Chapter 3: Implantation, Embryogenesis, and Pla cental Development

The Ovarian-Endometrial Cycle

The Ovarian Cycle

 see Speroff Notes

Estrogen Action
 Estradiol-17b - is the biologically potent estrogen secreted by the granulosa cell of the dominant ovarian
follicle
 Estradiol enters cells from blood by simple diffusion, but in estrogen responsive cells, estradiol-17b is
sequestered by binding to estrogen receptor protein molecules; has high affinity but low capacity for
estradiol
 The estradiol-17b-receptor complex, after transformational changes, is a transcriptional factor that
becomes associated with estrogen response elements of specific genes; i.e. stimulates the transcription
of progesterone receptor genes

Progesterone Action
 Also enters cells by diffusion and in responsive cells becomes associated with progesterone receptors
 Commonly the cellular content of progesterone receptors is dependent on previous estrogen action
 Transcription of progesterone induced genes causes a decrease in the synthesis of estrogen receptor
molecules; by this means, prog attenuates estrogen action

The Endometrial Cycle

Proliferative Phase of the Endometrium

 by Day 5 of the menstrual cycle, the epithelial surface of the endometrium has been restored and
revascularization of the endometrium is in progress; glands are narrow, tubular structures that pursue
an almost straight and parallel course
 Mitotic figures are identified by the fifth day after commencement of menstruation, and mitotic activity
persists until 2-3 days after ovulation
 Blood vessels are numerous and prominent, there is no extravasated blood or leukocytic infiltration
 Clearly, re-epithelialization and angiogenesis are important to the cessation of endometrial bleeding at
the end of menstruation, and these processes are dependent upon tissue regrowth
 Endometrium becomes thicker – result of glandular hyperplasia and an increase in stromal ground
substance (edema and proteinaceous material)
 Glands in the superficial endometrium are widely separated, compared with the deep zone, where the
glands are more crowded and tortuous, and the stroma is more dense
 At midcycle, as ovulation is approached, the glandular epithelium is taller and pseudostratified
 Day-by-day dating of the endometrium by histologic criteria is not possible in the proliferative phase,
and the secretory phase is remarkably consistent (12-14 days)

Secretory Phase of the Endometrium

 after ovulation, the estrogen primed endometrium responds to the rising levels of progesteronein a highly
predictacble manner
 Beginning on day 7 to 8 post-ovulation, the rates of progesterone and estrogen secretion by the corpus
luteum begin to decline and diminish progressively before menstruation
 Day 17 – glycogen accumulates in the basal portion of the glandular epithelium
 this creates vacuoles and pseudostratification and is the st sign of ovulation that can be seen
histologically
 Day 18 – vacuoles move to apical portion of the secretory nonciliated cells
 Day 19 – cells begin to realease glycoprotein and mucopolysaccharide conetnes into the lumen
 With this start of secretory activity, mitosis ceases in response to rising progesterone
 Also estrogen effects decrease as estradioil production decreases and estrone (less potent) increases
 Days 22-25 – predicudual transformation of the upper 2/3 of the funtionalis layer
 glands exhibit extensive coiling and secretions becomve visible within the lumen
 Pinopods also develop – protrusions of the apical cell surface into the lumen in preparation for
blastocyst
 also occurring during the luteal phase is an impressive increase in the length of the uterine spiral arteries

Menstruation
 towards the end of the cycle the functionalis layer accumulates PMN cells (perhaps in response to IL-8)
 the invading PMNs secrete MMP which tip the balance between protease and pretease inhibitors,
leading to menstruation
 from a vascular perspective, the spiral arteries coils severely enough to increase the resistance to blood
flow (this coiling may be in response to PGF2a, endothelins
 this causes hpoxia of the endometrium and tissue degeneration
 this also helps to limit blood loss during menstruation
 Menstrual bleeding is mostly from arterial rather than venous sources
 small hematoma formation helps to develop a cleavage plane to shed the endometrium

The Decidua of the Endometrium

 A specialized, highly modified endometrium of pregnancy
 Transformation of the secretory endometrium to decidua is dependent on estrogen, progesterone and
other stimuli provided by the implanting blastocyst
 Decidua basalis – the portion of deciduas directly beneath the site of implantation that is modified by
trophoblast invasion
 Decidua capsularis – the portion overlying the blastocyst and initially separating it from the rest of the
uterine cavity – most prominent during 2nd month of pregnancy, consisting of decidual cells covered by
a single layer of flattened epithelial cells without traces of glands; this portion of the decidua contacts
the avascular, extra-embryonic fetal membrane – the chorion leave
 Remainder of the uterus is lined by decidua parietalis – sometimes called the decidua vera when decidua
capsularis and decidua basalis are joined
 By 14-16 wks the expanding sac is large enough to fill the entire uterine cavity, and the decidua
capsularis and parietalis are fused
 The deciduas basalis and capsularis are each composed of 3 layers: the zona compacta, zona spongiosa
(middle) and zona basalis; the compacta and spongiosa fuse to form the zona functionalis, and the
zona basalis remains after delivery and gives rise to the new endometrium
 Decidual reaction – completed only with blastocyst implantation, but predecidual changes start first in
endometrial stromal cells adjacent to spiral arterioles, and then spread through the mucosa of the
uterus and then from the implantation site
 Endometrial stromal cells enlarge to form polygonal or round decidual cells – nuclei become round and
vesicular, cytoplasm becomes clear and slightly basophilic, surrounded by a translucent membrane
 Blood Supply – changes as a consequence of implantation
 Blood to deciduas capsularis is lost as it expands with fetus
 The supply to the parietalis through the spiral arterioles persists; they are still responsive to vasoactive
compounds
 The spiral arteriole system supplying the deciduas basalis right under the blastocyst is changed
considerably; the arterioles are invaded by cytotrophoblasts, and the walls of the vessels are
destroyed – leaving only a shell without smooth muscle or endothelial cells – these are vascular
conduits of maternal blood – which become the uteroplacental vessels – not responsive to vasoactive
substances
 Fetal chorionic vessels – transport blood between the placenta and fetus, contain smooth muscle and do
respond to vasoactive agents
 Histology
 Compact layer of the deciduas consists of large, closely packed, epithelioid, polygonal, lightly staining
cells with round vesicular nuclei
 Many stromal cells appear stellate
 Uterine large granular lymphocytes (a particular type of NK cell) – these are bone marrow
derived cells that entered the endometrium from peripheral blood, but then continue to arise
primarily by replication in the endometrium in situ at specific times in the cycle
 Spongy layer – marked by hyperplasia of the glands (which later disappear) and hypertrophy of the
stroma
 Decidua basalis contributes to the formation of the basal plate of the placenta, and differs histologically
from the deciduas parietalis by:
 Spongy layer of basalis consists mainly of arteries and widely dilated veins, by term the glands have
virtually disappeared
 Decidua basalis is invaded by trophoblastic giant cells which appear at the time of implantation;
number and depth vary greatly
 Nitabuch layer is a zone of degeneration where the trophoblasts and decidua meet
 defective or absent nitabuch layer is often present in placenta accreta
 Decidual necrosis is a normal phenomenon in T1 and T2, and not the cause of SA
 Prolactin in the decidua – Decidua is the source of prolactin in the amniotic fluid
 The concentration of prolactin in the fluid is extraordinarily high compared with the highest level of
prolactin in fetal or maternal plasma
 Prolactin enters the fluid preferentially, and little or none enters the maternal blood – is a classic
example of peculiar trafficking of molecules between maternal and fetal tissues of the paracrine arm
of the fetal-maternal communication system
 Physiological role of prolactin is unknown

Overview of Endometrial Function

 Contains epithelial (glandular) cells, stromal (mesenchymal) cells, blood vessels
 Superficial 2/3 of the endometrium is shed and regenerated
 The single physiologic function of the endometrium/decidua is to serve as the maternal tissue interface of
pregnancy
 Decidual cells are differentiated from the stromal cells of the endometrium under the influence of
progesterone and other stimuli
 The unique spiral arteries persist in the decidua parietalis, but are invaded and modified by trophoblasts
in the decidua basalis underlying the implantation site
 Decidua serves as a immunologically specialized tissue
 Endometrium/decidua and spiral arteries accept trophoblast invasion, providing for embryo/fetal
nutrition
 Decidua contributes cytokines, growth factors that promote placental growth, function and the inhibition of
trophoblast apoptosis
Implantation and Formation of the Placenta and Fetal Membranes
 The human placenta is a hemochorioendothelial type placenta
 The extra-villous and villous trophoblasts are the embryonic-fetal tissues of the anatomical interface of
the placental arm
 The avascular fetal membranes – amnion and chorion lavae – are the fetal tissues of the anatomical
interface of the paracrine arm of the system
 Maternal blood directly bathes the syncytiotrophoblast; fetal blood is contained in the fetal capillaries
which traverse within the intervillous spaces of the villi
 All cells with direct contact are maternal and extra-embryonic (trophoblasts) – not embryonic cells or
fetal blood

 Zygote – the cell that results from the fertilization of the ovum by the sperm
 Blastomere – Mitotic division of the zygote (cleavage) yields daughter cells called blastomeres
 Morula – the solid ball of cells formed by ~16 blastomeres
 Embryo – the embryo forming cells, group together in the inner cell mass and give rise to the embryo,
which is designated when the bilaminar embryonic disc forms. The embryonic period extends until the
end of the 7th week, at which time the major structures are present
 Fetus – after the embryonic period, the developing conceptus is called a fetus
 Conceptus – term refers to all products of conception – embryo, placenta, membranes; all tissues which
develop from the zygote

Fertilization and Implantation

 Fertilization occurs in the fallopian tube; within minutes to hours of ovulation
 Morula enters the uterine cavity ~3 days post fertilization
 Gradual accumulation of fluid between blastomeres within the morula results in the blastocyst – one end
has a compact group of cells, the inner cell mass (leads to embryo); outer cell mass destined to become
trophoblasts
 Zona pellucida disappears, and the blastocyst touches the endometrial surface (is composed of 107 –
256 cells)
 Implantation most commonly occurs on the upper part and posterior wall of the uterus; erosion of
epithelial endometrial cells, and invasion by trophoblasts
 Eventually the trophoblast becomes encased and covered by endometrium
 As the blastocyst and it’s surrounding trophoblasts grow and expand, one pole extends toward the
endometrial cavity, and the other pole remains buried in the endometrium/decidua
 The innermost pole forms the placenta – that is anchoring cytotrophoblasts and villous trophoblasts

Biology of the Trophoblast

 Trophoblasts are either cytotrophoblasts (inner ones) or syncytiotrophoblasts (outer ones)
 cytotrophoblasts are the germinal cells for the syncytiotrophoblasts
 the syncytium is composed of syncytiotrophoblasts and is essentially a single contiguous membrane with
amorphous cytoplasm, no cell borders multiple nuclei
 the absence of cell borders in the syncytium facilitates nutrient transport
 The functions of the trophoblast invading the endometrium is indistinguishable from those of metastasizing
malignant cells

Embryonic Development After Implantation

 after erosion of the surface endothmetrium, the invading trophoblasts burrow deeper into the
endometrium and by the 10th day the blastocyst is totally encased within the endometrium
 at day 9, the wall of the blastocyst facing toward the uterine cavity is a single layer of flattened cells
 the opposite thicker wall has 2 zones, the trophoblasts and the inner cell mass
 the inner cell mass (the embryonic disc) is further differentiated into primitive ectoderm and endoderm
 the space between the disc and the trophoblasts will be come the amniotic cavity
 The embryonic mesenchyme first appears as isolated cells in the blastocyst cavity, but the cavity is soon
lined by mesoderm – now called the chorionic vesicle (lined by chorion – composed of trophoblasts and
mesenchyme)
 The mesenchymal cells are most numerous around the embryo, where they eventually condense to form
the body stalk – this serves to join the embryo to the nutrient chorion and later develops into the
umbilical cord
 Decidual reaction intensifies in the surrounding stroma – this is characterized by enlargement of the
decidual stromal cells and glycogen storage

Chorionic Villi
 Chorionic Villi – villi can be distinguished 12 days after fertilization
 When a mesenchymal cord, presumably derived from cytotrophoblasts, invades the solid trophoblast
column, secondary villi are formed
 After angiogenesis occurs from the mesenchymal cords in situ, the resulting villi are termed tertiary
 By the 17th day, fetal blood vessels are functional and a placental circulation is established
 Fetal-placental circulation is completed when the blood vessels of the embryo are connected with the
chorionic blood vessels
 Until the end of month 3, the chorion lavae is separated from the amnion by the exocoelomic cavity –
thereafter, the amnion and chorion are in intimate contact
 The amnio-chorion constitute the paracrine arm of the fetal-maternal communication system

Placental Developoment

1. Development of the Chorion and Decidua

 the trophoblasts at the deepest pole of the blastocyst proliferate to form the chorion frondosum
 meanwhile the villi facing the endometrial cavity are restricted in blood supply and stop growing
 by the end of the 3rd month the chorion and amnion are in intimate contact
2. Trophoblast Invasion of the Endometrium
3. Decidual Spiral Artery Invasion
 The capillary network of the most superficial portion of the endometrium is invaded by cytotrophoblasts
 Subsequently the arterioles and then spiral arteries are invaded, and the walls of the vessels are
destroyed
 During implantation, the spiral arteries acquire a lining of cells within the endothelium that is derived from
invading cytotrophoblasts – during this, degenerative changes take place in the arterial wall –
affecting all layers, but the most striking is that vascular smooth muscle becomes unrecognizable
 Cytotrophoblasts that invade the spiral arteries can pass several cm along the vessel lumen; these
vascular changes are not seen in the decidua parietalis
 Intraluminal cytotrophoblasts diminish at term
 Invasion of maternal vascular tissue by trophoblasts involves only the decidual spiral arteries, not the
decidual veins
4. Establishment of Maternal Blood Flow
 at approximately 1 month, maternal blood enters the intervillous space from the spiral arteries and
bathes the syncytiotrophoblasts
5. Villous Branching
 some villi of the chorion frondsoum exted to the decidua to serve as anchoring villi
 most villi however, end short of this and just end in the intervillous spae
Placental Growth and Maturation

Placental Growth
 in the first trimester placental growth is faster than fetal
 by 17 wks, the weights are equal
 at term placental weight = 1/6 of fetal
 Individual cotyledons grow in size, but same number is maintained
 At term, on average: 185mm in diameter, 23 mm in thickness, average volume of 497 ml, and weight of
508g

Placental Maturation
 Placental Aging – the villi continue to branch and the terminal ramifications become smaller and the
volume and prominence of the cytotrophoblasts decrease
 As the syncitium thins, the vessels become more prominent and lie closer to the surface
 Stroma also becomes denser packed and the cells more spindly
 Hofbauer cells appear in the stroma – these are like fetal macrophages – round with vesicular, eccentric
nuclei and very granular or vacuolated cytoplasm
 By 4 months the apparent continuity of the cytotrophoblasts is broken, and the syncitium forms knots on
the more numerous smaller villi

Fetal and Maternal Blood Circulation in the Mature Placenta

Fetal Circulation

 fetal deoxygenated blood or ‘venous-like’ blood flows to the placenta through two umbilical arteries
 At the juncture of the umbilical cord with the placenta, the umbilical vessels branch repeatedly beneath
the amnion and again within the dividing villi
 Blood with significantly higher oxygen content returns from the placenta to the fetus through a single
umbilical vein
 The vessels on the placental surface (chorionic plate) are responsive to vasoactive substances – but
they are curious…
 Chorionic arteries always cross over the chorionic veins
 Immediately after entering the chorionic plate, the two umbilical arteries are connected transversely by
the Hyrtl Anastomosis (rarely missing)
 The 2 umbilical arteries then separate to supply branches to the cotyledons – there are 2 patterns of
branching – disperse (65%) – which are a fine network of vessels that go to the cotyledons, and
magistral (35%) which are arteries that traverse the placenta without appreciable decrease in the
diameter of the vessel
 truncal arteries are the perforating branches of the surface arteries that ass through the chorionic plate
– each supplyine one cotyledon – these arteries have decreased smooth muscle
 At ~10 post conceptional weeks the pattern of umbilical blood velocity waveforms changes
considerably i.e before this time, there is no end diastolic frequency
 ‘definitive’ chorionic plate is formed by 8-10 weeks as the amnion and the primary chorionic plate
mesenchyme fuse with each other
Maternal Circulation

 blood needs to leave the maternal circulation, flow into an amorphous space (lined by trophoblast
syncitium, rather than vascular endothelium) and then return through maternal veins without producing
arterio-venous like shunts that would prevent maternal blood from remaining in contact with the villi
long enough for adequate exchange
 arterial entrances as well as venous exits are scattered at random over the entire base of the placenta
 maternal blood enters through the basal plate pushed by maternal arterial pressure, and then lateral
dispersion occurs
 trophoblast invasion of the spiral areteries facilitaes creation of low-resistance uteroplacental vessels
 after bathing the extravillous surface of the chorionic villi, the maternal blood drains back through the
venous orifices in the basal plate and enters the uterine veins; the veins are usually parallel to the
uterine wall and the arteries are perpendicular, so blood is not squeezed back during a contraction
 after week 30, a prominent venous plexus separates the decidua basalis from the myometrium – this
participates in providing a plane of cleavage for placental separation

Immunological Considerations of the Fetal-Maternal Interface

 Trophoblasts have immunological peculiarity; they are all from conceptus origin i.e. no maternal cells
 It is still an enigma as to why maternal tissues tolerate the fetal graft
 HLA antigens are absent from villous trophoblasts - \ they may be immunologically inert
 BUT … invasive cytotrophoblasts do express HLA I molecules
 Uterine Large Granular Lymphocytes (LGLs)
 believed to oiriginate in the bone marrow
 infiltration increases in response to progesterone, IL-15, PRL
 LGLs may serve to regulate trophoblast invasion
 HLA-G Expression in Human Trophoblasts
 not expressed in villous trophoblast
 it is expressed in cytotrophoblasts that are contiguous with maternal tissues
 Trophoblasts express HLA-G – this is a monomorphic Ag, and is recognized as ‘self’, by the mother; it’s
expression might be stimulated by hypoxia
 there is also abnormal expression of HLA-G in trophoblasts from women with preclampsia)

The Amnion
 at term, is a tough, tenacious, pliable membrane
 it is the innermost fetal membrane; it is avascular; consists of 5 layers
o innermost – single layer of cuboidal cells
o basement membrane
o acellular compact layer of collagens I, III, V
o row of fibroblast-like mesenchymal cells
o acellular zona spongiosa (contiguous with the chorion)
 Development
o A space develops between the embryonic cell mass and the adjacent trophoblasts
o Small cells that line this space are called amniogenic cells
o The amnion is first identifiable on day 7-8 of embryo development
o As the amnion enlarges, it engulfs the growing embryo which prolapses into it’s cavity;
distention of the sac eventually brings it into contact with the chorion
o Amnion and chorion lavae are never intimately connected and can be separated easily,
even at term
 Histogenesis:
o It is generally accepted that the epithelial cells of the amnion are derived from fetal
ectoderm of the embryonic disc
o The apical surface of the epithelial cells is replete with highly developed microvilli,
consistent with a major site of transfer between amniotic fluid and amnion
o The amnion mesenchymal cells of the fibroblast layer are responsible for the major amnion
functions – the synthesis of the collagens, the source of the major tensile strength of the
amnion takes place here; likely mostly collagen III
o The mesenchymal cells can also synthesize cytokines, and do so in response to bacteria
 Metabolic functions: involved in solute and water transport, and produces vasoactive peptides,
growth factors and cytokines
 o these factors may diffuse into the chorion or into the amniotic fluid for the fetus to swallow
 Amniotic fluid: increases in quantity until 34 wks, and then decreases; average volume is ~1000cc
at term

Umbilical Cord and Related Structures

 Development – yolk sac, and umbilical vesicle into which it develops are quite prominent in early
pregnancy
 At first the embryo is a flattened disc between the amnion and the yolk sac
 As the embryo grows, it bulges into the amniotic sac, and the dorsal part of the yolk sac is
incorporated into the body of the embryo to form the gut
 The allantois projects into the base of the body stalk from the caudal wall of the yolk sac
 As pregnancy advances, the yolk sac becomes smaller, and the pedicle longer
 By the third month the expanding amnion obliterates the exocoelom, fuses with the chorion lavae
and covers the bulging placental disc, and the lateral surface of the body stalk – which is then
called the umbilical cord, or funis
 Remanats of the exocoelom in the anterior portion of the cord may contain loops of intestine, which
continue to develop outside the embryo
 The loops are later withdrawn, but the apex of the midgut loop retains it’s connection with the
attenuated vitteline duct
 The duct terminates in a crumpled, highly vascular sac, 3-5cm in diameter, lying on the surface of
the placenta between the amnion and chorion, or in the membranes just beyond the placental
margin, where it can be identified at term
 The right umbilical vein usually disappears during development, leaving only one vein (the left
one!)
 The intra-abdominal portion of the duct of the umbilical vesicle, which extends from the umbilicus to
the intestine, usually atrophies and disappears, but occasionally remains patent, forming a
Meckel’s diverticulum
 The most common vascular anomaly is one umbilical artery

 Structure and Function

o Surface of the cord is covered by amnion; diameter is 0.8-2cm and average length is
55cm (range 30 –100 cm)
o Extracellular matrix is comprised of Wharton’s jelly
o Blood flows from the umbilical vein via 2 routes – the ductus venosus, which empties
directly into the inferior vena cava, and numerous smaller openings into the fetal
circulation, then into the IVC by the hepatic vein
Placental Hormones
 Human trophoblasts produce a large amount of steroid and protein hormones
 A unique and obligatory relationship exists between the fetal adrenal secretion of large amounts
of C19 steroids which serve as plasma borne precursors for estrogen synthesis
 Human syncitiotrophoblast also takes up maternal LDL cholesterol for use in progesterone
biosynthesis
 Protein and peptide Hormones produced by the placenta: placental lactogen, hCG, ACTH,
proopiomelanocortin, chorionic thyrotropin, GH variant, PTH-rP, calcitonin, relaxin
 Hypothalamic like releasing and inhibiting hormones: TRH, GnRH, CRH, somatostatin, GHRH
 Also produces inhibins, activins, and ANP

Human Chorionic Gonadotropin (hCG)

 A glycoprotein with biological activity similar to LH
 They both act via the LH/hCG receptor
 HCG is produced almost exclusively in the placenta, specifically the syncitiotrophoblast cells
 Also synthesized by the fetal kidney, and quite a few fetal tissues produce the b-subunit or intact
hCG molecule
 Malignant tumors with neoplastic trophoblast cells also produce hCG
Chemical Characteristics

 HCG is a glycoprotien (40,000 D) with the highest CHO content of any human hormone (this
protects the molecule from catabolism)
 The plasma half life is 36 hrs
 The molecule is made of 2 dissimilar subunits: a (92 a.a.) and b (145 a.a.), which are
noncovalently linked – held together by electrostatic and hydrophobic forces
 HCG is related structurally to 3 other glycoprotein hormones: LH, FSH, TSH – the a.a. sequence of
the a-subunit is identical
Biosynthesis

 both subunits are synthesiszed as larger molecular weight precursors which are cleaved by
microsomal endopteptidases
 the molecule is released by exocytosis after the subunits are assembled
Cellular Origin of hCG

 Less than 5 wks origin is syncytiotrophoblasts and cytotrophoblasts

 later in gestation it is produced almost solely by syncytiotrophoblasts
Molecular Forms of hCG in Plasma and Urine

 there are variations in form due to varied degradation, synthesis and processing
 Free Subunits
o b-subunit production is slower so, there really isn’t any free subunits about
o b-subunit production peaks at 8-10 wks
o a-subunit production is dependent on placental size, so when b-subunit production is low,
the proportion of free a subunit peaks (3rd Trimester)
 Nicks in the b-HcG Molecule
o these occur naturally – the significance is unknown, but their detection is variable
o this is concerning in GTD because the proportion of nicked subunits can be higher
Concentrations of hCG in Serum and Urine

 HCG is detectable in plasma on day 7-9 after LH surge

 This corresponds to the entry of blastocyst implantation
 levels double q2days til max at 8-10 weeks
 there is variation in production during the course of a single day
 around week 10-12, levels start to decline
 nadir is reached ~ 20 wks where they remain stable
 fetal serum concentrations are 3% of maternal serum concentrations
 amniotic fluid concentrations is similar to maternal plasma concentration, but by term concentration
is only 1/5 of maternal plasma
Elevated or Depressed hCG Levels in Maternal Plasma or Urine

 High hCG found in pregnancies with multiple fetuses, D-Ag isoimmunization, mole or
choriocarcinoma
 Relatively higher levels are found in mid-trimester in pregnancies with Down’s – reason for this is
unclear, but speculated that placenta is less mature
Regulation of hCG Synthesis

 placental GnRH is likely involved, but in general the in vivo regulation of hCG is not understood
Metabolic Clearance

 30% renally cleared and otherwise metabolized in liver and kidney

Biological Functions of hCG

 Rescue of the Corpus Luteum: Best known biological function of hCG is ‘rescue’ and maintenance of
the function of the corpus luteum – that is continued progesterone production
 HCG Stimulation of Fetal Testis: peak of hCG is at the same time as max fetal testosterone
secretion i.e. critical time of male sexual differentiation – the hCG in this case acts as an LH
surrogate and stimulates replication of fetal testicular Leydig cells and testosterone synthesis;
reason is the fetal pituitary is not functioning yet so hCG acts as LH
 HCG stimulation of the maternal thyroid: some forms of hCG bind to the TSH receptors of the
thyroid cells; there is also some evidence that there are LH/hCg receptors in the thyroid
 Others: hCG acts in vivo to promote relaxin secretion by the corpus luteum and may promote
vascular vasodilation and smooth muscle relaxation in the uterus

Human Placental Lactogen

 Has potent lactogenic and growth hormone like bioactivity
 Concentrated in the syncitiotrophoblast; however like hCG, hPL is found in the cytotrophoblast from
6 weeks gestation
Chemical Characteristics:

 Single, non-glycosylated polypeptide chain containing 191 a.a., that has a 96% homology to
growth hormone
 HPL is structurally similar to prolactin (67% a.a. homology)
Gene Structure and Expression

 the expression near term is ~ 1 g/day and is the greatest, by far, of any known human hormone
Serum Concentration

 hPL is detected in placenta at 5-10 days post conception, and in serum 3 weeks after fertilization
 Maternal plasma conc rise steadily to 34-36 wks, and is approximately proportional to placental
mass
 Half life in maternal plasma is 10-30 minutes
 very little is found in fetal blood or urine of mother or babe
 amniotic fluid levels are lower than maternal plasma
Metabolic Actions

 Maternal Lipolysis and an increase in the levels of circulating ffa – thereby providing a source of
energy for maternal metabolism and fetal nutrition
 An anti-insulin action, leading to an increase in the maternal insulin levels, which favours protein
synthesis and provides a mobilizable source of a.a. for transport to the fetus
 Potent angiogenic hormone – may play an important role in formation of fetal vasculature

Other Placental Protein Hormones

Chorionic Adrenocorticotropin
 A protein similar to ACTH
 Physiological role of placental ACTH is unclear
Relaxin
 synthesized as a preprorelaxin molecule that is cleaved into A and B molecules
 structurally similar to insulin and insulin-like growth factor
 levels parallel HCG and early production is by corpus luteum
 may act on uterus to induce quiescence early inpregnancy
 may also play a role in the puerperium
Parathyroid Hormone-Related Protein (PTH-rP)
 Present in myometrium, endometrium, corpus luteum and lactating mammary tissue, and a number
of fetal tissues
 may have a role on the trophoblast to promote calcium transport for fetal bone growth and
ossification
 levels are elevated in maternal but not fetal circulation
Growth Hormone Variant
 Expressed in the placenta, but not in the pituitary
 Pattern of synthesis with gestation is not exactly known
 May mediate insulin resistance of pregnancy

Hypothalamic-Like Releasing Hormones

Gonadotropin-Releasing Hormone (GnRH)
 reulates hCG production and parallels it’s levels
 is also responsible for increased levels of maternal GnRH seen in early pregnancy
Corticotropin-Releasing Hormone (CRH)
 exist in low-levels pre-pregnancy, but increase dramatically by the end of gestation
 with the onset of labour, CRH levels further increase by 2-3 X
 function to increase ACTH secretion
  may induce Myometrial relaxation and cause immunosuppression
o yet … near the end of gestation, may cause Myometrial contractions
 may be involved in a unique positive feedback loop
Growth Hormone-Releasing Hormone (GHRH)
 has been found in placenta, but function unknown

Other Placental Peptide Hormones

Leptin
 normally secreted by adipocytes
 regulates bone growth and immune function
 levels correlate with fetal birthweight
Neuropeptide-Y
 36 a.a. peptide is widely distributed in the brain
 isolated in the cytotrophoblasts
 treatment of placental cells with NPY causes release of CRH
Inhibin and Activin
 Inhibin – a glycoprotein hormone that acts preferentially to inhibit FSH release by the pituitary;
produced by human testes and granulosa cells in ovary, includes CL
 Inhibin produced in placenta, along with high sex steroid levels may function to inhibit FSH and
preclude ovulation during pregnancy
 Inhibin may act via GnRH to regulate hCG synthesis/secretion in placenta
 Activin – closely related to inhibin; unknown role

Placental Progesterone Production

 After 6-7 weeks of gestation, there is very little progesterone produced by the ovary
 after 8 wks, placenta replaces ovarey as the source of progesterone
 there is a gradual increase in levels through remainder of pregnancy and by the end, levels are
up to 5000 times of nonpregnant
 Progesterone Production rates – 250mg/ day with singleton fetus (> 600 with multiples)
Source of Cholesterol for Placental Progesterone Biosynthesis

 Is synthesized in a 2 step reaction

o First, cholesterol converted, in mitochondria to pregnenolone
o Then, pregnenolone is converted to progesterone in endoplasmic reticulum
 Placenta relies on exogenous cholesterol for progesterone production
 Maternal plasma cholesterol is the principle placental precursor to progesterone biosynthesis in
human pregnancy
 Progesterone synthesis and fetal well-being – unlike estrogen synthesis, progesterone synthesis is not
dependent on a live fetus
Progesterone Metabolism During Pregnancy

Placental Estrogen Production

 placenta produces huge amounts of estrogen and progesterone
 during the first 2-4 wks of pregnancy, rising levels of hCG maintain production of estradiol in the
CL
 by the 7th week, 50% of estrogen entering maternal circulation is placental in origin
Placental Estrogen Biosynthesis

 Different biosynthesis than from the ovarian follicle

 Estrogen is produced in the placenta de novo from acetate or cholesterol – reason for this is that
steroid 17a-hydroxylase/ 17, 20 desmolase is not expressed in the human placenta
 Plasma C19 steroids as estrogen precursors – i.e. DHEAS, androstenedione and testosterone are all
converted to estrogens by the placenta using a sulfatase enzyme
o by the 30th week, 30-40% of DHEAS secreted by the maternal adrenal glands is
converted to estradiol-17b
 Placental Aromatase Enzyme – principle location is in the syncitiotrophoblast
 Secreted Estrogens – human placenta secretes 17b-estrodiol as well as estriol (via 16a-
hydroxyandrostenedione which is converted to 16a-hydroxyestrone, then converted to estriol)
 Metabolism of Dehydroepiandrosterone Sulfate – removed from maternal serum at a high rate via:
o Conversion to 17B-estradiol in the syncitium
o Accelerated 16a-hydroxylation (probably in maternal liver), with 30-40% converted near
term to 16a-DHA sulfate
 The maternal adrenal glands do not produce enough DHEAS during pregnancy to account for the
large amounts of placental estrogen, therefore the fetal adrenal glands are the quantitatively
important source of placental estrogen precursors in human pregnancy

Fetal Adrenal Glands

 Adrenal cortex in the fetus is the largest organ of the fetus
 >85% of the fetal gland is composed of a fetal zone, not found in adults
 daily production of steroids by the adrenal fetal gland is 100-200mg/day
 Contribution to Placental Estrogen Formation – it has been found that women carrying anencephalic
fetuses secrete very little estrogen – this is likely because the fetal pituitary is required to produce
ACTH to stimulate the adrenals, and if there is no brain then there is no stimulus for the adrenals to
enlarge and start to produce steroid progenitors
 Placental Estriol Synthesis – there is a disproportionate amount of estriol produced during
pregnancy; this is accounted for by the placental synthesis of estriol from 16a-
hydroxydehydroepiandrosterone sulfate – which is synthesized by the fetal adrenal and by 16a-
hydroxylation of plasma DHEAS by the fetal liver; near term the fetus is the source of 90% of the
estriol precursor
 Fetal Adrenal Development – primitive adrenal gland is formed by 6-8 wks
o ACTH is not necessary for the early stages of formation, \ adrenal gland is formed in
anemcephalic fetus
o ACTH is required though for gland development later in pregnancy
 Fetal Adrenal Morphology – inner fetal zone accounts for the bulk of the gland and is the source
for steroid precursors
o the outer zone is called the definitive zone and gives rise to the adult adrenal glomerulosa
o adrenal cortex undergoes involution beginning at birth; the weight of the adrenal glands
decreases strinkingly during the first few weeks of life and does not reach that size again
until adolescence
 Fetal Adrenal Growth – continues to grow during pregnancy, and in last 5-6 weeks, there is rapid
increase in adrenal size
 Precursor for fetal adrenal steroidogenesis is cholesterol, but cholesterol can also be synthesized
from 2-carbon fragments i.e. acetate
 Fetal adrenals are highly dependent on LDL for their cholesterol
 adrenals can’t make enough cholesterol to keep up, so it gets some from plasma
o majority of plasma cholesterol arises by de novo synthesis in the fetal liver
o low levels of LDL are indicative of high use
 o high levels of LDL in anencephalics

Fetal Conditions that affect Estrogen Production

1. Fetal Death – huge decrease in estrogen, but not progesterone
2. Fetal Anencephaly – all steroids produced are from placental use of maternal DHEAS; estriol
production is also disproportionately decreased
3. Fetal Adrenal Hypoplasia – very rare; hypoplasia of adrenal in otherwise normal fetus
4. Placental Sulfatase Deficiency – X-linked disorders (all affected fetuses are male) and is
associated with development of ichthyosis in affected males in later life
5. Placental Aromatase Deficiency – a few well documented examples; basically aromatase is
needed to convert the androstenedione (from all of the fetal DHEAS) to estriol and estradiol
using aromatase enzyme; if there is not aromatase then there is a build up of androstenedione
and testosterone, causing maternal virilization and virilization of a female fetus
 Pregnancies with aromatase deficiency and a male fetus are unremarkable – however the
estrogen deficient men do not have proper epiphyseal closure and continue to grow
during adulthood, becoming very tall and having deficient mineralization of bone
6. Down Syndrome – unconjugated estriol levels are very low; reason is unknown, but may be due
to inadequate formation of C19 steroids in the adrenal glands
7. Deficiency in Fetal LDL Cholesterol Biosynthesis – pregnancy in a woman deficient in LDL has
been described, but estrogen levels were lower than normal
8. Fetal Erythroblastosis – in some severe cases, the plasma estrogen level is high; likely due to
placental hypertrophy that occurs
9. Decreased Fetal Adrenal Use of LDL – most common cause of decreased placental estrogen
formation (aside from fetal death), is an acquired reduction in fetal adrenal use of plasma LDL
– this has been observed in pregnancies complicated by severe diabetes or HTN; the final
consequence is decreased estrogen levels

Maternal Conditions that Affect Estrogen Formation

1. Glucocorticoid Treatment – moderate to high dose causes striking reduction in placental
estrogen formation; act to inhibit maternal and fetal ACTH secretion, leading to decreased
estrogen precursor i.e. DHEAS
2. Maternal Adrenal Dysfunction – in women with Addison’s disease, estrogen levels are
decreased (decrease primarily affects estrone and 17B-estradiol)
3. Maternal Ovarian Androgen-producing tumors – virtually all androstenedione that enters the
intervillous space is taken up by syncitium and converted to 17B-estradiol (none escapes to the
fetus – so it would be the rare case that a female fetus is virilized by an androgen secreting
maternal tumor – only way this could happen is if a non-aromatizable steroid i.e. 5a-DHT, was
produced)
4. Maternal Renal Disease – lower levels of maternal urinary estriol are seen with pyelo –
presumably due to decreased clearance
5. Maternal Hypertensive disorders and diabetes – in disorders where there is decreased
uteroplacental blood flow, fetal adrenal formation of DHEAS is impaired
6. Gestational Trophoblastic Disease – in complete mole, there is no fetal adrenal source for C19
steroid precursor for trophoblast estrogen biosynthesis, so estrogen synthesis is limited by C19
steroids in the maternal plasma, and the estrogen produced is 17B-estradiol

Directional Secretion of Steroids from Syncitiotrophoblast

 Estrogens synthesized in the syncitium preferentially enter the maternal circulation, same is true of
progesterone
 Very little maternal plasma progesterone crosses the placenta to the fetus, and 85% of the
placental progesterone enters the maternal circulation
 The placental estrogens that enter the maternal circulation are estriol and 17B-estradiol – these
both enter the fetus (in small amounts) also - with estrone preferentially entering
 Placentally produced estriol enters both the mother and fetus, with 90% entering the mother
 Steroids easily enter the maternal circulation as they are produced by the syncitiotrophoblast cells,
since maternal blood bathes these cells
 Steroids from these trophoblasts enter the fetus traverse the cytotrophoblasts and enter the
intervillous space, they must then traverse the walls of the fetal capillaries to reach fetal blood;
this is difficult so the majority of steroids enter the maternal circulation