You are on page 1of 80

pregnancy

Maka Chikovani, MD
Department of Obstetrics and
Gynecology, TSMU Aladashvili
University Hospital

Objectives:
• Reminder of physiology of pregnancy
• early embryogenesis, placenta, placental
development and its functions,
• amniotic fluid, umbilicus and afterbirth,
• fetus development stages
• Labor and delivery

By the time a woman reaches puberty
each of her ovaries contains about
200 000 primary oocytes, enclosed in
primordial follicles. Each oocyte is
separated from the cellular primordial
follicle by a clear area, the
perivitelline space and a thickened
“shell”, the zona pellucida.

4.Pre-antral follicle

5. Each month from about the age of 15 to the age of 45.Each primordial follicle is capable of growing under the influence of follicle stimulating hormone (FSH) to form a mature follicle. some 20 of the primordial follicles grow through the stage of vesicular follicles to become mature antral follicles. .

6.Graafian follicles .

7.Structure of an Ovary .

Physiology of pregnancy In contrast to other body cells. . 8. to become a secondary oocyte. At some stage of its growth the oocyte undergoes a meiotic division of its nucleus and an unequal division of its cytoplasm. the oocyte has only 23 chromosomes.

at mid-cycle.Physiology of pregnancy With the release of luteinizing hormone (LH) surge by the pituitary. the follicle bursts expelling the ovum. which is gathered into Fallopian tube by the fimbria which project from its proximal end . 9.

Physiology of pregnancy Once the ovum has been expelled. The ovum is now ready to be fertilized should a sperm reach it. . the follicle collapses and turns yellow. 10. forming the corpus luteum.

11. .Physiology of pregnancy Fertilization Of the 60-100 million sperm ejaculated into a woman’s vagina at the time she ovulated. several million will negotiate the helical channels in the cervical mucus to reach the uterine cavity.

12.A sperm cell fertilising an ovum .

. 13. its head entering the substance of the ovary.Fertlization Several hundred sperm may pass through the narrow entrance to the Fallopian tubes. and a few will survive to reach the ovum in the fimbrial end of the Fallopian tube. One sperm may penetrate the zona pellucida of the ovum.

14.FERTILIZATION .

15.Fertilization and conception Once inside the cytoplasm of the ovum. The two naked nuclei approach each other and fuse. leaving a naked male pronucleus. also loses its nuclear membrane. Fertilization and conception have occurred. . the sperm’s nuclear membrane dissolves. having divided to produce a second polar body. The ovum.

. 16. further cell division proceeds rapidly until within 3 to 4 days a solid mass of cells (the morula) has formed.Fertlization and conception Within a few hours of fertilization. the fused nuclei divide to form two cells. Once this event has occurred.

17.Ovum Fertilization and Zygote Cleavage .

During its passage.18. fluid passes through canaliculae in the zona pellucida to create a central fluid-filled cavity in the morula. .Ovum Fertilization and Zygote Cleavage The morula is rapidly propelled along the Fallopian tube to enter the uterine cavity. forming a blastocyst.

Ovum Fertilization and Zygote Cleavage .19.

20.Fertilization .

Implantation of the Blastocyst On reaching the uterine cavity the zona pellucida becomes distended and thin. 21. It soon disappears leaving the surface cells of the blastocyst in with the endometrial stroma. .

The surface trophoblastic cells of the adhering blastocyst.Implantation of the Blastocyst About 50 per cent of blastocysts adhere to the endometrium. 22. and an outer syncytiotrophoblast. differentiate into an inner cellular layer. the cytotrophoblast. .

Implantation By the 10th day after fertilization. 23. the knobs of trophoblastic tissue have developed a mesodermal core and have pushed deeply into the endometrial stroma .

24.Embryonic Development after Implantation Early Trophoblast Invasion By the 9th and 10th day after fertilization a number of deep cells at one pole of the blastocyst differentiate to become an inner cell mass now called the embryonic disc. .

Embryonic Development after Implantation Early Trophoblast Invasion Between the embryonic disc and the trophoblast. some small cells appear that soon enclose a space that will become the amniotic cavity.25. .

26.EMBRYONIC DEVELOPMENT AFTERBREAK IMPLANTATION .

27.EMBRYONIC DEVELOPMENT AFTERBREAK IMPLANTATION .

the result is the maternal blood enters the fluid-filled space- the lacunae.Embryonic Development after Implantation Lacunae Formation Within the Syncytiotrophoblast As the embryo enlarges.28. . more maternal (deciduas basalis) tissue is invaded and the walls of the superficial endometrial-decidual capillaries are eroded.

the trophoblastic strands branch to form the solid primitive villi that traverse the lacunae. .29. the villi later disappear except over the most deeply implanted portion. which is the site destined to form the placenta.Embryonic Development after Implantation Development of Primary Villous Stalks With deeper burrowing and blastocystic invasion into the deciduas. Originally located over the entire blastocyst surface.

30. The mesenchymal cells within the cavity are most numerous about the embryo. where these eventually condense. .Embryonic Development after Implantation The diameter of the 12-day embryo is almost 1 mm. to form the body stalk that serves to join the embryo to the nutrient chorion and later develops into the umbilical cord.

a midline primitive groove develops. As cells proliferate rapidly and spread laterally from the primitive streak.Embryonic Development after Implantation During the third week after fertilization the primitive streak becomes a prominent structure. . and cephalic and caudal ends of the embryo become distinguishable.31.

and hence the embryonic disc is spread out upon it. has extended.32.Embryonic Development after Implantation Simultaneously. . A well-defined body stalk into which a narrow endodermal diverticulum. the allantois. the yolk sac enlarges.

and the dermis.Embryonic Development after Implantation As the neural folds develop. which give rise to the skelet and connective tissues. the muscles. during the third week the heart develops and links up with a primitive vascular system. .33. the somites. The primordium of the heart already has appeared. the underlying lateral mesoderm is divided into discrete blocks.

.Embryonic Development after Implantation During the fourth week the gut has formed. The heart and pericardium are very prominent because of the dilatation of the chambers of the heart.34. and the embryo about 4-5mm in length. By the end of the fourth week after fertilization the chorionic sac measures 2 to 3 cm in diameter. Arm and leg buds are present.

At this time the embryo is nearly 4 cm long. and the head is quite large compared with the trunk. At the end of the six week the embryo is 22 to 24 mm in length. . Fingers and toes are present. By the eighth week after fertilization. most of the organs have formed and the embryo becomes a fetus.35. and the external ears form definitive elevations on either side of the head.Embryonic Development after Implantation And by the six week a urogenital sinus has formed.

Placenta. Placental Development and Functions .

37.Placental Development .

38.Placental Development .

Placental Development and Functions The placenta acts for the fetus as: • an organ of respiration • an organ of nutrient transfer and excretion • an organ of hormone synthesis • it may act as an immunological barrier protecting the fetus (formed from paternal as well as maternal genes) from rejection by the mother’s immune system .Placenta.39.

Placental Development and Functions Transport of substances through the placenta takes place by: 1. Passive transport a.40. pynocytosis . facilitated diffusion 2. simple diffusion b. enzymatic reaction b.Placenta. Active transport a.

CO2. + .and di. phosphorus → + Antibodies Only IgG + + Erythrocytes → +. + saccharids Protein → Aminoacids + Fat → Free fatty acids + Vitamin A → Carotine + Vitamin B complex → + Vitamin C Iron. O2. Na. K.Transfer of substances through the placenta Maternal blood Intervillous Placental transfer methods space Passive Active Pynocytosis H2O. . urea → + Glucosae Fascilitated by + carrier molecule Polysaccharids Mono.41.

Placental Development and Functions Respiration functions of the placenta .42.Placenta.

43.Placenta. Placental Development and Functions Nutrient transfer .

44. Placental Development and Functions Drugs transfer through the placenta .Placenta.

Placenta. Placental Development and Functions Hormone synthesis. The main hormones produced are: • human chorionic gonadotrophin • human placental lactogen • estrogen • progesterone .45.

Amniotic Fluid Amniotic fluid is secreted into the amniotic sac by the amniotic cells which lie over the placenta. 46. . The fluid filling amniotic sac serves several important functions.

47.Amniotic Fluid This fluid is 99 per cent water and increases in quantity during pregnancy. . it reaches a maximum of about 1000ml at 36 to 38th week of gestation. The amniotic fluid increase rapidly to an average volume of 50 ml at 12th week of gestation and 400 ml at midpregnancy.

Umbilical cord A normal umbilical cord is 45-60cm long. The umbilical cord usually contains one vein and two arteries set in Wharton’s jelly. 48. but extremes of 200cm and 2cm have been recorded. .

Placenta.49. Umbilical Cord .Fetus. Amniontic Sac.

the embryo is nearly 4 cm long. 50. At this time.Fetus development stages The end of the embryonic period and the beginning of the fetal period are arbitrarily designated by most embryologists to occur 8 weeks after fertilization. .

51. . the crown-rump length of the fetus is 6 to 8 cm. • and the external genitalia are beginning to show definite signs of male or female sex.Fetus development stages Twelve gestational weeks. • early fingernail development. • the fingers and toes have become differentiated. • scattered rudiments of hair appear. By the end of the12th week of pregnancy.

52.Fetus development stages

Sixteen gestational weeks. By the end of 16th
week, the crown-rump length of the fetus is
12-14cm, and it weighs about 110 g.
• By careful examination of the external genital
organs, the sex of the fetus can be
identified;
• head erect;
• ears stand out from head;
• lower limbs are developed.

53.Fetus development stages

Twenty gestational weeks. The end of the
20th week is the midpoint of pregnancy or
gestation as estimated from the time of the
last normal menstrual period. The fetus now
weighs somewhat more than 300 g.
• The fetal skin become less transparent, a
downy lanugo covers its entire body
• and some scalp hair is visible;
• vernix caseosa present;
• early toenail development

54.Fetus development stages

Twenty-four gestational weeks. By the end of
the 24th week, the fetus weighs about 630g
• the skin is characteristically wrinkled, and
fat is deposited beneath it.
• The head is still comparatively quite large;
• eyebrows and eyelashes are usually
recognizable.
• A fetus born at this period will attempt to
breathe;

55.Fetus development stages

Twenty-eight gestational weeks. By the end of
the 28th week, a crown-rump length of about
25-27 cm is attained and the fetus weighs
about 1100 g.
• The thin skin is red and covered with vernix
caseosa.
• The papillary membrane has just disappeared
from the eyes.

• The surface of the skin is still red and wrinkled. At the end of 32 gestational weeks.Fetus development stages Thirty-two gestational weeks. the fetus has attained a crown-rump length of about 28-30 cm and a weight of about 1800 g. 56. • Fingernails and toenails present .

At the end of the 36 weeks gestation. • Because of the deposition of subcutaneous fat. the average crown- rump length of the fetus is about 32-34 cm and the weight is about 2500 g.Fetus development stages Thirty-six gestational weeks. 57. the body has become more rotund. . and the previous wrinkled appearance of the face is lost.

Slide N58 .

• At this time the fetus is fully developed. Term is reached at 40 weeks after onset of the last menstrual period.and toenails reach finger and toe tips. breasts protrude. • Prominent chest. • Testes in scrotum or palpable in inguinal canals.Fetus development stages Forty gestational weeks. . 59. the average crown-rump length is about 36 cm. and the weight is approximately 3400g. • Finger.

Slide N60 .

Maternal Physiology • The anatomical. and biochemical adaptations to pregnancy are profound. 61. • Many of these remarkable changes begin soon after fertilization and continue throughout gestation. physiological. and most occur in response to physiological stimuli provided by the fetus. .

knowing the drugs likely to require dose adjustments. 62. Maternal Physiology • A basic knowledge of these adaptations is critical for understanding normal laboratory measurements. and recognizing women who are predisposed to medical complications during pregnancy. .

and amnionic fluid. • The total volume of the contents at term averages about 5 L but may be 20 L or more. so that by the end of pregnancy the uterus has achieved a capacity that is 500 to 1000 times greater than in the nonpregnant state. by term. . • The corresponding increase in uterine weight is such that. placenta. Maternal Physiology REPRODUCTIVE TRACT • During pregnancy. 63. the uterus is transformed into a relatively thin- walled muscular organ of sufficient capacity to accommodate the fetus. the organ weighs approximately 1100 g.

but they increase during the last week or two. Maternal Physiology • From the first trimester onward. the contractions may occur as often as every 10 to 20 minutes. 64. • Until the last month of gestation. Braxton Hicks contractions are infrequent. the uterus undergoes irregular contractions that are normally painless. • In the second trimester. these contractions may be detected by bimanual examination. . At this time.

. plasma expansion essentially ceases while hemoglobin mass continues to increase. • Late in pregnancy. • The disproportion between the rates at which plasma and erythrocytes are added to the maternal circulation is greatest during the second trimester. 65. Maternal Physiology HEMATOLOGICAL CHANGES • The modest fall in hemoglobin levels during pregnancy is caused bya relatively greater expansion of plasma volume compared with the increase in red cell volume.

. 66. Maternal Physiology • Anemia is defined as hemoglobin concentration less than12 g/dL in nonpregnant women and less than 10 g/dL during pregnancy or the puerperium.

67.000/μL.000 to 16. Usually it ranges from 5000 to 12. . Maternal Physiology • The leukocyte count varies considerably during normal pregnancy.000/μL .000/μL or even more. however. During labor and the earlypuerperium it may become markedly elevated.attaining levels of 25. it averages 14.

the coagulation cascade is in an activated state. 68. Maternal Physiology COAGULATION. and d-dimer serum concentrations increase with gestational age. with a range from 300 to 600 mg/dL. • Fibrin-fibrinogen complexes circulate in normal pregnancy. In normal pregnancy. . fibrinogen concentration increases about 50 percent to average about 450 mg/dL late in pregnancy. • During normal pregnancy.

5cm • The ureters are dilated • GFR increases • Bladder vascularity increases and decreases muscle tone . Urinary tract changes • Kidneys are increasing in length by 1-1.

Normal Labor and delivery • Labor -sequence of uterine contractions that results in effacement and dilatation of cervix • Delivery .mode of expulsion of the fetus and placenta .

DELIVERY (partus). childbirth is not a medical issue.I Pregnancy is not a disease. pregnancy and childbirth are important personal. 71 . social events before be a medical issue (WHO 1997) Delivery (partus) – is a physiological process which ends with the birth of a newborn. sexual.

I Delivery – is a multifactor process which mechanism is still unclear. 72 . CAUSES OF DELIVERY START .

CAUSES OF DELIVERY START .Fetal cortisol and other fetal steroids .Fetal prostaglandin (E2) and oxytocin 73 .II Fetal factors of regulation of the initiation of delivery .

74 .II Nervous regulation of the initiation of delivery .Transformation of the dominant of pregnancy to the dominant of delivery in CNS. CAUSES OF DELIVERY START .

Increase of estrogens synthesis . CAUSES OF DELIVERY START .III Hormonal regulation of the initiation of delivery .Decrease of progesterone synthesis 75 .

Serotonin .Kinins .III Humeral regulation of the initiation of delivery . CAUSES OF DELIVERY START .Prostaglandins E2 and F2α .Histamine 76 .Oxytocin .

Cervical ripening 77 . Discharge of a smoll amount of blood-tinged mucus from the vagina. SIGNS PRIOR TO DELIVERY Bulging umbilicus Change parturient’s mood and sense Decrease of movement activities of fetus Loss of weight by 1-2 kg Unregulated uterin contractions and pain in lower abdomen and groin.

preparation for Labor • Lightening – settling of the fetal head into the brim of the pelvis • Braxton Hicks contractions – irregular. painless uterine contractions • Bloody show passage of a small amount of blood –tinged mucus from the vagina .

Stages of labour • The first stage of labor – period of cervical dilatation • The second stage of labor – birth of the baby • The third stage of labor – fetal annex period 79 .

22nd edition • Current obstetric and gynecologic diagnoses and treatment. references • Williams obstetrics. 10th edition 2007 • UpToDate .