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
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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