Topics today Normal puerperium Diseases of puerperium Gestational trophoblastic diseases,GTD.

Topics todayTopics today

Normal puerperium Diseases of puerperium Gestational trophoblastic

diseases,GTD

Normal puerperiumNormal puerperium(Postpartum care)(Postpartum care)

PuerperiumPuerperium

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 puerperiumPhysiology 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

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

Ovarian function the time of ovulation is 3 months in non-

breast -feeding women

Cardiovascular system: return to normal after 2-3 weeks

Clinical manifestaion of puerperium

T is less than 38ºc

Involution of uterus

After-pains

occuring at 1-2 days and maintant

2-3days

lochiadischarge comes from the placental site and maintants for 4-6 weeksLochia 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 Management of the puerperiumpuerperium

Maternal -infant bonding

rooming in Uterine complications postpartum hemorrhage, infection, the amount of lochia Bowel movement Urination Care of the perineum

Management of breastBreast-feedingthe benefits of breast-feeding increase the conversation decrease the cost improve infant nutrition and protect

against infection and allergic reaction uterus contraction

Finding Engorgement Mastitis Plugged duct

Onset Gradual Sudden Gradual

Location Bilateral Unilateral Unilateral

Swelling Generalized Localized Localized

Pain Generalized Intense,

localizedLocalized

Systemic symptoms

Feels well Feels ill Feels well

Fever No Yes No

Differential diagnosis of engorgement, mastitis and plugged duct

Diseases of puerperium

Puerperal infection Late puerperal hemorrhage Postpartum depression puerperal heat stroke

Puerperal infection

Puerperal infectionGenital infected by pathogenic microorganism during labor and puerperal periodThe incidence is about 1%-7.2%It is one of the four kinds of causes which result in maternal mortality

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.

Induction factors of puerperal infection

General asthenia, Dystrophy

Anemia ,Sexual intercourse

PROM, Infection of amnotic cavity

Obstetric operation

Hemorrhage pre and postpartum

The kinds of pathogen Bata-hemolytic streptococcus

Anaerobic streptococcus

Anaerobic bacillus

Staphylococcus

Bacillus coli

Pathology and clinical manifestation

Acute vulvitis, vaginitis,cervicitis

Acute endometritis, myometritis

Acute inflammation of pelvic connective

tissure, Salpingitis, Peritonitis

Thrombophlebitis

Pyemia and hematosepsis

Diagnosis and treatment supporting treatment

Delete the induction factors

Broad-spectrun antibiotic

Expectant treatment

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

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

Retained decidua

Infection of the placenta attachment

area

Sabinvolution of uterus

Fissuration of uterine insision

postcesarean

Trophoblastic tumor postpartum

Submucus myoma

Diagnosis and treatment supporting treatment

Delete the etiologic factors

Broad-spectrun antibiotic

Expectant treatment

Gestational trophoblastic diseases(GTD)

Molar pregnancy(hydatidiform mole) Invisave mole Choriocarcinoma Placentalsite trophoblastic tumor(PSTT)

Molar pregnancy Classification Complete molar pregnancy Partial molar pregnancy

EpidemiologyThe 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)

Etiology

Unknown?

Associated with

age

Dietary deficiencies

Economic status, et al

Genetic constitutionComplete 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

Histologic featuresTrophoblast proliferation

Villi interstitial edema

Fetal origin Capillary disappearance

Luteinizing cyst

Clinical presentationBleeding 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

DiagnosisClinical presentation

Ascertain the level of HCG

Ultrasound:snowstorm appearance

Histology

TreatmentRemove the intrauterine contents promply

Hysterectomy

in the older reproductive group who have no interest in further childbearing

Management of luteinizing cyst

Preventive chemotherapyAge 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

Follow-upPelvic 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

Invasive moleIs 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

Histology

Type I

amount of mole

Invading myometrium or vascular

Hemorrhage or necrosis rarely

Type IIModerate of mole

Trophoblast proliferation moderate

partial trophoblast undifferentiated

Hemorrhage and necrosis

Type IIIAmount of Hemorrhage or necrosis tissue

Trophoblast hyperproliferation and

undifferentiated

The histology is very same as choriocarcinoma

Clinical presentationPresentation of primary diseaseVaginal bleeding irregular

Involution of uterus prolonged

If the uterus perforation occuring

Abdominal pain

Presentation of intraperitoneal hemorrhage

Presentation of metastasisLung is the most common metastatic

location

The second is vagina, side of uterus and

brain

DiagnosisHistory 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

Ultrasound examination

Histologic diagnosis

Treatment and follow-up

Same as to choriocarconoma

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

HistologyOnly found

hyperproliferative trophoblast

Hemorrhage, Necrosis

No

Interstial cell

Fixed vascular

Chorionic Villi

Clinical presentation

Vaginal bleeding

Abdominal pain

Pelvic mass

Presentation of metastasis

Lung, vagina, brain, liver et al

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

Treatment Chemotherapy

Operation

Follow-up Every 1 month first year

Every 3 months 2 years

Every 1 year 2 years

Then every 2 yeas ……