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W O N D E R S O F F E R T I L I Z A T I O N

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W O N D E R S  O F  F E R T I L I Z A T I O N W O N D E R S O F F E R T I L I Z A T I O N Presentation Transcript

  • WONDERS OF FERTILIZATION STAGES OF FETAL GROWTH AND DEVELOPMENT
  •  
  • FERTILIZATION
    • Other terms: CONCEPTION, IMPREGNATION, OR FECUNDATION.
    • THE UNION OF SPERM CELL OR SPERMATOZOON AND EGG CELL OR OVUM
    • Occurs in the outer third of the fallopian tube
    • Fertilization may occur in about 72 hours
    • After ovulation the ovum is released from the graafian follicle
    • The ovum is surrounded by ZONA PELLUCIDA a ring of mucopolysaccharide fluid and a circle of cells the CORONA RADIATA.
    • These increase the bulk of the ovum thus facilitates the migration to the uterus
    • Peristaltic action of the tube and movement of the tube cilia help propel the ovum along the length of the tube.
    • Only one ovum reaches maturity each month
    • Once released fertilization must occur quickly because an ovum is capable of fertilization for only 24 hours (48 hours the most)
    • If not fertilized it atrophies and becomes non functional
    • Normally an ejaculation of semen averages 2.5 ml of fluid containing 50 – 200 million spermatozoa per milliliter, or an average of 400 million per ejaculations
    • 3 -5 cc or 1 teaspoon – normal amount of sperm
    • At the time of ovulation there is a reduction of cervical mucus viscosity, making it as an easy access for spermatozoon penetration
    • Spermatozoa deposited in the vagina during intercourse generally reach the cervix within 80 seconds and the outer end of fallopian tube within 5 minutes.
    • Sperm: pearly white, small head, long tail or flagella
    • Phonus – vibration of the head of the sperm and determines the location of the ovum
    • CAPACITATION – ability of the sperm to release proteolytic enzymes and penetrates corona radiata
    • This process, which happens as the sperm move toward the ovum, consist of plasma changes in the sperm head which reveals the sperm binding receptor sites
    • Only one spermatozoon is able to penetrate the cell membrane of the ovum
    • Once it penetrates the zona pelucida, the cell membrane becomes impervious to other spermatozoa.
    • After penetration of the ovum the chromosomal material of the ovum and spermatozoon fuse. They are now called the ZYGOTE
    • A fertilized ovum has 46 chromosomes
    • Spermatozoon and ovum each carried 23 chromosomes (22 autosomes and 1 sex chromosomes)
  •  
    • Fertilization depends on 3 factors :
      • Maturation of both sperm and ovum
      • The ability of the sperm to reach the ovum
      • The ability of the sperm to penetrate the zona pellucida and the cell membrane and achieve fertilization
  • IMPLANTATION
    • It takes 3 or 4 days for the zygote to reach the body of the uterus
    • During this time, mitotic cell division or cleavage, begins.
    • The first cleavage occurs at about 24 hours
    • PRE EMBRYONIC STAGE: By the time the fertilized cell reaches the body of the uterus, it consist of 16 to 50 cells.
    • Because of its bumpy outward appearance it is termed a morula (mullberry)
  •  
    • Morula continues to multiply as it floats free in the uterine cavity for 3 or 4 more days
    • Blastocyst – enlarging cell forming a cavity that becomes an embryo. These structures attaches to the uterine endometrium.
    • Thropoblast – covering of blastocyst that become placenta and membranes
    • The inner cell mass (embryoblast cells) is the portion that will later form the embryo.
  • Implantation/ Nidation
    • Occurs 8 to 10 days after fertilization
      • 3 Process of implantation
        • Apposition – Blastocyst begin to brush endometrium
        • Adhesion – Blastocyst begin to attach to endometrium
        • Invasion – Blastocyst begins to settle down into the soft folds of endometrium.
    • The trophoblast cell outside the blastocyst structure touch the endometrium, they produce proteolytic enzyme that dissolve the tissue they touch.
    • This action allows the blastocyst to burrow deeply into the endometrium and receive some basic nourishment of glycogen and mucoprotein from the endometrial gland
    • Effective communication network with the blood system of the endometrium is established
  • Embryonic and Fetal Structure
    • DECIDUA
      • After fertilization, corpus luteum in the ovary continues to function rather than to atrophy because of HCG secreted by trophoblast cells
      • Thus the endometrium continues to grow in thickness and vascularity
      • The endometrium is now termed DECIDUA
  • 3 separate area of Decidua:
    • Decidua Basalis – the part of the endometrium lying directly under the embryo ( the portion where the trophoblast cells are establishing communication with maternal blood vessels)
    • Decidua Capsularis – The portion of the endometrium that stretches or encapsulates the surface of the trophoblast
    • Decidua Vera – Remaining portion of the endometrium
  •  
  • CHORIONIC VILLI
    • As early as 11 th or 12 th day miniature villi, or probing “fingers” termed chorionic villi, reach out from the single layer of cells into the uterine endometrium.
    • At term, nearly 200 such villi will have formed
  • Chorionic Villi Sampling
    • Removal of tissue sample from the fetal portion of the developing placenta
      • Purpose – to determine the presence of genetic abnormalities; a transabdominal or transcervical approach may be used. Genetic screening.
      • Indications – as for amniocentesis but CVS can be performed earlier (9 to 12 weeks gestation) and results obtained sooner (1 to 2 weeks)
    • Complication rate is slightly higher than for amniocentesis primarily related to bleeding spontaneous abortion, rupture of membranes, infection, preterm birth fetal limb defects such as missing fingers of toes.
    • Protocol: Invasive procedure: needed consent and full bladder
      • Ultrasound – used throughout to guide the procedure
      • Client preparation – similar to that of an amniocentesis except full bladder may be needed to position the uterus for easier catheter insertion
    • Position depends on approach – transabdominal (supine) or transcervical (lithotomy)
    • Vital signs are monitored
    • Care after the procdure and discharge instructions are similar to those for an amniocentesis
  • Outline of Trophoblast Differentiation
    • CYTOTHROPOBLAST or Langhan’s layer – present as early as 12 days gestation.
      • Protects the growing embryo and fetus from certain infectious organisms such as the spirochete of syphilis.
      • This layer disappears between the 20 th and 24 th week.
  •  
  • SYNCTIOTROPHOBLAST or Syncytial layer
    • The outer layer containing fingerlike projections called chorionic villi
    • Gives rise to the fetal membranes:
    • 1.AMNION – inner membrane which gives rise to
      • UMBILICAL CORD/FUNIS – contains 2 Arteries and 1 Vein, which is supported by Wharton’s Jelly
  •  
    • AMNIOTIC FLUID
      • Clear albuminous fluid in which the baby floats
      • Begins to form at 11 – 15 weeks gestation
      • Approximates water in specific gravity (1.007 – 1.025) and is neutral to slightly alkaline
      • Near term is clear, colorless, containing little white specks of vernix caseosa and other solid particles
      • Produced at a rate of 500 ml in 24 hours and fetus swallows it at an equally rapid rate. By the 4 th lunar month urine is added to the amount of amniotic fluid.
  •  
    • Amniotic fluid therefore, is derived chiefly from maternal serum and fetal urine
    • Implications: a case of POLYHYDRAMNIOS (>1500ml of amniotic fluid) stems from inability of the fetus to swallow amniotic fluid rapidly as in tracheoesophageal fistula.
    • OLIGOHYDRAMNIOS (<500 ml of amniotic fluid, is due to inability of the kidneys to add urine to the amniotic fluid, as in Congenital renal Anomaly
  •  
    • Also known as Bag of Water (BOW), it serves the following purpose:
      • Protection – shields the fetus against blows or pressures on the mothers abdomen, against sudden changes in temperature and from infections
      • Diagnosis – as in amniocentesis; meconium stained amniotic fluid means fetal distress
      • Aids in the descent of fetus during active labor
    • Diagnostic test for Amniotic Fluid
    • AMNIOCENTESIS
      • Purpose: obtain a sample of amniotic fluid by inserting a needle through the abdomen into the amniotic sac; fluid is tested for
      • Genetic screening
        • Early testing time – 9 – 12 weeks with results available in 10 to 14 days
        • Traditional Testing time – 14 th to 16 th week with results available
        • Performed to determine presence of such problem as Down syndrome, Neural Tube Defect, Inborn errors of metabolism
  •  
  •  
    • 2. Determination of fetal maturity primarily by evaluating factors indicative of lung maturity
    • Testing time – During 3 rd trimester around 36 th when lung maturation have occurred
    • Factors – both should be present @ approximately 36 wks AOG
    • 1. L/S ratio (lecithin/ sphingomyelin) greater than 2;1
    • 2. Presence of phosphatidyglycerol (PG) termed PG+ (definite test for fetal lung maturity)
    • Indications:
      • Family History
      • Women of advance age, >35 years of age
      • Assurance of lung maturity prior to inducing labor or performing an elective cesarean section
      • Overall complication rate is 1 %:
      • Most common complication: Infection, Spontaneous abortion, Preterm labor
      • Position: Transvaginal = Lithotomy
      • Trans abdominal = Supine
      • Protocol: empty the bladder
    • Ultrasound – identify placental and fetal location to avoid damage and pinpoint amniotic fluid pockets
    • Preparation
      • Provide emotional support and assistance with relaxation techniques since woman may be restless and frightened
      • Verify informed consent forms are complete
      • Assist woman to empty bladder
      • Position: supine, be alert for supine hypotensive syndrome during and after the test.
    • Greenish Amniotic Fluid – Experience Hypoxia, common in post term baby
    • Yellowish Amniotic Fluid – Jaundice or hyperbilirubinemia
    • Cloudy Amniotic fluid – Infection
      • Shake test or Foam test:
      • Stable Bubbles – 2:1 L/S ratio
      • Bubbles evaporates – 1:2 L/S ratio/ Respiratory Distress Syndrome
    • 2. CHORION
    • Together with the decidua basalis, gives rise to the placenta, which starts to form at 8 th week gestation. Develop into 15 – 20 subdivisions called COTYLEDONS.
    • Placenta serves the following purpose:
      • Respiratory System – exchange of gases takes place in the placenta not in the fetal lungs
      • Renal System – waste products are being excreted through the placenta( Note: it is the mothers liver that detoxifies fetal waste products)
  •  
    • Gastrointestinal System – Nutrients pass to the fetus via the placenta by diffusion through the placental tissues
    • Circulatory System – feto-placental circulation is established by selective osmosis through the chorionic villi. About 100 maternal uterine artery supply the mature placenta.
      • To provide enough blood for exchange, the rate of uteroplacental blood flow to pregnancy increases from about 50ml/min at 10 weeks to 500 – 600 ml/min at term
    • At term, the placental circulatory network is so extensive that a placenta weighs 400 – 600 grams and is 1 sixth the weight of the baby.
    • Endocrine system – it produces the following important hormones
      • Human Chorionic Gonadotrophin – orders the corpus luteum to keep on producing estrogen and progesterone, that is why menstruation does not occur during pregnancy.
        • At about 8 weeks of pregnancy, the outer layer of cell of developing placenta begins to produce progesterone.
    • ESTROGEN – (Estriol) contributes to the mother’s mammary gland development in preparation for lactation and stimulates uterine growth to accommodate the developing fetus
    • PROGESTERONE – maintain the endometrial lining of the uterus during pregnancy. Reduce the contractility of the uterine musculature during pregnancy, which prevents premature labor
    • HUMAN PLACENTAL LACTOGEN(HUMAN CHORIONIC SOMATOMAMMOTROPIN) – promotes growth of mammary glands necessary for lactation. Also has growth stimulating properties
  • Origin and Development of Organ System
    • PRIMARY Germ layer – at the time of implantation, the blastocyst alreadt has differentiated to a point at which two separate cavities appear in the inner structure:
      • A large one the amniotic cavity, which is lined with ECTODERM
    • A smaller cavity, the yolk sac, which is lined with ENTODERM cells
    • Between the amniotic cavity and the yolk sac, a third layer of primary cells, the MESODERM forms.
    • The embryo will begin to develop at the point where the three cell layers meet
  • ECTODERM
    • Central Nervous System
    • Peripheral Nervous system
    • Skin, hair and nails
    • Sebaceous glands
    • Sense organs
    • Mucous membranes of the anus, mouth and nose
    • Tooth enamel and Mammary glands
  • MESODERM
    • Connective tissues, bones, cartilage, muscle, ligaments and tendons
    • Dentin of teeth
    • Kidneys and ureters
    • Reproductive system
    • Heart
    • Circulatory System
    • Blood cells and Lymph vessels
  • ENTODERM
    • Lining of pericardial, pleura, and peritoneal cavities
    • Lining of the Gastrointestinal tract
    • Respiratory tract, tonsils, parathyroid, thyroid, thymus glands
    • Bladder and Urethra
    • All organ systems are complete, atleast in a rudimentary form, at 8 weeks gestation. During this early time of ORGANOGENESIS, the growing structure is vulnerable to invasion by teratogens.
  • TERATOGENS
    • Any drug, virus or irradiation, the exposure to which may cause damage to the fetus
      • A. DRUGS
        • Streptomycin – ototoxic (poor hearing), CN 8 affected
        • Tetracycline – Staining of tooth enamel, Inhibits growth of long bones
        • Iodides – Enlargement of thyroid or Goiter
        • Thalidomides – Phocomelia or amelia
        • Steroids – Cleft lip, cleft palate, abortion
        • Lithium – congenital malformation
    • Alcohol
      • Low birth weight
      • Fetal alcohol withdrawal symptoms
      • Vasoconstrictions
      • SMOKING
      • CAFFEINE
      • Low birth weight
  • TORCH (teratogenic) Infections
    • Group of infections caused by organisms that can cross the placenta or ascend through birth canal and adversely affect fetal growth and development.
    • Often characterized by vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice
    • Devastating effect on the baby
    • T – TOXOPLASMOSIS – a protozoan infection transmitted by handling raw meat, cat litter or soil contaminated with cat feces, eating raw or inadequately prepared meat animal products and inadequately washed vegetables.
    • O – Others
      • HEPATITIS A – a viral infection transmitted by droplets, hands contaminated by oral fecal material while eating and eating food handled by persons with contaminated hands.
    • Hepatitis B (serum hepatitis) – a viral infection transmitted by contact substances containing blood. Use of or injury by contaminated needles or syringes, sexual intercourse, handling of materials containing blood including transfusions, dressings, drainage or exposure during a splash or spray of blood as may occur during birth, surgery.
    • HUMAN IMMUNODEFICIENCY VIRUS – a retrovirus transmitted by contact with contaminated body fluids including blood and semen; infected pregnant women can infect fetus – newborn transplacentally, contact with maternal blood, body fluids during labor and birth, ingestion of breast milk
    • SYPHILLIS (TREPONEMA PALLIDUM) – sexually transmitted disease caused by the spirochete, treponema pallidum. Transplacental transmission is possible after the 16 th to 18 th week of pregnancy resulting in stillbirth or congenital syphillis.
    • RUBELLA (GERMAN or 3 DAY Measles)- Viral infection transmitted by droplets
    • CYTOMEGALOVIRUS – Viral infection transmitted by contact with contaminated saliva respiratory secretions, urine, semen, breastmilk, blood cervical-vaginal secretions. Most often asymptomatic in the mother but produces several fetal and neonatal effects including hemolytic anemia, jaundice, hydrocephaly-microcephaly, pneumonitis, mental retardation
    • H - HERPES – SIMPLEX VIRUS – a sexually transmitted viral infection that occurs when contact is made with contaminated genital secretions. Infected women can infect fetus transplacentally especially during a primary infection when systemic findings occur and are most severe and through contact with other lesions and contaminated secretions during passage through the birth canal.
  • CARDIOVASCULAR SYSTEM
    • First systems to become functional in intrauterine life
    • Forms as early as 16 th day of life, beating as early as the 24 th day
    • The heartbeat maybe heard with a Doppler as early as the 10 th to 11th week of pregnancy
    • After the 28 th week of pregnancy, the heart rate begins to show a baseline variability of about 5 beats per minute
  • FETAL CIRCULATION
    • PLACENTA ---- OXYGENATED BLOOD IS CARRIED BY THE VEIN ---- LIVER ---- DUCTUS VENOSUS ---- INFERIOR VENACAVA ---- RIGHT ATRIUM ---- 70 % SHUNTED TO FORAMEN OVALE ---- LEFT ATRIUM ---- MITRAL VALVE ---- LEFT VENTRICLE ---- AORTA ---- LOWER EXTREMITIES
  •  
    • The remaining 30 % ---- tricuspid valve ---- right ventricle ---- pulmonary artery ---- lungs ---- vasoconstriction of lungs pushes the blood to Ductus arteriosus ---- aorta ---- to supply the upper extremities.
  • Fetal Hemoglobin
    • Fetal hemoglobin has greater oxygen affinity, which increases its efficiency, and is more concentrated
    • Hemoglobin level at birth is about 17.1 g/100ml (Adult 11g/100ml)
    • Hematocrit is about 53 % (adult 45 %)
  • RESPIRATORY SYSTEM
    • 7 th week of life DIAPHRAGM completely divide the thoracic cavity from abdominal cavity
    • Alveoli and Capillaries begin to form between 24 th and 28 th weeks.
    • Continues respiratory movements begins as early as 3 months of pregnancy
    • Surfactant is formed and excreted by the alveolar cells at about the 24 th week
    • Analysis of the Lecithin/sphingomyelin (LS) ratio by an amniocentesis technique is one of the primary tests for fetal maturity
    • L/S ratio is 2:1, at about 35 weeks, there is a surge in the production of lecithin.
  • NERVOUS SYSTEM
    • Active formation of the nervous system and sense organs has already begun during the 3 rd and 4 th week of life.
    • Brain waves can be detected on an electroencephalogram (EEG) by the 8 th week
    • By 24 weeks, the ear is capable of responding to sound; the eyes exhibit a pupillary reaction, indicating sight is present
    • Brain growth continue to occur rapidly during 1 st year and continues at high levels until 5 or 6 years of age.
  • DIGESTIVE SYSTEM
    • MECONIUM forms in the intestines as early as the 16 th week
    • Meconium is black or dark green ( obtaining its color from bile pigment) and sticky
    • It consist of cellular wastes, bile, fats, mucoprotein, mucopolysaccharides, and vernix caseosa, lubricating sustance that forms the fetal skin
    • Gastrointestinal tract is sterile before birth.
    • Vit K, essential for blood clotting, is synthesized by the action of bacteria in the intestines, this can cause vitamin K levels to be low in the newborn.
    • Sucking and swallowing reflexes matures at 32 weeks or until fetus weighs 1500 g.
    • GIT secretes enzymes essential for digestion of CHO and CHON at 36 weeks
    • Many newborn have not yet develop lipase, an enzyme needed for fat digestion.
    • Amylase is not mature until 3 months after birth
    • Liver is active throughout gestation, function as filter between incoming blood and fetal circulation and as a deposit for fetal stores such as iron and glycogen.
    • Hypoglycemia and hyperbilirubinemia two serious problems in the first 24 hours after birth.
  • MUSCULOSKELETAL SYSTEM
    • Fetus can be seen to move on ultrasound as early as the 11 th week, although the mother usually does not feel this movement (QUICKENING) until nearly 20 weeks.
    • Ossification of bone tissue begins about 12 th week.
  • REPRODUCTIVE SYSTEM
    • Child sex is determined at the moment of conception by a spermatozoon carrying an X or a Y chromosomes.
    • Can be determined as early as 8 weeks by chromosomal analysis
    • The GONADS form at about 6 th weeks of life
    • Testes descend from pelvic cavity at 34 th – 38 th week
  • URINARY SYSTEM
    • Rudimentary kidneys are present as early as the end of the 4 th week
    • Urine is formed by the 4 th week and excreted in the amniotic fluid by 16 th week
    • At term fetal urine is being excreted at the rate of 500ml/day
    • OLIGOHYDRAMNIOS an amount of amniotic fluid that is < normal suggest that fetal kidneys are not secreting adequate urine
  • INTEGUMENTARY SYSTEM
    • The skin of the fetus appears thin and almost translucent
    • Subcutaneous fat begins to be deposited at about 36 weeks
    • Skin is covered by soft downy hairs (LANUGO) and a cream cheese-like substance, vernix caseosa, which is important for lubrication and keeping the skin from macerating
  • IMMUNE SYSTEM
    • IgG maternal antibodies cross the placenta into the fetus during the 3 rd trimester of pregnancy (Giving fetus temporary passive immunity)
    • Little or no immunity to Herpes virus
    • Level of passive IgG immunoglobulins peaks at birth, then decreases by the next 8 months
  • MILESTONES OF FETAL GROWTH AND DEVELOPMENT
  •  
  • End of 4 Gestation Weeks
    • Length: .75 to 1 cm
    • Weight: 400 mg
    • Spinal cord is formed and fused at the midpoint
    • Lateral wing that form the body are folded forward to fuse at the midline
    • Head folds forward, becoming prominent, representing about 1/3 of the entire structure
    • The back is bent so the head almost touches the tip of the tail
    • Arms and legs are budlike structures
    • Rudimentary eyes, ears and nose are discernible
  •  
  • End of 8 th Gestation weeks
    • Length: 2.5 cm (1in)
    • Weight: 20 g
    • Organogenesis is complete
    • The heart with septum and valves, is beating rhythmically
    • Facial features are definitely discernible
    • Extremities have developed
    • External genitalia are present, but sex is not distinguishable
    • Primitive tail is regressing
    • Abdomen appears large as the fetal intestine is growing rapidly
  • End of 12 th Gestation week
    • Length: 7 to 8 cm
    • Weight: 45 g
    • Nail beds are forming on fingers and toes
    • Spontaneous movement are possible
    • Babinski reflex are present
    • Bone ossification centers are present
    • Sex is distinguishable by outward appearance
    • Kidney secretion has begun
    • Heartbeat is audible by a doppler
  • End of 16 th Gestation week
    • Length: 10 – 17 cm
    • Weight:4
    • 55 – 120 g
    • Fetal heart sounds are audible with an ordinary stethoscope
    • Lanugo (fine downy hair on the back and arms of newborns, servin as a source of insulation for body heat) is well formed
    • Liver and pancreas are functioning
    • Sex can be determined by ultrasound
    • Fetus actively swallows amniotic fluid
    • Urine is present in amniotic fluid
  • End of 20 gestation Weeks
    • Length: 25 cm
    • Weight: 223cm
    • Spontaneous fetal movements can be sensed by the mother
    • Antibody production is possible
    • Hair forms (eyebrows and hair on the head)
    • Meconium is present in the upper intestine
    • Brown fat begins to be formed behind the kidneys, sternum and posterior neck.
    • Fetal heartbeat is strong enough to be audible through the abdomen with an ordinary stethoscope
    • Vernix caseosa, a cream cheese-like substance produced by the sebaceous glands that serves as a protective skin covering during intrauterine life begins to form
    • Definite sleping and activity patterns are distinguishable
  • End of 24 Gestation Weeks
    • Length: 28 to 36 cm
    • Weight: 550 g
    • Meconium is present as far as the rectum
    • Active production of lung surfactant begins
    • Eyebrows and eyelashes are well defined
    • Eyelids are now open
    • Pupils are capable of reacting to light
    • Hearing can be demonstrated by response to sudden sound
  •  
  • End of 28 th Gestation weeks
    • Length: 35 to 38 cm
    • Weight: 1,200g
    • Lung alveoli begin to mature; surfactant can be demonstrated in amniotic fluid
    • Testes begin to descend into the scrotal sac from the lower abdominal cavity
    • The blood vessels of the retina are extremely susceptible to damage from high O2 concentrations
    • The eyes open
  • End of 32 Gestation Weeks
    • Length: 38 th to 43 cm
    • Weight: 1600g
    • Subcutaneous fat begins to be deposited
    • Fetus is aware of sounds outside the mother’s body
    • Active Moro reflex is present
    • Birth position may be assumed
    • Iron stores are beginning to be developed
    • Fingernails grow to reach the end of fingertips
  • End of 36 Gestation Weeks
    • Length: 42 – 48 cm
    • Weight: 1800 – 2700 g
    • Body source of calcium glycogen, iron and carbohydrates are augmented
    • Additional amount of subcutaneous fat are deposited
    • Amount of lanugo begins to diminish
    • Sole of the foot has only one or two crisscross creases
  • End of 40 Gestation Weeks
    • Length: 48 – 52 cm
    • Weight: 3000 g
    • Fetus kicks actively strong enough to cause considerable discomfort
    • Vernix caseosa is fully formed
    • Fingernails extend over the fingertips
    • Creases on the sole of the feet cover atleast 2/3 of the surface
    • Fetal Hgb begin its conversion to adult Hgb
  • Determination of Estimated Birth Date
    • NAGELE’S RULE
    • To calculate the date of birth by this rule count backward 3 calendar months from the first day of the last menstrual period and add 7 days.
  • Estimating Fetal Growth
    • McDONALD’S RULE
    • Is a method of determining, during mid pregnancy that the fetus is growing in utero by measuring fundal (uterine) height.
    • The measurement is made from the notch of symphysis pubis to over the top of the uterine fundus as the woman lies supine
  • PHYSIOLOGICAL ADAPTATION OF THE MOTHER TO PREGNANCY
  • SYSTEMIC CHANGES
    • CARDIOVASCULAR SYSTEM
      • Normal increase in blood volume by 30 – 50 % - for an adequate exchange of nutrients in the placenta and to provide adequate blood to compensate for blood loss at birth
      • Increase in plasma volume
      • Increase in cardiac workload: causes lassitude or easy fatigueability and hypertrophy of the heart
      • Palpitations
      • Epistaxis d/t hyperemia of mucous membrane
      • Supine Hypotension Syndrome
      • BP does not normally rise
    • Because of poor circulation resulting from pressure of the gravid uterus on the blood vessels of the lower extremities;
      • Edema of the LE occurs: Mgt: raise the legs above hip level
      • Varicosities of the lower extremities can also occur. Management:
      • Wear support hose or elastic stockings to promote venous flow
      • Apply elastic bandage
      • Avoid use of constricting garter (knee high stockings)
    • Physiologic Anemia (Pseudo anemia of pregnancy) Normal value: Hct (32-42%), Hgb (10.5-14 g/dl)
    • Criteria: 1 st and 3 rd Trimester – Hgb >11g/dl, Hct > 33%, 2 nd Trimester – Hgb <10.5 g/dl / Hct < 32%
    • Pathologic Anemia – Iron Deficiency Anemia – is the most common hematologic disorder. It affects roughly 20 % of pregnant women
      • Assessment: pallor, slowed capillary refill, concave finger nail, constipation
    • Nursing care:
      • Nutritional instructions: swamp cabbage, kangkong, liver and red meat
      • Parenteral Iron (Imferon): Z-tract technique
      • Oral iron supplements (ferrous sulfate 0.3 g, 3 times a day)
      • Monitor for hemorrhage
      • Nursing alerts: iron is better absorbed when taken with foods high in Vitamin C such as orange juice
      • Higher iron intake is recommended since circulating blood volume is increased and Heme is required from production of RBCs
  • GASTROINTESTINAL SYSTEM
    • At midpoint of pregnancy, the pressure may be sufficient to slow intestinal peristalsis and the emptying time of the stomach, leading to heartburn, constipation and flatulence
    • Morning sickness, nausea and vomiting bein to be noticed at the time that levels of Hcg and progesterone begin to rise
    • Management for morning sickness – Eat dry toast or crackers 30 minutes before arising in the morning or dry high CHO, low fat or low spices in the diet.
    • Hyperemesis Gravidarum – excessive nausea and vomiting which persist beyond 3 months; results in dehydration, starvation and acidosis.
    • Management: D10 NSS 3000ml is the priority treatment; complete bed rest is also important
    • Decrease emptying of bile from Gallbladder due to gradual slowing of gastrointestinal tract
    • Reabsorption of bilirubin to maternal bloodstream, giving rise to symptom of generalized itching (subclinical jaundice)
    • Hypertrophy of gumlines and bleeding of gingival tissue when they brush their teeth
    • Hyperptyalism – increased saliva formation as local response to increase levels of estrogen
    • Flatulence and constipation is common due to increase progesterone and displacement of stomach and intestines, thus slowing gastric emptying time.
    • Hemorrhoids due to gravid uterus
    • Heartburn due to pyrosis or reflux of stomach content to the esophagus
    • Improve condition of peptic ulcer during pregnancy because the acidity of the stomach is decrease
    • Relaxin may contribute to decreased gastric motility
  • RESPIRATORY SYSTEM
    • Shortness of breath
    • Diaphragm may be displaced by as much as 4 cm upward
    • Total oxygen consumption increases by as much as 20%
    • The fetal CO2 level is higher than that in the mother, allowing CO2 to cross readily from the fetus to the mother
    • Mild hyperventilation
    • Congestion and stuffiness of the nasopharynx, a response to increase estrogen level
  • URINARY SYSTEM
    • Urinary frequency, the only sign in pregnancy seen during the 1 st trimester, disappear during the 2 nd trimester and reappears during the 3 rd trimester
    • Early in pregnancy is due to increased blood supply to the kidneys and to the uterus rising out of the pelvic cavity.
    • In the last trimester is due to pressure of enlarged uterus on the bladder, especially with lightening
    • Decreased renal threshold for sugar due to increased production of glucocorticoids which cause lactose and dextrose to spill into the urine; also an effect of the increased progesterone
  • MUSCULOSKELETAL CHANGES
    • Because of the pregnant woman’s attempt to change her center of gravity; she makes ambulation easier by standing more straight and taller, resulting in a lordotic position “pride of pregnancy”
    • Increased production of the hormone RELAXIN, pelvic bones become more supple and movable, increasing the incidence of accidental falls due to the wobbly gait.
    • Advise use of low heeled shoes after the first trimester
    • Leg cramps
    • Causes:
      • Increased pressure of gravid uterus on lower extremities
      • Fatigue
      • Chills
      • Muscle tenseness
      • Low calcium, high phosphorus intake
      • Management: press knee of the affected leg and dorsiflex the foot
      • Do not massage and wear warm, more comfortable clothing
  • TEMPERATURE
    • Slight increase in basal body temperature due to increased progesterone, but the body adapts after the 4 th month
    • As the placenta takes over the function of the corpus luteum at about 16 weeks, the temperature generally decreases to normal
  • INTEGUMENTARY SYSTEM
    • Striae gravidarum – pink or reddish streaks appearing on the sides of the abdominal wall and sometimes on the thigh.
    • In the weeks after birth, striae gravidarum lighten to a silvery – white color (striae albicantes or atrophicae) and although permanent, become barely noticeable
    • Diastasis - separation of the rectus muscles
    • The umbilicus is stretched by pregnancy to such an extent that by the 28 th week, its depression becomes obliterated and smooth because it has been pushed so far outward
    • Extra pigmentation, a brown line (linea nigra) may be present, running from the umbilicus to the symphysis pubis and separating the abdomen into a right and left hemisphere
    • MELASMA (CHLOASMA) or the mask of pregnancy – darkened areas on the face, cheeks and across the nose
    • Palmar erythema (redness and itching)
    • Increase sweat gland activity
    • Vascular spiders (small fiery red-branching spots)
  • ENDOCRINE CHANGES
    • Addition of the placenta as an endocrine organ, producing large amounts of HCG, estrogen and progesterone
    • Moderate enlargement of the thyroid gland due to hyperplasia of glandular tissues and increased vascularity.
    • Increased size of the parathyroid probably to satisfy the increase need of the fetus for calcium
    • Increased size and activity of the adrenal cortex, thus increasing the amount of circulating cortisol, aldosterone and ADH all of which affect CHO and fat metabolism, causing hyperglycemia
    • Gradual increase in insulin production but the body’s sensitivity to insulin is decreased during pregnancy
  • LOCAL CHANGES
    • UTERUS
      • Weight increases to about 1000g at full term
      • Change in shape from pear-like to ovoid
      • HEGAR sign – change in consistency of lower uterine segment, seen at about 6 th weeks
      • Operculum – mucus plug in the cervix, which is produce to seal out bacteria
      • Goodles sign – cervix becomes more vascular and edematous resembling the consistency of an earlobe
    • BALLOTMENT – 16 th to 20 th week of pregnancy (‘from the french word balloter, meaning to toss about’)
    • BRAXTON HICKS CONTRACTIONs - uterine contraction beginning early in pregnancy, at least by 12 th week and are present throughout the rest of pregnancy.
    • A waves of tightness or hardness across her abdomen
  • Amenorrhea
    • Absence of menstruation because of the suppression of follicle stimulating hormone
    • A presumptive sign of pregnancy
  • CERVICAL CHANGES
    • Cervix becomes more vascular and edematous due to increasing level of circulating estrogen
    • Presence of tenacious coating of mucous plug which act to seal out bacteria during pregnancy and so help prevent infection in the fetus and membranes (OPERCULUM)
    • GOODELL’S SIGN – softening of the pelvis
    • the consistency of a nonpregnant cervix may be compared with that of the nose, whereas the consistency of a pregnant cervix more closely resembles that of an earlobe
    • Just before labor, the cervix becomes so soft that it takes on the consistency of butter and is said to be ripe for birth
  • VAGINAL CHANGES
    • Vaginal epithelium and underlying tissue become hypertrophic and enriched with glycogen
    • CHADWICK’S SIGN – the resulting increase in circulation to the vagina changes the color of the vaginal walls from the normal light pink to a deep violet
    • Vaginal secretions during pregnancy fall from a pH of over 7 (an alkaline pH0 to 4 or 5 (an acid pH) due to Lactobacillus acidophilus bacteria.
    • This changing acid content makes the vagina resistant to bacterial invasion for the length of pregnancy
    • Unfortunately, favors the growth of Candida Albicans, a species of yeastlike fungi.
    • Manifested by an ithching, burning sensation in addition to a cream cheese like discharge.
  • OVARIAN CHANGES
    • Ovulation stops with pregnancy. Progesterone and estrogen are being produced by the placenta
  • ABDOMINAL WALL CHANGES
    • STRIAE GRAVIDARUM – increase in uterine size results in rupture and atrophy of connective tissue layers, seen as pink or reddish streaks
    • Umbilicus is pushed out
  • SKIN
    • LINEA NIGRA – brown line running from umbilicus to symphysis pubis
    • MELASMA OR CHLOASMA – extra pigmentation on cheeks and across the nose due to increased production of melanocytes by the pituitary gland
    • Sweat glands unduly activated
  • BREAST
    • All changes due to increase in estrogen
    • Increase in size due to hyperplasia of mammary alveoli and fat deposits. Proper breast support with well fitting brassiere necessary to prevent sagging
    • Feeling of fullness and tingling sensation in the breast
    • Nipples more erect
    • For mothers who intend to breast feed, advise:
    • Nipple rolling
    • Drying nipples with rough towel to help toughen the nipples
    • Not to use soap or alcohol as this can cause drying which could lead to sore nipples
    • Montgomery glands become bigger and more protuberant. This keeps the nipples supple and prevent cracking and drying.
    • Areola becomes darker and diameter increases
    • Skin surrounding areola turns dark
    • By the fourth montha, a thin, watery, high protein fluid called colostrum, is formed. It is the precursor of breastmilk
  • SIGNS AND SYMPTOMS OF PREGNANCY
    • PRESUMPTIVE – s/s felt and observe by the mother but does not confirm positive diagnosis of pregnancy
    • PROBABLE – Signs observe by the members of health team but does not confirm a positive diagnosis of pregnancy
    • POSITIVE SIGN – undeniable signs confirmed by the use of instruments
  • FIRST TRIMESTER
    • PRESUMPTIVE:
      • B – reast changes
      • U – rinary frequency
      • F – atigue
      • A – menorrhea
      • M – orning sickness
      • E – nlarge uterus
  • PROBABLE
    • G – OODLES SIGN
    • C –HADWICK SIGN
    • H – EGARS
    • E – LEVATED BODY TEMPERATURE
    • P – OSITIVE HCG
  • POSITIVE
    • ULTRASOUND
  • SECOND TRIMESTER
    • PRESUMPTIVE
      • C – LOASMA
      • L – INEA NIGRA
      • I – NCREASED SKIN PIGMENTATION
      • S – TRIAE GRAVIDARUM
      • Q - UICKENING
  • PROBABLE
    • B – ALLOTMENT
    • E – NLARGE ABDOMEN
    • B – RAXTON HICKS CONTRACTION
  • POSITIVE
    • F – ETAL HEART TONE
    • F – ETAL MOVEMENT
    • F – ETAL OUTLINE
    • F – ETAL PARTS PALPABLE
  • PSYCHOLOGICAL ADAPTATION TO PREGNANCY
    • FIRST TRIMESTER
      • NO TANGIBLE SIGN AND SYMPTOMS
      • FEELING OF SURPRISE
      • MALADAPTATION: DENIAL OF PREGNANCY
      • DEVELOPMENTAL TASK: TO ACCEPT BIOLOGICAL FACTS OF PREGNANCY
      • FOCUS OF TEACHING: BODILY CHANGES OF PREGNANCY
  • SECOND TRIMESTER
    • TANGIBLE SIGN AND SYMPTOMS OF PREGNANCY
    • MOTHER IDENTIFIES fetus as a separate identity
    • Fantasy
    • Developmental task: accept the growing fetus as a baby to be nurtured
    • Focus of health teaching: Growth and development of fetus
  • THIRD TRIMESTER
    • Mother has personal identification with the appearance of the baby
    • Mother has fears
    • Let mother listen to FHT to ally fear of the
    • Developmental task: prepare for birth and parenting of the child
    • Focus of health teaching: Responsible perenthood. Best time to prepare baby’s layette, lamaze classes
  • Emotional Response to Pregnancy
    • Ambivalence – interwoven feelings of wanting and not wanting pregnancy
    • Grief – contributed by giving up or altering present roles to take on a mothering role
    • Narcissism – self centeredness is generally an early reaction to pregnancy
    • Introversion vs. Extroversion – introversion or turning inward to concentrate on oneself and one’s body, is a common finding during pregnancy
    • Stress
    • Couvade syndrome – psychosomatic reaction wherein father experiences what mother goes through. Men experiences physical symptoms such as nausea vomiting and back ache.
    • Emotional Lability – mood changes due to Hormonal changes, particularly the sustained increase in Estrogen and Progesterone
    • Changes in sexual desire –
      • First tri there is a decrease in libido because of the nausea, fatigue, and breast tenderness
      • During second trimester as blood flow to the pelvic area increases to supply the placenta, libido and sexual enjoyment rise markedly
      • Third trimester it may remain high or decrease because of difficulty finding a comfortable position and increasing abdominal sign.
  • The Pre-Natal Visit
    • Basic considerations
    • Frequency of visit:
      • 1 to 7 month: once a month
      • 8 to 9 months: Twice a month
      • 10 months: every week
      • The provision of prenat care is the primary factor in the improvement of maternal and infant morbidity and mortality statistics.
    • It should be remembered that patients understanding of the modalities of care is basic to cooperative action
    • The duration of a normal pregnancy is 266 – 280 days, or 38 – 42 weeks (average is 40 weeks), or 9 calendar months or 10 lunar months.
    • Any baby born before the 39 th week of gestation is called pre-term and a baby born after the 42 nd week of gestation is said to be post term
  • DIAGNOSIS OF PREGNANCY
    • URINE EXAMINATION – HCG in the urine is the basis for pregnancy tests.
    • Present from the 40 th day through the 100 th day reaching a peak level on the 60 th day
    • HCG therefore is most correct 6 weeks after the last menstrual period
  • Components of Prenatal visit
    • HISTORY TAKING
    • PERSONAL DATA – patients name, age address, civil status, family history, religion, occupation,educational background
    • With whom does she lives? Are there familial disease that could affect pregnancy
  • OBSTETRICAL ASSESSMENT
    • GESTATION
    • Time until the estimated date of confinement or estimated date of delivery
    • About 280 days
    • Nagele’s rule for estimating the date of confinement. This requires that the woman have a regular 28 th day menstrual cycle
    • Add 7 days to the 1 st menstrual period, subtract 3 months, and then add 1 year to the date
  • Gravidity and Parity
    • Gravidity
      • Gravida refers to a pregnant woman
      • Gravidity refers to the number of pregnancy
      • Nulligravida is a woman who has never been pregnant
      • Primigravida is a woman who is pregnant for the first time
      • Multigravida is a woman in at least her second pregnancy
  • PARITY
    • Is the number of births (not the number of fetuses, e.g., twins) past 20 weeks of gestation, whether the fetus was born alive or not
    • Nullipara is a woman who has not had a birth at more than 20 weeks of gestation
    • Primipara is a woman who has had one birth that occurs after the 20 th week of gestation
    • Multipara is a woman who has had two or more pregnancies resulting in viable offspring
  • Use of GTPAL
    • G is gravidity, the number of pregnancies
    • T is term births, the number born at births(40 weeks)
    • P is preterm births, the number born before 40 weeks’ gestation
    • A is abortions/miscarriages, the number of abortions and miscarriages
    • L is live births, the number of live births or living children
    • Example: A woman is pregnant for the fourth time. She had one elective abortion in the first trimester, a daughter who was born at 40 weeks gestation, and a son who was born at 36 weeks gestation.
    • What is the GTPAL?
    • Viability – the ability of the fetus to live outside the uterus at the earliest possible gestational age.
    • Age of viability: 20 – 24 weeks (5 – 6 months)
  • BASELINE DATA
    • Vital sign
    • Rollover test – mother will be place on sidelying position for 10 – 15 minutes, until BP is stable. Then mother is place in supine, then take BP immediately, systolic >30mmHg, Diastolic > 15mmHg
  • Weight Monitoring
    • First Trimester: Normal Weight Gain 1.5 – 3 lbs (1 lbs/month)
    • Second Trimester: Normal Weight Gain 10 – 12 lbs (4lbs/month)
    • Third Trimester: Normal Weight Gain 10 – 12lbs (4lbs/month)
  • Important Estimates
    • Mc Donald’s Rule – to determine age of gestation
    • From symphysis pubis to fundus
    • Fundic height in cm multiply to 7/8 = AOG
    • Bartholomew’s Rule – to determine age of gestation
    • Haases Rule – to determine length of fetus in cm ( 1 st half of pregnancy: month times 2, 2 nd half: month times 5)
  • Physical Examination
    • Danger signs of pregnancy:
      • C – hills and fever, cerebral disturbances
      • A – bdominal pain: epigastric pain (impending convulsion)
      • B – oard like abdomen (Abruptio placenta)
      • B – P elevated
      • B – lurred vision
      • S – welling, scotoma, sudden gush of fluids
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