ppt for nurse.pptx

1
Maternity and reproductive health For Nurse
(Obstetrics and Gynecology)
Teshome Melese( BSc, MSc in MRH, Ass’t prof. )
Ambo University Woliso campus, Midwifery dep’t
Email address: teshemele@gmail.com/kanboruw@gmail.com
Cellphone: +251913860839
Aug, 2023
10/1/2023 Teshome M. (BSc Midwifery, MSc RHMC, Ass't Prof.)

Reproductive health
10/1/2023 Teshome M. (BSc Midwifery, MSc RHMC, Ass't Prof.) 2

Definition and introduction
• A state of complete physical, mental, and social well being and not
merely the absence of disease or infirmity, in all matters related to the
reproductive system and to its functions and process”.
• It addresses the human sexuality and reproductive processes, functions
and system at all stages of life and implies that people are able to have
“a responsible, satisfying and safe sex life and that they have the
capability to reproduce and the freedom to decide if, when and how
often to do so.”

Cont…
• People have the right of access to appropriate health care services for
safe pregnancy and childbirth and provide couples with the best
chance of having a healthy infant.
• Reproductive health is life-long, beginning even before women and
men attain sexual maturity and continuing beyond a woman's child-
bearing years.

Development of Reproductive
Health
• Before 1978 Alma-Ata Conference
 Basic health services in clinics and health centers
• Primary health care declaration 1978
MCH services started with more emphasis on child survival
Family planning was the main focus for mothers
• Safe motherhood initiative in 1987
Emphasis on maternal health
Emphasis on reduction of maternal mortality

Cont…
• Reproductive health, ICPD in 1994
Emphasis on quality of services
Emphasis on availability and accessibility
Emphasis on social injustice
Emphasis on individuals woman's needs and rights
• Millennium development goals and reproductive health in 2000
MDG 4, 5 and 6 are directly related to health, while MDG 1,2,3, and 7 are
indirectly related to health.

ICPD Paradigm Shift (In 1994)
• International Conference on Population and Development 1994 Cairo.
• To move beyond a narrow focus on family planning to a more comprehensive
program of integrating population and health activities that would help individuals
to meet their Reproductive Health needs.
• Provision of family planning services within a broader type of reproductive
health service
• Interrelation of Reproductive Health with policies to empower women,
strengthen families, stabilize population growth and eradicate poverty.
7

ICPD Paradigm Shift….
• Improve women's equality in education, health and economic opportunities.
• Special focus on fulfilling women’s health needs, safe guarding their
reproductive rights and involving men as equal partners in meeting the goal of
responsible parenthood.
• Shift to Rights Based Approach
• Shift away From macro concerns at population level for reduction in its growth
for achievements of stabilization
• To micro concern at individual level for improvement in well being.
8

Three important elements behind
the paradigm shift
• Recognition of the needs of people in sexuality & reproduction
beyond fertility regulation.
• The articulation& interpretation of the international human rights
treaties in terms of rsh
• The advent of the HIV/AIDS pandemic
9

The Three Rights That Identified Were:
A. The right of couples and individuals to decide freely and responsibly
the number and spacing of children and to have the information and
means to do so;
B. The right to attain the highest standard of sexual and reproductive
health; and,
C. The right to make decisions free of discrimination, coercion or
violence.

Concepts of RH
Even though emphasis lies on improving the RH of women, the strategies
include :
All members of the society in regards to their reproductive needs:
Women & girls, adolescents in their reproductive ages; women in regards to their
roles in society & in the period of menopause.
Men as boys & adolescents;
Men in their reproductive ages, as heads of families, fathers & husbands & opinion
leaders (society, religion, politics, professional life).
11

Magnitude of Reproductive Health
Problem
• Complications associated with various maternal issues are indeed
major contributors to poor reproductive health among millions of
women worldwide.
• Half of the world’s 2.6 billion women are now 15 – 49 years of age.
• Ethiopia has one of the highest maternal mortality in the world
• Lack of access to comprehensive reproductive care is the main reason
that so many women suffer and die.

Components of Reproductive
Health
Quality family planning services
Promoting safe motherhood: prenatal, safe delivery and post natal
care, including breast feeding;
Prevention and treatment of infertility
Prevention and management of complications of unsafe abortion;
Safe abortion services, where not against the law.
Treatment of reproductive tract infections, including sexually
transmitted infections;

Cont…
Information and counseling on human sexuality, responsible
parenthood and sexual and reproductive health;
Active discouragement of harmful practices, such as female genital
mutilation and violence related to sexuality and reproduction;
Functional and accessible referral
The approach recognizes the central importance of gender equality,
men's participation and responsibility.

RH Indicators for
Global Monitoring
1. Total fertility rate
2. Contraceptive prevalence (any method)
3. Maternal mortality ratio
4. Antenatal care coverage
5. Births attended by skilled health personnel
6. Availability of basic essential obstetric care
7. Availability of comprehensive essential obstetric care
8. Perinatal mortality rate

Cont…
9. Low birth weight prevalence
10. Positive syphilis serology prevalence in pregnant women
11. Prevalence of anaemia in women
12. Percentage of obstetric and gynaecological admissions owing to abortion
13. Reported prevalence of women with FGM
14. Prevalence of infertility in women
15. Reported incidence of urethritis in men
16. HIV prevalence in pregnant women
17. Knowledge of HIV-related prevention practices

Cont…
• These indicators can be input, process, out-put and impact indicators.

Cont…
1. Inputs Resources: Manpower, Material Visits and Finance
2. Process Services: Contacts, Visits, Examinations, Morbidity,
Referrals
3. Outputs Results: Knowledge, Acceptance, Practice, Utilization,
Prevalence
4. Outcomes impacts: Fertility, Mortality, Morbidity
5. Policies & Products: National policies, legislation
6. Products Advocacy and IEC: Contraceptives, Logistics

Sources of data
• Routine service statistics: It gives input and process indicators.
• Population Census: provide the denominator for the construction of
process, output and impact indicators.
• Vital statistics reports: provide the numerator for the construction of
process, output and impact indicators.
• Special studies
• Sample surveys

Gender, gender equality,
and gender equity
Gender
socially defined roles and responsibilities
of men and women, boys and girls
Gender equality
equal treatment of women and men
Gender equity
fairness and justice in the distribution of benefits and
responsibilities between women and men
 Women’s health is directly related to their status in society.
10/1/2023 22
Teshome M. (BSc Midwifery, MSc RHMC, Ass't Prof.)

What are maternal health services?
Preconception care
Family planning
ANC
Abortion care
Delivery
Postnatal
STI/HIV

Magnitude of maternal health problems
• Maternal mortality rate worldwide, as defined by the number of maternal deaths
per 100,000 live births from any cause related to or aggravated by pregnancy or its
management, excluding accidental or incidental causes
• A woman's chance of survival during childbirth is closely tied to her social-
economic status, access to healthcare, where she lives geographically, and cultural
norms.
• Most of them died in developing countries due to little access to family planning
services, different cultural practices, lack of information, birthing attendants,
prenatal care, birth control, postnatal care, lack of access to health care, and are
typically in poverty.
• One of the international sustainable development goals developed by united
nations is to improve maternal health by a targeted 70 deaths per 100,000 live
births by 2030

Causes of maternal morbidity and mortality
During childbirth, women typically die from:
Severe bleeding,
Infections,
High blood pressure during pregnancy,
Delivery complications, or
Unsafe abortion.
Other reasons can be regional such as complications related to
diseases such as malaria and aids during pregnancy.
The younger the woman is when she gives birth, the more at risk she
and her baby are for complications and possible mortality

Major causes of maternal death
What are the leading causes of maternal death?
1. Hemorrhage
2. PIH (Pregnancy induced hypertension)
3. Obstructed labor
4. Sepsis/infection
5. Unsafe abortion

Anatomy and physiology of female
reproductive system

Female Reproductive System and Parts
The female reproductive system
is the body parts that help
women or people assigned
female at birth (AFAB):
• Have sexual intercourse.
• Reproduce.
• Menstruate.

Functions of the Female Reproductive System
Allowing a person to have sexual intercourse
Ovaries produce eggs
Produces sex hormones that maintain menstrual cycle.

Menstrual Cycle
It has phases:
The follicular phase (the egg develops).
The ovulatory phase (release of the egg).
The luteal phase (hormone levels decrease if the egg doesn’t implant).
There are four major hormones involved in the menstrual cycle.
1. Follicle-stimulating hormone.
2. Luteinizing hormone.
3. Estrogen.
4. Progesterone.

Normal Pregnancy
 Objectives
• Describe the physiology of pregnancy
• Describe stage of embryological development
• Enumerate the functions of placenta
• Describe placental abnormalities and its consequences
• Describe fetal circulation

Introduction
Pregnancy (gestation):- is the maternal condition of
having a developing fetus in the body which starts at
fertilization
Also called Conception, impregnation or
fecundation.

Fertilization
 fertilization is the union of a single egg & sperm
in the bench mark of the beginning of pregnancy.
The place where fertilization normally occurs is at the
Ampullary surface of the fallopian tubes.
-Conception can be achieved through sexual
intercourse or assisted reproductive technology (ART)
such as IVF and IUI

Cont…
• The functional life span of a spermatozoa is about 48
hours .
• And the functional life of ova is up to 24 hrs
• Therefore, sexual coitus after of ovulation up to 24 hr
time may result in fertilization (pregnancy).
• Or if ovulation is occurred within 48 hr of sexual
coitus pregnancy may occur.
• The sperm and the egg cell, which has been released
from one of the female's two ovaries, unite in one of
the two fallopian tubes.
• The fertilized egg, known as a zygote, then moves
toward the uterus, a journey that can take up to a week
to complete(3 days to reach into the uterus another 3
day to implant).

• Implantation
•
• By. Prof. Saeed Abuel Makarem

Cleavage of Zygote
• Begins about 30 hrs after
fertilization
• Zygote divides first into 2 then
4 then 8 & 16 cells
• Zygote is within the thick zona
pellucida during cleavage
• Zygote migrates in the uterine
tube from its lateral end to its
medial end.
• Zona pellucida is translucent
under light microscope

Cont…
• After fertilization of ova pass through the fallopian tube & reaches to
uterus after 3 days.
• Division takes place & the fertilized ovum divided into two cells, and
then into four, then eight & sixteen & soon until a cluster of cell is
formed known as morula when the cell division reaches 32.
• This cell division occurs once in every 12 hrs

Mechanism:
• The Morula reaches the uterine cavity by the 4th day after
fertilization, & remains free for one or two days
Fluid passes from uterine cavity to the Morula through the
zona pellucida.
• Now the Morula is called Blastocyst, its cavity is called
blastocystic cavity, its cells divided into Embryoblast &
Trophoblast.

Cont…
• The embryoblast projects into the blastocystic cavity, while the
trophoblast forms the wall of the blastocyst.
• Zona pellucida degenerates & disappears by the 5th day to allows the
blastocyst to increase in size and penetrates the endometrium.
• By 6th day the blastocyst adheres to the endometrium
• Trophoblast cells penetrate the epithelium of the endometrium.

Trophoblast layer
Trophoblast differentiated into layers:
1. Cytotrophoblast
Inner layer
Well defined single layer of cell
Produce HCG
2. Syncytiotrophoblast
Outer layer
Has indistinct cell boundary
Composed of nuclated protoplasm
3. mesoderm
Consist of loss conective tissue

 Endometrial cells undergo
apoptosis (programmed cell death)
to facilitates invasion of
endometrium by the
Syncytiotrophoblast.
 Syncytiotrophoblast engulf
these degenerating cells for
nutrition of the embryo.
Implantation
can be detected by:
1- Ultrasonography.
2- hCG (human chorionic
gonadotrophin which is secreted
by the Syncytiotrophoblast) about
the end of 2nd week

Cont….
Blood-filled Lacunae appear in the Syncytiotrophoblast
which communicate forming a network by the day 10th or 11th
Syncytiotrophoblast erodes the endothelial lining of maternal
capillaries which known as sinusoids.
 Now blood of maternal capillaries reaches the lacunae so
Uteroplacental circulation is established by 11th or 12th day.
By the tenth day conceptus is completely embedded in the
endometrium.
For about 2 days the site of penetration shows a defect in the
endometrium.
A fibrinous coagulum of blood closes this defect till the
endometrial epithelium creep over the closing plug by the 12th
day to cover the defect.

Definition of implantation:
• It is the process by which the Blastocyst penetrates the
superficial (Compact) layer of the endometrium of the
uterus.
Site:
• The normal site of implantation is the posterior wall of
uterus near the fundus.
Time:
• It begins about the 6th day after fertilization.
• It is completed by the 11th or 12th day.

Formation of embryonic disc
Two cavity appear on inner cell mass
Formation of amniotic cavity.
Lies on the side of ectoderm
Filled with fluid
Gradually enlarge and folds around the embryo to enclose it
Amnion forms from its lining
Formation of Yolk sac
On the side of endoderm
Provide nourishment to embryo
Part of it contribute to the formation of primitive gut
After birth what remain is vestigial structure on the base of
umbilical cord known as vitelline duct
Now it is called bilaminar embryonic disc.

The inner cell mass
The cell differentiates in to three layers each of which
will form particular parts of the fetus:
• The ectoderm –It forms the epidermis layer of the skin,
hair, nail & nervous system
• The mesoderm - forms bones, muscles, heart & blood
vessels, urogenital glands, connective tissue, dermis of
skin, blood& lymph cells.
• The endoderm - forms mucous membrane, epithelial
lining of the digestive, respiratory &urinary systems &
glandular cells of organs such as liver and pancreas.
The three layer together known as embryonic - plate

Blastocyst
Trophoblast
Placenta Chorinon
Inner cell
mass
Fetus Amnion
Umblical
cord

The embryo
 The developing offspring after implantation and until 8 week after
conception is called embryo .
During embryo all organ and systems of body are laid down in
rudimentary form
Fetus is term after embryo so that fetus grow a and mature for further
7 month

Summary of fetal development
0-4weeks-rapid growth
-formation of embryonic plate
-primitive CNS forms
-heart develops and begins to beat
- limb buds form

4-8 weeks
Very rapid cell division
All major organs laid down in primitive form
Head & facial features develop
Early movements and visible on U/S from 6 wks
External genitalia present but sex not distinguishable

8-12 weeks
Eyelids fuse
Kidney begin to function
At 10 wk pass urine passed
Sucking and swallowing begins
Fetal circulation begin properly
Sex apparent
Fingernails develop and lanugos appear
Some primitive reflexes present
Moves freely but not felt by the mother

12-16 weeks
Rapid skeletal development& visible on x-ray
Meconium present in gut
Nasal septum& palate fuse
Lanugo appears
16-20 weeks
fingernail can be seen
‘Quikening’ mother feels fetal movements
FHB heard on auscultation
vernix caseosa appears and skin cells begin to be
renewed

20-24 weeks
Most organs become capable of functioning
Periods of sleep& activity
Respond to sound
Skin red& wrinkled
24-28 weeks
Legally viable
Survival may be expected if born
Eyelids reopen open
Respiratory movements
28-32weeks
Begin to store fat& iron and testes descend into scrotum
Lanugo disappears from face
Skin becomes paler& less wrinkled

32-36 weeks
Head hair lengthens
Increased fat makes the body more rounded
Lanugo disappears from the body and nails reach tips
of fingers
Ear cartilage soft and plantar creases visible
36 weeks
Birth is expected
Rounded shape soft pliable skull formed.

Placenta Development
• Initially the ovum appear to be covered by fine ,downy hair
• This proliferate and branches from about 3 wk after fertilization
=forming chorionic villi
• Villi become profuse at area where blood supply is reach this part of
trophoblast is called chorion frondosum
• Villi under capsular decidua degenerate and form chorion leave

Placenta Development…
• Villi erode the walls of maternal blood vessels
• Maternal blood vessesls circulate slowly, this villi are
called nurientive vill
• A few villi are attached more deeply are called
anchoring villi
• Each chorionic villi is branching structure arising from
one steam
• The center consist of mesoderm, cytotrophoblast,
syncitotrophoblast, fetal blood vessels

Placenta Development…
• The placenta is completely formed at 10 wk
• In early stage it is relatively loose but become more compact as it
mature
• Between 12-20 wk placenta weights more than weight
• No mixing up of maternal and fetal blood

Functions of placenta
Respiration
Nutrition
Storage
Excretion
Protection
Endocrine/metabolism

Appearance of placenta at term
The placenta is a round flat mass
It is about 20cm in diameter & 2.5cm thickness from
the center
The placenta weights about 1/6 of baby’s weight
(body) at term.

Surface of Placenta
1. The maternal surface
the maternal blood gives this surface dark red colour
The surface is arranged in about 20 lobes
(cotyledon),which are separated by sulci (furrows)
into which decidua dips down
Lobes are made up of lobules
Lime salt may be present

Cont…
2. The Fetal surface of placenta
 The amnion covering the fetal surface of the placenta gives it a
whitish, shinny appearance.
Branches of umblical vein and arteries are visible
Amnion can be peeled off the surface ,leaving chorionic plate from
which the placenta has developed

The fetal sac
 Consists of a double membrane:
Chorion
Outer layer
Adhere to the uterine wall
Thick ,opaque friable membrane
Continues with the chorionic plate
Derived from trophoblat
Amnion
- The inner layer of amniotic sac containing an amniotic
fluid
Cover the fetal surface of the placenta
Tough; translucent, smooth
Derived from the inner cell mass

Anatomical variation of the placenta
Succenturiate lobe of placenta
• A small extra lobe is present, separates from the main
placenta & joined to it by blood vessels which through
the membrane to reach it.
• During delivery this small lobe may be retained
• Holes on the membrane with vessels running to it
Circumvallated placenta.
• an opaque ring is seen on the surface.
• formed by a doubling back of the chorion and amnion
• May result in the membranes leaving the placenta near
the center instead of at the edge as usually.

Battledore insertion of the cord
• the cord is attached at the very edge of the placenta in the manner of
the table tennis bat.
• Un important unless the attachment is fragile
Velamentous insertion of the cord
The cord is inserted in to the membranes some distance from the edge of
the placenta.
• If the placenta is situated normally no harm to the fetus but likely
detached up, on 3 rd stage management

Bipartite placenta
• Two complete & separate placental placenta are present each with
accord leaving it.
• Bi paritate cord joins a short distance
• In succenturate lobe the vessels are attached to the placenta never
directly the cord
Note - Tripartite placenta is similar with that of bipartite placenta, but it
is with three distinct parts.

Disease of placenta
Placenta infarction
Occurs when the blood supply to an area of the placenta is
blocked & tissue necrosis results.
It appears most commonly on maternal surface
Dx, you will see white or red patches on the surface
As infarction is present, fetal circulation will decrease it
leads to fetal death.
Other placental diseases are:
 Placental tumors
 Edema
 Calcification

Amniotic fluid
Functions of amniotic fluid
For the growth & free movement of the fetus.
It equalizes pressure and protects the fetus from
jarring or injury.
The fluid maintains a constant temperature provides
small amounts of nutrients.
Protects the placenta, & umbilical cord from the
pressure of uterine contraction.
Aids for effacement and dilatation of the cervix
It functions as a waste deposit medium.
It prevents the skin and eye from drying.
It forms a reservoir for proteins, minerals and fluid.

Origin of Amniotic Fluid
Source is both maternal and fetal
Secreted by amnion
Maternal blood vessel and fetal blood vessel
Fetal urine from 10 wk
Water in amniotic fluid is exchanged as often as 3hrs

Volume of Amniotic Fluid
• The total amount of amniotic fluid increase thought pregnancy until 38
wks when there is 1litter
• Then diminishes slightly till term when approximately about 800ml
• Normal range is 500-1500 ml
• Often amniotic fluid abnormalities are associated with congenital
abnormality

Constituents of Amniotic Fluid
• Is clear ,pale straw –colored
• 99% is water
• 1% is dissolved solid matter &waste product
• Amniocentesis
• Abnormal constituents of amniotic fluid - meconium

The umbilical cord
Extends from the fetal umbilicus to the fetal
surface of the placenta.
It contains - one umbilical vein &two umbilical
arteries
Wharton’s jelly - which encloses & protects the
two arteries & one vein.
The average length of umbilical cord is about
50cm.
The cord is short when it measures less than
40cm but no specific agreed length to say cord is
long
The whole cord is covered with amnion.

Physiology of Fetus
 There is no mixture between maternal & fetal blood.
The fetus in utero has its own circulatory system which is immature &
different from adult circulation.
The fetus produces its own red & white blood cell.
During intra uterine life the fetal gastro intestinal & respiratory system
are not functioning.

Temporary structures in fetal
circulation
Ductus venousus: This vessel carries oxygenated
blood from the umbilical vein to the inferior venacava.
Formamen ovale an opening between the two atria
of the fetal heart.
Ductus arterious - connect the pulmonary artery to
the descending arch of the aorta.
Hypogastric artery: These are branches of the
internal iliac artery. They return impure blood back to
the placenta.
Note- During fetal circulation the pure (oxygenated)
blood is carried by the veins & the impure
(deoxygenated) blood is carried by arteries.

Fetal circulation
The umbilical vein - leads from the umbilical cord to the
underside of the liver carries blood rich in O2 & nutrients.
Ducts venous join umblical vein to the inferior venaca
where it mix blood from the lower body
Here, there is a mixture oxygenated & deoxygenated
blood from the lower limp.
The blood enters the right atrium of the heart and most
blood passes through an opening known as foramen ovale
in to the left atrium.
The blood now passes from the left atrium into the left
ventricle through the mitral valve & is pumped out
through the aorta.

Fetal circulation…
Heart and brain each receive relatively well oxygenated blood since
coronary and carotid arteries are early branches of aorta
Arm get blood from sub clavian artery that is why arms are more
developed than the leg at birth

Fetal circulation…
The impure blood from the head & upper limbs enter the
right atrium through the superior venacava. Passing
through the tricuspid valve, into the right ventricle, which
it leaves by the pulmonary artery. Since the lungs are
inactive the blood will pass through the ductus arteriosus
(which connects the pulmonary artery to the aorta. Then
the descending aorta supplies the abdominal organs &
lower limbs.
 The deoxygenated blood then returned to the placenta
through the Hypogastric arteries, it branches off from the
internal iliac arteries. When the hypogastric arteries reach
to placenta joins the umbilical cord & becomes the two
umbilical arteries.Hypogastric arteries are the only artery
which carries unmixed blood

Physiological change during
pregnancy
 There are number of physiological ,biochemical and
anatomical changes that occur during pregnancy.
 These changes may be systemic or local.
 It is associated with the effect of the specific hormones.
Teshome M. (BSc Midwifery, MSc RHMC,
10/1/2023 78

Changes in the reproductive system
1. The body of the Uterus
 After conception, the uterus develops to provide a
nutritive and protective environment in which the
fetus will develop and grow.
10/1/2023 79

Decidua
A name given to endometrium during pregnancy
 Progesterone and oestrogen initially produced by the
enlarged corposluteum cause the deciduas to become
thicker, richer and more vascular at the fundus and in upper
body of the uterus.
The decidua provides a glycogen rich environment for the
blastocyst until the trophoblastic cells begin to form the
placenta.

Myometrium
• In early pregnancy uterine growth is due to hyperplasia and
hypertrophy
• During the first few month of pregnancy the uterian well
becomes thicker & less firm growing from 1cm to 2.5 cm by
4 th.
• As gestation advance become thinner
• At term uterus is soft and readily indent able wall of 0.5 cm -
1 cm
• Hyperplasia & hypertrophy of myometrial cells causes three
layers of myometrium more defined

Myometrium…
The myometrium smooth muscle cells in pregnancy grow
up to 15 - 20 times their non-pregnant length,
The weight increase from 50 – 60g to1000 g at term
The size of the uterus length 7.5cm to 30 cm width 5cm to
22.5 cm thickness – 2.5 cm to 20 cm at term
The coordination of synchronous contraction across the
whole organ is due to the presence of gap junction that
connect myometrial cells
Gap junctions are absent in most pregnancy but become
significant in number near term manifesting them selves
as braxton hicks contraction-painless but may
cause=falselabour
In the last few weeks of px Prelabour occurs
10/1/2023 82

Upper uterine surface Lower uterine
surface
peritoneum Firmly attached Loosely attached
myometrium middle oblique layer forms 8
shaped fibers around blood
vessels to control postpartum
hemorrhage.
2 layers: outer
longitudinal and inner
circular
decidua Well developed Poorly developed
membranes Firmly attached Loosely attached
activity Active, contracts, retracts and
becomes thicker during labor
Passive, dilates,
stretches and becomes
thinner during labor

10/1/2023 84

The Cervix
 Acts as an effective barrier against infection during
pregnancy; it remaining firmly closed.
Endocervical cell secrete mucus, which becomes
thicker and more viscous during pregnancy; forms a
cervical plug called the operculum, which provides
protection from ascending infection.
Cervix looks bluish in color
In late pregnancy softening, or ripening of the cervix
occurs - effacement takes place.

The vagina
The capacity of the vagina increases in size and
become more elastic
 increases the amount of normal white vaginal
discharge known as leucorrhea.
Vagina is more vascular & violet in color (chadwick’s
sign).
Increase in glycogen content

Breast changes
New duct and acini are formed
Fullness, heightened sensitivity, tingling and heaviness.
Enlargement of sebaceous glands around nipples
Heavy pigmentation of nipples and areola..
Increased blood supply resulting in visible vessels beneath
the skin.
Estrogen and progesterone are responsible for this change

Cardiovascular changes
 Increase PR ↑10-15b/m
Increased cardiac output (30-50%) and blood volume
(40-50%)
 The apical beat shifts laterally
Splitting of first and second sound ; murmurs and
gallop rhythm
Heart size increases by 12 %

Cardiovascular changes…
Systemic blood pressure declines slightly during
pregnancy
Venous pressure rise in lower extremities but central
venous pressure remain unchanged poor venous return in
later pregnancy may result in leg edema & varicose vein
Red blood cell increase (17%)
Decrease in hemoglobin and hematocrit
Increase in iron need

• Physiological anemia is a sign of excellent
physiological adjustment to pregnancy.
• The mean minimum acceptable Hgb level in pregnancy
is 11 – 12 g/dl.
Plasma protein
• During pregnancy (1st 20 wks) plasma protein reduced
35 to 25 g/l b/se of the increased plasma volume.
• This leads to lowered osmotic pressure => edema of the
lower limbs in late pregnancy.

Clotting factors
• Circulating levels of several coagulation factors increase
in pregnancy.
• Fibrinolytic activity is depressed during pregnancy
• Plasminogen concentrations increase concomitantly with
fibrinogen
• The capacity for clotting is increases for the prevention
of haemorrhage at placental separation,

• WBC are increased to 5000–12,000/L in the last trimester
• The neutrophils increase in which enhances the blood
phagocytic and bacteriocidal properties.
Immunity
• Level of immunoglobulin IGA, IGG and IGM decreased
from the 10th to the 30th wk.

Respiratory system
Vasodilatation of nasal vessels
Increase in rate of respiration.
Total lung capacity decreases as the gestational age increases.
Elevation of diaphragm with increase of gestational age.
Diaphragmatic excursion decreased
Women with respiratory problem in pregnancy do not
deteriorate as women as suffering from other chronic disorder
Increase in oxygen consumption (15-20%)
Breathing is more diaphragmatic and deeper;
Up to 70 % dyspnea is common
Increase in diameter and circumference of chest

Urinary system changes
Each kidney increase in length and weight
The renal pelvis and ureter dilate and lengthen
Renal plasma flow increase by 75 %
Increased glomerular filtration rate (30-50%)
 Urine volume dose not increase
 Increase in urinary frequency & urgency
Reduced bladder tone
Residual urine
Increase glucose and amino acid excretion
 blood urea nitrogen , creatnine ,uric acid level decrease

Gastrointestinal system
• Gum become oedematous, soft and spongy
• High vascular swelling known as epulis (gingivitis )
• Ptyalism inability of nauseated women to swallow normal
amount of saliva
• Change in sense of taste (dullness )
• Craving for unusual food items of very low nutrionl value
like clay and soap is called pica
• Increase in appetite but nausea and vomiting in first
triemester

Gastrointestinal system…
Heart burn is common complaint
Relive of symptoms of gastric ulcer
Constipation is common and hemorrhoids could occur
. aspiration pneumonitis in px women under going
general anesthesia
Favorable for gallstone formation
No significant change in anatomy of liver except
elevation of alkaline phosphate
10/1/2023 96

Endocrine changes
Increased secretion estrogen, progesterone, HCG HPL
Increased size of the anterior pituitary gland and
secretion of pituitary hormones like prolactin.
Increased thyroid gland (increased uptake of iodine)
Pregnancy has diabetgenic effect .
There is no change in TSH & ACTH

Integumentary system changes
Hyper pigmentation of the skin
Darkening of areola, nipples, axillae
Nails become brittle and can show horizontal grooves
(Beau's lines)
Thickening of the hair
Facial melasma (chloasma)/ pregnancy mask
Linea nigra and striae gravidarum
Spider angiomas and palmar erythema

Melasma
10/1/2023 99

Lineanigra and striaegravidarum
10/1/2023 100

Beau's lines
10/1/2023 101

Spider angiomas
10/1/2023 102

Musculoskeletal changes
Postural changes due to change in body and increasing
weight
Exaggerated lordosis “the proud walk of pregnancy”
Prarasthesia of hands
Relaxation of pelvic joint & ligaments cause pelvic
pain, gait problem

Weight gain
Weight gain during pregnancy comprises of product of
conception, hypertrophy of several maternal tissue
An optimal weight gain for an average pregnancy is 12.5
kg(9-12kg)
9kg of which is gained in the last 20 wks
This is associated with low risk of complications during
pregnancy and labor of low birth weight
10/1/2023 104

Neurologic changes
Sensory changes in the legs as a result of compression of
pelvic nerves by gravid uterus.
Pain from lordosis or compression of nerve roots.
Acroesthesia (numbness and tingling of the hands)
Tension headache from anxiety,
Light-headedness, fainting may be due to postural
hypotension or hypoglycemia.

Diagnosis of pregnancy
Presumptive signs
Amenorrhea
Fatigue
Breast changes
Morning sickness
Bladder irritability/frequency of micturation
Quickening

Diagnosis of pregnancy ….
Probable signs
Presence of HCG in the urine/serum
Abdominal enlargement
Ballotment of the fetus
Hegar’s sign
Braxton hick’s contraction
Chadwick's sign
Osiander’s sign

Cont…
• Chadwick's sign =dark purplish discoloration and congestion of the
vaginal membrane
• Osiander’s sign =increase pulsation of blood in the uterine arteries
felt with finger in the lateral vaginal fornix
10/1/2023 108

Diagnosis of pregnancy…
Positive signs
Fetal heart beat through fetoscope or U/S
Visualizing the fetus
Palpating fetal movement

Diagnosis of pregnancy…
Trans vaginal ultrasound gestational sac can be
visualized up to 4.5 wks and heart pulsation can be
seen at 5 wk
But in trans abdominal ultrasound 1 wks later
Doppler can detect fetal heart rate up to 11-12 wk
Palpation of fetal part and movement at 22 wks
All biochemical test depend up on the detection of
HCG
 Enzyme linked immuno sorbent assay (ELISA)

Minor disorders of pregnancy

Introduction
Sign and symptoms that occur during pregnancy due to
anatomic and physiological change
not life threatening, however it may complicate
pregnancy.
Managed by educating and providing explanation

1. Nausea and vomiting-
Common complaints during the first half of
pregnancy.
It is usually occurs in the morning but can occur any
time during the day
Have a functional role in promoting and maintaining
early placental growth
Aggravated by smelling of food
In some women the vomiting may be severe and
condition called hyperemesis gravidarum

Management of nausea and vomiting
Small, frequent meals and snacks
 Low fat, low carbohydrate, high protein diet
 Take more liquids than solids in the diet
Encourage fluids to prevent dehydration
Avoid an empty stomach
 Prevent a full stomach
Avoid rich, spicy or fatty foods
 Eating dry crackers before rising in the morning

2. Heart burn
• One of the most common complaints of pregnant
women
• Is a burning sensation in the mid chest region.
• Caused by the increased frequency of regurgitation
during pregnancy
• Management:
• Small and frequent meal,
• Remain upright for at least an hour after eating to reduce
reflux
• Avoid eating or drinking at bedtime and sleep
• Use antacids if sever

3. Pica
• This is the term used when mother craves certain
foods of unnatural substances such as coal, soil...etc.
• Ice (pagophagia), starch (amylophagia), or clay
(geophagia).
• This desire has been considered by some to be
triggered by severe iron deficiency
• No known cause
• Educating the women is all that needed

4. Constipation
• Progesterone effect , decreased peristaltic activity ,
compression of lower bowel
• Discomfort caused by passage of hard fecal material, bleeding
and painful fissures may develop in the edematous and
hyperemic rectal mucosa.
• Hemorrhoids and, prolapse of the rectal mucosa
Management:
- increase the intake of water, fresh fruit, vegetables and roughages in
the diet, exercise ,laxatives

5. Backache, joint pain and pelvic pain
• Minor degrees follow excessive strain or fatigue and
excessive bending, lifting, or walking.
• Increased with duration of gestation.
• Prior low back pain and obesity were risk factors.
• Severe back pain should not be attributed simply to
pregnancy
• It can be associated with UTI
Management:
Maintain correct posture
Advice the mother to sleep on firm bed.
Advice support mechanisms of the back.
Avoid high heeled shoes
Squat rather than bending to lift objects
Excluded UTI

6. Fainting
• In early pregnancy fainting may be due to the
vasodilatation occurring under the influence of
progesterone before there has been a compensatory increase
in blood volume.
• The weight of the uterine contents presses on the inferior
venacava and slows the return of blood to the heart.
Management:
• Avoid long period of standing
• Sit or lie down when she feels slight dizziness
• She would be wise not to lie on her back except during
abdominal examination

7. Varicositis
• Dilated superficial veins of lower extermities
• become more prominent as pregnancy advances, as
weight increases, and as the length of time spent upright is
prolonged
• Mostly asymptomatic, the only is cosmetic, discomfort
Management:
- Exercising the calf muscles by rising on the toes
- Elevate the leg
• elastic stockings
• Surgical correction of the condition during pregnancy
generally is not advised

8. Hemorrhoids
• Varicosis of rectal vein
• May appear first or exacerbated or recurrence of
previous hemorrhoids.
• Related to increased pressure in the rectal veins.
• Pain and swelling usually are relieved by topically
applied anesthetics, warm soaks, and stool-softening
agents

9. Ptyalism
• Women during pregnancy are occasionally distressed
by profuse salivation.
• The cause sometimes appears to be stimulation of the
salivary glands by the ingestion of starch.
• Most cases are unexplained.
• Simple explanation will suffice

10. Leukorrhea
Pregnant women commonly develop increased vaginal discharge
It is clear ,white ,odourless
Reassurance is usually sufficient
R/out bacterial vaginosis, trichomoniasis and candidiasis

11. Bacterial Vaginosis
Is a maldistribution of normal vaginal flora.
Numbers of lactobacilli are decreased, and
overrepresented species tend to be anaerobic bacteria,
including gardnerella vaginalis,
 it is associated with preterm birth.
Usually complain of a fishy-smelling discharge.
Treatment does not reduce preterm birth, and routine
screening is not recommended

12. Trichomoniasis
Is common in pregnancy
 vaginitis is characterized by foamy leukorrhea with
pruritus and irritation,
Identifying flagellated trichomonas and on wet mount
Linked to with preterm birth
Screening and treatment of asymptomatic women is
not recommended
During pregnancy metronidazole should not be given
in the first trimester

13. Candidiasis
• Asymptomatic colonization requires no treatment,
• But the organism may sometimes cause an extremely
profuse, irritating discharge associated with a pruritic,
painfully tender, and edematous vulva.
• Rx; miconazole, clotrimazole, and nystatin

Other Complaints
Fatigue; in early pregnancy, most women complain of fatigue and
desire for excessive sleep. usually remits spontaneously by the fourth
month of pregnancy and has no special significance.
Palpitation, chloasma, striae, legcramp, parastesia of hand, epistaxis,
gumbleeding, epulis gravidarum, frequency of urination, dependent
edema

Danger signs of pregnancy
• Most minor disorder can be advanced to a more serious
complication of pregnancy.
• The disorders require the immediate actions are as follows
Vaginal bleeding
Reduced fetal movement
Frontal of recurrent headaches
Sudden swelling
Rupture of the membrane
Premature onset of contractions
Maternal anxiety for whatever reason

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