Topics today Topics today Normal puerperium Diseases of puerperium Ectopic pregnancy Abortion

Zhao Aimin MD.PhD.

Normal puerperiumNormal puerperium(Postpartum care)(Postpartum care)

PuerperiumPuerperium

6 weeks periods after birth the reproductive tract return to its n

ormal, 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 birt

h

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 38?

Involution of uterus

After-pains

onsets 1-2 days and maintant

2-3days

lochiadischarge 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 puerManagement of the puerperiumperium

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

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 38 ? 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

Dys-involution of tuerus

Relax of cervix

Placenta tissure can be palpable

Retained decidua

Infection of the placenta attachment

area

Dys-involution of uterus

Fissuration of utrine insision

postcesarean

Trophoblastic tumor postpartum

Submucus myoma

Diagnosis and treatment

supporting treatment

Delete the etiologic factors

Broad-spectrun antibiotic

Expectant treatment

Ectopic pregnancy

Definition

Implantation outside of the uterine cavity is termed ectopic pregnancy

It is a condition that significantly jeopardizes the mother because catastrophic bleeding may occur when the implanting pregnancy erodes blood vessels or ruptures of the tubal wall

Implant locationsTubal 95% (80% ampullary portion)

Ovarian <1%

Abdominal 1-2%

Cervical 0.15%

Cornual 2%

EtiologySalpingitis have 6-fold increase the risk of ectopic

pregnancy

Operation of tubal

IUD(intrauterine device)

Dysfunction of tubal

Orther: endometriosis

Outcomes of ectopic pregnancyTubal abortion

8-12 Weeks ampullary portion

Rupture of tubal pregnancy

5 weeks isthmic portion

Tubal abortion with subsequent implantation

on an intraperitoneal structure for example liver pregnancy

Clinical manifestation of ectopic pregnancy

Amenorrhea 70-80% 6-8 weeks

Abdominal and pelvic pain

the most common symptom,which is present in nealy all patients. Pain is a result of distented of tubal and irritation of peritoneum by blood

Irregular vaginal bleeding

results from the sloughing of the decidua

Shock result from amount of blood loss

Abdominal mass

Physical findings in tubal pregnancy

General findings:

Anemic or pale face

pulse increased

BP decreased

T< 38 degree

Abdominal examinationdistention and tenderness with or without rebound

Decreased bowel sound

Shifting dullness positive

mass

Pelvic examinationSlightly open cervix with bleeding

Cervical motion tenderness

Adnexal tenderness

Adnexal mass

The uterus size may be normal or enlarged

Diagnostic proceduresTypical cases can be determined easy

Early ectopic pregnancy or unrupture type difficulty

It is nessesary to need assistant examination

HCG test 80-100% positive

Urinary HCG level

Blood HCG level

If HCG negative,ectopic pregnancy does not be rule out

Type B Utrasound

Culdocentesis

Aid in the identification of peritoneum bleeding

Positive (noncloting blood)

ectopic pregnancy may be confirmed

Negative ectopic pregnancy does not be depletion

LaproscopyIt is a direct visualization and accurte method to diagnosis ectopic pregnancy

Even laproscopy,however,carries 2-5% misdiagnosis rate, because an extremely early tubal pregnancy gestation may not be identified

Pothology of endometriun

Curettage of the uterine cavity can also help rule out ectopic pregnancy

Identification of chorionic villi in curetting may identify an intrauterine pregnancy

Differential diagnosisAbortion

Acute salpingitis

Acute appendicitis

Rupture of corpus luteum

Torsion of ovarian cyst

Treatment of ectopic pregnancy

Surgical treatment

Salpingectomy

Conservative operation

Salpinggostomy

Segmantal resection and tubal reanatomosis

Nonsurgical therapyChinese traditional medicine

Chemical therapy

Drug:MTX

Indication The diameter of the mass <3cm

Unrupture

Not significantly bleeding

HCG level <2000U/L

AbortionAbortion

Definition Abortion is the termination of a pregnancy

before 28 weeks from the first day of the

last menstrual period and the fetus weight

<1000g

ClassificationEarly abortion <12W

Late abortion 12-28W

Spontaneous abortion

Artificial abortion

EtiologyGenetic factors

Maternal factors

Infection

systemic factors heart disease sever anemia endocrine

Reproductive tract abnormality

Immunologic factors

Enviromental factors Toxin Radiation smoking alohol

Pathology1.Haemorrhage occurs in the decidua basalis leading to local necrosis and inflammation.

2. The ovum, partly or wholly detached, acts as a foreign body and irritates uterine contractions. The cervix begins to dilate.

3. Expulsion complete, The decidua is shed during the next few days in the lochial flow.

Clinical manifestationClinical manifestation

Haemorrhage is usually the first sign and may be significantly if placental separation is incomplete.

Pain is usually intermittent, ‘like a small labrur’. It ceases when the abortion is complete.

Threatened abortion

Low abdominal Pain company vaginal bleeding

Cervix is closed

unrupture of membrane

Embryo survive

Inevitable abortion

Bleeding increased

Pain development

Ruputure of membrane

Cevix dilation

Embryo tissue incarcerated in the cervix

Complete abortion

Uterine contractions are felt, the cervix dilates and blood loss continues.

The fetus and placenta are expelled complete, the uterus contracts and bleeding stops. No further treatment is needed.

Incomplete abortion

In spite of uterine contractions and cervical dilatation, only the fetus and some membranes are expelled. The placenta remains partly attached and bleeding continues. This abortion must be completed by surgical methods.

Missed abortionIs the retention of a failed intrauterine pregnancy for a extended period, usually defined as more than two menstrual cycles

Recurrent abortionIt is a term used when a patient has had two or more consecutive spontaneous abortions

Septic abortion

Treatment of abortion Incomplete abortionRemove the embryo and placenta as soon as possible

Negative pressure suction

Embryulcia

Missed abortion

Notice blood clot function prevent DIC

Septic abortion

Broad-spectrum antibiotics

Removal of placental tissue with ovum forceps.