Pregnancy Presentation

pregnancy
Maka Chikovani, MD
Department of Obstetrics and
Gynecology, TSMU Aladashvili
University Hospital
Objectives:
• Reminder of physiology of pregnancy
• early embryogenesis, placenta, placental
development and its functions,
• amniotic fluid, umbilicus and afterbirth,
• fetus development stages
• Labor and delivery
By the time a woman reaches puberty
each of her ovaries contains about
200 000 primary oocytes, enclosed in
primordial follicles. Each oocyte is
separated from the cellular primordial
follicle by a clear area, the
perivitelline space and a thickened
“shell”, the zona pellucida.
4.Pre-antral follicle
5.Each primordial follicle is capable of
growing under the influence of follicle
stimulating hormone (FSH) to form a
mature follicle. Each month from about
the age of 15 to the age of 45, some 20
of the primordial follicles grow through
the stage of vesicular follicles to
become mature antral follicles.
6.Graafian follicles
7.Structure of an Ovary
8.Physiology of pregnancy
In contrast to other body cells, the

oocyte has only 23 chromosomes. At
some stage of its growth the oocyte
undergoes a meiotic division of its
nucleus and an unequal division of its
cytoplasm, to become a secondary
oocyte.
With the release of luteinizing hormone

(LH) surge by the pituitary, at mid-cycle,
the follicle bursts expelling the ovum,
which is gathered into Fallopian tube by
the fimbria which project from its
proximal end
Once the ovum has been expelled, the

follicle collapses and turns yellow,
forming the corpus luteum. The ovum
is now ready to be fertilized should a
sperm reach it.
Fertilization
Of the 60-100 million sperm ejaculated

into a woman’s vagina at the time she
ovulated, several million will negotiate
the helical channels in the cervical
mucus to reach the uterine cavity.
12.A sperm cell fertilising an ovum
13.Fertlization
Several hundred sperm may pass through the

narrow entrance to the Fallopian tubes, and a
few will survive to reach the ovum in the
fimbrial end of the Fallopian tube. One sperm
may penetrate the zona pellucida of the ovum,
its head entering the substance of the ovary.
14.FERTILIZATION
15.Fertilization and conception
Once inside the cytoplasm of the ovum, the

sperm’s nuclear membrane dissolves, leaving a
naked male pronucleus. The ovum, having
divided to produce a second polar body, also
loses its nuclear membrane. The two naked
nuclei approach each other and fuse.
Fertilization and conception have occurred.
16.Fertlization and conception
Within a few hours of fertilization, the

fused nuclei divide to form two cells.
Once this event has occurred, further
cell division proceeds rapidly until within
3 to 4 days a solid mass of cells (the
morula) has formed.
17.Ovum Fertilization and Zygote Cleavage
18.Ovum Fertilization and Zygote Cleavage
The morula is rapidly propelled along the

Fallopian tube to enter the uterine cavity.
During its passage, fluid passes through
canaliculae in the zona pellucida to create a
central fluid-filled cavity in the morula,
forming a blastocyst.
19.Ovum Fertilization and Zygote
Cleavage
20.Fertilization
21.Implantation of the Blastocyst
On reaching the uterine cavity the zona

pellucida becomes distended and thin. It soon
disappears leaving the surface cells of the
blastocyst in with the endometrial stroma.
22.Implantation of the Blastocyst
About 50 per cent of blastocysts adhere to the

endometrium. The surface trophoblastic cells
of the adhering blastocyst, differentiate into
an inner cellular layer, the cytotrophoblast,
and an outer syncytiotrophoblast.
23.Implantation
By the 10th day after fertilization,

the knobs of trophoblastic tissue
have developed a mesodermal core
and have pushed deeply into the
endometrial stroma
24.Embryonic Development after Implantation
Early Trophoblast Invasion
By the 9th and 10th day after fertilization a

number of deep cells at one pole of the
blastocyst differentiate to become an inner
cell mass now called the embryonic disc.
Early Trophoblast Invasion
Between the embryonic disc and the

trophoblast, some small cells appear
that soon enclose a space that will
become the amniotic cavity.
26.EMBRYONIC DEVELOPMENT AFTERBREAK
IMPLANTATION
27.EMBRYONIC DEVELOPMENT AFTERBREAK
IMPLANTATION
Lacunae Formation Within the Syncytiotrophoblast
As the embryo enlarges, more maternal

(deciduas basalis) tissue is invaded and the
walls of the superficial endometrial-decidual
capillaries are eroded; the result is the
maternal blood enters the fluid-filled space-
the lacunae.
Development of Primary Villous Stalks
With deeper burrowing and blastocystic

invasion into the deciduas, the trophoblastic
strands branch to form the solid primitive villi
that traverse the lacunae. Originally located
over the entire blastocyst surface, the villi
later disappear except over the most deeply
implanted portion, which is the site destined
to form the placenta.
The diameter of the 12-day embryo is almost

1 mm. The mesenchymal cells within the cavity
are most numerous about the embryo, where
these eventually condense, to form the body
stalk that serves to join the embryo to the
nutrient chorion and later develops into the
umbilical cord.
During the third week after fertilization the

primitive streak becomes a prominent
structure, and cephalic and caudal ends of the
embryo become distinguishable. As cells
proliferate rapidly and spread laterally from
the primitive streak, a midline primitive
groove develops.
Simultaneously, the yolk sac enlarges, and hence

the embryonic disc is spread out upon it. A
well-defined body stalk into which a narrow
endodermal diverticulum, the allantois, has
extended.
As the neural folds develop, the underlying

lateral mesoderm is divided into discrete
blocks, the somites, which give rise to the
skelet and connective tissues, the muscles,
and the dermis.
The primordium of the heart already has
appeared, during the third week the heart
develops and links up with a primitive vascular
system.
During the fourth week the gut has formed. By

the end of the fourth week after fertilization
the chorionic sac measures 2 to 3 cm in
diameter, and the embryo about 4-5mm in
length. The heart and pericardium are very
prominent because of the dilatation of the
chambers of the heart. Arm and leg buds are
present.
And by the six week a urogenital sinus has

formed. At the end of the six week the
embryo is 22 to 24 mm in length, and the
head is quite large compared with the trunk.
Fingers and toes are present, and the
external ears form definitive elevations on
either side of the head.
By the eighth week after fertilization, most
of the organs have formed and the embryo
becomes a fetus. At this time the embryo is
nearly 4 cm long.
Placenta.
Placental Development and
Functions
37.Placental Development
38.Placental Development
39.Placenta. Placental Development and
Functions
The placenta acts for the fetus as:
• an organ of respiration
• an organ of nutrient transfer and excretion
• an organ of hormone synthesis
• it may act as an immunological barrier
protecting the fetus (formed from paternal
as well as maternal genes) from rejection by
the mother’s immune system
Functions
Transport of substances through the placenta takes
place by:
1. Passive transport a. simple diffusion

b. facilitated diffusion
2. Active transport a. enzymatic reaction

b. pynocytosis
41.Transfer of substances through the placenta
Maternal blood Intervillous Placental transfer methods
space
Passive Active Pynocytosis
H2O, O2, CO2, Na, K, urea → +
Glucosae Fascilitated by +
carrier
molecule
Polysaccharids Mono- and di- +
saccharids
Protein → Aminoacids +
Fat → Free fatty acids +
Vitamin A → Carotine +
Vitamin B complex → +
Vitamin C
Iron, phosphorus → +
Antibodies Only IgG + +
Erythrocytes → +, - +
Functions
Respiration functions of the placenta

Functions
Nutrient transfer
Functions
Drugs transfer through the placenta

Functions
Hormone synthesis. The main hormones

produced are:
• human chorionic gonadotrophin
• human placental lactogen
• estrogen
• progesterone
46.Amniotic Fluid
Amniotic fluid is secreted into the

amniotic sac by the amniotic cells which
lie over the placenta. The fluid filling
amniotic sac serves several important
functions.
47.Amniotic Fluid
This fluid is 99 per cent water and

increases in quantity during pregnancy.
The amniotic fluid increase rapidly to an
average volume of 50 ml at 12th week of
gestation and 400 ml at midpregnancy;
it reaches a maximum of about 1000ml
at 36 to 38th week of gestation.
48.Umbilical cord
A normal umbilical cord is 45-60cm long,

but extremes of 200cm and 2cm have
been recorded. The umbilical cord
usually contains one vein and two
arteries set in Wharton’s jelly.
49.Fetus. Placenta. Amniontic Sac.
Umbilical Cord
50.Fetus development stages
The end of the embryonic period and the

beginning of the fetal period are
arbitrarily designated by most
embryologists to occur 8 weeks after
fertilization. At this time, the embryo is
nearly 4 cm long.
Twelve gestational weeks. By the end of

the12th week of pregnancy, the crown-rump
length of the fetus is 6 to 8 cm;
• the fingers and toes have become
differentiated;
• early fingernail development;
• scattered rudiments of hair appear;
• and the external genitalia are beginning to
show definite signs of male or female sex.
Sixteen gestational weeks. By the end of 16th

week, the crown-rump length of the fetus is
12-14cm, and it weighs about 110 g.
• By careful examination of the external genital
organs, the sex of the fetus can be
identified;
• head erect;
• ears stand out from head;
• lower limbs are developed.
Twenty gestational weeks. The end of the

20th week is the midpoint of pregnancy or
gestation as estimated from the time of the
last normal menstrual period. The fetus now
weighs somewhat more than 300 g.
• The fetal skin become less transparent, a
downy lanugo covers its entire body
• and some scalp hair is visible;
• vernix caseosa present;
• early toenail development
Twenty-four gestational weeks. By the end of

the 24th week, the fetus weighs about 630g
• the skin is characteristically wrinkled, and
fat is deposited beneath it.
• The head is still comparatively quite large;
• eyebrows and eyelashes are usually
recognizable.
• A fetus born at this period will attempt to
breathe;
Twenty-eight gestational weeks. By the end of

the 28th week, a crown-rump length of about
25-27 cm is attained and the fetus weighs
about 1100 g.
• The thin skin is red and covered with vernix
caseosa.
• The papillary membrane has just disappeared
from the eyes.
Thirty-two gestational weeks. At the end of

32 gestational weeks, the fetus has attained
a crown-rump length of about 28-30 cm and a
weight of about 1800 g.
• The surface of the skin is still red and
wrinkled.
• Fingernails and toenails present
Thirty-six gestational weeks. At the end of

the 36 weeks gestation, the average crown-
rump length of the fetus is about 32-34 cm
and the weight is about 2500 g.
• Because of the deposition of subcutaneous
fat, the body has become more rotund, and
the previous wrinkled appearance of the face
is lost.
Slide N58
Forty gestational weeks. Term is reached at

40 weeks after onset of the last menstrual
period.
• At this time the fetus is fully developed, the
average crown-rump length is about 36 cm,
and the weight is approximately 3400g.
• Prominent chest; breasts protrude.
• Testes in scrotum or palpable in inguinal
canals.
• Finger- and toenails reach finger and toe tips.
Slide N60
61. Maternal Physiology
• The anatomical, physiological, and biochemical

adaptations to pregnancy are profound.
• Many of these remarkable changes begin soon
after fertilization and continue throughout
gestation, and most occur in response to
physiological stimuli provided by the fetus.
• A basic knowledge of these adaptations is

critical for understanding normal laboratory
measurements, knowing the drugs likely to
require dose adjustments, and recognizing
women who are predisposed to medical
complications during pregnancy.
REPRODUCTIVE TRACT
• During pregnancy, the uterus is transformed into a relatively thin-
walled muscular organ of sufficient capacity to accommodate the fetus,
placenta, and amnionic fluid.
• The total volume of the contents at term averages about 5 L but may
be 20 L or more, so that by the end of pregnancy the uterus has
achieved a capacity that is 500 to 1000 times greater than in the
nonpregnant state.
• The corresponding increase in uterine weight is such that, by term, the
organ weighs approximately 1100 g.
• From the first trimester onward, the uterus

undergoes irregular contractions that are normally
painless.
• In the second trimester, these contractions may be
detected by bimanual examination.
• Until the last month of gestation, Braxton Hicks
contractions are infrequent, but they increase during
the last week or two. At this time, the contractions
may occur as often as every 10 to 20 minutes.
HEMATOLOGICAL CHANGES
• The modest fall in hemoglobin levels during pregnancy is caused
bya relatively greater expansion of plasma volume compared with
the increase in red cell volume.
• The disproportion between the rates at which plasma and
erythrocytes are added to the maternal circulation is greatest
during the second trimester.
• Late in pregnancy, plasma expansion essentially ceases while
hemoglobin mass continues to increase.
• Anemia is defined as hemoglobin

concentration less than12 g/dL in nonpregnant
women and less than 10 g/dL during pregnancy
or the puerperium.
• The leukocyte count varies considerably during

normal pregnancy. Usually it ranges from
5000 to 12,000/μL. During labor and the
earlypuerperium it may become markedly
elevated,attaining levels of 25,000/μL or even more,
however, it averages 14,000 to 16,000/μL .
COAGULATION. In normal pregnancy, the coagulation

cascade is in an activated state.
• During normal pregnancy, fibrinogen concentration
increases about 50 percent to average about 450
mg/dL late in pregnancy, with a range from 300 to
600 mg/dL.
• Fibrin-fibrinogen complexes circulate in normal
pregnancy, and d-dimer serum concentrations
increase with gestational age.
Urinary tract changes
• Kidneys are increasing in length by 1-1,5cm

• The ureters are dilated
• GFR increases
• Bladder vascularity increases and decreases
muscle tone
Normal Labor and delivery
• Labor -sequence of uterine contractions that
results in effacement and dilatation of cervix
• Delivery - mode of expulsion of the fetus and
placenta
DELIVERY (partus)- I
Pregnancy is not a disease, childbirth is

not a medical issue, pregnancy and
childbirth are important personal,
sexual, social events before be a
medical issue (WHO 1997)
Delivery (partus) – is a physiological
process which ends with the birth of a
newborn.
71
CAUSES OF DELIVERY START - I
Delivery – is a multifactor
process which mechanism is still
unclear.
72
CAUSES OF DELIVERY START - II
Fetal factors of regulation of the

initiation of delivery
- Fetal cortisol and other fetal steroids

- Fetal prostaglandin (E2) and oxytocin
73
CAUSES OF DELIVERY START - II
Nervous regulation of the initiation of

delivery
- Transformation of the dominant of
pregnancy to the dominant of delivery in
CNS.
74
CAUSES OF DELIVERY START - III
Hormonal regulation of the initiation of

delivery
- Increase of estrogens synthesis
- Decrease of progesterone synthesis
75
CAUSES OF DELIVERY START - III
Humeral regulation of the initiation of

delivery
- Prostaglandins E2 and F2α
- Oxytocin
- Serotonin
- Kinins
- Histamine
76
SIGNS PRIOR TO DELIVERY
Bulging umbilicus
Change parturient’s mood and sense
Decrease of movement activities of fetus
Loss of weight by 1-2 kg
Unregulated uterin contractions and pain in lower
abdomen and groin.
Discharge of a smoll amount of blood-tinged mucus from
the vagina.
Cervical ripening
77
preparation for Labor
• Lightening – settling of the fetal head into the
brim of the pelvis
• Braxton Hicks contractions – irregular, painless
uterine contractions
• Bloody show passage of a small amount of
blood –tinged mucus from the vagina
Stages of labour
• The first stage of labor – period of

cervical dilatation
• The second stage of labor – birth of the
baby
• The third stage of labor – fetal annex
period
79
references
• Williams obstetrics, 22nd edition
• Current obstetric and gynecologic diagnoses
and treatment, 10th edition 2007
• UpToDate

Pregnancy Presentation

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pregnancy

In contrast to other body cells, the

With the release of luteinizing hormone

Once the ovum has been expelled, the

Of the 60-100 million sperm ejaculated

Several hundred sperm may pass through the

Once inside the cytoplasm of the ovum, the

Within a few hours of fertilization, the

The morula is rapidly propelled along the

On reaching the uterine cavity the zona

About 50 per cent of blastocysts adhere to the

By the 10th day after fertilization,

By the 9th and 10th day after fertilization a

Between the embryonic disc and the

As the embryo enlarges, more maternal

With deeper burrowing and blastocystic

The diameter of the 12-day embryo is almost

During the third week after fertilization the

Simultaneously, the yolk sac enlarges, and hence

As the neural folds develop, the underlying

During the fourth week the gut has formed. By

And by the six week a urogenital sinus has

1. Passive transport a. simple diffusion

2. Active transport a. enzymatic reaction

Respiration functions of the placenta

Drugs transfer through the placenta

Hormone synthesis. The main hormones

Amniotic fluid is secreted into the

This fluid is 99 per cent water and

A normal umbilical cord is 45-60cm long,

The end of the embryonic period and the

Twelve gestational weeks. By the end of

Sixteen gestational weeks. By the end of 16th

Twenty gestational weeks. The end of the

Twenty-four gestational weeks. By the end of

Twenty-eight gestational weeks. By the end of

Thirty-two gestational weeks. At the end of

Thirty-six gestational weeks. At the end of

Forty gestational weeks. Term is reached at

• The anatomical, physiological, and biochemical

• A basic knowledge of these adaptations is

• From the first trimester onward, the uterus

• Anemia is defined as hemoglobin

• The leukocyte count varies considerably during

COAGULATION. In normal pregnancy, the coagulation

• Kidneys are increasing in length by 1-1,5cm

Pregnancy is not a disease, childbirth is

Fetal factors of regulation of the

- Fetal cortisol and other fetal steroids

Nervous regulation of the initiation of

Hormonal regulation of the initiation of

Humeral regulation of the initiation of

• The first stage of labor – period of

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