Affairs, Department of Obstetrics and Gynecology, Albert Einstein Medical Center/ Thomas. Jefferson . The primary goal of this book is to provide the basic in-. Ian M Symonds; Sabaratnam Arulkumaran; E M Symonds Essential obstetrics and soundofheaven.info - Free ebook download as PDF File .pdf), Text File .txt) or . American College of Obstetrics and Gynecology (ACOG) with. Charles R. B. . The primary goal of this book is to provide the basic in- formation about obstetrics .
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This is the fifth edition of a popular, highly readable primer in obstetrics and gynaecology. It has been thoroughly updated and reconfigured to key into the new. Request PDF on ResearchGate | Essential Obstetrics & Gynaecology | Essential Obstetrics & Gynaecology is a textbook written to suit the new UK. This book is aimed at students of medicine, midwifery and nursing, and covers all the topics likely to be needed at this level in appropriate depth. The book is.
Incidence In the UK the definitions are different. Miles Hitchen Illustration Manager: Obstetrics and Gynaecology. Pituitary gland GnRH — median eminence of hypothalamus. The vagina is lined by stratified squamous epithelium. In mid-pregnancy. These cells migrate through the dorsal mesen- telophase.
In the sexually mature female. The corpus uteri consists of a mass of smooth muscle cells. The uterus may also be is capable of considerable distension. Situated in the pelvic The uterus cavity. Anatomy of the female pelvis Chapter 1 length and open between the labia minora and the vaginal the lower part of the vagina is separated from the anal orifice. The size of the uterus depends on the hormonal status of the female. The internal genitalia include the vagina.
It is lined by non-cornified squamous epi. The cavity of the uterus is triangular in shape and is Symphysis flattened anteroposteriorly so that the total volume of the cavity in the non-pregnant state is approximately 2 mL. The muscle fibres in the middle layer Uterus Coccyx are arranged in a circular manner and the inner layer con- tains a mixture of longitudinal.
Rectum endometrium depends on the phase of the menstrual Labium min. This has an important antibacterial function that reduces the risk of pelvic infection.
The vagina is a muscular tube some 6—7. Their function is to secrete mucus during sexual canal by the perineal body. External anal cycle. Four of the vulva.
The external Sacrum layers contain smooth muscle cells that pass transversely Tube across the uterine fundus into the lateral angles of the uterus. In cross-section. Cyst formation is relatively common but is the apposition to the ampulla of the rectum and in the upper result of occlusion of the duct.
By the second Urethra Anus half secretory phase of the cycle the endometrium has Vagina Internal anal grown to a thickness of up to 1 cm. The pH of the vagina in the sexually mature non- pregnant female is between 4. Although it does not strictly lie within the description The uterine cervix protrudes into the vaginal vault. The lateral fornices lie under the base of the broad liga- orly. The nature of the Labium maj. It Clitoris is lined by endometrium that consists on the surface of mucus-secreting columnar epithelium.
It consists of a body or corpus. Following menstruation. In the middle third. They are generally benign. The the tube. In pregnancy. If the opening to these maintaining its anteverted position. The to the expulsion of the fetus. Like the anterior opens into the uterine cavity through the isthmus of the ligaments. The internal os posterior surface of the broad ligament. Some of the the upper part of the labia majora.
Close to the cervix. The exact site of this junction is they enter the abdominal inguinal canal. These ligaments have cervical glands in the endocervical lining are extensively a weak supporting role for the uterus but do play a role in branched and mucus-secreting. In the lum is passed. The isthmus of the uterus joins the cervix to the corpus The cardinal ligaments transverse cervical ligaments uteri and in the non-pregnant uterus is a narrow.
They cover the Fallopian tubes from true ovarian cysts. Section 1 Essential reproductive science The cervix is a barrel-shaped structure extending from and the round ligaments. These Laterally. The tubes are enclosed in a mesosalpinx. In preg. The outer longitu. These liga.
The pelvic organs also depend for support on the integrity of the pelvic floor: Lower down. The tubes are approx- from the anterior aspect of the cervix across the superior imately 10—12 cm long and lie on the posterior surface of surface of the bladder to the peritoneal peritoneum of the the broad ligament.
They downward pressure of the viscera and the pelvic organs. In labour it becomes a fibrous tissue and smooth muscle that encloses the cervix part of the birth canal but does not contribute significantly and the vaginal vault and is known as the parametrium. In non-parous women the external os is round or ive role for the uterus. It has a weak supporting role. The They arise from the anterolateral surface of the uterus just transition between this epithelium and the stratified squa.
It also houses various embry- and non-striped muscle and extend from the cervix onto ological remnants such as the epoophoron. The widened cavity is and nerve supply enter the ovary through the medulla. The tubes are richly innervated and The major part of the blood supply to the pelvic organs is have an inherent rhythmicity that varies according to the derived from the internal iliac arteries sometimes known stage of the menstrual cycle and whether or not the woman as the hypogastric arteries.
The tubal pole of the ovary is attached to the pelvic brim by the suspensory liga- ment infundibulopelvic fold of the ovary. It terminates at the abdominal ostium. Anterior The surface of the ovary is covered by a cuboidal or low branch columnar type of germinal epithelium. It then reaches 3. The ovaries The internal iliac artery arises at the level of the lum- bosacral articulation and passes over the pelvic brim. Anatomy of the female pelvis Chapter 1 The tube is divided into four sections: The collections of epithelial cells that form the Graafian folli- lumen of the tube is narrow and the longitudinal cles at different stages of maturation and degeneration.
The blood vessels muscle coat is much thinner. As a result of these characteristics. The lower pole is attached to the lateral border of the uterus by a musculofi- brous condensation known as the ovarian ligament.
Round ligament The anterior border of the ovary is attached to the poste- rior layer of the broad ligament by a fold in the peritoneum External known as the mesovarium. The disease is silent and artery and often asymptomatic and thus presents late. These follicles can also be found in the highly vascular. This surface opens of internal directly into the peritoneal cavity. Each has Urinary a medial and a lateral surface. This fold contains the blood iliac artery vessels and nerves supplying the ovary.
Each ovary lies on the posterior surface of the broad ligaments in a shallow depression known as the ovarian fossa in close proximity to the external iliac Superior vesical artery vessels and the ureter on the lateral pelvic walls.
Beneath this layer extending from the emergence of the interstitial lies the cortex of the ovary. Deep Superficial inguinal inguinal The ovarian vessels The other important blood supply to the pelvic organs Ureteral comes from the ovarian arteries. They descend behind the peritoneum at the upper margin of the greater sciatic notch. At the point of contact with upper group lying parallel with the inguinal ligament and the vaginal fornix.
There are also parietal branches of the anterior division Aortic of the internal iliac artery and these include the obturator artery. The richness of the anastomosis of the uterine and ovarian vessels means that it is possible to ligate both internal iliac arteries and reduce bleeding Anterior division from the uterus and yet still maintain the viability of the The anterior division provides the structure for the umbili.
It also provides the ovarian vessels. It then continues as they reach the brim of the pelvis. The main saphenous vein. Section 1 Essential reproductive science the lumbosacral trunk of the sacral plexus of nerves and. The superior and middle branches. The lymphatic vessels follow the course of the blood It also forms the middle haemorrhoidal artery.
It initially runs The lymphatic drainage from the lower part of the downward in the subperitoneal fat under the inferior vagina. The branches of the two divisions of the internal iliac artery are as follows.
Iliac Posterior division Interiliac The posterior division divides into the iliolumbar branch Sacral and the lateral sacral and superior gluteal branches and Hypogastric does not play a major function in the blood supply to the Obturator Parametrial pelvic organs. Both the uterine and ovarian arteries ers blood via the internal iliac anterior division and its are accompanied by a rich plexus of veins. These arise from the front of the aorta between the origins of the renal and inferior Fig.
S2 and S3. There are also pelvic parietal nodes grouped around the Sympathetic chain major pelvic vessels. Anatomy of the female pelvis Chapter 1 Some of these nodes drain into the deep femoral nodes. Motor and anorectum arises from the S1.
S2 and S3 segments. The pelvic floor is natu- through sympathetic fibres that follow the ovarian vessels. Rectum pathetic and parasympathetic nerve supply to the pelvic organs Fig. These nerves The body of the uterus and the cervix receive sympa- include both efferent and afferent components. Perineal nerve Vagina Somatic innervation Fig.
Some of the lymphatics from the uterine fundus follow the round ligament into the deep and Ilioinguinal nerve superficial inguinal nodes. The sensory the lower abdomen and the high lumbar spine. The somatic innervation to the vulva and pelvic floor is provided by the pudendal nerves that arise from the S2.
These include the common iliac. S3 and S4 segments of the spinal cord. While the somatic innervation is both sensory and motor in function Pudendal nerve and relates predominantly to the external genitalia and the pelvic floor. B These muscles play an important role in defecation, C coughing, vomiting and parturition. The area is bounded anteriorly by the inferior margin of the pubic symphysis, the subpu- Muscles A. Clitoris bic arch and the ischial tuberosities.
Posteriorly, the 1. Ischiocavernosus boundaries are formed by the sacrotuberous ligaments B. Vagina and the coccyx. Superficial transverse perineal C. Bulb of vestibule The perineum is divided into anterior and posterior 3. Levator ani pubococcygeus D. Site of Bartholin's gland triangles by a line drawn between the two ischial tuberosi- iliococcygeus E.
Ischial tuberosity ties. The anterior portion is known as the urogenital trian- 4. External anal sphincter F. Pudendal vessels gle and includes part of the urethra; the urogenital 5. Gluteus maximus G. Perineal body diaphragm is a condensation of fascia below the level of Fig. The posterior or anal triangle includes the anus, the anal sphincter and the perineal body. The two triangles have plays an essential role in parturition and in urinary and their bases on the deep transverse perineal muscles.
The principal supports of the The ischiorectal fossa lies between the anal canal and pelvic floor are the constituent parts of the levator ani the lateral wall of the fossa formed by the inferior ramus muscles.
These are described in three sections: Posteriorly, the fossa is formed by the gluteus pelvic fascia, extends from the posterior surface of maximus muscle and the sacrotuberous ligament, and the pubic rami to the ischial spines and is inserted anteriorly by the posterior border of the urogenital into the anococcygeal ligament and the coccyx.
Chapter 2 Conception and nidation Roger Pepperell. The number of primary Learning outcomes oocytes falls progressively and by birth is down to about 1 million and to about 0. With the fertilization of the implantation egg by a sperm, the chromosome count is returned to the normal count of 46 chromosomes.
Primordial germ cells originally appear in the yolk sac and In meiosis, two cell divisions occur in succession, each can be identified by the fourth week of fetal development of which consists of prophase, metaphase, anaphase and Fig. These cells migrate through the dorsal mesen- telophase. The first of the two cell divisions is a reduction tery of the developing gut and finally reach the genital division and the second is a modified mitosis in which the ridge between 44 and 48 days post-conception.
Migration prophase is usually lacking Fig. At the end of the occurs into a genital tubercle consisting of mesenchymal first meiotic prophase, the double chromosomes undergo cells that appear over the ventral part of the mesonephros. The two centrioles move to opposite the ovary. A spindle forms in the middle and the membrane The sex cords subsequently break up into separate of the nucleus disappears. During this prophase period of clumps of cells and by 16 weeks these clumped cells meiosis I the double chromosomes, which are closely become primary follicles, which incorporate central germ associated in pairs along their entire length, undergo syn- cells.
After this time, no further cell division gametes came from the same mother. By birth, the The primary oocytes remain in suspended prophase oogonia have already begun the first meiotic division and until sexual maturity is reached, or even much later, with.
Yolk Primordial germ Reach genital Primary follicle with 7 million cells Fig. Blood vessels Follicle: Corpus Ruptured luteum follicle Meiosis Fig. Meiotic division resumes under stimulation by luteinizing hormone. In anaphase, the daughter chromatids separate The gross structure and the blood supply and nerve supply and move towards opposite poles. Meiosis II commences of the ovary have been described in Chapter 1. However, around the time the sperm attached to the surface of the microscopic anatomy of the ovary is important in the oocyte and is completed prior to final phase of understanding the mechanism of follicular development fertilization.
Thus, the nuclear events in oogenesis are virtually the The surface of the ovary is covered by a single layer of same as in spermatogenesis, but the cytoplasmic division cuboidal epithelium. The cortex of the ovary contains a in oogenesis is unequal, resulting in only one secondary large number of oogonia surrounded by follicular cells oocyte.
This small cell consists almost entirely of a nucleus that become granulosa cells. The remainder of the ovary and is known as the first polar body.
As the ovum enters consists of a mesenchymal core. Most of the ova in the the Fallopian tube, the second meiotic division occurs cortex never reach an advanced stage of maturation and and a secondary oocyte forms, with the development of a become atretic early in follicular development. At any small second polar body.
In the male the original cell given time, follicles can be seen in various stages of matu- containing 46 chromosomes ultimately results in 4 sepa- ration and degeneration Fig. About primary. This progressive loss occurs irrespective of follicle whether the patient is pregnant, on the oral contraceptive pill, having regular cycles or is amenorrhoeic, with the Antrum formation — menopause occurring at the same time irrespective of the follicular fluid number of pregnancies or cycle characteristics.
The vast majority of the follicles lost have undergone minimal or no actual maturation. The first stage of follicular development is characterized Corpus luteum Primary Ruptured by enlargement of the ovum with the aggregation of follicle follicle stromal cells to form the thecal cells.
When a dominant follicle is selected at about day 6 of the cycle, the inner- most layers of granulosa cells adhere to the ovum and form the corona radiata. A fluid-filled space develops in Egg nest the granulosa cells and a clear layer of gelatinous material collects around the ovum, forming the zona pel- Fig. The ovum becomes eccentrically placed and the Graafian follicle assumes its classic mature form. The mes- The process is initiated by the release of the enchymal cells around the follicle become differentiated gonadotrophin-releasing hormone GnRH , a major neu- into two layers, forming the theca interna and the theca rosecretion produced in the median eminence of the externa.
This hormone is a decapeptide and is As the follicle enlarges, it bulges towards the surface of released from axon terminals into the pituitary portal cap- the ovary and the area under the germinal epithelium illaries. It results in the release of both follicle-stimulating thins out. The corpus luteum in its The three major hormones involved in reproduction are mature form shows intense vascularization and pro- produced by the anterior lobe of the pituitary gland or nounced vacuolization of the theca and granulosa cells adenohypophysis, and include FSH, LH and prolactin.
This development Blood levels of FSH are slightly higher during menses and reaches its peak approximately seven days after ovulation subsequently decline due to the negative feedback effect and thereafter the corpus luteum regresses unless implan- of the oestrogen production by the dominant follicle. The corpus luteum tal FSH peak Fig. The LH surge is, in fact, made up degeneration is characterized by increasing vacuolization of two proximate surges and a peak in plasma oestradiol of the granulosa cells and the appearance of increased precedes the LH surge.
Plasma LH and FSH levels are quantities of fibrous tissue in the centre of the corpus slightly lower in the second half of the cycle than in the luteum.
This finally develops into a white scar known as pre-ovulatory phase, but continued LH release by the the corpus albicans Fig. Progesterone levels are low prior to ovulation but. Pituitary gland GnRH — median eminence of hypothalamus. Gonadotrophin-releasing hormone GnRH stimulates the release of gonadotrophins from the anterior lobe of the pituitary.
LSH, lutein-stimulating hormone. These features are shown in Figure 2. Antagonists to dopamine such as phenothiazine, reserpine and methylty- rosine also stimulate the release of prolactin, whereas dopamine agonists such as bromocriptine and cabergoline There are feedback mechanisms that regulate have the opposite effect.
This is principally achieved by the oestrogens and progesterone produced by the ovaries. In the presence Hyperprolactinaemia inhibits ovulation by an of ovarian failure, as seen in the menopause, the inhibitory effect on hypothalamic GnRH gonadotrophin levels become markedly elevated because production and release and is an important cause of of the lack of ovarian oestrogen and progesterone secondary amenorrhoea and infertility.
The action of gonadotrophins Prolactin is secreted by lactotrophs in the anterior lobe of the pituitary gland. Prolactin levels rise slightly at mid- FSH stimulates follicular growth and development and cycle, but are still within the normal range, and remain at binds exclusively to granulosa cells in the growing follicle.
Prolactin menstrual cycle, one becomes pre-eminent and is called tends to control its own secretion predominantly through the dominant follicle. The granulosa cells produce oestro- a short-loop feedback on the hypothalamus, which pro- gen, which feeds back on the pituitary to suppress FSH duces the prolactin-inhibiting factor, dopamine.
Oestro- release, with only the dominant follicle then getting gen appears to stimulate prolactin release, in addition to enough FSH to continue further development. At the same the release of various neurotransmitters, such as serotonin, time, FSH stimulates receptors for LH.
LH stimulates the process of ovulation, the reactivation rounds the ostia of the endometrial glands. The endome- of meiosis I and sustains development of the corpus trial cycle is divided into four phases: Menstrual phase. This occupies the first 4 days losa cells and in the corpus luteum.
There is a close inter- of the cycle and results in shedding of the action between FSH and LH in follicular growth and outer two layers of the endometrium. The onset maturation. The corpus luteum produces oestrogen and of menstruation is preceded by segmental progesterone until it begins to deteriorate in the late luteal vasoconstriction of the spiral arterioles.
This leads to phase Fig. What is clear clinically is that the menstruation due to the The normal endometrium responds in a cyclical manner shedding of the outer layers of the endometrium to the fluctuations in ovarian steroids. The endometrium occurs whether oestrogen or progesterone, or both, consists of three zones and it is the two outer zones that fall with the loss generally being less if both the are shed during menstruation Fig.
It is not 2. Phase of repair. This phase extends from day 4 to shed at the time of menstruation. The next adjacent zone day 7 and is associated with the formation of a new zona spongiosa contains the endometrial glands which are capillary bed arising from the arterial coils and with lined by columnar epithelial cells surrounded by loose the regeneration of the epithelial surface.
The surface of the endometrium is covered by a 3. Follicular or proliferative phase. This is the period compact layer of epithelial cells zona compacta that sur- of maximal growth of the endometrium and is. C A Proliferative phase. B Mid-luteal phase. C Menstrual phase. The spermatozoon consists of a head.
The epithelial cells exhibit basal despite coming from the same original cell. This condition is becomes adherent to the oocyte. The tail consists of a central core of two longitudinal ble for stimulation of spermatogenesis and LH for the fibres surrounded by nine pairs of fibres that terminate at stimulation of Leydig cells and the production of various points until a single ovoid filament remains.
Mitotic proliferation produces large numbers of generally day 14 of the cycle. Histological examination of the endometrium generally enables precise dating of the men. At the time of this final release meiosis II has is oedema of the stroma and a pseudodecidual been completed. Within 2 days of menstruation. During this phase.
The secretion subsequently becomes lumen of the seminiferous tubules and then into the vas inspissated and.
Luteal or secretory phase. As in the female. All phases of maturation can be seen in extends from day 7 until the day of ovulation the testis. This follows ovulation These spermatogonia are converted to spermatocytes and continues until 14 days later when menstruation within the testis. The nucleus is densely packed with the genetic material of the sperm.
The neck contains two centrioles. Full capacitation of the sperm. FSH is predominantly responsi.
Spermatocytes vacuolation and. These testosterone. This phase days Fig. The distal centriole is vestigial in mature spermatozoa but is func- tional in the spermatid. The head is flattened and ovoid in shape and is sumptive evidence of ovulation. In addition. C and is followed almost immedi- Sperm transport ately by the first cleavage division.
Under blastocyst Fig. The zygote undergoes cleavage and at the cell tive mucus in mid-cycle. Normal semen clots shortly after acrosome reaction. Capacitation Neck Basal body During their passage through the Fallopian tubes. The transported through the tube by muscular peristaltic speed of this migration depends on the presence of recep. Only a small number of spermatozoa reach the oocyte in Seminal plasma also contains high concentrations of the ampulla of the tube and surround the zona pellucida.
During the luteal phase. During the 36 hours after fertilization. It seems likely that these substances vesicles. Only motile spermatozoa reach the fimbriated end of the Head Acrosomal cap tube where fertilization occurs. Inhibitory substances in the plasma of the cauda epidi- Spermatozoa carry little nutritional reserve and therefore dymis and in seminal plasma can prevent capacitation and depend on seminal plasma for nutritional support.
The process allows the release of lytic enzymes. Following the deposition of semen near the cervical os. Conception and nidation Chapter 2 the motility of the sperm and must therefore also be dependent on active support within the uterine cavity. The sperm head decondenses to form the male pronu- The process of fertilization involves the fusion of the male cleus and eventually becomes apposed to the female and female gametes to produce the diploid genetic com.
Until recently. The plasma also contains high concentrations of amino acids. This process is known as syngamy Fig. The mem- plement from the genes of both partners.
A mucus is not receptive to sperm invasion and therefore fluid-filled cavity develops within the morula to form the very few spermatozoa reach the uterine cavity. Six days after ovulation. By the seventh post-ovulatory day.
The endometrial stromal cells both the male and the female. C Syngamy involves the passage of the nucleus of the sperm head into the cytoplasm of the oocyte with the formation of the zygote. Morula 6th day post-ovulation Blastocyst Ovum Fig. These levels consist of become large and pale. This is complete. In reaction. During orgasm. The vaginal walls become congested and purplish in sclerosis and diabetic neuropathy. Ejaculation may become less fre- During the resolution phase.
There Common sexual problems are discussed in Chapter The systemic Factors that determine human sexuality are far more changes of hyperventilation and rapid respiration persist. Secretion from the bulbourethral further stimulation. Following orgasm. Stimulation of the clitoris and the labia results in Erectile dysfunction may result from progression to the orgasmic platform.
At the same time. During the plateau phase. Expulsion of semen is brought of orgasm until late in life but her behaviour is substan- about by contraction of smooth muscle within the tially determined by the interest of the male partner. Blood pressure rises and there is some diminution in the level of awareness. The orgasmic phase is induced by stimulation of the glans The plateau phase may be sustained in the female and penis and by movement of penile skin on the penile shaft. Both intravaginal and intrauterine pressures rise during orgasm.
The female remains capable nervous system. Recreational drugs such as alcohol. Specific musculoskeletal activity occurs by a sweating reaction may persist. Conception and nidation Chapter 2 and S3.
These changes are accompanied by In the female. The plateau phase may be prolonged glands results in the appearance of a clear fluid at the if ejaculation does not occur. Sexual interest and performance also decline with age in the male and the older male requires more time to achieve excitement and erection. Although the frequency of intercourse and orgasm declines with age. This phoblast. The villous tro- during the first trimester should conception occur. The main type of decidual lymphocytes are the uterine growth and development of the fetus.
The decidua con- pregnancy on the wellbeing of the mother tains all the common immunological cell types. The endocrine. HLA-C and reasons for these changes: The of various tests related to cardiovascular. Pregnancy defies the laws of transplant immunology. Only two types Many maternal adaptations to pregnancy. Involution is rapid over the first 2 weeks leads to a thick mucus discharge and the development after delivery.
Myometrial growth is almost entirely due to as the partly suppressed immune state in pregnancy makes muscle hypertrophy and elongation of the cells from both new infections. Pregnancy may also induce block. The lymph nodes in the Eighty percent of the total protein in the non-pregnant para-aortic chain draining the uterus may increase in size.
The stimulus for myometrial growth and develop- ies. Th2 cytokine ratio shifts towards Th2. The characteristic changes in the cervix during preg- nancy are: The principal function of the cervix is to retain the conceptus Fig. The uterus consists of bundles of smooth The fetus expresses paternal antigens and these can muscle cells separated by thin sheets of connective tissue stimulate the production of maternal antibodies.
All versely. Thus the very polymorphic KIR in maternal tissues and the polymorphic HLA-C in the fetus make up a potentially very variable receptor—ligand system. The placental and decidual cells express most toll-like ment is the effect of the growing conceptus and oestrogens receptors TLRs. The uterus is functionally and morphologically divided leukins. They express surface killer immunoglobulin-like receptors KIRs.
HLA-C2 is highly inhibi- tory to trophoblast migration. The KIRs are highly polymorphic. Section 1 Essential reproductive science the systemic circulation. The muscle cells are confirming that the placenta is not an impermeable arranged as an innermost longitudinal layer. The arcuate arteries.
The secretory phase of an ovulatory menstrual cycle. The uterus changes from section expands. A small contribu- of choice for the incision for a caesarean delivery.
This decidualization Fig. The uterus changes throughout pregnancy to meet the The final vessels delivering blood to the intervillous needs of the growing fetus both in terms of physical size space Fig.
Cytoplasm endometrial epithelial and stromal cells stop Microvilli proliferating and begin to differentiate. The lower section shortens as the upper caudal point in the uterus. The myometrium must remain relatively quiescent until the onset of labour. It joins the muscle hypertrophy. Two or and in vascular adaptation to supply the nutrients required: The cavity expands from some 4 mL to mL at The isthmus full term.
By the 28th week pregnancy. Because of its relative through the uterine arteries. In later pregnancy. The uterine arteries dilate so that the fibres of the corpus to the dense connective tissue of the diameters are 1. The uterine and radial arteries are subject to regulation by the auto- The corpus uteri nomic nervous system and by direct effects from vasodila- tor and vasoconstrictor humoral agents.
Cytotrophoblast differentiates into changes is to turn the spiral arterioles into flaccid sinusoi- villous or EVT. EVT invades without pre-eclampsia. The uterus has both afferent and efferent nerve supplies.
Section 1 Essential reproductive science successful pregnancy. The intrauterine oxygen tension is very low sequent reduction in blood flow. Adapted from Cartwright JE et al. From 10—16 weeks. The latter can differentiate further into dal channels. There is an afferent lumen of the decidual portion of the vessel.
Reproduced by permission. This is a feature of pre- in the first trimester. These changes are brought about by both maternal immune cells decidual NK cells and macrophages and by invading interstitial and endovascular EVT. They do not produce cervical dilatation. Pro- inflammatory cytokine expression also increases. In late gestation. See Chapter 11 for a discussion of labour and delivery. Contractions during pregnancy are usually pain.
Once Fig. Progesterone antagonists such as mifepristone can induce labour from the first trimester. Physiological changes in pregnancy Chapter 3 uterine vessels are well supplied by adrenergic nerves. As the second trimester proceeds. Minutes tors. Uterine 0 activity occurs throughout pregnancy and is measurable as early as 7 weeks gestation. Other mech. In the third trimester they increase in both frequency and intensity. The musculature in the vaginal wall also becomes hypertrophic.
Data from Robson S. Chamberlain GV. Data are derived from studies in which pre-conception values were determined. Despite the rise in cardiac output. Am J Physiol Weeks of pregnancy yeast infections may thrive in this environment and 60 Candida infections are common in pregnancy. Robson SC. The vagina is lined by stratified squamous epithelium. Note that the changes are near maximal by the end of the first trimester. Hunter S. The rich venous vascular network in the SV mL 8 mmHg Cardiac output vaginal walls becomes engorged and gives rise to a slightly bluish appearance.
Churchill Livingstone. High oestro. As in the cervix. The three layers of superficial. Cardiac position and size which hypertrophies during pregnancy.
Many of Obstetrics and Gynaecology. Table 3. Table reproduced from Broughton Pipkin F Maternal physiology. The mean values shown are those at the end of each trimester.
As the uterus grows. The vaginal pH falls in 90 0 pregnancy to 3. In a nor- early and late pregnancy.
These two factors push the cardiac output up. The available. Posture has a significant effect on blood pressure in pregnancy. The fall in systemic velocities. There is probably a fall in baroreflex sensitivity as vasodilatation and vasoconstriction in pregnancy is a criti- pregnancy progresses and heart rate variability falls. Special care must be taken to use an appropriate cuff size for the measurement Total peripheral resistance of brachial pressures.
Myocardial contractility is increased during TPR is partly associated with the expansion of the vascular pregnancy. The fall in TPR during the first half of pregnancy causes cies. This means that failure in women with heart disease. PGI2 and locally synthesised nitric oxide. Stroke cal determinant of blood pressure and lies at the heart of volume rises a little later in the first trimester than heart the pathogenesis of pre-eclampsia.
Renal function. The balance between below. Most of Systolic blood pressure increases during the luteal phase the rise in cardiac output occurs in the first 14 weeks of the cycle and reaches its peak at the onset of menstrua- of pregnancy. Physiological changes in pregnancy Chapter 3 heart is displaced upwards and left laterally. The non-labouring change in cardiac output is luteal phase than in the follicular phase of the cycle. The total peripheral resistance has fallen by widens in pregnancy.
The vasodilatation that causes the fall in TPR is not due to a withdrawal of sympathetic tone. Blood pressure changes occur during the menstrual cycle.
Women who have an artificial pacemaker and thus a fixed Arterial blood pressure heart rate compensate well in pregnancy on the basis of increased stroke volume alone. The pressure falls during gestation in a similar way whether the pressure is recorded sitting. It rises again after this. These changes result in an inverted T wave in adaptations. This is especially important with Total peripheral resistance TPR is not measured directly. Plasma folate concen- nancy when the mother lies on her back.
The indices are under separate control mech- anisms. Maternal dietary Profound falls in blood pressure may occur in late preg- iron requirements more than double. Both cell number and cell size increase.
The circu- lating red cell mass rises from around mL in Non.
D Erythrocytes 60 There is a steady increase in red cell mass in pregnancy and the increase appears to be linear throughout preg- 40 nancy.
Central venous pressure and pressure in the upper increase is mainly due to an increase in neutrophil poly- arms remain constant in pregnancy. This phenome- tration halves by term. The total white cell count rises during pregnancy.
Automated sphygmomanometers are unsuita- absorption of iron from the gut rises and iron-binding ble for use in pregnancy when the blood pressure is raised. Both these factors may cause discrep- Haemoglobin concentration.
Erythropoietin rises in pregnancy. The white cells There is progressive venodilatation and rises in venous distensibility and capacitance throughout a normal preg. Pregnant adolescents conspicuous differences between brachial and femoral seem to be at particular risk of iron deficiency. Even relatively blood pressures in pregnancy. In the late results from the restriction of venous return from the lower s. This nancy. Pulmonary resistance falls in early pregnancy.
A further massive neutrophilia normally ing. Plasma volume changes are considered below BP mmHg 80 see: It although red cell folate concentrations fall less. It rises more Fig. Serum iron concentration falls but the is unclear. The a fourfold increase in the number of polymorphs.
When a woman turns from mild maternal anaemia is associated with increased placen- a supine to a lateral position in late pregnancy. Plasma fibrinogen levels increase from non-pregnant tion.
Protein C. This can be seen in the normal following severe placental abruption or in cases of menstrual cycle where the neutrophil count rises with severe pre-eclampsia.
Factors VII. Physiological changes in pregnancy Chapter 3 Possible increase in labour Box 3. In a situation where haemorrhage from the uterine death in the UK. The in the presence of severe disseminated intravascular lymphocyte count remains constant and the numbers of coagulation.
Platelet reactivity is increased in the second and third values of 2. The normal value in late the oestrogen peak in mid-cycle. X and IX Christmas factor all Platelets increase during pregnancy. It is the test used to monitor the dosage of warfarin and usually lies between 10 and 14 seconds There is also an increase in the metabolic activity of granu.
Values in the presence of this disorder T and B cells do not alter. The erythrocyte sedimentation rate rises early in pregnancy. On the other hand. There is. Carbon dioxide production rises sharply during the The level of the diaphragm rises and the intercostal angle third trimester.
Because of the increase in minute ventilation and the effect of progesterone increasing the level of carbonic anhydrase B in red cells. Edmonds DK ed not appear to be affected by pregnancy. Factors that increase during normal pregnancy are shown in bold type. Although there is upward pressure on the dia. It increases progressively during preg.
This increase is offset by the enlarging uterus. Since unloading to the fetus. This facilitates oxygen that can be expired after maximum inspiration. This improves gas mixing. Adapted from Broughton remain constant in pregnancy and women with asthma do Pipkin F Maternal physiology. Forced expira. Vital capacity is sociation curve. The collecting ducts until the Posm falls below the new osmotic ureters are not hypotonic or hypomotile and there is thirst threshold. Vesicoureteric reflux occurs pregnancy see below.
The filtration fraction thus falls in the first creatinine and urea. In the third trimester. The changes occur in the first trimester under physiology. Water retention must occur to allow the increase in The filtered load of sodium increases by — plasma volume.
Water retention is facilitated by the sodium retention of sia of the connective tissue. Creatinine clearance growth are associated with a poor increase in plasma is a useful indicator of GFR but gives values that are sig. This should be remembered when interpreting laboratory reports.
The total extracellular fluid volume rises by GFR increase during an ovulatory menstrual cycle. There is a marked fall in see: Renin—angiotensin system. Physiological changes in pregnancy Chapter 3 Overall. Standing upright is significantly sporadically and the combination of reflux and ureteric more antidiuretic than in non-pregnant subjects. This is physiological. Renal volume is disproportionately large. The bigger the Physiology expansion is. Tubular reabsorption is of glucose from the gut nor the half-life of insulin seem probably less complete during pregnancy.
A Maternal carbohydrate metabolism similar pattern is seen in relation to urea. The total net sodium gain amounts the gastric contents during the induction of general to mmol mainly stored in the maternal compartment.
There are Renal tubular function also changes significantly during marked individual differences in the globulin fractions. Hepatic extraction of circulating amino acids is lus. In later gestation. Section 1 Essential reproductive science retention of 3—5 mmol of sodium per day into the fetal rises.
Even so. During early pregnancy there is a normal plasma insulin response Gastric secretion is reduced in pregnancy and gastric motil. Using dipsticks to assess pro. Pregnant The tubular reabsorption of calcium is enhanced.
Heartburn resistance to insulin. By the end of the first trimester the increase in blood glucose following a carbohydrate load is less than outside pregnancy Fig. Uric acid is freely filtered through the glomeru.
Pregnant women are more prone to aspiration of and maternal stores. A similar change occurs with potassium ions. Glucose is the major substrate for fetal growth and nutri- Glucose excretion increases during pregnancy and inter. Adapted from Broughton Pipkin F is common. Renal bicarbonate rea- bsorption and hydrogen ion excretion appear to be unal. Neither the absorption lated to blood glucose levels. The gallbladder increases in size and empties uric acid filtration doubles. The excretion of to change.
Decreased motil. Thus in late pregnancy. Calcium Maternal total plasma calcium falls. This is partly due to which doubles by 24 weeks. The greatest changes are the approximate threefold increases in very low density lipo. The range of maternal weight gain in normal preg- to the fetus as building blocks for protein synthesis and nancy may vary from near zero to twice the mean weight gluconeogenesis. Birth weight and placental 5 weight are directly related to maternal VLDL triglyceride levels at term.
Levels of fat-soluble vitamins rise in pregnancy High risk pregnancy: Weiner C. Perinatal and maternal mortality Boon H. History taking and examination in obstetrics Edwin Chandraharan 7. Normal pregnancy and antenatal care Shaylee Iles 8.
Obstetric disorders Henry G. Murray 9. Maternal medicine Suzanne V. Wallace, Henry G. Murray and David James 1. Assessment of fetal wellbeing David James and Suzanne V. Wallace Management of labour Sabaratnam Arulkumaran Management of delivery Aldo Vacca Postpartum problems Shankari Arulkumaran Psychiatric disorders of childbirth Margaret R.
Basic clinical skills in gynaecology Ian M. Symonds Gynaecological disorders Ian S. Fraser Infertility William Ledger Early pregnancy care Ian M. Sexual and reproductive health Roger Pepperell 2. Gynaecological oncology Hextan Y. Ngan and Karen Chan Principles of perioperative care Stergios K. Governance, audit and research Tahir Mahmood C: Medicolegal aspects of obstetrics and gynaecology Roger Pepperell.