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. Finding Engorgement Mastitis Plugged duct OnsetGradualSuddenGradual LocationBilateralUnilateral SwellingGeneralizedLocalized PainGeneralized Intense, localized Localized Systemic symptoms Feels wellFeels illFeels well FeverNoYesNo 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  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 38 ºc 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 ……