Topics today Normal puerperium Diseases of puerperium Ectopic pregnancy Abortion Zhao Aimin MD.PhD.

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

It has reformed within several hours of 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

the time of ovulation is 3 months in non- 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

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

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

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

T of maternal more than 38 ? occurs twice 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

Bata-hemolytic streptococcus 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 locations Tubal 95% (80% ampullary portion) Ovarian <1% Abdominal 1-2% Cervical 0.15% Cornual 2%

Etiology Salpingitis have 6-fold increase the risk of ectopic pregnancy Operation of tubal IUD(intrauterine device) Dysfunction of tubal Orther: endometriosis

Outcomes of ectopic pregnancy Tubal 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 examination distention and tenderness with or without rebound Decreased bowel sound Shifting dullness positive mass

Pelvic examination Slightly open cervix with bleeding Cervical motion tenderness Adnexal tenderness Adnexal mass The uterus size may be normal or enlarged

Diagnostic procedures Typical cases can be determined easy Early ectopic pregnancy or unrupture type difficulty It is nessesary to need assistant examination

HCG test 80-100% positive Type B Utrasound Culdocentesis 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

Laproscopy It 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 diagnosis Abortion 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 therapy Drug:MTX Indication Chinese traditional medicine Chemical therapy Drug:MTX Indication The diameter of the mass <3cm Unrupture Not significantly bleeding HCG level <2000U/L

Abortion

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

Classification Early abortion <12W Late abortion 12-28W Spontaneous abortion Artificial abortion

Etiology Genetic factors Maternal factors Immunologic factors Infection systemic factors heart disease sever anemia endocrine Reproductive tract abnormality Immunologic factors Enviromental factors Toxin Radiation smoking alohol

Pathology 1.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 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 abortion Recurrent abortion Septic abortion Is the retention of a failed intrauterine pregnancy for a extended period, usually defined as more than two menstrual cycles Recurrent abortion It is a term used when a patient has had two or more consecutive spontaneous abortions Septic abortion

Treatment of abortion Incomplete abortion Missed abortion Remove 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.