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
the initial postpartum visit is scheduled at
42th days
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
? 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
?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
? Maternal -infant bonding
rooming in
? Uterine complications
postpartum hemorrhage,infection,
the amount of lochia
? Bowel movement
? Urination
? Care of the perineum
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
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
Differential diagnosis of engorgement,
mastitis and plugged duct
Diseases of puerperium
? Puerperal infection
? Late puerperal hemorrhage
? Postpartum depression
? puerperal heat stroke
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
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
?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)
?Etiology
Unknown?
Associated with
?age
?Dietary deficiencies
?Economic status,et al
?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
?Histologic features
?Trophoblast proliferation
?Villi interstitial edema
?Fetal origin Capillary disappearance
?Luteinizing cyst
?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
?Diagnosis
Clinical presentation
Ascertain the level of HCG
Ultrasound:snowstorm appearance
Histology
?Treatment
?Remove the intrauterine contents promply
?Hysterectomy
in the older reproductive group who have no interest
in further childbearing
?Management of luteinizing cyst
?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
?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
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
?Histology
?Type I
?amount of mole
?Invading myometrium or vascular
?Hemorrhage or necrosis rarely
?Type II
?Moderate of mole
?Trophoblast proliferation moderate
? partial trophoblast undifferentiated
?Hemorrhage and necrosis
?Type III
?Amount of Hemorrhage or necrosis tissue
?Trophoblast hyperproliferation and
undifferentiated
The histology is very same as choriocarcinoma
?Clinical presentation
?Presentation of primary disease
?Vaginal bleeding irregular
?Involution of uterus prolonged
?If the uterus perforation occuring
Abdominal pain
Presentation of intraperitoneal hemorrhage
?Presentation of metastasis
?Lung is the most common metastatic
location
?The second is vagina,side of uterus and
brain
?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
?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
?Histology
?Only 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 ……