the placenta and fetal membranes
TRANSCRIPT
DR. SNIGDHA KUMARI SENIOR RESIDENT
ESIC-PGIMSR, KOLKATA
THE PLACENTA AND FETAL MEMBRANES
The human placenta is -discoid haemochorial deciduatelarynthine
The placenta is attached to the uterine wall and establishes connection between the mother and fetus through the umbilical cord.
Fetal component– from chorion frondosum Maternal component – from decidua basalis
DEVELOPMENT
Interstitial implantation completed on 11th day.The blastocyst is surrounded on all sides by
lacunar spaces around cords of syncytial cells , called trabeculae.
Implantation of the blastocyst
Occurs 6 or 7 days after fertilization
On 13th day
- Stem villi developes from trabeculae .
- Stem villi connect the chorionic plate with the basal plate.
- Primary, secondary and tertiary villi are successively developed from stem villi.
On 21st day
- Arterio-capillary-venous system in the mesenchymal core of each villus is completed.
At 3rd to 4th week lacunar spaces become confluent and form multilocular receptacle lined by syncytium and filled with maternal blood.
This space becomes future intervillous space.
DECIDUA This is the endometrium of the gravid (pregnant) uterus.
It has four parts:
Decidua basalis
Decidua capsularis
Decidua parietalis
Decidua reflexa
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DEVELOPMENT OF PLACENTA Until the beginning of
the 8th week, the entire chorionic sac is covered with villi.
After that, as the sac grows, only the part that is associated with Decidua basalis retain its villi.
Villi of Decidua capsularis compressed by the developing sac.
Thus, two types of chorion are formed: Chorion
frondosum (villous chorion)
Chorion laeve – bare (smooth) chorion
About 18 weeks old, it covers 15-30% of the decidua and weights about 1\ 6 of fetus 14
C0nt..The villous chorion
( increase in number, enlarge and branch ) will form the fetal part of the placenta.
The decidua basalis will form the maternal part of the placenta.
The placenta will grow rapidly.
By the end of the 4th month, the decidua basalis is almost entirely replaced by the fetal part of the placenta.
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GROWTH OF THE PLACENTA
Upto 16th wk the placenta grows both
in thickness and circumference , after that there is little
increase in thickness but it increases circumferentially
till term.
Covered by smooth glistening amnion with the
umbilical cord attached at or near centre.
At term about four –fifths of the placenta is of fetal
origin.
FETAL SURFACE
Rough and spongy.
Maternal blood gives it a dull red colour.
It is mapped out into 15 to 20 somewhat convex polygonal areas known as lobes or cotyledons which are limited by fissures.
Only the decidua basalis and the blood in the intervillous space are of maternal in origin.
MATERNAL SURFACE
.
The placenta consists of two plates—
1. The chorionic plate lies internally and lined by amniotic membrane. The umbilical cord is attached to this plate.
2. The basal plate lies to the maternal aspect.
Between the two plates lies the intervillous space containing the stem villi and their branches , the space being filled with maternal blood.
From within outwards it consists of –
i. Primitive mesenchymal tissue containing branches of umbilical vessels
ii. A layer of cytotrophoblast andiii. Syncytiotrophoblast.
The stem villi arise from the plate. It forms the inner boundary of choriodecidual
space.
CHORIONIC PLATE
It consists of the following structures from outside inwards--
i. Part of the compact and spongy layer of the decidua basalis
ii. Nitabuch’s layer of fibrinoid degeneration of the outer Syncytiotrophoblast at the junction of the cytotrophoblastic shell and decidua.
iii. cytotrophoblastic shell iv. Syncytiotrophoblast
Perforated by the spiral branches of the uterine vessels through which the maternal blood flows into the intervillous space.
BASAL PLATE
Bounded on the inner side by the chorionic plate and the other side by the basal plate , limited on the periphery by the fusion of the two plates.
Lined internally on all sides by the Syncytiotrophoblast and is filled with slow flowing maternal blood.
Numerous branching villi which arise from the stem villi project into the space and constitute chief content of the intervillous space.
INTERVILLOUS SPACE
Arise from chorion plate and extends to the basal plate.
With progressive development primary, secondary and tertiary villi are formed.
Functional unit of placenta (fetal cotyledon or placentome) derived from a major stem villus.
Functional subunit (lobule)derived from a tertiary stem villi.
The total villi surface, for exchange , approx. varies between 10 to 14 sqms.
The fetal capillary system within the villi is almost 50 km long.
Blood vessels within the branching villi do not anastomose with the neighbouring one.
STEM VILLI
IN THE EARLY PLACENTA Each terminal villus has got the following
structure from outside inwards 1. Outer Syncytiotrophoblast 2. Cytotrophoblast3. Basement membrane4. Central stroma containing fetal capillaries,
primitive mesenchymal cells , connective tissue and a few phagocytic cells.
STRUCTURE OF A TERMINAL VILLUS
PLACENTA AT TERMNormal Placenta (At term)
Diameter : 15 to 22 cm Thickness : 2.0 ~ 2.5 cm Weights : approximately 500 g (about 1 lb)
Placental and fetal size and weight roughly correlate in a linear fashion.
Fetal growth depends on placental weight which is less with small for gestational age infants
-Heinonen and colleagues, 2001-
Placenta separates after the birth of the baby and the
line of separation is through the decidua spongiosum.
SEPARATION OF PLACENTA
Placental circulation consists of independent circulation of blood in two systems:
1. Utero-placental circulation 2. Feto-placental circulation
A mature placenta has a volume of about 500ml of blood ,350ml being occupied in the villi system and 150 ml lying in the intervillous space.
The blood of the intervillous spaces is replenished about 3 or 4 times per minute.
CIRCULATION OF THE PLACENTA
Blood in the intervillous space is temporarily outside maternal circulatory system.
It enters the intervillous space through 80 to 100 spiral endometrial arteries in the decidua basalis.
These vessels discharge into the intervillous space through gaps in the cytotrophoblastic shell.
Blood flowing from spiral arteries is pulsatile and is propelled in jet-like fountains by the maternal blood pressure.
Welfare of the embryo and fetus chiefly depends on adequate bathing of branch villi with maternal blood.
Reduction in utero-placental circulation result in fetal hypoxia and IUGR.
MATERNAL PLACENTAL CIRCULATION
Poorly oxygenated blood leaves fetus and passes through umbilical arteries to the placenta.
At the site of attachment of cord to placenta, these arteries divide into number of radially disposed chorionic arteries that branch freely in chorionic plate before entering chorionic villi.
Blood vessels form extensive arterio-capillary-venous system within chorionic villi, brings fetal blood extremely close to maternal blood.
FETAL PLACENTAL CIRCULATION
This system provides a very large area for exchange of metabolic and gaseous products between maternal and fetal blood streams.
Well-oxygenated fetal blood in fetal capillaries passes into thin walled veins.
This follow chorionic arteries to site of attachment of the umbilical cord, where they converge to form umbilical vein.
This large vessel carries oxygen-rich blood to the fetus.
Development of uteroplacental vessels proceeds in two waves or stages.
i. First wave occurs before 12 wks. post- fertilization and consists of invasion and modification of spiral arteries up to border between deciduas and myometrium.
ii. Second wave between 12 and 16 wks. involves some invasion of the intramyometrial segments of spiral arteries.
Remodeling by this two-phase invasion converts narrow-lumen, muscular spiral arteries into dilated, low-resistance uteroplacental vessels.
INVASION OF SPIRAL ARTERIES
Partition between fetal & maternal circulation. Not a perfect barrier.Thickness- ~0.025mmIn early pregnancy it consists of-- 1. Syncytiotrophoblast2. Cytotrophoblast3. Basement membrane 4. Stromal tissue5. Endothelium of the fetal capillary wall with its
basement membrane.
PLACENTAL BARRIER
PLACENTAL BARRIER AT TERM
Sparse cytotrophoblast & distended fetal capillaries almost fill the villus.
Attenuation of syncytial layer.
Thin ‘alpha zones’ also known as vasculo-syncitial membrane, where syncytiotrophoblast is thin & anuclear are for gas exchange.
Thick ‘beta zones’ with the layer remaining thick in patches containing extensive ER are for hormone synthesis.
Increase thickness of villus membrane found in IUGR & cigarette smokers.
Basement membrane becomes thicker.
Stroma contains dilated vessels along with all the constitute & few Hofbauer cells .
– Placental transfer– Metabolism– Hormone production– Haematopoietic– Immunological
FUNCTIONS OF THE PLACENTA
RESPIRATORY--
Gaseous exchange [CO2, O2] – Passive diffusion across a pressure gradient – assisted by maternal hyperventilation
[progesterone effect] & fetal haemoglobin.
Oxygen supply to the fetus @ 8ml/kg/min is achieved with cord blood flow of 165-330 ml/min.
Placental transfer
EXCRETORY
Waste products from fetus such as urea, uric acid & creatinine are excreted in maternal blood by simple diffusion.
NUTRITIVE
Glucose - facilitated diffusion Lipids - triglycerides & fatty acids directly
transported from mother to fetus.
Amino acids - active transport (amino acid concentration is higher in fetal blood than in maternal blood)
WATER AND ELECTROLYTES
Na, K, Cl - simple diffusion
Ca, P, Fe - active transport Water soluble vitamins - active transport
Fat soluble vitamins - slow transfer (remains at low level in fetal blood)
HORMONES
Insulin Adrenal steroids Thyroid hormonesChorionic gonadotrophin or placental
lactogen cross the placenta at a very slow rate to keep the fetal plasma concentration low.
Parathormone Calcitonindoes not cross the placenta.
Rate of metabolism similar to adult liver or kidney.
Oxygen consumption is of same order as that of pancreas and kidney.
Metabolic processes include: active glycolytic cycle, pentose phosphate pathway, tricarboxylic cycle, electron transmitter systems.
More than 60 placental enzymes have been described.
Placental metabolism
Diamine oxidase – inactivates the circulatory pressure amines.
Oxytocinase – neutralises the oxytocin
Phospholipase A2 - arachidonic acid synthesis.
Protein [polypeptides] Hormones
1. Human Chorionic Gonadotrophin –- rises in 1st-early 2nd trimester, low levels
after ~16 wks - responsible for fetal adrenal cortex
development
2. Human Chorionic Somatotrophin –- fosters embryonic development by increasing
fetal cell glucose absorption and stimulating lipid and CHO metabolism.
Placental hormonal production
3. Human Placental Lactogen –
- rises progressively from ~12 wks upto term- possibly useful in preparation for lactation- contributes to diabetogenic effects of
pregnancy
4. ACTH, TSH, Melanocyte Stimulating Hormone, Relaxin, Oxytocin, Vasopressin –
All isolated from placental tissue but most likely are of maternal or fetal origin.
All rise progressively to plateau at term
1. Progesterone – Maintains pregnancy Maintains uterine quiesence mammary growth Antialdosterone effect2.Oestrogens (oestriol) – uterine growth & vascular supply to decidua & myometrium - metabolism & placental enzyme systems.3. Androgens4. Corticosteroids
Steroid Hormones
Placenta takes up Fe, Vit. B12 & Folic acid tendency
towards anaemia in pregnancy.
Fetal erythropoietin may cross placenta to mother since
maternal reticulocyte counts are elevated in presence of fetal anaemia.
Placental haematopoiesis
Feto-placental unit is an allograft that defies the
foreign body tissue reaction. [Type IV cell-mediated reaction]
Fetus not antigenically mature.
Placental immunology
Abnormal Shape or Implantation Degenerative Placental Lesions Circulatory Disturbances Hypertropic Placental Abnormalities Tumors of the Placenta
PLACENTAL ABNORMALITIES
- Multiple placentas with a single fetusplacenta bipartita or bilobataplacenta duplex, triplex
- succenturiate lobes- membranaceous placenta- ring – shaped placenta- fenestrated placenta- placenta accreta, increta & percreta- extrachorial placentation
circumvallate placentacircummarginate placenta
Abnormal shape or implantation
Abnormality Definition Clinical significance
Multiple Pla-centas with a single fetus
Placenta bipartita or bilobata - The placenta is separated into lobes - Division is incomplete and the vessels of fetal origin extend from one lobe to the other before unit-ing to form the umbilical cord Placenta duplex, triplex - Two or three distinct lobes are separated entirely and the vessels remain distinct.
Bilobed Placenta
Succenturiate lobes - Small accessory lobe ≥1, develop
in the membranes at a distant from the periphery of the main placenta, to which they usually have vascular connections of fetal origin
- Retained in the uterus after delivery and may cause serious hemorrhage - Accompanying vasa pre-via dangerous fetal hemor-rhage at delivery
Abnormality Definition Clinical significance
Membranaceous Placentaor
Placenta Diffusa
- All of the fetal mem-branes are covered by functioning villi and the placental develops as a thin membranous structure oc-cupying the entire periphery of the chorion
- Serious hemorrhage d/t associated placenta previa or accreta
Ring – shaped Placenta
- Placenta is annular in shape and sometimes a com-plete ring of placental tissue - Variant of membraceous placenta - Tissue atrophy in a por-tion of the ring a horseshoe shape in more common
- Antepartum & postpartum bleeding and fetal growth restriction
Diagnosis Definition Clinical significance
Fenestrated Placenta
- Central portion of a dis-coidal placenta is missing - In some instances, there is an actual hole in the placenta but more often the defect in-volves only villous tissue with the chorionic plate intact
- Mistakenly considered to indicate that a missing portion of placenta
Placenta Accreta Increta
Percreta
- Serious variations in which trohpoblastic tissue in-vade the myometrium to vary-ing depths - Much more likely with placenta previa or with im-plantation over a prior uterine incision or perforation
- Torrential hemorrhage
Abnormalities of Placental invasion
Abnormality Definition Clinical significance
Extrachorial Placentation
Circumvallate Placenta
Circummarginate placenta
- When the chorionic plate, which is on the fetal side of the placenta, is smaller than the basal plate, which is located on the maternal side, the placental periphery is uncovered
- Fetal surface of such a placenta presents a central depression surrounded by a thickened, grayish- white ring. - Ring : composed of a double fold of amnion and chorion with degenerated decidua and fibrin in between - Within the ring, the fetal surface present the usual appearance, except that the large vessels terminate abruptly at the margin of the ring - Ring dose not have the central depression with the fold of membranes
- Antepartum hemor-rhage from placental abrup-tion and fetal hemorrhage - Preterm delivery - Perinatal mortaliy - Fetal malformations
- Less well defined
Causes : Trophoblast aging or impairment of uteroplacental circulation with infarction.
Deposition of calcium salts is heaviest on the maternal surface in the basal plate –
→ further deposition occurs along the septa and both increase as pregnancy progresses.
Diagnosis : Sonography
Degenerative placental lesions
Placental calcification
- Placental Infarctions
- Maternal Floor Infarction
- Placental Vessel Thrombosis
Circulatory disturbances
Skriking enlargement of the chorionic villi is commonly seen in association with
Severe erythroblastosis Fetal hydrops
Maternal diabetes Fetal CHF Maternal-fetal syphilis
Hypertrophic Lesions of Chorionic Villi
Gestational Trophoblastic Disease
Chorioangioma (hemangioma)
Tumours metastatic to the Placenta
Embolic Fetal Brain Tissue
Tumours of Placenta
CHORIOANGIOMA (HEMANGIOMA)
At term amnion is a tough, tenacious & pliable membrane.
Innermost avascular fetal membrane.
Contiguous with amnionic fluid.
Provides almost all tensile strength. Lacks smooth muscle cells, nerves, lymphatics &
blood vessels.
THE AMNION
Bourne (1962) described five separate layers of amnion –
- innermost single layer of cuboidal epithelium derived from embryonic ectoderm.
- basement membrane- acellular compact layer, which is composed
primarily of interstitial collagens- fibroblast-like mesenchymal cells, derived from
embryonic disc mesoderm- acellular zona spongiosa, contiguous with second
fetal membrane, the chorion laeve
Structure
Layers of Amniotic membrane
Early during implantation, a space develops between the embryonic cell mass and adjacent trophoblasts.
Small cells that line this inner surface of trophoblasts have been called amniogenic cells—precursors of amnionic epithelium.
The amnion is first identifiable about the seventh or eighth day of embryo development. It is initially a minute vesicle, which then develops into a small sac that covers the dorsal surface of the embryo.
As the amnion enlarges, it gradually engulfs the growing embryo, which prolapses into its cavity.
Development
Reflected amnion is fused to the chorion laeve.
Placental amnion covers placental surface & thereby is in contact with adventitial surface of chorionic vessels.
Umbilical amnion covers the umbilical cord.
In the conjoined portion of membranes of diamniotic-dichorionic twin placenta, fused amnions are separated by fused chorion laeve.
With diamniotic-monochorionic placenta, there is no intervening tissue between the fused amnions.
ANATOMY
Meconium Staining Chorioamnionitis Other Abnormalities
ABNORMALITIES OF THE MEMBRANES
Abnormalities Definition & causes Clinical significance
Amnionic cyst Lined by typical amnionic epithe-lium Fusion of amnionic folds with subsequent fluid retention
Amnion nodosum Tiny, creamy nodules in the amnion made up of vernix caseosa with hair, degenerated squames and sebum Oligohydramnios
Found in fetuses with renal agenesis Prolonged preterm ruptured Membranes The placenta of the donor fetus with twin-to-twin transfusion syndrome
Amnionic band Caused when disruption of the am-nion leads to formation of bands or strings that entrap the fetus and impair growth and development of the involve structure
Intrauterine amputation
Cord develops in yolk sac & umbilical vesicle which are prominent early in pregnancy.
Embryo, at first, is a flattened disc interposed between amnion & yolk sac.
Its dorsal surface grows faster than the ventral surface.
Embryo bulges into amnionic sac in association with elongation of neural tube.
Dorsal part of yolk sac is incorporated into the body of embryo to form gut.
DEVELOPMENT OF THE CORD
Allantois projects into base of body stalk from the caudal wall of the yolk sac & later, forms anterior wall of hindgut.
As pregnancy advances, yolk sac becomes smaller & its pedicle relatively longer.
By about middle of 3rd month, expanding amnion obliterates exocoelom, fuses with the chorion laeve, & covers the bulging placental disc & lateral surface of the body stalk.
Latter is then called the umbilical cord—or funis.
Cont..
It normally has two arteries and one vein .
Right umbilical vein disappears early during fetal development, leaving only the left vein.
Intra-abdominal portion of duct of umbilical vesicle, extending from umbilicus to intestine, usually atrophies & disappears.
If patent, it is known as Meckel’s diverticulum.
Most common vascular anomaly - absence of one umbilical artery which may be associated with fetal anomalies .
THE CORD AT TERM
Umbilical cord, or funis, extends from fetal umbilicus to fetal surface of placenta or chorionic plate.
Exterior is dull white, moist, & covered with amnion, through which three umbilical vessels may be seen.
Diameter - 0.8 to 2.0 cm.
Average length of 55 cm with a range of 30 to 100 cm.
Generally, cord length less than 30 cm is considered abnormally short.
STRUCTURE OF THE CORD
Folding and tortuosity of vessels, which are longer than cord itself, frequently create nodulations on the surface, or false knots, which are essentially varices.
The extracellular matrix is a specialized connective tissue referred to as Wharton’s jelly.
Two arteries are smaller in diameter than the vein.
Length Cord Coiling Single Umbilical Artery Four-vessel cord Abnormalities of cord insertion Cord Abnormalities capable of
impeding blood flow Hematoma Cysts
UMBILICAL CORD ABNORMALITIES
Appreciable variation, extremes range – No cord(acordia) ~ lengths up to 300cm
Excessively long cords : ≥ 70cm ( ≥2 SD )
Length
Short umbilical cordAdverse perinatal outcomes – -fetal growth restriction
- congenital malformations - intrapartum distress & risk of death (doubled)
(Krakowiak and associates,2004)
Excessively long cordAssociated with
-maternal systemic disease -delivery complications -cord prolapse, cord entanglement -fetal anomalies and respiratory distress
Perinatal mortality : nearly threefold
Umbilical vessels: in a spiraled manner
Hypocoiled cords- in various adverse outcome in fetuses- meconium staining, preterm birth and fetal distress
Hypercoiled cords - higher incidence of preterm delivery & cocaine abuse
- Rana and associates (1995)
Cord coiling
Umbilical cord –2 arteries
- 1 veinRisk factors –
omen with GDM, PIH, APH, epilepsy, oligohydramnios & hydramnios.
¼ of all infants with only 1 artery have associated congenital anomalies.
Single umbilical artery
Diagnosis - routine ultrasound screening
Prognosis - depends on whether 2 vessel cord is associated with other abnormalities
or whether it is an isolated finding
When a 2 vessel cord is an isolated finding
aneuploid ≥ ½
Renal aplasia, Limb-reduction defects, Atresia of hollow organs in such fetuses, suggesting a vascular etiology
Growth restriction did not occur in anatomically normal
fetus with a single arteryGoldkrand and associates (2001)
Venous remnant in 5%
Significance : unknown
Four – vessel cord
Usually inserted at or near center of fetal surface of placenta
Furcate insertion
Marginal insertion
Velamentous insertion
Vasa previa
ABNORMALITIES OF CORD INSERTION
Abnormalities Definition Incidence Significance
Furcate insertion
Umbilical vessels separate from the cord substance before
their insertion into the pla-centa
RareProne to twisting &
thromboses as vessels lose their cushioning
Marginal Inserion Battledore placenta:
Cord insertion at the placental margin
7% at termCord being pulled off
during delivery of the placenta
Velamentous Inser-tion Umbilical vessels separate in
the membranes at a distance from the placental margin
Reach surrounded only by a fold of amnion
1.1%
More frequently with twins
28% of triples
Velamentous Insertion
Associated with velamentous insertion when some of the fetal vessels in the membranes cross the region of the cervical os below the presenting fetal part
Associated with - Velamentous insertion (50%)- Marginal cord insertion- Bilobed or Succenturiate-lobed placentas (50%)
Risk factors- Bilobed , Succenturiate or low-lying placenta (80%)- Multifetal pregnancy- Pregnancy resulting from in vitro fertilization
VASA PREVIA
Diagnosis- Color Doppler examination
Perinatal diagnosis : associated with increased survival
Antenatal diagnosis : associated with decreased fetal mortality compared with discovery at delivery
Antepartum or intrapartum haemorrhage
Detecting fetal blood- Apt test- Wright stain : smear the blood on glass slides
stain the smears with Wright stain and
examine for nucleated RBC : normally are present in cord blood
but not maternal blood
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