Ob

BY ALEMAYEHU
T(BSC MIDWIFE)
By Alemyehu T March 22-2014 1

OBJECTIVES OF THE LECTURE
At the end of this chapter the students will be
able to:
Describe physiological changes during pregnancy
 list pregnancy diagnosis methods
Describe stage of embryological development
 Enumerate the functions of placenta
 Identify major care given for pregnant women
during pregnancy

Define the following terminologies
Ovulation
 Fetus
 Fertilization
 newborn
 Zygote
 Neonate
 Implantation
 Toddler
 Embryo
 Child
 Pregnancy
 adolescent

 It is the maternal condition of having a developing embryo or
fetus in the uterus.
 Pregnancy literally means (being with the child).
 The Normal pregnancy average duration is counting from first
day of last menstrual period is about 280 days or 40 weeks.
 It starts at fertilization.
 It ends at delivery of the fetus and placenta.

 Ovulation is the process in a female’s menstrual cycle by
which a mature ovarian follicle raptures and discharges an ovum.
 The process requires a maximum of 36hours to complete, and
it is arbitrarily separates in to three phases
oPreovulatory(proliferative phase)
oOvulatory and
oPost ovulatory

Fer tilization:
Fusion of the ovum(23x) and matured spermatozoa(23x or
23y)
It takes place in the fallopian tubes.
Fertilization must occur fairly quickly after release of the ovum
because it usually occurs in the outer third of a fallopian tube,
the ampullar portion.
The functional life span of spermatozoa is about 48 hours /
may be as long as 72 hours or longer
Therefore, sexual coitus during this time may result in
fertilization /pregnancy.

By Alemyehu T March 22-2014
Fertilization
in the
ampulle of
the FT.
7

Zygote:
(46xx or 46xy) is a cell that results from fertilization.
After fertilization the ova passes through the fallopian tube
and reaches the uterus 3 or 4 days later.
It divides and redivides forming daughter cells named
blastomeres.
Division takes place and the fertilized ovum divides into two
cells, and then into four, then eight, and sixteen and soon until
a cluster of cells is formed known as the morula.
It reaches 16 cell stage, it is named morula.

 These divisions occur quite slowly about once every 12 hours
 When fluid filled cavity appears in the morula a blastocyst is
formed.
 The cells of blastocyst are arranged in to two layers
Outer layer called trophoblast
Develops in to the placenta & chorion
Inner layer is called embr yoblast
Rise to the fetus, umbilical cord & amnion

Blastocyst
Trophoblast Inner cell mass
Placenta
Chorion
Fetus
Amnion
Umbilical
cord
A
10

The inner cell mass differentiate into three layers, each of which will
form particular parts of the fetus.
The ectoderm mainly forms the skin and nervous system
The mesoderm forms bones and muscles and also the heart and
blood vessels, including those which are in placenta.
The endoderm forms mucous membranes and glands.
The three layers together are known as the embryonic plate.

 Embryo is the stage after the inner layer formed two layer
(bilaminar disc).
 Embryonic period is a period where major structures are
formed and extends up to the end of seven weeks after
fertilization.
 Fetus is developing conceptus after the embryonic period.
 Conceptus is all tissue products of conception (embryo/fetus,
fetal membranes, and placenta)

 On day 4 after fertilization the blastocyst enters into the
uterine cavity.
 By day 7, it starts embedding itself in to the prepared
endometrium which is know called the decidua and this
process is called implantation.
 Implantation is an event that occurs early in pregnancy in
which the embryo adheres to the wall of the uterus.

 There are many physiologic changes in pregnancy.
 Some mimic the signs, symptoms, or laboratory finding of
disease in the nonpregnant woman yet are normal in
pregnancy.
 Therefore , knowledge of normal maternal physiologic
changes helps avoid unnecessary diagnostic or therapeutic
interventions.

There are physiological, biochemical and anatomical changes that
occur during pregnancy.
 These changes may be systemic or local.
 Most of the systemic changes return to pre pregnancy status 6
weeks after delivery.
 These changes occur during pregnancy to maintain a healthy
environment for the fetus with out compromising the mother’s
health.

1-Systemic changes:
-volume homeostasis.
-blood
-cardio vascular system.
2-Respiratory changes.
3-urinary tract and renal function.
4-Alimentary tract.
5-Reproductive organs.
6-endocrinological changes.

A. volume homeostasis:
 Fluid retention is the most fundamental systemic changes of
normal pregnancy.
 The total blood volume is increased during pregnancy 30%.
 The most marked expansion occurs in extra cellular volume
(ECV) with some increase in intra cellular water.

The contributing factors includes:
 Increase sodium retention.
 Decrease in plasma osmotic pressure.
 Decrease in thirst threshold.
 Resetting of osmostate.
 Decrease in plasma oncotic pressure.

 Blood Volume
 Blood volume expansion begins early in the first trimester, increases rapidly
in the second trimester, and plateaus at about the 30th week (Fig 7–1). The
approximately 50% elevation in plasma volume, which accounts for most of
the increment, results from a cascade of effects triggered by pregnancy
hormones. For example, increased estrogen production by the placenta
stimulates the renin-angiotensin system, which, in turn, leads to higher
circulating levels of aldosterone. Aldosterone promotes renal Na+
reabsorption and water retention. Progesterone also participates in plasma
volume expansion through a poorly understood mechanism; increased
venous capacitance is another important factor. Human chorionic
somatomammotropin, progesterone, and perhaps other hormones promote
erythropoiesis, resulting in the about a 30% increase in red cell mass.

 Increase in blood volume – most striking change
 The change occurs until term and the average increase in volume
is 45-50%
 The mechanism for increase the volume of blood is not well
understood (aldosterone related factor during pregnancy may
contribute to this effect), increase water and salt retention.

RBC increased by 33%
Iron need increases because of increase in red
blood cell mass.
This is why Iron suplimentation is necessary
during pregnancy.
WBC total count usually increase
Platelets increase in production

Hear t slightly shift in position( left-upward
displacement)
Enlarging Uterus diaphragm → → displace up ward
Results in decreased systemic vascular resistance→
↑CO 6 L/ min. Max. (22-28)wks.
Heart rate increase (10-20%).
Stroke volume increase (10%).
Cardiac out put increase (30-50%).
Mean arterial blood pressure decrease (10%)
Peripheral resistance decrease (35%).

Blood Pressure
Systemic blood pressure declines slightly during pregnancy.
There is little change in SBP but
DBP decrease by 5-10 mmHg from 12-26 weeks,
then increase to non pregnant level by term.

 Capillary dilatation occurs in the respiratory route
(Nasopharynx, larynx, trachea, bronchi) →make breathing
difficult through nose,
 enlarged Uterus pushes the diaphragm and the lungs as well.

Blood flow increase (60-70%).
Glomerular filtration increased (50%).
clearance of most substances is enhanced.
Plasma creatinine and urea are reduced
Glycosuria is normal.
Bladder
Is displaced upward and anteriorly by enlarged uterus as a result it
increases pressure leading to and urinary urgency and frequency.

The gums becomes spongy.
The lower oesophageal sphincter is relaxed (hurt burn).
Gastric secretion is reduced.
The intestinal musculature is relaxed (constipation).

A. the uterus:
 Upper part fundus and body change in to upper uterine
segment.
 Lower part cervix and isthmus change in to lower uterine
segment
 Weight increases from 60gm to l kg at term, volume 10ml to
5 liters.

B. the cer vix:
 The cervix becomes softer and swollen in pregnancy with the
result columnar epithelium lining cervical canal becomes
exposed to vaginal secretion.
 The mucus gland becomes distended and secrete mucus
which forms a mucus plug that is expelled in labour as the
show.
 Prostaglandins and collagenase especially in last weeks of
pregnancy act on collagen fiber make cervix more softer.

C. the vagina :
 The vaginal mucosa becomes thicker during pregnancy.
 The vaginal discharge during pregnancy increased due to
increase desquamation of the superficial vaginal mucosal cells.

D-breasts and lactation :
 Breast increases in size with enlargement of the nipple
and increased vascularity and pigmentation of areola.
 The earliest changes is a swelling of the breast tissue.
 Estrogen leads to increase in number of glandular ducts.
 Progesterone leads to proliferation of glandular epithelium of
the alveoli.
 Prolactin leads to active secretion of milk after birth.

 Prolactin concentration increases markedly but act after
delivery.
 Human growth hormone is suppressed .
 Insulin resistance develop.
 Thyroid function changes little.
 Trans placental calcium transport is enhanced.
 Corticosteroid concentration increased.
 Aldosterone concentration increased.
 Angiotensin and renine increased

human chorionic gonadotropin (HCG):
 It is secreted by trophoblast and can be detected in serum 10
days after conception (RIA).
 There is high level of circulating HCG in early pregnancy (to
provide a suitable environment for implantation and
development).
 To support corpus luteum secretion of estrogen and
progesterone in the first trimester until the placenta becomes
able to produce these hormone.

 The peak level normally occur in the 12th week
Constant level of HCG in late pregnancy is
useful in:
Controlling placental secretion of Estrogen progesterone.
Suppressing maternal immune system against fetus.
 The human chorionic gonadotropin normally disappear from
urine 7-10 days after delivery of placenta.

 It is secreted by syncytotrophoblast.
 Its level increase when the level of HCG start to drop .
HPL has no effect on fetus.
• HPL effect on :
1-the breast:
o Mammary growth during pregnancy.
o Produce of colostrums.
o Milk production lactation.

2-Protiens:
HPL stimulate protein synthesis at cellular level.
3-Carbohydrate:
 Stimulate insulin secretion .
 Inhibit insulin action.
4-Fat:
HPL mobilize fat from body store (lypolysis) lead to increase
maternal blood glucose and maternal tissue can not utilize the
glucose so the glucose will be available for fetus.

It is produced by corpus luteum in early pregnancy and
placenta in late pregnancy.
Role of estrogen:
On connective tissue: estrogen leads to polymerization of
monosaccharaides of the ground substance leads to loose
connective tissue mainly in the cervix.
On the protein: estrogen stimulate directly RNA synthesis
lead to protein synthesis.

 Its production is the same as estrogen.
 It has effect on smooth muscle leads to decrease muscle
excitability leads to muscle relaxation mainly in uterus.

1) -------is the maternal condition of having a developing embryo
or fetus in the uterus.
2) The normal pregnancy average duration is counting------------
days.
3) Pregnancy starts from------ and ends at ----------.
4) ------is the process in a female’s menstrual cycle by which a
mature ovarian follicle raptures and discharges an ovum.
5) How many days required to complete ovulation?

1. What is the out come of fertilization?
2. ------is the name of daughter cells, results from zygote division.
3. What is morula?
4. When fluid filled cavity appears in the morula ------- is
formed.
5. Trophoblast develops in to -------& -------.
6. Which inner cell layer is forms bones, muscles, heart and blood
vessels?

 Pregnancy is mainly diagnosed on the symptoms reported
by the woman and signs elicited by a health care provider.
 Signs and symptoms of pregnancy
 These signs and symptoms are divided in to three(3Ps)
classifications;
presumptive,
probable, and
 positive

PRESUMPTIVE SIGNS AND SYMPTOMS OF
PREGNANCY;
Presumptive signs and symptoms of pregnancy are those signs
and symptoms that are usually noted by the patient, which impel
her to make an appointment with a physician.
These signs and symptoms are not proof of pregnancy but they
will make the physician and woman suspicious of pregnancy.

1. Amenor rhea (Cessation of Menstruation)
Amenorrhea is one of the earliest clues of pregnancy.
The majority of patients have no periodic bleeding after the
onset of pregnancy.
However, at least 20 percent of women have some slight,
painless spotting during early gestation for no apparent reason
and a large majority of these continue to term and have normal
infants.

Other causes for amenorrhea must be ruled out, such as:
Menopause.
Stress (severe emotional shock, tension, fear, or a strong desire
for a pregnancy).
Chronic illness (tuberculosis, endocrine disorders, or central
nervous system abnormality).
Anemia.
Excessive exercise.

2. Nausea and Vomiting (Mor ning
Sickness)
Usually occurs in early morning during the first weeks of
pregnancy.
Usually spontaneous and subsides in 6 to 8 weeks or by the
twelfth to sixteenth week of pregnancy.
Hyperemesis gravidarum. This is referred to as nausea and
vomiting that is severe and lasts beyond the fourth month of
pregnancy. It causes weight loss and upsets fluid and electrolyte
balance of the patient.

Nausea and vomiting are unreliable signs of pregnancy since they
may result from other conditions such as:
Gastrointestinal disorders (hiatal hernias, ulcers, and
appendicitis).
Infection (influenza and encephalitis).
Emotional stress, upset (anxiety and anorexia nervosa).
 Indigestion.

3. Frequent Urination
Frequent urination is caused by pressure of the expanding uterus
on the bladder.
It subsides as pregnancy progresses and the uterus rises out of the
pelvic cavity.
The uterus returns during the last weeks of pregnancy as the head
of the fetus presses against the bladder.
Frequent urination is not a definite sign since other factors can be
apparent (such as tension, diabetes, urinary tract infection, or
tumors).

4. Breast Changes
In early pregnancy, changes start with a slight, temporary
enlargement of the breasts, causing a sensation of weight, fullness,
and mild tingling.

As pregnancy continues the patient may notice:
Darkening of the areola--the brown part around the nipple.
 Increased firmness or tenderness of the breasts.
 More prominent and visible veins due to the increased blood
supply.
 Presence of colostrum (thin yellowish fluid that is the precursor
of breast milk).
 NB ; These breast changes can be more positive if the patient
has not recently delivered and is not presently breastfeeding.

5. Quickening (Feeling of fetal mov’t)
This is the first perception of fetal movement within the uterus.
A multigravida can feel quickening as early as 16 weeks.
A primigaravida usually cannot feel quickening until after 18
weeks.

6. Skin Changes.
Striae gravidarum (stretch marks):
These are marks noted on the abdomen and/or buttocks.
These marks are caused by increased production or sensitivity to
adrenocortical hormones during pregnancy, not just weight gain.

Linea nig ra;
This is a black line in the midline of the abdomen that may run
from the sternum or umbilicus to the symphysis pubis.
This appears on the primigravida by the third month and keeps
pace with the rising height of the fundus.
The entire line may appear on the multigravida before the third
month.
This may be a probable sign if the patient has never been
pregnant.

Striae gravidarum Linea nigra
52

Chloasma:
This is called the "Mask of Pregnancy.“
 It is a bronze type of facial coloration seen more on dark-haired
women.
It is seen after the sixteenth week of pregnancy.
Fingernails:
Some patients note marked thinning and softening by the sixth
week.

7. Fatigue or weakness:
This is a common complaint by most patients during the first
trimester.
 Fatigue may also be a result of anemia, infection, emotional
stress, or malignant disease.

 Probable signs of pregnancy are those signs commonly noted by the
physician upon examination of the patient or the client.
These signs include:
1. Uterine Changes
 Position:- By the twelfth week, the uterus rises above the symphysis pubis
and it should reach the xiphoid process by the 36th week of pregnancy.
 These guidelines are fairly accurate only as long as pregnancy is normal
and there are no twins, tumors, or excessive amniotic fluid.

Size:- The uterine increases in width and length approximately
five times its normal size. Its weight increases from 60 grams to
1,000 grams.
2.Abdominal Changes
This corresponds to changes that occur in the uterus, as the
uterus grows, the abdomen gets larger.
Abdominal enlargement alone is not a sign of pregnancy.
Enlargement may be due to uterine or ovarian tumors, or edema.

3. Cer vical Changes.
Formation of a mucous plug.
This is due to hyperplasia of the cervical glands as a result of
increased hormones.
It serves to seal the cervix of the pregnant uterus and to protect
it from contamination by bacteria in the vagina.

4. Basal Body Temperature
This is a good indication if the patient has been recording for
several cycles previously.
A persistent temperature elevation spanning over 3 weeks since
ovulation is noted.
Basal body temperature (BBT) is 97 percent accurate.

5. Fetal Palpation
This is a probable sign in early pregnancy.
The physician can palpate the abdomen and identify fetal parts.
It is not always accurate.

 Positive signs of pregnancy are those signs that are definitely
confirmed as a pregnancy.
They include :
fetal hear t sounds,
ultrasound scanning of the fetus,
palpation of the entire fetus,
palpation of fetal movements,
x-ray, and
actual deliver y of an infant.

1. Fetal Hear t Sounds
The fetal heart begins beating by the 24th day following
conception.
It is audible with a Doppler by 10 weeks of pregnancy and with
a fetoscope after the 16th week.
The normal fetal heart rate is 120 to 160 beats.

2. Ultrasound Scanning of the Fetus
The gestation sac can be seen and photographed.
An embryo as early as the 4th week after conception can be
identified.
The fetal parts begin to appear by the 10th week of gestation.

3. Palpation of the Entire Fetus
Palpation must include the fetus head, back, and upper and
lower body parts.
This is a positive sign after the 24th week of pregnancy if the
woman is not obese.
4. Palpation of Fetal Movement
This is done by a trained examiner.
It is easily elicited after 24 weeks of pregnancy.

March 22-2014 By Alemyehu T 71

5. X-ray
An x-ray will identify the entire fetal skeleton by the 12th week.
In utero, the fetus receives total body radiation that may lead to
genetic or gonadal alterations.
An x-ray is not a recommended test for identifying pregnancy.
6. Actual delivery of an infant
Self-explanatory.

A. Tests are based on the presence of human chorionic
gonadotropin (HCG) in the urine or blood.
1)Urine. This test can be performed accurately 42 days after the
last menstrual period or 2 weeks after the first missed period.
The first urine specimen of the morning is the best one to use.
2)Blood. Radioimmunoassay (RIA) can detect HCG in the
blood 2 days after implantation or 5 days before the first
menstrual period is missed.

 Human chorionic gonadotropin (hCG) is a glycopeptide
hormone produced by the placenta during pregnancy.
The appearance and rapid rise in the concentration of hCG in
the woman's urine makes it a good pregnancy marker.
Usually, concentration of hCG in urine is at least 25 mIU/ml
as early as seven to ten days after conception.
The concentration increases steadily and reaches its maximum
between the eighth and eleventh weeks of pregnancy.

 Bring test components and specimens to room temperature
prior to testing.
Remove a Testing Device from the foil pouch by tearing at the
"notch" and place it on a level surface.
 Holding a Sample Dropper vertically, add exactly four drops of
the urine specimen to the sample well.
Read results at time indicated in procedure.

 If two color bands are visible the test is positive.
The presence of a Control Band only indicates a negative test.

The Control Band is used as a reference and built in quality
control check.
 If the Test Band is darker or similar to the Control band, the test
result is considered positive.
The Control Band is used for procedural control to check
whether the test reagents are working properly and that a
sufficient amount of urine sample has been applied to the test
area.

 If, after performing the test, no purple color band is visible
anywhere within the Results Window, the result is considered
invalid.
 If a color appears in the test area but NO color appears in
the control area, the test is invalid.

The directions may not have been followed correctly.
 Inadequate amount of sample has been exposed to the test
system.
The test may have deteriorated.

Do not use test kit components after the expiration dates.
Dispose of all used test components in a proper biohazard
container.
 If specimens or test components have been stored in a
refrigerator, allow them to warm to room temperature before
performing the test.
 Human specimens should be handled as if capable of
transmitting infectious agents.
March 22-2014
By Alemyehu T
84

 Besides pregnancy, elevated concentrations of hCG may be
found in patients with both gestational and non-gestational
trophoblastic diseases.
These conditions should be ruled out in the interpretation of
hCG levels to establish a diagnosis of pregnancy.
A low incidence of false results can occur.
Consult with a physician if unexpected or inconsistent results.
A normal pregnancy cannot be distinguished from an ectopic
pregnancy based on hCG levels alone.
A spontaneous miscarriage may cause confusion in interpreting
the test results. By Alemyehu T March 22-2014 85

Fer tilization
•1 day post-ovulation
SPERM + EGG(OOCYTE) = ZYGOTE
The fertilization process takes about 24 hours.
Sperm life = 48 hours/72hours
It takes about ten hours to navigate the female
Reproductive track, moving up the vaginal canal, through the
cervix, and into the fallopian tube where fertilization begins.

Mr. SPERM Mrs. EGG
88

Cleavage(division)
•1 - 3 days post-ovulation
The zygote now begins to cleave, with each division occurring
into two cells called blastomeres.
The zygote's first cell division begins a series of divisions, with
each division occurring approximately every twelve hours.

 When cell division generated about sixteen cells, the zygote
becomes a morula (mulberry shaped)
 It leaves the fallopian tube and enters the uterine cavity three to
four days after fertilization.

Blastocyst
•3 - 5 days post-ovulation
Two cell types are forming:
Embryoblast (inner cell mass on the inside of the blastocele)
Trophoblast (the cells on the outside of the blastocele).

Implantation
5 - 7 days post-ovulation
The trophoblast cells secretes an enzyme which erodes the
epithelial uterine lining and creates an implantation site for the
blastocyst.
Ovary continues producing progesterone

 Trophoblast cells continue releasing human chorionic
gonadotropin (hCG)
 Endometrial glands in the uterus enlarge in response to the
blastocyst and the implantation site becomes swollen with new
capillaries.
 Circulation begins, a process needed for the continuation of
pregnancy.

Gastrulation, Chorionic Villi Formation
•13 days post-ovulation
The formation of blood and
blood vessels of the embryo begins
Yolk sac begins to produce hematopoietic or
non-nucleated blood cells.
Gastrulation three layers of the embryo:
ectoderm, mesoderm and endoderm.

Neurulation and Notochordal Process
16 days post-ovulation
Endoderm forms the lining of lungs, tongue, tonsils, urethra
and associated glands, bladder and digestive tract.
Mesoderm forms the muscles, bones, lymphatic tissue, spleen,
blood cells, heart, lungs, and reproductive and excretory systems.
Ectoderm forms the skin, nails, hair, lens of eye, lining of the
internal and external ear, nose, sinuses, mouth, anus, tooth enamel,
pituitary gland, mammary glands, and all parts of the nervous
system.

Primitive Pit (depression, cavity), Notochordal Canal
and Neurenteric Canals
• 17-19 days post-ovulation
 The blood cells of the embryo are already developed and they begin to
form channels along the epithelial cells which form consecutively with
the blood cells.
• STAGE 8:19 - 21 days post-ovulation
 Endocardial (muscle) cells begin to fuse and form into the early
embryo's two heart tubes.

 21 - 23 days post-ovulation
• Cardiac muscle contraction begins
• Eye & ear cells are present
• Neural tube starts closing

23 - 25 days post-ovulation
A primitive S-shaped tubal heart is beating and peristalsis,
the rhythmic flow propelling fluids throughout the body,
begins.
At this stage, the neural tube determines the form of the
embryo

 25 - 27 days post-ovulation
The brain and spinal cord together are the largest and most
compact tissue of the embryo.
Valve & septa appear in the heart
The digestive epithelium layer begins to differentiate into the
future locations of the liver, lung, stomach and pancreas.
The beginning cells of the liver form before the rest of the
digestive system.

Approximately 27-29 postovulatory days
Forebrain, midbrain and hindbrain.
Forebrain senses, memory formation, thinking, reasoning,
problem solving.
Midbrain relay station, coordinating messages to their final
destination
Hindbrain regulates the heart, breathing and muscle
movements

 Lymphatic & thyroid start to develop
 Limb buds
 First thin layer of skin
 Liver & heart, etc.

 4 to 8 weeks post fer tilization
 Nervous sys developing further
 4 chamber heart
 lung sacs
Ureteric bud appear
 Nerve distribution process, innervation, begins in the upper
limbs.

 6 to 8 weeks post fertilization
 Further development of nervous system, heart.
 Innervations, the distribution of nerves, begins in the lower limb
buds.

 Approximately 41 postovulatory days
A Four Chambered Heart and a Sense of Smell
 Primitive germ cells arrive at the genital area and will respond
to genetic instructions to develop into either female or male
genitals.

Approximately 47-48 post ovulation days
 Brain Waves and Muscles
The trunk elongates and straightens
The bone cartilage begins to form a more solid structure.
 Muscles develop and get stronger.

 48-52 days post ovulation
 Spontaneous Involuntary Movement
 Brain is connected to tiny muscles and nerves and enables the
embryo to make spontaneous movements
Testes or ovaries are distinguishable

 approximately 56 - 57 post ovulation days
 essential external and internal structures complete
 layer of rather flattened cells, the precursor of the surface layer
of the skin, replaces the thin ectoderm of the embryo.

Week 10 - 11
Vocal cords formed
 Liver secretes bile, stored in the GB
 Pancreas produces insulin
Reflexes present
Male/female differentiate

Week 12 - 13
 Fetus begins to move
 Heartbeat can be found with Doppler
 Fetal sex now clearly distinguished
 Body begins to grow hair (lanugo)

Week 16 Post Fertilization
Growth continues, but no new structures form after this point
 Meconium begins to accumulate in the bowels.
 Meconium is the product of cell loss, digestive secretion and
swallowed amniotic fluid.
 Placenta equal in size to fetus

17 week
116

Week 18 Post Fer tilization
A dramatic growth period for the fetus.
 Fetus has phases of sleep and walking and may prefer a favorite
sleep position.
Ovaries containing primitive egg cells & uterus present
 Placenta is fully formed and grows in diameter though not in
thickness.

Week 20
 Fetus sucks thumb
 Extremely rapid brain growth (which lasts until five years after
birth) begins.
Testes of male fetuses begin descending from the pelvis into
the scrotum.
 Arms and legs move with more force, as muscles strengthen.

Week 26
 Lungs may be mature enough to breath air!
 Fetal body is two to three percent body fat.
 Eyes are partially open and eyelashes present.
 Sucking and swallowing improves.

Week 30
 Body growth slows down
The iris is colored
 The pupil reflexes responding to light.

Week 32
 Fetus rests on uterus - no longer floating.
 Eyes open during alert times and close during sleep.
 Eye color is usually blue, regardless of the permanent color as
pigmentation is not fully developed

Week 34
 Head may now position (head-down) into pelvis before labor.
Gastrointestinal system is very immature and will stay that way
until three or fourth years after birth.
 Fetus stores about 15% of weight in fat to keep temperature of
body warm

 40 weeks
 Full term
 15% of body is fat,
 80% of which is underneath the skin,
 the other 20% around the organs.

 It is temporary organ joining the mother and fetus.
 It receives nutrients, oxygen, antibodies and hormones from the
mother’s blood and passes out waste.

 Respiration –
 As pulmonary exchange of gases does not take place in the
uterus the fetus must obtain oxygen and excrete carbon dioxide
through the placenta.
 Nutrition –
 Food for the fetus derives from the mother’s diet and has already
been broken down into forms by the time reaches the placenta
site.

The placenta is able to select those substances required by the
fetus, even depleting the mother’s own supply in some instances.
 Storage –
 Metabolizes glucose and can also stores it in the form of
glycogen and reconverts it to glucose as required.
The placenta store iron and the fat soluble vitamins.

 Excretion
The main substance excreted from the fetus is carbon dioxide;
bilirubin will also be excreted as red blood cells are released
relatively frequently.
 Protection –
 It provides a limited barrier to infection with the exception of
the treponeona of syphilis and, few bacteria can penetrate.
 Viruses, however, can cross freely and may cause congenital
abnormalities as in the case the rubella virus and HIV virus.

 Endocrine –
 Human chorionic gondotroghin (HCG) is produced by the
synicytotrophoblast layer of the chorionic villi.

The placenta is completely formed and
 functioning from 10weeks after fertilization.
 Between 12 and 20 weeks gestation the placenta weighs
more than the fetus.
 Fetal blood, low in oxygen, is pumped by the fetal heart
towards the placenta along the umbilical arteries.
 Having absorbed oxygen the blood is returned to the fetus
via the umbilical vein.

 The placenta measures about 20 cm in diameter and 2.5cm
thick from its center.
 It weighs approximately one sixth of the baby’s weight at term.
 It has two surfaces.
1. Maternal surface
2. Fetal surface

1. The maternal surface
 maternal blood gives this surface a dark red colour and part of
the basal decidua will have been separated with it.
 The surface is arranged in about 20 lobes which are separated
by sulci

2 The fetal surface.
 The amnion covering the fetal surface of the placenta
gives it a whitish, shiny appearance.
 Branches of the umbilical veins and arteries are visible and
spreading out from the insertion of the umbilical cord
which is normally in the center.
 Chorion – Outer layer adhere to the uterine wall.
 Amnion -The inner layer of the amniotic sac containing
an amniotic fluid and cover the fetal surface of the
placenta and are what give the placenta its typical shiny
appearance.

The total amount of amniotic fluid is about 1 litter and
diminished to 800ml at 38 weeks of gestation (term).
 If the total amount exceeds 1500 ml, the condition is known as
polyhdramnous and
 If less than 300ml it is known as oligohydraminios.
 It constitutes 99% water and the remaining 1% is dissolved
organic maters including substances and waste products.

Functions of amniotic fluid
Allows for free movement of the fetus.
Protects the fetus from injury.
Maintains a constant temperature for the fetus
During labour it protects the placenta and umbilical cord from
the pressure of uterine contraction
Aids effacement and dilation of the cervix

The umbilical cord or funis extends from the fetus to the
placenta and transmits the umbilical blood vessels, two arteries
and one vein.
These are enclosed and protected by Wharton’s jelly, (a
gelatinous substance formed from mesoderm).
The whole cord is covered in a layer of amnion continuous with
that covering the placenta.
The length of the average cord is about 50cm.
A cord is considered to be short when it measures less than
40cm.

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.

There are four temporar y structures
•Ductus venosus: This vessel carries oxygenated blood from the
umbilical vein to the inferior venacava.
•Foramen ovale an opening between the two atria of the fetal
heart.
•Ductus ar teriosus - connect the pulmonary artery to the
descending arch of the aorta.
•Hypogastric ar tery : These are branches of the internal iliac
artery. They return impure blood back to the placenta.

CIRCULATION
The umbilical vein - leads from the umbilical cord to the
underside of the liver carries blood rich in O2 & nutrients. But
before it reaches to the liver ducts venous gives off to join the
inferior venacava.
Here, there is a mixture oxygenated & deoxygenated blood from
the lower limp.
The blood enters the right atrium of the heart and 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.
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 umbilical arteries
 Hypogastric arteries, it branches off from the internal iliac
arteries.

When the hypo gastric arteries reach to placenta joins the
umbilical cord & becomes the two umbilical arteries.
 Hypo gastric arteries are the only artery which carries unmixed
blood.

At birth the baby takes breath & blood is drawn to the lung
through the pulmonary arteries & returned by the pulmonary
vein to left atrium.
And the placental circulation ceases after birth & less blood will
return to right side of heart.
 In this way the pressure in the left side of the heart is greater
than the right side of the heart which causes closure of foramen
ovale then flow of blood from right side to left side of heart
will be stopped.

The cessation of the placental circulation results in the collapse
of umbilical vein, Ductus venous & Hypogastric arteries.
These vessels after collapse changes to the following structure.

The umbilical vein  The ligamentum teres
The Ductus venousus  The ligamentum venosum
The Ductus arteriosus  The ligamentum arteriosum
The foramen ovale  The fossa ovalis
TheHypogastric arteries  the obliterated Hypogastric arteries

• Defn: - Antenatal care is a medical( treatment of anemia,
HTN, STD) and general care(psychological) that is provided
to a woman during her pregnancy.

To promote & maintain good health of the mother & fetus
during pregnancy.
To ensure that the pregnancy results in a healthy infant &
healthy mother.
To detect early & treat appropriately ‘high’ risk conditions
(medical or obstetrical).
To prepare the women for labor, lactation & the subsequent
care of the baby.

Gravidity – refers to the number of Pregnancy
 Primigaravida - a woman pregnant for the first time.
Multig ravida - a woman who has had two or more
pregnancies.
 Parity - Refers to delivery above 28 weeks of gestation.
Nulipara - a woman who has not given birth to a child.

• Multipara - a woman who has given birth two times or more.
• Grand multipara - women who has given birth five or more
children
• Lie - is the relationship of the long axis (spine) of the fetus to
the long axis of the mother’s uterus.
 There are 3 lies:
-longitudinal --normal
-Transverse --Abnormal
-Oblique

• Attitude: is the relationship of the fetal parts to one another,
(head & limp to its trunk),
 There are 3 attitude;
-Flexion -- normal
- Extension --Abnormal
-Military ordeflection

• Presenting par t - is the part of the fetus felt at the lower
pole of the uterus & felt on abdominal examination and on
vaginal examination.
• Presentation - is the part of the fetus in the lower pole of the
uterus & the normal presentation is vertex,

 abnormal presentations are ;
 Breach
 Face
 Brow &
 Shoulder

Breach
153

Face
vertex Brow
154

Shoulder
155

• Position: is the relationship between the denominators of the
presentation to the six areas of the mother’s pelvis ( pelvic brim
land marks).
 Normal position is Occcipito anterior but abnormal
(Malposition) is Occcipito posterior position

Occcipito anterior Occcipito posterior
157

• Denominator-The part of the fetus which determines the
position
Vertex - Occiput
Breech - Sacrum
Face - Mentum
Brow – glabella
Shoulder – scapula

• Positions of ver tex presentation.
 Left Occipito anterior (LOA) - the occiput points to
the left Iliopectineal eminence. The sagital suture is on the
right oblique diameter.
 Right Occipito anterior (ROA) - the occiput points
to the right Iliopectineal eminence. The sagital suture is in
the left oblique diameter of the pelvis.

 Left Occipito lateral (LOL) - The occiput points to the
left Iliopectineal line mid way between the Iliopectineal
eminence & the sacroiliac joint. The sagital suture is in the
transverse diameter.
 Right Occipito lateral (ROL) - The occiput point to the
right Iliopectineal line midway between Iliopectineal eminence
& Sacro iliac joint. The sagital suture is in the transverse
diameter of the pelvis.

 Left Occipito posterior (LOP) –
 The occiput points to the left sacroiliac joint.
 The sagital suture is in the left oblique diameter of the pelvis.
 Right Occipito posterior (ROP) –
 The occiput point to the right sacroiliac joint.
 The sagital suture is in the right oblique diameter of the pelvis.

 Direct Occipito anterior (DOA) –
 The occiput points to the symphysis pubis.
 The sagital suture is in the anterior posterior diameter of the
pelvis.
 Direct Occipito posterior (DOP) –
 The occiput points to the sacrum, the sagital suture is in the
anterior posterior diameter of the pelvis.

• Engaged - When the biparietal diameters of the fetal head
passes through the pelvis brim.

There are two different models of ANC:
1. Traditional or standard or western model
2. WHO ANC model

 This type of model is recommended for pregnant mother by
dividing those mothers in to two categories depending on
different features
Risk group
Non-risk group

This model is focuses on disease prediction rather than disease
detection.
 In addition to the above issues the model is also planned a
number of subsequent visits to allow accurate dating of
pregnancy and appropriate preventive and therapeutic
interventions.

The frequency and timing of western ANC model is;
1st visit ---as early as the first missed period.
Thereafter, subsequent visits are planned every 4 weeks until
28 gestational weeks.
Every 2 weeks b/n 28-36 gestational weeks.
Every weeks after 36 gestational weeks.

 It is also named as focused antenatal care model.
 The main thing here is that disease detection rather than disease
prediction.
 It limits the number of visits and restricts laboratory tests and
procedures.

Focused ANC recommends a minimum of four visits:
1st visit---takes place at 16 gw or before.
2nd visit--- planned b/n 24-28 gw.
3rd visit--- planned b/n 30-32 gw.
4th visit---at 36-38 gw.

Major activities are:
 Diagnosis of pregnancy and determination of the gestational
age;
Risk assessment and determination of the medical status of the
mother;
 Health promotion by education on nutritional supplement,
danger signs of pregnancy and
Finally care provision like malaria prophylaxis, control MTCT
of HIV, iron supplementation and immunization with tetanus
toxoid.

• Major activities are;
 Screening for hypertension, multiple gestation, anemia, preterm
labor, diabetes mellitus and RH sensitization;
 Further health promotion and care provision and
 Plan birth place.

 Screening for hypertension, anemia, multiple pregnancy,
diabetes mellitus and RH sensitization;
 Health promotion and care provision and
 Plan birth place.

 Screening for hypertension, APH, multiple gestations;
 Check for fetal lie, presentation, growth and well being;
 Health promotion and care provision and
 Finally up date individualized birth plan.

I. Assessment
II. Health promotion
III. Care provision
Assessment contains:-
History
Physical examination &
Laboratory investigations

1.Identification
 Name
Age
Marital status
address
Religion
occupation
Date of admission
Ward and bed number

2. Chief complaints
 Patients may have come for routine ANC follow up or may
come with one or more specific complaints with its duration.
 E.g. amenorrhic for the last 2 months.
lower abdominal pain for the last 3days.
vaginal bleeding for the last 2 days.

3.Histor y of present pregnancy
Get information on the following points:
• Gravidity
• Parity
• abortion
• Last menstrual period(LMP)

• Expected date of delivery(EDD)
 w/c could be calculated by:
a) Naegale’s rule(using European calendar)
 LNMP-3onths+7days
b) Ethiopian calendars
NLMP+9months +10days if pagume is not passed
NLMP+ 9months+5 if pagume is passed

• Gestational age
 w/c is calculated by :
 subtracting NLMP from date of admission and put the
result by weeks and days.
• fetal quickening
• Presence of ANC else where ,place and number of visits
• Elaboration of chief complaints

• Danger symptoms of pregnancy like:
 Vaginal bleeding
Severe headache
Blurring of vision
Epigastric or severe abd.pain
Profuse v/discharge
Absence or reduction of fetal mov’t
Fever
Persistent vomiting

• Common complaints of px.(minor symptoms)
• Pregnancy –unwanted, unplanned and unsupported

Should be asked for all previous px:
• Date, month and year of gestation
• Length of gestation
• Significant antenatal medical problems like:
HPN,APH,DM…
• Onset of labour(spontaneous or induced)
• Fatal presentation
• Duration of labour
• Mode of delivery
• Fetal out come
• Post partum complications like:BPy APlemHyehu T March 22-2014 185

 FP methods -use, type, duration and side effects
 Sexual history-assess risk of STI and HIV/AIDS
Gynaecology operations-FGM, laparotomy, dilatation and
curettage and manual vacuum aspiration.
 Menstrual history(age of menarche, interval of period 21-36
days, amount of flow 10-80ml,duration of flow 1-8 days,
normally dark red and non-clotting)

 Blood transfusion important in haemolytic disease of new born
Drugs risk of teratogenicity or allergic rxns.
 Hx of DM ,HPN, hypo or hyperthyroidism w/c may the
affect px or get aggravated by px.
 Maternal infection-TORCH syndrome

 Childhood dev’t
 Educational status
 Habits like alcohol, smoking and elicit drugs
Occupation-exposure to radiation, anaesthesia, chemical
factory and others
 Income-low socio-economic status associated with obstetric
problems like preeclampsia, preterm labour
 Family history-DM, HPN, multiple px, genetic disorders
8.Review of systems
• Check all systems

 Examination must be done in private room.
 Proper explanation must be offered to the patient before,
during and after the examination.
 Bladder should be emptied and the patient properly positioned
on the couch.
Warm hands and instruments must be used.
 Adequate light, appropriate gloves and swabs should be
prepared.
 Always keep eye contact throughout the examination.

1. General appearance
• As she walks in, observe any deformity, stunted growth
• Does she look well or pale & tired?
2. Vital signs and anthropometric measurements
• Blood pressure
- Check and record at each visit
- Relative rise of 30 mmHg systolic of 15 mmHg diastolic is
one of the early signs of pre -eclampsia

• Pulse rate -increases 10-15 beats/minute in
pregnancy
• Respiratory rate -increases 1-4 breath /minute in
pregnancy
• Weight – increment 12kg/pregnancy

3. HEENT
• Emphasis on conjunctiva, sclera, teeth and buccal mucus
membrane to see pallor, jaundice, mucosal congestion and
dental carries.
4. Lymphoglandular system
• Thyroid gland for hyper or hypo thyroidism signs

5. Breast examination
 Asses the size of any lump in the breast by dividing into four
quadrant and find any mass starting from QI-IV by your
dominant fingers and supporting with the another hand
 Asses for nipple refraction, pigmentation, lumps, discharge,
colour discharge.
 Nipples are inverted or flat ,if the nipple are flat tell the
mother to roll several times a day
 Teach the mother self examination of the breast

• Steps in examination are essentially same as non pregnant
patient

AIMS
• To estimate the size of the uterus/fetus
• To find out lie /presentation
• To asses fetal health/fetal heart sound FHB)
• To diagnose the location of the fetal parts
• To detect any deviation from normal

Steps for abdominal examination
– Inspection
– Palpation
– Auscultation

• Shape
– Note contour is it round oval irregular or pendulous
– Longitudinal ovoid in primigaravida
– Round in multi gravida(a big round uterus may be due to
multiple pregnancy transverse lie ,hydroaminions or
obesity)
– Broad in transverse lie
• Size
• should correspond with the estimated period of gestation

• Skin- the dark line which is linea nigra- midline hyper
pigmentation due to melanocyte stimulating hormone .
• stirae gravidarum- purplish in new Striae and white in old
Striae. In both cases is due to distension, which causes
stretching.
• Scar any operation scar (c/s)

• Superficial palpation – checks for rigidity, tenderness,
superficial mass and characterize it ,abdominal wall defects.
• Deep palpation – palpate for mass, organomegaly and
characterize the mass
• Obstetric palpation or Leopold’s maneuver

A. The first Leopold maneuver or fundal palpation
I. Fundal height measurement:
• first correct for asymmetry before measurement.
• Then use one of the following methods:
 Finger method – one finger above umbilicus is equal to two
weeks and below umbilicus one finger is equal to one week.

• Uterus felt at symphysis corresponds to 12 weeks.
• At the umbilicus it is 20 weeks and at xiphysternum it is 38
weeks.
Tape measurement: symphysis to fundal height in
centimeter with tape meter between 18-34 weeks is accurate to
within two weeks of actual gestational age.

 Is assessment and monitoring the fetal behaviors and well
being
 It is offered to detect early signs of uteroplacental
insufficiency and hypoxia.
Methods of antenatal fetal assessment
 Clinical method /fetal movement
 Ultrasound
 Bioelectrical method
 Biophysical profile
 Biochemical profile

 The mother asked to count the fetal movement
 First quickening of the fetus is recognized at 18-20 weeks in
primigravida and at 16-18 weeks in multigravida
 The fetal movement is accepted if it is ≥6 kicks/2hours or 2-3
kicks/hour
 If <6 kicks,the mother is asked to :
 Eat/drink
 Change her position
 Go to quite room and count for another 2 hours

 D –death of fetus
 A-amniotic fluid decreased
 S –sleep
 H –hunger/thrist
Fetal movement is good indicator of placental function

Estimation of gestational age
 Done in first trimester(best between 8-12 weeks)
 Measurement of crown-rump-length (CRL) error-±3 days
Nuchal translucency u/s
 Done at 11th -14th weeks gestation
 Measures the amount of amniotic fluid behind the
neck of the fetus
 Used for screening fetal abnormalities. ex Down’s
syndrome

Fetal g rowth and anatomy
 Routinely done 18th -20th weeks (error-7days)
Routine 2nd trimester us
 Done 18th -22th weeks
 Helps to determine numbers fetus,gestation,location of
placenta ,fetal anomalities

Non-stress test (NST) ;external Doppler used to record
the fetal heart rate and its relationship to fetal movement
 The is no stress applied on fetus;so it is called NST
 Indication ;any suggestion of utroplacental insufficiency
 There are two scales NST chart:
 Upper chart –record FHR and lower chart –record uterine
contraction

 Characteristics of normal FHR
 Hear t rate: (100-180) hospital setting
 Heart rate (120-160) health center setting
 Variability: due to the effects of vagus nerve
 Shor t term variability ; from beat to beat
 Long term variability ; fluctuate over 1’
 Decreased variability ; >40’,need to assess the
fetal well being

 Acceleration ; it is increases of FHR above base
line
 It may occurs in response to fetal movement
 Normal acceleration in 20’is atleast acceleration
wich is bpm above base line ,lasting for ≥15”
 If all previous parameters are normal and called
reactive NST ;if not;it is called non reactive
NST
 The test done at 28th week

Contraction stress test ;demonstrate the
relationship between the FHR and uterine
contraction
 It is done when hypoxia suspected after NST
 In this test,the uterine contraction are
stimulated drugs /manipulation of nipple
 Normally ;there is no change in the FHR
 If there is late deceleration ;indicates placental
insufficiency
 If there is variable deceleration;indicates cord
compression

 It consists of a 30’ assessment of fetus
 The following parameters are recorded using
U/S
 Amniotic fluid volume
 Fetal breathing
 Fetal movement
 Fetal tone

 Indications :it is the test of choice for
 Non-reassuring NST
 Post term pregnancy
 Decreased fetal movement
 Any suggestion of fetal distress/
Uteroplacental insufficiency

Parameters Normal points(2) Abnormal (0)
1.Amniotic
Fluid pocket ≥2 ≤2
fluid volume
2.Breathing Atleast one episode
lasting for 30”
No breathing
3.Movement Atleast 3 movement of
trunk/limb
No movement/≤2
4.Tone Atleast one episode limb
extension followed by
flexion
No movement

 The total sum points for the parameter is
calculated :
 8 points ;normal fetus and BPP
 6 points;border line
 4-0 points urgent inter vention needed
NB:Maternal hypoglycemia may affect the results
of BPP

Triple marker screen
 Done in 2nd trimester (15th -20th weeks)
 Used to detect trisomy 21(Down’s syndrome),
trisomy 18(Edward’s syndrome), trisomy
13(Platau syndrome
March 22 By Alemyehu T -2014 215

Quadruple marker screen
 The 3 markers of triple serum screen +inhibin A
 This increases the rate of detection of Down’s syndrome
up to 80%
 Surfactant is a phospholipids consists of
lecithin$sphingomyelin

 These phospholipids can be measured in amniotic fluid
 The surfactant is good when the ratio of
lecithin/sphingomyelin >2
 Moreover ;presence of phosphatidyl-glycerol and
phosphatidyl-choline indicates lung maturity

uterine Doppler
 measures the blood flow in vessels using US
 It is used to assess the blood flow in to umbilicus ,uterus
and brain
 Useful to detect the conditions impairing the blood flow to
the placenta or fetus eg. HTN, Preeclampsia ,smoking
etc…
 these disease may result in IUGR & there fore US is useful
to detect impairment of blood fetus

contents
 Over view
 Effects of pregnancy on the course of HIV
 Effect of HIV infection on pregnancy
 Estimated risk of MTCT of HIV
 Factors affecting MTCT of HIV
 Interventions to prevent MTCT of HIV

 Introduction:?
◦ According to the calibrated single point estimate (2011),
the national adult HIV prevalence is reported to be 1.5
% (4.2 % in urban and o.6% in rural areas).
◦ 1,216,908 Ethiopians are living with HIV AIDS (41%
male, 59% females).
◦ An estimated 38,404 HIV positive pregnant women are
anticipated in 2012.

◦ Highest prevalence occurs with 30 – 34 years of age
group and prevalence is higher among females than males,
both among urban and rural areas.
◦ Prevalence appears to have leveled in urban areas but
continued to rise in rural areas, where 85% of population
l

 Of 40 million people living with HIV/AIDS worldwide,
17.5 are women (2009)
 77% of all women living with HIV are in sub-Saharan
Africa (2009)
 Among HIV positive adults, women account for 57% in
sub-Saharan Africa, 26% in southeast Asia, 27% in
Europe, and 25% in the US (2009)

 Biological
 Economic
 Social
 Cultural
“Women are most vulnerable to HIV infection, given the
social and economic disadvantages they face in their day to
day lives.”

 80 % of HIV infected women are of childbearing age
 Possible route of HIV transmission
I. sexual contact
II. parentral exposure to blood and body fluid.
III. from mother to child
antepartum
intrapartum
post partum

 Pregnancy itself does not affect the outcome of HIV
infection unless in late stage
 Progression from asymptomatic infection to AIDS is
uncommon in pregnancy
 So, the existence of a short term synergistic effect on the
immune system between pregnancy and HIV infection is
not supported

 spontaneous abortion
 ectopic pregnancy
 preterm labor
 abruptioplacentae
 low birth weight baby
 stillbirths
 postpartum infectious complications,
particularly after C/S.
 MTCT

 PMTCT is a term used to describe a package of services
intended to reduce the risk of mother-to-child transmission
of HIV.
 With out intervention the risk of MTCT is 20-45%

Estimated Risk of MTCT
Timing
Transmission Rate Without
Any Interventions
During pregnancy 5-10%
During labor and delivery 10-15%
During labor and delivery 5-20%
Overall without breastfeeding 15-25%
Overall with breastfeeding to six months 20-35%
Overall with breastfeeding to 18-24 months 30-45%

 Viral Load
◦ The higher the viral load, the higher the risk of MTCT
 Lower risk through:
◦ Use of ART during pregnancy and postpartum to
mother and newborn
◦ Adequate nutrition, particularly vitamin A?

 Maternal factors increasing risk:
◦ Viral or parasitic placental infection (especially malaria)
◦ Becoming infected with HIV during pregnancy
◦ Severe immune deficiency
◦ Advanced clinical and immunological state
◦ Maternal malnutrition

 Labor and delivery factors increasing risk:
◦ Prolonged rupture of membranes (>4 hours)
◦ Injury to birth canal during child birth
◦ Antepartum procedures
◦ Acute chorioamnionitis
◦ Invasive fetal monitoring
◦ Instrumental delivery
◦ Mixing of maternal and fetal body fluids
◦ Delayed infant cleaning and eye care
◦ Routine infant airway suctioning

 Primary prevention of HIV in childbearing women
 Prevention of unintended pregnancy in HIV-positive
women
 Prevention of transmission from HIV+ women to
their infants
 Treatment, care and support of women infected
with HIV, their infants and their families

 Health education
 Screening for anemia and micronutrient supplementation
 Screen and treat STDs in pregnant women
 Malaria chemoprophylaxis
 Family planning counseling
 Screen for TB
 Reduce maternal viral load using currently recommended
regimens of antiretroviral drugs.(option B+)
 History , examination and investigations in each ANC visits

 Routine counseling for all
 VCT
 ARV
 Infant feeding counseling
 Referral for care and support
 Comprehensive package of care (ANC, delivery and
postnatal care, child care, family planning)
 Male partner involvement strategy
 Community mobilization
 Support group
 Written implementation protocols

Mothers in need of ART for their own health should get
lifelong treatment
Initiate ART in pregnant women with CD4<350
regardless of clinical stage
Initiate ART in clinical stage 3 and 4 if CD4 not available
Start ART as soon as feasible
Importance and critical need of CD4 for decision-making
on ART eligibility

Option A Option B
Mother
• Antepartum AZT (from 14 weeks)
• sd-NVP at onset of labour*
• AZT + 3TC during labour & delivery*
• AZT + 3TC for 7 days postpartum*
Infant
Breastfeeding population
•Daily NVP (from birth until one wk after
all exposure to breast milk had ended)
Non-breastfeeding population
•AZT for 6 weeks OR
•NVP for 6 weeks
Mother
• Triple ARV (from 14 wks until one
wk after all exposure to breast milk has
ended)
• AZT + 3TC + LPV-r
• AZT + 3TC + ABC
• AZT + 3TC + EFV
• TDF + XTC + EFV
Infant
All exposed infants
• AZT for 4-6 weeks OR
• NVP for 4-6 weeks

During pregnacy
TDF/3TC/EFV
Continue HAART if already initiated
During delivery and labor
if HAART continue
women present for the first time start TDF/3TC/EFV
women who are in option A will be transitioned to
OPTION B PLUS

 Lactating and post partum
 continue ART if started
 initiate ART if not on treatment
 if women was in option A treatment change to OPTION B
plus
Infant
NVP for six weeks post partum

 Follow recommended infection prevention practices
◦ Wash hands thoroughly before and after each procedure
and examination
◦ Wear hand and eye protection
◦ Handle needles and other sharp instruments safely
◦ Dispose placenta and other waste materials and supplies
properly
◦ Process instruments, gloves and other items by
decontamination, cleaning and either sterilization or
high-level disinfection

Minimize vaginal examination
Use partograph to monitor labor
AVOID
Routine rupture of membranes
Prolonged labor
Unnecessary trauma during childbirth
Minimize risk of postpartum hemorrage
Use safe transfusion practice (blood screened for HIV,
Syphilis,malaria,hepatitisB and C when possible

 We need to follow the mother
 Clean genitalia with savlon
 Avoid invasive procedure like( episiotomy ,vacuum or
forceps)

Elective caesarean section
Consider elective caeserean delivery when safe and
Feasible
Done before the onset of labor or membrane rupture
Do C/S if there is active HSV

 Cesarean section before onset of labor and membrane
rupture decreases risk of MTCT 50–80%
 No evidence of benefit after onset of labor or
membrane rupture

 Special concerns with cesarean section in limited-resource
settings
◦ Increased maternal morbidity and possible mortality
◦ Availability of blood and blood safety
◦ Antibiotic prophylaxis
◦ Anesthesia availability
◦ Limited human resources — nursing care time

 Cut cord under the cover of gauze
 Determine mothers feeding choice
 Administer vitamin k
 Administer the first vaccines
 Do not
-suction unless meconium stained liquor is
present

 Tenascin-C is an innate broad-spectrum,HIV-1 –
neutralizing protein in breast milk.
 TNC is directed against the virus and not the target cell
 TNC concentration range of 2.2–671 μg/mL
 TNC was able to block up to 66% of infectious

 Monitoring adherence
 Follow up
 Grading and managing adverse effect
 Managing drug –drug interaction
 Giving preventive service
 Nutritional support

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