Obstetrics

Dr. Sundus Lec: -1-

27-Sep-06

The Normal Menstrual Cycle

Menstruation is initiated in response to changes in steroids produced by the ovaries
which themselves controlled by the pituitary gland and the hypothalamus.

Within the ovary the menstrual cycle can be divided into three phases :

1 - The Follicular phase.

2 - Ovulation.
3 - The luteal phase.

The development of the oocyte is the key event in the follicular phase in menstrual
cycle. LH and FSH hormones from the pituitary gland are the main regulators of this
development.

At the start of the menstrual cycle FSH level begin to rise and this will rescue the
number of follicles from atresia and initiate steriodogenesis which is described as two
cells two gonadotrophins hypothesis which state that the two cell type within the
follicle are the theca and granulosa cells which are responsive to the gonadotrophins
LH and FSH respectively.

Normally only one follicle destinat to grow to a pre ovulatory follicle and released
at ovulation called the dominant follicle which is the largest and most developed
follicle in the ovary at the mid follicular phase and it produce the greatest amount of
oestradiol and inhibin.

As the dominant follicle grows further oestrogen level increase until it is suffecient to
exert a positive feed back effect on the pituitary LH secretion which is increase more
rapidly from day 12 onward called the LH surge. Ovulation occur 36 hours after the
onset of the LH surge. After ovulation the luteal phase begin which characterized the
production of porgesteron from the corpus luteum which is formed from the granulosa
cells that remain after ovulation and from some of the theca cells that differentiate to
become the theca lutein cells.the duration of the luteal phase is fairly constant being
around 14 days in most women. In the absence of pregnancy the corpus luteum
regress at the end of the luteal phase by a process called lutealysis this is associated
with a reduction in the level of progesteron oestrogen and inhibin leading to
menstruation.

In the endometrium the follicular phase is characterized by glandular and

stromal growth where the epithelial lining change from a single layer of columner
epithelum into pseudo stratified epithelium. These events occur under the influence of
oestrogen produced by the dominant follicle.

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 The luteal phase in the endometrial is characterized by glandular secretary
activity under the influence of progesteron produced by CL after ovulation. There is
increase in the tortuisty of both the glandular and spiral arteries.

FERTILIZATION

If pregnancy occur HCG hormon will be produced by the zygot and it is responsible
to nourish the CL and prolong it life span to 3 months.

After ovulation the egg is picked up by the fimberia of the fallopian tube and
swept by the ciliary's action towards the ampulla of the tube where fertilization occur.
This ovum contain haploid number of chromosome (22+x).Similary the mature sperm
contain (22+x or y ) chromosome and has a complex structure that provide motility
and propulsion (tail) energy source (mid piece) and the arosome for penetrating the
oocyte. Many sperms may be attached to the zona pellucida which is a thick
glycoprotein sheet surrounding the cytoplasmic membrane of the egg ,but only one
sperm can penetrate it. At this point a series of complex macromolecular event occur
withen the sperm head transforming it into the male pronucleous .Similarily the egg
complete it is second mieotic division to form the female pronucleous and
fertilization end with successful fusion of male and female pronuclei resulting in a
single cell called the zygot with a diploid number of chromosomes. in human this
process is comleted within 20 hours .

As soon as the zygot is formed ,it begin to divid very rapidally and within 5days ,
a tiny mass of cells the blastocyst is formed.

The embryo remain in the fallopian tube for 3 to 4 days until it reach the morula
stage(8 TO 32 cell stage), the embryo proceed through the isthmus to the uterine
cavity where it floats freely for up to 72 hours ,by the 6 day it orients itself towards
the deciduas and begin to penetrate it epithelial surface .At this time a group of cells
pushed to the periphery and called the trophoblast, the remaining cells called the inner
cell mass ,also a cavity is acquired and change to blastocele.

The trophoblast later will form the placenta and membrane ,while the inner cell
mass will differentiate into the embryo. The inner cell mass fist differentiate into 2
distinct layers an outer ectodemal layer and an inner endodermal layer, on further
differentiation a third layer is produced between the above 2 called the mesoderm.

The ectoderm has the amniotic cavity, the ectoderm has the yolk sac. The blastocele
is filled with loose material with extraembryonic mesoderm. The extra embryonic
mesoderm which is continuous with that of the embryro itself. Later the amniotic
cavity enlarge more than the yolk sac.
Extra embryonic coelum develops in the mesoderm so the mesoderm is left in 3
spaces :

1 – Lining the cavity of coelum in future becomes part of fetal membrane.

2 – Part is invagenated between ectoderm and endoderm which will form
embryonic mesoderm.
3 – Some is collected in area of future umbilical cord called embryonic stalk.

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 The peripheral mesoderm lining the blastocyst will give the mesoderm of
blood vessels of villi.

During implantation between 7 – 8 th day of conception and while the blastcyst

is within the decidua. The trophoblast composed of:

1 – An inner,well arranged cells called cytotrophoblast with big nuclei and pink
cytoplasm.
2 – An outer cell called cytiotrophoblast which are loosely arranged and have
small nuclei and pale cytoplasm. They grow outward in projection like finger to give
attachment to the endometrium and grow all over the blastocyst in exaturated pattern.

The growth produce lacuni and vessels in between. The cells of trophoblast get
invasive property of blood vessels and glands of decidua basalis, so maternal blood
occupy these spaces ( lacuni and vacules ) i.e form the future intervillous spaces.

The decidua described in three layers :

1 – Basalis : between the conceptus and myometrium.

2 – Capsularis : covers the conceptus i.e between the conceptus and endometrial
cavity.
3 – Parietalis : covers the rest of endometrial cavity.

Villus structures is as follows :

1 – Projection of villi consist of the trophoblast by its 2 layers only with primary
villus.
2 – Then a layer of extra embryonic mesoderm passes into the primary villus to
form a villus of 3 layers , syncytium , cytotrophoblast and a core of mesoderm called
secondary villus.
3 – On the 16th day , inside the mesoderm “ fetal origin “ capillaries , arteries and
veins are formed , called tertiary villus which will function to exchange gases,
nutrients and water.

The vascular structure of uterus and villus system are maintained by progesteron and
oestrogen secreted by the CL which is maintained after the 14th day by the HCG from
trophoblast. HCG produced from the 6th day of conception and CL will function till
the 12th week of pregnancy, after that the placenta take over.

The villus structure in the area where blastocyst is attached to the endometrial cavity,
grows greater than other villi elsewhere giving rise to the chorion frondosum, the
other villi called chorion laevi.

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 The decidual plate ( basalis ) is the part to which large villi are attached , between
the villi the intervillous spaces are filled by maternal blood due to erosion and
destruction of blood vessels at the decidual plate by the trophoblast . So the exchange
occur between these spaces and fetal cappilaries ( placental barrier ) .

Some of the villi enlarge and responsible for anchoring of the blastocyst to the
decidua , so called anchoring villi , connecting GS to the placental place.

The villi at the periphery of decidual plate called terminal villi , arborizing in free –
like pattern , having much thinner layers than the anchoring villi forming better
exchange which is their main function.

Chorionic laevi start to degenerate and atrophy and become flat about the 8th week ,
while vast growth of chorion frondosum will form the future placenta.

The space of the uterus after implantation is called the decidual space . From which
blood may pass to the vagina , giving fear of threatened abortion. It will be closed at
18th week of gestation and uterine cavity is filled , the decidua parietalis , the chorion
laevi is atrophied.

Written By:
Rand Aras Najeeb