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Objectives
• Define placenta
• Explain the development of placenta
• State the gross anatomy of placenta at term
• Describe the structures of placenta
• Explain the placental circulation
• State the placental ageing
• List out the functions of placenta
• Explain the umbilical cord
• Describe the amniotic cavity, amnion and amniotic
fluid
• References
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The placenta
• Only the eutherian mammals possess placenta.
The human placenta is discoid, haemochorial
and deciduate.
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Development of placenta
• Developed from two sources.
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Development of placenta contd…
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Development of placenta contd…
• These two i.e., chorion frondosum and the
decidua basalis form the discrete placenta. It
begins at 6th week and is completed by 12th
week.
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The placenta at term
Gross anatomy
• Circular disc with a diameter of 15-20 cm and thickness
of about 2.5 cm at its center.
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The placenta at term contd…
Maternal surface
• Rough and spongy
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Maternal surface of placenta contd…
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The placenta at term contd…
• Margin: peripheral margin of the placenta is limited
by the fused basal and chorionic plates and is
continuous with the chorion leave and amnion.
• Attachment:
upper part of the body of the uterus encroaching to
the fundus adjacent to the anterior or posterior wall
with equal frequency.
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Structures of placenta
• The placenta is limited internally by the amniotic
membrane and chorionic plate; externally by the
basal plate and in between these two lies the
intervillous space containing the stem villi with their
branches, the space being filled with maternal blood.
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Structures of placenta contd…
Chorionic plate: From within outwards, it consists of
– Primitive mesenchymal tissue containing branches of umbilical
vessels
– A layer of cytotrophoblast and
– Syncytiotrophoblast
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Stem villi contd…
• Functional subunit is called lobule which is derived
from the tertiary stem villi.
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Structure of terminal villus contd…
• In the term placenta the syncytiotrophoblast becomes
relatively thin at places overlying the fetal capillaries and
thicker at other areas containing extensive endoplasmic
reticulum.
• The cytotrophoblast is relatively sparse.
• Basement membrane becomes thicker.
• Stroma contains dilated vessels along with all the
constituents and few Hofbauer cells.
• These cells have IgG surface receptors and can express
class II MHC molecules.
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Placental Circulation
Placental
circulation
Utero-
Feto-Placental
Placental
Circulation
circulation
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Uteroplacental circulation
(Maternal circulation)
• A mature placenta has a volume of about about 500 ml of
blood; 350ml being occupied in the villi system and 150 ml
lying in the intervillous space.
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Fetal circulation contd…
• Placental membrane: Inspite of close proximity, there is no
mixing of the maternal and fetal blood. The two are separated
by tissues called placental membrane or barrier, consisting of
the following. In the early pregnancy, it consists of
– Syncytiotrophoblast
– Cytotrophoblast
– Basement membrane
– Stromal tissue and
– Endothelium of the fetal capillary wall with its basement
membrane. It is about 0.025mm thick.
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1. Intervillous space (with maternal blood)
1. Intervillous space 2. Placental barrier of a terminal villus
2. Syncytiotrophoblast 3. Fetal capillaries
3. Cytotrophoblast 4. Merged basal membranes of the fetal
4. Villus mesenchyma capillary and of the syncythiothrophoblast
5. Fetal capillaries 5. Endothelial cells
6. Hofbauer macrophage 6. Rare cytotrophoblast cells
7. Basal membrane of the capillaries
8. Basal membrane of the trophoblast portion
9. Syncytiotrophoblast with proliferation knots
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(nuclei rich region) 31
Placental ageing
• As the placenta has got a life span, it is likely to undergo
degenerative changes as a mark of senescence. The
ageing process involves both the fetal and maternal
components.
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Placental ageing contd…
Villi changes: The following changes are observed:
• Decreasing thickness of the syncytium and appearance of
syncytial knots.
• Partial disappearance of Langhan's cells.
• Decrease in the stromal tissue including Hofbauer cells.
• Obliteration of some vessels and marked dilatation of the
capillaries.
• Thickening of the basement layer of the fetal endothelium
and the cytotrophoblast.
• Deposition of fibrin on the surface of the villi.
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Placental ageing contd…
• Decidual changes: There is an area of fibrinoid
degeneration, where trophoblast cells meet the
decidua. This zone is known as Nitabuch layer. The
membrane is absent in placenta accreta.
• Intervillous space: The syncytium, covering the villi
and extending into the decidua or intervillous space,
undergoes fibrinoid degeneration and form a mass
entangling variable number of villi. These are called
white infarcts. Calcification or even cyst formation
may occur on it. There may be inconsistent
deposition of fibrin called Rohr's stria at the bottom
of the intervillous space and surrounding the
fastening villi
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The fetal membranes
• It consists of two layers
• Outer chorion and the inner amnion.
Chorion:
• Represents the remnant of chorion laeve.
• Thicker than amnion
• Friable and shaggy on both sides.
• Internally, it is attached to the amnion by loose areolar
tissue and remnant of primitive mesenchyme.
• Externally, it is covered by vestiges of trophoblastic layer and
the decidual cells of fused decidua capsularis and parietalis .
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Functions of placenta
• Transfer of nutrients and waste products
• Enzymatic function
• Barrier function
• Immunological function
• Storage
• Endocrinal function
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Functions of placenta
1. Transfer of nutrients and waste products
between the mother and fetus.
• The mechanism involved in the transfer of
substances across the placenta are:
– Simple diffusion
– Facilitated diffusion (Carrier mediated)
– Active transfer (against concentration gradient)
– Endocytosis
– Exocytosis
– Leakage
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Transfer function contd…
Respiratory function:
• Although, the fetal respiratory movements are observed
as early as 11 weeks, there is no gaseous exchange.
• Intake of oxygen and output of carbon dioxide take place
by simple diffusion.
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Transfer function contd…
Nutritive function
a. Glucose:
• Principle source of energy
• Transferred to the fetus by facilitated diffusion
• Transfer rates decreases as maternal glucose concentration
increases.
b. Lipids
• For fetal growth and development
• Triglycerides and fatty acids are directly transported from
the mother to the fetus in early pregnancy but are
synthesized in the fetus later in the pregnancy.
• EFA are transferred more than non EFA
• Cholesterol is capable of direct transfer.
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Transfer function contd…
c. Amino acids
• Transferred by active transport through enzymatic
mechanism (ATPase).
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Functions of placenta contd…
d. Water and electrolytes
• Sodium, potassium and chloride cross by simple diffusion,
whereas calcium, phosphorus and iron cross by active
transport.
• Water soluble vitamins are transferred by active transport
but the fat soluble vitamins are transferred slowly.
e. Hormones-
• Insulin, steroids from the adrenals, thyroid, chorionic
gonadotrophin or placental lactogen cross the placenta at
very slow rate.
• Neither parathormone nor calcitonin crosses the placenta.
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Functions of placenta contd…
2. Enzymatic function:
• Diamine oxidase which inactivates the circulatory
pressure amines
• Oxytocinase which neutralizes the oxytocin
• Phospholipase A2 which synthesizes arachidonic acid
etc
3. Barrier function:
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Functions of placenta contd…
4. Immunological function
• Placental hormones, proteins (SP1), early pregnancy factor
(EPF), PAPP-A, steroids and chorionic gonadotrophin, have
got some immunosuppressive effect.
• Villous trophoblasts do not express HLA Class I and class II
molecules. Extravillous trophoblasts only express HLA class
I molecules and no HLA class II molecules.
• Though anti HLA antibodies and sentitised T cells against
paternal antigens have been detected in the maternal
serum, they have no significant effects on pregnancy.
• There is shift of maternal response from cell mediated (T
helper I) to humoral (T helper 2) immunity, which may be
beneficial to pregnancy.
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Functions of placenta contd…
• Decidual natural killer (NK) cells and trophoblast
(extravillous) HLA Class I molecules interact.
• The immunological response of implantation and that
of organ transplantation are different and not
comparable.
• Syncytiotrophoblast has got trophoblast lymphocytes
cross reactive antigen (TLX). Consequently there is
production of antibodies by the mother in response to
this TLX. These blocking antibodies protect the fetus
from rejection.
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Functions of placenta contd…
5. Storage
• The placenta metabolizes glucose, stores it in the form of
glycogen and reconverts it to glucose as required.
• It can also store iron and the fat soluble vitamins.
6. Endocrine Function
• Human Chorionic Gonadotropin
• Estrogen
• Progesterone
• Human Placental Lactogen
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The Umbilical Cord
• The umbilical cord is formed from the fetal membranes
• Provides a circulatory pathway that connects the embryo
to the chorionic villi of the placenta.
• Its function is to transport oxygen and nutrients to the
fetus from the placenta and to return waste products
from the fetus to the placenta.
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Development of umbilical cord
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The umbilical cord contd…
• The bulk of the cord is a gelatinous mucopolysaccharide
called Wharton’s jelly, which gives the cord body and
prevents pressure on the vein and arteries that pass
through it.
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The umbilical cord contd…
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The umbilical cord contd…
• The rate of blood flow is 350 mL/min at term.
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The umbilical cord contd…
Obliterated extra embryonic coelom: In the early period,
intraembryonic coelom is continuous with
extraembryonic coelom along with herniation of coils of
intestine. The condition may persists as a congenital
umbilical hernia or exomphalos.
Attachment:
• Early period- Cord is attached to the ventral surface of
the embryo close to the caudal extremity
• The point of attachment is moved permanently to the
center of the abdomen at fourth month.
• Unlike the fetal attachment, the placental attachment is
inconsistent, either centre or eccentric.
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Amniotic cavity, amnion and amniotic fluid
Development:
• Fluid accumulates slowly, at first, but ultimately the
fluid filled cavity obliterates the chorionic cavity.
• Initially the cavity is located on the dorsal surface of
the embryonic disc.
• With the formation of the head, tail and lateral folds,
it comes to surround the fetus.
• Its two growing margins merge into the body stalk.
• Thus, the liquor amnii surrounds the fetus
everywhere except at its attachment with the body
stalk.
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Structure of amnion
• Fully formed amnion is 0.02-0.5 mm in thickness.
• From within outwards the layers are:
– Single layer of cuboidal epithelium
– Basement membranes
– Compact layer of reticular structure
– Fibroblastic layer
– Spongy layer
• No blood supply, nerve supply nor any lymphatic
supply.
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Amniotic fluid
• Origin of amniotic fluid:
Mixed maternal and fetal origin. The following are the
speculative theories:
a. As a transudate across the umbilical cord or from fetal
circulation in the placenta or secretion from the
amniotic epithelium.
b. Transudate of fetal plasma through the highly
permeable fetal skin before it is keratinized at 20th
week.
c. Contribution from the fetus- Fetal daily urine output at
term is about 400-1200 ml. The fetal swallows about
200-500 ml of liquor every day at term.
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The origin and circulation of amniotic fluid
Secretes
Fetal Circulation
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Amniotic fluid contd…
Circulation: The water in the amniotic fluid is completely
changed and replaced in every 3 hours. The presence of
lanugo and epithelial scales in the meconium shows that the
fluid is swallowed by the fetus and some of it passes from the
gut into the fetal plasma.
Volume:
• 50ml at 12 weeks
• 400 ml at 20 weeks and
• reaches its peak of 1 litre at 36-38 weeks.
• Thereafter the amount diminishes, till at term it measures
about 600-800 ml.
• As the pregnancy continues post term, further reduction
occurs to the extent of about 200 ml at 43 weeks.
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Amniotic fluid contd…
Physical features:
• Faintly alkaline with a pH of about 7.2 with low specific gravity of
0.010.
• It becomes highly hypotonic to maternal serum at term pregnancy.
• Osmolarity of 250 m Osmol/liter (fetal maturity).
• 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).
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Abnormal colour of amniotic fluid
• Meconium stained (green) is suggestive of fetal distress in
presentation other than breech or transverse. Depending
upon the degree and duration of the distress, it may be thin
or thick or pea souped.
• Golden colour in Rh incompatibility is due to excessive
haemolysis of the fetal RBC and production of excess
bilirubin.
• Greenish yellow (saffron) in post maturity.
• Dark colored in accidental hemorrhage is due to
contamination of blood.
• Dark brown (tobacco juice) amniotic fluid is found in IUD.
The dark colour is due to frequent presence of old HbA.
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Amniotic fluid contd…
Composition:
• first half of pregnancy, the composition of fluid is almost
identical to a transudate of plasma.
• late pregnancy, the composition is altered mainly due to
contamination of fetal urinary metabolites.
• The composition includes- water (98-99%) and solid (1-2%).
• The following are the solid constituents:
Organic-
Protein- 0.3 mg%
Uric acid- 4 mg%
Glucose- 20 mg%
Creatinine- 2 mg%
Urea- 30 mg%
Total lipids- 50 mg%
NPN- 30 mg%
Hormones (Prolactin, insulin
and renin)
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Amniotic fluid contd…
Inorganic
• The concentration of the sodium, chloride and potassium
is almost the same as that found in maternal blood.
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Function of amniotic fluid
• Its main function is to protect the fetus.
During pregnancy:
• It acts as a shock absorber.
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Clinical importance of amniotic fluid
• Provides useful information about the well being and
also maturity of the fetus.
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References
• Jacob A.A comprehensive textbook of midwifery and
gynecological nursing.3rd edition.New
Delhi:Jaypee;2012.
• Fraser DM, Cooper MA.Myles textbook for
midwives.15th edition. Philadelphia:churchill
livingstone elsevier;2009
• Dutta DC.Textbook of obstetrics. 6th
edition.Calcutta:New central book agency;2004
• Pillitteri A. Maternal and Child health nursing: Care of
the childbearing and childrearing family. 6th edition.
Lippicott Williams and Wilkins : Philadelphia; 2010
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• The process of spiral artery remodeling during pregnancy. In early
pregnancy, two types of extravillous trophoblasts are found outside the
villous, endovascular and interstitial trophoblasts. Endovascular
trophoblasts invade and transform spiral arteries during pregnancy to
create low-resistance blood flow that is characteristic of the placenta.
Interstitial trophoblasts invade the decidua and surround spiral arteries.
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