PLACENTA

Only eutherian mammals possess placenta. The human placenta is discoid in shape haemochorial--- because of direct contact of chorion with maternal blood deciduate --- because some maternal tissue is shed at parturition attached to the uterine wall and establishes connection between the mother and fetus through the umbilical cord. DEVELOPMENT The placenta is developed from two sources, mainly from fetal that develops from the chorion frondosum and the maternal part consists of decidua basalis. The interstitial implantation completes on 11th day and then the blastocyst will be surrounded by cells called trabeculae. On the 13th day, stem villi are developed from the trabeculae. Three types of villi are formed : Primary --- finger-like projections surrounded by syncytium Secondary --- mesodermal cells penetrate the inner core of the primary villi to form secondary villi and forms the villous capillary system Tertiary --- it is the vasculature that has formed within the villous core. It is also known as definitive placental villus As pregnancy advances, villi on the embryonic pole grow and develop into the chorion frondosum and villi on the opposite abembryonic pole degenerate and is called chorion leave. Decidua overlying the chorion frondosum is called decidua basalis. The chorion frondosum along with the decidua basalis forms the placenta.

PLACENTA AT TERM
ANATOMY: The placenta, at term, is almost a circular disc with a diameter of 15-20 cm and thickness of about 2.5 cm at its centre. It thins off towards the edge. It feels spongy and weighs about 500 gm, the proportion to the weight of the baby being roughly 1 : 6 at term and occupies about 30% of uterine wall. It presents two surfaces, foetal and maternal, and a peripheral margin. Foetal surface : The foetal surface is formed by the chorion frondosum and the chorion plate and is covered over by blood vessels. It has got a smooth and glistening amnion with the umbilical cord attached at or near its centre. The amnion can be peeled off from the underlying chorion except at the insertion of the cord. At term, about four-fifths of the placenta is of foetal origin. Maternal surface : The maternal surface is formed by decidua basalis and is rough and spongy. Maternal blood gives it a dull red colour. A number of decidual septa divides this into about 15 20 lobes or cotyledons. Deposition of calcium in the degenerated areas give rise to small greyish spots which are of no clinical significance. The maternal portion of the placenta amounts to less than one fifth of the total placenta. Only the decidua basalis and the blood in the intervillous space are of maternal origin.

Margin : Peripheral margin of the placenta is limited by the fused basal and chorionic plates and is continuous with the chorion laeve and amnion. Essentially, the chorion and the placenta are one structure but the placenta is a specialised part of the chorion.

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Attachment: The placenta is attached to the upper part of the body of the uterus encroaching to the fundus adjacent to the anterior or posterior wall with equal frequency. Separation : Placenta separates after the birth of the baby and the line of separation is through the decidua spongiosum. STRUCTURES Foetal aspect ( internal ) --- amniotic membrane and chorionic plat Maternal aspect ( external ) --- the basal plate Intervillous space --- between these chorionic and basal plates and contains the stem villi with their branches, the space being filled with maternal blood Amniotic Membrane It consists of single layer of cubical epithelium loosely attached to the adjacent chorionic plate. It takes no part in formation of the placenta. Chorionic Plate : From within outwards, it consists of (i) primitive mesenchymal tissue containing branches of umbilical vessel (ii) a layer of cytotrophoblast (iii) syncytiotrophoblast. The stem villi arise from the plate Basal 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

 Intervillous space : It is lined internally on all sides by the syncytiotrophoblast and is filled with slow flowing maternal blood.

PLACENTAL CIRCULATION Placental circulation consists of independent circulation of blood in two systems Uteroplacental circulation Feto-placental circulation

UTERO-PLACENTAL CIRCULATION: (Maternal circulation) : It is the circulation of the maternal blood through the intervillous space. A mature placenta has a volume of about 500 ml of blood; 350 ml being occupied in the villi system and 150 ml lying in the intervillous space. As the intervillous blood flow at term is estimated to be 500-600 ml per minute, the blood in the intervillous space is completely replaced about 3 to 4 times per minute. The villi depend on the maternal blood for their nutrition, thus it is possible for the chorionic villi to survive for a varying period even after the fetus is dead. The pressure within the intervillous space is about 10 to 15 mm Hg during uterine relaxation and 30-50 mm Hg during uterine contraction. In contrast, the fetal capillary pressure in the villi is 20-40 mm Hg. Arterial circulation: About 120-200 spiral arteries open into the intervillous space through the basal plate. Venous drainage : The venous blood of the intervillous space drains through the uterine veins which pierce the basal plate. Circulation in intervillous space : Due to pressure, the arterial blood enters this space, reaches the chorionic plate. The villi helps in mixing and slowing of the blood flow. During uterine

contraction, the veins get occluded and uterine relaxation facilitates venous drainage.

FETO-PLACENTAL CIRCULATION : The two umbilical arteries carry the impure blood from the fetus. They enter the chorionic plate underneath the amnion, each supplying one half of the placenta. The arteries break up into small branches which enter the stems of the chorionic villi. Each in turn divides into primary, secondary and tertiary vessels. Maternal and fetal blood flows side by side, but in opposite direction. This counter current flow facilitates material exchange between mother and foetus. Placental membrane ( placental barrier ) : It consists of syncytiotro-phoblast cytotrophoblast basement membrane stromal tissue endothelium of the foetal capillary wall with its basement membrane.

It is about 0.025 mm thick and prevents mixing of maternal and foetal blood.

PLACENTAL AGEING The placenta has got a limited life span and so undergoes degenerative changes as a mark of senescence. The ageing process varies in degree and should be differentiated from the morbid process likely to affect the organ in some pathological states. The ageing process involves both the fetal and maternal components.

Villi Changes : Decreasing thickness of the syncytium and appearances of syncytial knots (aggregation of the syncytium in small areas on the sides of the villus) 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.

Decidual Changes : Nitabuch layer : This is an area of fibrinoid degeneration, where trophoblast cells (covered with syncytium) meet the decidua. This layer limits further invasion of the decidua by the trophoblast. This membrane is absent in placenta accreta.

FUNCTIONS OF PLACENTA

The main functions of the placenta_are : 1. Transfer of nutrients and waste products between the mother and fetus. Respiratory --- provides oxygen to the fetus at the rate of 8ml/Kg/min with a cord blood flow of 165 330 ml/min Excretory --- waste products from the fetus like urea, uric acid and creatinine are excreted to the maternal blood by simple diffusion Nutritive --- placenta provides nutrients like glucose, lipids, aminoacids, water, electrolytes and hormones.

2. Enzymatic Function : diamine oxidase which inactivates the circulatory pressure oxytocinase which neutralises the oxytocin phospholipase A2 which synthesises arachidonic acid 3. Barrier Function : Fetal membrane of the placenta acts as a protective barrier to the fetus against noxious agents circulating in the maternal blood. It offers immunological protection against graft rejection

TRANSFER OF SUBSTANCES ACROSS PLACENTA Mechanisms involved in the transfer of substances across the placenta are : Simple diffusion Facilitated diffusion (carrier mediated) Active transfer (against concentration gradient) Endocytosis Exocytosis: Release of the vesicle to the extracellular space. Immunoglobulin IgG is taken up by endocytosis from maternal circulation and is transferred to the fetus via exocytosis Leakage (breaking the placental membrane).

THE FETAL MEMBRANES

Fetal membrane constitutes two layers outer chorion and the inner amnion. CHORION : Is the remnant of chorion laeve and ends at the margin of the placenta. It is thicker than amnion, friable and shaggy on both the sides The term chorion means that contains no vessels or nerves. AMNION : It is the inner layer of the fetal membranes. Its internal surface is smooth and shiny and is in contact with liquor amnii. Fully formed amnion is 0.02 0.5 mm thick It has no blood, nerve, or lynph supply The amnion can be peeled off from the fetal surface of the placenta except at the insertion of the umbilical cord. FUNCTIONS : Helps in the formation of liquor amnii. Prevent ascending uterine infection Facilitate dilatation of the cervix during labour Has got enzymatic activities for steroid hormonal metabolism Is a rich source of glycerophospholipids containing arachidonic acid which is a precursor of prostaglandin E2 and F2a

AMNIOTIC CAVITY
Amniotic fluid gets filled in the cavity and surrounds the fetus everywhere except at its attachment with the body stalk.

AMNIOTIC FLUID
It fills the inside of the amniotic cavity and surrounds the fetus.

 ORIGIN : It is probably of mixed maternal and fetal origin. The theories that support this are : As a transudate from the maternal serum across the fetal membranes or from maternal circulation in the placenta. As a transudate across the umbilical cord or from fetal circulation in the placenta or secretion from the amniotic epithelium. Transudate of fetal plasma through the highly permeable fetal skin before it is keratinised at 20th week. Contribution from the fetusFetal daily urine output at term is about 400-1200 ml. The fetus swallows about 200-500 ml of liquor every day at term.

CIRCULATION : The water in the amniotic fluid is completely changed and replaced in every 3 hours. VOLUME : At 10 weeks --- 30 ml At 12 weeks --- 50 ml At 20 weeks --- 400 ml At 36 38 weeks --- 800 1000 ml At term --- 600 800 ml At 43 weeks --- 200 ml PHYSICAL FEATURES : Alkaline Low specific gravity of 1.010 Highly hypotonic to maternal serum at term pregnancy In case of fetal maturity, the osmolarity will be 250 mOsmol/litre COLOUR: In early pregnancy --- Colourless Near term --- Pale straw coloured 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. Clinical significance : Abnormal colour Meconium stained (green) --- fetal distress in presentations other than the breech or transverse. Green colour and thick with flakes --- chronic fetal distress Golden colour --- Rh incompatibility due to excessive haemolysis of the fetal RBC and production of excess bilirubin Greenish yellow (saffron) --- post maturity

Dark coloured --- in concealed accidental haemorrhage due to contamination of blood Dark brown (tobacco juice) --- Intra Uterine Death. The dark colour is due to frequent presence of old HbA.

COMPOSITION : First half of pregnancy --- like transudate of plasma Late pregnancy --- altered due to contamination of fetal urinary metabolites. The composition includes water ( 98-99% ) , solid (1 - 2%). Organic contents : Protein - 0.3 gm%, Glucose - 20 mg %, Urea - 30 mg %, NPN-30mg% Uric acid - 4 mg %, Creatinine - 2 mg%, Total lipids - 50 mg% Hormones (Prolactin, insulin and renin) Inorganic contents : Sodium, Chloride and Potassium Suspended particles : Lanugo, exfoliated squamous epithelial cells from the fetal skin, vernix caseosa, cast off amniotic cells and cells from the respiratory tract, urinary bladder and vagina of the fetus.

FUNCTION : Its main function is protective to the fetus. During pregnancy It acts as a shock absorber, protecting the fetus from possible extraneous injury Maintains an even temperature The fluid distends the amniotic sac and thereby allows for growth and free movement of the fetus and prevents adhesion between the fetal parts and amniotic sac Provides adequate water to the fetus

During labour: Helps in dilatation of the cervix During uterine contraction, the intact membrane prevents marked interference with the placental circulation Flushes the birth canal at the end of first stage of labour Protects the fetus and prevents ascending infection to uterine cavity by its aseptic and bactericidal action

CLINICAL IMPORTANCE: Study of the amniotic fluid provides useful information about the well being and maturity of the fetus

Intra amniotic instillation of chemicals is used as method of induction of abortion Rupture of the membranes with drainage of liquor is a helpful method in induction of labour Excess or less volume of liquor amnii is assessed by amniotic fluid index (AFI)

Amniotic fluid index ( AFI ) Maternal abdomen is divided into quardants with the umbilicus, symphysis pubis and the fundus as the reference points. By ultrasonography, the largest vertical pocket in each quadrant is measured. The sum of the four measurements (in cm) is the AFI. Clinical significance : To diagnose polyhydramnios and oligohydramnios

THE UMBILICAL CORD

The umbilical cord or funis is the connecting link between the fetus and the placenta through which the fetal blood flows to and from the placenta. It extends from the fetal umbilicus to the fetal surface of the placenta.

DEVELOPMENT: The umbilical cord is developed from the connective stalk or body stalk which is a band of mesoblastic tissue stretching between the embryonic disc and the chorion. Initially, it is attached to the caudal end of the embryonic disc STRUCTURES : Covering epithelium Wharton's jelly which has a protective function to the umbilical vessels Blood vessels : Initially, there are 4 vessels 2 arteries and 2 veins Arteries --- Carry the venous blood from the fetus to the placenta. Veins --- The right vein disappears by the 4th month and the remaining one carries oxygenated blood from the placenta to the fetus. Clinical significance Presence of a single umbilical artery --- in fetal congenital abnormalities Remnant of the umbilical vesicle (yolk sac) and its vitelline duct Allantois : A blind tubular structure may occasionally present near the fetal end which is continuous inside the fetus with its urachus and bladder.

Obliterated extra embryonic coelom : In the early period, intra embryonic coelom is continuous with extraembryonic coelom along with herniation of coils of intestine (midgut). Clinical significance : if this persists, it results in congenital umbilical hernia or exomphalos. CHARACTERISTICS : Length --- 50 cm ( 30-100 cm ) Diameter --- 1.5 cm ( 1-2.5 cm ) Thickness --- not uniform ; has nodes or swellings (false knots) due to dilatation of the umbilical veins or local collection of Wharton's jelly. It shows a spiral twist from the left to right (vein around the arteries ) Both the arteries and the vein do not possess vasavasorum.

ATTACHMENT: Fetal attachment --- In the early period, the cord is attached to the ventral surface of the embryo close to the caudal extremity and later the point of attachment is moved permanently to the centre of the abdomen at 4th month. Placental attachment : ---- mainly inconsistent ----- can be central or marginal he Eccentric insertion --- Between the centre and the edge of the placenta Velamentous insertion --- To the chorion leave, away from the placental margin