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  <head>
    <title>025-02 Reproductive timing, placental exchange, and adaptation across pregnancy</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Reproductive timing, placental exchange, and pregnancy">
      <outline text="Pulsatility and reproductive competence">
        <outline text="Pulsatile releasing hormone sustains gonadotropins"/>
        <outline text="Continuous exposure desensitises pituitary">
          <outline text="Used therapeutically after initial stimulation"/>
        </outline>
        <outline text="Energy, stress, sleep, leptin modulate drive"/>
        <outline text="Functional hypothalamic amenorrhoea">
          <outline text="Gonadotropins and oestradiol fall"/>
          <outline text="Fertility, bone, cardiovascular effects"/>
        </outline>
        <outline text="Central precocious puberty: early activation"/>
        <outline text="Peripheral steroids bypass central drive"/>
        <outline text="Growth pattern and bone age separate mechanisms"/>
      </outline>
      <outline text="Follicle selection and luteal physiology">
        <outline text="One follicle becomes dominant"/>
        <outline text="Two-cell cooperation needs both gonadotropins"/>
        <outline text="Sustained oestradiol triggers surge"/>
        <outline text="Progesterone: secretory endometrium, mucus, temperature"/>
        <outline text="Implantation needs embryo-endometrium synchrony"/>
        <outline text="Chorionic gonadotropin rescues corpus luteum"/>
        <outline text="Ovarian reserve is a probability marker">
          <outline text="Not natural fertility or oocyte quality"/>
        </outline>
      </outline>
      <outline text="Spermatogenesis and androgen regulation">
        <outline text="Sertoli cells form blood-testis barrier"/>
        <outline text="Intratesticular testosterone far above blood"/>
        <outline text="Exogenous androgen suppresses gonadotropins">
          <outline text="Reduced sperm, sometimes azoospermia"/>
          <outline text="Recovery varies with dose and duration"/>
        </outline>
        <outline text="Semen analysis varies, repeat when appropriate"/>
        <outline text="Erectile dysfunction can precede vascular disease">
          <outline text="Review medicines and cardiovascular risk"/>
        </outline>
      </outline>
      <outline text="Placental exchange">
        <outline text="Circulations separate but closely exchanging"/>
        <outline text="Oxygen transfer depends on content and flow">
          <outline text="Fetal haemoglobin, surface, membrane distance"/>
        </outline>
        <outline text="Glucose by facilitated transport"/>
        <outline text="Immunoglobulin G by receptor transport"/>
        <outline text="Drugs cross by size, charge, lipid, binding"/>
        <outline text="Not an impermeable shield">
          <outline text="Maternal hypoxaemia or anaemia cuts fetal supply"/>
          <outline text="Treating the mother often helps the fetus"/>
        </outline>
        <outline text="Inadequate spiral-artery remodelling">
          <outline text="Placental ischaemia releases factors"/>
          <outline text="Maternal endothelial dysfunction, hypertension"/>
        </outline>
      </outline>
      <outline text="Maternal cardiovascular and respiratory reserve">
        <outline text="Output rises, systemic resistance falls">
          <outline text="Unmasks stenosis, pulmonary hypertension"/>
        </outline>
        <outline text="Supine caval compression, left lateral displacement"/>
        <outline text="Labour adds autotransfusion and volume shifts">
          <outline text="Complications can emerge after birth"/>
        </outline>
        <outline text="Progesterone lowers carbon dioxide">
          <outline text="Non-pregnant normal may mean hypoventilation"/>
        </outline>
        <outline text="Low residual capacity, poor apnoea tolerance"/>
      </outline>
      <outline text="Renal, haematological, and metabolic adaptation">
        <outline text="Filtration rises early, creatinine and urea fall"/>
        <outline text="Glycosuria at lower glucose"/>
        <outline text="Haemodilution with rising iron demand"/>
        <outline text="Coagulation shifts toward thrombosis"/>
        <outline text="Insulin resistance can exceed beta-cell reserve">
          <outline text="Gestational diabetes: reassess postpartum"/>
        </outline>
        <outline text="Drug distribution and clearance change"/>
      </outline>
      <outline text="Fetal circulation and birth transition">
        <outline text="Umbilical vein carries highest oxygen"/>
        <outline text="Streaming via foramen ovale to brain"/>
        <outline text="Right ventricle output bypasses lungs via ductus"/>
        <outline text="Birth: aeration lowers pulmonary resistance"/>
        <outline text="Cord separation raises systemic resistance">
          <outline text="Removes placental prostaglandin influence"/>
        </outline>
        <outline text="Some lesions need an open ductus">
          <outline text="Prostaglandin therapy preserves it"/>
        </outline>
      </outline>
      <outline text="Labour, haemorrhage, and lactation">
        <outline text="Progress: power, position, pelvis, cervix, time"/>
        <outline text="Overstimulation can rupture a scarred uterus"/>
        <outline text="Haemorrhage: tone, tissue, trauma, thrombin">
          <outline text="Trauma bleeds despite a firm uterus"/>
          <outline text="Coagulation failure worsens all sources"/>
        </outline>
        <outline text="Placental delivery enables milk secretion"/>
        <outline text="Stress and pain inhibit ejection reflex"/>
      </outline>
      <outline text="Reproductive ageing">
        <outline text="Follicle number falls before final menstruation"/>
        <outline text="Fluctuating oestradiol, one value insufficient"/>
        <outline text="Faster bone turnover, genitourinary change"/>
        <outline text="Separate systemic from local symptom needs"/>
      </outline>
      <outline text="Synthesis across pregnancy care">
        <outline text="State drive, gonads, anatomy, goals, exposures"/>
        <outline text="Postpartum follow-up beyond bleeding">
          <outline text="Hypertension, thrombosis, mood, thyroid"/>
        </outline>
        <outline text="Weigh untreated disease against drug risk">
          <outline text="Abrupt withdrawal harms the fetus too"/>
        </outline>
        <outline text="Labs not judged on non-pregnant ranges alone">
          <outline text="Physiology must not hide pathology"/>
        </outline>
      </outline>
    </outline>
  </body>
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