FETAL ERYTHROPOIESIS

Similar to hematopoietic production of other cell lines, fetal

erythropoiesis is regulated by growth factors produced by the

fetus, not by the mother. Erythropoietin (EPO) does not cross

the human placenta. Stimulating maternal EPO production

does not stimulate of fetal erythropoiesis, and suppressing maternal

erythropoiesis by hypertransfusion does not suppress fetal

erythropoiesis.

It is unclear to what extent the mechanisms regulating erythropoiesis

in adults are operative in the fetus. Of all the factors

known to be involved in stimulating erythropoiesis, none plays a

more central regulatory role than does EPO, a 30-39 kd glycoprotein

that binds to specific receptors on the surface of erythroid

precursors and stimulates their differentiation and clonal maturation

into mature erythrocytes. Regulating EPO gene expression

involves an oxygen-sensing mechanism. EPO mRNA production

is regulated by cis-acting elements in the promoter and 3′ enhancer

regions that are responsive to hypoxia. Two factors, hepatic

nuclear factor 4 (HNF-4) and hypoxia inducible factor (HIF-1),

exhibit transcriptional activation for EPO and other hypoxiainducible

genes. HNF-4 binds to the EPO promoter and enhancer

regions of the gene. HIF-1 is a basic helix-loop-helix transcription

factor composed of HIF-1α and HIF-1β subunits that bind to

cis-acting hypoxia-response elements and induce EPO transcription.

HIF-1 is expressed in many cells and is involved in

upregulating a variety of oxygen-regulated proteins, including

vascular endothelial growth factor (VEGF). HIF-1α appears to

be constitutively expressed and rapidly degraded under normoxic

conditions. RNA stability depends on the ubiquitin proteasome

degradation system; inhibition of this system leads to increased

HIF-1 and increased EPO, even under normoxic conditions.

EPO is produced in fetal liver during the 1st and 2nd trimesters,

principally by cells of monocyte and macrophage origin.

After birth, the anatomic site of EPO production shifts to the

kidney. The specific stimulus for this shift is unknown but might

involve the increase in arterial oxygen tension that occurs at

birth. Epigenetic modification of gene expression might also play

a role, because it appears that renal and hepatic EPO genes are

methylated to different degrees. Although EPO mRNA and

protein can be found in the human fetal kidney, it is not known

whether this production is biologically relevant. However, it

appears that renal production of EPO is not essential for normal

fetal erythropoiesis, as evidenced by the normal serum EPO concentrations

and normal hematocrits of anephric fetuses.

HEMOGLOBINS IN THE FETUS AND NEONATE

The evolutionary development of oxygen-carrying proteins,

the hemoglobins, increased the ability of blood to transport

oxygen. The combination of oxygen with hemoglobin and its

dissociation from it are accomplished without expenditure of

metabolic energy.

Hemoglobin is a complex protein consisting of iron-containing

heme groups and the protein moiety globin. A dynamic interaction

between heme and globin gives hemoglobin its unique

properties in the reversible transport of oxygen. The hemoglobin

molecule is a tetramer made up of 2 pairs of polypeptide chains,

with each chain having a heme group attached. The polypeptide

chains of various hemoglobins are of chemically different types.

The major hemoglobin of a normal adult (HbA) is made up of 1

pair of alpha (α) and 1 pair of beta (β) polypeptide chains, represented

as α2β2. The major hemoglobin in the fetus (HbF), which

is made up of 2 alpha and 2 gamma globin chains, is represented

by α2γ2.

The various globin chains differ in both the number and

sequence of amino acids, and the synthesis of these chains

is directed by separate genes (Fig. 440-5). Two sets of genes

for the α chains are located on human chromosome 16. Two

pairs of alleles provide the genetic information for the structure

of the α chain. The β, γ, and δ genes are closely linked on chromosome

11.

Within the red blood cell (RBC) mass of an embryo, fetus,

child, and adult, 6 different hemoglobins may normally be

detected (Fig. 440-6): the embryonic hemoglobins, Gower-1,

Gower-2, and Portland; the fetal hemoglobin, HbF; and the adult

hemoglobins, HbA and HbA2. The electrophoretic mobilities of

hemoglobins vary with their chemical structures. The time of

appearance and quantitative relationships among the hemoglobins

are determined by complex developmental processes.

Embryonic Hemoglobins
The blood of early human embryos contains 2 slowly migrating

hemoglobins, Gower-1 and Gower-2, and Hb Portland, which

has HbF-like mobility. The zeta (ζ) chains of Hb Portland and

Hb Gower-1 are structurally quite similar to α chains. Both

Gower hemoglobins contain a unique type of polypeptide chain,

the epsilon (ε) chain. Hb Gower-1 has the structure ζ2ε2, and Hb

Gower-2 has the structure α2ε2. Hb Portland has the structure

ζ2γ2. In embryos of 4-8 wk of gestation, the Gower hemoglobins

predominate, but by the 3rd mo they have disappeared.

Fetal Hemoglobin

HbF contains γ polypeptide chains in place of the β chains of

HbA. Its resistance to denaturation by strong alkali is the basis

for determining the presence of fetal RBCs in the maternal circulation

(the Kleihauer-Betke test). After the 8th wk, HbF is the

predominant hemoglobin; at 24 wk of gestation it constitutes

90% of the total hemoglobin. During the 3rd trimester, a gradual

decline occurs, so that at birth HbF averages 70% of the total

hemoglobin. Synthesis of HbF decreases rapidly postnatally (Fig.

440-7), and by 6-12 mo of age only a trace is present.

Adult Hemoglobins

By the 24th wk of gestation, HbA constitutes 5-10% of total

hemoglobin. A steady increase in HbA continues throughout

gestation, reaching a level of 30% of total hemoglobin at term.By 6-12 mo of age, the normal
HbA pattern appears. The minor

HbA component HbA2 contains delta (δ) chains and has the

structure α2δ2. HbA2 is seen only when significant amounts of

HbA are also present. At birth, <1% of HbA2 is seen, but by

12 mo of age the normal level of 2.0-3.4% is attained. Throughout

life, the normal ratio of HbA to HbA2 is about 30 : 1.

Normal Relationships Among the Hemoglobins

During fetal life and early childhood, the rates of synthesis of γ

and β chains and the amounts of HbA and HbF are inversely

related. This relationship has been attributed to a “switch mechanism”

similar to genetic regulatory mechanisms in bacteria, but

the genetic, biologic, and developmental processes that direct a

switchover from predominantly γ-chain synthesis in utero to predominantly

β-chain synthesis after birth are unclear. It is not

certain whether the mechanisms involve selective genetic inhibition

or facilitation. The increase in the α1/α2 globin ratio occurring

after 36 wk of gestation corresponds with a rapid decline in

γ-globin synthesis, suggesting that these changes could be regulated

by a coordinated molecular mechanism. Differential selection

and amplified production of RBC precursors derived from

BFU-E cells result in considerable HbF production. This may be

the basis for the increased levels of HbF that occur in many

hypoproliferative or hemolytic anemias. Alternative explanations

involve more basic epigenetic regulation through processes such

as methylation and deacetylation in the DNA sequences that

flank the hemoglobin gene complexes.

Alterations of the Hemoglobins by Disease

Because hemoglobins containing ε chains normally are present

only very early in intrauterine life, in the past they were largely

of theoretical interest. In recent years, interest has been renewed

by the growing method of isolation of free fetal DNA in the

maternal circulation, allowing noninvasive fetal diagnosis of a

variety of genetic traits, such as RhD positivity in the fetus of an

RhD negative mother. In addition, small amounts of the Gowerhemoglobins have been
detectable in a few newborns with trisomy

13. Increased levels of Hb Portland have been found in cord

blood of stillborn infants with homozygous α-thalassemia.

HbF levels may be influenced by various factors. Because the

HbF level is elevated during the 1st year of life, knowledge of its

normal decline is important (see Figs. 440-6 and 440-7). In

persons heterozygous for β-thalassemia (β-thalassemia trait),

postpartum decrease of HbF is delayed; about 50% of such

persons have elevated levels of HbF (>2.0%) in later life. In

homozygous thalassemia (Cooley anemia) and in hereditary persistence

of HbF, large amounts of HbF characteristically are

found. In patients with major β-chain hemoglobinopathies

(HbSS, HbSC), HbF usually is increased, particularly during

childhood. Preterm infants treated with human recombinant EPO

increase HbF production during active erythropoiesis. Moderate

elevations of HbF can occur in many diseases accompanied by

hematologic stress, such as hemolytic anemias, leukemia, and

aplastic anemia, because of a minor population of RBCs that

contain increased amounts of HbF. Tetramers of γ chains (γ4 or

Hb Barts) or β chains (β4, HbH) may be found in α-thalassemia

syndromes.

The normal adult level of HbA2 (2.0-3.4%) is seldom altered.

Levels of HbA2 >3.4% are found in most persons with the

β-thalassemia trait and in persons with megaloblastic anemias

secondary to vitamin B12 and folic acid deficiency. Decreased

HbA2 levels are found in persons with iron-deficiency anemia

(Chapter 455) and α-thalassemia (Chapter 462).

RED CELL LIFE SPAN OF THE FETUS AND NEONATE

The differences in physical properties of RBCs derived from term

and preterm infants may account, in part, for the decreased life

span of neonatal RBCs within the circulation. The average life

span for a neonatal RBC is 60-90 days, approximately one half

to two thirds that of an adult RBC. When neonatal RBCs are

transfused into adults, they exhibit a shortened life span, owing

to alterations intrinsic to the neonatal RBC. In contrast, cells

transfused from adult donors appear to survive normally in newborns.

With increasing degrees of prematurity, remarkably shorter

red cell life spans (35-50 days) are found. The shortened red cell

life span of the preterm and term neonate may be explained by

some of the characteristics specific to newborn cells: a rapid

decline in intracellular enzyme activity and adenosine triphosphate

(ATP), loss of membrane surface area by internalization of

membrane lipids, decreased levels of intracellular carnitine,

increased susceptibility of membrane lipids and proteins to peroxidation,

and increased mechanical fragility due to increased

membrane deformability.
 Gower 1 #2 $2

Embryonic: Gower 2 %2 $2

Portland #2 &2

Fetal: Hemoglobin F %2 &2

Adult:

Hemoglobin A %2 "2

Hemoglobin A2 %2 '2