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Vulva
blood supply
lymph
nerve
- blood supply: external and internal pudendal arteries
- lymph: Medial group of superficial inguinal nodes
- nerve:
- - anterior → ilioinguinal nerves, genital branch of genitofemoral nerves;
- - posterior → perineal nerves and posterior cutaneous nerve of the thigh
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Vagina
blood supply
nerve
- Blood supply:
- -Vaginal branch of uterin artery (primary)
- -Middle rectal and inferior vaginal branches of hypogastric artery (internal iliac)
- Nerve:
- -Hypogastric plexus (sympathetic)
- -Pelvic nerve (parasympathetic)
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Uterus
anatomical components
- Fundus: uppermost region of uterus
- Corpus: body
- Cornu: part that joins the fallopian tubes
- Cervix: inferior part of cervix that connects vagina via cervical canal
- Internal os: opening of the cervix on the uterine side
- External os: opening of the cervix on the vaginal side
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Uterus
histology
- Mesometrium: visceral layer of peritoneum reflects against the uterus and forms this outmost layer
- Myometrium: smooth muscle layer of uterus
- 1. Outer longitudinal
- 2. Middle oblique
- 3. Inner longitudinal
- Endometrium: Mucosal layer, columnar epithelium
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Uterus
blood supply
nerve
- Blood supply:
- -Uterine arteries (from internal iliacs)
- -Ovarian arteries
- Nerve supply:
- -Superior hypogastric plexus
- -Inferior hypogastric plexus
- -Common iliac nerves
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Broad ligament
connection
contains
- Connection: lateral pelvic wall to the uterus and adenexa
- Contains: fallopian tube, round ligament, uterine and ovarian blood vessels, lymph, utererovaginal nerves, ureters
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Round ligament
connection
contains
- Connection: remains of gubernaculum; corpus of uterus down and laterally through the inguinal canal → labia majora
- Contains: nothing
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Cardinal ligament
connection
function
- Connection: cervix and lateral vagina to the pelvic wall
- Function: supports the uterus
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Fallopian (uterine) tubes
Connection
Blood supply
nerve
- Connection: extend from superior lateral uterus through superior fold of broad ligament to the ovaries
- Blood supply: uterine and ovarian arteries
- Nerve: Pelvic plexus (autonomic) and ovarian plexus)
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Fallopian tubes
anatomy
- Lateral to medial:
- Infundibulum: the lateralmost part; free edge is connected to the fimbriae
- Ampula: widest section
- Isthmus: narrowest part
- Intramural part: pierces uterine wall
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Ovaries
location
blood supply
nerve supply
histology
- Location: posterior aspect of broad ligament; attached to the broad ligament by the mesoovarium. NOT covered by peritoneum
- Blood supply: ovarian artery (from aorta at level L1); veins drain vena cava on the right, Left renal vein on the left
- Nerve supply: Aortic plexus
- Histology: covered by tunica albuginea (fibrous capsule); tunica albuginea is covered by germinal epithelium
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Dating a pregnancy
- Last menstrual period (LMP)
- Ultrasound: progressively less accurate as GA increases. Should not be used past 20 weeks.
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Symptoms of pregnancy
- Breast enlargement/tendernes (6 weeks GA)
- Areolar enlargement and increased pigmentation (after 6 weeks GA)
- Colostrum secretion (after 16 weeks GA)
- Nausea with or w/o vomiting (from missed period)
- Urinary frequency, nocturia, bladder irritability
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Chadwick's sign
Bluish discoloration of vagina and cervix, due to congestion of pelvic vasculature in pregnancy
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beta human chorionic gonadotropin (β-hCG)
site of production
detection
other uses
- hCG (glycoprotein)
- Production: syncytiotrophoblast cell s in developing placenta shortly after implantation
Detection: 8-10 days after fertilization
- Also elevated in:
- -hydatidiform mole
- -choriocarcinoma
- -germ cell tumors
- -Ectopically producing breast cancers and large cell carcinoma of the lung
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hCG levels during gestation
- Levels should double every 48 hours in early pregnancy
- 1 wk: 5-50mU/mL - assays detecting 25mU/mL recognize pregnancy with 95% sensitivity by 1 week post LMP
- 2 wks: 50-500mU/mL
- 3 wks: 100-10,000mU/mL
- 4 wks: 1,000-30,000mU/mL
- 5 wks: 3,500-115,000mU/mL
- 6-8 wks: 12,000-270,000mU/mL
- 8-12 wks: 15,000-220,000mU/mL
- 20-40 wks: 3,000-15,000mU/mL
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urine hCG
false positives
false negatives
- False positives:
- -proteinuria
- -Urinary tract infection
- False negatives:
- -too early
- -urine is dilute
-
plasma hCG
uses
- confirm urine hCG
- Diagnosing ectopic pregnancy
- Monitoring trophoblastic tumors
- Screening for fetal abnormalities
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Fundal height
- 12 wks: barely palpable
- 15 wks: midpoint between pubic symphysis and umbilicus
- 20 wks: at the umbilicus
- 28 wks: 6 cm above the umbilicus
- 32 wks: 6 cm below the xyphoid process
- 36 wks: 2 cm below xyphoid process
- 40 wks: 4 cm below xyphoid process
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Fetal heart tones
earliest, and worrisome
- Earliest: 8 weeks GA
- Worrisome: not auscultated by 11 weeks' GA, should do an ultrasound
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Physiology in pregnancy
terms
***
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Changes in pregnancy: Total body water
- Increased by ~8.5 L
- Composed of: fetal water, amniotic fluid, placental tissue, maternal tissue, edema, increased hydration of connective tissue, generalized swelling
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Changes in pregnancy: Energy requirement
- Increased gradually from 10 weeks to 36 weeks by 50 to 100 kcal/day
- Final 4 weeks, requirement increased by 300 kcal/day
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Changes in pregnancy: Weight gain
- Ideal: 25 to 35 lbs during pregnancy
- T1: 1.5 to 3 lbs
- T2 and T3: 0.8 lbs/wk
- Obese: should gain less that 25 lbs
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Changes in pregnancy: Metabolism
- Overal increases in the second half of pregnancy
- Carbohydrates: placenta is freely permeable to glucose
- Insulin: increased in first half; insulin resistance in second half
- Amino acids: plasma concentration of aa fall during pregnancy (hemodilution)
- Lipids: all raised (most increase in triglycerides); cross the placenta
- Fat: deposits in early pregnancy; primary source of energy in mid pregnancy
- Cholesterol: increase turnover, all increased during pregnancy; raised in postpartum
- Drugs: phenytoin falls during pregnancy; caffeine half-life is doubled; antibiotics are cleared more rapidly
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Screen for glucose intolerance/GDM
timeline
- Screen at 26 to 28 weeks' GA
- increased insulin in first half; insulin resistance in second half (physiologic)
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Changes in pregnancy: CNS
syncope
psychiatric sx
- Syncope:
- -venous pooling in lower extremities
- -dehydration
- -hypoglycemia
- -postprandial shunting of blood flow to the stomach
- -overexertion during exercise
- Psychiatric sx:
- -Hormonal changes of pregnancy
- -Progesterone → tiredness, dyspnea, depression
- -Euphoria secondary to endogenous corticosteroids
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Changes in pregnancy: Respiratory
Fetal P CO2 > maternal PCO2... must reset maternal respiratory center. Mechanism:
- 1. Progesterone reduces the CO2 threshold at which respiratory center is stimulated and increases respiratory center sensitivity
- →hyperventilation of pregnancy
2. Tidal volume (TV) increases by 200ml
3. Vital capacity (VC) increases by 100 to 200ml
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Changes in pregnancy: Cardiovascular
- CO increases by 40% by week 10
- -10% increase in stroke volume
- -10 to 15% increase in pulse rate
- -enlargement of heart and left ventricles
- -heart is displaced anterolaterally secondary to rise in diaphragm (ECG changes can mimic ischemia)
- Venous system: venous dilation
- -relaxation of vascular smooth muscle
- -pressure of enlarging uterus on IVC and iliac veins
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Changes in pregnancy: CV physical exam
- After midpregnancy: 90% have S3
- Systolic ejection murmurs: 96% of pregnant patients
- Diastolic murmurs: never normal
- During labor: CO increases by 30% during each contraction (increase in stroke volume, not heart rate)
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Changes in pregnancy: Gastrointestinal
Reflux esophagitis
Constipation
Gallbladder
Liver
- Reflux esophagitis
- -increased intragastric pressure
- -progesterone causes a relative relaxation of esophageal sphincter
Constipation: secondary to progesterone, which relaxes intestinal smooth muscle and slows peristalsis
- Gallbladder:
- -increased size
- -empties slower
- -Cholestasis, hormonal effects (?); also seen in some users of OCPs and hormone replacement therapy
- Liver:
- -hepatic function increases
- -Plasma globulin and fibrinogen concentrations increase
- -synthetic rate of albumin increases
- -Velocity of blood flow in hepatic veins decreases
- -Serum alkaline phosphatase increases largely due to placental production
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Changes in pregnancy: Genitourinary system
- Urinary stasis: decreased peristalsis, mechanical compression
- Asymptomatic bacteruria: 5 to 8% of pregnant women
- Urinary frequency increases: bladder compression by uterus, fetal head descent
- Nocturia: physiologic after T1 (up to 4 times per night)
- Stress incontinence: relaxation of bladder supports
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Changes in pregnancy: Bladder
- Bladder tone decreases
- bladder capacity increases
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Changes in pregnancy: Ureters
- Progressive dilatation and kinking in > 90% of women at >6 weeks
- -Decreased urine flow rate
- -dilatation is secondary to physical obstruction
- -extends up to calyces → enlarged kidneys
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Changes in pregnancy: Renal function
- RPF increases from T1: 30 to 50% above non-pregnant levels by 20 weeks; remains elevated until 30 weeks, then slowly declines
- GFR: increases; 60% above nonpregnant levels by 16 weeks, remains elevated
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Changes in pregnancy: Renal tubule changes
- Tubules lose some of their resorptive capacity: amino acids, uric acids, glucose are not as completely reabsorbed
- Iincrease protein loss of up to 300mg/24hr
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Changes in pregnancy: Hematologic
Plasma volume
RBC
Hemoglobin
ESR
WBC
Platelets
- Plasma volume: increased by 50% (hemodilution)
- RBC: increases progressively during pregnancy (Ret count increases by >2%); MCV ususally increases
- Hemoglobin: HbF concentration increases 1 to 2% during pregnancy
- Erythrocyte Sedimentation Rate: rises in early pregnancy due to increase in fibrinogen
- WBC: neutrophils increases in T1, rise until 30 weeks (number and activity/function); lymphocyte counts remains unchanged (function is suppressed)
- Platelets: reactivity increased in T2 and T3, returns to normal post partum
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Changes in pregnancy: Endocrine system
fetoplacental unit (hormones)
- hCG (luteotropic): Co-regulates and stimulates adrenal and placental steroidogenesis; stimulates fetal tissue to secrete testosterone. Possesses thyrotrophic activity
- hPL (human placental lactogen): anti-insulin and growth hormone-like effects (impaired maternal glucose and FFA release)
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Changes in pregnancy: Pituitary gland
- Increases in weight and sensitivity
- Prolactin: increases within a few days postconception; 10- to 20-fold higher at term
- FSH: blunted response to GnRH; progressive decreased response
- LH: response to GnRH diminishes and finally disappears
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Changes in pregnancy: Adrenal gland
- Plasma cortisol/other corticosteroids increase progressively from 12 weeks to term; 3-5 times the normal levels
- Half-life of plasma cortisol increases, clearance is reduced
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Changes in pregnancy: Thyroid gland
- Thought to be due to excess estrogen in pregnancy:
- -Increases in size
- -T3/T4 and Thyroxine-binding globulin increase (mother should remain euthyroid)
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Changes in pregnancy: Parathyroid glands
- PTH increases → increases maternal calcium absortpion (offset maternal loss to fetus)
- At term, PTH levels are higher in the mother, but calcitonin is higher in the fetus
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Changes in pregnancy: Plasma proteins
- Plasma protein concentrations fall by 20 weeks, mostly due to a fall in serum albumin
- Reduced colloid osmotic pressure in plasma → edema in pregnancy
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Changes in pregnancy: Pancreas
- Size of islets of Langerhans increases
- Number of beta cells increases
- Number of insulin receptor sites increases
- Insulin: rises in pregnancy, but insulin resistance increases as well
- Glucagon: levels are slightly raised in pregnancy, not as much as insulin levels
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Changes in pregnancy: Skin changes
- Pruritic urticarial papules and plaques of pregnancy (PUPPP) **
- Papular eruptions (prurigo gestationis and papular dermatitis)
- Pruritis gravidarum**
- Impetigo herpetiformis
- Herpes gestationis
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PUPPP
- pruritic urticarial papules and plaques of pregnancy
- Onset: T2-T3
- Severely pruritic
- LEsions: erythematous urticarial papules and plaques
- Distribution: abdomen, thighs, buttocks, occasionally arms and legs
- Incidence: common (.25-1%)
- No increased fetal morbidity/mortality
- Intervention: topical steroids, antipruritic drugs
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Changes in pregnancy: Melanocyte-stimulating hormone
- Increased in pregnancy causes:
- Linea nigra: black line of the abdomen that runs from above the umbilicus to the pubis
- Darkening of nipple and areola
- Facial cholasma/melasma: brown hyperpigmentation in exposed areas such as face
- Suntan acquired in pregnancy lasts longer than usual
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Changes in pregnancy: Estrogen effects
- Spider nevi are common (branched growth of dilated capillaries on the skin)
- Palmar erythema
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Changes in pregnancy: Corticosteroid effects
Striae on the abdomen, breasts, etc.
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Changes in pregnancy: Fingernails
Grow more rapidly during pregnancy
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Changes in pregnancy: Hair
- Shed rate is reduced
- Excess retained hair is often lost in the puerperium, secondary to maternal emotional stress
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Adaptations in pregnancy: Vagina
- Vaginal epithelum hypertrophies
- Increased quantity of glycogen-containing cells shed into vagina
- Connective tissue decreases in collagen content; increase in water content
- Vaginal becomes more acidic (pH = 4 to 5); hinders growth of most pathogens, favors growth of yeast
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Adaptations in pregnancy: Uterus
- Hypertrophy and hyperplasia of myometrial smooth muscle, secondary to:
- -steroid hormones
- -Uterine distension and wall thinning
- Term uterus weighs 1,100g with 20-fold increase in mass
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Adaptations in pregnancy: Round ligament
- Increased length, muscular content, diameter
- In pregnancy, may contract spontaneously, or in response to uterine movement
- In labor: contractions of ligaments pulls the uterus forward
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Adaptations in pregnancy: Vascular supply of uterus
- Nonpregnant: uterine artery
- Pregnant: ovarian arteries contribute 20 to 30% of blood supply
- Uterine arteries dilate to 1.5 times their diameter
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Adaptations in pregnancy: Cervix
- Softening: accumulation of glycosaminoglycans and increased water content and vasculatiry
- "cervical ripening": takes place over last few weeks of gestation
- Antibacterial mucous plug of the cervix: within endocervical canal
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Adaptations in pregnancy: Uterine isthmus
- uterine isthmus: small region of uterus that lies between the uterine corpus and the cervix
- At 12 weeks: isthmus enlarges and thins
- Labor: isthmus expands and is termed the lower uterine segment
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Conception: ovulation
- ovum leaves the ovary, carried into the fallopian tube
- surrounded by its zona pellucida
- Oocyte has completed its first meiotic division and carries its first polar body
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Conception: fertilization
- Occurs within 24hrs after ovulation in the ampulla (third of the tube adjacent the ovary
- Fertilization: signals the ovum to complete meiosis II and to discharge an additional polar body
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Conception: preimplantation
- Ovum remains in the ampulla for 80 hours, travels through isthmus of fallopian tube for 10 hours
- Egg → multicellular blastomere
- Blastomere passes into the uterine cavity
- blastomere → blastocyst, floats in endometrial cavity for 90 to 150 hours
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Conception: Implantation
- Day 5 to 6 of development: blastocyst adhere to the endometrium
- After attachment, endometrium proliferates around the blastocyst
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Conception: Placentation
- During week 2, cells in outer cell mass differentiate into trophoblasts
- Trophoblastic shell forms initial boundary between embryo and the endometrium
- Trophoblasts near the myometrium form placental disk; others form chorionic membranes
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Conception: Postimplantation
- Endometrium or lining of uterus during pregnancy is termed decidua
- Maternal RBCs may be seen in the trophoblastic lacunae in the second week postconception
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Embryology
timeline [wks]
- Embryo development
- wk 1: Early morula; no organ differentiation
- wk 3: Double heart recognized
- wk 4: initial organogenesis
- wk 6: Genetic sex determined
- wk 8: Sensory organ development and nondifferentiated gonadal development
- Fetal development
- wk 12: Brain configuration roughly complete, sex now specific, blood forming in marrow, external genitalia forming, uterus no longer bicornuate
- wk 16: Fetus is active, sex determined by visual inspection, myelination of nerves, heart muscle well developed, vagina and anus open, ischium ossified
- wk 20: Sternum ossifies
- wk 24: Primitive respiratory movements
- wk 28: Nails appear and testes at or below internal inguinal ring
- wk 36: Earlobe soft with little cartilage, scrotum small with few rugae
- wk 40: Earlobes stiffen by thick cartilage, scrotum well developed
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Developmental ages
timeline [days]
- 4: blastula
- 7-12: implantation
- 13: Primitive streak
- 16: Neural plate
- 19-21: First somite
- 23-25: Closure of anterior neuropore
- 25-27: Arms bud, closure of posterior neuropore
- 28: Legs bud
- 44: sexual differentiation
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Placenta
blood supply
- adapts over T2 and T3; primary producer of steroid hormones after 7 weeks' GA
- Blood supply: arcuate and radial arteries during normal pregnancy is high with low resistance (resistance falls after 20 weeks)
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Multiple gestation
- Division of embryos before differentiation of trophoblasts (< day 2 or 3): 2 chorions, 2 amnions
- Division of embryos after trophoblast differentiation and before amnion formation (days 3 to 8): 1 placenta, 1 chorion, 2 amnions)
- Division of embryos after amnion formation (day 8 to 13): 1 placenta, 1 chorion, 1 amnion
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Pregnancy proteins: hCG
- Source: placenta
- Function: Maintains the corpus luteum; stimulates adrenal and placental steroidogenesis
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Pregnancy proteins: ACTH
- Source: Trophoblasts
- Function: Stimulates an increase in circulating maternal free cortisol
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Pregnancy proteins: hPL
- Source: trophoblasts
- Function: Antagonizes insulin; maternal glucose intolerance, lipolysis, proteolysis
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Pregnancy proteins: CRH
- Source: placental tissue and decidua
- Function: Stimulates placental ACTH release and participates in the surge of fetal glucocorticoids associated with late T3 fetal maturation
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Pregnancy proteins: Prolactin
- Source: Decidualized endometrium
- Function: Regulates fluid and electrolyte flux through the fetal membranes
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Pregnancy proteins: Alpha-Fetoprotein (AFP)
- Source: Yould sac, fetal GI tract, fetal liver
- Function: regulates fetal intravascular volume (osmoregulator)
- -MSAFT peaks between 10 and 13 weeks' GA, then declines
- -Detectable as early as 7 weeks' GA
- MSAFP is decreased in pregnancies with Down's syndrome
- Amniotic fluid AFP
and maternal serum (MSAFP) are elevated in association with neural tube defects and low in trisomy 21
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Pregnancy steroids: Estrogens
- Function: estrogens affect uterine vasculature
- Estradiol: maternal ovaries (wks 1 through 6); placenta after T1. during T3, low estradiol levels are associated with poor outcomes
- Estrone: maternal ovaries, adrenals, and peripheral conversion for first 4 to 6 weeks; placenta therafter
- Estriol: placenta (need living fetus)
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Pregnancy steroids: Progesterone
- Source: corpus luteum before 6 weeks, placenta therafter (from LDL)
- Function: affects tubal motility, endometrium, uterine vasculatur, parturition; inhibits T lymphocyte-mediated tissue rejection
- *abortion will occur in 80% of women with progetserone levels under 10ng/mL
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Pregnancy steroids: Cortisol
- Source: Decidual tissue
- Function: Suppresses the maternal immune rejection response of the implanted coceptus
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Pregnancy steroids: LDL Cholesterol
- Source: fetal adrenal gland
- Function: regulatory precursor of corpus luteum progesterone production; lipoprotein utilized in fetal adrenal steroidogenesis
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