Reproduction Week 3

Front 1

Functions of the placenta

Back 1

• Transport/Exchange of gases, nutrients and waste products between M-F circulations

• Endocrine

Front 2

Which hormones does the placenta make?

Back 2

• Progesterone - placenta takes over production from corpus luteum after ~10 weeks
• Oestrogen – placenta lacks enzyme to make directly – cooperates with foetus to make eostrogens

• hCG

• Placental lactogen

Front 3

Function of hCG

Back 3

rescue Corpus Luteum from luteolysis

Front 4

Function of placental lactogen

Back 4

(chorionic somatotropin, hCS) is growth promoting, low lactogenic activity, stimulates maternal metabolism (lipolysis and insulin antagonism)

Front 5

Direct Maternal Death

Back 5

– Death of a woman during pregnancy, childbirth or in the 42 days of peurperium. (WHO)
– Result from obstetric complication of pregnancy, labour and peurperium
– Eclampsia, Postpartum Haemorrhage, Amniotic Fluid embolism

Front 6

Indirect Maternal Death

Back 6

– Result from pre‐existing disease or disease that develops during the pregnancy
– Aggravated by physiological changes in pregnancy
– Cardiac disease, renal disease

Front 7

Incidental Maternal Death

Back 7

– Pregnancy unlikely contributed to death
– Suicide, MVA

Front 8

Maternal mortality ratio

Back 8

– No. of deaths (Direct+ Indirect) per 100000 live births
– Risk of death once a woman falls pregnant

*this is the one we use

Front 9

Maternal mortality rate

Back 9

– No. of deaths (Direct + Indirect) per 100000 of women in the reproductive age
– Risk of death due to exposure to fertility

Front 10

Why do women die in developing countries?

Back 10

–Bleeding
–Infection
–Pre‐ eclampsia/ Eclampsia
–Unsafe abortion

Front 11

Top 5 direct causes of death in Australia

Back 11

1. Amniotic fluid embolism
2. VTE
3. Obstetric Haemorrhage
4. Eclampsia
5. Sepsis

Front 12

Top 3 indirect causes of death in Australia

Back 12

– Cardiac 26.3%
– Psychosocial 22.8%
– H1N1 Influenza 5.3%

Front 13

Things to cover in antenatal history

Back 13

• Diagnosis of pregnancy

• Symptoms of Pregnancy Complications

• Gynaecological History

• Obstetric History

• General Medical History

• Surgical history

• Medications

• Allergies
• Substance abuse
• Social History

Front 14

Important things in gynaecological history

Back 14

– Menstrual History
• LMP, Cycle irregularities
– Pap smear
– STD/ PID
– Fibroids, endometriosis, Polycystic Ovarian Syndrome

Front 15

Initial pregnancy examination

Back 15

• General
– Appearance, BMI, Vitals
• Thyroid
• CVS
– Heart Murmurs
• Abdominal
– Scars, Masses, Rash, Fundal Height
– Fetal Heart Rate
• Vaginal exam
– Pap smear
– PV bleeding
– Lesions

Front 16

Routine 1st visit antenatal screening

Back 16

1. FBC
• Anaemia, Haemogloginopathies (Thallasemia), Platelet discorders
2. Group and Antibodies
• Rh Status (Anti D)
• Risk of Fetal Haemolystic Disease
3. Serology
• HIV, Hep B, Hep C, Syphilis, Rubella
4. MSU
• Exclude asymptomatic Bacteruria which can cause preterm labour

Front 17

Screening at 11-13+6 weeks pregnancy

Back 17

– Fetal Aneuploidy Screening
• Nuchal Translucency Screening (Ultrasound/ Blood tests (PAPP‐A/ hCG)

– Prenatal Blood Screening

Front 18

Screening at 18- 22 weeks

Back 18

– Morphology Scan and Placental Location

Front 19

Screening at 24-28 weeks

Back 19

– Oral Glucose Tolerance Test
– FBC, Blood Group and Abs

Front 20

Screening at 35 weeks

Back 20

– Group B Strep Screening (Low Vaginal Swab)

Front 21

Why screen for Group B strep in mother?

Back 21

Group B strep is part of normal vaginal flora for mother but can cause infection in newborns who do not yet have antibodies to it

Front 22

Screening 36 weeks

Back 22

FBC/ Blood Group & ABs

Front 23

Frequency of visits during pregnancy

Back 23

• Every 4 weeks to k28, then
• Every 2 weeks to k36, then
• Every week till delivery

Front 24

What do we assess in each visit during the 2nd and 3rd trimester?

Back 24

• Events since last visit (pain, bleeding)
• Fetal movements
• Urinalysis
• Blood pressure
• Abdominal exam
– Symphysio‐Fundal Ht
• Ht in cm = Gestational weeks
– Clinical amniotic fluid assessment
– Fetal Presentation, lie, station
– Fetal Heart Rate

Front 25

Dietary advice for pregnant women

Back 25

• Recommendations
– Folic acid 400mcg/day in low risk
– Iodine 150mcg/day
• Iron needs increased
– Red meat and green leafy vegetables
– Routine iron supplementation/ Tablet is not indicated
• Avoid Listeriosis risk
– Pate, soft cheeses, unpasteurised milk
• Avoid Salmonella risk
– Raw poultry, raw egg products
• Avoid toxoplasmosis risk
– Wash vegetables

– Hand hygiene

Front 26

Placental villi are formed by which cell layer?

Back 26

Cytotrophoblast cell layer

Front 27

Placental villi are covered by which cell layer?

Back 27

Syncytiotrophoblastic layer

Front 28

Placenta Previa

Back 28

attachment of placenta too close to cervix

Front 29

Human Placenta – Structural Characteristics

Back 29

- Discoid

- Villous

- Hemochorial

- Multivillous Flow

Front 30

Intra-Uterine Growth Restriction (IUGR)

Back 30

Results from "under-invasion" of placental spiral arteries leading to reduced placental perfusion

Front 31

Transformation of the Spiral Arteries

Back 31

Involves dilation of the artery lumen, trophoblast invasion of the vessel wall, replacement of the muscular and elastic tissue of the arterial wall (media) by a thick layer of fibrinoid material

Front 32

What is pre-eclampsia associated with from a placental perspective?

Back 32

aberrant invasion of the trophoblast and failure
of complete spiral artery transformation

Front 33

When do syncytiotrophoblasts begin producing hCG?

Back 33

about 6-7 days post-conception

Front 34

What is the role of hCG in early development?

Back 34

It prevents luteolysis (destruction of the corpus luteum) by binding to LH receptors

Front 35

When does the placenta commence progesterone synthesis?

Back 35

Around 6 weeks

Front 36

Role of progesterone in pregnancy

Back 36

•maternal recognition of pregnancy, implantation, decidualisation
•maintain uterine and placental integrity and
synthetic capacity
•fetal tranquiliser
•maternal effects (increased appetite, fat
deposition, tranquilise, mammary development)
•modifies immune response

• quiescence of myometrium (quiets oxytocin and prostaglandins)

Front 37

Role of estrogen in pregnancy

Back 37

• uterine function and growth
• mammary growth
• myometrial growth (hypertrophy) and increased sensitivity to uterotonins (E stimulates the
expression of CAPs)

Front 38

Can the placenta convert progesterone through to oestrogen?

Back 38

No, estrogens are created in the placenta from DHEA-S, which comes from either the mother or the fetus

Front 39

Which estrogen is used as measure of fetal viability?

Back 39

Maternal plasma oestriol (unconjugated E3 or UE3); because its production is dependent on the normal function of the adrenal fetal gland & liver, and the placenta

Front 40

Alpha-fetoprotein (AFP)

Back 40

osmoregulator to help adjust fetal intravascular volume

Front 41

What do elevated levels of AFP indicate? Decreased levels?

Back 41

ELEVATED: neural tube defects

DECREASED: Downs syndrome

Front 42

Which changes in hormone levels can be indicative of Downs syndrome?

Back 42

Low ms AFP, elevated hCG, and low UE3 levels (triple screen)

Front 43

Somatomammotrophs

Back 43

• from syncytiotrophoblasts
• secreted into maternal plasma
• regulate maternal metabolism and breast development
• structurally similar to pituitary prolactin and GH

Front 44

Pueperium

Back 44

• From time of delivery of baby and placenta to 6 weeks after delivery
• Return to pre-pregnancy physiological state of most systems

Front 45

How soon after delivery do coagulation factors normalize?

Back 45

8 weeks postpartum

Front 46

How long does ureteral dilation last post delivery?

Back 46

6-12 weeks

Front 47

Why do pregnant women suffer from problems in the GI tract?

Back 47

Progesterone inhibits motilin which has a role in peristalsis

Front 48

Changes in reproductive hormones post-pregnancy

Back 48

• ßhCG: <5 within 2-4 weeks
• Low gonadotrophins & sex hormones in first few weeks

Front 49

Blood supply to breast during pregnancy?

Back 49

– doubles by 24/40
– Internal Mammary A. – 60%
– Lateral Thoracic A. – 35%

Front 50

Mammogenesis

Back 50

• Ductal sprouting & branching, cellular division & proliferation.
• HPL, Oestrogen, Prolactin

• Progesterone,Thyroid & Growth H

Front 51

Lactogenesis I

Back 51

•16 - 18 weeks secretory activity
• Prolactin, Insulin & Hydrocortisone

Front 52

Lactogenesis II

Back 52

• Onset of copious milk production
• 30-72 hrs post birth
• Occurs secondary to marked ↓progesterone

Front 53

Lactogenesis III

Back 53

• Maintenance of lactation
• Autocrine
• Depends on degree of breast fullness; infant
appetite;storage capacity;
• Feedback inhibition of lactation

Front 54

Unique properties of breast milk compared to cow milk

Back 54

1. Higher concentration of protein
2. Whey protein has a more physiologic balance of amino acids
3. Greater supply of medium- to intermediate- chain fatty acids
•making it more specific to the preterm infant
4. Increased bioavailability of lactose content
5. Higher levels of immune factors
• immunoglobulins & anti-inflammatory factors
6. Higher levels of energy
7. Higher levels of some vitamins and minerals

Front 55

Mastitis

Back 55

• Inflammation of the interstitial cells, cellulitis, can become an abscess
• Characterized by localized tenderness, redness, heat (non-infective), systemic reactions of fever, malaise, nausea and
vomiting (infective)
• Portal of entry is through lactiferous duct, nipple fissure or ineffective milk removal

* UNILATERAL

Front 56

High risk factors for mastitis

Back 56

– Lowered maternal resistance
– Tight clothing
– Missing a feed
– Weaning

Front 57

How do we treat mastitis?

Back 57

Feed from that breast + antibiotics

Front 58

How do we treat an abscess (as opposed to mastitis)?

Back 58

DO NOT feed from that breast! Need surgical incision and drainage + antibiotics