The Placenta

December 14, 2007

As an obstetrician, I am privileged to be in a specialty whose texts are some of the most beautifully written in medicine. The "Bible" of obstetrics, Williams Obstetrics, has a long tradition of beautiful writing, and it's a shame the general public is seldom exposed to it.  It is with this prelude that I continue, offering quotes from this graceful book for the enjoyment of all when talking about the human body's most amazing anatomical part.

It may not be pretty to look at, but it's the most beautiful organ there is. In the Old Testament it was thought to be the External Soul. In 1559 a man named Realdus Columbus called it "Placenta," after the Latin word for "circular cake." (Ref., Williams Obstetrics, 18thedition.)

The Function of the Placenta

The placenta is part of the communication between the fetus and the expectant mother. Most people tend to think of this communication as the route of exchange where the mother's blood and the fetus's blood mix and exchange, but the fetal blood and maternal blood do not mix. In fact, if this were to be the case, there would be such immunological protest from the mother that she would soon make antibodies to the baby's blood enough to destroy the pregnancy. So what exactly is meant by communication between the fetus and mother, and if no blood is exchanged, how does oxygen and nutrition get passed on to the developing baby?

The "blastocyst," an early cellular developmental stage of the soon-to-be embryo, is the principal influence in its own implantation (nidation) in the uterus (womb). From this early on there are chemical communications, and these chemical and hormonal messages continue in the best interest of the pregnancy until birth. Labor and lactation (milk let-down) are dependent on this communication.

It used to be felt that the baby was just along for the ride, not actively doing anything.

 

"It is now known that this is not the case. To comprehend the nature and importance of the fetal-maternal communication system of human pregnancy, it is important to acknowledge that the fetus enjoys a position of protection from the external environment that is never to be experienced again in life; but at the same time, it must be recognized that the fetus is the dynamic force in the orchestration of its own destiny." (Williams.)

The blastocyst causes the irritation that alters the lining of the uterus in such a way as to allow implantation. The pregnancy hormone, "hCG," is made by the blastocyst and embryo and causes that part of the ovary that makes progesterone, necessary for the rich lining of the womb, to continue until the fetal tissue can make its own. There are chemicals called prostaglandins that normally are made by the lining when pregnancy does not take place, and these chemicals cause that part of the ovary making progesterone to quit; the implanting blastocyst prevents this production of prostaglandins, the ovary continues making progesterone, and the implanted embryo is therefore protected by the rich uterine lining. Prostaglandins, by the way, are just one ingredient in the gumbo of biochemistry that initiates labor nine months later, so it appears that in keeping with the phrase "that the fetus is the dynamic force in the orchestration of its own destiny" that the fetus also contributes signals that promote the onset of labor and when to be born.

The mother's immune system doesn't reject the baby as a foreign transplanted organ because the blastocyst suppresses the irritants that promote rejection (called HLA antigens). This is called by Williams "Fetal contributions to the maternal acceptance of the...fetal graft."

Because of this, "the placenta and...fetal membranes appear to defy the laws of transplantation immunology."

Try transplanting a man's kidney into his wife and there will be trouble for sure.

Or even a rib!

Progesterone, made from cholesterol (of all things!) and made in abundance (lucky for us), seems to make a wonderful anti-inflammatory agent. We know this isn't the only chemical allowing the maternal tissue to forgive this invasion, but we also know it plays an important role. Another thing that helps is the complete separation of the maternal and fetal circulation. As stated above, there is no direct connection between the fetal bloodstream and the maternal bloodstream.
The placenta grows into the maternal uterine lining, but no blood vessels connect up to the mother's, like was once thought. Instead, the fetal red blood cells end their journey in a U-turn in very vascular capillaries; these capillaries sit in puddles, so to speak, called intervillous spaces. These are puddles of maternal blood that bathe the lining of the placental capillaries. The fetal tissue so bathed takes out of the maternal blood what the developing baby needs, leaving the rest for the mother. "The fetus is a demanding and efficient parasite," and its agent is the placenta.
Special tissue of the placenta, cells called "trophoblasts," are the cells that receive diffused and transferred substances from the mother's blood (those puddles). This interchange--handling oxygen, carbon dioxide, nutrients going in, and waste going out--provides in effect lungs, kidneys, stomach, and intestines. "Erasmus Darwin, in 1796, only 22 years after the discovery of oxygen, reasoned that the function of the placenta was comparable with that of the lungs and gills."(Williams.)

Labor And Delivery

Labor has been designated as having official "stages." The third stage of labor is when the placenta is delivered (after stages one and two which involve labor and delivery of the infant). It must be remembered that the uterus is a big sphere of muscle with an opening in the right place to expel a baby. When that baby no longer occupies the space inside the uterus, the uterus contracts down. Like a balloon that's been untied, the amount of surface area within gets smaller. Since the placenta is attached to the uterine wall, a property dependent on the original implantation of the blastocyst, this attached area gets smaller, causing the uterus to crimp.

"The separation of the placenta results primarily from the disproportion created between the unchanged size of the placenta and the reduced size of the underlying implantation site." (Williams.)

Since the net vector forces of the uterine contractions are outward, the placenta, once separated, follows the way of it's companion--the baby--to the outside world. And with the end of the third stage of labor, we say goodbye to the most important organ we've ever had. Beautiful.

Source: Williams Obstetrics, 18th Edition, F. Gary Cunningham, M.D., Paul C. MacDonald, M.D., Norman F. Grant, M.D., Appleton & Lange, Publishers.

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