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

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. 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

6. 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

7. Clinical manifestaion of puerperium
T is less than 38?
Involution of uterus
After-pains
onsets 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. Diseases of puerperium
Puerperal infection
Late puerperal hemorrhage
Postpartum depression
puerperal heat stroke

12. 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

13. 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.

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

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

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

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

18. 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

19. 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

20. Retained decidua
Infection of the placenta attachment
area
Dys-involution of uterus
Fissuration of utrine insision
postcesarean
Trophoblastic tumor postpartum
Submucus myoma

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

22. 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

23. Implant locations Tubal 95% (80% ampullary portion) Ovarian <1%
Abdominal 1-2%
Cervical 0.15%
Cornual 2%

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

25. 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

26. 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

27. Physical findings in tubal pregnancy General findings:
Anemic or pale face
pulse increased
BP decreased
T< 38 degree

28. Abdominal examination
distention and tenderness with or without rebound
Decreased bowel sound
Shifting dullness positive
mass

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

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

31. 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

32. 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

33. 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

34. Differential diagnosis
Abortion
Acute salpingitis
Acute appendicitis
Rupture of corpus luteum
Torsion of ovarian cyst

35. Treatment of ectopic pregnancy
Surgical treatment
Salpingectomy
Conservative operation
Salpinggostomy
Segmantal resection and tubal reanatomosis

36. 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

37. Abortion

38. 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

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

40. 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

41. Pathology
1.Haemorrhage occurs in the decidua basalis leading to local necrosis and inflammation.

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

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

44. 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.

45. Threatened abortion Low abdominal Pain company vaginal bleeding
Cervix is closed
unrupture of membrane
Embryo survive

46. Inevitable abortion Bleeding increased Pain development
Ruputure of membrane
Cevix dilation
Embryo tissue incarcerated in the cervix

47. 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.

48. 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.

49. 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

50. 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

51. Removal of placental tissue with ovum forceps.