322367215 Ob Supplement Handout by Dr Chris Soriano 1

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]

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 Myrtiormes: 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 perorated 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 Impreorate hymen 

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

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 surace separated labia resembles the majora mucous membrane Gape widely Project beyond MULTIPAROU Inner surace the labia majora S WOMEN become skin like GLANDS (+) Hairollicles 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 [email protected]

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

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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 Signicance

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 piriormis 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

inerior rectal

external anal sphincter, the mucous membrane o the anal canal, and the perianal skin

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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] • •

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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  –  –

•

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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 –

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 –

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Upper vaginal vaults Subdivided into anterior, posterior, and two lateral ornices by the uterine cervix  –

•

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

• •

• • 

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 ater 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, Preerred Preerred portion or passes applying clips or gradually into emale sterilization the wider, Preerred Preerred 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

•

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

•

•

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 biurcates 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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

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•

•

•

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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 surace 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 Inerior mesenteric Lumbar and vertebral Middle sacral arteries Branches rom Deep iliac circumex the External Inerior epigastric artery Iliac Artery Branches rom Medial emoral circumex the Femoral artery Artery Lateral emoral circumex 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 •

• •

•

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 deerens 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

Seminierous 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 ater 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 die 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 ier erat atio ion n & die dierrenti 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 ater ater 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 ate aterr 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 ater 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 Eects 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 eec 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 surace to stimulate nitric oxide production, leading to its rapid vasoactive properties. •

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E. Prog Proges este tero rone ne ee eect cts s Progesterone enters cells by diusion 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: Prolierative 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 surace 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 pseudostratied 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 lietime o most women. Day 5 o menses – the epithelial surace 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 surace cells show decreased microvilli and cilia • • •

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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 inltration  by neutrophils, giving a pseudoinammatory 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, eectively initiating matrix degradation. •

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Anatomical events Marked changes in endometrial blood ow Coiling o spiral arteries becomes suciently 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-inammatory 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 surace 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 – transormation 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 ater 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 Dierentiates into two distinct cell layers, the Epiblast and Hypoblast, orming a Bilaminar Embryonic Disk Epiblast -clets 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) Suraces 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 Hobauer cells • • •

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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 eect, 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 eect 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 surace 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 (let 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 ater 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) Ater 8 weeks: Placenta (Syncytiotrophoblast) o Function: Aects tubal motility, the endometrium, o

Conditions that Aect 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 Sulatase Defciency

very low estrogen levels in otherwise normal

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Neonata l period

Period ater birth o an inant up to 28 completed days ater birth

Fetal period

Begins rom 8 weeks ater ertilization or 10 weeks ater onset o last menses menses

Embryo nic period

Commences beginning o the 3 rd week ater 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) Occipitorontal (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 circumerence 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 inerior pole o o the etus preerably 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 occipitorontal 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 ater 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 eects o alkali. Mother’r RBC are sensitive, thus may o hemolyze •

FETAL PULMONARY SYSTEM

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Presence o suractant in the amnionic uid is evidence o etal lung maturity (ater 34 weeks) Suractant 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 ater 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 eor eorts ts,, it is appr apprec ecia iabl bly y greater greater.. The pregnancy pregnancy-induce -induced d increase increase is lost ater 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 thereater. thereater. 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 eec eects 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 modiying 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 circumerence circumerence increases about 6 cm, but not suciently 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 shits 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 unaected 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 dierence 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 sot sot 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 pero perora 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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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] •

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Cervical Mucus is rich in Ig and cytokines and may act as an immunological barrier to protect uterine contents against inection. 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 aecti aecting 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 ater 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 eects o impaired venous return in the supine and erect positions Saeguards the mother against the adverse o eects 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 Inammatory environment is required to secure cellular debris removal and adequate repair o the uterine epithelium Midpregnancy (anti-inammatory) o Period o rapid etal growth and development Parturition (recrudescence o inammatory o process) Inux o immune cells into the myometrium Suppressed activity:  T-helper  T-helper (Th) 1 cells o decreases secretion o IL-2, intereron-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, intereron-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

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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 surace 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 inections 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) – reux 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 sotened and

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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] •

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 ater 28 weeks o at 14 ng/ml Amniotic uid levels peak at 14 to 15 weeks o and slowly declines to reach baseline values ater 36 weeks. Maternal GH o Correlate positively with birthweight and negatively with etal growth restriction & uterine artery resistance Placental GH o Diers rom pituitary GH by 13 AA residues Secreted by syncitiotrophoblasts in a nonpulsatile ashion Appears to have some inuence on fetal growth  as well as the development o preeclampsia Major determinant o maternal insulin resistance ater 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-lie 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 outow. outow. Corneal sensitivity is decreased, particularly late in gestation Slight increase in corneal thickness due to edema. Krukenberg spindles – brownish-red opacities on the posterior surace o the cornea – have been observed duri ng pregnancy. pregnancy. Visual unction is unaected by pregnancy, except or transient loss o accommodation. •

•

• •

•

CNS •

•

•

Women oten 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 sulate 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 ater 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 inuenced by progesterone that prohibit erning Breast tenderness and tingling o

•

•

Fetal movemen ts

• • •

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.

•

•

•

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.

•

•

(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 dysunction. Illicit drugs include opium derivatives, barbiturates and amphetamines which may cause etal distress, low birthweight. Domestic violence reers 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 . Reer 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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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 Breaste teedi eding ng helps helps to stop stop bleedi bleeding ng ater ater delivery. Breas Breaste teedi 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 Eects on Infants of Human Milk and Breast Feeding (AAP, 1997) Decreased Possible protective Incidence/Severity eects Diarrhea Sudden inant death Lower respiratory inection syndrome Otitis media  Type-1  Type-1 Diabetes Bacteremia Inammatory 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 breasteed or a long time. A delay o even a ew hours will result in ailure to breaseed. • •

•

•

• •

2.

Rooming-in  There is no need or a mother and baby to rest rest separately ater 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 identiy ertile time each cycle and then modiy sexual behavior. Natural amily planning (NFP) reers to sexual abstinence during the ertile time. Fertility awareness-combined methods (FACM) (FACM) reer 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%.

IV. •

•

•

•

•

•

•

I. •

Standard Da Days Me Method Developed by the Institute or Reproductive Health at Georgetown University

•

•

•

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 dierent times in the menstrual cycle.  The ertile mucus is brought about byt increasing increasing levels o estrogen and the inertile mucus by the increase in progesterone. Dry days ater the menses are the indicators o the preovulatory phase or the frst inertile phase, which are relatively inertile days. Wet days signal the ovulatory phase and are thereore 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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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 unavourable or implantation.

•

•

•

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

o

•

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 eect against ovarian and o endometrial cancer o

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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 sus 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 dicult. 2. Delay in obtaini obtaining ng laborat laboratory ory results. results. Inormatio Inormation n rom laboratory tests would not reect the

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ties o coagulatio n)

abnormalities (e.g. hemophilia, vonWillebrands disease, hypofbrinogenemi a) DIC HELLP

liver disease

•

•

Sepsis Intrauterine demise

Spontaneous or assisted breech delivery is acceptable. Fetal manipulation applied ater 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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•

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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

o

o

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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