‘

‘
‘
‘
‘

‘‘
‘
 ‘

‘
Ú
 






Ú

 


Ú

c


‘

‘ ‘
‘

 

‘
‘

‘
A single sperm penetrates the
mother's egg cell, and the
resulting cell is called a zygote.
The zygote contains all of the
genetic information (DNA)
necessary to become a child.
Half of the genetic information
comes from the mother·s egg
and half from the father·s
sperm. The zygote spends the
next few days traveling down
the Fallopian tube and divides
to form a ball of cells.

‘
The zygote continues to divide, creating an inner group of cells with an outer
shell. This stage is called a blastocyst. The inner group of cells will become the
embryo, while the outer group of cells will become the membranes that nourish
and protect it.
The blastocyst reaches the womb (uterus) around day 5, and implants into the
uterine wall on about day 6. At this point in the mother's menstrual cycle, the
lining of the uterus has grown and is ready to support a baby. The blastocyst
sticks tightly to the lining, where it receives nourishment via the mother's
bloodstream.



‘
The cells of the embryo now multiply and begin to take on specific functions. This
process is called differentiation. It leads to the various cell types that make up a
human being (such as blood cells, kidney cells, and nerve cells).
There is rapid growth, and the baby's main external features begin to take form.
It is during this critical period (most of the first trimester) that the growing baby is
most susceptible to damage. The following can interfere with the baby's
development:

|‘ Alcohol, certain prescription and recreational drugs, and other substances

that cause birth defects
|‘ Infection (such as rubella or cytomegalovirus)
|‘ Nutritional deficiencies
|‘ ü rays or radiation therapy

 
 ‘
‘


‘‘

‘ 

‘
‘
The period of time between conception and birth during which the fetus grows
and develops inside the mother's womb is called gestation. In humans, the
length of pregnancy, or gestational age, is the time measured from the first day
of the woman's last menstrual cycle to the current date. It is measured in weeks.
The time interval of a gestation plus 2 weeks is called the gestation period, and
the length of time plus 2 weeks that the baby has spent developing in the womb
is called the gestational age. The following list describes specific changes that
occur in the womb:

|‘ eek 3 of gestation (embryo development); week 5 of pregnancy

„‘ The brain, spinal cord, and heart begin to develop.
„‘ The gastrointestinal tract begins to develop.
|‘ eeks 4 to 5 of gestation; week 6 7 of pregnancy
„‘ Arm and leg buds become visible.
„‘ The brain develops into five areas and some cranial nerves are visible.
„‘ The eyes and ear structures begin to form.
„‘ Tissue forms that develops into the vertebra and some other bones.
„‘ The heart continues to develop and now beats at a regular rhythm.

]
 „‘ dudimentary blood moves through the main vessels.

|‘ eek 6 of gestation; week 8 of pregnancy

„‘ The arms and legs have grown longer, and foot and hand areas can
be distinguished.
„‘ The hands and feet have fingers and toes (digits), but may still be
webbed.
„‘ The brain continues to form.
„‘ The lungs begin to form.
|‘ eek 7 of gestation; week 9 of pregnancy
„‘ Nipples and hair follicles form.
„‘ albows and toes are visible.
„‘ All essential organs have begun to form.
|‘ eek 8 of gestation; week 10 of pregnancy
„‘ The eyelids are more developed.
„‘ axternal features of the ear begin to take their final shape.
„‘ Facial features continue to develop.

[
 „‘ The intestines rotate.

The end of the eighth week marks the end of the "embryonic period" and the
beginning of the "fetal period."

|‘ eeks 9 to 12 of gestation; weeks 11 to 14 of pregnancy

„‘ ayelids close and will not reopen until about the 28th week.
„‘ The face is well formed.
„‘ {imbs are long and thin.
„‘ Àenitals appear well differentiated.
„‘ ded blood cells are produced in the liver.
„‘ The head makes up nearly half of the baby's size.
„‘ The baby can make a fist with its fingers.
„‘ Tooth buds appear for the baby teeth.
|‘ eeks 13 to 16 of gestation; weeks 15 to 18 of pregnancy
„‘ The skin is almost transparent.
„‘ Fine hair called lanugo develops on the head.
„‘ econium is made in the intestinal tract.
„‘ ore muscle tissue and bones have developed, and the bones
become harder.
„‘ The baby begins to make active movements.
„‘ The liver and pancreas produce fluid secretions.

r
 „‘ Úucking motions are made with the mouth.
|‘ eeks 17 to 19 of gestation; weeks 19 to 21 of pregnancy
„‘ The baby can hear.
„‘ The baby makes more movements.
„‘ The mother may feel a fluttering in the lower abdomen.
|‘ eek 20 of gestation; week 22 of pregnancy
„‘ {anugo hair covers entire body.
„‘ ayebrows and lashes appear.
„‘ Nails appear on the fingers and toes.
„‘ The baby is more active with increased muscle development.
„‘ The mother can feel the baby moving.
„‘ The fetal heartbeat can be heard with a stethoscope.
|‘ eeks 21 to 23 of gestation; weeks 23 to 25 of pregnancy
„‘ ×one marrow begins to make blood cells.
„‘ The lower airways of the baby's lungs develop but still do not produce
surfactant (a substance that allows the alveoli to open for gas
exchange).
„‘ The baby begins to store fat.
|‘ eek 24 of gestation; week 26 of pregnancy
„‘ ayebrows and eyelashes are well formed.
„‘ All eye parts are developed.
„‘ The baby has a hand and startle reflex.
„‘ Footprints and fingerprints are forming.
„‘ Air sacs form in lungs.
|‘ eeks 25 to 28 of gestation; weeks 27 to 30 of pregnancy
„‘ dapid brain development occurs.
„‘ The nervous system is developed enough to control some body
functions.
„‘ The eyelids open and close.
„‘ The respiratory system, while immature, has developed to the point
where gas exchange is possible.
|‘ eeks 29 to 32 of gestation; weeks 31 to 34 of pregnancy
„‘ A rapid increase in the amount of body fat occurs.
„‘ dhythmic breathing movements occur, but the lungs are not fully
mature.
„‘ The bones are fully developed, but still soft and pliable.
„‘ The baby's body begins storing iron, calcium, and phosphorus.
|‘ eek 36 of gestation; week 38 of pregnancy
„‘ {anugo begins to disappear.
„‘ ×ody fat increases.
„‘ Fingernails reach the end of the fingertips.
|‘ eeks 37 to 40 of gestation; weeks 39 to 42 of pregnancy
„‘ {anugo is gone except for on the upper arms and shoulders.
„‘ Fingernails extend beyond fingertips.
„‘ Úmall breast buds are present on both sexes.

6
 „‘ Head hair is now coarse and thicker.

‘‘ !‘"‘ #‘ #‘

"‘most dramatic changes and development occur during the first‘

 #$During the first eight weeks, a fetus is called an embryo.‘The embryo
develops rapidly and by the end of the first trimester it %&#‘ ‘ '#‘ "‘ #‘
'(‘ '),weighing approximately 1/2 to one ounce and measuring, on
average, three to four inches in length.

%(‘"‘)‘ |‘ ‘-‘#(##‘)‘!#‘%! ‘‘'

'‘*‘+,# |‘ "‘‘%‘(which becomes the % ‘)‘# ‘&)./‘"‘
) !# ‘#(#/‘)‘"‘"‘)‘& &(‘#(# begin to
form
|‘ "‘%!  !#‘'‘"‘(#‘)‘#‘are developing
|‘  (‘ %‘%)#‘‘(which will develop into arms and legs)
|‘ the "‘ #‘% !

%(‘"‘)‘ |‘ ‘-‘%)(‘#(##‘continue to develop and function,

'‘0‘+,# including "‘& &(/‘#/‘) !# /‘)‘ (‘#(##
|‘ "‘%(‘ #‘, !‘‘‘"‘#", although the head is larger
in proportion to the rest of the body

M
 |‘ "‘"‘ #‘) !‘"‘%)#‘(which will become baby teeth)
|‘ "‘(#/‘#/‘"/‘)‘#‘are becoming more distinct
|‘ "‘#‘)‘!#‘are clearly visible
|‘ "‘' !#‘)‘#‘are still webbed but can be clearly
distinguished
|‘ the main organs continue to develop and (‘&‘"‘"‘%%(1#‘
"%‘using an instrument called a Doppler
|‘ the %#‘%! ‘‘)‘and the #‘)‘-+#‘‘ )(‘
) !
|‘ "‘%(‘ #‘ ‘&#‘ ‘%‘&‘%‘'‘%(‘"‘"

'‘ '‘0‘+,#/‘"‘%(‘ #‘+‘')‘‘#‘‘'#(which means

%(‘‘ offspring or developing human from 8 weeks to birth).
'#
Although the fetus is only 1 to 1 1/2 inches long at this point, ‘-‘
!#‘)‘#(##‘"‘%‘').

) !‘ |‘ the 6‘! ‘!#‘are developed

+,#‘23 |‘ ' ! #‘)‘ #‘appear
45 |‘ ( )#‘‘')
|‘ '‘‘ &##
|‘ the #‘)‘!#‘‘'(‘')
|‘ the  &‘%6‘7(6.‘%! #‘‘'‘in the trachea

The fetus is most vulnerable during the first 12 weeks. During this period of
time, all of the major organs and body systems are forming and can be
damaged if the fetus is exposed to drugs, Àerman measles, radiation,
tobacco, and chemical and toxic substances.

aven though "‘!#‘)‘%)(‘#(##‘‘'(‘')‘%(‘"‘)‘'‘45‘

+,#/ the fetus cannot survive independently.

‘‘ !‘"‘&)‘ #‘

+‘"‘‘"‘-‘!#‘)‘#(##‘"‘')‘ ‘"‘'#/‘"‘'+ !‘

# 6‘"#‘+ ‘%‘#‘!+ !$ The weight of the fetus will multiply more than
seven times over the next few months, as the fetus becomes a baby that can
survive outside of the uterus.

×y the end of the second trimester, the fetus will be about 13 to 16 inches long
and weighs about 2 to 3 pounds. Fetal development during the second trimester
includes the following:

ë
 |‘ The fetus‘, &,#/‘#/‘)‘&‘‘'‘# )‘‘# ).
|‘ The eyes have been gradually moving to the front of the face and the
ears have moved from the neck to the sides of the head. "‘'#‘&‘
"‘"‘"1#‘ &$
|‘ A creamy white substance (called vernix caseosa, or simply  6.‘%! #‘
‘‘‘"‘'#‘)‘"#‘‘&‘"‘" ‘'‘#, . Vernix is
gradually absorbed by the skin, but some may be seen on babies even
after birth.
|‘ The fetus is developing '6#‘#&"‘#‘#++ !‘)‘#&, !.
|‘ The fetus &‘#)‘‘& ‘#  .
|‘ The placenta is fully developed.
|‘ The % ‘+ ‘)!‘ #‘#‘ ‘ )‘'‘!+"‘'‘"‘8"‘
"‘$
|‘ ! #‘"‘!+‘‘"‘ #‘'‘"‘' !#‘)‘#/‘)‘"‘' !#‘
)‘#‘‘'(‘#)$
|‘ The fetus goes through &(&#‘'‘#‘)‘+,'##.
|‘ , ‘ #‘+ ,(‘)‘)/‘&)‘+ "‘#'/‘)+(‘" ‘7&)‘!.$
|‘  ‘ #‘!+ !‘‘"‘")‘'‘"‘'#.
|‘ Fat begins to form on the fetus.
|‘
( )#‘‘%!  !‘‘‘)‘"‘(%+#‘)‘(#"#‘‘
 # %$
|‘ ! #‘)‘ #‘"‘').
|‘  )‘!+"‘is continuing in fetal size and weight.
|‘ The 20th week marks the halfway point of the pregnancy.

‘‘ !‘"‘" )‘ #‘

During the third trimester, the fetus & #‘ ‘ !+‘ ‘ # 9‘ )‘ + !". The
lungs are still maturing and the fetus begins to position itself head down. ×y the
end of the third trimester, the fetus is about 19 to 21 inches long and weighs, on
average, six to nine pounds. Fetal development during the third trimester
includes:

|‘ The fetus &‘#‘)‘".

|‘ The % ‘& #‘‘).
|‘ The %#‘'‘"‘#,‘ ‘#'‘‘,‘ ‘# ‘‘##‘"!"‘"‘
% "‘&$
|‘ For many babies, "‘  ##‘'‘"‘(#‘‘#‘%. The permanent eye
color will not appear until several days or weeks after birth.
|‘ The fetus &‘#&,‘ #‘"%‘)‘"#‘"‘%  (‘‘&(.
|‘ ×y 38 to 40 weeks, the fetus' !‘"#‘) #)‘#‘&($
|‘ ×y 38 to 40 weeks, "‘!#‘"‘)‘&(.
|‘ The baby is covered in vernix caseosa (or simply called vernix), a creamy,
protective coating on the skin.
|‘ The head will usually turn downward during the last couple of weeks of
pregnancy.

c

‘

‘ & ‘

‘
"‘)‘'‘"‘&) #&‘#(#‘‘
×egins to develop toward the end of the third week. Heart starts to beat at the
beginning of the fourth week. The critical period of heart development is from
day 20 to day 50 after fertilization. any critical events occur during cardiac
development, and any deviation from this normal pattern can cause congenital
heart defects, if development of heart does not occur properly. However, we will
concern ourselves with the events surrounding the circulatory changes at birth.

"‘'‘& & 

In the fetus the lungs are collapsed. Oxygen is provided by the placenta. The
placenta allows the passage of oxygen and nutrients from the mother's blood
through a % to the fetus. From here, it flows through the %  &‘&),
through the )&#‘## into the fetal blood supply.

ith the lungs collapsed, there is no need for the right side of the heart to send
blood to the lungs, the blood is already oxygen rich, from the placenta. Instead,
there are two short cuts that allow the blood to by pass the lungs. One is called

cc
the m
     and the other is the
 . The ductus arteriosus
steals blood normally directed to the lungs and lets it flow straight into the aorta
and on to the rest of the body. The foramen ovale is a hole in the middle wall of
the heart itself, allowing blood in the right side to flow through the wall into the
left side and out, likewise, to the rest of the body. In both cases, the lungs are
bypassed.

At birth, on cutting of the %  &‘

&). Air pressure develops, and a
reflex causes the neonate to gasp for
air. ith this gasp, the lungs expand
for the first time and convert from a
crimped up, solid block of tissue to
soft, air filled bags. It's the change in
the consistency of the lungs that starts
the process. hen the lungs are in
their unborn collapsed state, it takes a
lot of pressure to try to pump blood
through them. hen they inflate at
birth, this pressure falls so that it's easy
for blood to flow into them. ith this
sudden fall in resistance, the path to
the lungs becomes less resistant than
the force needed to pump blood
through the ductus arteriosus and
foramen ovale. The flow in the heart
becomes stronger on the left, which
causes a one way flap to slam shut
over the foramen ovale, closing it. The
large diameters of the pulmonary arteries to the lungs far out measure that of
the ductus. The laws of physics apply here: it is easier to flow to the lungs than
through the ductus and it withers. That first gasping causes the ductus and the
foramen to be bypassed, and the lungs that were previously bypassed, and the
lungs are functional.‘

"‘#"#‘ ‘"‘'‘& & ‘

4$‘&#‘ ##
« protects lungs against circulatory overload
« allows the right ventricle to strengthen
« high pulmonary vascular resistance, low pulmonary blood flow
« carries mostly med oxygen saturated blood

5$‘&#‘##‘
« fetal blood vessel connecting the umbilical vein to the IVC

c
« blood flow regulated via sphincter
« carries mostly hi oxygenated blood

 $‘ ‘
« shunts highly oxygenated blood from right atrium to left atrium

# (‘&"!#‘)‘"‘&"!#‘‘% "‘

 +
As soon as the baby is born, the foramen ovale, ductus arteriosus ductus
venosus and umbilical vessels are no longer needed. The sphincter in the ductus
venosus constricts, so that all blood entering the liver passes through the hepatic
sinusoids. Occlusion of the placental circulation causes an immediate fall of
blood pressure in the IVC and right atrium.

 &(‘)-##‘‘% ":‘

Increasing uptake of oxygen by lungs (first and subsequent breaths) induces a

vasoconstriction of ductus venosus and ductus arteriosis

 ‘'‘"‘!#‘‘% "‘ #‘##& )‘+ "‘

|‘ a dramatic fall in pulmonary vascular resistance due to lung expansion.

|‘ a marked increase in pulmonary blood flow (thus raising the left atrial
pressure above that of IVC and a progressive thinning of the walls of the
pulmonary arteries (due to stretching as lungs increase in size with first few
breaths)

"‘' #‘%": « the pulmonary alveoli open up:

« pressure in the pulmonary tissues decreases
« ×lood from the right heart rushes to fill the alveolar capillaries
« Pressure in the right side of the heart decreases
« Pressure in the left side of the heart increases as more blood is returned from
the well vascularized pulmonary tissue via the pulmonary veins to the left atrium

# !‘& &(‘&"!#‘ &):

« blood pressure is now high in the aorta and systemic circulation is well
established

‘'‘& & ‘ #‘‘'6‘'& ‘!):‘

« Peripherally by the baroreceptors in the aortic artch and carotid sinus

« Centrally by baroreceptors in the cardiovascular center of the medulla (in
close proximity of the chemoreceptors that regulate respiration)
« despiratory and circulatory reflexes are usually strong in the healthy full term

c 
newborn, but their efficiency in controlling cardiovascular function is susceptible
to environmental factors.‘

"‘"#‘‘"#‘#"#‘‘% ";‘

‘‘

×efore birth the foramen ovale allows most of the oxygenated blood entering
the right atrium from the IVC to pass into the left atrium. Prevents passage of
blood in the opposite direction because the septum primum closes against the
relatively rigid septum secundum. Closes at birth due to decreased flow from
placenta and IVC to hold open foramen, and more importantly because of
increased pulmonary blood flow and pulmonary venous return to left heart
causing the pressure in the left atrium to be higher than in the right atrium. The
increased left atrial pressure then closes the foramen ovale against the septum
segundum. The output from the right ventricle now flows entirely into the
pulmonary circulation.

"‘&"!#‘ ‘"‘"

The right ventricular wall is thicker than the left ventricular wall in fetuses and
newborn infants because the right ventricle has been working harder. ×y the end
of the first month the left ventricular wall is thicker than the right because it is now
working harder than the right one. The right ventricular wall becomes thinner
because of atrophy associated with its lighter workload.

<<$‘&#‘ ##‘

|‘ The DA constricts at birth, but there is often a small shunt of blood from the
aorta to the left pulmonary artery for a few days in a healthy, full term
infant.
|‘ In premature infants and in those with persistent hypoxia the DA may
remain open for much longer.
|‘ Oxygen is the most important factor in controlling closure of the DA in full
term infants. Closure of the DA appears to be mediated by bradykinin, a
substance released by the lungs upon initial inflation.
|‘ ×radykinin has potent contractile effects on smooth muscle. Action
depends upon the high oxygen content of the aortic blood resulting from
aeration of the lungs at birth.
|‘ hen the PO2 of blood passing through the DA reaches about 50 mm Hg,
the wall of the DA constricts. (ay be mediated direct or may be
mediated by Oxygenís effect on decreasing PÀ a2 and prostacylcin
secretion. (unlike in a coarctation of aorta which requires PÀa2 infusion to
reopen the DA for blood flow.
|‘ As a result of reduced pulmonary vascular resistance, the pulmonary
arterial pressure falls below the systemic level and the blood flow thru the
ductus arteriosis is diminished.

c]
A%  &‘ #‘&# &‘‘% "‘

|‘ To prevent loss of infantís blood.Umbilical cord is not tied for 30 60 seconds

so that blood flow thru umbilical vein continues, transferring fetal blood
from placenta to the infant.
|‘ ×lood change from fetal to adult pattern of circulation is not a sudden
occurrence in some changes occur during the first breath, others over
hours and days.
|‘ During the transitional stage right to left flow may occur through the
foramen ovale. The closure of the fetal vessels and the foramen ovale is
initially a functional change; later anatomic closure results from
proliferation of endothelial and fibrous tissues.

)‘  #‘'‘ ‘#&‘&#‘

×ecause of certain changes in the cardiovascular system at birth, certain vessels

and structures are no longer required. Over a period of months these fetal vessels
form nonfunctional ligaments, and fetal structures such as the foramen ovale
persist as anatomic vestiges of the prenatal circulatory system.

‘&‘ )‘&‘
‘ ‘
Foramen Ovale Fossa Ovalis
Umbilical Vein
{igamentum teres
(intra abdominal part)
Ductus Venosus {igamentum venosum
medial umbilical ligaments,
Umbilical Arteries and abdominal
superior vesicular artery (supplies
ligaments
bladder)
Ductus Arteriosum {igamentum arteriosum

+‘&‘)'&#:‘

4$‘‘)&#‘ ##‘‘
|‘ common in females 2 3 times more than males, unknown reason why
|‘ If instead of functional closure after birth there is patent structure then
aortic blood is shunted into the pulmonary artery.
|‘ ost common congenital anomaly associated with maternal rubella
infection during early pregnancy (mode of action by virus unclear)
|‘ Premature infants usually have a PDA due to hypoxia and immaturity.
|‘ Úurgical closure of PDA is achieved by ligation and division of the DA.

5$‘ ‘'‘‘

c[
‘
|‘ most common form of an Atrial Úeptal Defects (AÚDs)
|‘ a small isolated patent foramen ovale is of no hemodynamic
significance; but if other defects present (e.g. pulmonary stenosis or
atresia), blood is shunted through the foramen ovale into the left
ventricle, producing cyanosis, a dark bluish coloration of the skin and
mucous membranes resulting from deficient oxygenation of the blood.
|‘ A probe patent foramen ovale is present in up to 25% of people. A
probe can be passed from one atrium to the other through the
superior part of the floor of the fossa ovalis. Though not clinically
significant (usually small) but may be forced open because of other
cardiac defects and contribute to functional pathology of the heart.
desults from incomplete adhesion between the original flap of the
valve of the foramen ovale and the septum secundum after birth.

cr