Fertilization

• Mitosis : is a
process of
cell
duplication,
during which
one cell give
rise to two
genetically
identical
daughter
cells
. Meiosis: is
a division
of a germ
cells
involving
two
fusion of
the
nucleus
and
giving rise
to four
gametes,
or sex
cells
 GAMETOGENESIS
• The process involved in the maturation of the
highly specialised cells, spermatozoon in male
and ovum in female before they unite to form
zygote ---gametogenesis.

• The process involved in the development of a

mature ovum is called oogenesis.
• germ cells
mitosis
• Oo gonia

primary oocyte [46,xx]

arrested first meiotic division

[ upto puberty]

maturation of graafian follicle

• completion of 1st meiotic division

secondary oocyte 1st polar body

23,X 23,X
Ovulation

not fertilized fertilized

degenerate 24hrs com of 2nd meiotic div

female pronucleus 2nd PB 23,X

• Germ cells

• spermatogonia

• primary spermatocyte [46,XY]

• first meiotic division

• secondary spermatocytes

• 23, X 23,Y
• Second meiotic division

23,X 23 ,X 23, Y 23, Y

spermatids
• Fertilization is the process of fusion of the sperm
with the mature ovum

. To initiate the embryonic development of egg

• To restore the chromosome number of the
species
ovulation, the ovum is 0.15 mm in dia passes into
the uterine tube.
• No peristalic movement, moved by cilliary action
and peristalic muscular contraction.
• 300 million sperm deposited in posterior fornix of
vagina,
 Sperm capacitation and acrosome reaction

Is the physiochemical change in the sperm by

which it become hypermotile & is able to bind,
to fertilize secondary oocyte. Acrosome release
enzyme HYALURONIDASE [dissolve the covering
of the ovum in order to penerate]. The sperm
and ovum each contribute half the complement
of chromosome to make a total of 46
The fertilised ovum zygote [life span of oocyte
range from 12 to 24 hrs and sperm is 48 to 72
hrs]
 Prenatal Development

Embryonic Fetal
development development

fertilization - 8 weeks 9 weeks - birth

time period from fertilization to birth = gestation

Postnatal Development
 The first Trimester
weeks 1-12; fetus size ~ 3 in.; weight ~ 14 g

Cleavage
Implantation
Placentation
Embryogenesis

Basic organ plan and tissues laid out –

most susceptible to damage or disorganization at this
time
 Early division of zygote into multiple cells without increase in

Cleavage size, partitions contents

Morula
solid ball of cells

Zygote

Blastocyst
with blastocoele cavity
•
• BLASTOCYST

TROPHOBLAST INNER CELL MASS

PLACENTA + CHORION

FETUS + AMNION+ UMBLICAL CORD

 Implantation - embedding of blastocyst into
uterine lining begins at day 7

Blastocyst - with blastocoele

cavity
Trophoblast - outer layer of
cells
Inner cell mass - will form
embryo

Trophoblast forms syncytial trophoblast- erodes

into endometrium
Cellular trophoblast - carries nutrients to inner cell
mass

Lacunae and primary villi formed by

trophoblast
All of these form placental tissues

Fig 28-3
 Day 10
Embryo completely
embedded in
endometrium

Amnion and yolksac visible

Blastodisc formation (2
cell layers)
– Epiblast
– Hypoblast
 Formation of Extra-embryonic
Membranes
visible after day 10:

Amnion – Protection of
embryo/fetus

Yolk sac –
Early site of blood cell
formation
Gastrulation: 3 Germ Layers Formed
day 12:
Ectoderm (forms from epiblast)
Nervous system
Epidermis

Endoderm (forms from hypoblast)

Mucosae (eg: GI-tract
Associated glands

Mesoderm
Everything else
 Germ Layers

• Ectoderm Outer layer

• Nervous system including brain, spinal
cord and nerves
• Lining of the mouth, nostrils, and anus
• Epidermis of skin, sweat glands, hair, nails
 Germ Layers
• Mesoderm Middle Layer
• Bones and muscles
• Blood and blood vessels
• Reproductive and excretory systems
• Inner layer (dermis) of skin
 Germ Layers
• Endoderm Inner Layer
• Lining of digestive tract
• Lining of trachea, bronchi, and lungs
• Liver, pancreas
• Thyroid, parathyroid, thymus, urinary bladder
Placentation
Fig 28-5

Development of placenta from edges of blastocyst

Placenta = organ that forms from the chorion and the
endometrium and allow the embryo/fetus to exchange
nutrients and waste.
Chorionic villi provide surface area for exchange
Nutrient and gas exchange happens without actual blood
exchange
Umbilical cord - contains two umbilical arteries and one
umbilical vein
Fig 28-6
 Second and Third Trimester
• After the end of 8 weeks: Fetal development

• Week 12: all organ systems laid out

• Most teratogens not lethal anymore – but

produce major defects
• 3rd trimester mostly for size increase
and maturity.
Fig. 28-7
 Amniotic Sac

• Contains fluid
(amniotic fluid) that
protects fetus by
giving it a stable
environment and
absorbing shock
 Umbilical Cord

• two arteries and a

vein Connects the
fetus to the
placenta
 PLACENTA
• TROPHOBLAST: small projections, differentiated
into three layers
• Outer – syncytiotrophoblast
• Inner – cytotrophoblast
• Below – mesoderm

• The syncytiotrophoblast: is a nucleated protoplasm

which is capable of breaking down tissue in the
process of embedding , it erodes the walls of the
blood vessels of the decidua , making the nutrients
to the developing embryo.
• The cytotrophoblast:
single layer of cells which produce a hormone
know as HCG.

. The mesoderm: loose connective tissue, there is

similar tissue in the inner cell mass and the both
are continuous at a point where they join in the
body stalk
• These proliferate and branch from about 3 week after
fertilization
• Chrionic villi -----chorionic frondosum (that is, in the basal
decidua) develop into placenta.
• chorionic laeve (in the capsular
decidua) which will origin as chorion membrane

• The villi erode the walls of maternal blood vessels as they

penetrate the decidua, the opened blood vessels known as
sinuses
• The villi absorb food and oxygen and excrete waste – nutritive
villi
• Few villi deeply attached called anchoring villi

• Each chorionic villus is a branching structure arising from one

stem, its centre consists of mesoderm and fetal blood vessels,
these covered by single layer of cytotrophoblast cells and the
external layer of the villus is the syncytiotrophoblast , which
prevents mixing of two circulation,

• The placenta is matured and starts functioning from 10 week,

between 12 – 20 week it weighs more than fetus and later
pregnancy fetal organ liver starts to function and cyto and
syncytio gradually degenrate.
 PLACENTAL CIRCULATION
• UTERO - PLACENTAL CIRCULATION: ( maternal circulation). It
with concerns with circulation of the maternal blood through
the intervillous space.

• Intervillous haemodynamics:
1. volume of blood in mature placenta : 500ml
2. volume of blood in intervillous space : 150ml
3. blood flow in intervillous space : 500 – 600ml/mt
and completely replaced 3 – 4 times /mt
4. pressure in supplying uterine artery : 70 – 80 mm of Hg
5. pressure in the draining uterine vein: 8 mm of Hg
• FETAL HAEMODYNAMICS:
• Fetal blood flow through the placenta: 400ml/mt
• Pressure in the umbilical artery: 60 mm of Hg
• Pressure in the umbilical vein: 10 mm Hg
• O2 saturation 50 – 60% umb artery, 70 – 80% vein

• The maternal blood is delivered to the placental

bed in the decidua by spiral arteries and flows
into the blood spaces surrounding the villi, the
blood passes upwards and bathes the villus as it
circulates around it and drains back into a branch
• Of the uterine vein, the umbilical arteries transported
along their branches to the capillaries of the chorionic
villi, carbon dioxide and absorbed oxyygen , the blood
is returned to the fetus via the umblical vein
 THE FUNCTION OF PLACENTA
• FUNCTION
• TRANSFER OF NUTRIENTS AND WASTE PRODUCTS BETWEEN THE
MOTHER AND FETUS:
• Respiration, Excretory, Nutritive

• MECHANISM INVOLVED IN THE TRANSFER OF SUBSTANCE

ACROSS THE PLACENTA ARE:

1. Simple diffusion
2. Facilitated diffusion
3. Active transfer
4. Endocytosis
5. Exocytosis
6. leakage
• RESPIRATORY FUNCTION:
• The fetal respiratory movements are observed
as early as 11 weeks, intake of oxygen and
output of CO2 take place by simple diffusion
across fetal membrane.

• EXCRETORY FUNCTION:
• Waste products from the fetus such as urea,
uric acid and creatinine are excreted to the
maternal blood by simple diffusion
• NUTRITIVE FUNCTION:

• The fetus obtains its nutrients from the maternal blood , when
diet is inadequate, depletion of maternal tissue storage
• Glucose
• Lipids
• Amino acids
• Water and electrolytes
amino acids are required for body building, glucose for energy
and growth, calcium and minerals for bones and teeth, iron and
other minerals for blood formation

STORAGE: stores glycogen , lipids ,iron and fat soluble vitamins

• BARRIER FUNCTION: It provides a limited barrier
to infection with exception of treponema and
tubercle bacillus, but viruses can freely pass and
cause congenital abnormalities and also drugs
eg heparin.
• At the end of pregnancy IgM transferred to fetus

• ENDOCRINE FUNCTION:
• HCG: produce by cytotrophoplastic layer.
Responsible for maintaining for corpus luteum,
production peaks at eight weeks
• Estrogen and progestrone: synthesized by
synctiotrophoblast and maintain pregnancy
and corpus luteum is no longer needed
• Human placental lactogen: influences growth,
maternal mammary duct proliferation, lipid
and CHO metabolism
• Relaxin : produced by decidua cells softens the
cervix and pelvic ligaments
• HCT
• Insulin like growth factor:
Amniotic epthelium

• Secretes

AMNIOTIC FLUID
• Amniotic fluid fetal skin
fetal urine

Exchange with ingestion by fetus

Respiratory tract

intestinal absorption of water

Fetal circulation
• COMPOSITION:
• 1. water 98 – 99% 2, solid (1-2%)

• a. Organic –
• Protein – 0.3% ,glucose – 20mg %, urea –30 mg
%, uric acid – 4 mg%, Creatinine – 2%, total lipids
– 50%

• Inorganic; sodium , chloride and potassium

• Suspended particles include: lanugo, epithelial
cells skin, vernix caseosa, cells frm Rt etc
• Succenturiate Lobe
circumvallate
• CHANGES OF THE REPRODUCTIVE SYSTEM DURING PREGNANCY
• Figure 5-1. Appproximate height of the fundus
at various weeks of pregnancy.
• Changes in the body during pregnancy are most obvious in the
organs of the reproductive system.
• a. Uterus.
• (1) Changes in the uterus are phenomenal. By the time the
pregnancy has reached term, the uterus will have increased five
times its normal size:
• (a) In length from 6.5 to 32 cm.
• (b) In depth from 2.5 to 22 cm.
• (c) In width from 4 to 24 cm.
• (d) In weight from 50 to 1000 grams.
• (e) In thickness of the walls from 1 to 0.5 cm.
• Cervix. (1) The cervix undergoes a marked softening
which is referred to as the Goodell's sign."
• (2) A mucus plug, which is known as "operculum" is
formed in the cervical canal. This is the result of
enlarged and active mucus glands of the cervix. It
serves to seal the uterus and to protect the fetus
and fetal membranes from infection. The mucus plug
is expelled at the end of the pregnancy. This may
occur at the onset of labor or precede labor by a few
days. When the mucus is blood-tinged, it is referred
to as a "bloody show."
• (3) Additional changes and softening of the cervix
occur prior to the beginning of labor
• Vagina. Increased circulation to the vagina early in
pregnancy changes the color from normal light pink to a
purple hue which is known as the "Chadwick's sign."
• d. Ovaries. (1) The follicle-stimulating hormone (FSH)
ceases its activity due to the increased levels of estrogen
and progesterone secreted by the ovaries and corpus
luteum. The FSH prevents ovulation and menstruation.
• (2) The corpus luteum enlarges during early pregnancy and
may even form a cyst on the ovary. The corpus luteum
produces progesterone to help maintain the lining of the
endometrium in early pregnancy. It functions until about
the 10th to 12th week of pregnancy when the placenta is
capable of producing adequate amounts of progesterone
and estrogen. It slowly decreases in size and function after
the 10th to 12th week.
• CHANGES OF THE SKIN DURING PREGNANCY
• Alterations in hormonal balance and mechanical stretching
are responsible for several changes in the integumentary
system. The following changes occur during pregnancy:
• a. Linea Nigra. This is a dark line that runs from the
umbilicus to the symphysis pubis and may extend as high
as the sternum. It is a hormone- induced pigmentation.
After delivery, the line begins to fade, though it may not
ever completely disappear.
• b. Mask of Pregnancy (Chloasma). This is the brownish
hyper pigmentation of the skin over the face and
forehead. It gives a bronze look, especially in dark-
complexioned women. It begins about the 16th week of
pregnancy and gradually increases, then it usually fades
after delivery.
• c. Striae Gravidarum (Stretch Marks). This may
be due to the action of the
adrenocorticosteroids. It reflects a separation
within underlying connective tissue of the
skin. This occurs over areas of maximal
stretch--the abdomen, thighs, and breasts. It
will usually fade after delivery although they
never completely disappear.
• d. Sweat Glands. Activity of the sweat glands
throughout the body usually increases which
causes the woman to perspire more profusely
during pregnancy.
• 5-4. CHANGES OF THE BREASTS
• a. In early pregnancy, the breast may feel full or tingle,
and increase in size as pregnancy progresses. The
areola of the nipples darken and the diameter
increases. The Montgomery's glands (the sebaceous
glands of the areola) enlarge and tend to protrude. The
surface vessels of the breast may become visible due to
increased circulation and turns to a bluish tint to the
breasts.
• b. By the 16th week (2nd trimester) the breasts begin
to produce colostrum. This is the precursor of breast
milk. It is a thin, watery, yellowish secretion that
thickens as pregnancy progresses. It is extremely high in
protein.
 WEIGHT GAIN DURING PREGNANCY

WEIGHT GAIN UPTO 20 From 20 weeeks till full term total increase
WKS
2.0 kg 0.5kg/ wk 12Kg

A, Reproductive weight gain,

- Weight of fetus -- 3.3 Kg

- - weight of uterus -- 0.9 Kg
- Wt of placenta --- 0.6 kg
- Weight of liquor --- 0.8 Kg
Weight of breasts -- 0.4 Kg
• Net maternal weight gain:
• Increase in blood volume -- 1.3 kg
• Increase in extracellular fluid -- 1.2 kg
• Accumulation of fat and protein – 3.5 kg.
CHANGES OF THE RESPIRATORY SYSTEM
DURING PREGNANCY
• a. The respiratory rate rises to 18 to 20 to
compensate for increased maternal oxygen
consumption, which is needed for demands of
the uterus, the placenta, and the fetus.
• b. Women may feel out of breath and may need
to sit a moment to catch their breath.
• . CHANGES OF THE SKELETAL SYSTEM DURING
PREGNANCY
• a. There is a realignment of the spinal curvatures
during pregnancy to maintain balance. It is due
to the increase in size of the uterus and pressure
on the abdominal wall. The patient walks with
head and shoulders thrust backward and chest
protruding outward to compensate. This gives
the patient a "waddling" gait.
• b. There is a slight relaxation and increased
mobility of the pelvic joints, which allows
stretching at the time of delivery of the infant.
• 5-7. CHANGES OF BODY TEMPERATURE
DURING PREGNANCY
• a. A slight increase in body temperature in
early pregnancy is noted. The temperature
returns to normal at about the 16th week of
gestation.
• b. The patient may feel warmer or experience
"hot flashes" caused by increased hormonal
level and basal metabolic rate.
• CHANGES OF THE CIRCULATORY SYSTEM DURING
PREGNANCY
Anatomical changes
heart is pushed upwards and outwards
Abnormal clinical findings:
apex beat is shifted
hissing murmur in tricuspid area,

Heart rate and stoke volume increases (75 ml) due to

increased blood volume and increased oxygen
requirements of the maternal tissues and growing
fetus
• a. Blood Volume.
• (1) Blood volume increases gradually by 30 to 50
percent (1500 ml to 3 units). This results in
decrease concentration of red blood cells and
hemoglobin.
• Extra demand – placenta , metabolic needs extra
perfusion of kidney, counterbalance arterial and
venous capacity, blood loss
• (2) cardiac output is increased by the end of 1st
trimester 6.2 l/ mt, blood pressure does not rise
due to reduction in peripheral resistance
• Increase in plasma volume 3750ml reduces the
viscosity of blood and improves capillary flow,
total volume of red cells increases 1750 ml

• (3) Blood count is interpreted as anemia by the

physician if the hemoglobin falls below 10.5
grams per 100 ml and the hematocrit drops
below 30 percent.
• (4) plasma protein concentration reduces during
first 20 wks leads to lowered osmotic pressure
• c. Blood Pressure.
• (1) Normally, the patient's blood pressure will
not rise.
• (2) Nursing implications.
• (a) The patient's blood pressure should be
checked carefully and often since a significant
increase is one of the indicators of toxemia of
pregnancy.
• (b) When monitoring the blood pressure, be
sure it is done under the same circumstances
(that is, patient sitting and left arm).
  d. Venous Return.
• (1) The lower extremities are often hampered
in the last months of pregnancy due to the
expanding uterus restricting physical
movement and interfering with the return of
blood flow. This results in swelling of the feet
and legs.
• (2) Nursing implications.
• (a) Advise the patient to rest frequently. This
will improve venous return and decrease
edema.
• (b) Have the patient to elevate her feet and
legs while sitting.

• (c) Remind the patient not to lie in a supine

position since this inhibits return blood flood
flow as the heavy uterus presses on the
vessels. This leads to the vena cava syndrome
(see figure 5-2) or supine hypotension. The
patient may complain of feeling dizzy,
nauseated, or weak
• CHANGES OF THE URINARY SYSTEM DURING
PREGNANCY
• Each kidney -- incre in length by 1 – 1.5 cm
• Ureters - elongate, widenn and curve result
result in increase urinary stasis
Bladder – vascularity increase, bladder
mucosa oedamtous
Frequency
GFR – increase by about 50%
• a. The kidneys must work extra hard excreting the mother's
own waste products plus those of the fetus. There is an
increase in urinary output and a decrease in the specific
gravity.

• b. The patient may develop urine stasis and pyelonephritis in

the right kidney. This is due to pressure on the right ureter
resulting from displacement of the uterus slightly to the right
by the sigmoid colon.

• c. Frequent urination is a complaint during the first through

third trimester. As the uterus rises out of the pelvic cavity in
early pregnancy, pressure on the bladder decreases and
frequency diminishes. When lightening occurs during the
final weeks of pregnancy, pressure on the bladder returns to
cause frequency
• CHANGES OF THE GASTROINTESTINAL SYSTEM
DURING PREGNANCY
• as the pregnancy progresses, the uterus
enlarges. It rises up and out of the pelvic cavity.
This action displaces the stomach, intestines, and
other adjacent organs.
• Oral cavity: more saliva is produced and the
saliva is more acid, which promotes tooth decay.
the gums are more sensitive and may swell and
bleed easily, change in sense of taste. - Pica
• b. stomach and esophagus:
• Peristalsis is slowed because of the production
of the hormone progesterone, which decreases
tone and mobility of smooth muscles. This
slowing enhances the absorption of nutrients
and slows the rate of secretion of hydrochloric
acid and pepsin. Flare-up of peptic ulcers is
uncommon in pregnancy. Slow emptying may
increase nausea and heartburn (pyrosis).
• Relaxation of the cardiac sphincter may
increase regurgitation and chance for
heartburn. Movement through the large
intestines is also slowed due to an increase in
water consumption from this area. This
increases the chance for constipation
• c. Nursing implications.
• (1) If the mother has difficulty with nausea
and/or heartburn, advise her to eat small,
frequent meals.
• (2) The patient should eat a well- balanced
diet high in protein, iron, and calcium for fetal
growth; high fiber and fluids to prevent
constipation.
• (3) The mother should not lie flat for 1 to 2
hours after eating because this may cause
heartburn and/or regurgitation.
• . CHANGES OF SELECTED GLANDS OF THE
ENDOCRINE SYSTEM DURING PREGNANCY
• a. Parathyroid Gland. This gland increases in size
slightly. It meets the increased requirements for
calcium needed for fetal growth.
• b. Posterior Pituitary. Near the end of term, the
posterior pituitary will begin to secrete oxytocin
that was produced in the hypothalamus and
stored there. It will serve to initiate labor.
• c. Anterior Pituitary. At birth, the anterior
pituitary will begin to secrete prolactin. This
stimulates the production of breast milk.
• d. Placenta. The placenta acts as a temporary
endocrine gland during pregnancy. It produces
large amounts of estrogen and progesterone
by 10 to 12 weeks of pregnancy. It serves to
maintain the growth of the uterus, helps to
control uterine activity, and is responsible for
many of the maternal changes in the body.
 HIGH RISK PREGNANCY
• DEF: high risk pregnancy is defined as one which
is complicated by factor or factors that adversely
affects the pregnancy outcome

• INITIAL SCREENING
HISTORY:
1. Maternal age : pregnancy below the age of 17 or
above the age of 35years
2. Reproductive history:
a. two or more previous abortions or previous
induced abortion
2. Previous stillbirth, neonatal death or birth of babies with
congenital abnormality
3. Previous preterm lobour or birth of a small for date baby or
weight of baby 3. 5 kg or more
4. Previous LSCS or hysterotomy
5. Pre – eclampsia , eclampsia
6. Anaemia
7. Third stage abnormalities –
8. Previous infant with Rh – isoimmunisation or ABO
incompatibility
9. Medical or surgical disorder
10. Previous operation
11. Family history
• EXAMINATION
A General examination
B Pelvic examination

. COURSE OF THE PRESENT PREGANCY

COMPLICATION OF LABOUR

POSTPARTUM COMPLICATION