Anda di halaman 1dari 87

Female reproductive system

Event of oogenesis

Physiological Stages
Neonatal period: birth---4 weeks
Childhood: 4 weeks----12 years
Puberty: 12 years---18 years
Sexual maturation: 18 year---50 year
Perimenopause: decline of ovarian function
(40 years)----1 year postmenopause
Postmenopause:

Menstruation

1.
2.

3.

4.

Menstruation
cyclic endometrium sheds and bleeds due to cyclic
ovulation
Mense
Endometrium is sloughed (progesterone withdrawal)
Nonclotting menstrual blood mainly comes from
artery (75%)
Interval: 24-35 days (28 days). duration: 2-6 days. the
first day of menstrual bleeding is consideredy by day
1
Shedding: 30-50 ml

Central reproductive hormones

Hypothalamus-Pituitary-Ovary(H-P-O axis)

Central reproductive hormones

1.
1)

Neuroendocrine regulation
Gonadotropin-releasing hormone,GnRH
chemical structure
(pro)Glu-His-Trp-Ser-Tyr-Gly-Leu-Arg-Pro-Gly-NH2

2)

Synthesize and transport

nerve cells

portal vein

hypothalamus

pitutary

anterior lobe

Central reproductive hormones

Central reproductive hormones


3)

Regulation of GnRH
Hypothalams
GnRH

Pituitary
FSH, LH

Ovary
E,P

Central reproductive hormones


2.
1)

2)

Gonadotropins
Composition (glycoprotein)
Follicle stimulating hormone,FSH
Luteinizing hormone,LH
Synthesize and transport

Gonadotroph
(pulse)

Blood
circulation

ovary

Central reproductive hormones


Prolactin (PRL)
Regulated by the prolactin inhibiting factor (PIF)
3.

The Ovarian cycle

1.

2.

Function of ovary
Reproduction
development and maturation of follicle; ovulation
Endocrine
estrogens, progesterone, testosterone

The Ovarian cycle


Cyclic changes of ovary
1.
The development and maturation of follicle
1)
Primordial follicle: before meiosis
2)
Preantral follicle: zona pellucida, granulosa cells (FSH
receptor)
3)
Antral follicle: granulosa cells (LH receptor), E
4)
Mature follicle: E,P
Theca externa, theca interna, granulosa, follicular antrum,
mound, radiate coronal
5)
Follicular phase: day 1 to follicle mature (14 days)

The Ovarian cycle

The Ovarian cycle


Ovulation
1)
First meiosis completed collagen decomposed
oocyte ovulated
2)
Regulation
a)
LH/FSH peak
E2(mature follicle) GnRH (hypothalamus)
LH/FSH peak (positive feedback)
b)
P cooperation
LH P (follicle luteinized before ovulation)
positive feedback
2.

The Ovarian cycle


3.
1)
2)
3)

4)

Corpus luteum
follicle luteinized after ovulation: luteal cells
LH VEGF corpus hemorrhagicum
Regression
non fertilized corpus albicans
Luteal phase
Ovulation to day 1

The Ovarian cycle


sex hormones secreted by ovary
1.
Composition
Estrogen, progesterone, testosterone
2.
Chemical structure
Steroid hormone
3.
Synthesis
Cholesterolpregnenoloneandrostenedione
testosteroneestradiol
5 or 4 pathway of estrogen production

The Ovarian cycle


4.
5.
1)
a)

b)
c)

Metabolism: liver
Cyclic change of E and P in ovary
Estrogen
E(day 7) E peak (pre-ovulate) E E (1
day after ovulate) E peak (day 7-8) E
theca interna cells (LH receptor) testosterone
Granulosa (FSH receptor) estrogen

The Ovarian cycle


Progesterone
P (after ovulation) P peak (day 7-8) P
2)

granulosa
LH

progesterone

Ovarian responses

The Ovarian cycle


H-P-O axis
1.
Positive feedback
Sex hormones (E) GnRH or LH/FSH
E peak (200pg/ml) LH/FSH peak ovulation
2.
Negative feedback
Sex hormones (E) GnRH or LH/FSH
Follicular phase: E FSH
Luteal phase: EP LH/FSH(formation)
EP LH/FSH(regression)

The endometral cycle

1.

2.
3.

Proliferative phase
E(mitogen) stroma thickens and glands
become elongated proliferative endometrium
Duration: 2 weeks
Thickness: 0.5mm 5mm

The endometral cycle


Secretory phase
1.
P(differentiation) secretory endometrium
2.
Features
stroma becomes loose and edematous
blood vessels entering the endometrium become thickened
and twisted
glands become tortuous and contain secretory material
within the lumina
3.
Duration: 2 weeks
4.
Thickness: 5-6mm

Change of Other genital organs

Cervix

endocervical glands (E) mucus(thin,clear, watery)


maximal (ovulation)
endocervical glands (P) mucus(thick, opaque,
tenacious)

Vagina

Vaginal mucosa (E) thickening and secretory


changes
Vaginal mucosa (P) secrete

Pregnancy

1. Fertilization
2. Placenta development,
nutrition
3. Hormonal changes during
pregnancy

Fertilization

The sperm passes through the corona radiata, the outermost cell layer of the egg.
The sperm breaks through the zona pellucida.
This occurs with the aid of several enzymes possessed by the sperm that break
down the proteins of the zona pellucida, the most important one being acrosin.
When the sperm penetrates the zona pellucida, the Acrosome reaction occurs. This
makes the egg impermeable to any other sperms and prevents fertilization by more
than one sperm.
The cell membranes of the egg and sperm fuse together.
The female egg, also called a secondary oocyte at this stage, completes its second
meiotic division. This results in a mature ovum.
The sperm's tail and mitochondria degenerate with the formation of the male
pronucleus.
The male and female pronuclei fuse to form a new nucleus that is a combination of
the genetic material from both the sperm and egg.

Fertilization
Fertilization in
the ampulle of
the FT.

Prostaglandin
s
Oxytocin
Ectopic
(extrauterine)
gravidity

Fertilization
Transport into
the uterus - 35 days
Contraction
of the FT
isthmus
Relaxation progesteron

Fertilization
Implantation
5-7 days after
fertilization
Proteolytic
enzymes of
the
trophoblast
cells

Placenta

Placenta development
Early nutrition of the embryo - invasion of
trophoblastic cells into the decidua
Progesteron produced by CL - stimulates decidual
cells to concentrate glycogen, proteins and lipids

Placenta works as a
physiological A-V shunt

Placenta - oxygen
transport
Similarities betwen
placenta and lungs
Oxygen transport - simple difusion

Lungs
pO2 in alveoli..100mmHg
pO2 in the venous blood40mmHg
dO2 in (pressure gradient)60mmHg
Placenta:
pO2 in placental sinuses50mmHg
pO2 in fetal umbilical vein30mmHg
dO2 in (pressure gradient)20mmHg
How is a sufficient oxygenation of the fetus
possible?

Placenta - oxygen
transport

1. Fetal hemoglobin

2. Higher Hb
concentration in the
fetal blood
(50% more than in adults)
3. Double Bohr effect
- Hb can carry more
oxygen in low pCO2 than
in high pCO2

Placenta - CO2,
nutritients, waste
CO gradient - 2-3 mmHg, but extreme solubility
products
transport
(diffuses 20times faster than oxygen)
2

facilitated diffusion for glucose


(high glucose need in 3dr trimester)
free diffusion of fatty acids
diffusion of waste products based on concentration
gradient
drugs crossing placental barier - teratogens:
Talidomide, Carbamazepine, Coumarins,
Tetracycline
Alcohol, nicotine, heroin, cocaine, caffeine

Hormonal
Changes During
Pregnancy

Hormonal changes
HCG

Human Chorionic
Gonadotropin
prevent involution
(pregesterone, estrogen)

HCS

effect on the testes of


male fetus - development
of sex organs
Human Chorionic
Somatomammotropin
effect on latation
growth hormone effects
decreases insulin
sensitivity - more glucose
for the fetus

Hormonal changes
Progesterone

development of
decidual cells
decreases uterus
contractility
preparation for the
lactation

Estrogens

enlargement of uterus
breasts development
relaxation of ligments
estriol level - indicator
of
vitality of the fetus

Progesterone and Cortisol


metabolism
Placenta

Hormonal changes
Placenta
CRH

HCG
HC thyrotropin

Mother
ACTH

aldosterone
cortisol

hypertension

edema
insulin resistan
hyperthyroidism

Calcium demands

gestational
diabetes

Hyperparathyroidism

Other
Physiological
Changes

Cardiovascular changes
Cardiac output (CO)
30 -50% above normal
placental circulation
increased metabolism
skin - thermoregulation
renal circulation

ECG changes
functional
murmurs
heart sounds

decreases in last 8 weeks (uterus compresses


vena cava)
incr. 30% more during labor
Heart rate (HR) increases up to 90/min
Blood pressure (BP) drops, periferal resistance
decreases

Hematologic changes
plasma volume increases (50%)
erythropoesis (RBC) increases (25%)
decreased Hb, hematocrite
Iron requirements increases significantly
Iron suplements needed

Respiratory changes
oxygen consumption increases
20% above normal
Progesterone increases
sensitivity
for CO2 in respiratory
centre
Growing uterus

Frequency
increases
Minute ventilation
increases (50%)
pCO2 decreases
slightly

Urinary system
Glomerulat filtration rate and renal plasma
flow increases
(up to 30 - 50 %)
Increased reabsorption of ions and water
- placental steroids
- aldosterone
Slight increase of urine formation
Postural changes affect renal functions
- upright position
- supine position
- lateral position during sleep

Preeclampsia, Eclampsia
Preeclampsia - pregnancy induced hypertension
+ proteinuria
Incresing BP since 20th week - hypertension
Salt and water retention - edema formation
RBF and GFR decreases
extensive secretion of placental hormones ?
insufficient blood supply to placenta - ischemia
- increased resistance
- TNF alfa, cytokines ?
Eclampsia - vascular spasms, chronic seizures, coma

Nutrition and
Metabolism

Maternal weight gain


Fetus
5 kg

Mothe
6 kg

Maternal-Fetal
Metabolism
250 - 300 extra kcal/day should be ingested
- 85% fetal metabolism, 15% stored in maternal
fat
Extra protein intake - 30g/day
End of pregnancy - fetal glucose need 5mg/kg/min
(mother 2,5mg/kg/min)
2 phases of pregnancy:
1st - 20th week - mothers anabolic phase:
- anabolic metabolism of the mother
- quite small nutrition demands of the
conceptus
21 - 40 week (esp. last trimester):
- high metabolic demands of the fetus

Maternal-Fetal
Metabolism
Mothers anabolic phase:
- normal or increased sensitivity to insulin
- lower plasmatic glucose level
- lipogeneses, glycogen stores increases
- growth of breasts, uterus,weight gain
Catabolic phase (accelerated starvation):
- maternal insuln resistance
- increased transport of nutritients trough
placental
membrane
- lipolysis
Insulin resistance caused by HCS, cortisol and
growth hormone

Special nutrition need in


pregnancy
High protein diet, higher energy uptake
Iron supplements - 300mg ferrous sulfate
B - vitamins - erythropoesis
Folic acid (folate) - reduces risk of neural tube defects
Vitamin D3 + Ca supplements
Before parturition - K vitamin (prevention of
intracranial bleeding
during the labor)

Parturition
Birth of the baby
Both Biological and Social Event
Expected Day of Delivery

266 days (38 weeks) after fertilization


280 days (40 weeks) after last menstrual
period
Onset of Labor not completely understood
but we do know its about:
1. Mechanical Factors (psst this means muscles)
2. Hormonal Factors (oh yes there are more!!)

Its Like a Marathon:


The Body Prepares

Training: fitness of mom


and fetus are important
during labor (remember
hypoxia bad!)
Stretching: Ligaments
relax esp. pubic symphisis
making more room in
pelvic brim
Practice makes perfect:
Braxton-Hicks Contractions
give the top myometrium
a workout, stretch the
bottom muscles and help
dilate the cervix

Your Favorite:
Hormones!

Fetal Hormones
High Estrogen vs.
Progesterone
Prostaglandins
Oxytocin
Relaxin
All combine for a
POSITIVE feedback
loop

On Your Mark, Get Set,


Go! The Onset of Labor

Fetal Hypothalmus secretes Corticotropin


Releasing Hormone near term which stimulates
the
Fetal Anterior Pituitary to secrete
adrenocorticotropin hormone (ACTH)
ACTH stimulates fetal adrenal cortex to produce
cortisol
Cortisol stimulates secretion of estrogen from
placenta, inhibition of P synthesis -> uterine
contractions -> stimulates oxytocin -> hyp
Fetuses with adrenal hypoplasia are often postdate and labor is slow to start

Estrogen and
Progesterone
Progesterone
inhibits
contractibility
Estrogen increases
contractibility
At 7th month,
estrogen still
increasing but
progesterone
drops off slightly
High Estrogen:
Progesterone ratio
excites uterus

Oxytocin: The Hormone


of Love Michel Odent
-

Peptide hormone created in hypothalmus


Once E:P stimulating contraction,
hypothalmus signaled to send oxytocin to
posterior pituitary
E and Prostaglandin increase sensitivity of
oxytocin receptors
Stimulates uterine contraction and breasts
Administered to stimulate labor as pitocin
Fun Fact: hormone involved in orgasm!!

Two More!!

Prostagladins
Release stimulated
by estrogen and
oxytocin
Also stimulates
oxytocin (+ loop)
Promotes uterine
contractions

Relaxin
Peptide hormone
produced by the
corpus luteum
Looses ligaments
Softens cervix
Increases # of
oxytocin receptors

Three Stages of Labor

Dilation and
Effacement
Descent and
Expulsion
Expulsion of
Placenta

Stage One: Dilation

Intermittent
contractions < 10
minutes
Cervix dilating and
thinning
Average 12 hours
primigravidas, 7
hours for
multigravidas

Vertex and Transverse


Positions

Vertex position (head


down) is normal
Uterus contracts
pushing the occiput
bone to put pressure
on cervix to dilate
Transverse lie is worst
case scenario with
shoulder as presenting
part

Breech Presentation

Stage Two: Expulsion

Begins when cervix


fully dilated (10
cm)
Contractions are
strongest at top of
uterus pushing
fetus downward
Average 50 minutes
prima, 20 min multi

Head Crowing

Can You Tell the


Difference?

Most US hospitals encourage women to deliver in


supine position
Physiologically worst position because works
against gravity, compresses blood vessels
endangering baby and increases chance of 3rd
and 4th degree tears with episiotomy

Working Hard
Mom and Baby

Pain from contractions comes first from


hypoxia to uterine muscles and then from
stretching and straining
Contractions intermittent because babys
blood supply compromised and fetal HR
drops with every contraction, thus hypoxia
can occur (esp when too much pit is given)
Baby is an active participant in birth
pushing and negotiating bony structure to
get through birth canal

This Little Guy is All Tuckered Out

Stage 3: Placenta

Uterus contracts reducing


area of attachment
Separation of placenta
results in bleed and clotting
Placenta expelled
Represents stage when
hemorrhage can occur
Pitocin administered to aid
uterine contraction
Manual Extraction if retained
Lasts about 15 minutes

Recovery Time

Contraction of uterus result in


constriction of spiral arteries
(what was their role again?)
Mother - Father - Baby
Bonding Time: intense period
of hormone release: prolactin,
serotonin, dopamine, the
happy hormones
In first hour of life, babies can
crawl and self-attach to breast
however babies that are
drugged are almost always too
disoriented to do so
Happy Mom Breastfeeding

If All Else Fails


Cesarean Section

Indications:

Cord Prolapse
Tranverse Lie
Fetal Distress
Placenta Previa
Placenta Abruption
Failure to Progress
VBAC: risk of uterine
rupture
Cephlo-Pelvic
Disproportion

Warning: Midwife
Speaking

US C-section rate 25-30%


WHO says >10% unnecessary
Interventions such as
epidurals, withholding food
and water, supine position
increase chance of C-section
Hospital settings induce
anxiety, release of
adrenaline, labor STOPS
Feminist critique: Much of
language used to describe
birth is very unempowering
(ie failure to progess,
stubborn uterus)

If we hope to create
a non-violent world
where respect and kindness
replace fear and hatred
We must begin
with how we treat each other
at the beginning of life.
For that is where
our deepest patterns are set.
From these roots
grow fear and alienation
~or love and trust.
~Suzanne Arms

If we want to create a less violent world, we


must begin with birth

Thank you for


attention