Cevix dilation Embryo tissue
incarcerated in the cervix
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Complete abortion Uterine contractions are felt,
the cervix dilates and blood loss continues. The
fetus and placenta are expelled complete, the
uterus contracts and bleeding stops. No further
treatment is needed.
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Incomplete abortion In spite of uterine
contractions and cervical dilatation, only the
fetus and some membranes are expelled. The
placenta remains partly attached and bleeding
continues. This abortion must be completed by
surgical methods.
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Missed abortion Is the retention of a failed
intrauterine pregnancy for a extended period,
usually defined as more than two menstrual
cycles Recurrent abortion It is a term used when
a patient has had two or more consecutive
spontaneous abortions Septic abortion
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• Treatment of abortion
• Incomplete abortion
• Remove the embryo and placenta as soon as
  possible
• Negative pressure suction
• Embryulcia
• Missed abortion
• Notice blood clot function prevent DIC
• Septic abortion
• Broad-spectrum antibiotics

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Removal of placental tissue with ovum forceps.
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