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Date: 11-12-17
Qarshi University
Subject:
Embryology

Topic:
Ninth to thirty eight week

Presented to:
Miss Ana Ambreen

Presented by:
Mueen Ahmed Hashmi
Muhammad Inaam Ullah

Third Month to Birth: The Fetus and Placenta

DEVELOPMENT OF THE FETUS

The period from the beginning of the ninth week to birth is known as the
fetal period. It is characterized by maturation of tissues and organs and rapid
growth of the body. The length of the fetus is usually indicated as the crown
rump length (CRL) (sitting height) or as the crown-heel length (CHL), the
measurement from the vertex of the skull to the heel (standing height). These
measurements, expressed in centimeters, are correlated with the age of the fetus
in weeks or months. Growth in length is particularly striking during the third,
fourth, and fifth months, while an increase in weight is most striking during the
last 2 months of gestation. In general, the length of pregnancy is considered to
be 280 days, or 40 weeks after the onset of the last normal menstrual period
(LNMP) or, more accurately, 266 days or 38 weeks after fertilization. For the
purposes of the following discussion, age is calculated from the time of
fertilization and is expressed in weeks or calendar months.

Monthly Changes:

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One of the most striking changes taking place during fetal life is the
relative slowdown in growth of the head compared with the rest of the body.
At the beginning of the third month, the head constitutes approximately half of
the CRL. By the beginning of the fifth month, the size of the head is about one
third of the CHL, and at birth, it is approximately one quarter of the CHL.
Hence, over time, growth of the body accelerates but that of the head slows
down.
During the third month, the face becomes more human looking. The eyes,
initially directed laterally, move to the ventral aspect of the face, and the ears
come to lie close to their definitive position at the side of the head. The limbs
reach their relative length in comparison with the rest of the body, although the
lower limbs are still a little shorter and less well developed than the upper
extremities. Primary ossification centers are present in the long bones and skull
by the 12th week.
Also by the 12th week, external genitalia develop to such a degree that
the sex of the fetus can be determined by external examination (ultrasound).
During the sixth week, intestinal loops cause a large swelling
(herniation) in the umbilical cord, but by the 12th week, the loops have
withdrawn into the abdominal cavity. At the end of the third month, reflex
activity can be evoked in aborted fetuses, indicating muscular activity.
During the fourth and fifth months, the fetus lengthens rapidly, and at the
end of the first half of intrauterine life, its CRL is approximately 15 cm, about
half the total length of the newborn. The weight of the fetus increases little
during this period and by the end of the fifth month is still <500 g. The fetus is
covered with fine hair, called lanugo hair; eyebrows and head hair are also
visible. During the fifth month, movements of the fetus can be felt by the mother.
During the second half of intrauterine life, weight increases considerably,
particularly during the last 2.5 months, when 50% of the full term weight
(approximately 3,200 g) is added.
During the sixth month, the skin of the fetus is reddish and has a wrinkled
appearance because of the lack of underlying connective tissue. A fetus born
early in the sixth month has great difficulty surviving. Although several organ
systems are able to function, the respiratory system and the central nervous
system have not differentiated sufficiently, and coordination between the two
systems is not yet well established. By 6.5 to 7 months, the fetus has a CRL of
about 25 cm and weighs approximately 1,100 g. If born at this time, the infant
has a 90% chance of surviving.
Some developmental events occurring during the first 7 months are
indicated in. During the last 2 months, the fetus obtains well-rounded contours
as the result of deposition of subcutaneous fat. By the end of intrauterine life,
the skin is covered by a whitish, fatty substance (vernix caseosa) composed of
secretory products from sebaceous glands.

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At the end of the ninth month, the skull has the largest circumference of
all parts of the body, an important fact with regard to its passage through the
birth canal. At the time of birth, the weight of a normal fetus is 3,000 to 3,400 g,
its CRL is about 36 cm, and its CHL is about 50 cm. Sexual characteristics are
pronounced, and the testes should be in the scrotum.

Time of Birth:
The date of birth is most accurately indicated as 266 days, or 38 weeks,
after fertilization. The oocyte is usually fertilized within 12 hours of ovulation;
however, sperm deposited in the reproductive tract up to 6 days prior to
ovulation can survive to fertilize oocytes. Thus, most pregnancies occur when
sexual intercourse occurs within a 6-day period that ends on the day of
ovulation. A pregnant woman usually will see her obstetrician when she has
missed two successive menstrual bleeds. By that time, her recollection about
coitus is usually vague, and it is readily understandable that the day of
fertilization is difficult to determine.
The obstetrician calculates the date of birth as 280 days or 40 weeks from
the first day of the LNMP. In women with regular 28-day menstrual periods, the
method is fairly accurate, but when cycles are irregular, substantial
miscalculations may be made. An additional complication occurs when the
woman has some bleeding about 14 days after fertilization as a result of erosive
activity by the implanting blastocyst. Hence, the day of delivery is not always
easy to determine. Most fetuses are born within 10 to 14 days of the calculated
delivery date. If they are born much earlier, they are categorized as premature;
if born later, they are considered post mature.
Occasionally, the age of an embryo or small fetus must be determined. By
combining data on the onset of the last menstrual period with fetal length,
weight, and other morphological characteristics typical for a given month of
development, a reasonable estimate of the age of the fetus can be formulated. A
valuable tool for assisting in this determination is ultrasound, which can
provide an accurate (1 to 2 days) measurement of CRL during the 7th to 14th
weeks. Measurements commonly used in the 16th to 30th weeks are bipartitely
diameter (BPD), head and abdominal circumference, and femur length. An
accurate determination of fetal size and age is important for managing
pregnancy, especially if the mother has a small pelvis or if the baby has a birth
defect.

Placenta and Fetal Membranes

The fetal part of the placenta and fetal membranes separate the embryo
or fetus from the endometrium—the inner layer of the uterine wall. The chorion,
amnion, umbilical vesicle, and allantois constitute the fetal membranes. An

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interchange of substances (e.g., nutrients and oxygen) occurs between the

maternal and fetal blood through the placenta.
The vessels in the umbilical cord connect the placental circulation with
the fetal circulation.

PLACENTA:
The placenta is the primary site of nutrient and gas exchange between the
mother and fetus.
The placenta is a fetomaternal organ that has two components:
• A fetal part that develops from part of the chorionic sac
• A maternal part that is derived from the endometrium, the mucous membrane
comprising the inner layer of the uterine wall
The placenta and umbilical cord form a transport system for substances
passing between the mother and fetus. Nutrients and oxygen pass from the
maternal blood through the placenta to the fetal blood, and waste materials and
carbon dioxide pass from the fetal blood through the placenta to the maternal
blood. The placenta and fetal membranes perform the following functions and
activities: protection, nutrition, respiration, excretion of waste products, and
hormone production. Shortly after birth, the placenta and fetal membranes are
expelled from the uterus as the afterbirth (extruded waste products).

Decidua:
The decidua is the endometrium of the uterus in a pregnant woman. It is
the functional layer of the endometrium that separates from the remainder of
the uterus after parturition (childbirth). The three regions of the decidua are
named according to their relation to the implantation site:
• Decidua basalis—the part of the decidua deep to the conceptus (embryo and
membranes) that forms the maternal part of the placenta
• Decidua capsularis—the superficial part of the deciduas overlying the
conceptus
• Decidua parietalis—the remaining intervening parts of the deciduas
In response to increasing progesterone levels in the maternal blood, the
connective tissue cells of the deciduas enlarge to form pale-staining decidual
cells. These cells enlarge as glycogen and lipid accumulate in their cytoplasm.
The cellular and vascular changes in the deciduas that result from
pregnancy are referred to as the decidual reaction. Many decidual cells
degenerate near the chorionic sac in the region of the syncytiotrophoblast and,
together with maternal blood and uterine secretions, provide a rich source of
nutrition for the embryo. Decidual regions, clearly recognizable during
ultrasonography, are important in diagnosing early pregnancy.

Development of Placenta:

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Early placental development is characterized by the rapid proliferation of

the trophoblast and development of the chorionic sac and chorionic villi. By the
end of the third week, the anatomical arrangements necessary for physiologic
exchanges between the mother and embryo have been established. By the end of
the fourth week, a complex vascular network develops in the placenta, allowing
maternal-embryonic exchanges of gases, nutrients, and metabolic waste
products.
Chorionic villi cover the entire chorionic sac until the beginning of the
eighth week.
As this sac grows, the villi associated with the deciduas capsularis are
compressed, reducing the blood supply to them. These villi soon degenerate,
producing a relatively avascular bare area, the smooth chorion.
As these villi disappear, those associated with the deciduas basalis
rapidly increase in number, branch profusely, and enlarge. This bushy part of
the chorionic sac is the villous chorion, or chorion frondosum.
Homeobox genes (HLX and DLX3) expressed on the trophoblast and
blood vessels help to regulate the development of the placenta. Fetomaternal
Junction The fetal part of the placenta (villous chorion) is attached to the
maternal part of the placenta (decidua basalis) by the cytotrophoblastic shell,
the external layer of trophoblastic cells on the maternal surface of the placenta.
The chorionic villi attach firmly to the deciduas basalis through the
cytotrophoblastic shell and anchor the chorionic sac to the decidua basalis.
Endometrial arteries and veins pass freely through gaps in the
cytotrophoblastic shell and open into the intervillous space.
The shape of the placenta is determined by the shape of the persistent
area of chorionic villi.
Usually this is a circular area, giving the placenta a discoid shape. As the
chorionic villi invade the decidua basalis during placental formation, decidual
tissue is eroded to enlarge the intervillous space. This erosion produces several
wedge-shaped areas of decidua—placental septa— that project toward the
chorionic plate. The placental septa divide the fetal part of the placenta into
irregular convex areas—cotyledons. Each cotyledon consists of two or more
stem villi and many branch villi.
The decidua capsularis, the layer overlying the implanted chorionic sac,
forms a capsule over the external surface of the sac. As the conceptus enlarges,
the decidua capsularis bulges into the uterine cavity and becomes greatly
attenuated. Eventually, parts of the decidua capsularis make contact and fuse
with the decidua parietalis, thereby slowly obliterating the uterine cavity. By 22
to 24 weeks, reduced blood supply to the decidua capsularis causes it to
degenerate and disappear.

Intervillous Space:

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This space of the placenta contains maternal blood, which is derived from
the lacunae that developed in the syncytiotrophoblast during the second week of
development. The large, blood-filled space results from the coalescence and
enlargement of the lacunar networks. The intervillous space is divided into
compartments by the placental septa; however, free communication occurs
between the compartments because the septa do not reach the chorionic plate,
the part of the chorion associated with the placenta. Maternal blood enters the
intervillous space from the spiral arteries in the decidua basali; these arteries
pass through gaps in the cytotrophoblastic shell and discharge blood into the
intervillous space. This large space is drained by endometrial veins that also
penetrate the cytotrophoblastic shell. The numerous branch villi, arising from
stem villi, are continuously showered with maternal blood as it circulates
through the intervillous space. The blood in this space carries oxygen and
nutritional materials that are necessary for fetal growth and development. The
maternal blood also contains fetal waste products, such as carbon dioxide,
salts, and products of protein metabolism.

Amniochorionic Membrane:
The amniotic sac enlarges faster than the chorionic sac. As a result, the
amnion and smooth chorion soon fuse to form the amniochorionic membrane.
This composite membrane fuses with the decidua capsularis and, after
disappearance of this part of the decidua, adheres to the decidua parietalis. It is
the amniochorionic membrane that ruptures during labor. Preterm rupture of
this membrane is the most common event leading to premature labor. When the
amniochorionic membrane ruptures, the amniotic fluid escapes through the
cervix and vagina.

Placental Circulation:
The many branch chorionic villi of the placenta provide a large surface
area where materials (e.g., oxygen, and nutrients) are exchanged across the
very thin placental membrane interposed between the fetal and maternal
circulations. It is through the branch villi that the main exchange of material
between the mother and the fetus takes place. The placental membrane consists
of extrafetal tissues.

Fetoplacental Circulation:
Poorly oxygenated blood leaves the fetus and passes through the
umbilical arteries. At the attachment of the umbilical cord to the placenta, these
arteries divide into a number of radially disposed chorionic arteries that branch
freely in the chorionic plate before entering the chorionic villi. The blood
vessels form an extensive arteriocapillary venous system within the chorionic
villi, which brings the fetal blood extremely close to the maternal blood. This

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system provides a very large surface area for the exchange of metabolic and
gaseous products between the maternal and fetal blood. Normally, no
intermingling of fetal and maternal blood occurs. The well-oxygenated fetal
blood in the fetal capillaries passes into thin-walled veins that follow the
chorionic arteries to the site of attachment of the umbilical cord, where they
converge to form the umbilical vein. This large vessel carries oxygen-rich blood
to the fetus.

Maternal-Placental Circulation:
The maternal blood enters the intervillous space through 80 to 100 spiral
endometrial arteries in the deciduas basalis. The entering blood is at
considerably higher pressure than that in the intervillous space, so the blood
spurts toward the chorionic plate. As the pressure dissipates, the blood flows
slowly around the branch villi, allowing an exchange of metabolic and gaseous
products with the fetal blood. The blood eventually returns through the
endometrial veins to the maternal circulation. Reductions of uteroplacental
circulation result in fetal hypoxia (decreased level of oxygen) and intrauterine
growth restriction. The intervillous space of the mature placenta contains
approximately 150 ml of blood that is replenished three or four times each
minute. Placental Membrane The membrane consists of the extrafetal tissues
that separate the maternal and fetal blood. Until about 20 weeks, the placental
membrane consists of four layers: syncytiotrophoblast, cytotrophoblast,
connective tissue of the villus, and endothelium of the fetal capillaries. After the
20th week, microscopic changes occur in the branch villi that result in the
cytotrophoblast becoming attenuated in many villi.
Eventually, cytotrophoblastic cells disappear over large areas of the villi,
leaving only thin patches of syncytiotrophoblast. As a result, the placental
membrane at full term consists of only three layers in most places. In some
areas, the placental membrane becomes markedly thinned. At these sites, the
syncytiotrophoblast comes in direct contact with the endothelium of the fetal
capillaries to form a vasculosyncytial placental membrane.
Only a few substances, endogenous or exogenous, are unable to pass
through the placental membrane. In this regard, the membrane acts as a true
barrier only when the molecule or organism has a certain size, configuration,
and charge. Most drugs and other substances in the maternal plasma pass
through the placental membrane and are found in the fetal plasma.
During the third trimester, numerous nuclei in the syncytiotrophoblast of
the villi aggregate to form syncytial knots—nuclear aggregations. These knots
regularly break off and are carried from the intervillous space into the maternal
circulation. Some knots may lodge in capillaries of the maternal lungs, where
they are rapidly destroyed by local enzyme action. Toward the end of
pregnancy, fibrinoid material forms on the surfaces of villi.

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Functions of Placenta:
The placenta has many functions:
• Metabolism (e.g., synthesis of glycogen)
• Transport of gases and nutrients as well as drugs and infectious agents
• Protection by maternal antibodies
• Excretion of waste products
• Endocrine synthesis and secretion (e.g., human chorionic gonadotropin)

Placental Metabolism:
The placenta synthesizes glycogen, cholesterol, and fatty acids, which
serve as sources of nutrients and energy for the embryo or fetus. Many of the
metabolic activities of the placenta are critical for two of its other major
activities: transport and endocrine secretion. Placental Transport The large
surface area of the placental membrane facilitates the transport of substances in
both directions between the placenta and the maternal blood. Almost all
materials are transported across the placental membrane by one of the
following four main transport mechanisms: simple diffusion, facilitated
diffusion, active transport, and pinocytosis.
Passive transport by simple diffusion is usually characteristic of
substances moving from areas of higher to lower concentration until
equilibrium is established.
Facilitated diffusion requires a transporter but no energy.
Active transport against a concentration gradient requires energy. This
mechanism of transport may involve carrier molecules that temporarily
combine with the substances to be transported.
Pinocytosis is a form of endocytosis in which the material being engulfed
is a small amount of extracellular fluid. Some proteins are transferred very
slowly through the placenta by pinocytosis.

Transfer of Gases. Oxygen, carbon dioxide, and carbon monoxide cross the
placental membrane by simple diffusion. Interruption of oxygen transport for
several minutes endangers the survival of the embryo or fetus.
The efficiency of the placental membrane approaches that of the lungs for gas
exchange. The quantity of oxygen reaching the fetus is generally flow-limited,
rather than diffusion-limited. Fetal hypoxia results primarily from factors that
diminish either uterine blood flow or fetal blood flow through the placenta.
Nitrous oxide, an inhalation analgesic and anesthetic, also readily crosses the
placenta.

Nutritional Substances. Nutrients constitute the bulk of substances transferred

from the mother to the embryo or fetus. Water is rapidly exchanged by simple

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diffusion and in increasing amounts as pregnancy advances. Glucose produced

by the mother and placenta is quickly transferred to the embryo or fetus by
facilitated diffusion mediated primarily by GLUT-1—an insulin-independent
glucose carrier. Maternal cholesterol, triglycerides, and phospholipids are
transferred. Although free fatty acids are transported, the amount transferred
appears to be relatively small with a preference toward long-chain
polyunsaturated fatty acids. Amino acids cross the placenta to the fetus in high
concentrations by active transport. Vitamins cross the placental membrane and
are essential for normal development. A maternal protein, transferrin, crosses
the placental membrane and carries iron to the embryo or fetus. The placental
surface contains special receptors for this protein. Protein hormones such as
insulin and pituitary hormones do not reach the embryo or fetus in significant
amounts, except for a slow transfer of thyroxine and triiodothyronine.
Unconjugated steroid hormones cross the placental membrane relatively freely.
Testosterone and certain synthetic progestins also cross the placenta.

Electrolytes. These compounds are freely exchanged in significant quantities,

each at its own rate. When a mother receives intravenous fluids with
electrolytes, they also pass to the fetus and affect the fetal water and electrolyte
status.
Drugs and Drug Metabolites. Most drugs and drug metabolites cross the
placenta by simple diffusion. Drugs taken by the mother can affect the embryo
or fetus, directly or indirectly, by interfering with maternal or placental
metabolism. Some drugs cause major birth defects. Fetal drug addiction may
occur after maternal use of drugs such as heroin, and neonates may experience
withdrawal symptoms. Most drugs used for the management of labor readily
cross the placental membrane. Depending on the dose and timing in relation to
delivery, these drugs may cause respiratory depression of the neonate.
Neuromuscular blocking agents such as succinylcholine, which might be used
during operative obstetrics, cross the placenta in only very small amounts.
All sedatives and analgesics affect the fetus to some degree. Inhaled
anesthetics can also cross the placental membrane and affect fetal breathing if
used during parturition. Infectious agents Cytomegalovirus, rubella, and
coxsackieviruses, as well as viruses associated with variola, varicella, measles,
and poliomyelitis, may pass through the placental membrane and cause fetal
infection. In some cases, as with the rubella virus, severe birth defects may
result. Treponema pallidum can cause fetal syphilis, and Toxoplasma gondii
can produce destructive changes in the brain and eyes of the fetus.

Placental Protection by Maternal Antibodies:

The fetus produces only small amounts of antibodies because of its
immature immune system. Some passive immunity is conferred on the fetus by

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placental transfer of maternal antibodies. Only immunoglobulin G is

transferred across the placenta (receptor-mediated transcytosis).
Maternal antibodies confer fetal immunity for diseases such as
diphtheria, smallpox, and measles; however, no immunity is acquired to
pertussis (whooping cough) or varicella (chickenpox).

Placental Excretion of Waste Products:

Urea, a nitrogenous waste product, and uric acid pass through the
placental membrane by simple diffusion. Conjugated bilirubin (which is fat
soluble) is easily transported by the placenta and is quickly cleared.

Placental Endocrine Synthesis and Secretion:

Using precursors derived from the fetus, the mother, or both, the
syncytiotrophoblast of the placenta synthesizes protein and steroid hormones.
Protein hormones synthesized by the placenta include the following:
• Human chorionic gonadotropin (hCG)
• Human chorionic somatomammotropin (human placental lactogen)
• Human chorionic thyrotropin
• Human chorionic corticotropin
The glycoprotein hCG, similar to luteinizing hormone, is first secreted by
the syncytiotrophoblast during the second week of development. The hCG
maintains the corpus luteum, preventing the onset of menstrual periods. The
concentration of hCG in the maternal blood and urine rises to a maximum by
the eighth week and then declines. The placenta also plays a major role in the
production of steroid hormones (i.e., progesterone and estrogens).
Progesterone is essential for the maintenance of pregnancy.

Uterine Growth During Pregnancy:

The uterus of a nonpregnant woman is in the pelvis. It increases in size
during pregnancy to accommodate the growing fetus. As the uterus enlarges, it
increases in weight and its walls become thinner. During the first trimester, the
uterus expands out of the pelvic cavity, and by 20 weeks, it usually reaches the
level of the umbilicus. By 28 to 30 weeks, the uterine fundus reaches the
epigastric region, the area between the xiphoid process of the sternum and
umbilicus.

PARTURITION:
Parturition (childbirth) is the process during which the fetus, placenta,
and fetal membranes are expelled from the mother. Labor is the sequence of
uterine contractions that result in dilation of the uterine cervix and delivery of
the fetus and placenta from the uterus. The factors that trigger labor are not
completely understood, but several hormones are related to the initiation of

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contractions. The fetal hypothalamus secretes corticotropin-releasing hormone,

stimulating the pituitary gland to produce adrenocorticotropic hormone
(ACTH). ACTH causes the suprarenal cortex to secrete cortisol, which is
involved in the synthesis of estrogens. Peristaltic contractions of the uterine
smooth muscle are elicited by oxytocin, which is released by the maternal
neurohypophysis of the pituitary gland. This hormone is administered clinically
when it is necessary to induce labor. Oxytocin also stimulates the release of
prostaglandins that, in turn, stimulate myometrial contractility by sensitizing
the myometrial cells to oxytocin. Estrogens also increase myometrial contractile
activity and stimulate the release of oxytocin and prostaglandins.

Stages of Labor:
Labor is a continuous process; however, for clinical purposes it is
divided into three stages:
• Dilation begins with progressive dilation of the cervix and ends with complete
dilation of the cervix. During this phase, regular contractions of the uterus
occur less than 10 minutes apart. The average duration of the first stage is
approximately 12 hours for first pregnancies (primigravidas) and
approximately 7 hours for women who have had a child previously
(multigravidas).
• Expulsion begins when the cervix is fully dilated and ends with delivery of the
fetus. During this stage, the fetus descends through the cervix and vagina. As
soon as the fetus is outside the mother, it is called a neonate. The average
duration of this stage is 50 minutes for primigravidas and 20 minutes for
multigravidas
• Placental separation begins as soon as the fetus is born and ends with the
expulsion of the placenta and fetal membranes. A hematoma forms deep to the
placenta and separates it from the uterine wall. The placenta and fetal
membranes are then expelled. Contractions of the uterus constrict the spiral
arteries, preventing excessive uterine bleeding. The duration of this stage is
approximately 15 minutes. A retained or adherent placenta—one not expelled
within 1 hour of delivery—is a cause of postpartum bleeding.

Placenta and Fetal Membranes after Birth:

The placenta usually has a discoid (disc-like) shape, with a diameter of
15 to 20 cm and a thickness of 2 to 3 cm. The margins of the placenta are
continuous with the ruptured amniotic and chorionic sacs.

Variations in Placental Shape:

As the placenta develops, chorionic villi usually persist only where the
villous chorion is in contact with the decidua basalis. When villi persist
elsewhere, several variations in placental shape occur, such as accessory
placenta. Examination of the placenta, parentally by ultrasonography or

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postnatally by gross and microscopic study, may provide clinical information

about the causes of placental dysfunction, intrauterine growth restriction, fetal
distress and death, and neonatal illness. Postnatal placental examination can
also determine whether the expelled placenta is intact. Retention of cotyledons
or an accessory placenta in the uterus causes postpartum uterine hemorrhage.

Maternal Surface of Placenta:

The cobblestone appearance of the maternal surface of the placenta is
produced by slightly bulging villous areas—the cotyledons—which are
separated by grooves formerly occupied by placental septa.

Fetal Surface of Placenta:

The umbilical cord usually attaches near the center of the fetal surface,
and its epithelium is continuous with the amnion adhering to the chorionic plate
of the placenta, giving the fetal surface a smooth texture. The chorionic vessels
radiating to and from the umbilical cord are visible through the transparent
amnion. The umbilical vessels branch on the fetal surface, forming the
chorionic vessels, which enter the chorionic vill.

Umbilical Cord:
The attachment of the cord to the placenta is usually near the center of
the fetal surface of the placenta, but it may attach at other locations. The cord is
usually 1 to 2 cm in diameter and 30 to 90 cm in length. Doppler
ultrasonography may be used for prenatal diagnosis of the position and
structural abnormalities of the cord. Long cords have a tendency to prolapse
through the cervix or to coil around the fetus. Prompt recognition of prolapse of
the cord is important because, during delivery, it may be compressed between
the presenting body part of the fetus and the mother’s bony pelvis, causing fetal
anoxia. If the deficiency of oxygen persists for more than 5 minutes, the fetus’s
brain may be damaged.
The umbilical cord usually has two arteries and one vein surrounded by
mucoid connective tissue (Wharton jelly). Because the umbilical vessels are
longer than the cord, twisting and bending of the cord is common. The cord
frequently forms loops, producing false knots that are of no significance;
however, in approximately 1% of pregnancies, true knots form in the umbilical
cord. These may tighten and cause fetal death secondary to fetal anoxia. In most
cases, the knots form during labor as a result of the fetus passing through a
loop of the cord. Because these knots are usually loose, they have no clinical
significance. Simple looping of the cord around the fetus occasionally occurs. In
approximately one fifth of all deliveries, the cord is loosely looped around the
neck without causing increased fetal risk.

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AMNION AND AMNIOTIC FLUID:

The amnion forms a fluid-filled, membranous amniotic sac that surrounds
the embryo and later the fetus; the sac virtually all of the fluid in the amniotic
cavity is water, in which undissolved material (such as desquamated fetal
epithelial cells) is suspended. Amniotic fluid contains approximately equal
portions of dissolved organic compounds and inorganic salts. Half of the
organic constituents are protein; the other half is composed of carbohydrates,
fats, enzymes, hormones, and pigments. As pregnancy advances, the
composition of the amniotic fluid changes as fetal urine is added. Because fetal
urine enters the amniotic fluid, fetal enzyme systems, amino acids, hormones,
and other substances can be studied by examining fluid removed by
amniocentesis. Studies of cells in the amniotic fluid permit the detection of
chromosomal abnormalities.

Significance of Amniotic Fluid:

The embryo floats freely in the amniotic sac. Amniotic fluid has critical
functions in the development of the embryo and fetus:
• Permits uniform external growth of the embryo
• Acts as a barrier to infection
• Permits fetal lung development
• Prevents adherence of the amnion to the embryo
• Cushions the embryo against injuries by distributing impacts that the mother
may receive
• Helps to control embryonic body temperature by maintaining a relatively
constant temperature
• Enables the fetus to move freely, thereby aiding muscular development (e.g., in
the limbs)
• Assists in maintaining homeostasis of fluid and Electrolytes

UMBILICAL VESICLE:
The umbilical vesicle can be observed sonographically early during the
fifth week of gestation. At 32 days, the umbilical vesicle is large. By 10 weeks,
the umbilical vesicle has shrunk to a pear-shaped remnant approximately 5 mm
in diameter. By 20 weeks, the umbilical vesicle is very small.

Significance of Umbilical Vesicle:

The umbilical vesicle is nonfunctional as far as yolk storage is concerned
(hence the name changes from yolk sac to umbilical vesicle), but the presence of
the vesicle is essential for several reasons:
• It has a role in the transfer of nutrients to the embryo during the second and
third weeks before the uteroplacental circulation is established.

Created by; MUEEN AHMEED HASHMI and MUHAMMAD INAAM ULLAH

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• Blood cells first develop in the well-vascularized, extraembryonic mesoderm

covering the wall of the umbilical vesicle beginning in the third week, and
continue to develop there until hematopoietic activity begins in the liver during
the sixth week.
• During the fourth week, the dorsal part of the umbilical vesicle is incorporated
into the embryo as the primordial gut. Its endoderm, derived from the epiblast,
gives rise to the epithelium of the trachea, bronchi, lungs, and alimentary canal.
• Primordial germ cells appear in the endodermal lining of the wall of the
umbilical vesicle in the third week and subsequently migrate to the developing
gonads—testis or ovary. The cells differentiate into spermatogonia in males and
oogonia in females.

MULTIPLE PREGNANCIES:
Multiple pregnancies (gestations) are associated with higher risks of
chromosomal anomalies, fetal morbidity, and fetal mortality than single
gestations. The risks are progressively greater as the number of fetuses
increases. In North America, twins naturally occur approximately once in every
85 pregnancies, triplets approximately once in every 902 pregnancies,
quadruplets approximately once in every 903 pregnancies, and quintuplets
approximately once in every 904 pregnancies.

Twins and Fetal Membranes:

Twins that originate from two zygotes are dizygotic (DZ) twins—fraternal
twins, whereas twins that originate from one zygote are monozygotic (MZ)
twins—identical twins. The fetal membranes and placentas vary according to
the origin of the twins. Approximately two thirds of twins are dizygotic, and the
rate of DZ twinning increases with maternal age. The study of twins is
important in human genetics because it is useful for comparing the effects of
genes and environment on development. If an abnormal condition does not
show a simple genetic pattern, comparison of its incidence in MZ and DZ twins
may show that heredity is involved.

Dizygotic Twins:
Because they result from the fertilization of two oocytes by two sperms,
DZ twins may be of the same sex or different sexes. For the same reason, they
are no more alike genetically than brothers or sisters born at different times.
DZ twins always have two amnions and two chorions, but the chorions and
placentas may be fused. DZ twinning shows a hereditary tendency. The
recurrence risk in families with one set of DZ twins is approximately triples that
of the general population. The incidence of DZ twinning shows considerable
racial variation, ranging from 1 in 500 in Asian populations, to 1 in 125 in
white populations, to as high as 1 in 20 in some African populations.
Monozygotic Twins because they result from the fertilization of one oocyte and

Created by; MUEEN AHMEED HASHMI and MUHAMMAD INAAM ULLAH

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develop from one zygote, MZ twins are of the same sex, are genetically
identical, and are similar in physical appearance. Physical differences between
MZ twins are environmentally induced, such as by anastomosis of the placental
vessels, resulting in differences in blood supply from the placenta.
MZ twinning usually begins in the blastocyst stage, approximately at the
end of the first week, and results from division of the embryoblast into two
embryonic primordia. Subsequently, two embryos, each in its own amniotic sac,
develop within one chorionic sac and share a common placenta, a
monochorionicdiamniotic twin placenta. Uncommonly, early separation of the
embryonic blastomeres (e.g., during the two- to eight-cell stage) results in MZ
twins with two amnions, two chorions, and two placentas that may or may not
be fused. In such cases, it is impossible to determine, from the membranes
alone, whether the twins are monozygotic or dizygotic.

Other Types of Multiple Births:

Triplets may be derived from:
• One zygote and be identical
• Two zygotes and consist of identical twins and a Singleton Three zygotes and
be of the same sex or of different sexes, in which case the infants are no more
similar than infants from three separate pregnancies Similar combinations
occur in quadruplets, quintuplets, sextuplets, and septuplets.

Created by; MUEEN AHMEED HASHMI and MUHAMMAD INAAM ULLAH