Topics today

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

2. Normal puerperium(Postpartum care)

3. 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

4. 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

5. 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

6. Ovarian function the time of ovulation is 3 months in non- breast -feeding women • Cardiovascular system: return to normal after 2-3 weeks

7. Clinical manifestaion of puerperium • T is less than 38ºc • Involution of uterus • After-pains occuring at 1-2 days and maintant 2-3days

8. 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

9. 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

10. 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

11. Differential diagnosis of engorgement, mastitis and plugged duct

12. Diseases of puerperium • Puerperal infection • Late puerperal hemorrhage • Postpartum depression • puerperal heat stroke

13. 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

14. 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.

15. Induction factors of puerperal infection • General asthenia, Dystrophy • Anemia ,Sexual intercourse • PROM, Infection of amnotic cavity • Obstetric operation • Hemorrhage pre and postpartum

16. The kinds of pathogen • Bata-hemolytic streptococcus • Anaerobic streptococcus • Anaerobic bacillus • Staphylococcus • Bacillus coli

17. Pathology and clinical manifestation • Acute vulvitis, vaginitis,cervicitis • Acute endometritis, myometritis • Acute inflammation of pelvic connective tissure, Salpingitis, Peritonitis • Thrombophlebitis • Pyemia and hematosepsis

18. Diagnosis and treatment • supporting treatment • Delete the induction factors • Broad-spectrun antibiotic • Expectant treatment

19. 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

20. 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

21. Retained decidua • Infection of the placenta attachment area • Sabinvolution of uterus • Fissuration of uterine insision postcesarean • Trophoblastic tumor postpartum • Submucus myoma

22. Diagnosis and treatment • supporting treatment • Delete the etiologic factors • Broad-spectrun antibiotic • Expectant treatment

23. Gestational trophoblastic diseases(GTD) • Molar pregnancy(hydatidiform mole) • Invisave mole • Choriocarcinoma • Placentalsite trophoblastic tumor(PSTT)

24. Molar pregnancy • Classification • Complete molar pregnancy • Partial molar pregnancy

25. 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)

26. Etiology • Unknown? • Associated with • age • Dietary deficiencies • Economic status, et al

27. 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

28. Histologic features • Trophoblast proliferation • Villi interstitial edema • Fetal origin Capillary disappearance • Luteinizing cyst

29. 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

30. Diagnosis • Clinical presentation • Ascertain the level of HCG • Ultrasound:snowstorm appearance • Histology

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

32. 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

33. 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

34. 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

35. Histology • Type I • amount of mole • Invading myometrium or vascular • Hemorrhage or necrosis rarely

36. Type II • Moderate of mole • Trophoblast proliferation moderate • partial trophoblast undifferentiated • Hemorrhage and necrosis

37. Type III • Amount of Hemorrhage or necrosis tissue • Trophoblast hyperproliferation and undifferentiated The histology is very same as choriocarcinoma

38. Clinical presentation • Presentation of primary disease • Vaginal bleeding irregular • Involution of uterus prolonged • If the uterus perforation occuring • Abdominal pain • Presentation of intraperitoneal hemorrhage

39. Presentation of metastasis • Lung is the most common metastatic location • The second is vagina, side of uterus and brain

40. 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

41. Ultrasound examination • Histologic diagnosis • Treatment and follow-up • Same as to choriocarconoma

42. 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

43. Histology • Only found • hyperproliferative trophoblast • Hemorrhage, Necrosis • No • Interstial cell • Fixed vascular • Chorionic Villi

44. Clinical presentation • Vaginal bleeding • Abdominal pain • Pelvic mass • Presentation of metastasis • Lung, vagina, brain, liver et al

45. 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

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