Reproductive Health & The Family

Female Reproductive Organs (Internal Genitalia)

• Suspensory ligament

• Fallopian tube

• Fimbriae: Fingerlike projections.

• Ovary

• Fundus of uterus

• Sacrum

• Perimetrium.

• Pouch of Douglas

• Posterior fornix

• Round ligament

• Urinary bladder

• Symphysis pubis

• Mons pubis

• Urethra

• Clitoris

• Labium minus

• Labium majus

• Cervix

• Anterior fornix

• Rectum

• Vagina: Muscular tube connecting the outside to the uterus.

• Urogenital diaphragm

• Anus

• Bartholin's gland

• Perineal Body

Uterus

• Pear-shaped organ.

• Located at the top of the uterus.

• Strongest muscle for birthing.

• Narrow opening.

• Fundus

• Uterine cavity

• Cornua

• Isthmus of fallopian tube

• Corpus (uterine body)

• Isthmus

• Perimetrium: Outermost layer.

• Myometrium: Muscles of the uterus.

• Endometrium: Innermost layer.

• Internal os

• Cervix

• External os

• Vagina

Uterine Ligaments

• Keep uterus centrally located.

• Supports and suspends from pelvis.

• Uterus is only attached at the cervix.

• Infundibulopelvic ligament (suspensory ligament of the ovary).

• Round ligament

• Broad ligament

• Ovarian ligament

• Uterosacral ligament

• Cardinal ligament

• Ovary

• Ovarian vessels

Fallopian Tubes

• Longest part of tubes, usually where a patient gets sterilized.

• Fertilization takes place here.

Fimbriae

• Finger-like projections that reach when released.

Cervix

• Supports the baby.

• Direct toward the true.

• What the baby has to fit through.

Endometrium

• Enlarge to receive blood to implant the baby.

• Expell Follicle.

• Final maturation.

Female Reproductive Cycle

• Anterior pituitary

• Ovarian cycle

• Ovarian hormones

• Endometrial changes during the menstrual cycle

• Functional layer

• Basal layer

• Uterine Phases:

  • Menstrual

  • Proliferative

  • Secretory

  • Ischemic

• Ovarian Phases:

  • Follicular

  • Luteal

• Hormones:

  • FSH (Follicle Stimulating Hormone)

  • LH (Luteinizing Hormone)

  • Estrogen

  • Progesterone

• Follicles:

  • Primary follicle

  • Secondary follicle

  • Graafian follicle

• Ovulation

• Corpus luteum

• Degenerating corpus luteum

• Nurse needs to Know cycle pattern

Four Phases of Uterine Cycle

• Menstrual: Days 1-6

  • Shedding of endometrial cells.

• Proliferative: Days 7-14

  • Endometrium and myometrium thicken due to increased estrogen.

  • Cervical mucus more elastic (Spinnbarkeit greater than 5 cm), thin, clear, alkaline - better for sperm.

• Secretory: Days 15-26

  • Progesterone causes marked swelling of epithelium, vascularity of uterus increases to provide nourishing bed for implantation.

• Ischemic: Days 27-28

  • Begins if implantation doesn't occur.

  • Estrogen and progesterone levels decrease.

  • Corpus luteum degenerates (blood released from uterine cells getting ready to be shed).

Male Reproductive System

• Vas deferens

• Ampulla of vas deferens

• Seminal vesicle

• Ejaculatory duct

• Corpus cavernosum penis

• Corpus spongiosum

• Epididymis

• Scrotum

• Rectum

• Prostate

• Prostatic urethra

• Bulbourethral (Cowper's) gland

• Testis

• Glans

• Urethra

• Symphysis pubis

Testes

• Functions:

  • Urinary

  • Fertilization

  • Protects the testes

• Epididymis: Reservoir For mature sperm.

• Vas Deferens: Shoots sperm film the urethra.

• Sperm motility/metabolism.

Cellular Division

• Mitosis:

  • For growth and tissue repair.

  • Process by which our body cells divide and replace themselves.

  • Exact copies of original cell.

• Meiosis:

  • Process leading to development of eggs and sperm.

  • Cells only contain half the genetic material of chromosomes so that when fertilization occurs the normal cell number is restored.

Gametogenesis

• Meiosis occurs during gametogenesis which is the process in which gametes (sperm and ovum) are produced.

• Oogenesis:

  • Produces the female gamete (ovum).

  • Develop early in the fetal life of the female - all ova the female will have are present at birth.

• Spermatogenesis:

  • Produces the male gamete (sperm).

  • Spermatogenesis does not begin to take place until puberty.

Ovum

• 22 autosomal chromosomes

• 1 sex chromosome X

• Total: 23 chromosomes

• Components:

  • Corona radiata

  • Cytoplasm

  • Zona pellucida

  • Nucleus

Spermatozoon

• 22 autosomal chromosomes

• 1 sex chromosome either X or Y

• Total: 23 chromosomes

• Components:

  • Acrosome

  • Nucleus

  • Head section

  • Middle piece with mitochondria

  • Tail (flagellum)

Fertilization

• Granulosa cells of corona radiata

• Zona pellucida

• Extracellular space

• Oocyte cytoplasm

• Oocyte plasma membrane

• Cortical granule

• Sperm nucleus

• Acrosome

• Acrosomal reaction

• Fusion of oocyte and sperm plasma membrane

• Sperm nucleus engulfed by oocyte cytoplasm

• Cortical reaction

Fertilization Details

• Ova fertile 12-24 hrs after ovulation.

• Sperm live 48-72 hrs but probably only fertile for 24 hrs.

• Limited timeframe to unite.

• Fertilization takes place in the ampulla of fallopian tube.

• Only single sperm enters ovum, leading to fertilization.

• 46 chromosomes pair up, creating diploid zygote.

• Females XX.

• Males XY.

Fertilized Ovum to Implantation

• Fertilization

• Early cleavage

• Late cleavage (morula)

• Blastocyst formation

• Ovulation

• Ovum

• Zona pellucida

• Uterus

• Endometrium

• Decidua

• Decidua capsularis

• Implantation of zygote

• Decidua basalis

• Trophoblast

• Ovary

Embryonic Membranes

• Maternal blood

• Chorionic villus

• Chorion

• Extraembryonic coelom

• Decidua capsularis

• Amnion

• Amniotic fluid

• Amniotic cavity

• Umbilical blood vessels in umbilical cord

• Yolk sac: Red blood cells made here until the liver is produced.

• Decidua basalis

Fraternal vs Identical Twins

• Fraternal (Dizygotic):

  • Usually genetic.

  • Two ova.

  • Two sperm.

  • Two blastocysts

  • Two amnions

  • Two chorions

• Identical (Monozygotic):

  • Random + happens.

  • One ovum.

  • One sperm.

  • One blastocyst.

  • Inner cell mass splits in two.

  • Two amnions

  • One chorion

Cleavage Stages

• Morula

• Days 1-3

• Days 4-8

• Blastocyst Formed

• Implanted Blastocyst

• Days 8-13

• Embryonic Disc

• Days 13-15

• Dichorionic/Diamniotic

• Monochorionic/Diamniotic

• Monochorionic/Monoamniotic

• Conjoined Twins

Placental Overview

• Umbilical arteries

• Umbilical vein

• Chorion

• Amnion

• Umbilical cord

• Fetal portion of placenta (chorion)

• Maternal portion of placenta (decidua basalis)

• Maternal vein

• Myometrium

• Maternal artery

• Fetal arteriole

• Fetal venule

• Maternal blood pools within intervillus space

• Variable compression.

  • More curvy

  • Less compression

Placenta Functions

• Passes through for fetal growth.

• Filters out waste products.

• Provides Natural passive Immunity from mom baby.

• Prevents the involution of the corpus luteum at the end OF menstruation.

• Aids maternal metabolic production of protiens/glucose/minerals.

• Helps with implantation and contractions of uterus.

• Responsible for Enlargement of uterus breast and vasodilation.

Amniotic Fluid

• Derived from maternal plasma and fetal cells.

• Functions:

  • Maintains constant body temperature for fetus.

  • Cushions the fetus from trauma.

  • Allows the umbilical cord to be relatively free from compression.

  • Promotes fetal movement.

• Without Amniotic fluid the Fetus could grow asymmetrically.

• Lungs grow best in Fluid.

• Low fluid could cause brittle lungs could cause premature contractions.

• Less cushion of the cord brittle lungs.

Umbilical Cord

• Body stalk connecting placenta with fetus.

• Contains 2 arteries (deoxygenated), 1 vein (oxygenated).

• Surrounded by special connective tissue called Wharton's jelly.

• No sensory or motor innervations.

• Twisted, spiral shape due to fetal movement.

• Less Compression.

Placenta Sides

• Fetal side:

  • "Shiny" Schultz

  • Baby side

• Maternal side:

  • "Dirty" Duncan

  • Mom's side

Patent Ductus Arteriosus

• Patent leads to complications.

Fetal Development Stages

• Fertilization

• 1-week conceptus

• 2-week conceptus

• Embryo

• 3-week embryo

• 4-week embryo

• 5-week embryo

• 6-week embryo

• 7-week embryo

• 8-week embryo

• 9-week fetus

• 12-week fetus

Fetal Development: Week 4

• Heart begins to beat.

• Arm and leg buds present.

• Somites develop - beginning vertebrae.

• Primary lung buds present.

• Eyes and ears begin to form.

Five Week Embryo

• Brain

• Yolk sac

• Placenta

• Heart

• Umbilical cord

• Eye

• Branchial arch

• Somites

• Liver

• Arm bud

• Tail bud

• Leg bud

• Pharynx

• Parathyroid glands and thymus

• Thyroid gland

• Connection to yolk sac

• Allantois

• Esophagus

• Trachea

• Right and left lungs

• Stomach

• Liver

• Pancreas

• Gallbladder

• Small intestine

• Large intestine

Fetal Development: Week 6-7

• Body is straighter.

• Trachea developed.

• Nares present.

• Liver produces blood cells.

• Heart begins circulating blood.

• Digits develop.

• Tail begins to recede.

• Eyelids begin to form.

Fetal Development: Week 8

• All body organs formed.

Fetal Development: Week 12

• Face well developed.

• Eyelids are closed.

• Tooth buds appear.

• Genitals are well differentiated.

• Urine is produced.

• Spontaneous movement occurs.

• Fetal heart tones can be heard by doppler (8-12 weeks).

Fetal Development: Week 16

• Sex determination possible.

Fetal Development: Week 28

• Brain develops rapidly (28-26 weeks).

• Nervous system begins to regulate.

• Eyelids open and close.

• Testes begin to descend.

• Lungs can provide gas exchange.

Fetal Development: Week 36

• Increase in subcutaneous fat.

• Lanugo begins to disappear.

• Male - testes to descend into upper scrotum.

• Female - labia majora & labia minora equally prominent.

Fetal Development: Week 37-40

• Full term.

• Skin smooth and polished.

• Vernix caseosa increases and folds.

• Head bigger than chest.

• Antibodies passively received by mother.

Key Facts to Remember - Fetal Development

• 4 weeks: The fetal heart begins to beat.

• 8 weeks: All body organs are formed.

• 8 to 12 weeks: Fetal heart rate can be heard by ultrasound Doppler device.

• 16 weeks: Baby's sex can be seen.

• 20 weeks: Although thin, the fetus looks like a baby. Heartbeat can be heard with fetoscope. Mother feels movement (quickening).

• 24 weeks: Baby develops a regular schedule of sleeping, sucking, and kicking. Hands can grasp. Baby assumes a favorite position in utero.

• 28 weeks: Vernix (lanolinlike covering) protects the body, and lanugo (fine hair) keeps oil on skin. Head hair, eyebrows, and eyelashes present. Weighs 780 g (1 lb, 10 oz). Activity is increasing. Fetal respiratory movements begin.

• 32 weeks: Eyes open and close. Baby can breathe at this time. Surfactant needed for breathing at birth is formed.

• 38+ weeks: Baby is two-thirds its final length. Baby has fingernails and toenails. Subcutaneous fat is being laid down. Baby appears less red and wrinkled. Baby fills total uterus. Baby gets antibodies from mother.

Special Reproductive Concerns

• Infertility: Lack of conception despite unprotected sexual intercourse for at least 12 months.

• 10-15% of couples are infertile in the US.

• Secondary infertility: Unable to conceive or sustain a pregnancy after one or more successful pregnancies.

Essential Components of Fertility: Female

• Favorable cervical mucus

• Patent tubes with normal motility

• Ovaries produce and release normal ova

• No obstruction between ovary and uterus

• Favorable endometrium

• Adequate reproductive hormones

Essential Components of Fertility: Male

• Normal quality, quantity, and motility of spermatozoa

• Unobstructed genital tract

• Normal genital tract secretions

• Ejaculated spermatozoa reach cervix

Improve Fertility

• Avoid douching

• Retain sperm - recumbent position for at least 20-30 minutes after intercourse

• Avoid leaking of sperm - elevate hips.

• Intercourse every other day during fertile period.

• Decrease anxiety and stress

• Adequate nutrition

Spinnbarkeit

• Spinnbarkeit (elasticity) is greater than 5 cm.

Infertility Workup - Male

• Male infertility

• Ductal obstruction or dysfunction

• Surgery, medication

• Abnormalities of sperm production or sperm function (90% of male infertility)

• Semen and sperm analysis

• FSH and testosterone hormone lab work up

• Hormone replacement medication

Treatments for Infertility (Female)

• Pharmacological agents:

  • Clomiphene citrate (Clomid) - stimulate ovulation by causing pituitary to release more FSH and LH.

  • Gonadotropins (FSH and LH components) - injections that stimulate the ovary to produce multiple eggs.

  • Metformin - used with insulin resistance in women with polycystic ovary syndrome (PCOS). Also, Letrozole (Femara)

  • Bromocriptine (Parlodel) - if problem due to overproduction of prolactin which reduces estrogen (anovulation) and testosterone (decreased sperm production).

Assisted Reproductive Technology (ART)

• Technology used to achieve pregnancy in procedures such as fertility medication, in vitro fertilization, and surrogacy.

• Types:

  • Intrauterine Insemination (IUI)

  • In Vitro Fertilization (IVF)

  • Gamete Intrafallopian Transfer (GIFT)

  • Zygote Intrafallopian Transfer (ZIFT)

IUI - Intrauterine Insemination

• Washed Sperm

• Catheter

In Vitro Fertilization (IVF)

• Woman's eggs is collected from ovaries, fertilized in lab, and placed in uterus after normal embryonic development has begun.

• Sometimes many embryos are placed in uterus to increase chance of pregnancy.

• Progesterone supplements given to promote implantation and support pregnancy.

In Vitro Fertilization (IVF) Process

• Stage 1: Ovarian hyperstimulation

• Stage 2: Transvaginal oocyte retrieval

• Stage 3: Sperm preparation

• Stage 4: Co-incubation

• Stage 5: Embryo transfer

• Stage 6: Pregnancy

Gamete Intrafallopian Transfer (GIFT)

• Removal of oocytes by laparoscopy and returned with washed motile sperm in the fallopian tube - where fertilization takes place. (in vivo rather than in vitro)

• Fertilized egg travels to uterus for implantation.

• Practice acceptable to Roman Catholic Church.
  *Note: Sperm and eggs are placed in a fallopian tube to allow fertilization in the natural site. The woman must have at least one normal, open fallopian tube.

Zygote Intrafallopian Transfer (ZIFT)

• Tubal Embryo Transfer (TET)

• Eggs are retrieved and incubated with man's sperm (fertilization is documented)

• Placed back into the fallopian tubes at the Zygote stage.

• TET

• Eggs are retrieved and incubated with man's sperm (fertilization is documented)

• Placed back into the fallopian tubes at the embryonic stage.

Surrogacy

• Alternative method of reproduction where a woman agrees to carry and deliver a child for a contracting couple or person.

  • Gestational carrier

  • Traditional surrogate
    *Surrogacy contracts are not legal in all states.

Adoption

• Gather information from reliable sources.

• International vs National adoptions

• Reputable adoption agency

Genetic Disorders

• Hereditary material are on strands of DNA known as Chromosomes

• 22 pairs are autosomes (non-sex chromosomes)

• 1 pair are the sex chromosome

• Karyotype:

  • Pictorial analysis of chromosomes

• Phenotype:

  • Observable expression of the trait.

Phenotype

• Phenotype - observable characteristic

• Example 1:

  • Phenotype: Blue Eyes

  • Genotype: bb

  • Recessive: b

• Example 2:

  • Phenotype: Brown Eyes

  • Genotype: Bb or BB

  • Dominant: B

Abnormal Chromosomal Number

• Down's syndrome - Trisomy 21

• female

• Trisomy 21 Karyotype - Down Syndrome 47,XX,+21

Abnormal Chromosomal Number

• Trisomy 18

• male

Chromosomal Syndromes - Altered Chromosome: 21

• Genetic defect: trisomy 21 (Down syndrome) (secondary nondisjunction or 14/21 unbalanced translocation)

• Incidence: average 1 in 700 live births, incidence variable with age of woman

• Characteristics:

  • CNS: mild to moderate intellectual disability (mental retardation); hypotonia at birth

  • Head: flattened occiput; depressed nasal bridge; mongoloid slant of eyes; epicanthal folds; white specking of the iris (Brushfield spots); protrusion of the tongue; high, arched palate; low-set ears

  • Hands: broad, short fingers; abnormalities of finger and foot; dermal ridge patterns (dermatoglyphics); transverse palmar crease (simian line)

  • Other: congenital heart disease in 30% to 60%, usually correctable by surgery

Chromosomal Syndromes - Altered Chromosome: 18

• Genetic defect: trisomy 18

• Incidence: 1 in 3000 live births

• Characteristics

  • CNS: intellectual disability; severe hypotonia

  • Head: prominent occiput; low-set ears; corneal opacities; ptosis (drooping eyelids)

  • Hands: third and fourth fingers overlapped by second and fifth fingers; abnormal dermatoglyphics; syndactyly (webbing of fingers)

  • Other: congenital heart defects (>90%); renal abnormalities; single umbilical artery; gastrointestinal tract abnormalities; rocker-bottom feet; cryptorchidism; various malformations of other organs

Abnormal Chromosome Structure

• Translocation of the chromosome - partly fused

• 14, 21 and a 14/21 Chromosome.

• Sex chromosome abnormalities

• Turner's Syndrome

Chromosomal Syndromes - Altered Chromosome: X (Sex Chromosome)

• Genetic defect: only one X chromosome or partially missing second X chromosome in female (Turner syndrome)

• Incidence: 1 in 5000 live female births

• Characteristics

  • CNS: no intellectual impairment; some perceptual difficulties

  • Head: low hairline; webbed neck

  • Increased risk for intrauterine fetal death (IUFD) (>95% of all conception)

  • Trunk: short stature; cubitus valgus (increased carrying angle of arm); excessive nevi (congenital discoloration of skin because of pigmentation); broad, shieldlike chest with widely spaced nipples; puffy feet; no toenails

  • Other: fibrous streaks in ovaries; underdeveloped secondary sex characteristics; primary amenorrhea; usually infertile; renal anomalies; coarctation of the aorta

Chromosomal Syndromes - Altered Chromosome: XXY (Sex Chromosome)

• Genetic defect: extra X chromosome in male (Klinefelter syndrome)

• Incidence: 1 in 1000 live male births

• Characteristics

  • CNS: mild mental retardation

  • Trunk: occasional gynecomastia (abnormally large male breasts); abnormal body proportions (long legs, short trunk, shoulder equal to hip size)

  • Other: small, soft testes; underdeveloped secondary sex characteristics; reduced fertility

Autosomal Dominant Inheritance

• Affected individual has affected parent

• Affective individuals have 50% chance of passing on to their children

• Parent may have mild form of the disease and child may have severe.

• Examples: Huntington disease, Polycystic kidney disease, Marfan syndrome

Autosomal Recessive Inheritance

• Affected individuals have clinical normal parents, but both are carriers.

• When both are carriers, both have a 25% of passing on to any of the offspring.

• If child of two carrier parents, 50% chance child is carrier of the disease.

• Examples: Cystic fibrosis, Sickle cell anemia, Tay-Sachs disease

Nurse's Role

• Identify families at risk for genetic problems

• Determine how the genetic problem is perceived

• Assist families in acquiring accurate information

• Act as liaison - work with community support groups.

• Provide referrals for genetic testing (will discuss under Antepartum slides)

• Assure continuity of care.