FERTILIZATION AND

IMPLANTATION
REPRODUCTIVE HEALTH I
CLINICAL MEDICINE CLASS
INTRODUCTION
The Sperm:
• The spermatozoa leave the testis carrying 23 chromosomes but not
yet capable of fertilization.
• Their maturation is completed through their journey in the 6 meters
of the epididymis and when mixed with the seminal plasma from the
epididymis, seminal vesicle and prostate gland.
• After semen is ejaculated, the sperms reach the cervix by their own
motility within seconds leaving behind the seminal plasma in the
vagina.
INTRODUCTION
• At time of ovulation, the cervical mucous is in the most favourable
condition for sperm penetration and capacitation as:
• It becomes more copious, less viscous and its macromolecules arrange in
parallel chains providing channels for sperms passage.
• Its contents from glucose and chloride are increased.
• The sperms ascent through the uterine cavity and Fallopian tubes to
reach the site of fertilization in the ampulla by:
• its own motility,
• uterine and tubal peristalsis which is aggravated by the prostaglandins in
the seminal plasma.
INTRODUCTION
• The sperms reach the tube within 30-40 minutes but they are capable of
fertilization after 2-6 hours.
• This period is needed for sperm capacitation.
• Capacitation of sperms is the process after which the sperm becomes able
to penetrate the zona pellucida, that surrounds the ovum and fertilize it.
• The cervical and tubal secretions are mainly responsible for this
capacitation.
• Capacitation is believed to be due to:
a. increase in the DNA concentration in the nucleus
b. increase permeability of the coat of sperm head to allow more release of
hyaluronidase
INTRODUCTION
The ovum:
• The ovum leaves the ovary after rupture of the Graafian follicle,
carrying 23 chromosomes and surrounded by the zona pellucida and
corona radiata.
• The ovum is picked up by the fimbriated end of the Fallopian tubes
and moved towards the ampulla by the ciliary movement of the cells
and rhythmic peristalsis of the tube.
INTRODUCTION
OVULATION
• Ovulation is a process whereby a secondary oocyte is released from the ovary
following rupture of a mature Graafian follicle and becomes available for
conception.
Changes in the follicle
• There is preovulatory enlargement of the Graafian follicle due to accumulation of
follicular fluid and measures about 20 mm in diameter.
• The cumulus oophorus separates from the rest of the granulosa cells and floats
freely in the antrum.
• The inner layer of the cells surrounding the oocyte is arranged radially corona
radiata
• The follicular wall near the ovarian surface becomes thinner.
INTRODUCTION
Changes in the oocyte
• Cytoplasmic volume is increased along with changes in the number,
distribution of mitochondria and in the Golgi apparatus.
• Completion of the arrested first meiotic division occurs with
extrusion of first polar body, each containing haploid number of
chromosomes (23, X).
INTRODUCTION
CAUSES
1. Endocrinal  the combined LH/FSH midcycle surge is responsible for the
final stage of maturation, rupture of the follicle and expulsion of the oocyte.
• LH surge: Sustained peak level of estrogen for 24–36 hours in the late
follicular phase → LH surge occurs from the anterior pituitary.
• Ovulation approximately occurs 16–24 hours after the LH surge.
• LH peak persists for about 24 hours.
• The LH surge stimulates completion of reduction division of the oocyte
and initiates luteinization of the granulosa cells, synthesis of
progesterone and prostaglandins.
INTRODUCTION
• FSH rise: Preovulatory rise of progesterone facilitates the positive
feedback action of estrogen to induce FSH surge → increase in
plasminogen activator → plasminogen → plasmin → helps lysis of the
wall of the follicle.
2. Stretching factor
3. Contraction of the micromuscles in the theca externa and ovarian
stroma due to increased prostaglandin secretion.
• Following ovulation, the follicle is changed into corpus luteum.
• The ovum is picked up into the Fallopian tube and undergoes either
degeneration or further maturation
FERTILIZATION
• Fertilization is the process of fusion of the spermatozoon with the
mature ovum.
• It begins with sperm egg collision and ends with production of a
mononucleated single cell called the zygote.
Goal:
1. To initiate the embryonic development of the egg
2. To restore the chromosome number of the species.
APPROXIMATION OF THE GAMETES
• The ovum, after ovulation is picked up by the tubal fimbriae.
• This action is thought to be muscular or suction or ciliary action or a
positive chemotaxis exerted by the tubal secretion.
• The ovum is rapidly transported to the ampullary part.
• Fertilizable life span of oocyte ranges from 12 to 24 hours whereas
that of sperm is 48 to 72 hours.
• Out of hundreds of millions of sperms deposited in the vagina at
single ejaculation, only thousands enter the uterine tube while only
300–500 reach the ovum.
CONTACT AND FUSION OF THE
GAMETES
• Complete dissolution of the cells of the corona radiata occurs by the
chemical action of the hyaluronidase liberated from the acrosomal
cap of the hundreds of sperm present at the site
• Penetration of the zona pellucida is facilitated by the release of
hyaluronidase from the acrosomal cap.
• More than one sperm may penetrate the zona pellucida.
• One touches the oolemma.
CONTACT AND FUSION OF THE
GAMETES
• After the sperm fusion, penetration of other sperm is prevented by
zona reaction (hardening) and oolemma block.
• This is due to release of cortical granules by exocytosis from the
oocyte.
• Alteration of its electrical potential.
CONTACT AND FUSION OF THE
GAMETES
• Completion of the second meiotic division of the oocyte immediately
follows, each containing haploid number of chromosomes (23, X)
• The female pronucleus and the second polar body which is pushed to
the perivitelline space.
• The head and tail of the spermatozoon enter the cytoplasm of the
oocyte but the plasma membrane is left behind on the oocyte
surface.
• Head and the neck of the spermatozoon become male pronucleus
containing haploid number of chromosomes (23, X) or (23, Y).
CONTACT AND FUSION OF THE
GAMETES
• The male and the female pronuclei unite at the center with
restoration of the diploid number of chromosomes (46) which is
constant for the species.
• The zygote formed contains both the paternal and maternal genetic
materials.
Immunological reaction (chemotaxis).
• An antigen called fertilizin present on the cortex and its coat of the
ovum, reacts with the antibody called antifertilizin liberated at the
plasma membrane of the sperm head.
CONTACT AND FUSION OF THE
GAMETES
Sex Determination:
• Sex of the child is determined by the pattern of the sex chromosome
supplied by the spermatozoon.
• The mature ovum carries 22 autosomes and one X chromosome,
while the mature sperm carries 22 autosomes and either an X or Y
chromosome.
• If the fertilizing sperm is carrying X chromosome the baby will be a
female (46 XX), if it is carrying Y chromosome the baby will be a male
(46 XY).
MORULA
• After the zygote formation, typical mitotic division of the nucleus
occurs by producing two blastomeres.
• The two cell stage is reached approximately 30 hours after
fertilization.
• Each contains equal cytoplasmic volume and chromosome numbers.
• The blastomeres continue to divide by binary division through 4, 8,
16 cell stage until a cluster of cells is formed called morula,
resembling a mulberry.
MORULA
• In the 16-64 cell stage, after spending about 3 days in the uterine
tube, the morula enters the uterine cavity through the narrow uterine
ostium (1 mm) on the 4th day
• The transport is a slow process and is controlled by muscular
contraction and movement of the cilia.
• The central cell of the morula is known as inner cell mass which forms
the embryo proper and the peripheral cells are called outer cell mass
which will form protective and nutritive membranes of the embryo.
BLASTOCYST
• The morula remains free in the uterine cavity on the 4th and 5th day,
covered by a film of mucus.
• A cavity appears within the morula converting it into a cystic structure
called blastocyst.
• Due to blastocyst enlargement the zona pellucida becomes stretched,
thinned and gradually disappears.
• Lysis of zona and escape of embryo is called zona hatching.
BLASTOCYST
• The cells on the outer side of the morula (polar) become trophectoderm
and the inner cells (apolar) become inner cell mass by the mediation of
epithelial cadherin (E-cadherin) (protein).
• Trophectoderm differentiates into chorion (placenta) and the inner cell
mass into the embryo.
• Completely undifferentiated cells are called the pluripotent embryonic
stem (ES) cells.
• ES cells are able to produce mature somatic cells of any germ layer
(ectoderm, mesoderm and endoderm).
• The blastocyst remains free in the uterine cavity for 3-4 days, during
which it is nourished by the secretion of the endometrium (uterine milk).
IMPLANTATION (nidation)
• Implantation occurs in the endometrium of the anterior or posterior
wall of the body near the fundus on the 6th day which corresponds to
the 20th day of a regular menstrual cycle.
• Implantation occurs through four stages
• Apposition
• Adhesion
• Penetration
• Invasion
CHANGES IN THE BLASTOCYST
• The polar trophoblast cells adjacent to the inner cell mass are
primarily involved in adhesion to the endometrial cells.
• The factors responsible for blastocyst attachment are:
• P. selectin, heparin sulfate, proteoglycan, EGF (epidermal growth
factor), integrins, trophinin and others.
• The signals for trophoblast multiplication arise from the inner cell
mass.
ENDOMETRIUM AT THE
IMPLANTATION SITE
• The endometrium is in the secretory phase corresponding to 20–21
days of cycle.
• The microvilli on the surface of the trophectoderm interdigitate with
the decidual cells to form the junctional complexes.
• Endometrial receptivity and molecular signaling during implantation is
induced by progesterone, LIF (leukemia inhibitory factor),
prostaglandins and COX-2 (cyclooxygenase).
APPOSITION
• Occurs through pinopod formation.
• Pinopods are long finger like projections (microvilli) from the
endometrial cell surface.
• These pinopods absorb the endometrial fluid which is secreted by the
endometrial gland cells.
• This fluid, rich in glycogen and mucin provides nutrition to the
blastocyst initially.
• Unless this fluid is absorbed, adhesion phase cannot occur.
ADHESION
• Adhesion of blastocyst to the endometrium occurs through the
adhesion molecules like integrin, selectin and cadherin
(glycoproteins).
PENETRATION AND INVASION
• Actual penetration and invasion occur through the stromal cells in
between the glands and is facilitated by the histolytic action of the
blastocyst.
• With increasing lysis of the stromal cells, the blastocyst is burrowed
more and more inside the stratum compactum of the decidua.
• Vacuoles appear in the advancing syncytium which fuse to form large
lacunae.
• Concurrently, the syncytial cells penetrate deeper into the stroma and
erode the endothelium of the maternal capillaries
PENETRATION
• The syncytium by penetrating the vessels becomes continuous with the
endothelial lining and permits the maternal blood to enter into the lacunar
system.
• Erosion of few maternal arteries with formation of blood space (lacunae) occurs.
• Nutrition is now obtained by aerobic metabolic pathway from the maternal
blood.
• Further penetration is stopped probably by the maternal immunological factor
and the original point of entry is sealed by fibrin clot and later by epithelium.
• The process is completed by 10th or 11th day which corresponds to D 24-25
from LMP.
PENETRATION
• This type of deeper penetration of the human blastocyst is called
interstitial implantation and the blastocyst is covered on all sides by
the endometrium (decidua).
• Occasionally, there may be increased blood flow into the lacunar
spaces at the abembryonic pole.
• This results in disruption of the lacunae and extravasation of blood
into the endometrial cavity.
• This corresponds approximately to 13th day after fertilization  the
expected day of the following period.
PENETRATION
• This may produce confusion in determination of the expected date of
delivery.
• The process of implantation is controlled by the immunomodulatory
role of various cytokines (interleukins 3, 4, 5, 6, 10, 13), many local
peptides like epidermal growth factor (EGF), insulin like growth factor
(IGF) and prostaglandins.
• Both the decidua and the embryo synthesize these molecules.
TROPHOBLAST
• The cells of the blastocyst differentiate into an outer trophectoderm and
an inner cell mass.
• Just before implantation, the trophectoderm is further differentiated
into an inner mononuclear cellular layer called cytotrophoblast or
Langhans’ layer and an outer layer of multinucleated syncytium called
syncytiotrophoblast.
• The cytotrophoblasts that line the villous stems are the villous
cytotrophoblasts.
• The cytotrophoblast cells that invade the decidua are known as
‘interstitial extravillous cytotrophoblast’ and those that invade the
lumens of the maternal spiral arteries are known as ‘intravascular
extravillous cytotrophoblast’
TROPHOBLAST
• Throughout pregnancy, syncytiotrophoblast is derived from the
cytotrophoblast.
• Placenta and the fetal membranes are developed from the
trophoblast.
• It is involved in most of the functions ascribed to the placenta as a
whole.
• Thus, it serves at least 3 important functions — invasion, nutrition and
production of hormones for the maintenance of pregnancy.
• Local cytokines regulate the invasion of the cytotrophoblasts in the
decidua.
THE DECIDUA
• It is the thickened vascular endometrium of the pregnant uterus.
• It is called so because it casts of after parturition.
• The glands become enlarged, tortuous and filled with secretion.
• The stroma cells become large with small nuclei and clear cytoplasm,
these are called decidual cells.
• The decidua, like secretory endometrium, consists of three layers:
• the superficial compact layer
• the intermediate spongy layer
• the thin basal layer
STRUCTURE OF DECIDUA
THE DECIDUA
• The separation of placenta occurs through the spongy layer while the
endometrium regenerates again from the basal layer.
• The trophoblast of the blastocyst invades the decidua to be
implanted in:
• the posterior surface of the upper uterine segment in about 2/3
of cases
• the anterior surface of the upper uterine segment in about 1/3
of cases.
THE DECIDUA
• After implantation the decidua becomes differentiated into:
• Decidua basalis (serotine) under the site of implantation (the portion of
the decidua in contact with the base of the blastocyst).
• Decidua capsularis (reflexa) covering the ovum (the thin superficial
compact layer covering the blastocyst).
• Decidua parietalis (vera) lining the rest of the uterine cavity.
• As the conceptus enlarges and fills the uterine cavity the decidua
capsularis fuses with the decidua parietalis. (decidual space)
• This occurs nearly at the end of 12 weeks.
THE DECIDUA
• At term, they become atrophied due to pressure and the two cannot be
defined as a double layer.
• The decidua basalis retains its characteristic appearance till term and
becomes the maternal portion of the placenta
• The decidua has the following functions:
1. It is the site of implantation.
2. It resists more invasion of the trophoblast.
3. It nourishes the early implanted ovum by its glycogen and lipid contents.
4. It shares in the formation of the placenta.
CHORION
• The chorion is the outermost layer of the two fetal membranes
(chorion and amnion).
• After implantation, the trophoblast differentiates into 2 layers:
a. an outer one called syncytium (syncytiotrophoblast) which is
multinucleated cells without cell boundaries,
b. an inner one called Langhan’s layer (Cytotrophoblast) which is
cuboidal cells with simple cytoplasm.
CHORION
• A third layer of mesoderm appears inner to the cytotrophoblast.
• The trophoblast and the lining mesoderm together form the
chorion.
• Mesodermal tissue (connecting stalk) connects the inner cell mass to
the chorion and will form the umbilical cord later on.
• Spaces (lacunae) appear in the syncytium, increase in size and fuse
together to form the " chorio-decidual space" or " intervillus space".
• Erosion of the decidual blood vessels by the trophoblast allows blood
to circulate in this space.
CHORION
• The outer syncytium and inner Langhan’s cells form finger-like buds
surrounding the developing ovum called primary villi.(9th day)
• When the mesoderm invades the center of the primary villi they are
called secondary villi. (16th day)
• When blood vessels (branches from the umbilical vessels) develop
inside the mesodermal core, they are called tertiary villi. (21st day)
CHORION
• At first, the chorionic villi surround the developing ovum.
• After the 12th week, the villi opposite the decidua capsularis atrophy
leaving the chorion laeve which forms the outer layer of the foetal
membrane and is attached to the margin of the placenta.
• The villi opposite the decidua basalis grow and branch to form the
chorion frondosum and together with the decidua basalis will form
the placenta.
• Some of these villi attach to the decidua basalis ( the basal plate)
called the "anchoring villi", other hang freely in the intervillous
spaces called "absorbing villi"
AMNION
• On the 8th day, the embryoblast differentiates into bilaminar germ disc
which consists of dorsal ectodermal layer and ventral endodermal layer.
• The bilaminar germ disc is connected with the trophoblast by
mesenchymal condensation (connecting stalk)
• Two cavities appear one on each side of the germ disc, the amniotic
cavity and yolk sac.
• The layer of cells at the floor of the amniotic cavity will give the
ectodermal structures of the foetus and the layer of cells at the roof of
the yolk sac will give the endodermal structures of the foetus and the
mesoderm in between will give the mesodermal structure.
AMNION
Phases of conceptus development:
1. The ovum: the products of conception in the first 2 weeks after
fertilization.
2. The embryo: from 3 to 5 weeks.
3. The foetus: the developing infant (6-40 wks).
THE PLACENTA
• The placenta develops from the chorion frondosum (foetal origin)
and decidua basalis (maternal origin).
• It begins at 6th week and is completed by 12th week
Anatomy At Term:
• Shape discoid. Diameter: 15-20 cm. Weight : 500 gm.
• Thickness 2.5 cm at its center and gradually tapers towards the
periphery.
• Position in the upper uterine segment (99.5%), either in the
posterior surface (2/3) or the anterior surface (1/3).
THE PLACENTA
Surfaces:
A. Foetal surface: smooth, glistening and is covered by the amnion which is
reflected on the cord.
• The umbilical cord is inserted near or at the center of this surface and its
radiating branches can be seen beneath the amnion.
• At term, about four-fifths of the placenta is of fetal origin.
B. Maternal surface: dull greyish red in colour and is divided into 15-20
cotyledons.
• Each cotyledon is formed of the branches of one main villus stem covered
by decidua basalis.
THE PLACENTA

Fetal surface of the placenta Maternal surface of the placenta

PLACENTAL CIRCULATION
• Placental circulation consists of independent circulation of blood in two
systems:
• Uteroplacental circulation
• Fetoplacental circulation
UTEROPLACENTAL CIRCULATION (maternal circulation)
• It is concerned with the circulation of the maternal blood through the
intervillous space.
• The blood in the intervillous space is completely replaced about 3–4
times per minute.
• The villi depend on the maternal blood for their nutrition
PLACENTAL CIRCULATION
FETOPLACENTAL CIRCULATION
• The umbilical arteries carry the impure blood from the fetus
• umbilical vein
• chorionic veins
• arteriocapillary venous system of villi
• chorionic arteries
• The fetal blood flow through the placenta is about 400 mL/min.
• This is mainly facilitated by the pumping action of the fetal heart.
FUNCTIONS OF THE PLACENTA
1. Respiratory function
• O2 and CO2 pass across the placenta by simple diffusion.
• The foetal haemoglobin has more affinity and carrying capacity than adult
haemoglobin.
• 2,3 diphosphoglycerate (2,3-DPG) which competes for oxygen binding sites in the
haemoglobin molecule, is less bounded to the foetal haemoglobin (HbF) and thereby
allows a greater uptake of O2 (O2 affinity).
• The rate of diffusion depends upon:
a. maternal/ foetal gases gradient.
b. maternal and foetal placental blood flow.
c. placental permeability.
d. placental surface area.
FUNCTIONS OF THE PLACENTA
2. Nutritive function
• The transfer of nutrients from the mother to the foetus is achieved
by:
• Simple diffusion: e.g. water and electrolytes.
• Facilitated diffusion: e.g. glucose.
• Active diffusion: e.g. amino acids.
• Pinocytosis: e.g. large protein molecules and cells.
FUNCTIONS OF THE PLACENTA
3. Excretory function
• Waste products of the foetus as urea are passed to maternal blood by
simple diffusion through the placenta.
4. Production of enzymes
• e.g. oxytocinase, monoamino oxidase, insulinase, histaminase and
heat stable alkaline phosphatase.
5. Production of pregnancy associated plasma proteins (PAPP)
• e.g. PAPP-A, PAPP-B, PAPP-C, PAPP-D and PP5. The exact function of
these proteins is not defined.
FUNCTIONS OF THE PLACENTA
6. Barrier function
• The foetal blood in the chorionic villi is separated from the maternal blood, in the
intervillous spaces, by the placental barrier which is composed of :
• endothelium of the foetal blood vessels
• the villous stroma
• the cytotrophoblast
• the syncytiotrophoblast
• However, it is an incomplete barrier.
• It allows the passage of antibodies (IgG only), hormones, antibiotics, sedatives, some
viruses as rubella and smallpox and some organisms as treponema pallida.
• Substances of large molecular size as heparin and insulin cannot pass the placental
barrier.
FUNCTIONS OF THE PLACENTA
7. Endocrine function
(A) Protein hormones:
1- Human chorionic gonadotrophin (hCG):
• It is a glycoprotein produced by the syncytiotrophoblast.
• It supports the corpus luteum in the first 10 weeks of pregnancy to
produce oestrogen and progesterone until the syncytiotrophoblast can
produce progesterone.
• HCG molecule is composed of 2 subunits:
a. alpha subunit which is similar to that of FSH, LH and TSH.
b. beta subunit which is specific to hCG.
FUNCTIONS OF THE PLACENTA
• HCG rises sharply after implantation, reaches a peak of 100.000
mIU/ml about the 60th day of pregnancy then falls sharply by the day
100 to 30.000 mIU/ml and is maintained at this level until term.
• Estimation of beta-hCG is used for:
a) diagnosis of early pregnancy.
b) diagnosis of ectopic pregnancy.
c) diagnosis and flow-up of trophoblastic disease.
FUNCTIONS OF THE PLACENTA
2- Human placental lactogen (hPL)
• It is a ploypeptide hormone produced by the syncytiotrophoblast.
• The supposed actions of hPL include:
a. lipolysis: increasing free fatty acids which provide a source of energy for mother and foetal
nutrition.
b. inhibition of gluconeogenesis: thus spare both glucose and protein explaining the anti-insulin
effect of hPL.
c. somatotrophic: i.e. growth promotion of the foetus due to increased supply of fatty acids, glucose
and amino acids.
d. mammotropic and lactogenic effect.
• HPL can be detected by the 5-6th week of pregnancy, rises steadily until the 36th week
to be 6m g/ml.
• Its level is proportional to the placental mass.
FUNCTIONS OF THE PLACENTA
3- Human chorionic thyrotrophin (hCT)
• No significant role has been established for it, but it is probably
responsible for increased maternal thyroid activity and promotion of
foetal thyroid development.
4- Hypothalamic and pituitary like hormones
• e.g. gonadotropin releasing hormone (GnRH) ,corticotropin releasing
factor (CRF), ACTH and melanocyte stimulating hormone.
5- Others as inhibin, relaxin and beta endorphins.
FUNCTIONS OF THE PLACENTA
(B) Steroid Hormones:
1- Oestrogens
• They are synthetized by syncytiotrophoblast from their precursors
dehydroepiandrosterone sulphate (DHES)
• Oestrogens are excreted in the maternal urine as oestriol (E3), oestradiol
(E2) and oestrone (E1).
• Oestriol (E3) is the largest portion of them.
• Maternal urinary and serum oestriol level is an important index for foetal
wellbeing as its synthesis depends mainly on the integrity of the foetal
adrenal and liver as well as the placenta (foeto- placental unit).
FUNCTIONS OF THE PLACENTA
• Urinary oestriol increases as pregnancy advances to reach 35-40 mg
per 24 hours at full term.
• Progressive fall in urinary oestriol indicates that the foetus is
jeopardous.
• Oestrogens are responsible with progesterone for the most of the
maternal changes due to pregnancy especially that in genital tract and
breasts.
FUNCTIONS OF THE PLACENTA
2- Progesterone
• It is synthetized by syncytiotrophoblast from the maternal cholesterol.
• Excreted in maternal urine as pregnandiol.
• Increasing gradually during pregnancy to reach a daily production of
250 mg per day in late normal single pregnancy.
• It provides a precursor for the foetal adrenal to produce
glucocorticoids and mineralocorticoids.
 ABNORMALITIES OF THE PLACENTA
Abnormal Shape:
• Placenta Bilobata The placenta consists of two equal
lobes connected by placental tissue.
• Placenta Bipartita The placenta consists of two equal
parts connected by membranes.
• Placenta Succenturiata The placenta consists of a large
lobe and a smaller one connecting together by
membranes.
• Placenta Fenestrata A gap is seen in the placenta
covered by membranes giving the appearance of a window.
ABNORMALITIES OF THE PLACENTA
• Placenta Circumvallata A whitish ring composed of
decidua, is seen around the placenta from its foetal
surface.
• This may result when the chorion frondosum is two
small for the nutrition of the foetus, so the peripheral
villi grow in such a way splitting the decidua basalis into
a superficial layer ( the whitish ring) and a deep layer.
• It can be a cause of abortion, antepartum haemorrhage,
premature labour and intrauterine foetal death.
ABNORMALITIES OF THE PLACENTA
Abnormal Diameter
• Placenta membranacea A great part of the chorion develops into
placental tissue.
• The placenta is large, thin and may measure 30-40 cm in diameter.
• It may encroach on the lower uterine segment placenta praevia.
Abnormal Weight
• The placenta increases in size and weight as in congenital syphilis,
hydrops foetalis and diabetes mellitus.
ABNORMALITIES OF THE PLACENTA
Abnormal Position
• Placenta Praevia The placenta is partly or completely attached to the
lower uterine segment.
Abnormal Adhesion
• Placenta Accreta The chorionic villi penetrate deeply into the uterine
wall to reach the myometrium, due to deficient decidua basalis.
• When the villi penetrate deeply into the myometrium, it is called
placenta increta and when they reach the peritoneal coat it is called
placenta percreta.
ABNORMALITIES OF THE PLACENTA
Placental Lesions
• Placental Infarcts
• Seen in placenta at term, mainly in hypertensive states with pregnancy.
a. White infracts due to excessive fibrin deposition. Normal placenta may
contain white infracts in which calcium deposition may occur.
b. Red infarcts due to haemorrhage from the maternal vessels of the decidua.
Old red infarcts finally become white due to fibrin deposition.
• Placental Tumour
• Chorioangioma is a rare benign tumour of the placental blood vessels
which may be associated with hydramnios
THE UMBILICAL CORD
Anatomy
• Origin It develops from the connecting stalk.
• Length At term, it measures about 50 cm.
• Diameter 2 cm.
• Structure It consists of mesodermal connective tissue called
Wharton's jelly, covered by amnion. It contains:
• One umbilical vein carries oxygenated blood from the placenta to the foetus,
• Two umbilical arteries carry deoxygenated blood from the foetus to the
placenta,
• Remnants of the yolk sac and allantois
THE UMBILICAL CORD
• Insertion The cord is inserted in the foetal surface of the placenta
near the center "eccentric insertion" (70%) or at the center "central
insertion" (30%).
• The constituents of the umbilical cord when fully formed are
• Covering epithelium
• Wharton’s jelly
• Blood vessels
• Allantois
• Obliterated extraembryonic coelom
• Remnant of the umbilical vesicle (yolk sac) and its vitelline duct
ABNORMALITIES OF THE UMBILICAL
CORD
Abnormal cord insertion
• Marginal insertion in the placenta (battledore insertion).
• Velamentous insertion in the membranes and vessels connect the
cord to the edge of the placenta.
• If these vessels pass at the region of the internal os , the condition is
called " vasa praevia".
• Vasa praevia can occur also when the vessels connecting a
succenturiate lobe with the main placenta pass at the region of the
internal os.
ABNORMALITIES OF THE UMBILICAL
CORD
Abnormal cord length
• Short cord which may lead to:
• intrapartum haemorrhage due to premature separation of the
placenta
• delayed descent of the foetus during labour
• inversion of the uterus.
ABNORMALITIES OF THE UMBILICAL
CORD
• Long cord which may lead to:
• cord presentation and cord prolapse
• coiling of the cord around the neck
• true knots of the cord
Knots of the cord
• True knot when the fetus passes through a loop of the cord.
• If pulled tight, fetal asphyxia may result.
• False knot localized collection of Wharton’s jelly containing a loop
of umbilical vessels.
ABNORMALITIES OF THE UMBILICAL
CORD
Torsion of the cord
• May occur particularly in the portion near the foetus where the
Wharton's jelly is less abundant.
Haematoma
• Due to rupture of one of the umbilical vessels.
Single umbilical artery
• May be associated with other foetal congenital anomalies
THE FOETAL MEMBRANES
The chorion
• It is the outer membrane.
• It is in contact with the uterine wall.
• It is attached to the margins of the placenta.
• Histologically, it is composed of 4 layers:
• Cellular layer
• dense reticulum
• pseudo - basement membrane
• outer trophoblast
THE FOETAL MEMBRANES
The amnion
• It is a transparent greyish membrane which lines the chorion.
• It covers the foetal surface of the placenta and the umbilical cord.
• The amniotic sac contains the foetus swimming in the liquor amnii.
• Histologically, it is composed of 5 layers:
• cellular layer
• basement membrane,
• compact layer
• fibroblast layer
• outer spongy layer adherent to the cellular layer of the chorion.
THE FOETAL MEMBRANES
FUNCTIONS
• Contribute to the formation of liquor amnii
• Intact membranes prevent ascending uterine infection
• Facilitate dilatation of the cervix during labor
• Has got enzymatic activities for steroid hormonal metabolism
• Rich source of glycerophospholipids containing arachidonic acid
THE AMNIOTIC FLUID (THE LIQUOR
AMNII)
Nature
• It is a clear pale, slightly alkaline (pH 7.2) fluid.
• Low specific gravity of 1.010.
• It becomes highly hypotonic to maternal serum at term pregnancy.
• An osmolarity of 250 mOsmol/L is suggestive of fetal maturity.
• The amniotic fluid’s osmolality falls with advancing gestation
• It is about 50 mL at 12 weeks, 400 ml at mid pregnancy, reaches
about 1000 ml at 36-38 weeks then decreases later on to be scanty in
post-term pregnancy, 200 mL at 43 weeks.
THE AMNIOTIC FLUID
Color
• In early pregnancy it is colorless, but near term it becomes pale straw colored
due to the presence of exfoliated lanugo and epidermal cells from the fetal
skin.
• It may look turbid due to the presence of vernix caseosa.
Abnormal color
• Deviation of the normal color of the liquor has got clinical significance.
• Meconium stained (green)  is suggestive of fetal distress in presentations
other than the breech or transverse.
• Depending upon the degree and duration of the distress, it may be thin or thick or pea
soup (thick with flakes). Thick with presence of flakes suggests chronic fetal distress.
THE AMNIOTIC FLUID
• Golden color  in Rh incompatibility is due to excessive hemolysis of
the fetal RBC and production of excess bilirubin.
• Greenish yellow (saffron) in post maturity.
• Dark colored  in concealed accidental hemorrhage is due to
contamination of blood.
• Dark brown (tobacco juice)  is found in IUD. The dark color is due to
frequent presence of old HbA.
THE AMNIOTIC FLUID
Composition • enzymes (alkaline phosphatase)
• Water (98-99%) • minerals (sodium, potassium and
• carbohydrates (glucose and chloride)
fructose) • suspended materials as
• proteins ( albumin and globulins) • vernix caseosa
• Lipids • lanugo hair
• desquamated epithelial cells
• hormones (oestrogen and
progesterone) • meconium
THE AMNIOTIC FLUID
Circulation of amniotic Fluid
• The amniotic fluid is not in a static state but is in a continuous turn
over, 500 ml of it are replaced each hour.
Origin
1. Foetal
• Active secretion from the amniotic epithelium.
• Transudation from the foetal circulation.
• Foetal urine.
THE AMNIOTIC FLUID
2. Maternal
• Transudation from maternal circulation.

• The foetal origin contributes more in the production of the amniotic

fluid.
• Uptake of amniotic fluid is by absorption through the amnion to the
maternal circulation and by foetal swallowing.
THE AMNIOTIC FLUID
Functions
• During pregnancy
1. Protects the foetus against injury.
2. A medium for free foetal movement.
3. Mantains the foetal temperature.
4. Source for nutrition of the foetus.
5. A medium for foetal excretion.
• During Labour:
1. The fore-bag of water helps the dilatation of the cervix during labour.
2. It acts as an antiseptic for the birth canal after rupture of the membranes.
3. It guards against umbilical cord compression
THE FETUS
• Normal fetal growth is characterized by cellular hyperplasia followed by
hyperplasia and hypertrophy and lastly by hypertrophy alone.
• The fetal growth increases linearly until 37th week.
• It is controlled by genetic factor in the first half and by environmental
factors in the second half of pregnancy.
• The important physiological factors are: Race; Sex; Parental height and
weight; Birth order and Socioeconomic factors.
• Fetal growth is predominantly controlled by IGF-1, insulin and other growth
factors.
• Growth hormone is essential for postnatal growth.
• At term, the average fetal weight varies from 2.5 kg to 3.5 kg.
FETAL DEVELOPMENT

0-4 weeks 4-8 weeks

• Rapid growth • Very rapid cell division
• Formation of embryonic plate • Head and facial features develop
• Primitive central nervous system • All major organs laid down in
forms primitive form
• Heart develops and begins to • External features genitalia present
beat sex not distinguishable
• Limbs bud form • Early movements
• Visible on ultra sound from 6 weeks
FETAL DEVELOPMENT
8-12 weeks
• Eye lids fuse
• Kidney begin to function and fetus passes urine from 10 weeks
• Fetal circulation functioning properly
• Sucking and swallowing begin
• Sex apparent
• Moves freely (not felt by mother)
• Some primitive reflexes present
FETAL DEVELOPMENT
12-16 weeks
• Rapid skeletal development
• Meconium present in gut
• Lanugo appears
• Nasal septum and palate fuse
16-20 weeks
• Quickening- mother feels fetal
movements
• Heart rate heard on auscultation
• Vernix caseosa appears
• Finger nails can be seen
• Skin cells begin to be renewed
FETAL DEVELOPMENT

20-24 weeks 24-28 weeks

• Most organs become capable of
functioning
• Periods of sleep and activity
• Responds to sound
• Skin red and wringled
• Survival expected if birth occurs
• Eye lids reopen
• Respiratory movements
FETAL DEVELOPMENT
28-32 weeks
• Begins to store fat and iron
• Testes descend into scrotum
• Lanugo disappears from face
• Skin becomes paler and less
wrinkled
32-36 weeks
• Increased fat makes the body more
rounded
• Lanugo disappears from the body
• Head hair lengthens
• Nails reach tip of fingers
• Ear cartilage soft
• Plantar and palmer creases visible
FETAL DEVELOPMENT
36-40 weeks
• Term is reached and birth is due
• Contours rounded
• Skull firm
• Labor can start any time
FETAL PHYSIOLOGY
1. Fetal blood
• Fetal blood originates from the inner cell mass together with other
fetal organs
• The fetus inherits genes which determine its blood group from its
parents ie ABO
• Fetal haemoglobin HbF has a higher affinity for oxygen and has a
higher concentration (18-20g/dl) than that of adults and obtains its
oxygen from the placenta site where the oxygen concentration is
lower than in the atmosphere
FETAL PHYSIOLOGY
• Renal functions begin at around 10 weeks
• Adrenal glands produce precursors for oestriols
• Liver is normally larger occupying most of the abdominal cavity. It
starts forming red blood cells fro 3rd to 6th intra uterine month and
towards the end of pregnancy store iron
FETAL PHYSIOLOGY
Alimentary tract
• Forms from the yolk sac
• It is mainly non functional before birth
• From 12 weeks gestation, swallowing of amniotic fluid and other
debris in the intestines begin and there are acted upon by gastric
juices to for meconium which is retained in the gut until the time of
birth which is passed as first stool of the newborn.
FETAL PHYSIOLOGY
Lungs
• Before 24 weeks gestation, the lungs are immature with limited
number of alveola surface and bronchioles and lack of adequate
surfactant which is a lipoprotein which reduces alveoli surface tension
and aids gaseous exchange
• Surfactant production starts from20 weeks and amount increases
until maturity reaching 100mls at 30-34 weeks gestation
• At birth about a third of this is expelled while the rest is absorbed
FETAL PHYSIOLOGY
Skin and central nervous system
• They are both derived from the ectoderm
• From 18 weeks the skin is covered by a white creamy substance called
vernix caseosa which protects it from fluid and friction against itself
• At 20 weeks a fine dowry hair covers the fetus and it is called lanugo
FETAL CIRCULATION
• Fetal circulation is unique in the sense that all the oxygen, nutrition
supply and elimination of wastes is from the placental site through
the umbilical cord.
• Several temporary structures including the placenta and umbilical
cord enable fetal circulation to take place while allowing for changes
at birth.
TEMPORARY STRUCTURES OF FETAL
CIRCULATION
• Umbilical vein carries blood rich in oxygen and nutrients to the liver and
other organs
• Ductus venosus from a vein to a vein. Connects the umbilical vein in the
cord to the inferior vena cava where the oxygeneted blood mixes with
deoxygeneted blood from the rest of the body making it partially
oxygenated
• Foramen ovale (oval opening) A temporary opening between the two
atria which allows blood entering the right atrium from the inferior vena
cava to pass into the left atrium.
• This is because the blood does not need to pass through the lungs as it is
already oxygenated.
TEMPORARY FETAL CIRCULATION
STRUCTURES
• The ductus arteriosus (from an artery to an artery) Leads from the
bifurcation of the pulmonary artery to the descending aorta entering
it just beyond the point where the subclavian and carotid arteries
leave
• Hypogastric arteries They branch off from the internal iliac arteries
and become the umbilical arteries.
• They return blood to the placenta
PHYSIOLOGY OF FETAL CIRCULATION
• From the placenta blood passes along the umbilical vein through the
abdominal wall to the under surface of the liver.
• This is the only vessel in the fetus which carries unmixed blood.
• The ductus venosus carries blood to the inferior vena cava where it
mixes with blood from the lower body to the right atrium
• This blood crosses to the left atrium through the foramen ovale where
it enters the left ventricle and then to the rest of the fetal body
through the aorta
ADAPTATION TO EXTRA-UTERINE LIFE
• The placental circulation stops immediately after birth leading to less blood in
the right side of the heart.
• At birth the baby takes a deep breath and blood is drawn to the lungs through the
pulmonary arteries.
• It is then collected and taken returned to the left atrium via pulmonary veins
resulting in sudden inflow of blood.
• This leads to an increased pressure in the left side of the heart and a lesser one at
the right side.
• This leads to the closure of the flap over the foramen ovale which seperates the
two sides and stops blood from flowing from the right to the left.
• Establishment of pulmonary circulation leads to higher oxygen concentration
which leads to constriction and clossure of the ductus arteriosus
TEST YOUR UNDERSTANDING
1. The portion of the decidua where the placenta is to be formed:
a) Decidua basalis
b) Decidua capsularis
c) Decidua parietalis
d) All of the above
TEST YOUR UNDERSTANDING
2. Secondary chorionic villus is characterized by:
a) Cytotrophoblast, syncytiotrophoblast and extra- embryonic
mesoderm with fetal blood vessels
b) Cytotrophoblast, syncytiotrophoblast and extra- embryonic
mesoderm
c) Cytotrophoblast and syncytiotrophoblast
d) Syncytiotrophoblast only
TEST YOUR UNDERSTANDING
3. All are layers of placental barrier except:
a) 2 layers of trophoblast
b) Mesoderm
c) Endothelium of fetal blood vessel
d) Septum
TEST YOUR UNDERSTANDING
4. Attachment of umbilical cord at the margin of placenta is called:
a) Furcate
b) Battledore
c) Circumvallate
d) Fenestrated
TEST YOUR UNDERSTANDING
5. The condition in which placenta extends into the lower uterine
segment:
a) Placenta succenturiata
b) Battledore placenta
c) Circumvallate placenta
d) Placenta praevia