Beruflich Dokumente
Kultur Dokumente
OB-GYN
Tranx No. 2
The Decidua, Placenta, and Placental Hormones 2009 December 14 Vincent Fortun, MD
Pages
Ronnelaine Cortez
OUTLINE
I. II. III. IV. The Decidua The Placenta Placental Hormones Abnormalities of Fetal Membranes
I. A. The Decidua
THE DECIDUA
E. Vascular Supply
The spiral arteries of the decidua are a very prominent organ/structure. They arise from the arcuate arteries which are branches of the uterine vessels. These are the high-pressure blood vessels bringing oxygenated blood to the decidua. The ovarian and endometrial cycles specific modifications in the rate of blood flow in these arteries are essential for: 1. The initiation of menstruation 2. The limitation of blood loss in the menses
F. Menstruation
Menstrual bleeding is of both arterial and venous origin. (But arterial bleeding is, quantitatively, appreciably greater than venous.)
The Decidua, The Placenta, Placental Hormones and Abnormalities of Fetal Membranes Page 1 of 8
smooth, shiny, and relatively free of blood bloody, dark red, with lobes and cotyledons
HEMOCHORIOENDOTHELIAL PLACENTATION o Unique to humans o At all sites of direct cell-to-cell contact, maternal tissues (both eciduas and blood) are juxtaposed (closely attached) to extraembryonic cells (trophoblasts) and NOT to the embryonic cells or fetal blood. o There is no mixing of fetal and maternal blood. Otherwise, problems will occur. There is always an intervening structure. o Maternal blood in the intervillous space directly bathes the trophoblasts. Transfer of substances (oxygen, nutrients) from mother to fetus is accomplished first by transfer from the intervillous space into the syncytiotrophoblast. Theres no direct transfer from maternal to fetal blood.
A. EARLY HUMAN DEVELOPMENT (Review) (Take note of the chronology. Again, common board exam question.)
Fertilization of the egg by a spermatozoan occurs in the fallopian tube. A common misconception is that fertilization occurs in the uterus. The mature ovum becomes a zygote (a diploid cell with 46 chromosomes). Zygote undergoes cleavage to form blastomeres. Sixteen or so blastomeres form a solid ball called morula (3rd to 4th day after fertilization takes place). The blastocyst is formed after the morula reaches the uterus (usually 6-7 days after fertilization), with the formation of a fluid-filled cavity within it. The inner cell mass gives rise to the embryo. Embryonic period lasts until the end of the 7th week. After embryonic period, the developing conceptus is referred to as the fetus. *Remember: Before 7 weeks AOG = embryonic period After 7 weeks AOG = the conceptus is now called the fetus 1. IMPLANTATION The blastocyst adheres to the endometrium of the uterus. (~7 days after fertilization) The implanting blastocyst becomes completely buried in and covered by the endometrium.
The Decidua, The Placenta, Placental Hormones and Abnormalities of Fetal Membranes Page 2 of 8
2. TROPHOBLAST A very specialized cell, Dr. Fortuns favorite cell: Without it, you and I would not be here. Responsible for implantation Its invasiveness provides for attachment of the blastocyst to the uterus. Role in nutrition of the conceptus Endocrine function is essential to maternal physiological adaptations and the maintenance of pregnancy 2 kinds: Cytotrophoblast and Syncytiotrophoblast Becomes the bane of women in trophoblastic cancer. CYTOTROPHOBLAST Well-demarcated borders Single, distinct nucleus Frequent mitosis Cellular progenitors of the syncytiotrophoblasts Produce cellular enzymes which allow it to move between and attach to endometrial epithelial cells during blastocyst implantation. Pale-staining SYNCYTIOTROPHOBLAST No cell borders Nuclei are multiple and diverse in size and shape Amorphous cytoplasm Controls transport processes across the synctia (very important for fetal nutrition) Secretes hormones (most important function) Very dark-staining because of very high nuclear activity
*How come the developing embryo is able to attach itself into the endometrium of the mother when 50% of its DNA is foreign? Normally, when there is something foreign that enters our body, our immune system tends to destroy that foreign body. The wonder of pregnancy is in the immunologic acceptance of the fertilized ovum.
C. PLACENTAL DEVELOPMENT
After blastocyst implantation, cytotrophoblasts proliferate rapidly and invade the surrounding decidua. Anchoring and villous trophoblasts form the early placenta. Walls of superficial decidual capillaries are eroded and the walls of spiral arteries are destroyed. (The fertilized ovum is a parasite, so it has to find source of nutrition and oxygen for it to survive. Hence, the trophoblasts now seek out these capillaries/arteries.) Maternal blood directly bathes the syncytiotrophoblasts in the intervillous space (14th to 15th day of life).
MUST-KNOW! Villi in contact with the decidua basalis proliferate to form the chorion frondosum (the fetal component of the placenta). Villi in contact with the decidua capsularis degenerate to form the chorion laeve. After the 3rd month, the chorion laeve and the amnion come into contact and form the amniochorion/fetal membranes.
D. PLACENTAL BARRIER
Substances that pass from maternal to fetal blood must first traverse: 1. Syncytiotrophoblast 3 components of the placental barrier 2. Stroma of the intravillous space 3. Fetal capillary wall However, the placenta does not maintain absolute integrity of the fetal and maternal circulations at times such as in cases of erythroblastosis fetalis.
The Decidua, The Placenta, Placental Hormones and Abnormalities of Fetal Membranes Page 3 of 8
E. PLACENTA AT TERM
185 mm in diameter 23 mm in thickness 497 ml average volume 508 g weight 10 to 38 cotyledons (cotyledons separated by septae)
F. PLACENTAL AGING
Decreased thickness of syncytium Formation of syncytial knots (stroma within the placenta) Villous stroma, Hobauer cells, and Langhans cells are reduced Thickening of the basement membranes of the capillaries and trophoblasts (very important because if theres thickening of the basement membrane, there is less amount of oxygen and nutrients that can reach placental circulation) Obliteration of certain fetal vessels Deposition of fibrin on the surface of villi, basal and chorionic plates, and intervillous space
*The placenta degrades as the pregnancy nears term, this is why we dont want post-term babies (>42 weeks AOG)
H. MATERNAL CIRCULATION
Maternal blood enters the intervillous space in spurts produced by maternal blood pressure. Blood is then forced toward the chorionic plate. Lateral spread of blood occurs. Arterial pressure forces blood toward exits in the basal plate to the uterine veins During uterine contractions, both inflow and outflow are curtailed, while the volume of the blood in the intervillous space is maintained; thus, providing for continuous exchange. Even if the uterus is contracting vigorously during labor, there is still an adequate amount of blood within the placenta to maintain constant exchange of nutrients and waste products between maternal and fetal blood.
I.
ABNORMALITIES OF PLACENTATION
Multiple placentas with a single fetus - The placenta occasionally is separated into lobes. When the division is incomplete and the vessels of fetal origin extend from one lobe to the other before uniting to form the umbilical cord, the condition is termed placenta bipartita or bilobata. If the two or three distinct lobes are separated entirely, and the vessels remain distinct, the condition is designated placenta duplex or placenta triplex. Succenturiate placenta - An extra placenta separate from the main placenta. In anatomy, "succenturiate" means substituting for or accessory to an organ. In this case, a succenturiate placenta is an accessory placenta. Ring-shaped placenta - the placenta is annular in shape, and sometimes a complete ring of placental tissue is present. Because of tissue atrophy in a portion of the ring, a horseshoe shape is more common. Membranous/Membranaceous placenta - Very rarely, all of the fetal membranes are covered by functioning villi, and the placenta develops as a thin membranous structure occupying the entire periphery of the chorion. This finding is called placenta membranacea and also is referred to as placenta diffusa. Fenestrated placenta - In this rare anomaly, the central portion of a discoidal placenta is missing. In some instances, there is an actual hole in the placenta, but more often the defect involves only villous tissue with
The Decidua, The Placenta, Placental Hormones and Abnormalities of Fetal Membranes Page 4 of 8
the chorionic plate intact. Clinically, it may be mistakenly considered to indicate that a missing portion of placenta has been retained in the uterus. Extrachorial placenta - A placenta in which there is a rim of placental tissue that extends beyond the vascular plate, accompanied by fibrin on the margin. Large/Mega placenta Placental polyp
J.
K. THE AMNION
Identifiable at the 7th to 8th day of embryonic development The innermost fetal membrane (contiguous with the amniotic fluid) Provides almost all of the tensile strength of the fetal membrane (Evals Question) Does not contain smooth muscles, nerves, lymphatics, and blood vessels. o Used as biological dressings since the tensile strength is good and no other structures are prone to degradation
1. Development of the Amnion At the 7th or 8th day of embryonic development, the amnion develops into a small sac that covers the dorsal surface of the embryo. Amnion enlarges and covers the whole embryo Comes into contact with the interior surface of the chorion laeve Apposition of the chorion laeve and amnion causes obliteration of the extraembryonic coelom 2. Layers of the Amnion Epithelium Basement membranes Compact layers o Responsible for tensile strength Mesenchymal cell layer Zona spongiosa 3. Metabolic Functions of the Amnion Transports solutes and water to maintain amniotic fluid homeostasis Produces vasoactive peptides (no need to memorize) o Endothelin-1 o Parathorome-related protein o Enkephalinase o Brain natriuretic peptide o Cortocotropin-relaxing hormone Secretes growth factors and cytokines 4. Amniotic Fluid Clear Increases in quantity as pregnancy progresses till near term Average volume: 1,000 mL In early pregnancy, it is an ultrafiltrate of maternal plasma. By the 2nd trimester, it consists largely of extracellular fluid which diffuses through the fetal skin. After 20 weeks, it is composed largely of fetal urine. Pulmonary fluid and fluid filtering through the placenta also contribute.
5. Chorioamnionitis Inflammation of the fetal membranes Frequently associated with prolonged membrane rupture and long labors
The Decidua, The Placenta, Placental Hormones and Abnormalities of Fetal Membranes Page 5 of 8
Mononuclear and polymorphonuclear leukocytes infiltrate the chorion (a pathologic diagnosis) Managed by antibiotics and immediate delivery (otherwise, the baby will have sepsis)
2. hCG Concentrations in Pregnancy hCG enters maternal blood at the time of blastocyst implantation (about 7-9 days post-ovulation Concentration in the maternal plasma is equal to the concentration in maternal urine o Before the advent of urine testing, we used to determine if a woman is pregnant by getting a blood sample. 1,000 mIU/mL = 6 weeks of pregnancy 100,000 mIU/mL = 8 to 11 weeks of pregnancy Concentrations in the plasma start to decline at 10 weeks (nadir at 20 weeks) In normal single pregnancies, the level should not go beyond 100,000 mIU/mL 3. Conditions with Elevated hCG levels (>100,000 mIU/mL) Pregnancies with multiple fetuses Erythroblastotic fetus Syphilis in pregnancy H-mole or choriocarcinoma Fetus with Down Syndrome Non-trophoblastic tumors (germ cell tumors) 4. Conditions with Depressed hCG levels Ectopic pregnancy
The Decidua, The Placenta, Placental Hormones and Abnormalities of Fetal Membranes Page 6 of 8
Impending spontaneous abortion Death of fetus 5. Biologic Functions of hCG rescue and maintenance of function of the corpus luteum MOST IMPORTANT Stimulation of fetal testicular testosterone secretion o Promote male sexual differentiation Were it not for hCG, all of us would be females Stimulation of maternal thyroid gland Promotes relaxin secretion by corpus luteum
B. HUMAN PLACENTAL LACTOGEN (hPL) Concentrated in syncytiotrophoblasts (5 weeks) Maximal concentrations at 34-36 weeks Rate of secretion is proportional to placental mass o Low levels in trophoblastic disease patients Also secreted by malignancies other than that of trophoblast or of gonad o Bronchogenic Ca, hepatoma, lymphoma, pheochromocytoma Metabolic Functions of hPL Lipolysis and increased levels of free fatty acids o Provides source of energy for maternal metabolism and fetal nutrition Anti-insulin action o Increased maternal insulin levels favors protein synthesis for transport to the fetus. C. ESTROGEN Human pregnancy is an hyperestrogenic state Syncytiotrophoblast secretes two estrogens: o Estradiol-17 Beta o Estriol Promotes growth of the endometrium D. PROGESTERONE Produced by syncytiotrophoblast Facilitates and permits the maintenance of pregnancy Formation occurs through the uptake and use of maternal LDL cholesterol E. OTHER PROTEIN HORMONES OF THE PLACENTA (No need to memorize) Chorionic Adenocorticotropin Chorionic Thyrotropin Hypothalamic-like Releasing Hormones Relaxin o Promotes uterine relaxation Parathyroid Hormone-related Protein o PTH of fetus Human Growth Hormone-Variant o Biological activity similar to hPL Neuropeptide-Y Inhibin o In conjunction with sex steroids, may serve to inhibit FSH secretion during pregnancy (no ovulation) Activin Atrial Natriuretic Peptide o Promotes uterine relaxation
The Decidua, The Placenta, Placental Hormones and Abnormalities of Fetal Membranes Page 7 of 8
B.
C.
D.
The Decidua, The Placenta, Placental Hormones and Abnormalities of Fetal Membranes Page 8 of 8