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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

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 nonbreast -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
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 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 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

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
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
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
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

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.