Prenatal.pdf

Learning Objectives: Prenatal Development  Describe the changes that occur in the three periods of prenatal development  Describe what occurs during prenatal brain development  Define teratogens and describe the factors that influence their effects  List and describe the...

Learning Objectives: Prenatal Development  Describe the changes that occur in the three periods of prenatal development  Describe what occurs during prenatal brain development  Define teratogens and describe the factors that influence their effects  List and describe the effects of several common teratogens  Explain maternal and paternal factors that affect the developing fetus  Explain the types of prenatal assessment  Describe both the minor and major complications of pregnancy Prenatal Development Now we turn our attention to prenatal development which is divided into three periods: The germinal period, the embryonic period, and the fetal period. The following is an overview of some of the changes that take place during each period. The Germinal Period Figure 2.4 The germinal period (about 14 days in length) lasts from conception to implantation of the fertilized egg in the lining of the uterus (See Figure 2.5). At ejaculation millions of sperm are released into the vagina, but only a few reach the egg and typically only one fertilizes the egg. Once a single sperm has entered the wall of the egg, the wall becomes hard and prevents other sperm from entering. After the sperm has entered the egg, the tail of the sperm breaks off and the head of the sperm, containing the genetic information from the father, unites with the nucleus of the egg. It is typically fertilized in the top section of the fallopian Sperm and Ovum at Conception tube and continues its journey to the uterus. As a result, a new cell is formed. This cell, containing the combined genetic information from both parents, is referred to as a zygote. During this time, the organism begins cell division through mitosis. After five days of mitosis there are 100 cells, which is now called a blastocyst. The blastocyst consists of both an inner and outer group of cells. The inner group of cells, or embryonic disk will become the embryo, while the outer group of cells, or trophoblast, becomes the support system which nourishes the developing organism. This stage ends when the blastocyst fully implants into the uterine wall (U.S. National Library of Medicine, 2015a). Approximately 50-75% of blastocysts do not implant in the uterine wall (Betts et al., 2019). 45 Mitosis is a fragile process and fewer than one half of all zygotes survive beyond the first two weeks (Hall, 2004). Some of the reasons for this include the egg and sperm do not join properly, thus their genetic material does not combine, there is too little or damaged genetic material, the zygote does not replicate, or the blastocyst does not implant into the uterine wall. The failure rate is higher for in vitro conceptions. Figure 2.5 illustrates the journey of the ova from its release to its fertilization, cell duplication, and implantation into the uterine lining. Figure 2.5 Germinal Period "Human Fertilization" by Ttrue12 Source The Embryonic Period Starting the third week the blastocyst has implanted in the uterine wall. Upon implantation this multi-cellular organism is called an embryo. Now blood vessels grow forming the placenta. The placenta is a structure connected to the uterus that provides nourishment and oxygen from the mother to the developing embryo via the umbilical cord. During this period, cells continue to differentiate. Growth during prenatal development occurs in two major directions: from head to tail called cephalocaudal development and from the midline outward referred to as proximodistal development. This means that those structures nearest the head develop before those nearest the feet and those structures nearest the torso develop before those away from the 46  center of the body (such as hands and Figure 2.6 The Embryo fingers). The head develops in the fourth week and the precursor to the heart begins to pulse. In the early stages of the embryonic period, gills and a tail are apparent. However, by the end of this stage they disappear and the organism takes on a more human appearance. Some organisms fail during the embryonic period, usually due to gross chromosomal abnormalities. As in the case of the germinal period, often the mother does not yet know that she is pregnant. It is during this stage that the major structures of the body are taking form Photo by Lunar Caustic making the embryonic period the time when the organism is most vulnerable to the greatest amount of damage if exposed to harmful substances. Potential mothers are not often aware of the risks they introduce to the developing embryo during this time. The embryo is approximately 1 inch in length and weighs about 8 grams at the end of eight weeks (Betts et al., 2019). The embryo can move and respond to touch at this time. The Fetal Period From the ninth week until birth, the organism is referred to as a fetus. During this stage, the major structures are continuing to develop. By the third month, the fetus has all its body parts including external genitalia. In the following weeks, the fetus will develop hair, nails, teeth and the excretory and digestive systems will continue to develop. The fetus is about 3 inches long and weighs about 28 grams. During the 4th - 6th months, the eyes become more sensitive to light and hearing develops. The respiratory system continues to develop, and reflexes such as sucking, swallowing and hiccupping, develop during the 5th month. Cycles of sleep and wakefulness are present at this time as well. The first chance of survival outside the womb, known as the age of viability is reached at about 24 weeks (Morgan, Goldenberg, & Schulkin, 2008). Many practitioners hesitate to resuscitate before 24 weeks. The majority of the neurons in the brain have developed by 24 weeks, although they are still rudimentary, and the glial or nurse cells that support neurons continue to grow. At 24 weeks the fetus can feel pain (Royal College of Obstetricians and Gynecologists, 1997). 47 Figure 2.7 Fetus Between the 7th - 9th months, the fetus is primarily preparing for birth. It is exercising its muscles and its lungs begin to expand and contract. The fetus gains about 5 pounds and 7 inches during this last trimester of pregnancy, and during the 8th month a layer of fat develops under the skin. This layer of fat serves as insulation and helps the baby regulate body temperature after birth. At around 36 weeks the fetus is almost ready for birth. It weighs about 6 pounds and is about 18.5 inches long. By week 37 all of the fetus’s organ systems are developed enough that it could survive outside the mother’s uterus without many of the risks associated with premature birth. The fetus continues to gain weight and grow in length until approximately 40 weeks. By then the fetus has very little room to move around and birth becomes imminent. The progression Source through the stages is shown in Figure 2.8. Figure 2.8 Prenatal Development Age Milestones Source 48 Prenatal Brain Development Prenatal brain development begins in the third gestational week with the differentiation of stem cells, which are capable of producing all the different cells that make up the brain (Stiles & Jernigan, 2010). The location of these stem cells in the embryo is referred to as the neural plate. By the end of the third week, two ridges appear along the neural plate first forming the neural groove and then the neural tube. The open region in the center of the neural tube forms the brain’s ventricles and spinal canal. By the end of the embryonic period, or week eight, the neural tube has further differentiated into the forebrain, midbrain, and hindbrain. Brain development during the fetal period involves neuron production, migration, and differentiation. From the early fetal period until midgestation, most of the 85 billion neurons have been generated and many have already migrated to their brain positions. Neurogenesis, or the formation of neurons, is largely completed after five months of gestation. One exception is in the hippocampus, which continues to develop neurons throughout life. Neurons that form the neocortex, or the layer of cells that lie on the surface of the brain, migrate to their location in an orderly way. Neural migration is mostly completed in the cerebral cortex by 24 weeks (Poduri & Volpe, 2018). Once in position, neurons begin to produce dendrites and axons that begin to form the neural networks responsible for information processing. Regions of the brain that contain the cell bodies are referred to as the gray matter because they look gray in appearance. The axons that form the neural pathways make up the white matter because they are covered in myelin, a fatty substance that is white in appearance. Myelin aids in both the insulation and efficiency of neural transmission. Although cell differentiation is complete at birth, the growth of dendrites, axons, and synapses continue for years. Teratogens Good prenatal care is essential. The developing child is most at risk for some of the severe problems during the first three months of development. Unfortunately, this is a time at which many mothers are unaware that they are pregnant. Today, we know many of the factors that can jeopardize the health of the developing child. The study of factors that contribute to birth defects is called teratology. Teratogens are environmental factors that can contribute to birth defects, and include some maternal diseases, pollutants, drugs and alcohol. Factors influencing prenatal risks: There are several considerations in determining the type and amount of damage that might result from exposure to a particular teratogen (Berger, 2005). These include:  The timing of the exposure: Structures in the body are vulnerable to the most severe damage when they are forming. If a substance is introduced during a particular structure's critical period (time of development), the damage to that structure may be greater. For example, the ears and arms reach their critical periods at about 6 weeks after conception. If a mother exposes the embryo to certain substances during this period, the arms and ears may be malformed.  The amount of exposure: Some substances are not harmful unless the amounts reach a certain level. The critical level depends in part on the size and metabolism of the mother. 49   The number of teratogens: Fetuses exposed to multiple teratogens typically have more problems than those exposed to only one.  Genetics: Genetic make-up also plays a role on the impact a particular teratogen might have on the child. This is suggested by fraternal twins exposed to the same prenatal environment, but they do not experience the same teratogenic effects. The genetic make- up of the mother can also have an effect; some mothers may be more resistant to teratogenic effects than others.  Being male or female: Males are more likely to experience damage due to teratogens than are females. It is believed that the Y chromosome, which contains fewer genes than the X, may have an impact. Figure 2.9 illustrates the timing of teratogen exposure and the types of structural defects that can occur during the prenatal period. Figure 2.9 Critical Periods of Prenatal Development Source Alcohol: One of the most commonly used teratogens is alcohol, and because half of all pregnancies in the United States are unplanned, it is recommended that women of child-bearing age take great caution against drinking alcohol when not using birth control or when pregnant (CDC, 2005). Alcohol use during pregnancy is the leading preventable cause of intellectual disabilities in children in the United States (Maier & West, 2001). Alcohol consumption, particularly during the second month of prenatal development but at any point during pregnancy, may lead to neurocognitive and behavioral difficulties that can last a lifetime. 50 In extreme cases, alcohol consumption during pregnancy can lead to fetal death, but also can result in Fetal Alcohol Spectrum Disorders (FASD), which is an umbrella term for the range of effects that can occur due to alcohol consumption during pregnancy (March of Dimes, 2016a). The most severe form of FASD is Fetal Alcohol Syndrome (FAS). Children with FAS share certain physical features such as flattened noses, small eye holes, and small heads (see Figure 2.10). Cognitively, these children have poor judgment, poor impulse control, higher rates of ADHD, learning issues, and lower IQ scores. These developmental problems and delays persist into adulthood (Streissguth et al., 1996) and can include criminal behavior, psychiatric problems, and unemployment (CDC, 2016a). Based on animal studies, it has been hypothesized that a mother’s alcohol consumption during pregnancy may predispose her child to like alcohol (Youngentob et al., 2007). Binge drinking, or 4 or more drinks in 2 to 3 hours, during pregnancy increases the chance of having a baby with FASD (March of Dimes, 2016a). Figure 2.10 Fetal Alcohol Spectrum Disorders Fetal Alcohol Spectrum Disorder Facial Features Facial Feature Potential Effect of Fetal Alcohol Head size Below-average head circumference Eyes Smaller than average eye opening, skin folds at corner of eyes Nose folds nasal Low at corners of eyes bridge, short nose Midface Smaller than average midface size Lip and philtrum Thin upper lip, indistinct philtrum Source Tobacco: Another widely used teratogen is tobacco as more than 7% of pregnant women smoked in 2016 (Someji & Beltrán-Sánchez, 2019). According to Tong et al. (2013) in conjunction with the Centers for Disease Control and Prevention, data from 27 sites in 2010 representing 52% of live births, showed that among women with recent live births:  About 23% reported smoking in the 3 months prior to pregnancy.  Almost 11% reported smoking during pregnancy.  More than half (54.3%) reported that they quit smoking by the last 3 months of pregnancy.  Almost 16% reported smoking after delivery. When comparing the ages of women who smoked:  Women