Proff. Dr.

Abdelmageed Mashaley

,Obstetrics & Gynecology,Faculty of Medicine .Mansoura University abdelmageedmashaley@yahoo.com

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Obstetrics
• A branch of science dealing with pregnancy , labor and puerperium.

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Fertilization
• Definition : • Union of mature ovum and mature sperm to form zygote. • Timing :12 – 24 hours , after ovulation. • Site : ampulla of uterine tube ( in vivo • fertilization. Petri dish containing physiologic solution ( in vitro).
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Fertilization - Mechanism
1- Sperm capacitation :removal of seminal plasma proteins from cell membrane in head of sperm. 2- Sperm acrosome reaction :release of hyalourindase & trypsin like enzyme.

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Fertilization - Mechanism
3-Passage of sperm through corona radiata : by hyalournidase. 4-Passage of sperm through zona pelucida : by trypsin like enzyme. 5-Fusion of plsma membrane of ovum and sperm.

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Fertilization - Mechanism
6-Complection of 2nd meiotic division of ovum. 7-Formation of male pronucleus : from sperm nucleus. 8-Union of male and female pronuclei.

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Fertilization - Results
• Zygote formation : ovum (2ry oocyte ,22 + x ) + sperm ( 22 + x or y) = 44,xx or xy. • Sex determination : male (XY) or female (XX). • Health or disease determination: determination Normal karyotype or abnormal karyotype. • Zygote cell division to form morula or blastula.
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Morula and blatsula
• Morula = solid mass of 16-32 cells :mitotic cell division of zygote for 3 days during transfer in uterine tube. • Blastula =embryo blast and trophoblast : further cell division and cavity formation within morula ;for 3 days in uterine cavity. Trophoblast : outer syncitiotrophoblast & inner cytotrphoblast.
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Morula and blatsula

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Morula

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Implantation
• Definition :embedding of blatsula in decidua ( endometrium of pregnant uterus). • Timing : begins one week and ends two weeks after fertilization. • Normal site : upper part of body of uterus near funds, 60% posterior ,40% anterior.

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Implantation: abnormal sites
1-Lower part of body of uterus , near internal os (placenta previa). previa 2-Uterine tube (tubal pregnancy). pregnancy 3-Ovary (ovarian pregnancy). pregnancy 1ry ovarian pregnancy : direct implantation of fertilized ovum. 2ry ovarian pregnancy : 2ry to rupture of tubal pregnancy and re- implantation on the ovary.

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Implantation: abnormal sites
4-Peritoneum (abdominal pregnancy). pregnancy 1ry abdominal pregnancy : direct implantation of fertilized ovum. 2ry abdominal pregnancy : 2ry to rupture of tubal pregnancy and re- implantation in the abdomen.

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Implantation - Mechanism
• Stage of apposition of blastula to decidua. • Stage of adhesion of blastula to decidua. • Stage of penetration of blastula to decidua and its covering by decidua capsularis.

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Decidua
• Definition: endometrium of pregnant uterus. • Control : progestrone of corpus leuteum. • Decidual reaction : makes decidua suitable for implantation : • Endometrial glands increase secretion of mucin and glycogen for nutrition of blastula. • Stroma cells become loaded with glycogen. • Increased vascularity of stroma.

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Decidua – Parts & Fate
1-Decidua basalis : between blastoula and uterine wall. 2-Decidua capsularis :covers blastula. 3-Decidua parietalis : lines rest of uterine wall. • Fate : 1-Decidua basalis : forms maternal part of placenta. 2-Decidua capsularis and parietalis fuse together at 12 weeks when cavity is filled by concepts.
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Placenta
• Development : • Maternal part : decidua basalis & maternal blood in intervillous spaces. • Fetal part : chorion frondosum that forms chorionic villi : • 1ry villi : trophoblast = outer syncitiotrophoblast & inner cytotrphoblast.

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Placenta
• 2ry villi : trophoblast +core of mesoderm. • 3ry villi : trophoblast +core of mesoderm blood vessels. Anchoring villi : 3ry villi that attach to decidua. Absorbing villi :3ry villi that responsible for nutrition.

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Placental Barrier
• Definition : barrier between maternal blood & fetal blood. • Structure : 4 layers of 3ry villi : • Syncitiotrophoblast. • Cytotrophoblast. • Core of mesoderm. • Blood vessels. • Functions : explain functions of placenta.
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Placenta at Term
• • • • • Shape : discoid. Diameter : 15 – 20 cm. Thickness : 1.5 – 3.0 cm. Weight : 500 – 600 gm. Surfaces :

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Placenta at Term
• Maternal surface : contains 15 – 20 cotyledons ( bulging villous area ) separated by decidual septa. • fetal surface : covered by amniotic membrane (smooth), containing blood vessels from umbilical cord that attached near centre. • Intervillous spaces : containing maternal blood.

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Anomalies of Placenta
• Anomalies of site : Lower part of body of uterus , near internal os (placenta previa). previa • Anomalies of attachment to uterus: placental adhesion ( simple adhesion , placenta accreta). • Anomalies of attachment of cord : • Eccentric attachment : away from center. • Marginal attachment : to margin.
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Anomalies of Placenta
• Velamentous attachment : to fetal membranes , where vessels traverse to placenta. • Anomalies in shape : • Bilobed (Bipartite) placenta : 2 lobes. • Trilobed ( tripartite) placenta: 3 lobes. • Irregular ( not circular ) placenta. • Membranous placenta :
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Anomalies of Placenta
• Placenta succentorita : small accessory lobe + main placenta. • Anomalies in size & weight: e.g. large placenta in erythroblastosis fetalis & diabetes , syphilis.

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Functions of Placenta
• Gas exchange : between mother and fetus through placental barrier: fetal Hb. has greater affinity to O2 than maternal adult Hb.). Simple diffusion. • Nutrition of fetus : through placental barrier by simple diffusion , facilitated diffusion ,active transport, endocytosis. • Excretion of fetus : waste pr through placental barrier products to amniotic fluid.

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Functions of Placenta
• Hormone production : syncitiotrophoblast steroid hormones (estrogen& progestrone) & protein hormones ( human chorionic gonadotrophic , human placental lactogen. Decidua & membranes secrete prolactin & relaxin. • Protein production :pregnancy associated associated plasma protein(PAPP). • Enzyme production : oxytinase ,insulinase , ..
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Functions of Placenta
• Hemoglobin production : Fetal Hb. • Placental barrier action : allow passage of small molecule e.g. IgG ,some viruses ( e.g. rubella) ,some bacteria (e.g. treponema). some parasites(e.g. toxoplasma gondi). Not allow passage of large molecules (e.g. heparin & insulin).

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Estrogen
• source: fetal adrenal (90%) , syncitiotrophoblast (10%). • Action : proliferation & hypertrophy of uterus increases vascularity of genital tract. Preparation of breast for lactation Significance : maternal urinary estriol assess fetal welling.
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Progesterone
• Source : corpus leuteum of pregnancy, then syncitiotrophoblast. • Action : formation & maintenance of decidua. • Relaxation of smooth muscles of uterus& other body systems. • Preparation of breast for lactation.

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Human placental lactogen
• Source : syncitiotrophoblast . • Action : somatotrophic ( growth) , lactogenic ( formation of milk) , erythopoietic( formation of fetal Hb.)

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Human chorionic gonadotropin
• Source : syncitiotrophoblast. • Level : secretion starts one day after implantation , gradually increase till peak at 10th week (60-70 days) , then gradually decreases till day 100 & becomes plateau till delivery.

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Human chorionic gonadotropin
• Structure :glycoprotein ,2 subunits : Alpha subunit (identical to alpha subunit of FSH , LH , TSH). Beta subunit : specific to hCG . Actions : Maintans corpus luteum in early (8-10 weeks) pregnancy to secrete progesterone & estrogen.

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Human chorionic gonadotropin
• Maintains pregnancy by immunesuppressive effect. • Development of male genitalia ,in fetus. • Uses : • Diagnosis of early pregnancy) immunologic test). • Diagnosis of early abortion. • Diagnosis of ectopic pregnancy.
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Human chorionic gonadotropin
• Diagnosis & follow up of vesicular mole. • Diagnosis & follow up of chorio-carcinoma. • Induction of ovulation & spermatogenesis in infertility.

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Umbilical cord
• Development : connecting stalking. • Umbilical cord at term : 50 cm. in length , 1-2 cm. in diameter. Covered by amnion , containing Warton jelly , 2 arteries carrying deoxygenated blood & one vein carrying oxygenated blood. Attached to fetus at umbilicus ,to placenta ( 70% eccentric ,30% centric).
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Anomalies of umbilical cord
• Abnormal insertion : Marginal insertion , velamentous insertion. Abnormal length : Too long : leads to prolapse , coiling around neck, true knots. Too short : leads to premature separation of placenta , delayed descend of fetus during labor , inversion of uterus.

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Anomalies of umbilical cord
• Knots : True knots : fetus pass through loop , leads to asphyxia. False knot : localized collection of Wartons, kinking or dilatation of blood vessels. • Hematoma : rupture of one vessel.

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Anomalies of umbilical cord
• Torsion of cord : • Single umbilical artery. • Tumors : cyst , myxoma, hemangioma ,melanoma. • Inflammation (funitis). • Varices ,edema ( erythroblasosis fetalis).

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Fetal Membranes
• Outer Chorion & inner amnion. • Chorion : leave ,lines uterine wall ,attached to margins of placenta. • Amnion : lines chorion leave ,covers fetal surface of placenta & cord, forms amniotic sac that contains amniotic fluid & fetus.

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(Amniotic Fluid (liquor amnii
Characters : clear , slightly alkaline, opaque ,1 liter ( 0 .5-1.5 liter) at birth. • Source : Fetal : Fetal circulation transudation Fetal urine . Amniotic secretion. Maternal : Maternal circulation transudation

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(Amniotic Fluid (liquor amnii
• Composition: 99% water. 1% fetal epithelial cells, lango hair, vernix caseosa.organic substances ,inorganic substances. Circulation: dynamic circulation , turn over= 3 hours.

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(Amniotic Fluid (liquor amnii
Fetus swallow & inspire AF, urinate into AF. Placenta, cord ,amnion transudate & absorb AF. Anomalies : Polyhydramnios : excess volume > 2 liters. Oligohydramnios: little volume < 0.5 liter.

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Amniotic Fluid ((functions during pregnancy
Allows fetal growth & movement. Fetus swallow & inspire AF, urinate into AF. • Protects fetus from external trauma. • Protects fetus from adhesion to amnion. • Protects fetus from infection ( antiseptic). • Regulates fetal body temperature.

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Amniotic Fluid )(functions during labor
• Allows dilatation of cervix by formation of bag of forewaters. • Washing , sterilization & lubrication of vagina. • Prevents cord compression during uterine contraction.

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Amniocentesis
• Definition : aspiration of AF sample from amniotic sac. • Timing : 12 -14weeks. • Amount : 10 -20 ml. • Diagnostic Indications : • Diagnosis of fetal lung maturity : lecithin / sphingomylein (L/S) ratio > 2 after 35 W.

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Amniocentesis
• Diagnosis of fetal renal maturity : creatinine . 2 mg./100 ml. • Diagnosis of chromosomal anomalies e.g. Down syndrome ( karyotype of fetal cells). • Diagnosis of open neural tube defects e.g. anencephaly (alpha fetoprotein ).

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Amniocentesis
• Diagnosis of amniotic infection. • Detection of bilirubuin concentration in Rh. Isoimmunization. • Detection of meconium in fetal distress. • Therapeutic indication : • Chronic Polyhydramnios with pressure symptions.

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(Amniocentesis (complications
• Abortion. • Trauma to fetus , placenta , cord. • Leakage of AF, bloody tap.

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Fetal circulation
• One umbilical vein carries oxygenated blood from placenta to fetus where it divides into : a) ductus venosus , joining IVC , b) ductus sinus joining portal vein . • Right atrium receives deoxygenated blood from SVC & mixed blood from IVC , most of it pass to left atrium through foramen ovale , rest pass to right ventricle.
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Fetal circulation
• Right ventricle ejects mixed blood to pulmonary trunk , through ductus arteriosus ,it passes to aorta for distribution allover body. • Two umbilical arteries transport deoxygenated blood to placenta.

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Changes in fetal circulation at birth
Closure of foramen ovale giving fossa ovale : due to increase in left atrial P. Closure of ductus arteiosus giving ligamentum arteiosum : due to opening of pulmonary capillary bed. Closure of ductus venosus giving ligamentum venosum:

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Changes in fetal circulation at birth
• Closure of 2 umbilical arteries giving 2 lateral umbilical ligaments. • Closure of umbilical vein ligamentum teres.

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