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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 immune-
suppressive 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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