Mcn Midterm 2014

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Fertilization

Fertilization is the union of mature egg

cell (ovum) and sperm cell usually in theampulla (outer third) of the fallopiantube resulting in a fertilized ovum knownas the zygote. It is also termedconception, fecundation, impregnation.

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Fertilization occurs when the malepronucleus unites with the femalepronucleus unites, thus the chromosomediploid number (46) is restored and anew cell, the zygote, is created with anew combination of genetic materialwhich creates a unique individualdifferent from the parents and anyoneelse.

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Pre-embryonic Stage- 1st 14 days afterconception- OVUM – first 2 weeks afterconception

Zygote- fertilized ovum. This cell undergoesmitosis.

Lifespan of zygote – from fertilization to 2months- EMBRYO.

Cleavage- series of mitotic cell division bythe zygote.

Blastomeres- daughter cells arising from themitotic cell division of the zygote.

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Morula – mulberry-like ball, solid ball of cellswith 16 – 50 cells, 4 days free floating andmultiplication; called as “travelling” form

because it is in this form when it migratesthrough the FT(oviduct) and reachesuterine cavity about 3-4 days afterovulation.

EMBRYO- 2nd week to 2 months or 8 weeksafter conception

Blastocyst – enlarging cells that forms afluid-filled cavity that later becomes theembryo.

Blastocyst – covering of blastocyst that laterbecomes placenta and trophoblast

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Implantation/ Nidation- occurs afterfertilization 7 – 10 days. Site- upper fundalportion or upper one- third of the uterus;

can be anterior or posterior. At the time of implantation, the

blastocyst is completely buried in the

endometrium. While the blastocyst is thestage of implantation, its outer layer thetrophoblast, is responsible for actualimplantation.

Fetus- 2 months or 8th-10th weeks to birth. NEONATE- after birth (the first month after

birth)

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Signs of implantation:

1. slight pain

2. slight vaginal spotting- if with fertilization – corpus luteum continues to function &become source of estrogen andprogesterone while placenta is notdeveloped

3 Processes of Implantation

1. Apposition- blastocyst brushes against theuterine endometrium

2. Adhesion- blastocyst attaches to thesurfaces of the endometrium

3. Invasion- blastocyst settles down into theendometrium’s soft fold

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Greek – pancake, combination of chorionicvilli + deciduasbasalis. The major endocrineorgan in pregnancy.

a. Dimension Discoid: 15-20cm in diameter and 2-3 cm

thick; or 1 inch thick and 8” diameter

Fetal side: covered with amnion; beneath if

the fetal vessels course with the arteriespassing over the veins. Amnion: 0.02 to0.5mm thick; a sac that engulfs the growingfetus. Amniotic fluid: clear fluid that collectswithin the amniotic cavity

Maternal side: divided into irregular lobes;consists of fibrous tissue with sparse vessels

Average weight at term- 500 grams

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Feto-placental weight ratio at term- 6:1

Schultz- shinny bluish side delivered first;

center to edge; fetal side first ; lessexternal bleeding concealed behindplacenta; inverted umbrella shape; 80%

Duncan-dirty; edge to center; roughreddish maternal side out first; moreexternal bleeding; bloody; blood loss is250-300 ml; umbrella- shaped placenta

delivered sideways Check complete cotyledons; complete

membrane- first nursing action

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Calkin’s sign- first sign

1. discoid to globular; soft to firm ;

2. uterus mobile rises up to the umbilicus-midline;

3. sudden gushing of blood;

4. slight lengthening of the cord- the mostdefinit sign that the placenta hasdetached.

Uterine atony- soft, boggy and non-

palpable- massage fundus until firm.Apply ice cap to contract the uterusnever hot water bag. Injectmethylergonovine maleate- methergine

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Decidua – the endometrium in pregnancy orthickened endometrium 5-10 mm in depth (Latin – falling off)

1. Basalis (base)- part of endometrium locatedunder fetus where placenta is delivered;portion of deciduas directly beneath the site ofimplantation, under the imbedded ovum.

2. Capsularies – the portion overlying the

developing ovum; separates ovum from therest of the uterine cavity; most prominent by2nd month; encapsulate the fetus

3. Vera/ Parietalis – lines the remaining portionof endometrium. initially, the deciduascapsularis and decidua vera are separated bya space because the gestational sac does notfill the entire uterine cavity; by the 4th month,the growing sac fills the uterine cavity.

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Layers of decidua basalis and deciduas vera a. zona compacta- uppermost, surface layer

made up of compact cells b. zona spongiosum- middle, spongy layer; with

glands and small blood vessels c. zona basalis- lowest most or basal layer. The

zona basalis and zona spongiosum togetherform the functional layer- zona functionales.

The zona basalis remains after delivery orplacental separation. 5. Decidual aging: Nitabuch’s layer, a zone of

fibrinoid degeneration, is where invadingtrophoblast meets the dicidua.

c. Placental Maturity: 12 weeks or 3 months;functions most effectively through 40-41 weeks;may be dysfunctional beyond 42 weeks

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Placental Functions:

1. Transports nutrients and water solublevitamins to fetus

a. fluid and gas transport

Diffusion: oxygen, carbon dioxide, waterand electrolytes move from greater tolesser concentration

Facilitated transport: glucose

Active transport: amino acid, calcium, iron

Pinocytosis: fat, gamma globulin, albumin

Leakage allows fetal and maternal bloodto mix slightly because of placental defects;normally, there is no mixture of fetal andmaternal blood

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b. excretory with the amniotic fluid as themedium of excretion

c. respiratory organs of the fetus

d. acts as a protective barrier to somesubstances and organism like heparin andbacteria; ineffective for virus, alcohol,nicotine, antibiotics, depressants and

stimulants. e. secretes hormone estrogen,

progesterone, HCG and human placentallactogen (HPL), aka human chorionicsomatomammotropin (HCS).

f. estrogen and progesterone’s majorsource of production after the first 2 monthsin the placenta.

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HCG- secreted as early as 8-10 days afterfertilization, radioimmunoassay-implantation; urine test- 10 days or 2 weeksafter missed period.

Function: prolongs life of the corpus luteum;serves as the basis for the pregnancy test.The hormone found elevated in excessivevomiting.

Normal value: 400,00 IU/ 24 hoursHCS or HPL- secreted by 3rd week after

ovulation.

Functions: Influences somatic cellular

growth of the fetus; resembles the growthhormone. The principal diabetogenic factoras it is the major insulin antagonist, orglucose sparing hormone. Prepares thebreasts of the mother for lactation.

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Chorionic Villi- 10 – 11th day, finger lifeprojections. Failure to develop into

placenta- hydatidiform mole; H-mole3 vessels=

A – unoxygenated blood

V – O2 blood A – unoxygenated blood

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Chorionic villi sampling (CVS) – removal oftissue sample from the fetal portion of thedeveloping placenta for genetic screening.

Done early in pregnancy.Commoncomplication fetal limb defect. Ex missingdigits/toes.

Cytotrophoblast – inner layer or langhanslayer – protects fetus against syphilis 24wks/6 months – life span of langhans layerincrease. Before 24 weeks critical, might getinfected syphilis

Synsitiotrophoblast – synsitial layer – responsible production of hormone

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Umbilical Cord- FUNIS, whitish grey, 50 – 55cm, 20 – 21”.

Short cord: abruptio placenta or inverteduterus.

Long cord: cord coil or cord prolapsea. length: 55 cm, 1 inch across at term

b. parts:

1. one left umbilical vein: carries oxygenated

blood to the fetus2. two umbilical arteries right and left; carrydeoxygenated blood from fetus toplacenta

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The cord extends from the fetal surface of theplacenta to the fetal umbilicus. Transportoxygen and nutrients to the fetus and to return

metabolic wastes including carbon dioxidefrom the fetus to the placenta. Wharton’s Jelly – gelatinous substance; an

extension of the amnion; protects cord againstcompression

Two embryonic membranes form to protectand support embryo- chorion and amnion-until appearance of primary villi

All tissues and organs develop from the 3primary germ layers- ectoderm, mesodermand endoderm

Amnion and chorion - Amnion- inner layer;Chorion – outer layer; where placenta isdeveloped

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Amniotic Fluid – bag of H2O, clear, straw-

colored fluid, odor mousy/musty, withcrystallized forming pattern, slightly alkaline orneutral ; reaction: pH 7-7.25.

Origin: both maternal and fetal; amnioticepithelium maternal serum and in later part-10th week , fetal urine; constantly beingreplaced so there in no “dry labor” inpremature rupture of the bag of water.

Abnormal color- green – tinged in a non-

breech presentation is a sign of fetal distress;golden-colored fluid may be found inhemolytic diseases. Erythroblastosis fetalis;pathologic jaundice

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cushions fetus against sudden blows or trauma

separate fetus from membranes allowingsymmetrical growth and development

acts as medium of excretion

serves as fetal drink; abnormality deglutination

center, esophageal atresia- cant swallow,amniotic fluid accumulates- polyhydramnios

serves as specimen for periodic diagnostic

exams

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facilitates musculo-skeletal development

maintains fetal temp

prevents cord compression

equalizes uterine pressure and prevents

interference with placental circulation

during labor

helps in delivery process

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Normal amount of amniotic fluid – 500 to

1000cc at term ; polyhydramnios-greater than 1000 or 1500 mL;oligohydramnios- less than 300-500 mL.

polyhydramnios, hydramnios- GIT

malformation TEF/TEA tracheo-esophageal fistula/ atresia

oligohydramnios- kidney diseases

abnormal colors: green-tinge in a non-breech presentation is a sign of fetaldistress; golden-colored fluid may befound in hemolytic disease.

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Amniocentesis empty bladder before

performing the procedure. Purpose – obtain a sample of amniotic fluid

by inserting a needle through the abdomen

into the amniotic sac; fluid is tested for:

Genetic screening- maternal serum alpha

feto-protein test (MSAFP) – 1st trimester

Determination of fetal maturity primarily by

evaluating factors indicative of lungmaturity – 3rd trimester

Testing time – 36 weeks

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decreased MSAFP= down syndrome

increase MSAFP = spina bifida or openneural tube defect; deficiency in folate

Common complication of amniocenthesis – infection

Dangerous complications – spontaneousabortion

3rd trimester- pre term labor Important factor to consider for

amniocentesis- needle insertion site

Aspiration of yellowish amniotic fluid –

jaundice baby Greenish – meconium

Amnioscopy – direct visualization or examto an intact fetal membrane.

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determine if amniotic fluid has ruptured or not (blue paperturns green/grey + ruptured amniotic fluid)

Specimen: Vaginal swab obtained from the posteriorvaginal pool.- avoid the use of any lubricants or antiseptics- use a sterile swab and do not touch the mucus plug

- prepare a thin smear on a glass microscope slide byspreading evenly.

Testing: Allow the slide to air dry- do not apply heat and do not

coverslip the slide.

Examine the fully-dried slide microscopically, using the 10Xobjective

Observe for "fern-like" crystals. Presence of crystalsindicates that the fluid is amniotic fluid.

Record the results: Write your name, the date, time and

findings on the patient record.

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Fern test refers to detection of acharacteristic 'fern like' pattern of cervical

mucus when a specimen of cervical mucus isallowed to dry on a glass slide and is viewedunder a low power microscope. Fern test isused to provide indirect evidence

of ovulation and fertility Ferning is due to the presence of sodium

chloride in the mucus under estrogen effect.When high levels of estrogen are present, just

before ovulation, the cervical mucus formsfern-like patterns due to crystallization ofsodium chloride on mucus fibers. This patternis known as arborization or 'ferning'.

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When progesterone is the dominant hormone, as is just after ovulation, fern pattern is no longerdiscernible. Fern pattern is completely absent by22nd day of cycle. Disappearance of fern patternafter 22nd day suggests ovulation and itspersistence throughout menstrual cycle suggestsan-ovulation (infertility).

The pH test involves sampling vaginal fluid to see

how acidic or alkaline it is. Normal pH for vaginalfluid is between 4.5 and 5.5, and normal pH ofamniotic fluid usually falls between 7.0 and 7.5.(When measuring pH, the higher the number, themore alkaline the substance.) If a sample of yourvaginal fluid is more alkaline than normal vaginalpH, then it is very likely that the membranes haveruptured and amniotic fluid has leaked into thevagina.

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Interfering Substances/ limitations:If present, blood, urine or cervical mucus

can result in a false positive finding. False negative findings can result fromprolonged rupture of membranes (>24hr).

Quality control:

Follow the procedural instructions exactly.

There are no external(nor internal) quality

controls to be performed at the unitlevel.

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Diff. amniotic fluid & urine. Paper turns yellow- urine.Paper turns blue green/gray-(+) rupture of amniotic

fluid. The Nitrazine test involves placing small amounts (a

drop or two) of vaginal fluid onto paper stripsprepared with Nitrazine dye.

A chemical reaction occurs and the strips change

color, indicating the pH of the vaginal fluid. If thecolor shows the pH is greater than 6.5, it's likely themembranes have ruptured.

False readings can occur, however. Women withblood-tinged mucus, for example, can test positiveon the Nitrazine test because blood has a pH closerto amniotic fluid than vaginal fluid. Some vaginalinfections can also increase the pH of fluid in thevagina, and so can recent intercourse, becausesemen has a high pH or alkaline.

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PURPOSE

Nitrazine (Phenaphthazine ) paper is used to measure thevaginal pH of expectant mothers.

PRINCIPLE

Nitrazine paper is impregnated with an indicator dye

Phenaphthazine. The color changes as pH changes, givinga broad range of colors from yellow through blue.

SUPPLIES

Phenaphthazine reagent strip.

STORAGE

Store Phenaphthazine reagent strips at room temperature.PATIENT PREPARATION

No patient preparation other than that required by a writtenprotocol.

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Obtain a strip of Nitrazine paper approximately

three inches long from the dispenser. Wrap the paper around the ends of the fingers of

one hand.

Insert the fingers and paper into the birth canal.

Remove the paper and excess fluid.

Compare the resulting color to the paperdispenser’s pH scale.

Record results on the patient chart.

Reports results as:

6.5 -6.5 =positive.6.0 and below = negative.

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Criteria for Unacceptable Specimens: The specimen is estimated to be stable for 2-5

minutes at room. Contamination with blood will

interfere with the reading. Bloody specimensshould be read with caution, as it is difficult tointerpret the color reaction.

EXPECTED VALUES Normal vaginal pH is acidic (below 7.0). pH

results above 7.0 ( basic) indicate thatamniotic fluid is present. Bring results to theattention of the attending physician.

QUALITY CONTROL Supplies: pH calibrating buffers; pH 6.0 and pH 8.0 Store

buffers at room temperature. Buffers are stableuntil the expiration date on the bottles

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Ratio- 2:1 signifies fetal lung maturity not

capable for RDS The lecithin – sphingomyelin ratio (aka L-S or

L/S ratio) is a test of fetal amniotic fluid toassess for fetal lung immaturity. Lungsrequire surfactant, a soap-like substance, to

lower the surface pressure of the alveoli inthe lungs.

This is especially important for prematurebabies trying to expand their lungs after

birth. Surfactant is a mixture of lipids,proteins, and glycoproteins, lecithin andsphingomyelin being two of them. Lecithinmakes the surfactant mixture moreeffective.

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The lecithin – sphingomyelin ratio is a markerof fetal lung maturity. The outward flow ofpulmonary secretions from the fetal lungsinto the amniotic fluid maintains the level oflecithin and sphingomyelin equally until 32 – 33 weeks gestation.

If a sample of amniotic fluid has a higherratio, it indicates that there is moresurfactant in the lungs and the baby will

have less difficulty breathing at birth.

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An L – S ratio of 2 or more indicates fetallung maturity and a relatively low risk

of infant respiratory distress syndrome,and an L/S ratio of less than 1.5 isassociated with a high risk of infantrespiratory distress syndrome.

If preterm delivery is necessary (asevaluated by a biophysical profile orother tests) and the L – S ratio is low, the

mother may need to receive steroidssuch as betamethasone to hasten thefetus' surfactant production in the lungs.

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Procedure

An amniotic fluid sample is collected

via amniocentesis and the sample isspun down in a centrifuge at 1000 rpmfor 3 – 5 minutes.

Thin layer chromatography (TLC) isperformed on the supernatant, whichseparates out the components. Lecithinand sphingomyelin are relatively easy to

identify on TLC and the predictive valueof the test is good.

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Definition: a test for fetal pulmonary maturity,

determined by the ability of pulmonarysurfactant in amniotic fluid to generatestable foam in the presence of ethanol aftermechanical agitation.

Synonym(s): shake test

The shake test is a qualitative measurementof the amount of pulmonary surfactant

contained in the amniotic fluid. It evaluates the ability of pulmonary

surfactant to generate a stable foam in thepresence of ethanol.

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Ethanol, a nonfoaming competitivesurfactant, eliminates the contributions of

protein, bile salts and salts of free fattyacids to the formation of a stable foam.

At an ethanol concentration of 47.5percent, stable bubbles that foam after

shaking are due to amniotic fluid lecithin. Positive tests, a complete ring of bubbles

at the meniscus with a 1:2 dilution ofamniotic fluid, are rarely associated with

neonatal RDS. It is a screening test that gives useful

information if mature.

f

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Reference Values Normal Positive: persistence of a foam ring for 15 minutes after

shaking (at an amniotic fluid – alcohol dilution of 1:2)

indicates lung maturity.Procedure: 1. Test is based on the ability of amniotic fluid surfactant to

form a complete ring of bubbles on the surface of theamniotic fluid in the presence of 95% ethanol.

2. Place a mixture of 95% ethanol and amniotic fluid in anappropriate container and shake for 15 seconds. Acommercial kit is also available.

Clinical implications: 1. If a complete ring of foam forms and persists for 15

minutes the test is positive.2. If no ring of bubbles forms, the test is negative.3. The test has a high false – negative rate but a low false –

positive rate. The L/S ratio must be >4:1 for this test to bepositive.

Interfering Factors

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Interfering Factors 1. Blood or meconium contamination can alter

results.

2. Contamination of glassware or reagents canalter test results.Interventions Pretest patient care 1. Obtain informed consent.

2. Explain the procedure and the reason foetesting.

3. Use sterile techniques.Posttest patient care

1. Interpret test outcome counsel appropriately.2. Provide counseling if test is negative.3. Provide future treatment modalities.

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PG+ definitive test to determine fetal lung

maturity Phosphatidylglycerol is

a glycerophospholipid found in pulmonarysurfactant.

The general structure of phosphatidylglycerolconsists of a L-glycerol 3-phosphate backboneester-bonded to either saturated orunsaturated fatty acids on carbons 1 and 2.

The head group substituent glycerol is bondedthrough a phosphomonoester. It is theprecursor of surfactant and its presence (>0.3)in the amniotic fluid of the newborn indicatesfetal lung maturity.

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Approximately 98% of alveolar wall surface area isdue to the presence of type I cells, with type II cellsproducing pulmonary surfactant covering around 2%

of the alveolar walls. Once surfactant is secreted by the type II cells, it

must be spread over the remaining type I cellularsurface area.

Phosphatidylglycerol is thought to be important inspreading of surfactant over the Type I cellularsurface area. The major surfactant deficiency inpremature infants relates to the lack ofphosphatidylglycerol, even though it comprises less

than 5% of pulmonary surfactant phospholipids. It is synthesized by head group exchange of a

phosphatidylcholine enriched phospholipid using theenzyme phospholipase D

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Human Chorionic Gonadrophin – maintains corpus luteum alive.

Human placental Lactogen orsommamommamotropin Hormone – formammary gland development. Has adiabetogenic effect – serves as insulinantagonist

Relaxin Hormone- causes softening joints& bones

Estrogen

Progestin

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Fetal Stage “ Fetal Growth andDevelopment”.

After fertilization, the ovum (zygote) beginswith a process of rapid cell division (mitosis orcleavage) leading to formation of

blastomeres, which eventually become a ball-like structure called morula.

The morula changes into blastocyst afterentering the uterus. Implantation occurs within

7-10 days, when the exposed cells of thetrophoblast (cellular walls of the blastocyst)implant in the anterior or posterior fundalportion of the uterus.

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Th f t

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The fetus

From 8 weeks to birth

The period of post-differentiation oforgans

All structures found in full term neonatepresent

When exposed to a teratogen, amalformation is least likely to occur

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The cell of the embryo will differentiate into3 main groups:

a. Endoderm: the outer layer; developsinto:

Nervous system

Hair, nails, skin epidermis, sebaceous andsweat glands

Salivary glands, mucous membrane ofmouth

Epithelium of nasal oral passages

b Mesoderm: the middle layer; develops into:

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b. Mesoderm: the middle layer; develops into:

Dermis

Cardiovascular system

Reproductive system Musculo-skeletal system

Urogenital system, except the bladder

c. Ectoderm or Entoderm: the inner layer;develops into:

Linings of GIT from pharynx to rectum

Liver, pancreas, thyroid, parathyroid

Respiratory tract

Bladder, thyroid, thymus

Development of brain, skin and senses, hair,nails, mucus membrane or anus and mouth

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Age Development

4 weeks Beginning formation of eyes, nose, GIT

Heart chambers formed; heart beating

(14 days)With arms and leg buds

8 weeks Head large in proportion to the body

Neuromuscular development- some

movements

Rapid brain developmentExternal genitalia appear

Age De elopment

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Age Development

12 weeks Placenta fully formed and functioning

Kidney develops; secret urine

Centers of ossification in most bonesWith sucking and swallowing

Sex distinguishable

FHB detected by ultrasound in 10-12

weeks

16 weeks More human appearance

Quickening- multigravida

Meconium in bowels

External genitalia obvious

Scalp hair developsFormed eyes, nose, ears

FHT by fetoscope

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Age Development

20 weeks With vernix caseosa and downy lanugo

Quickening stronger, felt by primigravida

FHT audible using stethoscopeBone hardening

24 weeks Body well-proportioned

Skin red and wrinkled

Hearing establishedEyebrows, eyelashes recognizable

When born, may breath, but usually

doesn’t

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Age Development

28 weeks Viable; immature if born at this time

Surfactant production begins

Body is less wrinkledWith iron storage

Nails appear

Papillary membrane has just

disappeared from the eyes32 weeks Subcutaneous fats begin to deposit

Skin is smooth and pink

More reflexes present

With iron and calcium storage

Good chances of survival if delivered

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Age Development

36 weeks Lecithin / sphyngomyelin ratio 2:1 (L/S)

Nails firm

With definite sleep/wake patternSurvival same as term

40 weeks Full term with good muscle tone and

reflexes

Little lanugoIf male, testes in scrotum

The age at time of EDC

With other characteristic features of the

newborn

Fi t t i t

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First trimester: 1st month - Brain & heart development GIT&resp Tract – remains as single tube

1. Fetal heart tone begins – heart is the oldestpart of the body

2. CNS develops – dizziness of mom due tohypoglycemic effect

Food of brain – glucose complex CHO – pregnant womans food (potato)Second Month All vital organs formed, placenta developed Corpus luteum – source of estrogen &

progesterone of infant – life span – end of 2nd month

Sex organ formed Meconium is formed

Third Month

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Third Month

Kidneys functional

Buds of milk teeth appear

Fetal heart tone heard – Doppler – 10 – 12 weeks

Sex is distinguishable

Second Trimester: FOCUS – length offetus

Fourth Month

lanugo begins to appear fetal heart tone heard fetoscope, 18 – 20

weeks

buds of permanent teeth appear

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Fifth Month

lanugo covers body

actively swallows amniotic fluid 19 – 25 cm fetus,

Quickening- 1st fetal movement. 18- 20 weeks

primi, 16- 18 wks – multi

fetal heart tone heard with or without

instrument

Sixth Month

eyelids open

wrinkled skin

Vernix caseosa present

Third trimester: Period of most rapid growth

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Third trimester: Period of most rapid growth.FOCUS: weight of fetus

Seventh Month – development of surfactant –

lecithinEighth Month

lanugo begin to disappear

sub Q fats deposit

Nails extend to fingers

Ninth Month

lanugo &vernixcaseosa completely

disappear Amniotic fluid decreases

Tenth Month – bone ossification of fetal skull

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The study of the patterns of inheritance of specific traits.Associated with childbearing decision making and

caring for children genetic disorders.Basics of Genetics:a. Nucleus of cells contains chromosomes which are made

up of genesb. Gene is a unit of heredity

c. Chromosome is a thin filament-like nuclear structure thatstores genetic information as base sequence in DNA

d. Each chromosome has 22 autosomes and 1 pair of sexchromosomes

e. The number, form and size of individual chromosomes

are termed karyotypef. Sequence of maternal and paternal gene pair maybe

homozygous (identical) or heterozygous (different)

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Oxygenated blood from the placenta passes tothe umbilical vein (one that contains the mostamount of oxygenated blood at its entry into the

liver); closes at birth with cord clamping andbecomes ligamentum teres. From the umbilicalvein, a small amount of blood goes to the liver tonourish the liver (and not for the blood to bedetoxified). Most of the blood in the umbilical

vein goes to the inferior vena cava throughductus venosus which closes at birth with cordclamping and becomes ligamentum venosum.

From the inferior vena cava, blood goes to theright atrium and is shunted to the left atrium by

the way of the foramen ovale, thus bypassing thelungs. It functionally closes with establishment ofrespiration (as early as 1 hour) about 1-3 daysand anatomically closes in a few months (about2-3 months).

From the left atrium blood goes to the left

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From the left atrium, blood goes to the leftventricle to the aorta and to the lower partsof the body.

From the hypogastric arteries (branches ofthe aorta), the right and left umbilicalarteries receive unoxygenated blood whichis directed back to the placenta for

oxygenation and purification. The umbilicalarteries close at birth with cord clampingand later become umbilical ligaments.

Blood from the upper parts of the body

enters the heart by the way of the superiorvena cava. From the SVC, it goes to theright atrium, then to the right ventricle andto the pulmonary artery.

From p lmonar arter a small amo nt of

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From pulmonary artery, a small amount ofblood goes to the lungs, but most of the bloodis shunted to the aorta by the way of the ductus

arteriosus (bypassing the lungs). The ductusarteriosus, like the foramen ovale functionallycloses with establishment of respiration (asearly as 1 hour) about 1-3 days and

anatomically closes in a few months about 2-3months becoming ligamentum arteriosum. Ifductus arteriosus fails to close, it will becomean acyanotic heart disease- patent ductus

arteriosus- with machinery-like murmurs as animportant sign.

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Drugs:

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Drugs: Anticholinergics- neonatal meconium ileus Streptomycin – anti TB & or Quinine (anti malaria)

– damage to 8th

cranial nerve – poor hearing anddeafness Tetracycline – staining tooth enamel, inhibit

growth of long bone Vitamin K – hemolysis (destruction of RBC),

hyperbilirubenia or jaundice Iodides – enlargement of thyroid or goiter Thalidomides – Amelia or pocomelia, absence of

extremities

Steroids – cleft lip or palate Lithium – congenital malformation Phynytoin- growth retardation, CNS defects Warfarin- skeleton and CNS defects

Alcohol – lowered weight (vasoconstriction

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Alcohol – lowered weight (vasoconstrictionon mom), fetal alcohol withdrawalsyndrome characterized by microcephaly

Smoking – low birth rate Caffeine – low birth rate

Cocaine – low birth rate, abruptionplacenta

TORCHES- toxoplasmosis- spontaneousabortion; other infections such as hepatitis,HIV, syphilis; rubella- congenital defects ofthe eyes, heart, ears and brain;cytomegalovirus- mental retardation, heartdefects or fetal death; and herpes simplexcausing draining vesicles

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For any ailment seek medicalattention. Take only prescribeddrugs.

Do not self- medicate.Do not take over-the-counter

drugs including vitamins and

minerals.Do not take alcohol no matter

how slight.

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Category A- Fetal risk not revealed incontrolled studies in humans

Category B- Fetal risk not confirmed instudies in humans but has been shown in

some studies in animals. Category C- Fetal risk revealed is studies in

animals but not established or not studiedin humans; may be used it benefits

outweigh risk to fetus Category X- Contraindicated; benefit does

not outweigh risk

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ANTEPARTAL PERIOD

The period of pregnancy or the periodbefore labor is the antepartal period, alsocalled prenatal period. The woman in thisperiod is called the gravid.

LENGTH OF PREGNANCY

a. Days- 267 to 280

b. Calendar months- 9

c. Weeks- 40d. Trimesters- 3

e. Lunar months- 10

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First trimester: period of rapidorganogenesis; teratogens like alcohol,drugs, virus, and radiation are highlydamaging.

Second trimester: most comfortable forthe mother; with continued growth ofthe fetus.

Third trimester: with rapid deposition offats, iron and calcium; period of mostrapid fetal growth

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Reproductive System Changes

1. Uterus

a. Uterine size- increased due tohypertrophy

Weight increases from 60 grams- non-pregnant to 1000 grams – full term

Length increases from 7.5 cm to 32 cm;width from 4 cm to 24 cm and depthfrom 2.5 cm to 22 cm.

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Uterine shape changes from globular tooval.

New fibroelastic tissues are formed; thismake up stronger uterine walls.

Fundic height changes:

12th week- level of symphysis pubis

13th week- rising from pelvic cavity;maybe palpable just above thesymphysis pubis

14th weeks- an abdominal content 20th – 22nd weeks- at umbilical level

36th weeks- at xiphoid process level

Increased vascularity to the pelvic region( ff ) l

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(estrogen effect) results:

Hegar’s sign- softening of lowering uterine

segment called isthmus- easy compressibilityof the uterus

Goodell’s sign- softening of cervix;

consistency of the tip of the nose- non-

pregnant cervix; consistency of ear lobe- pregnant cervix-

positive Goodell’s sign;

consistency of whipped butter- cervix ripe for

labor Chadwick’s sign- bluish or purplish

discoloration of the vaginal mucosa andcervix

Braxton-Hicks contractions- intermittent

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Braxton Hicks contractions intermittent,irregular, painless, abdominal, and muscletightening by

about 4 month; more pronounced at 8months.

Ballottement- rebounding of fetal headagainst examining fingers by 4-5 months

Secondary amenorrhea- due to thepersistence of the corpus luteum

Cervix – shorter, thicker, more elastic; with

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Cervix shorter, thicker, more elastic; withedema, hyperplasia of mucus lining- mucusplug (week 7); it seals the cervix, prevents

bacterial contamination of the uterinecavity. Increased vascularity causes cervixto be soft: Goodell’s sign.

Vagina- hypertrophy and hyperplasia-

thickened vaginal mucosa; leukorrhea-whitish, mucoid, non-foul, non-pruriticvaginal secretions increase as estrogenlevel increase; provides increased vaginal

acidity, an added protection from bacterialinvasion. Increased vascularity results tobluish discoloration- Chadwick’s sign.

4 Perineum- hypertrophy edema and

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4. Perineum hypertrophy, edema andrelaxation; there is an increase in size;increased vascularization; changes intodeeper color.

5. Ovaries- ovum production ceases;corpus luteum persists and takes overhormonal production task in earlypregnancy. Placenta – major endocrine

organ in pregnancy.

Breasts

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a. increased size and firmness

b. tingling sensation in the nipples in 4weeks and breast tenderness

c. enlargement of areola, alveoli duct andalveoli system

d. darkening of areola and skin around ite. enlargement and prominence of

superficial veins

f. enlargement of Montgomery’s glands

g. colostrums 4-5 months- thin, watery, lightyellow, high protein secretion. IgA

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Mcn Midterm 2014