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Obstetrics

Dr. Hana Lec: -1-


7-Oct-06

Normal fetal development & growth

Fetal growth & maturation

Determinants of birth weight are multi-factorial


Fetal growth is dependent on adequate transfer of nutrients & oxygen across the
placenta.

Factors affecting normal fetal growth

A- Physiological variables affecting normal fetal growth include

1- pre-pregnancy weight & maternal booking weight


2-maternal height
3-maternal age & parity
4- ethnic group
5- fetal sex
6paternal height

B-Other factors affecting intrinsic growth potential\

• Reduced fetal growth potential

1- chromosome defects,e.g.trisomy 18, tiploidy


2- single gene defects,e.g. seckl` s syndrome.
3-structural abnormalities ,e.g. renal agenesis.
4- infections ,e .g , CMV, toxoplasmosis.

Reduced fetal growth support

A- maternal factors

Under nutrition ,e .g, poverty. Eating disorders


Maternal hypoxia ,e .g, altitude, cyanotic heart disease
Drugs ,e .g, cigarette smoking, alcohol, cocaine.

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Placental factors

Reduced uteroplacental perfusion


Inadequate trophoblastic invasion, APS, diabetes mellitus, sickle cell disease, multiple
gestation.
Reduced feto-placental perfusion ,e.g., single umbilical artery , twin pregnancy.
3-fetal hormones
1-insulin-like growth factors (IGFs)
2- insulin
3- thyroid hormone
4-cortisol

In developed countries , the average birth weight is about 3.5 kg at the end of a
normal pregnancy lasting an average of 40 weeks.

Growth- restricted fetuses have significantly


• *Higher perinatal mortality & morbidity rate
*hypoxia/asphyxia
* stillborn
*HIE
*hypothermia
*hypoglycaemia
* infection & necrotizing entercolitis
* in adulthood they are at great risk of hypertension, IHD, DM.

Cardiovascular system

the fetal circulation is quite different from that of the adult.


Its distinctive features are as follow .
1-oxygenation occurs in the placenta not the lungs
2- the right & the left ventricles work in parallel rather than in series
3- the heart , brain & upper body receive blood from the left ventricle, while the
placenta &the lower body receive blood from both right & left ventricles.
Modifications in fetal vascularity ensure that the best , oxygenated blood from the
placenta is delivered to fetal brain.
1- the ductus venosus
2- the foramen ovale
3-the ductus arteriosus

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Respiratory system

Full differentiation of capillary & canalicular elements of the fetal lung is apparent
by 20 weeks gestation.
Alveoli develop after 24 weeks.
The lung alveoli are lined by a group of phospholipids known collectively as
surfactant.
Surfactant prevents the collapse of small alveoli during expiration by lowering surface
tension. it is continually replaced by synthesis from type 2 alveolar cells.
The predominant phospholipids (80%) is phosphotidylcholine (lecithin), the
production of lecithin is enhanced by cortisol, growth restriction & prolonged rupture
of the membrane. its production is delayed by diabetes.
Other phospholipids ,is phosphotidylglycerol

Normal lung development requires an adequate amniotic fluid volume & fetal
breathing movement

Causes of pulmonary hypoplasia


1- oligohydramnios
2- decreased intrathoracic space (e.g. ,diaphragmatic hernia )
3-chest wall deformities
Respiratory distress syndrome
It is specific to babies born prematurely& is associated with surfactant deficiency.

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Complications
1-hypoxia & asphyxia
2-intraventricular haemorrhage
3- necrotizing entercolitis

Prevention
The incidence &severity of RDS can be reduced by administering steroids antenatally
to mothers at risk of preterm delivery.
Fetal blood
The bone marrow starts to produce red cells at 7-8 weeks & is the predominant source
of red cells from 26 w gestation.
Most Hb in the fetus is fetal Hb (HbF) , which has two gamma chains. This differs
from the adult Hb (Hb A & Hb A2).
At term the ratio of Hb F/ Hb A is 80/20.after 6 months only 1% of Hb F persists.
Thalassaemia are a group of genetic haematological disorders characterized by
reduced or absent production of one or more of the globin chains of Hb.
B thalassaemia
Alpha thalassaemia

Immune system

The fetus enquire an effective immune system to resist intrauterine & perinatal
infection.
Lymphocytes appear from 8 w & by the middle of the second TM all phagocytes ,T
&B cells &complement are available to mount a response.
IgG originates mostly from the maternal circulation & cross the placenta to provide
passive immunity.
The fetus normally produces only small amounts of IgM & IgA which do not cross
the placenta
General immunological defenses include
Amniotic fluid (lysosomes, IgG)
The placenta (lymphoid cells ,phagocytes, barrier).
Granulocytes from liver
Interferon from lymphocytes

Skin & homeostasis

Fetal skin protects & facilitates homeostasis. A stratum corneum forms in the fifth
month & after approximately 23 w the appearance of the skin approaches that of the
adult epidermis.`
During the last weeks , skin is covered by vernix, which consists of desquamated skin
cells ,cholesterol & glycogen.
Preterm babies have no vernix &thin skin, this allows a proportionately large amount
of insensible loss.
Thermal control in cool , ambient temperatures is limited by a large surface-to-body-
weight ratio&poor thermal insulation.
Heat may be conserved by peripheral vasoconstriction & can be generated by brown
fat catabolism.
The response to warm ambient temperature is also poor ,due to poor response of
eccrine gland & can result in overheating of the infant.

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Alimentary system & energy stores

The primitive foregut & hind gut are present by the end of the fourth week &at this
stage the intestine is almost a straight tube , suspended by the mesentery from the
dorsal body wall . the midgut herniates into the base of the umbilical cord during the
sixth week .re-entering the abdominal cavity by 12 weeks
Failure of this process will result in development of an omphalocele.
The fetus continually & increasingly swallows amniotic fluid. Up to approximately 20
ml/h at term.
Peristalsis in the intestine occurs from the second TM. The large bowel is filled with
meconium at term.
While the body water content gradually diminishes , glycogen & fat stores increase
about five fold in the last TM.
Preterm infants have virtually no fat ,poorly developed alimentary system therefore
are more prone to hypoglycemia within the early neonatal period.

Fetal liver & gallbladder

 The primitive liver appears at about the 8th day of embryonic life as
adiverticulum arising from the duodenum.
 The large portion of this diverticulum gives rise to paranchymal cells &
hepatic ducts, while the smaller portion gives rise to the gallbladder.in utero
,the normal metabolic functions of the liver are performed by the placenta .
 The fetal liver has a reduced ability to conjugate bilirubin because of relative
deficiencies in glucuronyl transferase.

The loss of placental route of excretion of unconjugated bilirubin, particularly in the


premature infant, may result in transient unconjugated hyperbilirubinaemia
(physiological jaundice).
Fetal liver play an important role in haemopoiesis, which starts at 6 w, peak at 12-16
w continues until approximately 36 w.
Glycogen is stored within the liver in small quantities in the1st TM ,but storage is
maximum at 3rd TM.

Kidney &urinary tract

After regression of Wolffian duct, the metanephros forms the renal collecting
system(ureter, pelvis, calyces & collecting ducts)& induces the formation of the renal
secretary system (glomeruli, convoluted tubes ,loops of henle)from the mesenchyme
of the nephrogenic cord. Nephrogenesis is complete by 36 w,but the maturation of the
excretory &concentrating ability of the fetal kidneys is gradual.
Fetal urine forms much of the amniotic fluid, which is a protein free, sugar free
hypotonic ultra-filtrate of fetal plasma. Fetal urine production rises gradually with
fetal maturation reaching about 38 ml/h at 40 w
Renal agenesis therefore result in sever reduction or absence of amniotic fluid
(oligohydramnios)

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Fetal behavior

Quickening can 1st be perceived by the mother at 18 w in primigravida & two weeks
earlier in multigravida
1F is similar to quiet sleep (non REM ), with an absence of eye &body movement.
2F periodic eye &body movement(REM) sleep
3F has eye movement but no body movements(I,e.equivalent to quiet wakefulness)
4F is an active phase with ongoing eye movement & fetal activity.

Amniotic fluid

The A.F is initially secreted by the amnion, but by the 10th w it is mainly a transudate
of the fetal serum via the skin & umbilical cord. From 16 w gestation, the fetal skin
becomes impermeable to water &the net increase in AF is through a small imbalance
between the contributions of fluid through the kidneys & lung fluid& removal by fetal
swallowing .AF increases progressively reaching about 1000 cc at 38 w,but there is a
rapid fall in volume (at 40 w = 350 ml)
Function of AF is to
1-protect the fetus from mechanical injury
2-permit movement of the fetus while preventing limb contructure
3-prevent adhesions between fetus &amnion
4- permit fetal lung maturation
Oligohydramnios, caused by renal agenesis, cystic kidneys, IUGR.
Polyhydramnios caused by anencephaly, esophageal/ duodenal atresia

Written By:
Rand Aras Najeeb

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