PHYSIOLOGY OF PREGNANCY ISKANDAR ZULQARNAIN A. ABADI.

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1 PHYSIOLOGY OF PREGNANCY ISKANDAR ZULQARNAIN A. ABADI

2 IT Obstetri 1 : Obstetri Fisiologi 1. Fertilisasi, inplantasi dan nidasi. 2. Hormon-hormon plasenta. 3. Perubahan morfologi janin dan fisiologi janin. 4. Perubahan anatomik dan Fisiologi ibu hamil. 5. Asuhan antenatal.

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4 ENDOMETRIUM & DECIDUA Maternal tissues of fetal-maternal communication system Maternal tissues of fetal-maternal communication system Direct cell to cell contact (blastocyst- maternal endometrium)  since 6 th days after fertilization (“blastocyst apposition”) Direct cell to cell contact (blastocyst- maternal endometrium)  since 6 th days after fertilization (“blastocyst apposition”) Then occurred immunological acceptance of the conceptus, maternal recognition of pregnancy, placental development, pregnancy maintenance, & fetal nutrition Then occurred immunological acceptance of the conceptus, maternal recognition of pregnancy, placental development, pregnancy maintenance, & fetal nutrition

5 Endometrial / decidual function The hormonal responsiveness and phenotypic changes of the endometrial / decidual cells facilitates apposition and implantation of the blastocyst. The hormonal responsiveness and phenotypic changes of the endometrial / decidual cells facilitates apposition and implantation of the blastocyst. The decidua serves as an immunologically specialized tissue. The decidua serves as an immunologically specialized tissue.

6 Endometrial / decidual function The endometrium/decidua and the spiral arteries accept trophoblast invasion, providing for embryo-fetal nutrition. The endometrium/decidua and the spiral arteries accept trophoblast invasion, providing for embryo-fetal nutrition. The decidua contributes cytokines and growth factors that promote placental growth, function, and the inhibition of (trophoblast) apoptosis. The decidua contributes cytokines and growth factors that promote placental growth, function, and the inhibition of (trophoblast) apoptosis.

7 Hormonal regulation of the endometrium Estrogen Estrogen estradiol-17b & other bioactive estrogens in vivo cause replication of the epithelium indirectly (probably through actions on the stromal cells) estradiol-17b & other bioactive estrogens in vivo cause replication of the epithelium indirectly (probably through actions on the stromal cells) estrogen acts on the endometrial stromal cells to promote the synthesis of an endometrial epithelial cell growth factor, which functions in a paracrine manner to cause replication of the adjacent epithelial cells. estrogen acts on the endometrial stromal cells to promote the synthesis of an endometrial epithelial cell growth factor, which functions in a paracrine manner to cause replication of the adjacent epithelial cells. Progesterone Progesterone progesterone receptors is dependent on previous estrogen action progesterone receptors is dependent on previous estrogen action Progesterone actions  a decreases in the synthesis of estrogen receptor molecules Progesterone actions  a decreases in the synthesis of estrogen receptor molecules progesterone acts to increase the rate of enzymatic inactivation of estradiol-17b through an increase in the activity of estradiol dehydrogenase. progesterone acts to increase the rate of enzymatic inactivation of estradiol-17b through an increase in the activity of estradiol dehydrogenase.

8 PLACENTA & FETAL MEMBRANES the fetus is dependent upon the placenta as its lung, liver, and kidneys. the fetus is dependent upon the placenta as its lung, liver, and kidneys. The organ serves these purposes until sufficient maturation of the fetus allows it to survive ex utero as an air-breathing organism The organ serves these purposes until sufficient maturation of the fetus allows it to survive ex utero as an air-breathing organism

9 PLACENTAL DEVELOPMENT The blastocyst + its surrounding tropho- blasts grow and expand The blastocyst + its surrounding tropho- blasts grow and expand extends  endometrial cavity extends  endometrial cavity buried in the endometrium/decidua. buried in the endometrium/decidua. The innermost pole enters into the formation of the placenta  the anchoring cytotrophoblasts and the villous trophoblasts. The innermost pole enters into the formation of the placenta  the anchoring cytotrophoblasts and the villous trophoblasts.

10 PLACENTAL DEVELOPMENT The trophoblasts of the villus are the outer layer of syncytium and an inner layer of cytotrophoblasts. The trophoblasts of the villus are the outer layer of syncytium and an inner layer of cytotrophoblasts. The pole developing toward the endometrial cavity is covered by the chorion frondosum,  at this time by decidua (capsularis). The pole developing toward the endometrial cavity is covered by the chorion frondosum,  at this time by decidua (capsularis). decidua capsularis + decidua parietalis  decidua vera. decidua capsularis + decidua parietalis  decidua vera.

11 Hormonal regulation of the endometrium Estrogen Estrogen estradiol-17b & other bioactive estrogens in vivo cause replication of the epithelium indirectly (probably through actions on the stromal cells) estradiol-17b & other bioactive estrogens in vivo cause replication of the epithelium indirectly (probably through actions on the stromal cells) estrogen acts on the endometrial stromal cells to promote the synthesis of an endometrial epithelial cell growth factor, which functions in a paracrine manner to cause replication of the adjacent epithelial cells. estrogen acts on the endometrial stromal cells to promote the synthesis of an endometrial epithelial cell growth factor, which functions in a paracrine manner to cause replication of the adjacent epithelial cells.

12 Hormonal regulation of the endometrium Progesterone Progesterone progesterone receptors is dependent on previous estrogen action progesterone receptors is dependent on previous estrogen action Progesterone actions  a decreases in the synthesis of estrogen receptor molecules Progesterone actions  a decreases in the synthesis of estrogen receptor molecules progesterone acts to increase the rate of enzymatic inactivation of estradiol-17b through an increase in the activity of estradiol dehydrogenase. progesterone acts to increase the rate of enzymatic inactivation of estradiol-17b through an increase in the activity of estradiol dehydrogenase.

13 TROPHOBLASTIC BIOLOGY Syncytiotrophoblast Syncytiotrophoblast The cytotrophoblast  the syncytium The cytotrophoblast  the syncytium Chorionic villi Chorionic villi Villi can first be distinguished easily in the human placenta  the 12th day after fertilization Villi can first be distinguished easily in the human placenta  the 12th day after fertilization Cytotrophoblasts  mesenchymal cord, invades the solid trophoblast column  secondary villi Cytotrophoblasts  mesenchymal cord, invades the solid trophoblast column  secondary villi

14 TROPHOBLASTIC BIOLOGY Placental cotyledons Placental cotyledons the short, thick, early stem villi branch repeatedly, forming progressively finer subdivisions & >> increasingly small villi the short, thick, early stem villi branch repeatedly, forming progressively finer subdivisions & >> increasingly small villi the main stem (truncal) villi & their ramifications (rami)  placental cotyledon (lobe) the main stem (truncal) villi & their ramifications (rami)  placental cotyledon (lobe) each cotyledon is supplied with a branch (truncal) of the chorionic artery; and for each cotyledon, there is a vein, constituting a 1:1:1 ratio of artery to vein to cotyledon. each cotyledon is supplied with a branch (truncal) of the chorionic artery; and for each cotyledon, there is a vein, constituting a 1:1:1 ratio of artery to vein to cotyledon.

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16 PLACENTAL AGING placentas of early pregnancy,  the branching connective tissue cells are separated by an abundant loose intercellular matrix placentas of early pregnancy,  the branching connective tissue cells are separated by an abundant loose intercellular matrix

17 PLACENTAL AGING histological changes histological changes decrease in thickness of the syncytium decrease in thickness of the syncytium partial reduction of cytotrophoblastic cells partial reduction of cytotrophoblastic cells decrease in the stroma decrease in the stroma increase in the number of capillaries increase in the number of capillaries the approximation of these vessels to the syncytial surface the approximation of these vessels to the syncytial surface

18 PLACENTAL AGING Other changes Other changes thickening of the basement membranes of the trophoblast capillaries thickening of the basement membranes of the trophoblast capillaries obliteration of certain fetal vessels obliteration of certain fetal vessels fibrin deposition on the surface of the villi in the basal and chorionic plates & intervillous space. fibrin deposition on the surface of the villi in the basal and chorionic plates & intervillous space.

19 PLACENTAL AT TERM Boyd and Hamilton (1970) Boyd and Hamilton (1970) the placenta at term + Ǿ185 mm & 23 mm (thickness) the placenta at term + Ǿ185 mm & 23 mm (thickness) Volume +497 ml & weight 508gs Volume +497 ml & weight 508gs From the maternal surface, the number of slightly elevated convex areas (lobes or if small, lobules) varies from 10 to 38 From the maternal surface, the number of slightly elevated convex areas (lobes or if small, lobules) varies from 10 to 38 The lobes are also referred to as cotyledons. The lobes are also referred to as cotyledons.

20 BLOOD CIRCULATION IN THE MATURE PLACENTA Fetal circulation Fetal circulation Fetal deoxygenated, or "venous-like," blood  2 umbilical arteries Fetal deoxygenated, or "venous-like," blood  2 umbilical arteries Blood, with ↑↑ oxygen content ∞ placenta  fetus through 1 umbilical vein. Blood, with ↑↑ oxygen content ∞ placenta  fetus through 1 umbilical vein. Maternal circulation Maternal circulation Maternal blood  the basal plate Maternal blood  the basal plate driven high up  the chorionic plate driven high up  the chorionic plate by the head of maternal arterial pressure by the head of maternal arterial pressure After bathing the external microvillus surface of chorionic villi, the maternal blood drains back  venous orifices in the basal plate  the uterine veins. After bathing the external microvillus surface of chorionic villi, the maternal blood drains back  venous orifices in the basal plate  the uterine veins.

21 AMNION Structure Structure Bourne (1962)  5 layers of amnion tissue The inner surface  single layer of cuboidal epithelial cells, derived from embryonic ectoderm The inner surface  single layer of cuboidal epithelial cells, derived from embryonic ectoderm distinct basement membrane distinct basement membrane

22 AMNION Structure Structure the acellular compact layer the acellular compact layer fibroblast-like mesenchymal cells (widely dispersed at term), derived from mesoderm fibroblast-like mesenchymal cells (widely dispersed at term), derived from mesoderm the relatively acellular zona spongiosa  contiguous with the chorion laeve. the relatively acellular zona spongiosa  contiguous with the chorion laeve.

23 AMNION Development Development amniogenic cells, line this inner surface of trophoblasts  the precursors of the amnionic epithelium amniogenic cells, line this inner surface of trophoblasts  the precursors of the amnionic epithelium the human amnion is 1 st identifiable +7 th or 8 th day of embryo development. the human amnion is 1 st identifiable +7 th or 8 th day of embryo development. The amnion  a small sac that covers the dorsal surface of the embryo The amnion  a small sac that covers the dorsal surface of the embryo

24 AMNION Development Development as the amnion enlarges, it gradually engulfs the growing embryo as the amnion enlarges, it gradually engulfs the growing embryo the amnion and chorion laeve, though slightly adherent, are never intimately connected, and usually can be separated easily, even at term. the amnion and chorion laeve, though slightly adherent, are never intimately connected, and usually can be separated easily, even at term.

25 AMNION Amnion cell histogenesis Amnion cell histogenesis the epithelial cells of the amnion are derived from fetal ectoderm the epithelial cells of the amnion are derived from fetal ectoderm the epithelial cells line the innermost (amnionic fluid) side of the amnion the epithelial cells line the innermost (amnionic fluid) side of the amnion a layer of fibroblast-like (mesenchymal) cells, derived from embryonic mesoderm. a layer of fibroblast-like (mesenchymal) cells, derived from embryonic mesoderm.

26 AMNION Amnion cell histogenesis Amnion cell histogenesis early in pregnancy, the epithelial cells of the amnion replicate faster than the mesenchymal cells early in pregnancy, the epithelial cells of the amnion replicate faster than the mesenchymal cells At term, the epithelial cells form a continuous uninterrupted epithelium on the fetal surface of the amnion. At term, the epithelial cells form a continuous uninterrupted epithelium on the fetal surface of the amnion.

27 AMNIONIC FLUID average volume +1000 mL is found at term average volume +1000 mL is found at term may vary widely from a few milliliters to many liters may vary widely from a few milliliters to many liters abnormal conditions abnormal conditions oligohydramnios oligohydramnios polyhydramnios or hydramnios polyhydramnios or hydramnios

28 UMBILICAL CORD Development Development At first, the embryo is a flattened disc interposed between amnion and yolk sac At first, the embryo is a flattened disc interposed between amnion and yolk sac the embryo bulges into the amnionic sac and the dorsal part of the yolk sac is incorporated into the body of the embryo to form the gut. the embryo bulges into the amnionic sac and the dorsal part of the yolk sac is incorporated into the body of the embryo to form the gut.

29 UMBILICAL CORD Development Development The allantois projects into the base of the body stalk from the caudal wall of the yolk sac or, later, from the anterior wall of the hindgut. The allantois projects into the base of the body stalk from the caudal wall of the yolk sac or, later, from the anterior wall of the hindgut. The cord at term normally has 2 arteries and 1 vein The cord at term normally has 2 arteries and 1 vein

30 UMBILICAL CORD Structure & function Structure & function Blood flows from the umbilical vein by two routes the ductus venosus empties directly into the inferior vena cava the ductus venosus empties directly into the inferior vena cava numerous smaller openings  the fetal hepatic circulation  the hepatic vein  the inferior vena cava numerous smaller openings  the fetal hepatic circulation  the hepatic vein  the inferior vena cava

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32 PLACENTAL HORMONES Human placental lactogen (hPL1) Human placental lactogen (hPL1) human chorionic gonadotropin (hCG) human chorionic gonadotropin (hCG) chorionic adrenocorticotropin (ACTH2) chorionic adrenocorticotropin (ACTH2)

33 PLACENTAL HORMONES proopiomelanocortin, chorionic thyrotropin, growth hormone variant, parathyroid hormone- related protein (PTH-rP), calcitonin, and relaxin proopiomelanocortin, chorionic thyrotropin, growth hormone variant, parathyroid hormone- related protein (PTH-rP), calcitonin, and relaxin hypothalamic-like releasing and inhibiting hormones  thyrotropin-releasing hormone (TRH), gonadotropin-releasing hormone (GnRH), corticotropin-releasing hormone (CRH), somatostatin & growth hormone-releasing hormone (GHRH) hypothalamic-like releasing and inhibiting hormones  thyrotropin-releasing hormone (TRH), gonadotropin-releasing hormone (GnRH), corticotropin-releasing hormone (CRH), somatostatin & growth hormone-releasing hormone (GHRH)

34 MATERNAL ADAPTATION TO PREGNANCY Uterus Uterus During pregnancy, uterine enlargement involves stretching and marked hypertrophy of muscle cell s During pregnancy, uterine enlargement involves stretching and marked hypertrophy of muscle cell s

35 MATERNAL ADAPTATION TO PREGNANCY Cervix Cervix softening and cyanosis of the cervix softening and cyanosis of the cervix vascularity and edema of the entire cervix vascularity and edema of the entire cervix hypertrophy and hyperplasia of the cervical glands. hypertrophy and hyperplasia of the cervical glands.

36 MATERNAL ADAPTATION TO PREGNANCY Ovarium Ovulation ceases during pregnancy and the maturation of new follicles is suspended Ovulation ceases during pregnancy and the maturation of new follicles is suspended only a single corpus luteum of pregnancy can be found only a single corpus luteum of pregnancy can be found functions maximally during the first 6-7 wks of pregnancy (4-5 wks postovulation) functions maximally during the first 6-7 wks of pregnancy (4-5 wks postovulation)

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38 MATERNAL ADAPTATIONS Fallopian tubes Fallopian tubes The musculature of the fallopian tubes  little hypertrophy The musculature of the fallopian tubes  little hypertrophy The epithelium of the tubal mucosa  flattened The epithelium of the tubal mucosa  flattened Decidual cells may develop in the stroma of the endosalpinx, but a continuous decidual membrane is not formed. Decidual cells may develop in the stroma of the endosalpinx, but a continuous decidual membrane is not formed. Vagina & perineum Vagina & perineum increased vascularity and hyperemia develop in the skin and muscles of the perineum and vulva increased vascularity and hyperemia develop in the skin and muscles of the perineum and vulva softening of the normally abundant connective tissue of these structures softening of the normally abundant connective tissue of these structures Increased vascularity prominently affects the vagina Increased vascularity prominently affects the vagina The copious secretion and the characteristic violet color of the vagina during pregnancy (Chadwick sign) The copious secretion and the characteristic violet color of the vagina during pregnancy (Chadwick sign) hypertrophy of the smooth-muscle cells hypertrophy of the smooth-muscle cells The papillae of the vaginal mucosa  hypertrophy, creating a fine, hobnailed appearance The papillae of the vaginal mucosa  hypertrophy, creating a fine, hobnailed appearance

39 SKIN CHANGES In the later months of pregnancy, reddish, slightly depressed streaks -----  develop in the skin of the abdomen,the breasts and thighs In the later months of pregnancy, reddish, slightly depressed streaks -----  develop in the skin of the abdomen,the breasts and thighs the reddish striae of the present pregnancy, glistening, silvery lines that represent the cicatrices of previous striae the reddish striae of the present pregnancy, glistening, silvery lines that represent the cicatrices of previous striae the midline of the abdominal skin becomes markedly pigmented, assuming a brownish-black color to form the linea nigra the midline of the abdominal skin becomes markedly pigmented, assuming a brownish-black color to form the linea nigra irregular brownish patches of varying size appear on the face and neck, giving rise to chloasma or melasma gravidarum (mask of pregnancy) irregular brownish patches of varying size appear on the face and neck, giving rise to chloasma or melasma gravidarum (mask of pregnancy) accentuation of pigment of the areolae and genital skin accentuation of pigment of the areolae and genital skin

40 BREAST CHANGES 1 st month  breast tenderness and tingling 1 st month  breast tenderness and tingling 2 nd month  the breasts increase in size 2 nd month  the breasts increase in size the nipples  larger, more deeply pigmented, and more erectile the nipples  larger, more deeply pigmented, and more erectile Then  a thick, yellowish fluid, colostrum, can often be expressed from the nipples by gentle massage Then  a thick, yellowish fluid, colostrum, can often be expressed from the nipples by gentle massage the areolae  broader and more deeply pigmented the areolae  broader and more deeply pigmented Scattered through the areolae  glands of Montgomery, (hypertrophic sebaceous glands) Scattered through the areolae  glands of Montgomery, (hypertrophic sebaceous glands)

41 METABOLIC CHANGES Water metabolism Water metabolism At term, the water content of the fetus, placenta, and amnionic fluid amounts to about 3.5 L. At term, the water content of the fetus, placenta, and amnionic fluid amounts to about 3.5 L.

42 METABOLIC CHANGES Water metabolism Water metabolism Increased water retention is a normal physiological alteration of pregnancy. Increased water retention is a normal physiological alteration of pregnancy. This is mediated by a fall in plasma osmolality of approximately 10 mOsm/kg induced by a resetting of osmotic thresholds for thirst and vasopressin secretion This is mediated by a fall in plasma osmolality of approximately 10 mOsm/kg induced by a resetting of osmotic thresholds for thirst and vasopressin secretion

43 METABOLIC CHANGES Water metabolism Water metabolism Another 3.0 L accumulates as a result of increases in the maternal blood volume and in the size of the uterus and the breasts. Another 3.0 L accumulates as a result of increases in the maternal blood volume and in the size of the uterus and the breasts. Thus, the minimum amount of extra water that the average women retains during normal pregnancy is about 6.5 L. Thus, the minimum amount of extra water that the average women retains during normal pregnancy is about 6.5 L.

44 PROTEIN METABOLISM At term, the fetus + placenta 4 kg & contain approximately 500 g of protein, or about half of the total pregnancy increase. At term, the fetus + placenta 4 kg & contain approximately 500 g of protein, or about half of the total pregnancy increase. The remaining 500 g is added to the uterus as contractile protein, to the breasts primarily in the glands, and to the maternal blood as hemoglobin and plasma proteins. The remaining 500 g is added to the uterus as contractile protein, to the breasts primarily in the glands, and to the maternal blood as hemoglobin and plasma proteins.

45 PROTEIN METABOLISM Amino acids used for energy are not available for synthesis of maternal protein. Amino acids used for energy are not available for synthesis of maternal protein. With increasing intake of fat and carbohydrates as energy sources, less dietary protein is required to maintain positive nitrogen balance. With increasing intake of fat and carbohydrates as energy sources, less dietary protein is required to maintain positive nitrogen balance.

46 CARBOHYDRATE METABOLISM Normal pregnancy is characterized by mild fasting hypoglycemia, postprandial hyperglycemia, and hyperinsulinemia Normal pregnancy is characterized by mild fasting hypoglycemia, postprandial hyperglycemia, and hyperinsulinemia pregnancy-induced state of peripheral resistance to insulin pregnancy-induced state of peripheral resistance to insulin 1. Increased insulin response to glucose. 2. Reduced peripheral uptake of glucose. 3. Suppressed glucagon response.

47 FAT METABOLISM The concentrations of lipids, lipoproteins, and apolipoproteins in plasma increase. The concentrations of lipids, lipoproteins, and apolipoproteins in plasma increase. Low-density lipoprotein cholesterol (LDL- C) levels peak week 36 ∞ the hepatic effects of estradiol and progesterone Low-density lipoprotein cholesterol (LDL- C) levels peak week 36 ∞ the hepatic effects of estradiol and progesterone

48 FAT METABOLISM High-density lipoprotein cholesterol (HDL- C) peaks at week 25, decreases until week 32, and remains constant for the remainder of pregnancy. High-density lipoprotein cholesterol (HDL- C) peaks at week 25, decreases until week 32, and remains constant for the remainder of pregnancy. High-density lipoprotein-2 and -3 cholesterol levels peak at approximately 28 weeks and remain unchanged throughout the remainder of pregnancy High-density lipoprotein-2 and -3 cholesterol levels peak at approximately 28 weeks and remain unchanged throughout the remainder of pregnancy

49 HAEMATOLOGICAL CHANGES the blood volumes at or very near term averaged about 40 to 45 percent above their nonpregnant levels the blood volumes at or very near term averaged about 40 to 45 percent above their nonpregnant levels hemoglobin concentration and the hematocrit decrease slightly during normal pregnancy hemoglobin concentration and the hematocrit decrease slightly during normal pregnancy

50 HAEMATOLOGICAL CHANGES The total iron content of normal adult women ranges from 2.0 to 2.5 g The total iron content of normal adult women ranges from 2.0 to 2.5 g The leukocyte ranges 5000 - 12,000/Ul The leukocyte ranges 5000 - 12,000/Ul fibrinogen concentration increases about 50 percent to average about 450 mg/dL late in pregnancy, with a range from 300 to 600 fibrinogen concentration increases about 50 percent to average about 450 mg/dL late in pregnancy, with a range from 300 to 600

51 CARDIOVASCULAR SYSTEM CHANGES The most important changes in cardiac function  the first 8 weeks of pregnancy The most important changes in cardiac function  the first 8 weeks of pregnancy Cardiac output is increased  the 5 th week of pregnancy Cardiac output is increased  the 5 th week of pregnancy Between weeks 10 - 20, plasma volume ↑,preload ↑ Between weeks 10 - 20, plasma volume ↑,preload ↑

52 RESPIRATORY SYSTEM CHANGES The diaphragm rises + 4 cm during pregnancy. The diaphragm rises + 4 cm during pregnancy. The subcostal angle widens ∞ transverse diameter of the thoracic cage ↑ +2 cm The subcostal angle widens ∞ transverse diameter of the thoracic cage ↑ +2 cm The thoracic circumference increases + 6 cm The thoracic circumference increases + 6 cm

53 RESPIRATORY SYSTEM CHANGES The amount of oxygen needs ↑ The amount of oxygen needs ↑ The respiratory rate is little changed during pregnancy The respiratory rate is little changed during pregnancy the tidal volume, minute ventilatory volume, and minute oxygen uptake increase appreciably as pregnancy advances the tidal volume, minute ventilatory volume, and minute oxygen uptake increase appreciably as pregnancy advances

54 GI TRACT CHANGES Gastric emptying and intestinal transit times are delayed in pregnancy because of hormonal or mechanical factors. Gastric emptying and intestinal transit times are delayed in pregnancy because of hormonal or mechanical factors. Pyrosis (heartburn) is common during pregnancy and is most likely caused by reflux of acidic secretions into the lower esophagus Pyrosis (heartburn) is common during pregnancy and is most likely caused by reflux of acidic secretions into the lower esophagus

55 FERTILIZATION & NIDATION

56 GESTATIONAL AGE The Nägele rule ∞ estimated date of confinement (EDC). The Nägele rule ∞ estimated date of confinement (EDC). Using last menstrual period minus 3 months, plus 1 week and 1 year Using last menstrual period minus 3 months, plus 1 week and 1 year the assumptions  a normal gestation is 280 days & 28-day menstrual cycles the assumptions  a normal gestation is 280 days & 28-day menstrual cycles Physical examination Physical examination Ultrasound confirmation Ultrasound confirmation

57 EMBRIOLOGICAL DEVELOPMENT

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59 ANTENATAL CARE  Minimum antenatal care  1x  1 st trimester  1x  2 nd trimester  2x  3 rd trimester  Effective normal antenatal care  every month  early pregnancy – 28 wks GA  every 2 wks  28 – 36 wks GA  every wks  37 wks GA - delivery

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