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Topics today. Normal puerperium Diseases of puerperium Gestational trophoblastic diseases,GTD. Normal puerperium (Postpartum care). Puerperium. 6 weeks periods after birth the reproductive tract return to its normal, non-pregnancy state

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topics today
Topics today
  • Normal puerperium
  • Diseases of puerperium
  • Gestational trophoblastic diseases,GTD
puerperium
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

physiology of the puerperium
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

slide5
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
slide6

Ovarian function

the time of ovulation is 3 months in non-

breast -feeding women

  • Cardiovascular system:

return to normal after 2-3 weeks

slide7

Clinical manifestaion of puerperium

  • T is less than 38ºc
  • Involution of uterus
  • After-pains

occuring at 1-2 days and maintant

2-3days

slide8

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

management of the puerperium
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
slide10

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
slide12

Diseases of puerperium

  • Puerperal infection
  • Late puerperal hemorrhage
  • Postpartum depression
  • puerperal heat stroke
slide13

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

slide14

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.

slide15

Induction factors of puerperal infection

  • General asthenia, Dystrophy
  • Anemia ,Sexual intercourse
  • PROM, Infection of amnotic cavity
  • Obstetric operation
  • Hemorrhage pre and postpartum
slide16

The kinds of pathogen

  • Bata-hemolytic streptococcus
  • Anaerobic streptococcus
  • Anaerobic bacillus
  • Staphylococcus
  • Bacillus coli
slide17

Pathology and clinical manifestation

  • Acute vulvitis, vaginitis,cervicitis
  • Acute endometritis, myometritis
  • Acute inflammation of pelvic connective

tissure, Salpingitis, Peritonitis

  • Thrombophlebitis
  • Pyemia and hematosepsis
slide18

Diagnosis and treatment

  • supporting treatment
  • Delete the induction factors
  • Broad-spectrun antibiotic
  • Expectant treatment
slide19

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

slide20

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
slide21

Retained decidua

  • Infection of the placenta attachment

area

  • Sabinvolution of uterus
  • Fissuration of uterine insision

postcesarean

  • Trophoblastic tumor postpartum
  • Submucus myoma
slide22

Diagnosis and treatment

  • supporting treatment
  • Delete the etiologic factors
  • Broad-spectrun antibiotic
  • Expectant treatment
slide23

Gestational trophoblastic diseases(GTD)

  • Molar pregnancy(hydatidiform

mole)

  • Invisave mole
  • Choriocarcinoma
  • Placentalsite trophoblastic

tumor(PSTT)

slide24

Molar pregnancy

  • Classification
  • Complete molar pregnancy
  • Partial molar pregnancy
slide25

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)

slide26

Etiology

  • Unknown?
  • Associated with
  • age
  • Dietary deficiencies
  • Economic status, et al
slide27

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
slide28

Histologic features

  • Trophoblast proliferation
  • Villi interstitial edema
  • Fetal origin Capillary disappearance
  • Luteinizing cyst
slide29

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
slide30

Diagnosis

  • Clinical presentation
  • Ascertain the level of HCG
  • Ultrasound:snowstorm appearance
  • Histology
slide31

Treatment

  • Remove the intrauterine contents promply
  • Hysterectomy
  • in the older reproductive group who have no interest in further childbearing
  • Management of luteinizing cyst
slide32

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
slide33

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
slide34

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
slide35

Histology

  • Type I
  • amount of mole
  • Invading myometrium or vascular
  • Hemorrhage or necrosis rarely
slide36

Type II

  • Moderate of mole
  • Trophoblast proliferation moderate
  • partial trophoblast undifferentiated
  • Hemorrhage and necrosis
slide37

Type III

  • Amount of Hemorrhage or necrosis tissue
  • Trophoblast hyperproliferation and

undifferentiated

The histology is very same as choriocarcinoma

slide38

Clinical presentation

  • Presentation of primary disease
  • Vaginal bleeding irregular
  • Involution of uterus prolonged
  • If the uterus perforation occuring
  • Abdominal pain
  • Presentation of intraperitoneal hemorrhage
slide39

Presentation of metastasis

  • Lung is the most common metastatic

location

  • The second is vagina, side of uterus and

brain

slide40

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

slide41

Ultrasound examination

  • Histologic diagnosis
  • Treatment and follow-up
  • Same as to choriocarconoma
slide42

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
slide43

Histology

  • Only found
  • hyperproliferative trophoblast
  • Hemorrhage, Necrosis
  • No
  • Interstial cell
  • Fixed vascular
  • Chorionic Villi
slide44

Clinical presentation

  • Vaginal bleeding
  • Abdominal pain
  • Pelvic mass
  • Presentation of metastasis
  • Lung, vagina, brain, liver et al
slide45

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
slide46

Treatment

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