Tuesday, April 24, 2012

Fetus in-utero

The lie 

Relationship between the long axis of the fetus and the long axis of the centralized uterus or maternal spine

Longitudinal
long axis of the fetus is aligned to the mother’s
this is the only NORMAL position

Transverse
long axis of the fetus is perpendicular to that of the mother’s

Oblique
long axis of the fetus is 0-90 degrees (or 90-180 degrees) to that of the mother’s



The presentation

The part of the fetus which occupies the lower pole of the uterus

Vertex
head down in the pelvis

Brow

Facial

Breech 
head is up in the uterine fundus and the buttock in the pelvis

Shoulder

Attitude

Relationship of fetal parts to each other:
Flexed 
Deflexed 
Extended

Denominator

Arbitrary bony fixed point on the presenting part

PRESENTATION

Vertex
Brow
Facial
Breech
Shoulder


ATTITUDE

Flexed
Deflexed (vertex)
Extended (vertex)

DENOMINATOR

Occiput
Frontal eminence
Mentum
Sacrum
Acromion

Flexed Vertex Presentation 8 Possibilities

LOL 
ROL
LOA
ROA

ROP
LOP 
OP
OA

Leopold’s Maneuver

Four-part process 
Aim
Determine the position of the baby  in utero 
Determine the expected presentation during labor and delivery 

Questions to ask yourself when performing the exam:
  • Is the fundal height consistent with the fetal maturity?
  • Is the lie longitudinal, transverse or oblique?
  • Is the presentation cephalic or breech? 
  • If cephalic, is the attitude vertex or facial? 
  • Is the vertex engaged?

Preparation

Woman is supine, head slightly elevated and knees slightly flexed
If the doctor is R handed, stand at the woman’s R side facing her for the first 3 steps, then turn and face her feet for the last step (L handed, left side).



First Maneuver

What part is in the fundus?

Facing the mother, palpate the fundus with both hands
Assess for shape, size, consistency and mobility

Fetal head: firm, hard, and round
Detectable by ballotement

Buttocks/breech: softer and has bony prominences

Second Maneuver

Determine position of the back.

Still facing the mother, place both palms on the abdomen
Hold R hand still and with deep but gentle pressure, use L hand to feel for the firm, smooth back 
Repeat using opposite hands
Once you’ve located the back, confirm your findings by palpating the fetal extremities on the opposite side  (“lumpy”)

Third Maneuver

Determine what part is lying
above the inlet.

Gently grasp just above symphisis pubis with the thumb and fingers of the R hand 
Confirm presenting part (opposite of what’s in the fundus)
Head will feel firm
Buttocks will feel softer and irregular
If it’s not engaged, it may be gently pushed back and forth
Proceed to the 4th step if it’s not engaged…


Fourth Maneuver

Flexed/Deflexed/Extended?

Turn to face the woman’s feet
Move fingers of both hands gently down the sides of the abdomen towards the pubis 
Palpate for the cephalic prominence (vertex)
Prominence on the same side as the small parts suggests that the head is flexed (optimum)
Prominence on the same side as the back suggests that the head is extended


Using a Fetoscope

Fetal heart Rate (FHR) can be determined by use of:
Fetoscope 
specifically designed instruments 
Clinical stethescope
Electronic Doppler


Doppler Method

Employs a continuous ultrasound
Can detect the fetal heart at 10-12 weeks’ gestation

Amplifiers allow both the practitioner and parents to hear


Fetoscope

Can pick up the fetal heart rate at 17-19 weeks’ gestation


Fetal heart tones are best heard over the baby’s back
Used in conjunction with Leopold’s maneuver
Auscultation may be difficult if
Mother is overweight
Placenta is in the front of the uterus

*Always easier in later stages of the pregnancy


Where will you hear the FHTs?


Thursday, April 5, 2012

Fetal Physiology


Consists of :                            
Fetal blood
Pulmonary system
Immune system
Skin 
Nervous system
Gastro-intestinal  system
Urinary system
Endocrine glands
Cardiovascular

Fetal blood

Haematopoesis:
1st fetal blood cells  : Day 14 embryo : in yolk sac

Next, major site is liver: 6th wk embryo  : (hence, enlarged liver) & spleen (lesser extent)
Finally, bone marrow starts to produce RBC:16 wks

By 26 wks :  bone marrow is the predominant source of RBC

As the fetus grows, volume of blood in fetoplacental circulation increases.
       At term, 125 ml/kg fetal wt.
Hb in the fetal blood also rises.
       At term, Hb  18 g/dl. Why ? Enhances    the transfer of O2 across placenta.
Fetal RBC has shorter lifespan.
       At term, 90 days.


Hb in fetus:
Mostly fetal haemoglobin (HbF):    α2 γ2  instead of adult Hb A (α2 β2 ) and Hb A2 (α2 δ2 )
   
     10 – 28 wks    90 % of fetal Hb is HbF
     28 – 34 wks    HbF: HbA= 80:20
     6 mths age     HbF = 1 %
HbF vs HbA
     HbF has greater O2 binding capacity and it is resistant to denaturation by acid/alkali.


Fetal Haemoglobin
HbF  has higher affinity for O2 than adult in vivo due to a lower sensitivity to DPG (2,3 diphosphoglyceric acid)

Partial pressure of O2 in fetal circulation is low (92.7KPa) but this is compensated for by high Hb concentration and greater oxygen affinity


CVS

Differences (fetal vs adult circulation):

Major portion of Rt ventricular output bypasses the lungs coz fetal blood does not need to enter pulmonary vasculature
Oxygenation occurs in the placenta
Right & Left ventricles work in parallel ,rather than in series
Heart, brain & upper body receive blood from left ventricle ; placenta & lower body receive blood from both right & left ventricles

Presence of shunts:
         1. Ductus Venosus
         2. Foramen ovale
         3. ductus arteriosus

Fetal Circulation

Fetal blood pathway



Placenta  ----   umbilical vein 
----
      ductus      venosus  
----
        IVC 
----
      right atrium  
----
      foramen ovale  
----
      left atrium  
----
       left      ventricle   
----
       ascending aorta
  •    coronary/cerebral arteries       SVC      right atrium       right ventricle       pulmonary artery        ductus arteriosus       descending aorta        umbilical artery      placenta



After birth, constriction/collapse of:
 umbilical arteries: instantaneous functional closure / actual obliteration takes 2-3 mths. Distal part – form lateral umbilical ligament. Proximal part – remain as superior vesical arteries

Umbilical veins: closure a little later than arteries. Forms ligamentum teres.
ductus arteriosus: functional closure soon after pulmonary circn is established. Anatomical obliteration takes 1-3 mths. Forms ligamentum arteriosum.

foramen ovale: functional closure soon after birth, anatomical closure in 1 yr.

ductus venosum: forms ligamentum venosum


Incidence of closure of fetal channels
Fetal circulatory response to hypoxia
  • Heart rate falls
  • Resistance in the umbilical artery increases
  • Resistance in the middle cerebral artery decreases thus protecting flow to the fetal brain
  • Blood flow increased to heart and adrenals
  • Blood flow reduced to kidneys producing oligohydramnios (reduced volume of amniotic fluid)



Control of Fetal Heart Rate
Control of FHR is complex.

It is subject to modulating influences such as catecholamines and baroreceptors.
These influences generally act on FHR via the autonomic nervous system.

Parasympathetic tone dominates


Fetal Heart rates (FHR):
-20 weeks 155/minute
-30 weeks 144minute
-Term 140/min


FHR decreases in response to hypoxia


Fetal  Lung and Breathing


Development consist of

Pseudoglandular stage: 5-16 w
Canalicular stage: 16-25 w
Terminal sac stage: type II cells begin to produce surfactant 
At birth only 15% of adult alveoli are present in lungs       continue to grow up to 8 years


20 wks: full differentiation of capillary & canalicular elements of fetal lung

24 wks: alveoli develop, surfactant appear.

   Lung alveoli lined by surfactant (a group of phospholipids). 
   Prevents collapse of small alveoli during expiration by lowering surface tension
   Synthesized by type 2 alveolar cells ( 10 % of lung parenchyma)
   Lecithin ( phosphatidyl choline): main (80%)

Increased lecithin production :
Cortisol
Growth restriction
Prolonged rupture of membranes

Delayed lecithin formation in:
diabetes 

Phosphatidyl glycerol is more predictive of RDS esp in diabetic fetus.


Surfactant:

Composition: 90% lipids, 10% proteins
Phosphatidylcholine (lecithins):
                  DPPC: active component(50%)
                  PG: second(8-15%)
At birth,with first breath, an air to tissue interface is produced in the alveolus. Surfactant spreads to line alveolus to prevent collapse during expiration

Glucocorticoids and Surfactant :

Accelerate type 2 alveolar cell development

Accelerate surfactant synthesis

Accelerate lung structural maturation

Glucocorticoids play essential role in maturation of many fetal organs but excess amounts reduce fetal growth

Fetal breathing: 

Numerous but intermittent fetal breathing
   movements occur in utero especially during 
   sleep ( lung maturation).
Immune system

8 wks:  lymphocytes appear

Mid 2nd trimester: all phagocytic cells, T & B cells, complement

 Fetus consists almost totally of maternal IgG (transferred across placenta).
           16 wks: Maternal IgG transfer begins & increases
            Last 4 wks: bulk of IgG acquired.
            Hence, preterm :  less IgG
            Newborns produce IgG slowly & adult values are   reached only after 3 yrs.

IgM & IgA: very little is produced by fetus.
           not transferred across placenta.
          

General immunological defences:

1.Amniotic fluid (lysosomes, IgG)

2.Placenta (lymphoid cells, phagocytes, barrier)

3.Liver ( granulocytes)


Skin

16 wks: lanugo appears but disappears near term

1 month gestation till birth: skin thickness progressively increases

20 wks:  stratum corneum  distinct

Last wks: skin covered by vernix caseosa
                   desquamated skin cells
                   rich in cholesterol and glycogen

Preterm babies
  • No vernix & thin skin ie, larger insensible loss

  • Deficient brown fat

  • Delayed development of sweat glands

Alimentary system & energy stores
  • 10 wks: Swallowing reflex develops & gradually matures. Continuously and increasingly swallows amniotic fluid

  • 2nd trimester:  Peristalsis in intestines

  • Term : Large bowel is filled with meconium
    
  • But defaecation in utero (meconium in amniotic fluid) unusual unless fetal anoxia

Intestinal villi well developed by 19weeks


  • Gut development important for amniotic fluid
    homeostasis; (fetus swallows amniotic fluid
    from 12 weeks and amniotic fluid contains
    hormones and growth factors that stimulate
    gut development)

  • Gastrin, motilin and somatostatin regulate
    growth and development      present in gut by 13
    weeks         matures by 24 weeks

  • Digestive enzymes eg disaccharidases
    present by 9-10 weeks maturity at term

Meconium

Lanugo, vernix, scalp hair, epithelial cells from skin, mucus, exfoliated intestinal epithelium, intestinal juices
    
Liver:

Reduced capacity for conjugation of bilirubin esp. in preterm

Preterm infants:

Virtually no fat, so severely reduced ability to withstand starvation
Incompletely developed alimentary system
Poor and unsustained sucking ability
Uncoordinated swallowing mechanism
Delayed gastric emptying
Poor absorption of carbohydrates/fat/other nutrients

Kidney & urinary tract
  • Urine usu found in UB of even small fetuses

  • Fetal urine  gives rise to much of amniotic fluid. 
   (protein-free & sugar-free hypotonic ultrafiltrate of fetal plasma)
       12 wks:  urine production starts
       32 wks:  12 ml per hour
       40 wks:   38 ml per hour 

  • 36 wks: nephrogenesis complete
   But maturation of excretory & concentrating ability of fetal kidneys is gradual

   Preterm: immature, so abnormal

Amniotic fluid

Source:
  • Early pregnancy: ultrafiltrate of maternal plasma
  • 10 wks: transudate of fetal serum via skin & umbilical cord
  •  After 20 wks: mainly fetal urine ( as cornification of fetal skin, impermeable to water).
    Pulmonary fluid and fluid filtering through  placenta contribute little.

  • AF volume:

        Varies at each week of gestation. 
        Volume increases with increasing    gestation.
        10 wks: 30 ml
        20 wks: 300 ml
        30 wks: 600 ml
        38 wks: 1000 ml
        40 wks:  800 ml
        42 wks:  350 ml

Functions of AF:
  • Cushions fetus: Protect fetus from mechanical injury
  • Permits movements of fetus while preventing limb contracture
  • Prevents adhesions between fetus & amnion
  • Maintains temperature
  • Minimal nutritive function
  • Permit fetal lung development--  2 way movements of fluid into fetal bronchioles
  •    Absence of AF in 2nd trimester:  pulmonary hypoplasia
  • Promotes growth & differentiation of GI tract 

  • Renal agenesis, cystic kidney, IUGR ----oligohydramnios----reduced contribution of fluid into amniotic sac ----- major alterations in AF volume.

  • Anencephaly, oesophageal atresia, duodenal atresia ----- polyhydramnios----- reduced removal of fluid

Fetal behaviour
  • 18 wk: first fetal movements (quickening) perceived in primipara
    Several wks earlier in multipara
  • Formal counting of fetal movements (screening)

Reduced or Absent in 

  • Chronic hypoxia & growth failure
  • fetal death

  • Spinal cord extends along entire length of vertebral column in embryo, but after that, it grows more slowly.
    By 24 wks:  spinal cord extends to S1
    At birth:  L3
    In adults:  L1
  • Myelination of spinal cord:  starts mid-preg
  • 10 wks: swallowing
  • 14-16 wks: respiration evident
  • After 24 wks: ability to suck
  • 24-25 wks: can hear some sounds in utero
  • 28 wks: sensitive to light

Fetal endocrinology
  • 10 wks: GH, ACTH, PRL , TSH produced by fetal pituitary
  • 1st trimester: Vasopressin, oxytocin from posterior pituitary
  • Fetal adrenal: hypertrophy of reticular zone (site of synthesis of DHEA-dehydroepiandrosterone). This zone is absent in anencephaly. Adrenal medulla produces catecholamines.
  • 11 wks: Fetal thyroid produces small amount thyroxine
  • Fetal ovaries remain inactive



  • Fetal testicles mediate development of male reproductive structures



  • 12 wks: fetal pancreas secrete insulin


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