TOPNOTCH MEDICAL BOARD PREP OB SUPPLEMENT HANDOUT BY CHRISTOPHER JOSEPH SORIANO, MD For inquiries visit www.topnotchboardprep.co.nr or email us at
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OBSTETRICS SUPPLEMENT HANDOUT TABLE OF CONTENTS Maternal Anatomy Menstrual Physiology Fertilization Placenta Fetal Development Maternal Physiology Prenatal Care Postpartum Changes Postpartum hemorrhage Dystocia
1 5 9 10 11 13 19 22 25 25
VESTIBULE Functionally mature emale structure o the urogenital sinus o the embryo. Extends rom clitoris to orchette •
STRUCTURES IN THE VESTIBULE HYMEN Non keratinized Stratifed squamous epithelium During frst coitus, frst that ruptures is usually at the 6 o’clock position Caruncle Myrtiormes: Remnants o hymen in adult emale Periurethral Glands “ Skene’s Glands” GLANDUL AR Vulvovaginal Glands “Bartholin’s STRUCTU Glands” RES 6 Vaginal introitus OPENING Urethral opening S: Paired Para urethral glands opening Paired Bartholin ducts opening
MATERNAL ANATOMY
EXTERNAL GENITALIA SURFACE ANATOMY Structure Mons Pubis Labia Majora
Labi Labia a Min Minor ora a
Clitoris Vestibule Vestibule
Vestibular Glands Urethral opening Vestibular bulbs Vaginal opening/hyme n
escutheon 7-8 7-8x2-3 2-3x1-1. -1.5cm 5cm round ligaments terminate at their upper borders conn connec ecti tive ve tiss tissue ue with with many many vessels, elastin fbers, and some smooth muscle fbers points downward and inward toward the vaginal opening; rarely exceeds 2 cm unctionally mature emale structure derived rom the embryonic urogenital membrane perorated by six openings: urethra, the vagina, two Bartholin gland ducts, and two ducts o the Skene glands Bartholin glands, paraurethral glands (Skene glands diverticulum) minor vestibular glands lower two thirds o the urethra lie immediately above the anterior vaginal wall. 1 to 1.5 cm below the pubic arch lie beneath the bulbocavernosus muscle on either side o the vestibule vulvar hematoma. Hymenal caruncles Impreorate hymen
GLANDULAR STRUCTURES PERIURETHRA L GLANDS “ Skene’s glands” Lesser vestibular Other name glands Male Prostate homolog y Type of Tubulo Tubulo alveolar gland Location Adjacent to the urethra Patholog Urethral y diverticulum
DIFFERENCE OF LABIA MAJORA AND LABIA MINORA LABI LABIA A MAJ MAJOR ORA A LABI LABIA A MIN MINOR ORA A Scrotum Ventral Ventral portion HOMOLOGY o the penis Skin o the penis LINING Outer- KSSE NKSSE Inner- NKSSE EPITHELIUM Lie in close Not visible NULLIPAROU apposition behind the non S WOMEN Inner surace separated labia resembles the majora mucous membrane Gape widely Project beyond MULTIPAROU Inner surace the labia majora S WOMEN become skin like GLANDS (+) Hairollicles No hair ollicles (+) Sweat No sweat glands glands (+) Sebaceous (+) Sebaceous glands glands TOPNO PNOTCH TCH MEDI EDICAL CAL BOA BOARD PRE PREP OBST BSTETR ETRICS HANDOU NDOUT T BY CHRIST RISTO OPHER PHER JOSE OSEPH SORI SORIA ANO, MD For inquiries visit www.topnotchboardprep.co.nr or email us at
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VULVOVAGINAL GLANDS “Bartholin’s glands” Greater vestibular glands Bulbourethral gland
Compound alveolar/ compound acinar 4 and 8 o clock of the vagina Bartholins’s cyst/ abscess
Page 1 of 33
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PERINEUM
closed compartment
bounded deeply by the perineal membrane and superfcially by Colles ascia ischiocavernosus, bulbocavernosus, and superfcial transverse perineal muscles; Bartholin glands; vestibular bulbs; clitoral body and crura; and branches o the pudendal vessels and nerve
ischiocavernos us muscle
clitoral erection
bulbocavernos us muscles
Bartholin gland secretion Clitoral erection
superfcial transverse perineal muscles
may be attenuated or even absent Contributes to the perineal body
Urogenital (Anterior) Triangle: DEEP SPACE Anterior Triangle (DEEP SPACE)
Clinical Signicance
Boundary
Continuou s space with the pelvis
lies deep to the perineal membrane and extends up into the pelvis Contents: compressor urethrae and urethrovaginal sphincter muscles, external urethral sphincter, parts o urethra and vagina, branches o the internal pudendal artery, and the dorsal nerve and vein o the clitoris
Ishorectal ossae
wedge-shaped spaces ound on either side o the anal canal and comprise the bulk o the posterior triangle Continuous space
Landmark
Anterior
pubic symphysis
Anterolatera l
ischiopubic rami and ischial tuberosities
Posterolater al
sacrotuberous sacrotuberous ligaments
posterior
coccyx
PUDENDAL NERVE AND VESSELS
Roots
Anterior rami o the 2nd to 4th sacral nerve
Course
between the piriormis and coccygeus muscles and exits through the greater sciatic oramen in a location posteromedial to the ischial spine à obturator internus internus muscle muscle à pudendal canal (Alcock Canal) à enter the perineum and divides into three terminal branches
Triangle
Anterior à Superfcial and deep
Posterior
Urogenital triangle Boundaries: Superrior- pubic rami Lateral-ischial tuberosities Posterior: superfcial transverse perineal muscle Anal triangle ischiorectal ossa, anal canal, anal sphincter complex, and branches o the internal pudendal vessels and pudendal nerve
Terminal Terminal Branches: dorsal nerve o the clitoris
skin o the clitoris
perineal nerve
muscles o the anterior triangle and labial skin
inerior rectal
external anal sphincter, the mucous membrane o the anal canal, and the perianal skin
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•
• • • •
H-shaped lower portion o the vagina i s constricted (urogenital hiatus in the levator ani) Stratifed squamous non keratinized epithelium without glands Upper part is more capacious It extends rom the vulva to the cervix. Ruggae that has an accordion like distensability Vaginal length: Anterior wall: 6-8 cm Posterior wall: 7-10 cm Potential space: Lower third – –
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CERVIX ENDOCERVIX EXOCERVIX Supravaginal portion Portio vaginalis Extends rom the isthmus Extends rom the (Internal Os) to the ectocervix squamo columnar and contains the endocervical junction to the canal external orifce Single layer o mucous Non keratinized secreting highly ciliated stratifed columnar epithelium which is squamous thrown into olds orming epithelium complex glands and crypts Hormone Sensitive Extensive amount o nerves Few nerves only Blood supply: Cervicovaginal branch o uterine artery located at the lateral walls
Cervix: SQUAMO-COLUMNAR JUNCTION
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Vesicovaginal septum Separates the vagina rom the bladder and urethra Rectovaginal septum Separates the lower portion o the vagina rom the rectum Rectouterine pouch o Douglas Separates the upper ourth o the vagina rom the rectum –
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Upper vaginal vaults Subdivided into anterior, posterior, and two lateral ornices by the uterine cervix –
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Prepubertal women Original SCJ at or near the exocervix o Reproductive Age women Eversion o endocervical epithelium and o
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UTERUS
SIZE
•
Nulliparous: 6 to 8 cm (undus=cervix) , 50-70 g multiparous: 10 cm (cervix 1/3), 80 g or more
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Isthmus
Lower uterine portion
Fallopian tubes
Attaches at the cornua
Posterior wall
Completely covered by visceral peritoneum
Anterior wall
Only upper portion with peritonem à vesicouterine pouch
ENDOMETRI UM
STRATUM FUNCTIONALE Shed during menstruation Supplied by the Spiral Arteries Superfcial 2/3 •
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Zona Spongios a Zona compact a
STRATUM BASALE Source o Stratum Functionale ater menstruation Supplied by the Straight arteries Basal 1/3 lympathics Inner Longitudinal Middle oblique Outer longitudinal lymphatics •
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MYOMETRIU M SEROSA
SEGMENTS OF THE FALLOPIAN TUBE 2% o ectopic Intramural Embodied pregnancy Interstitial within the muscular wall Ectopic pregnancy at o the uterus this area result in severe maternal morbidity The narrow Most highly Isthmus portion o the developed tube that musculature adjoins the Narrowest portion uterus, Preerred Preerred portion or passes applying clips or gradually into emale sterilization the wider, Preerred Preerred portion or lateral tubal ligation portion. 12% o ectopic pregnancy Ampulla Widest and Site o ertilization most tortuous 80% o ectopic area pregnancy Infundibul Fimbriated 5% o ectopic extremity pregnancy um Tunnel Tunnel shaped opening o the distal end o the allopian tube
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LIGAMENTS OF THE UTERUS Broad Two Two wing-like structure that extend ligament rom the lateral margins margins o the uterus uterus to the pelvic walls Divide the pelvic cavity into anterior and posterior compartments Reproductive Fallopian tubes structures ovaries Vessels: Vessels: Ovarian arteries Uterine arteries Ligaments: Ovarian ligament Round ligament o uterus Cardinal AKA Transverse Transverse Cervical Ligament or ligament Mackenrodt Ligament Originated orm the densest portion o the broad ligament Medially united to the supravaginal wall o the cervix Provide the major support o the uterus and cervix Maintain the anatomic position o the cervix and upper part o the vagina Uterosac From From posterolateral to the ral supravaginal portion o the cervix ligament encircling the rectum Insert into the ascia over S2 and S3 Round Extend rom the lateral portion o the •
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sing single le laye layerr o colum columna narr cell cells, s, some some o them them ciliated and others secretory. No submucosa supplied richly with elastic tissue, blood vessels, and lymphatics Sympathetic innervation Diverticula
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OVARIES Lies on the posterior aspect o the broad ligament, in the ovarian ossa late latera rall to the the uter uterus us in the the pelv pelvic ic side sidewa wall ll o where the common iliac artery biurcates ovarian ossa o Waldeyer o Are Are atta attach ched ed to the the broa broad d liga ligame ment nt by the the mesovarium. They are not covered by peritoneum. peritoneum.
Ovaries: LAYERS OUTER Innermos CORTEX t portion
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Primordial and Graafan ollicles in various stages o development Outermo Tunica Tunica Albuginea- dull st portion and whitish fbrous connective tissue covering the surace o the ovary Germinal epithelium o Waldeyer- a single layer o cuboidal epithelium over the Tunica Tunica Albuginea Composed o loose connective tissue that is continuous with that o
INNER MEDULL
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Pelvic Organs: BLOOD SUPPLY MAJOR BLOOD SUPPLY TO THE FEMALE REPRODUCTIVE SYSTEM Pudenda Internal Pudendal artery Vagina Vaginal Artery o the Uterine Artery Cervix Cervicovaginal branch o Uterine artery Uterus Uterine Artery Fallopian tubes Ovarian Artery Ovaries PARTICIPANTS IN THE COLLATERAL CIRCULATION OF THE FEMALE PELVIS Branches rom Ovarian artery the Aorta Inerior mesenteric Lumbar and vertebral Middle sacral arteries Branches rom Deep iliac circumex the External Inerior epigastric artery Iliac Artery Branches rom Medial emoral circumex the Femoral artery Artery Lateral emoral circumex artery
Outlet increase by 1.5 -2.0 cm
PELVIC TENDENCY AND TYPE Anterior – dictates the tendency o the pelvis Posterior – dictates the type or character o the pelvis • •
GYNECOID
ANDROI D
ANTHROP OID
PLATYPELLOID
FREQUENC Y
50%
20%
25%
5% rarest
INLET SHAPE
Round
Heart Shaped
Vertically oriented oval
SIDEWALL S
Straight
Converg ent
Convergent
Horizontally oriented oval Divergent, then convergent
ISCHIAL SPINES
Non promin ent
Promine nt
Prominent
Non prominent
SACRUM
Inclined neither anterior ly nor posterio rly
Straight = pelvis deeper than other 3 types
Well curved and rotated backward
Increased incidence o Face Delivery Good prognosis or vaginal delivery
Poor prognosis or vaginal delivery
Fals e
ANT: lower abdomen POST: POST: lumbar vertebra LATERAL: LATERAL: iliac il iac ossa
L INEA TERMINALIS
Tru Tru e
SUPERIOR BOUNDARY: BOUNDARY: Pelvic inlet INFERIOR BOUNDARY: Pelvic outlet ANTERIOR: Pubic Bones, Ascending Rami O Ischial Bones, Obturator Foramina LATERAL: LATERAL: Ischial Bones and Sacrosciatic Notch SIGNIFICA NCE
Good prognos is or vaginal delivery
Forward and straight with little curvatur e Increase d incidenc e o Deep Transver Transver se Arrest Limited posterior space or etal head, poor prognosi s
EMBRYOLOGIC STRUCTURES AND DERIVATIVES EMBRYOLOGIC STRUCTURES LABIOSCROTAL SWELLING UROGENITAL FOLDS PELVIC PELVIC JOINTS JO INTS Anterior: symphysis pubis/ arcuate ligament o the pubis Posterior: sacroiliac Hormonal changes during pregnancy cause laxity o these joints By 3-5 months POST PARTUM, PARTUM, laxity has •
• •
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PHALLUS (GENITAL TUBERCLE) UROGENITAL SINUS
MALE
FEMALE
Scrotum
Labia Majora
Ventral portion o the penis Penis
Labia Minora
Urinary bladder Prostate gland
Urinary bladder Urethral and Paraurethral
Clitoris
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PARAMESONEPHR IC DUCT
Appendix o testes
MESONEPHRIC DUCT
Appendix o Appendix o epidydymis vesiculosis Ductus o Duct o epididymis epoophoron Ductus Gartner’s deerens Duct Ejaculatory duct Seminal Vesicle Ureter Renal Pelvis Calyces Collecting system Glomerulus Renal Collecting Tubules Testes Testes Ovary
METANEPHRIC DUCT URETERIC BUD METANEPHRIC MESENCHYME UNDIFFERENTIAT ED GONAD CORTEX MEDULLA GUBERNACULUM
Seminierous tubules Rete Testis Gubernaculu m testis
Hydatid o Morgagni Uterus and Cervix Fallopian Tubes Tubes Upper ¼ o the vagina
Ovarian Follicles Rete Ovarii Round ligament o uterus
MENSTRUAL PHYSIOLOGY Overview of Menstrual Cycle Spontaneous, cyclical ovulation occurs at 25- to 35-day intervals Cyclical ovulation continues or almost 40 years between menarche and menopause Approximately 400 opportunities for pregnancy, which may occur with intercourse on any of 1,200 days (includes day o ovulation and its two preceding days) during the reproductive age o most women. Menstrual cycle days 20 to 24 is the narrow window o endometrial receptivity to blastocyst implantation. Mother and etus coexist as two disctinct immunological systems because o modifcations on both etal and maternal tissues in a manner not seen elsewhere. Endometrium-decidua is the anatomical site o blastocyst apposition, implantation, and placental development.
Selection o dominant “ovulatory” ollicle Luteal phase (days 14 to 21), the corpus luteum (CL) produces estrogen and progesterone, which prepare the endometrium or implantation. I implantation occurs, the developing blastocysts will begin to produce hCG and rescue the CL, thus maintaining progesterone production.
o •
A. Follicul Follicular ar or or preovula preovulatory tory ovarian ovarian phase phase FOLLICLE PROFILE Event Numbers At Birth 2 Million oocytes Puberty 400,000 ollicles Depletion rate 1,000 ollicles/month (puberty to 35y/o) Total Total ollicles released 400 ollicles during reproductive age Atresia (apoptosis) o 99.9% ollicles OOCYTE CYCLE Primary Oocyte ormed by 5 th etal month o Started their frst meiotic division o Arrested in Prophase rom 5th etal month until o the onset o puberty Will complete the frst meiotic division at the o onset o puberty Secondary Oocyte Formed ater completion o Meiotic I o Release o the frst Polar Body During ovulation o Arrested in Metaphase II until ertilization o Completion o 2ND Meiotic Division only occurs i o there is ertilization •
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Key Players: 1. Ante Anteri rior or pitu pituit itar ary y a. FSH b. LH 2. Ovar Ovaria ian n oll ollic icle le a. Theca cells lls b. Gra Granulo nulosa sa ce cells lls 3. Estrogen 4. Proge roges ster terone one 5. Endometriu rium a. Basalis
Oocyte transforming growth factors: 1. Gro Growth wth di die erentia ntiati tio on ac acto torr 9 (GDF (GDF9) 9) 2. Bone Bone morp morpho hoge gene neti tic c pr protei otein n 15 15 (BM (BMP P-15) 15) Functions: 1. Regul egulat ate e prol proli ier erat atio ion n & die dierrenti entiat atio ion n o granulosa cells (GC) as primary ollicles grow 2. Stab Stabil iliz ize e and and expan xpand d the the cumul umulus us oocy oocyte te complex in the oviduct
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7.
GC secrete progesterone which will cause LH release. 8. GC produce uce inhibin B to inhibit FSH release. 9. Increase Increase estradiol estradiol & inhibin production production causes causes drop of FSH 10. Drop o FSH FSH causes causes failure of other follicles to develop. 11. LH stimulates stimulates theca theca cells to produce produce androstenediol.
HORMONE PRODUCTION
CORPUS LUTEUM Key events: 1. Cons Consta tant nt at 12 to 14 day days. s. 2. Lutein Luteiniza izatio tion n occurs occurs ater ater ovulat ovulation ion when when the CL develops. 3. Baseme Basement nt membra membrane ne separa separating ting the the granulo granulosasalutein and theca-lutein cells breaks down 4. Day Day 2 post postov ovul ulat atio ion, n, blood vessels and capillaries invade the granulosa cell layer. layer. 5. Increase Increased d capacit capacity y o granulosa-lu granulosa-lutein tein cells to produce progesterone is due to increased access to steroidogenic precursors through blood-borne LDL-derived cholesterol. 6. Just Just ate aterr ovu ovula lati tion on,, estrogen levels decrease . 7. Mid-l Mid-lut utea eall pha phase se is a secondary rise that reaches a peak production o 0.25 mg/day o 17B-estradiol. 8. Toward oward the end end o the luteal luteal phase, phase, there is secondary decrease in estradiol production. 9. Ovarian progesterone peaks at 25 to 50 mg/day during the midluteal phase. (With pregnancy, pregnancy, CL continues progesterone production in response to embryonic hCG) 10. CL is a transie transient nt endocrine endocrine organ organ that will rapidly regress 9 to 11 days ater ovulation. LUTEOLYSIS Luteolysis may be due to the following: 1. Decr Decrea ease sed d lev level els s o o cir circu cula lati ting ng LH in the the late late luteal phase and 2. Dec Decrease ease LH sens ensitiv itivit ity y o o lut lute eal cells lls 3. Apoptosis Eects of luteolysis: 1. Drop Drop in circ circul ulat atin ing g est estra radi diol ol and and pro proge gest ster eron one e levels. 2. Allo Allows ws oll ollic icul ular ar deve develo lopm pmen entt and and ovul ovulat atio ion n during the next ovarian cycle 3. Sign Signal als s the the endo endome metr triu ium m to to ini initi tiat ate e mol molec ecul ular ar events that lead to menstruation.
Ovarian steroid production: 1. growth o a Estrogen levels rise in parallel to growth dominant ollicle. 2. Increase in in it its nu number o o granulosa cells . 3. GC are the exclusive site o FSH receptor expression. 4. Incr Increa ease se in FSH FSH duri during ng the the late late lute luteal al phas phase e stimulates increase in FSH receptors & ability o cytochrome P450 to convert androstenedione into estradiol .
B. Ovul vulation OVULATION Key events: 1. Preovulatory o ollicles increase estrogen secretion 34 to 36 hours before release o
D. Estr Estrog ogen en e eec ects ts 17B- estradiol is the most biologically potent naturally occuring estrogen secreted by granulosa cells o the dominant ollicles and luteinized granulosa cells o the CL. Estrogen is the essential hormonal signal on which most events in the normal menstrual cycle depend. Estrogen receptor (ER-alpha & ER-beta) interaction can promote synthesis o specfc m-RNAs and proteins (e.g. estrogen and progesterone) Acts at endothelial cell surace to stimulate nitric oxide production, leading to its rapid vasoactive properties. •
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E. Prog Proges este tero rone ne ee eect cts s Progesterone enters cells by diusion and in •
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Numerous mitotic gures
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Late proliferative phase: Days 11-14 Endometrium thickens rom both glandular hyperplasia and increased stromal ground substance. Functionalis layer – glands are widely separated, loose stroma is especially prominent. Basalis layer – gl ands are more crowded and stroma is denser.
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Endometrial histologic eatures: Prolierative phase – straight to slightly coiled, o tubular glands are lined by pseudostratifed columnar epithelium with scattered mitoses. Early secretory phase – coiled glands with a o slightly widened diameter are lined by simple columnar epithelium that contains clear subnuclear vacuoles. Luminal secretions are seen. Late secretory phase – serrated, dilated glands o with intraluminal secretion are lined by short columnar cells. Menstrual phase – ragmented endometrium o with condensed stroma and glands with secretory vacuoles are seen in a background o blood. Layers o endometrium Basalis layer – supplied by straight artery o Functionalis layer – supplied by spiral artery o
Midcycle (near ovulation): Glandular epithelium becomes taller and pseudostratifed. Superfcial epithelial cells acquire: 1. microvilli (i (increase epithelial su surace area) and 2. cilia (aid in the movement o endometrial secretions during the secretory phase) Ovulation is evidenced by presence o subnuclear vacuoles in 50% o glands
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B. Secretory Secretory or postovulat postovulatory ory endometria endometriall phase Early secretory phase: coiled glands with a slightly widened diameter lined by simple columnar epithelium that contains clear subnuclear vacuoles. Luminal secretions are seen. Late secretory phase: serrated, dilated glands with intraluminal secretion are lined by short columnar cells. • •
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A. Proliferat Proliferative ive or or preovula preovulatory tory endometria endometriall phase Features: glands Straight to slightly coiled, tubular glands are lined by pseudostratied columnar epithelium with scattered mitoses. Epithelial (glandular) cells, stromal (mesenchymal) cells and blood v essels replicate cyclically. Functionalis layer is shed and regenerated rom the deepest basalis layer almost 400 times during the reproductive lietime o most women. Day 5 o menses – the epithelial surace o the endometrium has been restored, and revascularization is in progress. •
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Early proliferative phase: Endometrium is thin, usually < 2 mm thick Glands are narrow , tubular structures that are • •
Early secretory phase Dating based on glandular epithelium. Day 17: glycogen accumulates in the basal portion o glandular epithelium, creating subnuclear vaculoes and pseudostratifcation (1 st sign o ovulation) Day 18: vacuoles move to the apical portion o the secretory nonciliated cells Day 19: cells begin to secrete glycoprotein and mucopolysaccharide contents into the lumen; glandular cell mitosis ceases with secretory activity. •
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Mid- to late-secretory phase Dating is based on endometrial stroma Days 21 to 24: stroma becomes edematous “window of implantation” epithelial surace cells show decreased microvilli and cilia • • •
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[email protected] •
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Rapid angiogenesis is regulated through estrogenand progesterone-regulated synthesis o VEGF Changes in blood ow through these vessels aid in endometrial growth Excessive coiling and stasis in blood ow coincide with regression o CL unction and lead to a decline in endometrial tissue volume Coiling leads to endometrial hypoxia and necrosis Prior to endometrial bleeding, intense vasospasm occurs to limit blood loss with menstruation
MENSTRUATION Late premenstrual phase endometrium Stromal inltration by neutrophils, giving a pseudoinammatory appearance to the tissue Endometrial stromal and epithelial cells produce IL-8, which is a chemotactic activating actor or neutrophils, and serves to recruit neutrophils prior to menstruation Invading leukocytes secrete enzymes that are members o the matrix metalloproteinase (MMP) amily. Rising level o MMP’s tips the balance between proteases and protease inhibitors, eectively initiating matrix degradation. •
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Anatomical events Marked changes in endometrial blood ow Coiling o spiral arteries becomes suciently severe that resistance to blood ow i ncreases strikingly, causing hypoxia or the endometrium Resultant stasis is the primary cause o endometrial ischemia and tissue degeneration. Intense vasoconstriction & endometrial cytokine changes, activation o proteases (MMP-1 & MMP-3) • •
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Prostaglandins & menstruation Role o prostaglandin: Vasoconstriction o Myometrial contractions o Upregulation o pro-inammatory responses responses o Progesterone withdrawal increases expression o inducible COX-2 enzyme to synthesize prostaglandins and decrease expression o 15hydroxyprostaglandin dehydrogenase (PGDH), which degrades prostaglandin Increased prostaglandin production o stromal cells along with increased prostaglandin receptor density on blood vessels and surrounding cells. PGF2-alpha Vasoconstriction Vasoconstriction o spiral arteries, causing the o uppermost endometrial zones to become hypoxic Potent inducer o angiogenesis and vascular o permeability actors such as VEGF •
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Origin of menstrual blood Arterial bleeding is appreciably greater than venous. Endometrial bleeding appears to ollow rupture o an arteriole o a coiled artery, with consequent hematoma ormation. With a hematoma, the superfcial endometrium is distended and ruptures. Fissures Fissures develop in the adjacent unctionalis layer, and blood, as well as tissue ragments o various sizes, are sloughed. Hemorrhage stops with arteriolar constriction as well as changes that accompany partial tissue necrosis. Endometrial surace is restored by growth o anges, or collars, that orm the everted ree ends o the endometrial glands •
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Interval between menses Modal interval o menstruation is 28 days. •
Decidua Specialized, highly modifed endometrium o pregnancy and is a unction o hemochorial placentation Decidualization – transormation o secretory endometrium to decidua; dependent on estrogen and progesterone and actors secreted by the implanting blastocyst •
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Structure 3 parts Decidua basalis – directly beneath blastocyst o implantation, modifed by trophoblast invasion Decidua capsularis – overlies the enlarging o blastocyst, and initially separates it rom the uterine cavity. cavity. Prominent during the 2nd month o pregnancy. Decidua parietalis – remainder o the uterine o lining Decidua vera – vera – when capsularis and parietalis o are joined later in pregnancy. pregnancy. By 14 to 16 weeks AOG – gestational sac completely flls the uterine cavity and unctionally obliterated. 3 layers o decidua parietalis and basalis: zona compacta – compact zone; part o zona o unctionalis zona spongiosa – spongy, middle portion, with o remnants o glands and numerous small blood vessels; part o zona unctionalis zona basalis – basal zone which remains ater o delivery and gives rise to new endometrium. •
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Reaction Decidual reaction is completed only with •
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remain responsive to vasoactive agents that act on their smooth muscle or endothelial cells. Spiral arterioles and arteries are invaded by cytotrophoblasts. As a consequence, the walls o vessels in the basalis are destroyed. These vascular conduits o maternal blood, devoid o smooth muscle or endothelial cells, are not responsive to vasoactive agents. FERTILIZATION
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Zygote cytoplasm is successively cleaved to orm a blastula, which consists o increasing smaller blastomeres At 32 -cell stage, the blastomeres orm a morula, which consists o an inner cell mass and outer cell mass The morula enters the uterine cavity at about 3 days post conception
BLASTOCYST FORMATION Occurs when uid secreted within the morula orms the blastocyst cavity Inner cell mass – uture embryo, is now called the Embryoblast The outer cell mass – uture placenta, is now now called the Trophoblast •
EVENTS IN FERTILIZATION
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IMPLANTATION Blastocyst implants at around 7 days post conception within the posterior superior wall o the uterus This is during the secretory phase o the menstrual cycle, so implantation occurs within the unctional layer o endometrium. •
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POST CONCEPTION: WEEK 2 EMBRYOBLAST Dierentiates into two distinct cell layers, the Epiblast and Hypoblast, orming a Bilaminar Embryonic Disk Epiblast -clets develop within the Epiblast to o orm the amniotic cavity Hypoblast -orm the yolk sac o •
1. The sper sperm m binds binds to zona zona pelluc pellucida ida o o the secondary oocyte and triggers the acrosome reaction, causing release o acrosomal enzymes 2. Sperm Sperm penetra penetrates tes the the zona zona pelluc pellucida ida and and unite unite with the oocyte’s oocyte’s plasma membrane, eliciting the cortical reaction and rendering the secondary oocyte impermeable to other sperm 3. Sperm Sperm and secon secondar dary y oocyte oocyte cell cell membr membrane anes s use and contents o the sperm enter the cytoplasm Male genetic material orms the male pronucleus Tail Tail and mitochondria degenerate 4. Secondary Secondary oocyte oocyte comple completes tes meiosis meiosis II, II, orming orming a mature ovum. The nucleus o the ovum is the emale pronucleus 5. The male male and and emal emale e pronu pronucle cleii use use to orm orm a zygote −
TROPHOBLAST Cytotrophoblast divide mitotically Syncytiotrophoblast Does not divide mitotically o Produces the HCG o Continues its growth into the endometrium to o make contact with the endometrial blood vessels • •
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POST CONCEPTION: WEEK 1 1. Cleavage 2. Blas Blasto tocy cyst st orm ormat atio ion n 3. Impl Implan anta tati tion on
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EMBRYO PERIOD: WEEK 3-8 The beginning o the development o major organ systems Coincides with the frst missed menstrual period Period o high susceptibility to teratogen Gastrulation is a process that establishes the 3 primary germ layers, orming a trilaminar embryonic disk Ectoderm o Endoderm o Mesoderm o
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genitalia AMNIOTIC FLUID Normal amniotic uid volume By 12 weeks = 60ml o By 34-36 weeks = 1L o By term = 840 ml o By 42 weeks = 540 ml o Production of amniotic uid Initially by amniotic epithelium o Fetal kidneys and urine production o *Amniotic uid volume is also dependent on the extent o maternal plasma expansion Removal and regulation of amniotic uid volume Fetal swallowing o Fetal aspiration o Exchange through skin and etal membranes o •
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PERIOD OF TERATOGENICITY
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THE PLACENTA AT TERM Volume 497 Ml Weight 508 grams (450-500 grams) Suraces Fetal o Covered with amniotic membrane giving it white, glistening appearance Where the umbilical cord arises Maternal o Attached to the decidua Deep, bloody appearance arranged into 15-20 irregular lobes, cotyledons Hobauer cells • • •
DRUGS IN PREGNANCY Category
A
B
C
D
Examples
Adequate and well-controlled human studies have ailed to demonstrate a risk to the etus in the frst trimester Folic acid o pregnancy (and there is no evidence o risk in later trimesters). Animal reproduction studies have ailed to demonstrate a risk to the etus and there are no adequate and well-controlled studies in pregnant Paracetamol, women OR Animal studies have amoxicillin, shown an adverse eect, but cephalexin, adequate and well-controlled studies in pregnant women have ailed to demonstrate a risk to the etus in any trimester. Animal reproduction studies have shown an adverse eect on the etus and there are no adequate and wellcontrolled studies in humans, but paroxetine potential benefts may warrant use o the drug in pregnant women despite potential risks. There is positive evidence o human etal risk based on adverse reaction data rom investigational or marketing Phenytoin, experience or studies in humans, but tetracyclne, potential benefts may warrant use o aspirin, the drug in pregnant women despite potential risks.
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Circulation in the Mature Placenta
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Fetal surace covered by amnion beneath which the etal chorionic vessels course chorionic villi àintervillous space àdecidual plate à myometrium
FUNIS Umbilcal cord Two Two artery, one vein (let or right?) Ave lenght: 55 cm • • •
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Estradiol-17 Estriol Progesterone Aldosterone Deoxycorticosterone Cortisol
0.1–0.6 0.02–0.1 0.1–40 0.05–0.1 0.05–0.5 10–30
15–20 50–150 250–600 0.250–0.600 1–12 10–20
hCG • • • •
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Almost exclusively produced by the placenta Glycoprotein Alpha and beta subunit Functions: rescue and maintenance o unction o the corpus luteum, stimulates etal testicular testosterone secretion, materanl thyroid gland stimulation (chorionic (chorionic thyrotropins), thyrotropins), promotion promotion o relaxin secretion detectable in plasma o pregnant women 7 to 9 days ater the midcycle surge o LH that precedes ovulation. Plasma levels increase rapidly, doubling every 2 days, with maximal levels being attained at 8 to 10 weeks At 10 to 12 weeks, plasma levels begin to decline, and a nadir is reached by about 16 weeks Clearance: mainly hepatic, renal (30%)
Placental Estrogen Production
hPL • • •
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Similar to hGH detected in maternal serum as early as 3 weeks Maternal plasma concentrations are linked to placental mass, and they rise steadily until 34 to 36 weeks production rate near term: approximately 1 g/ day Functions: Maternal lipolysis , anti-insulin or "diabetogenic”, potent angiogenic
PROGESTERONE Source: First 6-7 6-7 weeks o pregnancy: pregnancy: Corpus luteum o (ovary) Ater 8 weeks: Placenta (Syncytiotrophoblast) o Function: Aects tubal motility, the endometrium, o
Conditions that Aect Hormone Levels in Pregnancy Condition
Findings
Fetal Demise
dec estrogen
Fetal anencephaly
Dec estrogen gen (estriol)
Fetal adrenal hypoplasia
absence o C 19-precursors
Fetal-Placental Sulatase Defciency
very low estrogen levels in otherwise normal
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Neonata l period
Period ater birth o an inant up to 28 completed days ater birth
Fetal period
Begins rom 8 weeks ater ertilization or 10 weeks ater onset o last menses menses
Embryo nic period
Commences beginning o the 3 rd week ater ovulation and ertilization and lasts up to 8 weeks AOG 8 weeks period rom the time o ertilization 10 weeks period rom the time o the last menstrual cycle/Ovulation
Abortus
Fetus or embryo removed or expelled ro uterus during the frst hal o gestation 20 weeks or less, or in the absence o accurate dating criteria, born weighing less than 500 grams
breathe, but many will die because the terminal sacs have not yet ormed 28
crown-rump length is approximately 25 cm skin is red and covered with vernix caseosa pupillary membrane has just disappeared rom the eyes born at this age has a 90-percent chance o survival
36
CRL o 32 deposition o subcutaneous at
40
average crown-rump length is about 36 cm weight is approximately 3400 g
HEAD DIAMETERS Bitemporal diameter (8.0cm) Greatest TRANSVERSE diameter o the head o Biparietal diameter (9.5 cm) Occipitomental ( 12.5 cms) Occipitorontal (11.5 cms) The plane that corresponds corresponds to the greatest o CIRCUMFERENCE 34.5 cm o Suboccipitobregmatic ( 9.5 cms) The plane that corresponds to the smallest o circumerence o the head 32 cm o •
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GESTATIONAL AGE vs. OVULATION AGE Gestational age/menstrual age The time elapsed since the last menstruation o Precedes ertilization/ovulation by 2 weeks o Ovulation age/post conceptional age Measures the actual age o the embryo rom o the time o ertilization/ovulation *A etus that is 18 weeks AOG. What is the ovulation age? •
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DETERMINING THE AGE OF THE FETUS Naegele’s Rule Crown Rump Length (CRL) Measured rom the superior to inerior pole o o the etus preerably in extended position Used or First trimester o Biparietal Diameter (BPD) Measured at the outer to outer aspect o the o skull at the level o the occipitorontal plane Used during the second and third trimester o • •
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FETAL PERIOD
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FETAL CIRCULATION 3 vessels (AVA) 2 arteries o 1 vein o Three Shunts: Ductus venosus o Foramen ovale o Ductus arteriosus o •
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Hemoglobin F Hemoglobin A (adult hgb) Hemoglobin A2
Fetal Circulation: CHANGES AFTER BIRTH Foramen ovale – functionally closed w/in several minutes; anatomically used 1 year ater birth Ductus arteriosus – functionally closed by 10-12 hours after birth; anatomically closed by 2-3 weeks Ductus venosus constrict and becomes the ligamentum venosum •
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Kleihauer-Betke test Rationale: Fetal RBC’s are resistant to denaturating o eects o alkali. Mother’r RBC are sensitive, thus may o hemolyze •
FETAL PULMONARY SYSTEM
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Presence o suractant in the amnionic uid is evidence o etal lung maturity (ater 34 weeks) Suractant is ormed in the type II pneumocytes pneumocytes that line the alveoli Starts to appear in the amniotic uid at 28-32 weeks. 90% lipid and 10% proteins Phosphatidylcholines (lecithin) account or o
testes or ovaries? Dependent on the presence o SRY gene present on the Y chromosome or the Testes Determining region Phenotypic Sex Is it a penis or a vagina? o Dependent on the hormones produced o o o
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B. Card Cardia iac c Soun Sounds ds Exaggerated splitting o the frst heart sound with increased loudness o both components No defnite changes in the aortic and pulmonary elements o the second sound Loud, easily heard third sound Systo Systolic lic murm murmur ur in 90% 90% o preg pregna nant nt pati patien ents ts which was intensifed during inspiration in some or expiration in others, and disappeared shortly ater delivery.
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C. Card Cardia iac c out outpu putt Mean Mean arteri arterial al pressu pressure re and vascul vascular ar resis resistan tance ce decrease, while blood volume and basal metabolic rate increase. Cardiac output at rest, when measured in lateral recu recumb mben entt posi positi tion on,, incr increa ease ses s sign signifc ifcan antl tly y begin beginni ning ng in early early preg pregna nanc ncy y. It cont continu inues es to inc increas ease and and remain main eleva levate ted d duri during ng the the remainder o pregnancy. During late pregnancy with a woman in SUPINE position, position, the large pregnant uterus compress compresses es veno venous us retu return rn rom rom the the lowe lowerr body body.. It may may compre compress ss the aorta and cardia cardiac c flling flling may be redu reduce ced d with with dimis dimishe hed d card cardia iac c outp output ut.. Fetal etal oxygen oxygen saturation saturation is approximat approximately ely 10% higher when a labouring woman is in a lateral recumbent positi position on compar compared ed with with supine supine.. Upon Upon standi standing, ng, cardiac output all to the same degree as in the non-pregnant woman. Duri During ng the the 1st stag stage e o labo labor, r, card cardiac iac outp output ut increases moderately. During the 2md stage, with vigor vigorou ous s expu expuls lsive ive eor eorts ts,, it is appr apprec ecia iabl bly y greater greater.. The pregnancy pregnancy-induce -induced d increase increase is lost ater delivery.
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D. Circula Circulatio tion n and blood blood press pressure ure Brachial artery pressure when sitting is lower than that that whe when in the the lat latera eral recum ecumbe bent nt supine position. Arterial pressure usually decreases to a nadir at 24 to 26 weeks and rises thereater. thereater. Diastolic pressure decreases more than systolic. In about 10% o women, supine compression o •
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C-type natriuretic natriuretic peptide (CNP), is secreted secreted by noncardiac tissues. This peptide appears to be a major regulator o etal bone growth. Pros Prosta tagl glan andi dins ns Renal Renal medulla medullary ry prost prostagla aglandin ndin E2 synthe synthesis sis is increased markedly during late pregnancy and is presumed to be natriuretic. Prostacyclin (PGI2), the principal prostaglandin o endothelium endothelium,, is increased increased during late pregnancy pregnancy and and regul egulat ates es bloo blood d pres pressu sure re and and plat platel elet et unc uncti tion on.. It also also has has been been impl implic icat ated ed in the the angiotensin angiotensin resistanc resistance e characteris characteristic tic o normal normal pregnancy.
G. Endo ndothel thelin in Endo Endoth thel elin in-1 -1 is a pote potent nt vaso vasoco cons nstr tric icto torr in endothelial and vascular smooth muscle cells and regu regulat lates es loca locall vaso vasomo moto torr tone tone.. It stim stimul ulat ates es secretion o ANP, aldosterone, and catecholamines. There are endothelin receptors in pregnant and nonpregnant myometrium. They are also also iden identif tifed ed in the amnio amnion, n, amnio amnioti tic c uid, uid, decidua, and placental tissue. Vascular sensitivity to endo endoth thel elin in-1 -1 is not not alte altere red d duri during ng norm normal al pregnancy pregnancy.. Vasodila Vasodilating ting actors actors counterbala counterbalance nce the the endo endoth thel elinin-1 1 vaso vasoco cons nstr tric icto torr eec eects ts and and produce reduced peripheral vascular resistance. •
H. Nitr Nitric ic Ox Oxid ide e It is a potent vasodilator released by endothelial cells and have important implication or modiying vascular resistance during pregnancy. pregnancy. •
PULMONARY SYSTEM A. Anat Anatom omic ic Chan Change ges s Diaphragm rises about 4 cm during pregnancy. pregnancy. Subcostal angle widens appreciably as the transverse diameter o the thoracic cage increases approximately 2 cm. Thoracic circumerence circumerence increases about 6 cm, but not suciently to prevent a reduction in the residual lung volume created by the elevated diaphragm • •
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y reserve volume Functiona l residual capacity Vital capacity
1,700
1,350
3,200
3,200
which shits the curve back to the right. Reduced PCO2 rom maternal hyperventilation aids CO2 (waste) transfer from the fetus to the mother while also facilitating O2 release to the fetus.
Elevated diaphragm
REPRODUCTIVE SYSTEM
UNCHANGED Respiratory rate is essentially unchanged. Lung compliance is unaected by pregnancy Maximum breathing capacity and orced or timed vital capacity are not altered appreciably • • •
INCREASED Airway conductance is increased possibly as a result o progesterone Amount o oxygen delivered into the lungs by the increased tidal volume clearly exceeds O2 requirements imposed by pregnancy. Total Total haemoglobin mass, and in turn total oxygenoxygencarrying capacity, increases appreciably. appreciably. •
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DECREASED Peak expiratory ow rates decline progressively as gestation advances. Total Total pulmonary resistance reduced reduced possible as a result o progesterone Maternal arteriovenous oxygen dierence is decreased due to increased total oxygen carrying capacity. •
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•
A. Uterus Non-pregnant weight o 70g to almost 1100 grams by term. Non-pregnant capacity o 10 ml to a total volume o 5 to 20 liters by term Uter Uterine ine enla enlarg rgem emen entt invo involve lves s stretching and marked hypertrophy o muscle cells, production o new myocytes is limited. Accumulation o fbrous tissue, particularly in the external muscle layer, with an increase in elastic tissue to strengthen the uterine wall Uterine wall thins near term to only 1 to 2 cm. It beco become mes s sot sot and and read readily ily identable through which the etus can be palpated. Uterine hypertrophy early in pregnancy probably is stim stimul ulat ated ed by the the acti action on o estr estrog ogen en and and perh perhap aps s that that o prog proges este tero rone ne.. By 12 week weeks, s, incr increa ease se in size size is relat related ed pred predom omina inant ntly ly to pressu pressure re exert exerted ed by the expand expanding ing produc products ts o conception. Uterine enla enlarg rgem emen entt mo most st mark marked ed in the the fundus. Early Early mont months hs o preg pregnan nancy cy – all allop opia ian n tube tubes, s, ovarian and round ligaments attach slightly below the apex o the undus Late Laterr mont months hs o preg pregna nanc ncy y – allo allopi pian an tube tubes, s, ovarian ovarian and round round ligamen ligaments ts are located located above the middle of the uterus Portion Portion o the uterus surrounding surrounding placental placental site enlarges more rapidly. Arrangement of muscle cells : Outer hoodlike layer, which arches over the o undus and extends into various ligaments muscle le Midd Middle le layer layer, dens dense e netw networ ork k o musc o fber fbers s pero perora rate ted d in all all dire direct ctio ions ns by blood blood vessels Internal Internal layer layer, with sphinctersphincter-like like bers o •
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C. Acid Acid-B -Bas ase e Equi Equili libr briu ium m Blood Gas NonFirst pregna trimest nt er HCO3 Not 22-26 (mEq/L reported ) PCO2 Not (mmH 38-42 reported g)
Second trimest er
Third trimest er
Not reported
16-22
Not reported
25-33
•
•
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[email protected] •
•
•
Cervical Mucus is rich in Ig and cytokines and may act as an immunological barrier to protect uterine contents against inection. Cervi Cervica call mucu mucus s bead beading ing occu occurs rs as a resu result lt o progesterone. Aria Ariass-St Stel ella la reac reacti tion on – endo endoce cerv rvic ical al glan gland d hyperplasia and hypersecretory appearance
C. Ovaries Ovulation ceases and maturation o new ollicles is suspended. Corpus luteum unctions maximally during the frst 6 – 7 weeks o pregnancy, produces progesterone. Decidu Decidual al react reaction ion – elevate elevated d patche patches s o tissue tissue which bleed easily. Repres Represents ents cellular cellular detritus detritus rom the endometrium endometrium that has passed passed through through the allopian tubes. Relaxin – protein hormone secreted by the corpus luteum, luteum, decidua deciduas s and placen placenta. ta. Remod Remodelli elling ng o reproductive ive tract connective tissue to accommodate pregnancy •
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D. Vagin agina a & per perin ineu eum m Chadwic Chadwick k sign sign – incre increase ased d vascul vascularit arity y aecti aecting ng vagina and results results in violet discoloration •
SKIN a. Abdo Abdomi mina nall wall wall 1. Striae Striae gravid gravidaru arum m or stretc stretch h mark marks s 2. Diastasis Diastasis recti recti – rectus rectus muscles muscles separat separate e in the midline b. Hyperpigmentation – due elevated levels o
1. 2. 3. 4.
Fetus etus and place placenta nta weigh weigh about about 4 kg and and contain contain approximately 500 g o protein Remai Remainin ning g 500 g is added added to uter uterus, us, brea breasts sts primarily in the glands, and to hemoglobin and plasma proteins Nitrog Nitrogen en balance balance incre increase ased d with gestat gestation ional al age Matern Maternal al muscle muscle brea breakdow kdown n is not requ require ired d to meet metabolic demands.
d. Carboh Carbohydr ydrate ate metabo metabolis lism m Pregnancy is characterized by mild asting hypoglycemia, postprandial hyperglycemia, and hyperinsulinemia Pregnancy-induced state o peripheral insulin resistance occurs to ensure a sustained postprandial supply o glucose to the etus. Progesterone and estrogen, may act, directly or o indirectly to mediate this insensitivity Placental lactogen may increase lipolysis and o liberation o ree atty acids. Increased ree atty acids may aid increased tissue resistance to insulin Pregnant women changes rapidly rom a postrprandial state characterized state characterized by elevated and sustained glucose levels to a asting state characterized by decreased plasma glucose and some amino acids •
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e. Fat meta metabo boli lism sm Lipids, lipoproteins and apolipoproteins increase appreciably during pregnancy. pregnancy. Increased insulin resistance and estrogen stimulation are responsible or maternla •
•
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Iron requirement
Potassium Total Total serum calcium (ionized & non-ionized) Serum magnesium
HEMATOLOGIC CHANGES a. Blo Blood vol volume ume Hypervolemia averages 40 to 45% above nonpregnant blood volume ater 32 to 34 weeks Functions of hypervolemia: Meets the metabolic demands o the enlarged o uterus and its greatly hypertrophied vascular system Provides abundant nutrients and elements to o support the rapidly growing placenta and etus Protects the mother and etus against the o deleterious eects o impaired venous return in the supine and erect positions Saeguards the mother against the adverse o eects o parturition-associated blood loss Maternal blood volume expands most rapidly during the second trimester. trimester. Blood volume expansion results rom an i ncrease in both plasma and erythrocytes. Moderate erythroid hyperplasia is present in the bone marrow Reticulocyte count is elevated slightly. slightly. Elevated maternal plasma erythropoietin levels – peaks early during the 3rd trimester and corresponds to maximal erythrocyte production. Hemoglobin & hematocrit DECREASE slightly Whole blood viscosity DECREASES.
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Blastocyst must break through the uterine cavity epithelial lining to invade endometrial tissue Trophoblast Trophoblast must replace endometrium endometrium and vascular smooth muscle o maternal blood vessels to secure adequate supply or the placenta Inammatory environment is required to secure cellular debris removal and adequate repair o the uterine epithelium Midpregnancy (anti-inammatory) o Period o rapid etal growth and development Parturition (recrudescence o inammatory o process) Inux o immune cells into the myometrium Suppressed activity: T-helper T-helper (Th) 1 cells o decreases secretion o IL-2, intereron-g, and TNF-B suppressed Th1 response is requisite or pregnancy continuation suppressed Th1 during pregnancy results in remission o some autoimmune disorders such as rheumatoid arthritis, multiple sclerosis, and Hashimoto thyroiditis ailure o Th1 suppression may be related ot development o preeclampsia T-cytotoxic T-cytotoxic (Tc) (Tc) 1 cells o Decreases secretion o IL-2, intereron-g, and TNF-B
•
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Maintenan ce o acidbase
Decreased bicarbonate threshold; Progesterone stimulates respiratory center
Plasma osmolality
Osmoregulation altered; Osmotic thresholds or vasopressin (AVP) release and thirst decrease Hormonal disposal rates increase
borderline); Protein, amino acid, and glucose excretion all increase Serum bicarbonate decreased by 4-5 mEq/L; PCO2 decreased 10 mmHg; PCO2 or 40 mmHg already represents CO2 retention Serum osmolality decreases 10 mOsm/L (serum Na ≈ 5 mEq/L) during normal gestation Increased placental metabolism o AVP may cause transient diabetes insipidus during pregnancy.
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1. Loss Loss of nut nutri rien ents ts Amino acids and water-soluble vitamins o are lost in urine in greater amounts 2. T
f r
l f
ion
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Increase in size and tortuosity o its blood vessels Bladder pressure (primigravidas) increased rom 8 cm H20 (early pregnancy) to 20 cm H20 (at term). Absolute and unctional urethral lengths INCREASED Maximal intraurethral pressure INCREASED rom 70 to 93 cm H20, thus continence is maintained End o pregnancy changes: Entire base o blader is pusched orward and o upward, converting normal convex surace to concave due to presenting part Pressure o presenting part impairs drainage o o blood and lymph rom the bladder base which may lead to edema, and susceptibility to trauma and inections GASTROINTESTINAL TRACT Appendix displaced upward and laterally as the uterus enlarges, and it may reach the ank Gastric emptying time is UNCHANGED. During labor and administration o analgesic agents, it becomes prolonged. General anesthesia may cause regurgitation and aspiration during delivery. Pyrosis (heartburn) – reux o acidic secretions into the lower esophagus due to: Altered position o o the stomach o Decreased LES tone o Intraesophageal pressures are lower compared o to intragastric pressures Esophageal peristalsis has lower wave speed o and lower amplitude Gums may become hyperemic and sotened and
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Enlarges by approximately 135% but rarely cause visual disturbance rom compression o optic chiasma Not essential for maintenance of pregnancy
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1. Grow Growth th Horm Hormon one e (GH (GH)) First trimester – secreted predominantly rom o maternal pituitary gland; serum and amniotic uid concentrations are within nonpregnant values (0.5 to 7.5 ng.ml) At 8 weeks AOG – growth hormone secreted by o placenta becomes detectable At 17 weeks AOG – placenta is the pr incipal o source o growth hormone secretion Maternal serum levels plateau ater 28 weeks o at 14 ng/ml Amniotic uid levels peak at 14 to 15 weeks o and slowly declines to reach baseline values ater 36 weeks. Maternal GH o Correlate positively with birthweight and negatively with etal growth restriction & uterine artery resistance Placental GH o Diers rom pituitary GH by 13 AA residues Secreted by syncitiotrophoblasts in a nonpulsatile ashion Appears to have some inuence on fetal growth as well as the development o preeclampsia Major determinant o maternal insulin resistance ater midpregnancy Fetal growth progresses in the −
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Thyroid gland undergoes moderate enlargement enlargement as a result o glandular hyperplasia and increased vascularity. vascularity. Volume increase rom 12 ml (frst trimester) to 15 ml (at term) Normal pregnancy does not typically cause signifcant thyromegaly. thyromegaly. Goiter should be investigated. Thyroxin-binding globulin – increases in the frst trimester and reaches its zenith at about 20 weeks, and stabilizes at approximately double baseline values or the remainder o pregnancy Total Total serum thyroxine – INCREASE sharply between 6 and 9 weeks and reaches a plateau at 18 w eeks Free Free serum T4 – rise slightly and peak along with hCG levels, and return to normal Total Total triiodothyronine (T3) – INCREASE up to 18 weeks and plateaus. Thyroid-releasing hormone (TRH) – are NOT INCREASED, but CROSSES the placenta and may stimulate the etal pi tuitary to secrete thyrotropin TSH and hCG has identical a-subunits, thus hCG has intrinsic thyrotropic activity and cause thyroid stimulation. Thyroid-stimulating hormone (TSH) or or thyrotropin DECREASES in more than 80% o pregnant women, but remain normal or non-pregnant women. Normal suppression o TSH may lead to a misdiagnosis o subclinical HYPERTHYROIDISM. HYPERTHYROIDISM.
c. Parat arathy hyro roid id glan glands ds Regulation o calcium concentration is closely •
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o
calcium rom bone and absorption rom the intestines Conversion to active Vitamin D3 Ingestion o Vit D or synthesis in the skin LIVER – Vitamin D converted to 25-OH Vit D3 KIDNEY, DECIDUA & PLACENTA – 25-OH Vit D3 converted to 1, 25 diOH Vit D3 (biologically active orm) which is INCREASED in pregnancy. PTH, low calcium and phosphate levels acilitates conversion o 25-OH Vit D3 to 1, 25 diOHVit D3 Calcitonin OPPOSES conversion o Vit D to its active orm.
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d. Adrenals Adrenals – undergo undergo little little morpho morphologic logical al change 1. Cort Cortis isol ol – INCR INCREA EASE SED D Much o serum cortisol is bound by transcortin o (cortisol-binding globulin) Rate o adrneal cortisol secretion is not o increased, and probably it is decreased compared with that o the nonpregnant state. Metabolic clearance rate is LOWER during o pregnancy because its hal-lie is nearly doubled. During early pregnancy – ACTH levels are o reduced strikingly As pregnancy progresses, ACTH and ree o cortisol rises Elevation in cortisol may be a result o o “resetting” “resetting” o the maternal eedback
Pelvic joints normally relax, particularly the symphysis pubis. Most relaxation takes place in the frst hal o pregnancy. Symphyseal separation greater than 1 cm may cause signifcant pain. Regression begins immediately ollwing delivery, and it is usually complete within 3 to 5 months.
Eyes Intraocular pressure decreases during pregnancy, attributed to increased vitreous outow. outow. Corneal sensitivity is decreased, particularly late in gestation Slight increase in corneal thickness due to edema. Krukenberg spindles – brownish-red opacities on the posterior surace o the cornea – have been observed duri ng pregnancy. pregnancy. Visual unction is unaected by pregnancy, except or transient loss o accommodation. •
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CNS •
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Women oten report problems with attention, concentration, and memory throughout pregnancy and the early postpartum period. Attention and memory were improved in women with preeclampsia receiving magnesium sulate compared with normal pregnant women (Rana and associates, 2006). Mean blood ow in the middle and posterior cerebral arteries decreased progressively rom non-pregnant state to late in the 3 rd trimester. Unknown clinical signifcance (Zeeman and coworkers, 2003)
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Established through signs and symptoms, chorionic gonadotropin, ultrasound recognition Signs and symptoms o pregnancy Sign or Comments symptom Occurs 10 days ater expected menses One to two episodes o bloody Cessation discharge, reminiscent o of menses menstruation, can be due to blastocyst implantation or “implantation bleeding” Fern-like Fern-like pattern – Day 7 to 18 o menses due to increased NaCl when estrogen is produced. Cervical Beaded pattern – Day 21 menses or mucus pregnancy due to decreased NaCl inuenced by progesterone that prohibit erning Breast tenderness and tingling o
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Fetal movemen ts
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with maternal pulse. Heard at lower portion o uterus produced by dilated uterine arteries. 18-20 weeks: Primigravid 16-18 weeks: Multigravid 20 weeks: examiner can begin to detect etal movements.
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Presumptive
Probable
Symptoms Nausea, vomiting Bladder requency/urgen cy Perception o etal movement Breast enlargement
Symptoms Abdominal distention Braxton-Hicks
Positive
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50 grams OGCT/100g OGTT Gonococcal or * Chlamydial culture HIV * *High-risk women
+ •
*
Components o Initial Prenatal Evaluation: A. Pren Prenat atal al Rec Recor ord d Terminologies Terminologies or prenatal record: record: a. Nulligravida. Woman who is NOT now and never has been pregnant. b. Gravida. Woman who is or has been pregnant, irrespective o the pregnancy outcome. With the establishment o frst pregnancy, she becomes primigravida, and with successive pregnancies, a multigravida. c. Nullipara. Woman who has never completed a pregnancy beyond 20 weeks gestation.
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(SIDS), placental abruption, placenta previa, premature rupture o membranes Ethanol: potent teratogen and causes etal alcohol syndrome, characterized by growth restriction, acial abnormalities and CNS dysunction. Illicit drugs include opium derivatives, barbiturates and amphetamines which may cause etal distress, low birthweight. Domestic violence reers to violence against adolescent and adult emales within the context o amily or intimate relationships.
C. Physical examination. Includes speculum and pap smear, digital pelvic examination and rectal exams. D. Laboratory tests . Reer to table above. Iron status or women during pregnancy and the postpartum period. (CPG on Iron Defciency Anemia, November 2009) Iron Iron •
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[email protected] o
o
o
Diagnosis o OVERT DIABETES is given among women with any o the ollowing results in their frst visit. FBS > 126 mg/dl (7 mmol/L) RBS > 200 mg/dl (11.1 mmol/L) HbA1c > 6.5% 2 hour 75 g OGTT > 200 mg/dl (11.1 mmol/L) Diagnosis o GDM is made i any one (1) o the ollowing pl asma values are exceeded: FBS > 92 mg/dl (ADA/IADPSG/POGS 1 hour > 180 mg/dl 2 hour > 153 mg/dl (ADA/IADPSG) or > 140 mg/dl (WHO/POGS) For Filipino Filipino gravidas with no other risk actors aside rom race or ethnicity and the initial test (FBS, HbA1c or RBS) is normal, screening or GDM should be done at 24-28 weeks using a 2 hour 75 gram OGTT. OGTT. I there are other risk actors identifed, screening should proceed
Category Underwei ght Normal Overweig ht Obese
BMI (AsiaPacifc) 29
5 – 9.1
III. Nutrition Calories
Protein
2000 calories/day + 300 kcal/day (2nd & 3rd trimester) 9 grams/day Protein defciency may lead to lowering o hemoglobin-producing actors in the liver, which may result in hypochromic anemia. Absorption o calcium rom intestinal tract may be
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3. 4. 5. 6. 7. 8.
Breas Breastt milk milk never never goes goes sour sour or bad bad in the bre breast ast even i a woman does not eed her baby or some days. Breas Breaste teedi eding ng helps helps to stop stop bleedi bleeding ng ater ater delivery. Breas Breaste teedi eding ng on deman demand d helps helps to prote protect ct against another pregnancy. It helps helps them them to bond, bond, becom become e attach attached ed to each each other and love each other. It is is ree. ree. You don’t don’t have have to buy buy it. It is excl exclusi usively vely or or your your baby baby and and cannot cannot be be served to other adults.
Protective Eects on Infants of Human Milk and Breast Feeding (AAP, 1997) Decreased Possible protective Incidence/Severity eects Diarrhea Sudden inant death Lower respiratory inection syndrome Otitis media Type-1 Type-1 Diabetes Bacteremia Inammatory bowel
V. How should breastfeeding begin. (DOH, 1991) 1. Firs irst eed First eed should be on the delivery table. Cover both mother and baby to keep them warm. Let the mother hold the baby close and let hi m suck at the breast. Sucking stimulates the production o oxytocin which helps to deliver the placenta and stop hemorrhage. Baby gets valuable colostrums. More likely to breasteed or a long time. A delay o even a ew hours will result in ailure to breaseed. • •
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Rooming-in There is no need or a mother and baby to rest rest separately ater a normal delivery. delivery. 3. Dem Demand and e eedin eding g Let the mother pick up her baby and eed him •
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TOPNOTCH MEDICAL BOARD PREP OB SUPPLEMENT HANDOUT BY CHRISTOPHER JOSEPH SORIANO, MD For inquiries visit www.topnotchboardprep.co.nr or email us at
[email protected] •
The skin becomes dry and is more easily easily damaged and fssured.
FAMILY PLANNING Fertility Awareness-based (FAB) Methods Family planning methods that attempt to identiy ertile time each cycle and then modiy sexual behavior. Natural amily planning (NFP) reers to sexual abstinence during the ertile time. Fertility awareness-combined methods (FACM) (FACM) reer to using barrier method during the ertile time. Various methods o periodic abstinence have pregnancy rates estimated rom 5 to 40 per 100 woman years. The unwanted pregnancy rate during the frst year o use is approximately 20%.
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Standard Da Days Me Method Developed by the Institute or Reproductive Health at Georgetown University
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Cerv Cervic ical al Mucu Mucus s Rhyt Rhythm hm Meth Method od Also called “Billings method”, developed by John Billings, depends on awareness o vaginal “dryness” and “wetness”. These are the consequences consequences o changes in the amount and quality o cervical mucus at dierent times in the menstrual cycle. The ertile mucus is brought about byt increasing increasing levels o estrogen and the inertile mucus by the increase in progesterone. Dry days ater the menses are the indicators o the preovulatory phase or the frst inertile phase, which are relatively inertile days. Wet days signal the ovulatory phase and are thereore ertile days. The ertile type mucus is more copious, slippery/lubricative, stretchy and wet. At times, it has the appearance o raw egg white. This mucus makes it easy or the sperm to travel through the cervix, uterus and the tubes to meet the egg. Last day o the wetness is called the peak day. day. Its
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TOPNOTCH MEDICAL BOARD PREP OB SUPPLEMENT HANDOUT BY CHRISTOPHER JOSEPH SORIANO, MD For inquiries visit www.topnotchboardprep.co.nr or email us at
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actors. Thus, prevents pituitary secretion o FSH and LH. Progestins action: i. Preve Prevent nt ovul ovulati ation on by by suppr suppress essing ing LH ii. Thick Thicken en cervic cervical al mucus mucus,, thereb thereby y retarding sperm passage. iii. iii. Rend Render er the the end endom omet etri rium um unavourable or implantation.
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Displays antiadrogenic activities Provides antialdosterone action to minimize water retention Antimineralocorticoid properties that may cause potassium retention and hyperkalemia. Serum potassium level monitoring or the frst month is
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barbiturates, primidone, and topiramate (Topamax) Metabolic changes COCs increase serum levels o o triglycerides and total cholesterol. Estrogen decreases LDL o Estrogen increases HDL and VLDL o OCP are NOT atherogenic o Women with LDL >160 mg/dl or with o
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For all women, VTE risk with drospirenone-containing COCs has been shown.
Neoplasia Overall, COCs are not associated with an increased risk or cancer. Protective eect against ovarian and o endometrial cancer o
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TOPNOTCH MEDICAL BOARD PREP OB SUPPLEMENT HANDOUT BY CHRISTOPHER JOSEPH SORIANO, MD For inquiries visit www.topnotchboardprep.co.nr or email us at
[email protected] o
o
o
Branches o the medial antebrachial cutaneous nerve can be injured i the implant or insertion needle is placed too deeply or i exploration or a lost implant is aggressive. Numbness and paresthesia over the anteromedial aspect o the orearm Nonpalpable devices may require radiological imaging or localization
4. Need Need or or tran trans sus usio ion. n. Problems with the above defnitions: 1. Clinica Clinicall estimat estimation ion o blood blood loss loss is requ requent ently ly inaccurate and the brisk nature o blood loss during delivery or the presence o amniotic uid can make this more dicult. 2. Delay in obtaini obtaining ng laborat laboratory ory results. results. Inormatio Inormation n rom laboratory tests would not reect the
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ties o coagulatio n)
abnormalities (e.g. hemophilia, vonWillebrands disease, hypofbrinogenemi a) DIC HELLP
liver disease
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Sepsis Intrauterine demise
Spontaneous or assisted breech delivery is acceptable. Fetal manipulation applied ater spontaneous delivery to the level o umbilicus. Nuchal arms may be reduced by Lovset maneuver .
Suspected breech Pre- or early labor ultrasound to assess type o o breech, etal growth, EFW, attitude o etal
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Labor & vaginal delivery is NOT CONTRAINDICATED CONTRAINDICATED or women with EFW up to 5 kg in the absence o maternal DM Indication or CS: >4,500 g, and o prolonged 2nd stage or arrest o descent in 2 nd o stage Prophylactic CS: EFW > 5,000 g (w/o maternal DM) o
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Cleidotomy – deliberate racture o the anterior clavicle to ee the shoulder impaction. Symphysiotomy – intervening symphyseal cartilage and much o its ligamentous support is cut to widen the symphysis pubis
GUIDELINES FOR CESAREAN SECTION Indications
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