Obstetrics: Normal and Problem Pregnancies, 5th Edition

1379 Pages·2007·40.8 MB·English

by  Steven G. Gabbe MD

Contributors
KRISTINA M. ADAMS, MD DEBRA L. BOGEN, MD
Assistant Professor, University of Washington, Assistant Professor of Pediatrics, University of
Seattle, Washington Pittsburgh School of Medicine; Children’s Hospital
Maternal-Fetal Immunology of Pittsburgh, Pittsburgh, Pennsylvania
Psychiatric Disorders
MARGARET ALTEMUS, MD
Associate Professor, Weill Medical College, Cornell D. WARE BRANCH, MD
University; Associate Attending Physician, New York Professor, Department of Obstetrics and Gynecology,
Presbyterian Hospital, Weill Cornell Medical Center, and H.A. and Edna Benning Presidential Chair,
New York, New York University of Utah Health Sciences; University of
Psychiatric Disorders Utah LDS Hospital, Salt Lake City, Utah
Collagen Vascular Diseases
GEORGE J. ANNAS, JD, MPH
Edward R. Utley Professor and Chair, Department GRAHAM J. BURTON, MA, MD, DSC
of Health Law, Bioethics, and Human Rights, Professor of Reproductive Biology, Department of
Boston University School of Public Health, Boston, Physiology, Development and Neuroscience,
Massachusetts University of Cambridge, Cambridge, United Kingdom
Legal and Ethical Issues in Obstetric Practice Placental Anatomy and Physiology
AHMET ALEXANDER BASCHAT, MD MITCHELL S. CAPPELL, MD, PHD
Associate Professor, and Director, Fetal Surgery Chief, Division of Gastroenterology, William Beaumont
Program, University of Maryland, Baltimore, Hospital, Royal Oak, Michigan
and University of Maryland Medical Center, Gastrointestinal Disorders
Baltimore, Maryland
Intrauterine Growth Restriction PATRICK M. CATALANO, MD
Professor, Department of Reproductive Biology, Case
LEAH R. BATTISTA, MD Western Reserve University; Chairman, Department
Clinical Instructor, University of California, Irvine, of Obstetrics and Gynecology, MetroHealth Medical
School of Medicine, Irvine; Southern California Center, Cleveland, Ohio
Permanente Medical Group, Baldwin Park, California Diabetes Mellitus Complicating Pregnancy
Abnormal Labor and Induction of Labor
DAVID H. CHESTNUT, MD
RICHARD L. BERKOWITZ, MD Director of Medical Education, Gundersen Lutheran
Professor of Obstetrics and Gynecology, Columbia Health System; Professor of Anesthesiology,
Presbyterian Medical Center, New York, New York University of Wisconsin School of Medicine and
Multiple Gestations Public Health, La Crosse, Wisconsin
Obstetric Anesthesia
HELENE BERNSTEIN, MD, PHD
Assistant Professor of Obstetrics and Gynecology, USHA CHITKARA, MD
David Geffen School of Medicine at UCLA, Professor of Obstetrics and Gynecology, Stanford
Los Angeles, California University School of Medicine, Stanford, California
Maternal and Perinatal Infection—Viral Multiple Gestations
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viii Contributors
JANE CLEARY-GOLDMAN, MD SHERMAN ELIAS, MD
Assistant Clinical Professor of Obstetrics and John J. Sciarra Professor and Chair, Department of
Gynecology, Columbia Presbyterian Medical Center, Obstetrics and Gynecology, Feinberg School of
New York, New York Medicine, Northwestern University; Chair,
Multiple Gestations Department of Obstetrics and Gynecology,
Northwestern Memorial Hospital, Chicago, Illinois
DAVID F. COLOMBO, MD Legal and Ethical Issues in Obstetric Practice
Assistant Professor, Division of Maternal-Fetal
Medicine, Department of Obstetrics and Gynecology, M. GORE ERVIN, PHD
The Ohio State University College of Medicine, Professor and Graduate Coordinator, Department
Columbus, Ohio of Biology, Middle Tennessee State University,
Renal Disease Murfreesboro, Tennessee
Fetal Physiology
LARRY J. COPELAND, MD
Professor and Chair, William Greenville Pace III and
MARK I. EVANS, MD
Joann Norris Collins-Pace Chair, Department
Professor of Obstetrics and Gynecology, Mount Sinai
of Obstetrics and Gynecology, The Ohio State
School of Medicine; President, Fetal Medicine
University College of Medicine, Columbus, Ohio
Foundation of America, and Director, Comprehensive
Malignant Diseases and Pregnancy
Genetics, New York, New York
MYRIAM J. CURET, MD Fetal Therapy
Associate Professor of Surgery, Stanford University;
Stanford Hospital, Stanford, California ALAN W. FLAKE, MD
Surgical Procedures in Pregnancy Professor of Surgery and Obstetrics and Gynecology,
University of Pennsylvania School of Medicine;
JAN DEPREST, MD, PHD Director, Children’s Institute for Surgical Science,
Director, Center for Surgical Technologies, and and Pediatric Surgery Residency Training Program,
Professor of Obstetrics and Gynaecology, Katholieke Children’s Hospital of Philadelphia, Philadelphia,
Universiteit Leuven, Leuven, Belgium Pennsylvania
Fetal Therapy Fetal Therapy
MICHAEL Y. DIVON, MD MICHAEL R. FOLEY, MD
Chairman, Department of Obstetrics and Gynecology, Clinical Professor, University of Arizona, Tucson;
Lenox Hill Hospital, New York, New York Medical Director of Academic Affairs, Scottsdale
Prolonged Pregnancy Healthcare, Scottsdale, Arizona
Antepartum and Postpartum Hemorrhage
MITCHELL P. DOMBROWSKI, MD
Professor and Chair, Department of Obstetrics KARRIE E. FRANCOIS, MD
and Gynecology, St. John Hospital, Detroit,
Clinical Assistant Professor, University of Arizona,
Michigan
Phoenix; Perinatal Medical Director, Scottsdale
Respiratory Diseases in Pregnancy
Healthcare, Scottsdale, Arizona
MAURICE L. DRUZIN, MD Antepartum and Postpartum Hemorrhage
Professor of Gynecology and Obstetrics, and Chief,
STEVEN G. GABBE, MD
Division of Maternal-Fetal Medicine, Department
of Gynecology and Obstetrics, Stanford University Dean, Vanderbilt University School of Medicine;
Medical Center, Stanford, California Professor of Obstetrics and Gynecology,
Vanderbilt University Medical Center, Nashville,
Antepartum Fetal Evaluation
Tennessee
PATRICK DUFF, MD Antepartum Fetal Evaluation; Intrauterine Growth
Professor, Residency Program Director, Department Restriction; Diabetes Mellitus Complicating Pregnancy
of Obstetrics and Gynecology, and Associate
Dean for Student Affairs, University of Florida, HENRY GALAN, MD
Gainesville, Florida Professor and Chief, Section of Maternal-Fetal
Maternal and Perinatal Infection—Bacterial Medicine, and Director, Maternal-Fetal Medicine
Fellowship Program, Department of Obstetrics
THOMAS R. EASTERLING, MD and Gynecology, University of Colorado at Denver
Professor, Obstetrics and Gynecology, University of Health Sciences Center, Denver, Colorado
Washington Medical Center, Seattle, Washington Operative Vaginal Delivery; Intrauterine Growth
Heart Disease Restriction
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Contributors ix
THOMAS J. GARITE, MD JAY D. IAMS, MD
Professor Emeritus, University of California, Irvine; Frederick P. Zuspan Professor and Endowed Chair,
Director of Research and Education, Pediatrix Division of Maternal-Fetal Medicine, Vice-Chair,
Medical Group, Orange, California Department of Obstetrics and Gynecology, The Ohio
Intrapartum Fetal Evaluation State University, Columbus, Ohio
Preterm Birth
ETOI GARRISON, MD, PHD
Assistant Professor of Obstetrics and Gynecology,
ERIC R. M. JAUNIAUX, MD, PHD
Vanderbilt University Medical Center, Nashville,
Professor and Honorary Consultant, Academic
Tennessee
Department of Obstetrics and Gynecology,
Normal Labor and Delivery; Operative Vaginal Delivery
Institute of Women’s Health, Royal Free and
WILLIAM M. GILBERT, MD University College London Medical School, London,
United Kingdom
Professor of Obstetrics and Gynecology, University
Placental Anatomy and Physiology; Pregnancy Loss
of California, Davis; Regional Medical Director,
Women’s Services, Sutter Health, Sac-Sierra Region,
Sutter Medical Center, Sacramento, California TIMOTHY R. B. JOHNSON, MD
Amniotic Fluid Disorders Chair and Bates Professor of Diseases of Women
and Children, Arthur F. Thurnau Professor, and
LAURA GOETZL, MD, MPH Professor, Women’s Studies, Department of
Assistant Professor, Department of Obstetrics- Obstetrics and Gynecology, University of Michigan
Gynecology, Medical University of South Carolina, Health System, Ann Arbor, Michigan
Charleston, South Carolina Preconception and Prenatal Care: Part of the Continuum
Obstetric Anesthesia
VERN L. KATZ, MD
MICHAEL C. GORDON, MD
Clinical Professor of Obstetrics and Gynecology,
Associate Professor, University of Texas Health Science
Oregon Health Science University, Portland; Adjunct
Center at San Antonio, San Antonio, Texas
Professor of Physiology, University of Oregon,
Maternal Physiology
Eugene; Medical Director, Obstetric Services,
Sacred Heart Medical Center, Eugene, Oregon
KIMBERLY D. GREGORY, MD, MPH
Postpartum Care
Vice Chair, Women’s Healthcare Quality and
Performance Improvement, Cedars-Sinai Medical
Center, Los Angeles, California SARAH KILPATRICK, MD, PHD
Preconception and Prenatal Care: Part of the Continuum Professor, and Chief of Service/Physician Surgeon,
University of Illinois at Chicago, Chicago, Illinois
MICHAEL R. HARRISON, MD Normal Labor and Delivery; Operative Vaginal Delivery
Professor of Surgery, Pediatrics, Obstetrics, Gynecology
and Reproductive Sciences, and Director, CHARLES KLEINMAN, MD
Fetal Treatment Center, University of California, Adjunct Professor of Clinical Pediatrics, and Attending
San Francisco, San Francisco, California Physician, New York Presbyterian Hospital; Professor
Fetal Therapy of Clinical Pediatrics, Columbia University College of
Physicians and Surgeons, New York, New York
JOY L. HAWKINS, MD
Fetal Therapy
Professor of Anesthesiology, University of Colorado
School of Medicine; Director of Obstetric Anesthesia,
GEORGE KROUMPOUZOS, MD, PHD
University of Colorado Hospital, Denver, Colorado
Clinical Assistant Professor of Dermatology, Brown
Obstetric Anesthesia
Medical School, Providence, Rhode Island
CALLA HOLMGREN, MD Hepatic Disorders; Dermatologic Disorders of Pregnancy
Fellow, University of Utah; LDS Hospital,
Salt Lake City, Utah DANIEL V. LANDERS, MD
Collagen Vascular Diseases Former Director, Maternal-Fetal Medicine, University
of Minnesota Medical School; Maternal-Fetal
WOLFGANG HOLZGREVE, MD Medicine Specialist, San Diego Perinatal Center,
Chairman and Chief of Service, Department of Sharp Mary Birch Hospital for Women,
Obstetrics and Gynecology, University of Basel, San Diego, California
Basel, Switzerland Maternal and Perinatal Infection: The Sexually Transmitted
Genetic Counseling and Genetic Screening Diseases Chlamydia, Gonorrhea, and Syphilis
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x Contributors
MARK B. LANDON, MD KENNETH J. MOISE, JR., MD
Professor and Vice Chairman, and Director of Professor of Obstetrics and Gynecology, Baylor College
Maternal-Fetal Medicine, Department of Obstetrics of Medicine, Houston, Texas
and Gynecology, The Ohio State University College Red Cell Alloimmunization
of Medicine, Columbus, Ohio
EDWARD R. NEWTON, MD
Cesarean Delivery; Diabetes Mellitus Complicating
Professor and Chairman, Department of Obstetrics and
Pregnancy; Malignant Diseases and Pregnancy
Gynecology, Brody School of Medicine, East
SUSAN M. LANNI, MD Carolina University, Greenville, North Carolina
Breast-Feeding
Associate Professor of Obstetrics and Gynecology and
Maternal-Fetal Medicine, and Director, Labor and JENNIFER R. NIEBYL, MD
Delivery, Virginia Commonwealth University Medical
Professor and Head, Department of Obstetrics and
Center, Richmond, Virginia
Gynecology, University of Iowa Hospitals and
Malpresentations
Clinics, University of Iowa College of Medicine,
Iowa City, Iowa
CHARLES J. LOCKWOOD, MD
Preconception and Prenatal Care: Part of the Continuum;
The Anita O’Keefe Young Professor and Chair, Drugs and Environmental Agents in Pregnancy and
Department of Obstetrics, Gynecology and Lactation: Embryology, Teratology, Epidemiology;
Reproductive Sciences, Yale University School of Neurologic Disorders
Medicine; Chief of Obstetrics and Gynecology,
Yale-New Haven Hospital, New Haven, Connecticut PETER E. NIELSEN, MD
Thromboembolic Disorders Adjunct Associate Professor of Obstetrics and
Gynecology, F. Edward Hébert School of Medicine,
ERIKA J. LU, MD Uniformed Services University of the Health Sciences,
Bethesda, Maryland; Clinical Associate Professor of
Resident, Department of Surgery, Stanford University
Obstetrics and Gynecology, University of Washington
and Stanford Hospital, Stanford, California
School of Medicine, Seattle, Washington; Chairman,
Surgical Procedures in Pregnancy
Department of Obstetrics and Gynecology, Madigan
JACK LUDMIR, MD Army Medical Center, and Obstetrics/Gynecology
Consultant to The Surgeon General, United States
Professor, Obstetrics and Gynecology, University of
Army Medical Command, Madigan Army Medical
Pennsylvania School of Medicine; Chief, Department
Center, Tacoma, Washington
of Obstetrics and Gynecology, Pennsylvania Hospital,
Operative Vaginal Delivery
University of Pennsylvania Health System,
Philadelphia, Pennsylvania DONALD NOVAK, MD
Cervical Incompetence
Professor of Pediatrics, University of Florida; Vice
Chair of Clinical Affairs, Shands Children’s Hospital,
MAUREEN P. MALEE, PHD, MD Gainesville, Florida
Director, Division of Maternal-Fetal Medicine, Fetal Physiology
Department of Obstetrics and Gynecology,
Vanderbilt University Medical Center, Vanderbilt LUCAS OTAÑO, MD
University School of Medicine, Nashville, Tennessee Professor, Division of Obstetrics and Gynecology,
Pituitary and Adrenal Disorders in Pregnancy Hospital Italiano de Buenos Aires, Buenos Aires,
Argentina
BRIAN M. MERCER, MD, FRCSC, FACOG Prenatal Genetic Diagnosis
Professor, Reproductive Biology, Case Western Reserve
JOHN OWEN, MD
University; Vice Chair, Director of Obstetrics
Professor of Obstetrics and Gynecology, University of
and Maternal-Fetal Medicine, Department of
Alabama at Birmingham, Birmingham, Alabama
Obstetrics and Gynecology, MetroHealth Medical
Cervical Imcompetence
Center, Cleveland, Ohio
Premature Rupture of the Membranes JOHN PAPOUTSIS, PHD
Professor, School of Administration of Health Units
JORGE H. MESTMAN, MD and Welfare, TEI of Antikalamos, Messinia, Greece
Professor of Medicine and Obstetrics and Gynecology,
Dermatologic Disorders of Pregnancy
Keck School of Medicine, University of Southern
California, Los Angeles, California JAMES M. PEREL, PHD
Thyroid and Parathyroid Diseases in Pregnancy Professor Emeritus of Psychiatry, Professor of
Pharmacology and Graduate Neuroscience,
DAWN MISRA, MHS, PHD University of Pittsburgh; Director of Clinical
Associate Professor, University of Michigan School of Pharmacology, Western Psychiatric Institute and
Public Health, Ann Arbor, Michigan Clinic, Pittsburgh, Pennsylvania
Psychiatric Disorders Psychiatric Disorders
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Contributors xi
CHRISTIAN M. PETTKER, MD PHILIP SAMUELS, MD
Instructor, Yale University School of Medicine; Director, Residency Program, Department of Obstetrics
Clinical Fellow, Division of Maternal-Fetal and Gynecology, The Ohio State University/Mount
Medicine, Department of Obstetrics, Gynecology and Carmel Health; Associate Professor, Division of
Reproductive Sciences, Yale-New Haven Hospital, Maternal-Fetal Medicine, Department of Obstetrics
New Haven, Connecticut and Gynecology, The Ohio State University College
Thromboembolic Disorders of Medicine, Columbus, Ohio
Renal Disease; Hematologic Complications of Pregnancy;
KIRK D. RAMIN, MD Neurologic Disorders
Professor, Department of Obstetrics and Gynecology,
and Interim Director, Maternal-Fetal Medicine, JOHN W. SEEDS, MD
University of Minnesota Medical School; Interim Professor and Chairman of Obstetrics and Gynecology,
Director, Maternal-Fetal Medicine, University of Virginia Commonwealth University Medical Center,
Minnesota Medical Center, Minneapolis, Richmond, Virginia
Minnesota Malpresentations
Maternal and Perinatal Infection: The Sexually Transmitted
LAURENCE E. SHIELDS, MD
Diseases Chlamydia, Gonorrhea, and Syphilis
Former Professor of Obstetrics and Gynecology,
University of Washington, Seattle, Washington;
KATHRYN L. REED, MD
Staff Perinatologist, Sierra Vista Medical Center,
Professor and Head of Obstetrics and Gynecology,
San Luis Obispo, California
University of Arizona College of Medicine,
Maternal-Fetal Immunology
Tucson, Arizona
Antepartum Fetal Evaluation BAHA M. SIBAI, MD
Professor, University of Cincinnati College of Medicine;
SARAH K. REYNOLDS, PHD The University Hospital, Cincinnati, Ohio
Assistant Professor of Psychiatry, Western Psychiatric Hypertension
Institute and Clinic, University of Pittsburgh Medical
Center, Pittsburgh, Pennsylvania COLIN P. SIBLEY, PHD
Psychiatric Disorders Professor of Child Health and Physiology, Division of
Human Development, The Medical School, Univer-
DOUGLAS S. RICHARDS, MD sity of Manchester, Manchester, United Kingdom
Professor, Obstetrics and Gynecology, University of Placental Anatomy and Physiology
Florida College of Medicine; Director of Ultrasound
JOE LEIGH SIMPSON, MD
Section, Department of Obstetrics, University of
Florida College of Medicine, Gainesville, Florida Executive Associate Dean for Academic Affairs,
Ultrasound for Pregnancy Dating, Growth, and the Professor of Obstetrics and Gynecology, and
Diagnosis of Fetal Malformations Professor of Human and Molecular Genetics,
Florida International University College of Medicine,
ROBERTO ROMERO, MD Miami, Florida
Genetic Counseling and Genetic Screening; Prenatal
Chief, Perinatology Research Branch, and Program
Genetic Diagnosis; Drugs and Environmental Agents in
Director of Obstetrics and Perinatology, National
Pregnancy and Lactation: Embryology, Teratology,
Institute of Clinical Health and Human Development,
Epidemiology; Pregnancy Loss
National Institutes of Health/Department of Health
and Human Services, Bethesda, Maryland; Professor, DOROTHY K. Y. SIT, MD
Molecular Obstetrics and Genetics, Wayne State
Assistant Professor of Psychiatry, Department of
University School of Medicine, Detroit, Michigan
Psychiatry, University of Pittsburgh School of
Preterm Birth Medicine, Western Psychiatric Institute and Clinic,
Women’s Behavioral Healthcare, Pittsburgh,
ADAM A. ROSENBERG, MD Pennsylvania
Professor of Pediatrics, University of Colorado School Psychiatric Disorders
of Medicine; Director of Newborn Services, Denver,
Colorado JAMES F. SMITH JR., MD
The Neonate Clinical Associate Professor, Department of Obstetrics
and Gynecology, Stanford University School of
MICHAEL G. ROSS, MD, MPH Medicine, Stanford, California
Professor of Obstetrics and Gynecology and Public Antepartum Fetal Evaluation
Health, David Geffen School of Medicine at UCLA,
Los Angeles; Chairman of Obstetrics and KAREN STOUT, MD
Gynecology, Harbor-UCLA Medical Center, Assistant Professor, Medicine/Cardiology, University of
Torrance, California Washington Medical School, Seattle, Washington
Fetal Physiology; Intrauterine Growth Restriction Heart Disease
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xii Contributors
KEERTHY R. SUNDER, MD KATHERINE L. WISNER, MD, MS
Staff Psychiatrist, City and County of San Francisco, Professor of Psychiatry, Obstetrics and Gynecology
San Francisco, California \and Reproductive Sciences, and Epidemiology,
Psychiatric Disorders University of Pittsburgh School of Medicine;
Director, Women’s Behavioral Healthcare, and
JANICE E. WHITTY, MD
Associate Member, Magee Women’s Research
Professor and Director of Maternal-Fetal Medicine, Institute, Western Psychiatric Institute and Clinic,
Department of Obstetrics and Gynecology, Meharry University of Pittsburgh Medical Center, Pittsburgh,
Medical College, Nashville, Tennessee Pennsylvania
Respiratory Diseases in Pregnancy Psychiatric Disorders
DEBORAH A. WING, MD
Associate Professor of Clinical Obstetrics and Gyne-
cology, University of California, Irvine, School of
Medicine, Irvine; Associate Professor and Director,
Division of Maternal-Fetal Medicine, Department of YUVAL YARON, MD
Obstetrics and Gynecology, University of California, Director, Prenatal Diagnosis Unit, Genetic Institute,
Irvine, Medical Center, Orange, California Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
Abnormal Labor and Induction of Labor Fetal Therapy
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Preface to the Fifth Edition
Welcome to the fi fth edition of Obstetrics: Normal who have continued to contribute. A special tribute is
and Problem Pregnancies! For those readers who have due to 10 leaders in our specialty who have written
included our previous editions in their libraries, we chapters in every edition of our textbook: Drs. George J.
greatly appreciate your continued loyalty and support. Annas, Richard L. Berkowitz, D. Ware Branch, Sherman
For our new readers, we believe you will fi nd this book Elias, Timothy R. B. Johnson, Mark B. Landon, Adam
a valuable resource in your study of normal and high-risk A. Rosenberg, Phillip Samuels, John W. Seeds, and Baha
obstetrics. Sibai.
Like its four predecessors, this book provides an in- We greatly appreciate the support of our new pub-
depth presentation of the basic science and physiology of lisher, Elsevier, who has joined us for this fi fth edition.
normal and complicated obstetrics followed by chapters We have synergistically made signifi cant changes that
describing the most updated, evidence-based information should benefi t our readers. Illustrations are now in full
on normal obstetrics and high-risk obstetrics. The efforts color. Each chapter provides a list of key abbreviations
of a new team of associate editors, the contributions of that will facilitate reading. A paginated outline appears at
more than 30 new authors, and a new publisher have the beginning of each chapter making it easier to locate
enabled us to greatly enhance the content and access to information on specifi c topics. The edges of the pages for
the information in this fi fth edition. Four carefully chosen the two appendices have been colored so that they can
new associate editors, Drs. Henry Galan, Laura Goetzl, be quickly located.
Mark Landon, and Eric Jauniaux, each bring their own We recognize the outstanding efforts of Melissa Dudlick,
expertise and insight to this fi fth edition. The addition of Judith Fletcher, Rebecca Gaertner, Stephanie Donley and
an international editor from London, Dr. Jauniaux, has their team at Elsevier. In addition to the Elsevier staff, the
enabled us to expand the coverage of this text to include editors have had the invaluable editorial and secretarial
information on clinical care from abroad. support of Robyn Cosby, Nancy Schaapveld, and Belinda
Life-long learning has become essential for the best Felder. Because this fi fth edition will be online and will
practice of obstetrics. Our readers will fi nd 14 new chap- be continually updated, this entire team will continue to
ters, many added to refl ect important changes in our work closely with the editors.
knowledge base since the fourth edition in 2001. These Nearly 25 years ago, the three of us met to discuss
new chapters include placental anatomy and physiology, our plans for the fi rst edition of Obstetrics: Normal
immunology of pregnancy, diagnostic techniques for pre- and Problem Pregnancies. Like most medical specialties,
natal diagnosis, management of abnormal labor, operative obstetrics has since become more complex and challeng-
vaginal delivery, cervical incompetence, preterm prema- ing. Yet, we continue to feel strongly that the practice of
ture rupture of the membranes, amniotic fl uid disorders, normal and high-risk obstetrics remains among the most
thyroid and parathyroid diseases, adrenal and pituitary fascinating and rewarding in medicine and nursing. We
disorders, thromboembolic disorders, sexually transmit- believe that this fi fth edition will not only serve as an
ted diseases, viral infections, and psychiatric disorders. inspiration to those considering a career in obstetrics and
An appendix of normal laboratory values has been added gynecology but will also be a valued resource for those
to accompany the appendix on anatomy. who have already joined us in this exciting fi eld.
This fi fth edition includes more than 30 authors who
have joined us for the fi rst time, and we greatly value Steven G. Gabbe, MD
the new information they have brought to our readers. Jennifer R. Niebyl, MD
We also want to recognize the 29 outstanding authors Joe Leigh Simpson, MD
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Placental Anatomy and
Physiology
GRAHAM J. BURTON, COLIN P. SIBLEY, AND ERIC R. M. JAUNIAUX
CHAPTER 1
Introduction 3 The Topology of the Villous Bulk Flow/Solvent Drag 15
Overview of the Delivered Trees 10 Diffusion 15
Placenta 3 Placental Histology 11 Transporter-Protein–Mediated
Placental Development 4 The Integrity of the Villous Processes 16
The Amnion and Yolk Sac 6 Membrane 12 Endocytosis/Exocytosis 17
The Maternofetal Relationship During Placental Vasculature 13 Placental Nutrient Supply and
the First Trimester 6 Physiology of the Secondary Yolk Sac Intrauterine Growth Restriction 17
Extravillous Trophoblast and Exocoelomic Cavity 13 Placental Endocrinology 17
Invasion and Physiologic Conversion Placental Transport 14 Progesterone 17
of the Spiral Arteries 7 Overview of the Exchange Physiology Estrogens 18
The Role of the Endometrium During of the Placenta and Its Development Human Chorionic Gonadotropin 18
the First Trimester 9 Over Gestation 15 Placental Growth Hormone 19
INTRODUCTION
KEY ABBREVIATIONS
The placenta is a remarkable organ. During a relatively
Alpha-fetoprotein AFP short life span, it undergoes rapid growth, differentiation,
adenosine triphosphate ATP and maturation. At the same time, it performs diverse
Cyclic adenosine monophosphate cAMP functions, including the transport of gases and meta-
Cyclic guanosine monophosphate cGMP bolites, immunologic protection, and the production of
Cytochrome P450scc P450scc steroid and protein hormones. As the interface between
Dehydroepiandrosterone DHA the mother and her fetus, the placenta plays a key role
Dehydroepiandrosterone sulfate DHAS in ensuring a successful pregnancy. In this chapter, we
Epidermal growth factor EGF review the structure of the human placenta, and relate
Exocoelomic cavity ECC this to the contrasting functional demands placed on the
Glucose transporter 1 GLUT1 organ at different stages of gestation. Because many of
Human chorionic gonadotropin hCG the morphologic features are best understood through an
Human chorionic sommatotropin hCS understanding of the organ’s development, and because
Human immunodefi ciency virus HIV many complications of pregnancy arise through aberra-
Human placental lactogen hPL tions in this process, we will approach the subject from
Insulin-like growth factor IGF this perspective. First, however, for the purposes of ori-
Immunoglobulin G IgG entation and to introduce some basic terminology we
Intervillous space IVS provide a brief description of the macroscopic appear-
Intrauterine growth restriction IUGR ance of the delivered organ, with which readers are most
Luteinizing hormone LH likely to be familiar.
Nicotinamide-adenine dinucleotide NADPH
phosphate
P450 cytochrome aromatase P450arom OVERVIEW OF THE DELIVERED
Potential difference PD PLACENTA
Placental growth hormone PGH
Steroidogenic acute regulatory StAR At term, the human placenta is usually a discoid organ,
protein 15 to 20 cm in diameter, approximately 3 cm thick at the
Secondary yolk sac SYS center, and weighing on average 500 g. These data show
Type 1 3β-hydroxysteroid 3β-HSD considerable individual variation and are also infl uenced
dehydrogenase strongly by the mode of delivery.1,2 Macroscopically, the
organ consists of two surfaces or plates; the chorionic
3
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4 Section I Physiology
Umbilical cord
Chorion laeve
Amnion
Chorionic plate
Basal plate
Stem villus
Septum
MC Spiral artery
Lobe
Lobule Intervillous space
Figure 1-1. Cross-section through a mature placenta showing the chorionic and basal plates bounding the intervillous space. The
villous trees arise from stem villi attached to the chorionic plate, and they are arranged as lobules centered over the openings
of the maternal spiral arteries.
plate to which the umbilical cord is attached, and the basal core containing branches of the umbilical arteries and
plate that abuts the maternal endometrium (Fig. 1-1). tributaries of the umbilical vein. Because of this repeated
Between the two plates is a cavity that is fi lled with branching, the tree takes on the topology of an inverted
maternal blood, delivered from the endometrial spiral wine glass, often referred to as a lobule, and there may
arteries through openings in the basal plate. This cavity be two to three within a single placental lobe (Fig. 1-1).
is bounded at the margins of the disc by the fusion of As is seen later, each lobule represents an individual
the chorionic and basal plates, and the smooth chorion, maternofetal exchange unit. Toward term, the continual
or chorion laeve, extends from the rim to complete the elaboration of the villous trees almost fi lls the cavity of the
chorionic sac. The placenta is incompletely divided into placenta, which is reduced to a network of narrow spaces
10 to 40 lobes by the presence of septae created by collectively referred to as the intervillous space (IVS). The
invaginations of the basal plate. The septae are thought maternal blood percolates through this network of chan-
to arise from differential resistance of the maternal tissues nels, exchanging gases and nutrients with the fetal blood
to trophoblast invasion, and they may help to compart- circulating within the villi, before draining through the
mentalise maternal blood fl ow through the organ. The basal plate into openings of the uterine veins. Therefore,
fetal component of the placenta comprises a series of the human placenta is classifi ed in comparative mam-
elaborately branched villous trees that arise from the malian terms as being of the villous hemochorial type,3,4
inner surface of the chorionic plate and project into the although as we shall see, this arrangement really pertains
cavity of the placenta. This arrangement is somewhat only to the second and third trimesters of pregnancy.5
reminiscent of the fronds of a sea anemone wafting in the
seawater of a rock pool. Most commonly, each villous tree
originates from a single stem villus that undergoes several PLACENTAL DEVELOPMENT
generations of branching until the functional units of the
placenta, the terminal villi, are created. These consist of Development of the placenta is initiated morphologi-
an epithelial covering of trophoblast, and a mesodermal cally at the time of implantation, when the embryonic
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