WEEK 4: FETAL GROWTH AND DEVELOPMENT

NCMA 217 - Maternal and Child Health Nursing (LECTURE)

2ND YEAR - BS NURSING | FIRST SEM (PRELIMS)

which is why, at birth, the entire inner surface of

OUTLINE the uterus is stripped away, leaving the organ
1. Embryonic Structure and Fetal Structures highly susceptible to hemorrhage and infection
a. The Decidua ● After fertilization, the corpus luteum in the ovary
b. Chorionic Villi continues to function rather than atrophying,
c. The Amniotic Membranes because of the influence of human chorionic
d. The Amniotic Fluid gonadotropin (hCG), a hormone secreted by the
e. The Umbilical Cord trophoblast cells.
2. Fetal Development ● This causes the uterine endometrium to continue
2.1. Origin of Organ Systems to grow in thickness and vascularity, instead of
3. Milestones of Fetal Growth and Development
sloughing off as in a usual menstrual cycle.
3.1. First Trimester (Period of Organogenesis
Most Critical) ● The endometrium is now termed the decidua (the
3.2. Second Trimester (Period of Continuous Latin word for “falling off”), because it will be
Growth & Development) discarded after the birth of the child.
3.3. Third Trimester (Period of Most Rapid
Growth) B. Chorionic Villi
3.3.1. Fetal Circulation ● Once implantation is complete, the trophoblast
layer of cells of the blastocyst begins to mature
1. Embryonic Structure and Fetal Structures rapidly. As early as the 11th or 12th day,
miniature villi that resemble probing fingers,
termed chorionic villi, reach out from the single
A. The Decidua
layer of cells into the uterine endometrium to
● Term used for the thick vascular endometrium begin formation of the placenta. At term, almost
after implantation 200 such villi will have formed (Knuppel, 2007).
● The decidua has three separate areas: ● All chorionic villi have a central core of
connective tissue and fetal capillaries. A double
layer of trophoblast cells surrounds these.
● The outer of the two covering layers is the
syncytiotrophoblast,or the syncytial layer. This
layer of cells produces various placental
hormones, such as hCG, somatomammotropin
(human placental lactogen [hPL]), estrogen, and
progesterone.
● The middle layer, the cytotrophoblast or
Langhans’ layer, is present as early as 12 days’
gestation. It appears to function early in
pregnancy to protect the growing embryo and
fetus from certain infectious organisms such as
the spirochete of syphilis. This layer of cells
disappears, however, between the 20th and 24th
1. Decidua basalis, the part of the endometrium weeks. This is why syphilis is not considered to
that lies directly under the embryo (or the portion have a high potential for fetal damage early in
where the trophoblast cells establish pregnancy, only after the point at which
communication with maternal blood vessels) cytotrophoblast cells are no longer present
2. Decidua capsularis, the portion of the (Ainbinder, Ramin, & DeCherney, 2007). The
endometrium that stretches or encapsulates the layer appears to offer little protection against viral
surface of the trophoblast invasion at any point.
3. Decidua vera, the remaining portion of the
uterine lining. As the embryo continues to grow, it
pushes the decidua capsularis before it like a
blanket.

● Eventually, the embryo enlarges so much that

this action brings the decidua capsularis into
contact with the opposite uterine wall (the
decidua vera). Here, the two decidua areas fuse,
 mother during pregnancy. Because the outer
chorionic villi layer is only one cell thick after the
third trimester minute breaks do occur and allow
occasional fetal cells to cross into the maternal
bloodstream, as well as fetal enzymes such as
alpha-fetoprotein (AFP) from the fetal liver.
● About 100 maternal uterine arteries supply the
mature placenta. To provide enough blood for
exchange, the rate of uteroplacental blood flow in
pregnancy increases from about 50 mL/min at 10
weeks to 500 to 600 mL/min at term. The
woman’s heart rate, total cardiac output, and
blood volume increase to supply blood to the
placenta
● Uterine perfusion, and thus placental circulation,
is most efficient when the woman lies on her left
side. This position lifts the uterus away from the
inferior vena cava, preventing blood from being
trapped in the woman’s lower extremities. If the
woman lies on her back and the weight of the
uterus compresses the vena cava, placental
circulation can be so sharply reduced that supine
hypotension (very low maternal blood pressure
and poor uterine circulation) occurs (Knuppel,
2007).
● At term, the placental circulatory network has
grown so extensively that a placenta weighs 400
The Placenta
to 600 g (1 lb), onesixth the weight of the baby. If
● The placenta (Latin for “pancake,” which is
a placenta is smaller than this, it suggests that
descriptive of its size and appearance at term)
circulation to the fetus may have been
● arises out of the continuing growth of trophoblast
inadequate. A placenta larger than this may also
tissue.
indicate that circulation to the fetus was
● Its growth parallels that of the fetus, growing from
threatened, because it suggests that the placenta
a few identifiable cells at the beginning of
was forced to spread out in an unusual manner
pregnancy to an organ 15 to 20 cm in diameter
to maintain a sufficient blood supply. The fetus of
and 2 to 3 cm in depth, covering about half the
a woman with diabetes may also develop a
surface area of the internal uterus at term.
larger-than-usual placenta from excess fluid
collected between cells.
Circulation
● As early as the 12th day of pregnancy, maternal
Endocrine Function
blood begins to collect in the intervillous spaces
● Aside from serving as the conduit for oxygen and
of the uterine endometrium surrounding the
nutrients for the fetus, the syncytial (outer) layer
chorionic villi. By the third week, oxygen and
of the chorionic villi develops into a separate,
other nutrients, such as glucose, amino acids,
important hormone-producing system.
fatty acids, minerals, vitamins, and water,
osmose from the maternal blood through the cell
1. Human Chorionic Gonadotropin.
layers of the chorionic villi into the villi capillaries.
○ The first placental hormone produced,
From there, nutrients are transported to the
hCG, can be found in maternal blood
developing embryo.
and urine as early as the first missed
● Placental osmosis is so effective that all except a
menstrual period (shortly after
few substances are able to cross from the
implantation has occurred) through
mother into the fetus. Because almost all drugs
about the 100th day of pregnancy.
are able to cross into the fetal circulation, it is
○ Because this is the hormone analyzed
important that a woman take no nonessential
by pregnancy tests, a false-negative
drugs (including alcohol and nicotine) during
result from a pregnancy test may be
pregnancy (Rogers-Adkinson & Stuart, 2007).
obtained before or after this period.
● For practical purposes, because the process of
○ The woman’s blood serum will be
osmosis is so effective, there is no direct
completely negative forhCG within 1 to 2
exchange of blood between the embryo and the
weeks after birth. Testing for hCG after

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 birth can be used as proof that placental of these nutrients are always available to
tissue is no longer present. the fetus (Taylor & Lebovic, 2007).
○ The purpose of hCG is to act as a
fail-safe measure to ensure that the Placental proteins
corpus luteum of the ovary continues to ● The placenta also produces several plasma
produce progesterone and estrogen. proteins. The function of these has not been well
○ This is important because, if the corpus documented, but it is thought that they may
luteum should fail and the level of contribute to decreasing the immunologic impact
progesterone fall, the endometrial lining of the growing placenta through being part of the
will slough and the pregnancy will be complement cascade (Knuppel, 2007).
lost. hCG also may play a role in
suppressing the maternal immunologic C. The Amniotic Membranes
response so that placental tissue is not
detected and rejected as a foreign
substance.
2. Estrogen
○ Estrogen (primarily estriol) is produced
as a second product of the syncytial
cells of the placenta.
○ Estrogen contributes to the woman’s
mammary gland development in
preparation for lactation and stimulates
uterine growth to accommodate the
developing fetus.
3. Progesterone
○ Estrogen is often referred to as the Chorionic Membrane Amniotic Membrane
“hormone of women”; progesterone as ● Outermost fetal ● Second
the “hormone of mothers.” membrane membrane /
○ This is because, although estrogen ● Purpose: to form inner lining
influences a female appearance, the sac that ● Purpose:
progesterone is necessary to maintain contains the Produces
the endometrial lining of the uterus amniotic fluid/ to amniotic fluid
during pregnancy. support the ● and produces
○ It is present in serum as early as the amniotic fluid phospholipids
fourth week of pregnancy, as a result of that initiates the
the continuation of the corpus luteum. release of
After placental synthesis begins (at prostaglandins
about the 12th week), the level of which can cause
progesterone rises progressively during uterine
the remainder of the pregnancy. contractions and
○ This hormone also appears to reduce may be trigger
the contractility of the uterus during that initiates
pregnancy, preventing premature labor. labor
4. Human Placental Lactogen (Human Chorionic
Somatomammotropin).
○ hPL is a hormone with both ● The chorionic villi on the medial surface of the
growth-promoting and lactogenic trophoblast (those that are not involved in
(milk-producing) properties. implantation, because they do not touch the
○ It is produced by the placenta beginning endometrium) gradually thin, leaving the medial
as early as the sixth week of pregnancy, surface of the structure smooth (the chorion
increasing to a peak level at term. It can laeve, or smooth chorion).
be assayed in both maternal serum and ● The smooth chorion eventually becomes the
urine. chorionic membrane, the outermost fetal
○ It promotes mammary gland (breast) membrane. Its purpose is to form the sac that
growth in preparation for lactation in the contains the amniotic fluid.
mother. ● A second membrane lining the chorionic
○ It also serves the important role of membrane, the amniotic membrane or amnion,
regulating maternal glucose, protein, forms beneath the chorion. Early in pregnancy,
and fat levels so that adequate amounts these membranes become so adherent that they

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 seem as one at term. At birth they can be seen ● The most important purpose of amniotic fluid is
covering the fetal surface of the placenta, giving to shield the fetus against pressure or a blow
that surface its typically shiny appearance. There to the mother’s abdomen. Because liquid
is no nerve supply, so when they spontaneously changes temperature more slowly than air, it also
rupture at term or are artificially ruptured, neither protects the fetus from changes in temperature.
woman nor child experiences any pain. As yet another function, it aids in muscular
● In contrast to the chorionic membrane, the development, because it allows the fetus
amniotic membrane not only offers support to freedom to move. Finally, it protects the umbilical
amniotic fluid but also actually produces the fluid. cord from pressure, protecting the fetal oxygen
In addition, it produces a phospholipid that supply. Even if the amniotic membranes rupture
initiates the formation of prostaglandins, which before birth and the bulk of amniotic fluid is lost,
can cause uterine contractions and maybe the some will always surround the fetus in utero,
trigger that initiates labor because new fluid is constantly formed. Amniotic
fluid is slightly alkaline, with a pH of about 7.2.
D. The Amniotic Fluid Checking the pH of the fluid at the time of rupture
helps to differentiate it from urine, which is acidic
(pH 5.0–5.5).

IMPORTANT INFO

Amniotic Fluid
● Alkaline fluid which is composed of 99% water
and 1% solid particles containing albumin,
urea, uric acid, creatinine, lecithin,
sphingomyelin, bilirubin, and vernix caseosa
● Should be clear, colorless to straw-colored
with tiny specks of vernix caseosa
● 800 – 1200 ml at term
● Amniotic fluid is constantly being newly formed
● Very important as it serves many functions
and reabsorbed by the amniotic membrane, so it
never becomes stagnant. Some of it is absorbed
Functions of amniotic fluid
by direct contact with the fetal surface of the
● Shock absorber
placenta.
○ shield fetus against pressure or a
● The major method of absorption, however,
blow to the mothers abdomen –
occurs because the fetus continually swallows
● Thermoregulator
the fluid. In the fetal intestine, it is absorbed into
○ because liquid changes temperature
the fetal bloodstream. From there, it goes to the
more slowly than air
umbilical arteries and to the placenta, and it is
● Prevents compression of the cordprevents
exchanged across the placenta.
pressure, protecting the fetal oxygen supply
● At term, the amount of amniotic fluid has
● Aids in muscular development
increased so much it ranges from 800 to 1200
○ allows the fetus the freedom to move
mL
● If for any reason the fetus is unable to swallow
Normal
(esophageal atresia or anencephaly are the two
● 800-1200 mL
most common reasons), excessive amniotic
fluid,or hydramnios(more than 2000 mL in total,
More than 2000 ml
or pockets of fluid larger than 8 cm on
● hydramnios may be due to DM excessive fluid
ultrasound), will result. Hydramnios also tends to
shifts into the amniotic space
occur in women with diabetes, because
hyperglycemia causes excessive fluid shifts into
Less than 300ml oligohydramnios due to
the amniotic space (Bush & Pernoll, 2007).
disturbance of kidney function Color:
● Early in fetal life, as soon as the fetal kidneys
● Green - meconium stained
become active, fetal urine adds to the quantity of
● Gray- infection
the amniotic fluid. A disturbance of kidney
● Gold- Hemolytic disease (Rh Incompatibility)
function may cause oligohydramnios, or a
● Brown – Fetal death
reduction in the amount of amniotic fluid (less
● Bloody – vasa previa / abruptio placenta
than 300 mLin total, or no pocket on ultrasound
larger than 1 cm) (Knuppel, 2007).

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E. The Umbilical Cord
Ectoderm Mesoderm Endoderm
● The umbilical cord is formed from the fetal
membranes (amnion and chorion) and Nervous system -Supporting -Lining of the
provides a circulatory pathway that connects - Skin, hair, nails structures of the pericardial
the embryo to the chorionic villi of the - Sebaceous body pleura
placenta. glands -Dentin of teeth and peritoneal
- Sense organs -Upper portion cavities
● Its function is to transport oxygen and
- Mucous of Lining of the GI
nutrients to the fetus from the placenta and to membranes of the urinary tract, respiratory
return waste products from the fetus to the anus, mouth, system tract, tonsils,
placenta. and -Reproductive parathyroid,
● It is about 53 cm (21 in) in length at term and nose system thyroid,
about 2 cm (3 ⁄4 in) thick. - Tooth enamel -Cardiovascular thymus glands
● The bulk of the cord is a gelatinous - Mammary system -Lower urinary
glands -Lymph vessels system
mucopolysaccharide called Wharton’s jelly,
which gives the cord body and prevents
pressure on the vein and arteries that pass
through it. The outer surface is covered with
amniotic membrane.
● An umbilical cord contains only one vein
(carrying blood from the placental villi to the
fetus) but two arteries (carrying blood from
the fetus back to the placental villi). The
number of veins and arteries in the cord is
always assessed and recorded at birth because
about 1% to 5% of infants are born with a cord
that contains only a single vein and artery. From
15% to 20% of these infants are found to have
accompanying chromosomal disorders or
congenital anomalies, particularly of the kidney
and heart (Lubusky et al., 2007).Blood can be
withdrawn from the umbilical vein or transfused ● At the time of implantation, a blastocyst already
into the vein during intrauterine life for fetal has differentiated to a point at which two
assessment or treatment (termed percutaneous separate cavities appear in the inner structure:
umbilical blood sampling [PUBS]). (1) a large one, the amniotic cavity, which is
● In about 20% of all births, a loose loop of cord is lined with a distinctive layer of cells, the
found around the fetal neck (nuchal cord) at birth. ectoderm, and (2) a smaller cavity, the yolk
If this loop of cord is removed before the sac, which is lined with endoderm cells.
newborn’s shoulders are born, so that there is no ● In humans, the yolk sac appears to supply
traction on it, the oxygen supply to the fetus nourishment only until implantation. After that, its
remains unimpaired (Jackson, Melvin, & Downe, main purpose is to provide a source of red blood
2007). Because the umbilical cord contains no cells until the embryo’s hematopoietic system is
nerve supply, it can be cut at birth without mature enough to perform this function (at about
discomfort to either the child or woman the 12th week of intrauterine life). The yolk sac
then atrophies and remains only as a thin white
2. FETAL DEVELOPMENT streak discernible in the cord at birth. Between
the amniotic cavity and the yolk sac, a third layer
2.1 Origin of Organ Systems of primary cells, the mesoderm, forms. The
embryo will begin to develop at the point where
the three cell layers (ectoderm, entoderm, and
A. Primary germ layers mesoderm) meet, called the embryonic shield.
● Involved in organogenesis Each of these germ layers of primary tissue.
● Ectoderm, Mesoderm, Endoderm ● Knowing the origins of body structures helps to
explain why certain screening procedures are
ordered for newborns with congenital
malformations. A radiographic examination of the
kidney, for example, may be ordered for a child
born with a heart defect. A child with a
malformation of the urinary tract is often

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 investigated for reproductive abnormalities as II. End of 8th Gestational Week (8th week, 2nd
well. month)
● All organ systems are complete, at least in a ● Length: 2.5 cm (1 in)
rudimentary form, at 8 weeks’ gestation (the end ● Weight: 20 g
of the embryonic period). During this early time of ● Organogenesis is complete.
organogenesis (organ formation), the growing ● The heart, with a septum and valves, is beating
structure is most vulnerable to invasion by rhythmically.
teratogens (any factor that adversely affects the ● Facial features are definitely discernible.
fertilized ovum, embryo, or fetus, such as ● Arms and legs have developed.
cigarette smoking). ● External genitalia are forming, but sex is not yet
distinguishable by simple observation.
● The primitive tail is regressing.
3. MILESTONES OF FETAL GROWTH AND
● The abdomen bulges forward because the fetal
DEVELOPMENT
intestine is growing so rapidly.
● An ultrasound shows a gestational sac,
FIRST TRIMESTER diagnostic of pregnancy (Fig. 9.8).
PERIOD OF ORGANOGENESIS MOST CRITICAL
I. End of 4th Gestational Week (4th week, 1st
Month)
At the end of the fourth week of gestation, the human
embryo is a group of rapidly growing cells but does not
yet resemble a human being.
● Length: 0.75–1 cm
● Weight: 400 mg
● The spinal cord is formed and fused at the
midpoint.
● Lateral wings that will form the body are folded
forward to fuse at the midline.
● The head folds forward and becomes prominent,
representing about one-third of the entire
structure.
● The back is bent so that the head almost touches
the tip of the tail.
● The rudimentary heart appears as a prominent
bulge on the anterior surface.
● Arms and legs are budlike structures.
● Rudimentary eyes, ears, and nose are
discernible.

III. End of 12th Gestational Week (First

Trimester)
● Length: 7–8 cm
● Weight: 45 g
● Nail beds are forming on fingers and toes.
● Spontaneous movements are possible, although
they are usually too faint to be felt by the mother.
● Some reflexes, such as the Babinski reflex, are
present.
● Bone ossification centers begin to form.
● Tooth buds are present.
● Sex is distinguishable by outward
appearance.
● Urine secretion begins but may not yet be
evident in amniotic fluid.
● The heartbeat is audible through Doppler
technology.

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 SECOND TRIMESTER
FOCUS: LENGTH OF FETUS
I. End of 16th Gestational Week
● Length: 10–17 cm
● Weight: 55–120 g
● Fetal heart sounds are audible by an ordinary
stethoscope.
● Lanugo is well formed
● Liver and pancreas are functioning.
● Fetus actively swallows amniotic fluid,
demonstrating an intact but uncoordinated
swallowing reflex; urine is present in amniotic
fluid.
● Sex can be determined by ultrasound.

III. End of 24th Gestational Week

● Length: 28–36 cm
● Weight: 550 g
● Meconium is present as far as the rectum
● Active production of lung surfactant begins.
● Eyebrows and eyelashes become well defined.
● Eyelids, previously fused since the 12th week,
now open.
● Pupils are capable of reacting to light.
● When fetuses reach 24 weeks, or 601 g, they
have achieved a practical low-end age of viability
(earliest age at which fetuses could survive if
born at that time), if they are cared for after birth
II. End of 20th Gestational Week in a modern intensive care facility.
● Length: 25 cm ● Hearing can be demonstrated by response to
● Weight: 223 g sudden sound.
● Spontaneous fetal movements can be sensed by
the mother.
● Antibody production is possible.
● The hair forms on the head, extending to include
eyebrows.
● Meconium is present in the upper intestine.
● Brown fat, a special fat that will aid in
temperature regulation at birth, begins to be
formed behind the kidneys, sternum, and
posterior neck.
● Vernix caseosa begins to form and cover the
skin.
● Passive antibody transfer from mother to fetus
begins.
● Definite sleeping and activity patterns are
distinguishable (the fetus has developed
biorhythms that will guide sleep/wake patterns
throughout life).
THIRD TRIMESTER
Period of Most Rapid Growth
FOCUS: Weight of Fetus
I. End of 28th Gestational Week
● Length: 35–38 cm
● Weight: 1200 g
● Lung alveoli begin to mature, and surfactant
can be demonstrated in amniotic fluid.

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 ● Testes begin to descend into the scrotal sac from ● Sole of the foot has only one or two crisscross
the lower abdominal cavity. creases, compared with the full crisscross
● The blood vessels of the retina are formed but pattern that will be evident at term.
thin and extremely susceptible to damage from ● Amount of lanugo begins to diminish.
high oxygen concentrations (an important ● Most babies turn into a vertex (head down)
consideration when caring for preterm infants presentation during this month.
who need oxygen).

II. End of 32nd Gestational Week IV. End of 40th Gestational Week (Third
● Length: 38–43 cm Trimester)
● Weight: 1600 g ● Length: 48–52 cm (crown to rump, 35–37 cm)
● Subcutaneous fat begins to be deposited (the ● Weight: 3000 g (7–7.5 lb)
former stringy, “little old man” appearance is ● Fetus kicks actively, hard enough to cause the
● lost) mother considerable discomfort.
● Fetus responds by movement to sounds outside ● Fetal hemoglobin begins its conversion to adult
the mother’s body. hemoglobin. The conversion is so rapid that at
● Active Moro reflex is present. birth, about 20% of hemoglobin will be adult in
● Iron stores, which provide iron for the time during character.
which the neonate will ingest only milk after ● Vernix caseosa is fully formed.
● birth, are beginning to be developed. ● Fingernails extend over the fingertips.
● Fingernails grow to reach the end of fingertips. ● Creases on the soles of the feet cover at least
two thirds of the surface

III. End of 36th Gestational Week IMPORTANT INFO

● Length: 42–48 cm
● Weight: 1800–2700 g (5–6 lb) FETAL GROWTH AND DEVELOPMENT
● Body stores of glycogen, iron, carbohydrate, and ● 266-280 days (37-42 weeks)
calcium are deposited. ● 280/28 = 10 lunar months
● Additional amounts of subcutaneous fat are ● 280/30 = 9.7 calendar months
deposited.

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FETAL CIRCULATION day, such as from sun rays), it causes no
1. As early as the third week of intrauterine life, fetal damage. However, in large doses (e.g., the
blood begins to exchange nutrients with the amount of radiation necessary to treat cancer of
maternal circulation across the chorionic villi. the cervix), serious fetal defects or death can
Blood arriving from the placenta is highly occur
oxygenated. ● The timing of the teratogenic insult makes a
2. Blood enters at the umbilical vein ( carries significant impact on damage done to the fetus. If
oxygenated blood) because the direction of the a teratogen is introduced before implantation,
blood is toward the fetal heart. either the zygote is destroyed or it appears
3. Special structures present in the fetus then shunt unaffected. If the insult occurs when the main
blood flow to first supply the most important body systems are being formed (in the second to
organs of the body. Brain, liver, heart and eighth weeks of embryonic life), a fetus is very
kidneys. vulnerable to injury. During the last trimester, the
4. Blood flows from the umbilical vein going to potential for harm again decreases because all
ductus venosus- an accessory vessel that directs the organs of a fetus are formed and are merely
oxygenated blood directly to the fetal liver. maturing.
5. Then blood empties into the fetal inferior vena ● Two exceptions to the rule that deformities
cava -- --so oxygenated blood is directed to the usually occur in early embryonic life are the
right side of the heart 6 effects caused by the organisms of syphilis and
6. Enters Right atrium then going into left atrium toxoplasmosis. These two infections can cause
through Foramen ovale. Then left atrium going to abnormalities in organs that were originally
aorta formed normally.
7. Small amount of blood that returns to the heart ● A third factor determining the effects of a
via the vena cava does leave the right atrium via teratogen is the teratogen’s affinity for specific
the adult circulatory route then through tricuspid tissue. Lead and mercury, for example, attack
valve into the right ventricle, and then into the and disable nervous tissue. Thalidomide, a drug
pulmonary artery and lungs to service the lung once used to relieve nausea in pregnancy,
tissue. However, the larger portion of even this causes limb defects. Tetracycline, a common
blood is shunted away from the lungs through antibiotic, causes tooth enamel deficiencies and,
ductus arteriosus directly into the descending possibly, long-bone deformities. The rubella virus
aorta can affect many organs: the eyes, ears, heart,
8. Most blood flow from the Descending aorta is and brain are the four most commonly attacked.
transported to umbilical arteries( called arteries
though they are transporting deoxygenated Teratogenic Maternal Infections
blood) they are carrying blood away from the 1. Toxoplasmosis
fetal heart) back through umbilical cord going to ○ Toxoplasmosis, a protozoan infection, is
placental villi where new oxygen takes place spread most commonly through contact
with uncooked meat, although it may
Preventing Fetal Exposure to Teratogens also be contracted through handling cat
● A teratogen is any factor, chemical or physical, stool in soil or cat litter (Friars, 2007).
that adversely affects the fertilized ovum, ○ As many as 1 in 900 pregnancies may
embryo, or fetus. At one time, it was assumed be affected by toxoplasmosis.
that a fetus in utero was protected from chemical ○ A woman experiences almost no
or physical injury by the presence of the amniotic symptoms of the disease except for a
fluid and by the absence of any direct placental few days of malaise and posterior
exchange between mother and fetus. When cervical lymphadenopathy. Even in light
infants were born with disorders, it was attributed of these mild symptoms,
to the influence of fate, bad luck, or, in some ○ If the infection crosses the placenta, the
cultures, evil spirits. Today, it is acknowledged infant may be born with central nervous
that a fetus is extremely vulnerable to system damage, hydrocephalus,
environmental injury. microcephaly, intracerebral calcification,
and retinal deformities.
Effects of Teratogens on a Fetus ○ Pre Pregnancy serum analysis can be
● Several factors influence the amount of damage done to identify women who have never
a teratogen can cause. The strength of the had the disease and so are susceptible
teratogen is one of these. For example, radiation (about 50% of women).
is a known teratogen. In small amounts ○ Instruct pregnant women to avoid
(everyone is exposed to some radiation every undercooked meat and also not to

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 change a cat litter box or work in soil in microcephaly, spasticity) or with eye damage
an area where cats may defecate to (optic atrophy, chorioretinitis), hearing
avoid exposure to the disease. impairment, or chronic liver disease. The child’s
○ If the diagnosis is established by serum skin may be covered with large petechiae
analysis during pregnancy, therapy with (“blueberry-muffin” lesions).
sulfonamides may be prescribed. ● However, diagnosis in the mother or infant can
○ Pyrimethamine, an antiprotozoal agent, be established by the isolation of CMV antibodies
may also be used. This drug is an anti in blood serum.
folic acid drug, so it is administered with ● Unfortunately, there is no treatment for the
caution early in pregnancy to prevent infection even if it presents in the mother with
reducing folic acid levels. enough symptoms to allow detection. Because
2. Rubella there is no treatment or vaccine for the disease,
● The rubella virus usually causes only a mild rash routine screening for CMV during pregnancy is
and mild systemic illness in a woman, but the not recommended.
teratogenic effects on a fetus can be devastating ● Women can help prevent exposure by thorough
(Johnson & Ross, 2007). hand washing before eating and avoiding crowds
● Fetal damage from maternal infection with of young children at daycare or nursery settings.
rubella (German measles) includes hearing
impairment, cognitive and motor challenges, 4. Herpes Simplex Virus (Genital Herpes Infection)
cataracts, cardiac defects (most commonly ● The first time a woman contracts a genital herpes
patent ductus arteriosus and pulmonary infection, systemic involvement occurs. The virus
stenosis), intrauterine growth restriction (IUGR), spreads into the bloodstream (viremia) and
thrombocytopenic purpura, and dental and facial crosses the placenta to a fetus posing substantial
clefts, such as cleft lip and palate. fetal risk (ACOG, 2007).
● Typically, a rubella titer from a pregnant woman ● If the infection takes place in the first trimester,
is obtained on the first prenatal visit. A titer severe congenital anomalies or spontaneous
greater than 1:8 suggests immunity to rubella. A miscarriage may occur.
titer of less than 1:8 suggests that a woman is ● If the infection occurs during the second or third
susceptible to viral invasion. A titer that is greatly trimester, there is a high incidence of premature
increased over a previous reading or is initially birth, intrauterine growth restriction, and
extremely high suggests that a recent infection continuing infection of the newborn at birth.
has occurred. Unless recognized and treated, the fetal mortality
● A woman who is not immunized before and morbidity rates are as high as 80% (ACOG,
pregnancy cannot be immunized during 2007).
pregnancy because the vaccine uses a live virus ● If a woman has had herpes simplex virus type 1
that would have effects similar to those occurring infections before the genital herpes invasion or if
with a subclinical case of rubella. After a rubella the genital herpes (type 2) infection is a
immunization, a woman is advised not to become recurrence, antibodies to the virus in her system
pregnant for 3 months, until the rubella virus is prevent spread of the virus to a fetus across the
no longer active. placenta.
● All pregnant women should avoid contact with ● If genital lesions are present at the time of birth,
children with rashes. Infants who are born to however, a fetus may contract the virus from
mothers who had rubella during pregnancy may direct exposure during birth. For women with a
be capable of transmitting the disease for a time history of genital herpes and existing genital
after birth. Because of this, an infant may be lesions, cesarean birth is often advised to reduce
isolated from other newborns during the newborn the risk of this route of infection.
period. ● This awareness of the placental spread of herpes
simplex virus has increased the importance of
3. Cytomegalovirus obtaining information about exposure to genital
● Cytomegalovirus (CMV), a member of the herpes herpes or any painful perineal or vaginal lesions
virus family, is another teratogen that can cause that might indicate this infection at prenatal visits.
extensive damage to a fetus while causing few ● Intravenous or oral acyclovir (Zovirax) can be
symptoms in a woman (Lilleri et al.,2007). administered to women during pregnancy (Karch,
● It is transmitted from person to person by droplet 2009). The primary mechanism for protecting a
infection such as occurs with sneezing. fetus, however, focuses on disease prevention.
● If a woman acquires a primary CMV infection Urging women to practice safe sex is important
during pregnancy and the virus crosses the to lessen their exposure to this and other
placenta, the infant may be born severely sexually transmitted infections. Advising
neurologically challenged (hydrocephalus, adolescents to obtain a vaccine against HPV

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 (Gardasil) should lessen the incidence of genital the disease was treated during
herpes infection in the future pregnancy.
c. The newborn with congenital syphilis
5. Other Viral Diseases may have congenital anomalies,
● It is difficult to demonstrate other viral extreme rhinitis (sniffles), and a
teratogens, but rubeola (measles), characteristic syphilitic rash, all of which
coxsackievirus, infectious parotitis (mumps), identify the baby as high risk at birth
varicella (chickenpox), poliomyelitis, influenza, (Chakraborty & Luck, 2007). When the
and viral hepatitis all may be teratogenic. baby’s primary teeth come in, they are
Parvovirus B19, the causative agent of erythema oddly shaped (Hutchinson teeth).
infectiosum (also called fifth disease), a common
viral disease in school age children, if contracted B. Lyme disease
during pregnancy, can cross the placenta and a. Lyme disease, a multisystem disease
attack the red blood cells of a fetus. Infection with caused by the spirochete Borrelia
the virus during early pregnancy is associated burgdorferi, is spread by the bite of a
with fetal death. If the infection occurs late in deer tick. The highest incidence occurs
pregnancy, the infant may be born with severe in the summer and early fall. The largest
anemia and congenital heart disease (Barankin, outbreaks of the disease are found on
2008). the east coast of the United States
(Mullen, 2007). After a tick bite, a typical
A. Syphilis skin rash, erythema chronicum migrans
a. Syphilis, a sexually transmitted infection, (large, macular lesions with a clear
is of great concern for the maternal–fetal center), develops. Pain in large joints
population despite the availability of such as the knee may develop. Infection
accurate screening tests and proven in pregnancy can result in spontaneous
medical treatment, as it is growing in miscarriage or severe congenital
incidence and places a fetus at risk for anomalies.
intrauterine or congenital syphilis b. To spread the spirochete, the tick must
(Walker, 2009). Early in pregnancy, be present on the body possibly as long
when the cytotrophoblast layer of the as 24 hours. After returning home from
chorionic villi is still intact, the causative an outing, therefore, a woman should
spirochete of syphilis, Treponema inspect her body carefully and
pallidum, cannot cross the placenta and immediately remove any ticks found. If
damage the fetus. When this layer she has any symptoms that suggest
atrophies at about the 16th to 18th week Lyme disease or knows she has been
of pregnancy, however, the spirochete bitten, she should contact her primary
then can cross and cause extensive health care provider immediately.
damage. If syphilis is detected and c. Treatment of Lyme disease for pregnant
treated with an antibiotic such as women differs from that for nonpregnant
benzathine penicillin in the first trimester, women. The drugs used for nonpregnant
a fetus is rarely affected. If left untreated adults, tetracycline and doxycycline,
beyond the 18th week of gestation, cannot be used during pregnancy
hearing impairment, cognitive challenge, because they cause tooth discoloration
osteochondritis, and fetal death are and, possibly, long-bone malformation in
possible. a fetus. A course of penicillin will be
b. For this reason, serologic screening (by prescribed to reduce symptoms in the
either a VDRL or a rapid plasma reagin pregnant woman.
test) should be done at a first prenatal d. Because the symptoms of Lyme disease
visit; the test may then be repeated are chronic but not dramatic (a migratory
again close to term (the 8th month) if rash and joint pain), women may not
exposure is a concern. Even when a report them at a prenatal visit unless
woman has been treated with they are educated about their
appropriate antibiotics, the serum titer importance and are asked at prenatal
remains high for more than 200 days; an visits if such symptoms are present.
increasing titer, however, suggests that
reinfection has occurred. In an infant 6. Potentially Teratogenic Vaccines
born to a woman with syphilis, the ● Live virus vaccines, such as measles, HPV,
serologic test for syphilis may remain mumps, rubella, and poliomyelitis (Sabin type),
positive for up to 3 months even though are contraindicated during pregnancy because

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 they may transmit the viral infection to a fetus incidence of congenital deformities and cognitive
(Rojas, Wood, & Blakemore, 2007). Care must impairment. It was assumed in the past that
be taken in routine immunization programs to these defects were the result of the mother’s
make sure that adolescents about to be poor nutritional status (drinking alcohol rather
vaccinated are not pregnant. Women who work than eating food), not necessarily the direct result
in biologic laboratories where vaccines are of the alcohol.
manufactured are well advised not to work with ● However, alcohol has now been firmly isolated as
live virus products during pregnancy. a direct teratogen. Fetuses cannot remove the
breakdown products of alcohol from their body.
7. Teratogenic Drugs The large buildup of this leads to vitamin B
● Many women, assuming that the rule of being deficiency and accompanying neurologic
cautious with drugs during pregnancy applies damage.
only to prescription drugs, take over-the-counter ● Women during pregnancy should be screened for
drugs or herbal supplements freely. Although not alcohol use because an infant born with fetal
all drugs cross the placenta (heparin, for alcohol syndrome (FAS) not only is small for
example, does not because of its large molecular gestational age but can be cognitively challenged
size), most do. Also, even though most herbs are (Shankar, Ronis, & Badger, 2007).
safe, ginseng, for example, used to improve ● Women are best advised, therefore, to abstain
general well-being, or senna, used to relieve from alcohol completely. Be certain to ask about
constipation, may not be safe (Der Marderosian binge drinking (consuming more than five
& Beutler, 2007). alcoholic drinks in an evening) as women may
● Any drug or herbal supplement, under certain refer to this as only “occasional drinking.” Refer
circumstances, may be detrimental to fetal women with alcohol addiction to an alcohol
welfare. Therefore, during pregnancy, women treatment program as early in pregnancy as
should not take any drug or supplement not possible to help them reduce their alcohol intake.
specifically prescribed or approved by their
physician or nurse-midwife. 9. Teratogenicity of Cigarettes
● A woman of childbearing age and ability should ● Cigarette smoking is associated with infertility in
not take any drug other than one prescribed by a women. Cigarette smoking by a pregnant woman
physician or nurse-midwife to avoid exposure to has been shown to cause fetal growth restriction
a drug should she become pregnant. (Lawrence & Haslam, 2007). In addition, a fetus
● The use of recreational drugs during pregnancy may be at greater risk for being stillborn
puts a fetus at risk in two ways: the drug may (Hogberg & Cnattingius, 2007) and, after birth,
have a direct teratogenic effect, and intravenous may be at greater risk than others for sudden
drug use risks exposure to diseases such as HIV infant death syndrome. Low birth weight in
and hepatitis B (Donnelly et al., 2008). infants of smoking mothers results from
● Narcotics such as meperidine (Demerol) and vasoconstriction of the uterine vessels, an effect
heroin have long been implicated as causing of nicotine. This limits the blood supply to a fetus.
intrauterine growth restriction (IUGR). The use of ● Another contributory effect may be related to
marijuana alone apparently does not, although inhaled carbon monoxide. Secondary smoke, or
the long-term effects of marijuana during inhaling the smoke of another person’s
pregnancy are still unstudied. Cocaine, cigarettes, may be as harmful as actually
particularly its crack form, is potentially harmful to smoking the cigarettes. All prenatal healthcare
a fetus because it causes severe settings should be smoke-free environments for
vasoconstriction in the mother, compromising this reason.
placental blood flow and perhaps dislodging the ● The best way to urge women to discontinue
placenta. Its use is associated with spontaneous smoking is to educate them about the risks to
miscarriage, preterm labor, meconium staining, themselves and their fetus at a first prenatal visit.
and IUGR (Rojas, Wood, & Blakemore, 2007). It may be effective to encourage women to sign a
● An area of recreational drug use that needs to be contract with a health care provider to try to stop
examined is that of inhalant abuse (“huffing”). or to join a smoking-cessation program.
Substances frequently used as inhalants include
gasoline, butane lighter fluid, Freon, glue, and 10. Radiation
nitrous oxide (NIOSH, 2007). ● Rapidly growing cells are extremely vulnerable to
destruction by radiation. That makes radiation a
8. Teratogenicity of Alcohol potent teratogen to unborn children because of
● Evidence over the years has shown that when their high proportion of rapidly growing cells.
women consume a large quantity of alcohol Radiation produces a range of malformations
during pregnancy, their babies show a high depending on the stage of development of the

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 embryo or fetus and the strength and length of
exposure. If the exposure occurs before
implantation, the growing zygote apparently is
killed. If the zygote is not killed, it survives
apparently unharmed. The most damaging time
for exposure and subsequent damage is from
implantation to 6 weeks after conception (when
many women are not yet aware that they are
pregnant). The nervous system, brain, and retinal
innervation are most affected.
● As a rule, therefore, all women of childbearing
age should be scheduled for pelvic x-ray
examinations only in the first 10 days of a
menstrual cycle (when pregnancy is unlikely
because ovulation has not yet occurred), except
in emergency situations. A serum pregnancy test
can be done on all women who have reason to
believe they might be pregnant before diagnostic
tests involving x-rays are scheduled.

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