Alterations in Reproductive Function

HPO axis

hypothalamic pituitary ovarian axis; hormonal feedback for reproductive system

Menarche

 first menstrual cycle

Os

opening from uterus through cervix into vagina, dilation measure shows labour progress

Fundus

top of uterus

Fundus can be measuring point for

fetus growth (symphysis-fundal height)

After delivery the fundus is palpated to monitor

resolution phase

Define infertility

fail to become pregnant after 1yr of unprotected intercourse (6 months for 35+ yo)

What does IUI stand for and describe this

intra uterine insemination; catheter into uterus via vagina and cervix so semen can be instilled into uterus

What does IVF stand for and describe

in vitro fertilization

ova and semen collected and mixed together, 3-5 days later 1-2 growing embryos returned to uterus, remaining fertilized ova can be frozen for future attempts

Prenatal meaning

conception to birth (antenatal period)

Postnatal meaning

delivery to complete resolution of the body to pre-pregnant state (6-8 weeks)

parity

number of deliveries the woman has had over 20 weeks gestation

Define grand mutiparity

parity >5

Go through what each letter stands for in GTPAL and describe each.

• G gravida: ALL pregnancies (total pregnancies regardless of outcome)

• T term: deliveries over 37 weeks gestational age

• P preterm: deliveries between 20 and 36 weeks and 6 days gestational age

• A abortions: spontaneous (occur on own) or therapeutic (by surgical intervention). Including miscarriage (spontaneous)

• L living children

When calculating GTPAL first thing to do

check if client currently pregnant. Include this on top of the history (so if pt has 4 previous pregnancies and is currently pregnant, G = 5)

Benchmark for term delivery

37 weeks

Define still birth

fetus born unalive

Macrosomia

fetal head size has grown larger than can be passed vaginally

polyhydramnios

amount of amniotic fluid more than 2 standard deviations above norm for gestational age

Pre-term vs term vs post-term infant

Pre-term infant before 37 wks (36 weeks and 6 days)

Term infant between 37-42 wks

Post-term infant after 42 wks

When does sexual differentiation of embryo occur and what is it determined by

around week 7 gestation

determined by sex chromosome (XX = female, XY = male)

Testes determining factor

SRY protein on male (Y)

what produces secondary oocytes and estrogen, progesterone, inhibin, relaxin

ovaries

Ovaries at birth vs after puberty

At birth: contain primary oocytes

Secondary oocytes formed after puberty during ovulation

Usual fertilization sites of oocytes

uterine (fallopian) tubes

Describe the uterine layers

endometrium (inner lining)

myometrium (middle muscle)

perimetrium (outer protective)

Does the position of the uterus remain the same throughout the lifetime?

yes

With puberty onset hypothalamic neurosecretory cells release ____ > binds to anterior _____ cells (______) > stimulates them to increase ___ and ___

GnRH

pituitary gonadotropes

FSH LH

FSH role

stimulates growth of follicles of ovaries to produce estrogen, progesterone and inhibin

LH role

stimulates ovulation (LH surge > corpus luteum formation)

Estrogen role

Development and maintenance of reproductive structures, and secondary female characteristics (adipose tissue deposition, voice pitch, broad pelvis, hair growth)

2 other estrogen roles

• Can work with growth hormone, can increase protein synthesis (bones)

• Lowers blood cholesterol

Progesterone produced by what and role

by corpus luteum in last two weeks of menstrual cycle, works with estrogen to prepare and maintain endometrium and mammary glands for lactation

Relaxin produced by what and role

by corpus luteum relaxes uterine smooth muscle

Inhibin produced by what and role

by follicle granulosa cells, work with estrogen and progesterone to stimulate or inhibit FSH and LH release

Normal cycle length range

24-36 days

Biggest variation in cycles usually during what phase

pre-ovulatory

describe day 1-5 phase

MENSTRUAL

• uterus sheds all but deepest layers of endometrium, 50-150ml blood, tissue, fluid

  • Discharge due to decreased progesterone and estrogen

  • Ovarian hormones are at the lowest > GnRH > FSH and LH

Describe day 6-14 phase

VARIABLE PRE-OVULATORY

• FSH influence, maturation of dominant follicle

  • Proliferative phase: estrogen promotes endometrial growth

When does ovulation occur and describe

~day 14

secondary oocyte released, leftover cells in ovary become corpus luteum > estrogen, progesterone, inhibin, relaxin

Describe day 15-28 phase

POST-OVULATORY

• progesterone and estrogen by corpus luteum > growth and coiling, endometrium thickening (prep for fertilized ovum)

• Without fertilized ovum > corpus luteum degenerates > decreased progesterone

• Decreased progesterone > menstruation

Describe: zygote, blastocyst, embryo, fetus

• Zygote fertilized ovum

• Blastocyst >2 wks collection of rapid proliferating cells

• Embryo 2-8 wks embryo

• Fetus 8wks-birth

What must fertilized zygote do in order to achieve pregnancy

penetrate into endometrial layer of uterus

During day 10-12 post-fertilization rise in, what is the importance of this?

beta subunit of glycoprotein human chorionic gonadotrope hormone (hCG)

Marker to detect pregnancy in urine and blood

How long after implantation do trophoblasts start to produce hCG

a few hours

Roles (2) of hCG

1. Maintains corpus luteum

2. Produces progesterone > support and thicken uterine lining

What is sloughing

hCG insufficient, corpus luteum regresses, progesterone drops

hCG pattern in early pregnancy

doubles every two days (typically)

Blood vs urine test

Blood test more sensitive to smaller levels of hCG then urine test

Best to use first void in morning

Why do some women experience spotting or light bleed around time next menses is due

Potential implantation bleed from burrowing of zygote through endometrial layers

Embryogenesis

rapid development of ectodermal, endodermal and mesodermal layers for all structures and systems in embryo and fetus

By end of __ week gestation, all major structures and pathways formed and remainder of pregnancy is more about ?

13th

growth and fine-tuning

Which trimester most important

First

What two layers form the chorion membrane

• Inner layer from ectoderm

• Outer layer is mesoderm

Inner layer from ectoderm becomes _______ which does what

Trophoblast

creates small finger-like projections to uterine myometrium to start forming chorionic villi

Outer layer mesoderm does what

fills in projections with branches of umbilical vessels

What happens next in development at 8-10 weeks

Placenta develops and take over producing progesterone and hCG > corpus luteum degenerates

What happens in development at 10-14 weeks

chorionic villi and intervillous spaces or maternal sinuses has blood which facilitates nutrient and gas exchange

Provider of all fetal nutrition during pregnancy

Placenta

Placenta is formed by

week 10 gestation

Overall role of placenta

filters nutrients, oxygen and fetal waste products by diffusion between mother and fetus

Define lochia flow

after baby delivered at placenta attachment location (healing)

Define amnion

membranous sac surrounds developing fetus

Amnion becomes fluid filled by

week 4 or 5

Amniotic fluid (liquour) continues to accumulate to about, then what

1-2L at term > amniotic sac opens (water breaks)

(2) of fluid are assessed of amniotic fluid, why

Quantity, colour

Determine if fetus has passed meconium prior to birth

(baby can aspirate if it inhales own first stool)

What different amniotic fluid appearances mean

Thin, light-green fluid: older, historical passage of meconium or a mild episode that carries a lower risk of severe airway blockage.

Thick, "pea-soup" green fluid: recent or heavy passage of stool. Thick meconium is highly dangerous because it can easily plug the baby's airways. > Preparation for Meconium Aspiration Syndrome (MAS)

Polyhydramnious defined, can lead to, potential for

excessive amniotic fluid around fetus

poor descent of presenting part into the pelvis

prolapse of umbilical cord

Polyhydramnious associated with

gestational diabetes

Gestational HTN can be associated with ________ (define), which can lead to

oligohydramnious (too little fluid around the baby) > intolerances such as fetal heart decelerations

Third stage of labour

placenta delivery

What is the cord inspected for during the third labour stage

three vessels (1 vein, 2 arteries)

Umbilical veins vs arteries

Umbilical vein carries oxygenated blood to fetus

two umbilical arteries remove deoxygenated blood AWAY from fetus to placenta (waste management site)

When is placenta sent to pathology for histological studies (3)

If baby is small <2500 grams at full term birth, or placenta does not appear normal, or post dates (born after 41 weeks gestation)

Difference between velamentous (circumvallate) cord insertion, vasa previa (succenturiate), and placenta accreta

• Velamentous (circumvallate) cord insertion major umbilical vessels separate in fetal membranes first  before reaching placenta, vessels unprotected through membranes

• Vasa previa (succenturiate) accessory lobe of placenta, vessels unprotected over/near cervix 

• Placenta accreta from lack of formation of normal decidual plate

  • Chorionic villi abnormally extend into myometrium, placenta can’t separate normally after delivery > severe hemorrhage

Velamentous (circumvallate) cord insertion could lead to

greater chance for cord trauma and bleeding on delivery

Decidual plate usually

does not extend past endometrium (in accreta it does > stuck)

Cellular boundary of maternal side of placenta and uterus

Risk factors for development of placenta previa (4)

grand multiparity, recurrent abortions, miscarriages or uterine surgery

Placental previa

placenta forms so that it is covering the uterine os

Major risk of placental previa, what is recommended to avoid this

Antepartum hemorrhage

Complete pelvic rest

Describe the 4 different types of placental previas

1. Complete placenta previa: placenta completely covers the internal os

2. Partial placenta previa: placenta partially covers the internal os.

3. Marginal placenta previa: placenta just reaches internal os, but does not cover it

4. Low-lying placenta: placenta extends into lower uterine segment but does not reach the internal os.

Screening done for placenta positions - describe and when is this done

Antenatal ultrasound placenta commented on done at 18-20 wks gestation

If there is a finding of abnormal placentation what is done next

They measure how close the leading edge of the placenta is to uterine os > delivery options

Delivery options for different types of placental previas

• Complete os coverage > c-section

• Low lying or marginal > consider vaginal delivery usually with a double set-up (prep to perform c-section at a moments notice)

Key hormonal changes in pregnancy (4)

rise in estrogen

rise in progesterone

appearance of hCG and placental proteins

_______ mainly maintains the corpus luteum of pregnancy

beta-hCG

beta-hCG also does what

stimulates maternal thyroid gland to increase circulating thyroid hormones

Role of maternal thyroxin

crosses placenta and facilitates fetal development

Sometimes maternal thyroid dysfunction can be associated with increased risk of (5)

preeclampsia, gestational HTN, low birth wt, preterm delivery, perinatal morbidity

What is human chorionic somatomammotrophin (hCS)

protein hormone with immunological and biological similarities to pituitary growth hormone

hCS ______ hormone for pregnancy with ________ characteristics

growth

anti-insulin (decreases glucose uptake and increases free fatty acids) and prolactin-like (lactinogenic bioactivity)

Where is hCS found

maternal circulation (very little reaches fetal circulation)

(makes sense given prolactin bioactivity)

hCS is the glycoprotein responsible for

maintaining corpus luteum

hCS alpha VS hCS beta

• hCS alpha fertility treatments to promote ovulation

• hCS beta measured with pregnancy tests

Role of human chorionic corticotropin (hCC)

ACTH-like placental hormone (stress response)

releases cortisol

Where is hCC found

Levels in both maternal and fetal circulations

What protein measured for Down’s syndrome screening

PAPP-A

Trend of placental CRH throughout pregnancy and does what during labour?

CRH increases throughout pregnancy and peaks during labour

CRH has major role in, as well as

parturition timing (smooth muscles relaxing, formation of prostaglandins)

Fetal lung maturation and development of fetal surfactant

How is cortisol associated with fetal lung maturation

signals lungs to start producing surfactant