Ebook Concise Clinical Embryology An Integrated Case Based Approach PDF Full Chapter PDF

Concise Clinical Embryology: an
Integrated, Case-Based Approach -

eBook PDF
Visit to download the full and correct content document:
https://ebooksecure.com/download/concise-clinical-embryology-an-integrated-case-b
ased-approach-ebook-pdf/
Any screen.
Any time.
Anywhere.
Activate the eBook version
of this title at no additional charge.
Student Consult eBooks give you the power to browse and find content,
view enhanced images, share notes and highlights—both online and offline.
Unlock your eBook today.

1 Visit studentconsult.inkling.com/redeem
2 Scratch off your code
3 Type code into “Enter Code” box
4 Click “Redeem”
5 Log in or Sign up
6 Go to “My Library”
Place Peel Off
It’s that easy! Sticker Here
For technical assistance:

email [email protected]
call 1-800-401-9962 (inside the US)
call +1-314-447-8200 (outside the US)
Use of the current edition of the electronic version of this book (eBook) is subject to the terms of the nontransferable, limited license granted on
studentconsult.inkling.com. Access to the eBook is limited to the first individual who redeems the PIN, located on the inside cover of this book, at
studentconsult.inkling.com and may not be transferred to another party by resale, lending, or other means.
2015v1.0
CONCISE CLINICAL
EMBRYOLOGY
AN INTEGRATED,
CASE-BASED APPROACH
Mark G. Torchia, DipBT, MSc, PhD

Associate Professor, Department of Surgery and Department of
Human Anatomy and Cell Sciences, Max Rady College of Medicine,
Rady Faculty of Health Sciences, University of Manitoba
Vice-Provost (Teaching and Learning), University of Manitoba
Winnipeg, Manitoba, Canada
T.V.N. (Vid) Persaud MD, PhD, DSc, FRCPath (Lond.), FAAA

Professor Emeritus and Former Head, Department of
Human Anatomy and Cell Science
Professor of Pediatrics and Child Health
Associate Professor of Obstetrics, Gynecology,
and Reproductive Sciences
Max Rady College of Medicine, Rady Faculty of Health Sciences,
University of Manitoba, Winnipeg, Manitoba, Canada
Elsevier
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
CONCISE CLINICAL EMBRYOLOGY:

AN INTEGRATED, CASE-BASED APPROACH ISBN: 978-0-323-69615-9
Copyright © 2021 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or any information storage and retrieval system, without permission in writing
from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies
and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency,
can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than
as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using
any information, methods, compounds or experiments described herein. Because of rapid advances in the medical
sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest
extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or
damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or
operation of any methods, products, instructions, or ideas contained in the material herein.
Library of Congress Control Number: 2020951836
Content Strategist: Jeremy Bowes

Content Development Specialist: Erika Ninsin
Publishing Services Manager: Deepthi Unni
Project Manager: Srividhya Vidhyashankar
Design Direction: Margaret Reid
Printed in United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Mark:
For Eddie James Torchia
Our dear grandson and little ray of sunshine.
To my wife, Barbara, our children Erik and Muriel, and their spouses Sarah and Caleb
- thank you for your love and support.
Vid:
For Gisela
My lovely wife and best friend, for her endless support and patience.
Preface
This comprehensive yet concise textbook is designed for ongoing discussion amongst peers, advanced learning and
students in all health fields learning human embryology, knowledge testing.
as well as for the review of human embryology in clinical Each chapter also provides fundamental molecular biol-
practice. The text is copiously illustrated to provide visual ogy considerations. This information is derived from the
cues and resources for better understanding. Accompany- extant literature and is based mainly on experiments with
ing this book, in online format, are 18 exceptional colour animal models including mice because the human cells or
animations, with narrations, which will assist the student tissues required to examine such science are not generally
in learning the various stages of human embryo and fetal available. As such, keep in mind that as knowledge of mo-
development. lecular genetics and biology progresses, the specific genes
A clinical case scenario is provided at the beginning of and their products that are identified may change or be ex-
each chapter. These cases are not straightforward and many panded upon.
of the concepts or considerations will require the reader The section on Clinical Issues in each chapter provides a
to seek information outside the direct field of clinical em- description of the common congenital anomalies and other
bryology; this helps to place the knowledge and details clinical information related to the embryology details con-
of embryology within the larger concept of clinical care. tained in the chapter. Finally, each chapter has a brief refer-
Follow-on scenarios for each case are found at the end of ence list that can be used to find additional details about the
each chapter and provide the reader with an opportunity to clinical cases, molecular biology and clinical embryology.
further expand the ability to problem solve, think broadly Learners wanting to test their knowledge or prepare for
and search for answers beyond this textbook. Answers are examinations will also benefit from the multiple choice
not provided to these cases so that they can be used for questions we have provided through the website.
vi
Acknowledgements
We are indebted to Mr. Jeremy Bowes, Senior Content Project Manager/Health Content Manager for their help-
Strategist, for his invaluable insights and unstinting sup- ful suggestions. Finally, we would like to Dr. Brad Smith,
port in the preparation of Concise Clinical Embryology. University of Michigan, for graciously providing the image
We are particularly grateful to Ms. Erika Ninsin, Content (Carnegie Stage 18 human embryo) which is on the cover
Development Specialist, Ms. Meghan Andress, Content of this book (Imaging performed at the Center for In-Vivo
Development Manager, and Ms. Sri Vidhya Vidhyashankar, Microscopy, Duke University).
vii
Contents
SECTION 1
GENERAL DEVELOPMENT SECTION 2
DEVELOPMENT OF
OF THE EMBRYO AND ORGAN SYSTEMS
FETUS
8 Development of the Cardiovascular,
1 Introduction 2 Haematopoietic and Lymphatic Systems 44
2 Reproductive Organs and Gametogenesis 4 9 Development of the Body Cavities, Diaphragm,

Respiratory System, and Head and Neck 58
3 Fertilisation and Reproductive
Technologies 12 10 Development of the Nervous System, Eyes and
Ears 71
4 Implantation and Week 2 18
11 Development of the Alimentary System 82
5 Weeks 3 to 8—General Organogenesis 23
12 Development of the Urogenital System 89
6 Placentation and Membranes 31
13 Development of Skeletal, Muscular and
7 Fetal and Neonatal Period 37 Integumentary Systems 98
14 Teratogenesis and Birth Defects 107
Multiple Choice Question Answers 112
Index 115
viii
Video Table of Contents
Video 3.1 Fertilisation 12 Video 9.3 Pharyngeal Apparatus 64
Video 3.2 Blastocyst 12 Video 9.4 Face and Palate 66
Video 4.1 Implantation 18 Video 10.1 Nervous System 71
Video 5.1 Gastrulation 23 Video 10.2 Eyes 76
Video 5.2 Folding 28 Video 10.3 Ears 78
Video 8.1 Heart 44 Video 11.1 Gastrointestinal 82
Video 8.2 Vascular 49 Video 12.1 Urinary 89
Video 9.1 Body Cavities 58 Video 12.2 Reproductive System 91
Video 9.2 Respiratory System 61 Video 13.1 Limbs 101
ix
SECTION 1
GENERAL DEVELOPMENT OF
THE EMBRYO AND FETUS
PART OUTLINE
1 Introduction 4 Implantation and Week 2
2 Reproductive Organs and 5 Weeks 3 to 8—General
Gametogenesis Organogenesis
3 Fertilisation and Reproductive 6 Placentation and Membranes
Technologies 7 Fetal and Neonatal Period
1 Introduction
visual resource to further enhance the textual explanations
Case Scenario and development paths.
A clinical case scenario is provided for each chapter. As
A 26-year-old woman (GW) presents to you, a nurse practitio-
you will discover, the cases are not straightforward, and many
ner at a public health clinic, with severe odynophagia. The his-
tory and physical examination leads you to strongly believe she of the words, concepts or considerations will require the
has a streptococcal pharyngitis; a swab is taken for rapid strep reader to seek information outside the direct field of clinical
test (which is positive) and you prescribe amoxicillin. When you embryology—this helps to situate the knowledge and details
inquire about her obvious pregnancy, GW reports being ap- of embryology within the larger concept of clinical care. The
proximately 5 months pregnant based on when she remem- clinical case in this chapter is a good example. You will need
bered having had her last menstrual period. She said that the to consider, for example, infectious disease, genetics, phar-
father is a 55-year-old companion. GW has been living on the macology and neonatal cardiology and combine that knowl-
street and in shelters for the past year since discharge from edge to answer the question. The follow-on scenarios to the
an inpatient facility for treatment of a crystal methamphetamine original case, found at the end of each chapter, will further
addiction. She vehemently denies use of methamphetamine
expand your need to problem solve, think broadly and search
since that treatment. She has not sought any other medical
care in the interim. GW has had only one previous pregnancy for answers beyond this textbook. Answers are not provided
which resulted in the birth of a son, now 5 years old, and cur- to the cases so that they can be used for ongoing discussion
rently living with the maternal grandparents. Her son was born amongst peers, advanced learning and knowledge testing.
with a bilateral cleft palate. You recommend a fetal ultrasound Each chapter also provides molecular biology consider-
as soon as possible, to which she agrees. ations. This information is based mainly on experiments
Questions for reflection: Why might an ultrasound fetal with animal models including mice because the human cells
assessment be warranted? What concerns might you have or tissues required to examine such science are not gen-
related to the health of GW? What impact, if any, might erally available. As such, keep in mind that as knowledge
these issues have on the health of her fetus, including
of molecular genetics and biology progresses, the specific
risk for anomalies? Is the father’s age or the fact that her
5-year-old son had a cleft palate relevant to the current
genes and their products that are identified may change or
pregnancy? Why? be expanded upon.
The study of embryology is essential for the understanding Molecular Biology Considerations
of both normal anatomy and congenital anomalies. Moreover,
• TFG-ß, BMP, FGF10, MX1, IRF6—most commonly impli-
the practice of obstetrics and neonatal–perinatal medicine
cated pathways for palatine clefting
involves clinical embryology. Although infant mortality rates
have been decreasing steadily in North America for the past
50 years, the 2018 rate in the United States remains at 5.6 The section Clinical Issues in each chapter provides a
per 1000 live births, 4.3 per 1000 in Canada and 11 per 1000 description of the common congenital anomalies and other
in Mexico. Given that congenital anomalies are the second clinical information, related to the embryology details con-
leading cause of infant mortality (behind premature birth), tained in the chapter.
the need to better understand the mechanisms of normal Finally, each chapter provides a brief reference list that
embryo and fetal development and the factors that impact can be used to find additional details about the clinical
this development, leading to congenital anomalies remains cases, molecular biology and details of clinical embryology.
very high. The growing field of molecular biology and the We encourage you to seek additional information during
development of many novel laboratory techniques have led to your studies as the timing of book printing, relative to the
a significant improvement of our knowledge of the temporal constant gain of knowledge and reporting, negates the pos-
and regional expression of genes and their products to con- sibility of including the very most recent literature, although
trol such processes as morphogenesis. the authors have tried their utmost to provide citations that
are as current as possible.
USING THIS TEXTBOOK
OTHER IMPORTANT INFORMATION
This textbook is designed to offer a concise knowledge base
for the study or review of clinical embryology. The accompa- Throughout this textbook, the specified age of embryos
nying illustrations (drawing and medical imaging) provide a and fetuses as it relates to specific structures and other
2
CHAPTER 1 — Introduction 3
developments, has been quoted as fertilisation age—length • The primary palate, with each other, and the nasal sep-
of time from the date of fertilisation. tum (secondary palate cleft).
In the clinical context, gestational age is indicated as the
Some clefts appear as part of single mutant gene or chro-
time from the date of the start of the last menstrual period
mosomal syndromes or following the effects of teratogenic
(LMP). Given that ovulation (and shortly thereafter, fertili-
substances.
sation) occurs typically around 14 days after the start of the
menstrual period, gestational age LMP is approximately
2 weeks or 14 days greater than fertilisation age.
It is important to specifically describe the method used Case Outcome
for indicating ‘gestational age’, so that confusion does not
arise, especially when ordering or interpreting ultrasound Fetal ultrasound showed a male fetus of approximately 22
images or comparing between times within a patient history. weeks of age (based on femur length, biparietal diameter, head
Because the Federative International Committee on circumference and abdominal circumference), which would ap-
Anatomical Terminology does not recommend the use of proximately align with the predicted age based on the patient’s
eponyms, for the most part, this book follows suit (there last menstrual period. The ultrasound also detected an isolated
are few exceptions to this when the clinical eponym is most membranous ventricular septal defect (VSD). The remainder of
the examination was normal. Sixteen weeks later, GW had a
commonly used).
vaginal delivery. The neonate had good Apgar scores (7/8 at
There will be a number of terms in this book that may 1/5 minutes). The birth weight was at the 4th percentile. Other-
not be familiar to the reader, not limited to just those of wise the infant appeared normal.
embryology. It is recommended that the reader search for Additional reflection: What is the error rate for estimating
those definitions from a reliable source of such medical delivery dates from a single ultrasound examination at 22
information. weeks? Was it likely that the ultrasound was in error or that
Anatomical position and direction terms are used GW delivered early or both or neither? Why? What is the
throughout this book. In adults, the terms anterior and pos- likely cause of the VSD? How common are these anoma-
terior are used to describe the front and back of the body lies and what treatment is required and when, if any? What
or limbs or relative positions of one structure to another. In might be the causes for the baby to be born at such a low
percentile birth weight? What other concerns might you
the fetus or embryo, the terms ventral and dorsal are used,
have regarding the health of the neonate or GW?
respectively. In addition, the terms caudal or rostral are used
to denote a relationship to the head, whereas caudal is used
to denote relationship to the caudal eminence or tail.
CLINICAL ISSUES
BIBLIOGRAPHY
CLEFT PALATE Methods for estimating the due date. Committee Opinion No. 700.
American College of Obstetricians and Gynecologists. Obstet Gyne-
Palate clefts arise from failure of the lateral palatine process col 2017;129:e150–154.
Deshpande AS, Goudy SL. Cellular and molecular mechanisms of
to fuse with: cleft palate development. Laryngoscope Investig Otolaryngol
• The primary palate (anterior palate cleft) 2019;4(1):160–4.
• Each other and the nasal septum (posterior palate cleft)
2 Reproductive Organs and
Gametogenesis
tissues of the uterus and vagina (endometrium and mucosa,

Case Scenario respectively) increase in thickness. It is not until approxi-
mately 30 months later that menstruation begins, although
A 24-year-old woman (KR) presents at her new family physician
the regularity of menstruation may be variable for a number
with difficulty conceiving. She and her husband have been try-
ing to have a child for almost 5 years. Her husband recently had
of months as anovulatory cycles are common. In general,
his sperm count and morphology tested, and this has proven the age at which puberty begins in females has been decreas-
to be normal. KR is now seeking additional advice and investi- ing since the mid-1940s; the reasons for this are not known,
gation for herself. KR describes her menstrual cycle as varying but may be related to the increase in child obesity or other
in length, and occasionally she has missed her period entirely. environmental factors.
Otherwise, she has been healthy. KR also has severe acne. It In males, the enlargement of the testicles and develop-
had been previously controlled after a course of antibiotics and ment of pubic hair are the early signs of the onset of pu-
topical gel treatment when she was 21 years old, but the acne berty, typically occurring at approximately 10 years of age
has now returned. KR mentioned that she has had acne since (SMR 2). The testes and the penis continue to enlarge until
she was 13 years old. Recently, she began to notice more dark
late adolescence under the influence of both LH and tes-
hair growth on her chin and areolas, and that her leg hair has
had a noticeable regrowth after shaving. Her body mass index
tosterone secretion as do the prostate and seminal vesicles.
(BMI) is 20.6. Sperm appear approximately 3 to 4 years following the onset
Questions for reflection: Are there other fertility consid- of puberty. Although males undergo some degree of breast
erations for KR’s husband beyond the semen analysis that enlargement, gynaecomastia, during puberty, this tends to
might be investigated? What might be the connection, if resolve spontaneously in later stages of adolescence.
any, between KR’s recurrent acne and potential fertility
concerns? What further testing or consultation might be
appropriate for KR?
MALE REPRODUCTIVE ORGANS
The penis (Fig. 2.1) acts as the conduit for both urine and
ejaculate to exit the body. It consists of the glans or head,
PUBERTY which in uncircumcised men is covered by the prepuce or
foreskin. The urethral opening is found at the tip of glans
The reproductive organs (or primary sex characteristics) penis which forms from the expanded distal end of the cor-
develop in utero. Maturation of the reproductive organs pus spongiosum. The vascular corpus cavernous surrounds
and the appearance of secondary sex characteristics (such the corpus spongiosum, which when expanded by blood,
as breast growth, presence of axillary and public hair) oc- provide the erectile function of the penis. The erectile tissue
cur after puberty—the transitional process from childhood of the corpus spongiosum supports the urethra and main-
to adulthood. The exact biological trigger that starts the tains its patency during an erection.
process of puberty is unclear; however the initiation of go- The testes are the oval-shaped, sperm- and testosterone-
nadotropin-releasing hormone (GnRH) pulsing leads to the producing organs found within the scrotum. The testes are
secretion of luteinising hormone (LH) and follicle-stimulat- covered with a thick fibrous capsule, the tunica albuginea,
ing hormone (FSH) by the pituitary. LH and FSH, in turn, and contain a series of coiled seminiferous tubules within
stimulate the secretion of androgens and oestrogens from which sperm development occurs. The seminiferous tu-
the gonads (the hypothalamic–pituitary–gonadal axis). The bules are connected to the tubuli recti. The rete testes are
Tanner scale or sexual maturity rating (SMR; 1 = preadoles- connected to the epididymis. The duct of the epididymis
cence to 5 = sexual maturity) is used as a framework on (ductus deferens) passes from the epididymis through the
which to objectively classify the development of secondary inguinal canal into the pelvic cavity. The ductus deferens
sexual characteristics. traverses the prostate gland where it joins the urethra. The
In females, the appearance of breast buds is the start of prostate gland secretes prostatic fluid into the semen, which
SMR 2, the first indication of the onset of puberty, and typi- supports transportation and nutrition of the sperm. Paired
cally occurs between the ages of 8 and 12 years. Simultane- seminal vesicles and the bulbourethral glands provide ad-
ously, the labia, uterus and ovaries increase in size, and the ditional secretion to the semen.
4
CHAPTER 2 — Reproductive Organs and Gametogenesis 5
Fig. 2.1 Sagittal section of the male pelvic region. (From Moore KL, Persaud TVN, & Torchia MG. The Developing Human: Clinically Oriented Em-
bryology. 10th ed. Philadelphia: Elsevier; 2015.)
(internal), myometrium (middle muscular) and perime-

FEMALE REPRODUCTIVE ORGANS trium (external). The endometrium can be further distin-
guished into the compact, spongy and basal layers, and var-
The vagina (Fig. 2.2) is a fibromuscular organ that extends ies in thickness according to stages of the menstrual cycle.
from the external genitalia (vulvar structures) to the cervix The uterine tubes are continuous with the uterine horns
of the uterus. The opening of the vagina is situated posterior found at the superior end of the uterus, the fundus. The
to the opening of the urethra and is covered by the labia uterine tubes are approximately 10-cm long, and consist
minora. The uterus is a thick-walled muscular organ con- of four parts: infundibulum, ampulla, isthmus and uterine
sisting of the body (upper two-thirds) and the cervix (lower part. The tubes are lined with cilia that help to propel the
one-third). The cervix is cylindrical with constricted open- ovum and sperm, first to the site of fertilisation (ampulla)
ing at both ends, the internal and external os. The body of and then to assist in moving the cleaving zygote to the uterus
the uterus is comprised of three tissue layers, endometrium for implantation.
Fig. 2.2 Sagittal section of the female pelvic region. (From Moore KL, Persaud TVN, & Torchia, MG. Before We Are Born: Essentials of Embryology
and Birth Defects. 9th ed. Philadelphia: Elsevier; 2016.)
6 SECTION 1 — General Development of the Embryo and Fetus
The ovaries are oval-shaped glands adjacent to the uterus

and the uterine tube infundibulum, with its finger-like fim- GAMETOGENESIS
briae. The ovaries produce the oocytes, as well as hormones
(oestrogen and progesterone) that regulate the process of Gametogenesis (oogenesis and spermatogenesis) (Fig. 2.3)
sexual development, menstruation and pregnancy. is the process that produces oocytes and sperms from bipo-
The external female genitalia consist of the labia minora, tential primordial germ cells and prepares these gametes for
labia majora and the clitoris. fertilisation. The sperm and oocyte are highly specialised
Fig. 2.3 Simplified diagram showing normal gametogenesis. (From Moore KL, Persaud TVN, & Torchia MG. The Developing Human: Clinically
Oriented Embryology. 10th ed. Philadelphia: Elsevier; 2015.)
sex cells, each of which contains the haploid number of containing several enzymes and other factors which, when
chromosomes that are present in somatic cells. The number released, facilitate dispersion of the follicular cells of the co-
of chromosomes is reduced during meiosis, a special type of rona radiata and sperm penetration of the zona pellucida
cell division that occurs only during gametogenesis. Meiosis during fertilisation. The tail has four segments: the connect-
involves two meiotic cell divisions resulting in diploid germ ing, middle, principal and end pieces, and it provides the
cells giving rise to haploid gametes. motility of the sperm for transport to the site of fertilisation.
The first meiotic division is a reduction division because The axoneme is the motility machinery of the sperm and is
the chromosome number is reduced to haploid by pairing comprised of cytoskeleton and dyneins (ATPase molecular
of homologous chromosomes in prophase and their seg- motors). The helically arranged mitochondria in the middle
regation at anaphase with one representative of each pair piece provide the energy required for motility. Sperm travel
randomly going to each pole of the meiotic spindle. At this at approximately 3 mm/min.
stage, the chromosomes are double-chromatid chromo- Spermatogonia (primordial male germ cells) are dor-
somes. (The X and Y chromosomes are not homologues, mant in the seminiferous tubules of the testes during the
but they have homologous segments at the tips of their fetal and postnatal periods. At puberty, spermatogenesis
short arms and pair in these regions only.) This disjunction begins, a 2-month highly complex process that transforms
of paired homologous chromosomes is the physical basis of spermatogonia into mature sperms. More than one dozen
segregation, the separation of allelic genes during meiosis. different subtypes of male germ cells have been identified.
The second meiotic division does not have an interphase, There are also a number of cells and factors within the tes-
but each double-chromatid chromosome divides, and each tes involved in sperm development. Peritubular myoid cells
half, or chromatid, is drawn to a different pole. Thus the are found surrounding and supporting the seminiferous tu-
haploid number of chromosomes remains, and each daugh- bules and are thought to regulate Sertoli cells, assist in man-
ter cell has one representative of each chromosome pair aging the blood–testis barrier (an important controller of
(now a single-chromatid chromosome). The process of mei- the germ cell microenvironment) and push testicular fluid
osis provides constancy of the chromosome number from with sperm towards the rete testis. Leydig cells (LCs) are
generation to generation, allows random assortment of ma- found clustered near seminiferous tubules and the adjacent
ternal and paternal chromosomes between the gametes and blood vessels. LCs produce testosterone, which is released
relocates segments of maternal and paternal chromosomes into the systemic circulation. LCs ensure a much higher lo-
by crossing over of chromosome segments, which produces cal concentration of testosterone, which is required for nor-
a recombination of genetic material. mal sperm production. LCs also produce oestradiol from
testosterone, which appears to be required for successful
spermatogenesis. Sertoli cells (SCs) make up approximately
SPERM CHARACTERISTICS AND 20% of the epithelial cells of the seminiferous tubules. The
DEVELOPMENT role of the SCs is complex and broad. Their unique struc-
ture allows each SC to shepherd up to 50 germ cells during
Sperms are highly differentiated, actively motile cells con- differentiation; this is accomplished by sophisticated cyto-
sisting of a head and a tail (Fig. 2.4) and approximately skeletal elements. SCs produce anti-Müllerian hormone,
4 µm in length. The head forms most of the bulk of the critical to the normal embryological develop of male and
sperm and contains the nucleus. The anterior two-thirds of female reproductive organs. SCs also act as macrophages,
the head is covered by the acrosome, a saccular organelle and produce inhibin B (regulating FSH production) and
androgen-binding protein.
The male germ cells are arranged in the seminiferous
tubules in a specific manner with least-mature cells in the
basal compartment and more-mature cells found adjacent
to the lumen.
The earliest germ cells in the testes (gonocytes) remain
in G0 phase of the cell cycle until after birth. In the first
few neonatal months, they are transformed into inactive
spermatogonia which begin to undergo rapid mitosis at ap-
proximately 6 years of age. Later, at puberty, the spermato-
gonia undergo the process of spermatogenesis. Briefly,
spermatogonia first develop into primary spermatocytes,
the largest germ cells in the seminiferous tubules of the
testes. Each primary spermatocyte subsequently undergoes
the first meiotic division to form two haploid secondary
spermatocytes. These secondary spermatocytes undergo
the second meiotic division and form four haploid sper-
matids. The spermatids are gradually transformed into
four mature sperms by a process known as spermiogenesis.
When spermiogenesis is complete, the sperms enter the lu-
Fig. 2.4 Main parts of the human sperm. (From Moore KL, Persaud mina of the seminiferous tubules. Sperms are transported
TVN, & Torchia MG. The Developing Human: Clinically Oriented Embryol- passively from the seminiferous tubules to the epididymis,
ogy. 10th ed. Philadelphia: Elsevier; 2015; Fig. 2.5.) where they are stored.
progresses only to metaphase. If a sperm penetrates the sec-

OOCYTE CHARACTERISTICS AND ondary oocyte at fertilisation, the second meiotic division
DEVELOPMENT is completed, and most cytoplasm is again retained by one
cell, the fertilised oocyte. The second polar body is formed
The mature (secondary) oocyte (Fig. 2.5) is an immotile cell and will degenerate.
with a diameter of approximately 100 µm, making it one of There are approximately 2 million primary oocytes in the
the largest cells in the female human body, and just visible ovaries of a neonate, but most of them regress during child-
to the unaided eye. It typically contains a transparent mod- hood so that by adolescence no more than about 40,000
erately granular cytoplasm with refractile structures such as primary oocytes remain. Of these, only approximately 400
lipid, lipofuscin bodies, and autophagic vacuoles. A single become secondary oocytes and are expelled at ovulation
polar body is also associated with the secondary oocyte (see during the reproductive period. Very few of these oocytes, if
later). any, are fertilised. The long duration of the first meiotic divi-
Oogenesis transforms oogonia (primordial female germ sion (up to 45 years) may account in part for the relatively
cells) into mature oocytes. All oogonia develop prenatally, high frequency of meiotic errors that occur with increasing
and the process of oogenesis ceases following menopause. maternal age.
In early fetal life, oogonia proliferate by mitosis and enlarge
to form primary oocytes, each surrounded by a single layer
of flattened, connective tissue follicular cells. The primary
oocyte enclosed by this layer of follicular cells constitutes
FEMALE REPRODUCTIVE CYCLE
a primordial follicle. As the primary oocyte enlarges dur-
The female reproductive cycle (Fig. 2.6) is highly complex
ing puberty, the follicular epithelial cells become columnar
and involves activities of the hypothalamus, pituitary gland,
shaped and the oocyte becomes covered with the glycopro-
ovaries, uterus, uterine tubes, vagina and mammary glands,
teinaceous zona pellucida. Primary oocytes begin the first
all towards preparation of the reproductive system for preg-
meiotic divisions before birth, but completion of prophase
nancy.
does not occur until puberty. The follicular cells surround-
GnRH secreted by the hypothalamus stimulates the an-
ing the primary oocytes secrete a substance, oocyte matura-
terior lobe of the pituitary gland to release FSH, which
tion inhibitor, which keeps the meiotic process of the oo-
stimulates the development of ovarian follicles and the pro-
cyte arrested. With puberty, the ovarian follicle (typically
duction of oestrogen by the follicular cells, and LH, which
only one) matures each month. As a follicle matures, the
triggers ovulation and stimulates follicular cells and corpus
primary oocyte increases in size and shortly before ovula-
luteum to produce progesterone and causes growth of the
tion it completes the first meiotic division to give rise to a
follicles and endometrium.
secondary oocyte and the first polar body. The secondary
As the primary follicle increases in size, the adjacent con-
oocyte receives almost all the cytoplasm; the polar body is
nective tissue organises into a capsule, the theca folliculi.
destined for degeneration. At ovulation, the nucleus of the
This theca soon differentiates an internal vascular and glan-
secondary oocyte begins the second meiotic division, but it
dular layer (theca interna) and a capsule-like layer (theca
externa). The follicular cells produce a stratified layer
around the oocyte. Fluid-filled spaces appear around the
follicular cells, which coalesce to form the antrum, contain-
ing follicular fluid at this stage; the ovarian follicle is then
called a secondary follicle. The primary oocyte is pushed
to one side of the follicle. At approximately the midpoint
of the cycle, FHS and LH stimulation cause rapid follicle
growth leading to the formation of a small avascular spot,
follicular stigma, on the surface of the ovary. Rupture of the
stigma and expulsion of the secondary oocyte (ovulation)
occurs 12 to 24 hours after this surge of LH production. The
expelled secondary oocyte is surrounded by the zona pel-
lucida and one or more layers of radially arranged follicular
cells (corona radiata). Shortly after ovulation, the walls of
the ovarian follicle and theca folliculi collapse and develop
into the corpus luteum. The corpus luteum secretes proges-
terone and some oestrogen, causing the endometrial glands
to secrete and prepare the endometrium for implantation
of the blastocyst. If the oocyte is fertilised, the corpus lu-
teum enlarges to form a corpus luteum of pregnancy and
increases its hormone production. The corpus luteum of
pregnancy remains functionally active throughout about
the first 20 weeks of pregnancy. By this time, the placenta
has assumed the production of oestrogen and progesterone
Fig. 2.5 Photomicrograph of a human oocyte. (From Zhang P, Zuc- necessary for the maintenance of pregnancy. If the oocyte is
chelli M, Bruce S, et al. Transcriptome profiling of human pre-implan- not fertilised, the corpus luteum involutes and degenerates
tation development. PLoS One 2009; 4(11): e7844. With permission.) 10 to 12 days after ovulation.
Fig. 2.6 Schematic drawing of the ovarian and menstrual cycles. (From Moore KL, Persaud TVN, & Torchia MG. The Developing Human: Clinically
Oriented Embryology. 10th ed. Philadelphia: Elsevier; 2015.)
MENSTRUAL CYCLE by the corpus luteum stimulates the glandular epithelium

to secrete a glycogen-rich material. The glands become
Changes in the oestrogen and progesterone levels cause cy- wide, tortuous and saccular, and the endometrium thickens
clic changes in the structure of the female reproductive tract, because of the influence of progesterone and oestrogen
notably the uterine endometrium (Fig. 2.6). The menstrual from the corpus luteum. As the spiral arteries grow into the
cycle is a continuous process lasting on average 28 days, with superficial compact layer, they become increasingly coiled.
each phase gradually passing into the next. Day 1 is desig- The venous network becomes complex, and large lacunae
nated as the day menstrual flow begins. In the menstrual (venous spaces) develop in the endometrium. If fertilisation
phase (4–5 days), the functional layer of the endometrium does not occur the corpus luteum degenerates, oestrogen
is sloughed off as the menses (blood discharged from the va- and progesterone levels fall, and the secretory endome-
gina combined with small pieces of endometrial tissue). After trium enters an ischemic phase. The spiral arteries con-
menstruation, the remaining endometrium is thin. strict, glandular secretion stops, interstitial fluid is reduced,
During the proliferative phase (9 days), the ovarian fol- endometrium shrinks and venous stasis occurs. This leads
licles grow and the uterine surface epithelium reforms to patchy ischaemic necrosis of the functional layer of the
and covers the endometrium. The uterine glands increase endometrium. Rupture of damaged vessel walls allows blood
in number and length and endometrial spiral arteries to leak into the surrounding connective tissue, resulting in
elongate. The luteal (secretory) phase lasts approximately bleeding (typical loss of 20–80 mL).
13 days and coincides with the formation, functioning and If fertilisation occurs, the zygote undergoes cleavage and
growth of the corpus luteum. The progesterone produced blastogenesis, and the blastocyst begins to implant in the
endometrium (sixth day of the luteal phase). The embryo implantation. No hormone-based contraceptive is avail-
syncytiotrophoblast produces chorionic gonadotropin, able for men. Barrier methods, including condoms (male
which keeps the corpora luteum secreting oestrogens and or female) and contraceptive diaphragms, prevent sperm
progesterone; the luteal phase continues and menstruation from entering the vagina or uterus, respectively. Sterilisation
does not occur. (implant, vasectomy or tubal ligation) are permanent forms
of birth control.
Molecular Biology Considerations NONDISJUNCTION

• PI3K/PTEN and TSC/mTOR pathways—activation of pri- Nondisjunction is an error in cell division in which there is
mordial follicles failure of a chromosomal pair (autosome or sex chromo-
• GDF9 and BMP15—development of secondary and pre- some) to separate during mitosis or meiosis, resulting in
ovulatory follicle numeric aberrations of chromosomes. Nondisjunction may
• cAMP meiotic arrest occur during maternal or paternal gametogenesis, resulting
• MAPK3/1—ovulation control in some gametes having 24 chromosomes while others have
• bFGF—maintenance of blood–testis barrier only 22. If these gametes should become fertilised with a
• TGF-a/b and GNDF—maintenance of spermatogenesis normal gamete, a zygote with either trisomy (three copies of
microenvironment
a chromosome) or monosomy (one copy of a chromosome)
• PModS—regulates Sertoli cell function
• HOX—shaping of sperm head results. Clinical conditions resulting from such nondis-
junction include trisomy 21 (Down syndrome), trisomy 18
(Edwards syndrome), XXY trisomy (Klinefelter syndrome)
and monosomy X (Turner syndrome).
CLINICAL ISSUES Case Outcome
FERTILITY KR was sent for blood tests as well as endocrine and gyn-
aecological consultations. Higher than normal levels of andro-
In 85% to 90% of cases, heterosexual couples are able to gens were detected in her blood; there were no other abnormal
achieve pregnancy through sexual intercourse. In the re- findings. A pelvic examination was normal. A pelvic ultrasound
maining couples, fertility issues for both the male and fe- demonstrated multiple cysts on her ovaries (see Fig. 2.7). She
male require investigation; these male/female concerns was diagnosed with polycystic ovarian syndrome (PCOS) and
returned to her family physician for discussion of treatment op-
often coexist. In men, the most common causes of reduced
tions and follow-up.
fertility are a blockage of sperm delivery, altered sperm mor- Additional reflection: Did KR present with the typi-
phology, motility and function and reduced sperm numbers. cal signs for PCOS? Given KR’s desire for children, how
Previous infection, retrograde ejaculation, prior trauma and might this be a consideration for her long-term treatment
tumours are examples of causes of blocked semen flow. Ab- of PCOS? What is the likelihood of KR conceiving a child,
normal sperm morphology includes large or double heads should her husband’s fertility prove to be normal? What
and bent or double tails; causes include genetic disorders, might be some psychological implications of PCOS?
exposure to environmental toxins or high testicular tem-
peratures. Men with fewer than 10 million sperms per milli-
litre of semen are less likely to be fertile, especially when the
specimen contains immotile and abnormal sperms. Envi-
ronmental factors (drug or alcohol abuse, exposure to envi-
ronmental toxins), medication and hormone imbalance are
only a few of the reasons that low sperm counts may occur.
In women, the most common causes of infertility are
blockage of oocyte transportation attributed to tubal scar-
ring or endometriosis, reduced production of oocytes be-
cause of increased age, and hormonal imbalances such as
from polycystic ovarian syndrome (PCOS) and obesity.
CONTRACEPTION
The use of hormonal methods of female contraception can
result in some or all of thickened cervical mucus, alteration
of the endometrium, prevention of ovulation or blockage
of sperm. These contraceptives include progestin-only pills,
combined oestrogen–progestin pills, emergency contracep- Fig. 2.7 Pelvic ultrasound demonstrating cystic structures on
tive pills, vaginal rings, contraceptive patches and inject- the oval in polycystic ovarium syndrome. (From Karakas SE. New
able long-acting medications including drug-integrated biomarkers for diagnosis and management of polycystic ovary syn-
implants. Intrauterine devices may contain either hormones drome. Clin Chim Acta 2017; 471: 248–253.With permission.)
or copper and prevent sperm from reaching the ovum or
QUESTIONS
1. Which of the following types of germ cell does not un- c. disturbances in spermiogenesis
dergo cell division? d. disturbances in mitosis
a. spermatogonia e. abnormal spermatogonia
b. primary oocytes
c. spermatids BIBLIOGRAPHY
d. secondary spermatocytes Datta J, Palmer MJ, Tanton C, et al. Prevalence of infertility and help seek-
e. oogonia ing among 15,000 women and men. Hum Reprod 2016;31:2108–18.
Neto FTL, Bach PV, Najari BB, Li PS, Goldstein M. Spermatogenesis in
2. An infant is diagnosed as having 47 chromosomes instead humans and its affecting factors. Sem Cell Dev Biol 2016;59:10–26.
Pasquali R. Contemporary approaches to the management of polycystic
of 46. This abnormal condition (trisomy) results from:
ovary syndrome. Ther Adv Endocrinol Metb 2018;9(4):123–34.
a. gene mutation
b. nondisjunction
3 Fertilisation and Reproductive
Technologies
genital tract. Oocytes are usually fertilised within 12 hours

Case Scenario of ovulation, and it appears that they cannot be fertilised
after 24 hours (see Video 3.1).
A 49-year-old woman (PG) presents to her family physician
The usual site of fertilisation is in the ampulla of the uter-
reporting a positive home pregnancy test and claims to be
approximately 2-months pregnant based on timing of her last ine tube. If the oocyte is not fertilised, it slowly passes along
normal menstrual period. She is concerned because this is her the tube to the body of the uterus, where it degenerates and
first pregnancy; she and her partner have not used birth control is resorbed.
for the past three months because her menstrual periods have Fertilisation is a sequence of coordinated events (Fig. 3.2),
been very irregular for the past year and she believed that she beginning with the passage of a sperm through the corona
was ‘in menopause and not infertile’. radiata. Hyaluronidase released from the sperm acrosome,
A second pregnancy test was ordered which was positive. tubal mucosa enzymes and sperm motion appear to cause
An ultrasound (endovaginal sonogram) showed a live embryo dispersal of the follicular cells of the corona radiata. Passage
with crown–rump length of approximately 9 mm, aged between of a sperm through the zona pellucida is the next phase and
35 and 38 days.
also results from the action of enzymes released from the
Given PG’s age, she was counselled regarding the options
for (or no) prenatal screening for fetal aneuploidies. acrosome, including acrosin, esterase and neuraminidase.
Questions for reflection: Why is PG’s age a concern and Once a sperm penetrates the zona pellucida, a change in the
how may age impact normal gametogenesis. What types properties of the zona pellucida (zona reaction) occurs that
of prenatal screening are available and at what gestational makes it impermeable to other sperms. The zona reaction is
age? Which of the tests is considered diagnostic? What believed to result from the action of lysosomal enzymes re-
are the most common aneuploidies? leased by cortical granules near the plasma membrane of the
oocyte. The contents of these granules also cause changes in
the plasma membrane that make it impermeable to other
sperms. Fusion and localised breakdown of cell membranes
of the oocyte and sperm occurs next, resulting in the head
FERTILISATION and tail of the sperm entering the cytoplasm of the oocyte
(the cell membrane and mitochondria of the sperm remain
During ovulation, the fimbriated end of the uterine tube be- behind). Penetration of the oocyte by a sperm activates the
comes closely applied to the surface of the ovary. The sweep- oocyte into completing the second meiotic division and
ing action of the tube and of fluid currents produced by the forming a mature oocyte and a second polar body. The ma-
ciliated mucosal cells of the fimbriae, causes the extruded ternal chromosomes decondense and the nucleus of the ma-
oocyte to enter the infundibulum of the uterine tube. The ture oocyte becomes the female pronucleus.
oocyte then passes into the ampulla of the tube, mainly as The nucleus of the sperm enlarges to form the male pro-
the result of tube peristalsis. During sexual intercourse and nucleus and the tail of the sperm degenerates. Both pronu-
ejaculation, sperms are rapidly transported from the epidid- clei duplicate their DNA and the oocyte becomes an ootid.
ymis to the urethra by peristaltic contractions of the thick When the pronuclei fuse into a single diploid aggregation
muscular coat of the ductus deferens. Between 200 and 600 of chromosomes, the ootid becomes a zygote. The chromo-
million sperms are deposited in the vagina, around the ex- somes in the zygote become arranged on a cleavage spin-
ternal os and the fornix, and then some pass through the dle in preparation for cleavage of the zygote. The zygote is
cervical canal. The cervical mucus increases in amount and genetically unique.
becomes less viscid during ovulation, making it more favour-
able for sperm passage. Approximately 200 sperms reach
the ampulla of the uterine tube; the remainder degenerate
and are absorbed in the female genital tract. Sperms must CLEAVAGE OF THE ZYGOTE AND
undergo capacitation, lasting approximately 7 hours, before FORMATION OF THE BLASTOCYST
they are able to fertilise the oocyte. During this process, a
glycoprotein coat and seminal proteins are removed from Cleavage occurs approximately 30 hours after fertilisation
the surface of the sperm acrosome and the membrane com- as the zygote, within the zona pellucida, passes along the
ponents of the sperms are extensively altered. Sperms are uterine tube towards the uterus. Cleavage consists of re-
usually capacitated while they are in the uterus or uterine peated mitotic divisions of the zygote, resulting in a rapid
tubes by substances secreted by these parts of the female increase in the number of cells (blastomeres) and decrease
12
CHAPTER 3 — Fertilisation and Reproductive Technologies 13
Fig. 3.1 Timeline of development related to fertilisation.
Fig. 3.2 Events taking place in fertilisation. (From Moore KL, Persaud TVN, & Torchia MG The Developing Human: Clinically Oriented Embryology.
10th ed. Philadelphia: Elsevier; 2015.)
in the size of subsequent blastomeres with each successive After the blastocyst has floated in the uterine secretions
cleavage division. After the nine-cell stage, the blastomeres for approximately 2 days, shedding of the zona pellucida
undergo compaction, changing their shape and tightly occurs, permitting the blastocyst to increase rapidly in size.
aligning themselves against each other to form a compact While in the uterus, the embryo derives nourishment from
ball of cells. Compaction changes the cell cytoskeleton, per- secretions of the uterine glands. At approximately 6 days, the
mitting greater cell-to-cell interaction. Polarisation of the blastocyst (usually adjacent to the embryonic pole) attaches
blastomeres into apical and basolateral domains also takes to the endometrial epithelium. The trophoblast proliferates
place. Compaction is necessary for segregation of the inter- rapidly and differentiates into two layers—an inner layer
nal cells that will form the embryoblast (inner cell mass) of of cytotrophoblast that is mitotically active and forms new
the blastocyst from surrounding cells that form the tropho- mononuclear cells that migrate into the increasing mass of
blast (Fig. 3.3). At the 12- to 32-blastomeres stage, the devel- syncytiotrophoblast, and an outer layer of syncytiotropho-
oping embryo is called a morula. Shortly after the morula blast (multinucleated protoplasmic mass) (Fig. 3.4). The
enters the uterus (approximately 4 days postfertilisation), syncytiotrophoblast begins to invade the uterine connective
the fluid-filled blastocystic cavity appears inside the morula tissue so that the blastocyst can now derive its nourishment
separating the blastomeres into the trophoblast (thin outer from the eroded maternal tissues. Endometrial cells assist
cell layer giving rise to the embryonic part of the placenta) to control the depth of penetration of the syncytiotropho-
and the embryoblast (centrally located blastomeres which blast. At approximately 7 days, a layer of cells, the hypoblast
form the embryo). Early pregnancy factor (EPF), an immu- (primary endoderm), appears on the surface of the embryo-
nosuppressant protein, is secreted by the trophoblastic cells blast facing the blastocystic cavity. Comparative embryologi-
and aids in the prevention of early maternal immune attack cal data suggest that the hypoblast arises by delamination of
of the embryo (see Video 3.2). blastomeres from the embryoblast.
Fig. 3.3 Stages of development during the first week. (A) Ovulated oocyte; (B) fertilisation; (C) pronuclei formation; (D) first cleavage spindle; (E–G)
cleavage of zygote; (H) morula; (I) blastocyst. (From Mitchell B, Sharma R. Embryology: An Illustrated Colour Text. 2nd ed. London: Elsevier; 2009.)
many women who are sterile to have children. Since 1978,

when Robert G. Edwards and Patrick Steptoe pioneered IVF,
several million children have been born following an IVF pro-
cedure. The steps involved during IVF and embryo transfer
are briefly noted. Beginning on day 1 of the menstrual cycle,
ovarian follicles are stimulated to grow and mature (super-
ovulation), typically by the administration of a drug that in-
creases follicle-stimulating hormone (FSH) and/or luteinis-
ing hormone (LH) secretion by the pituitary. At the optimal
time (often determined by ultrasound), another medication
(synthetic human chorionic gonadotropin [hCG]) is given to
trigger ovulation. Using an ultrasonically guided, minimally
invasive procedure, several mature oocytes (typically 8–15)
are aspirated from mature ovarian follicles. The oocytes are
then placed in a Petri dish containing a special culture me-
Fig. 3.4 A 7-day blastocyst beginning to implant. (From Mitchell B, dium and capacitated sperms. Fertilisation of the oocytes and
Sharma R. Embryology: An Illustrated Colour Text. 2nd ed. London: cleavage of the zygotes are monitored by microscope for 3
Elsevier; 2009.) to 5 days. Depending on the mother’s age, one to three of
the resulting embryos (four-cell to eight-cell stage, or early
blastocysts) are transferred by introducing a catheter through
the vagina and cervical canal into the uterus. Any remaining
Molecular Biology Considerations embryos are frozen for later use. Approximately 2 weeks later,
a pregnancy test is performed.
• SPAM1, HYAL5, ACE3, ADAMS1–3—gamete fusion
• Hippo—segregation of embryoblast from trophoblast CRYOPRESERVATION OF EMBRYOS
• TGF-b—proliferation and differentiation of the trophoblast
Early embryos resulting from IVF can be preserved for long
periods by freezing them in liquid nitrogen with a cryopro-
tectant (e.g., glycerol or dimethyl sulfoxide). Successful
transfer of four- to eight-cell embryos and blastocysts to the
CLINICAL ISSUES uterus after thawing is now a common practice. The longest
period of sperm cryopreservation that resulted in a live birth
ASSISTED REPRODUCTIVE TECHNOLOGIES was reported to be 21 years.
IN VITRO FERTILISATION AND EMBRYO TRANSFER INTRACYTOPLASMIC SPERM INJECTION

In vitro fertilisation (IVF) of oocytes and transfer of cleav- A sperm can be injected directly into the cytoplasm of a ma-
ing zygotes into the uterus have provided an opportunity for ture oocyte. This technique has been successfully used for
the treatment of couples in whom typical IVF has failed, or

in cases where there are too few sperms available.
ASSISTED IN VIVO FERTILISATION

Gamete intrafallopian (intratubal) transfer enables fertilisa-
tion to occur in the uterine tube. It involves superovulation
(similar to that used for IVF), oocyte retrieval, sperm col-
lection and laparoscopic placement of several oocytes and
sperms into the uterine tubes. Using this technique, fertilisa-
tion occurs in the ampulla, its usual location.
SURROGATE MOTHERS
Some women produce mature oocytes but are unable to
become pregnant, for example, a woman who has had a
hysterectomy. In these cases, IVF may be performed, and
the embryos transferred to another woman’s uterus for fetal
development and delivery.
Fig. 3.5 Three-dimensional ultrasound image of a fetus with trisomy
21, showing characteristic features including a protruding tongue
PREGNANCY TESTING (macroglossia).
Most pregnancy tests are based on the detection or measure-

ment of human chorionic gonadotropin (hCG) produced nose and eyes, holoprosencephaly, polydactyly, skin defects;
by the syncytiotrophoblast. hCG can be measured in urine trisomy 18—includes clenched hands, prominent occiput,
or in blood. hCG rapidly increases in concentration from short sternum, small pelvis, cryptorchidism) and have ma-
the time of early implantation (approximately day 6–12). jor neurodevelopmental disabilities. Infants with these life-
The blood testing performed by clinical laboratories uses limiting disorders (trisomy 18 and 23) have a 1-year survival
a more sensitive assay, and it also measures hCG concentra- rate of approximately 6% to 12%. Infants with trisomy 21
tion which can be followed over time depending on clinical (Fig. 3.5) have abnormalities that include cognitive defi-
needs. There are a number of biological and pharmacologi- ciency, hypotonia, bradycephaly, upward slanting palpebral
cal factors that can produce false positive and negative hCG fissures, protruding tongue, small ears, heart defects such as
test results including heterotrophic antibodies, rheumatoid endocardial defects, ventricular septal defect or atrial septal
factors and ectopic pregnancies. defect, and a transverse palmar flexion crease. More than
Transvaginal ultrasonography can detect the gestational one-half of trisomic embryos spontaneously abort early. Tri-
sac at approximately 2.5 to 3 weeks following conception. somy of the autosomes occurs with increasing frequency
as maternal age increases. For example, trisomy 21 occurs
ANEUPLOIDY once in approximately 1400 births among mothers between
the ages of 20 and 24 years but once in approximately 25
Aneuploidy, usually resulting from nondisjunction, is any births among mothers 45 years and older. Because of the
deviation from the diploid number of 46 chromosomes and current trend of increasing maternal age, it has been esti-
is the most common (3%–4% of pregnancies) and clinically mated that children born to women older than 34 years will
significant numeric chromosomal abnormalities. account for 39% of infants with trisomy 21.
MONOSOMY X TRISOMY OF SEX CHROMOSOMES
The incidence of Turner syndrome (45,X) is about 1:8000 These disorders are not usually detected until puberty be-
live births. Only 1% of monosomy X female embryos survive, cause there are no characteristic physical findings in in-
with 45,X being the most common abnormality detected in fants or children. These disorders include XYY syndrome
all spontaneous abortions. When it is possible to trace, it is (1:1000; tall stature, cognitive disabilities, severe acne, au-
the paternal X chromosome that is missing in approximately tism spectrum disorder, normal fertility), XXX (1:1000;
75% of cases. In some cases, mosaicism occurs (XX/X and normal puberty, normal fertility, some degree of cognitive
XY/X mosaics) and in these cases there is a lesser degree deficiency can occur); and XXY syndrome (Klinefelter syn-
of abnormalities. The abnormalities typically seen with 45,X drome) (1:500; most common cause of hypogonadism and
include small stature, ovarian dysgenesis, broad chest with infertility, gynaecomastia, inadequate virilisation, long limbs
wide-spaced nipples, congenital lymphedema and a short and possible developmental delay).
and/or webbed neck.
AUTOSOMAL TRISOMY MOSAICISM

Trisomy is the most common aneuploidy. Trisomy of auto- A person with at least two cell lines with two or more geno-
somes is mainly associated with three syndromes: trisomy 18 types is considered a mosaic. The autosomes or sex chromo-
(Edwards syndrome, 1.3:10,000 live births), trisomy 13 (Pa- somes may be involved. The defects usually are less serious
tau syndrome, 0.8:10,000) and trisomy 21 (Down syndrome, than in persons with monosomy or trisomy. For instance,
12:10,000). Infants with trisomy 13 and trisomy 18 are se- the features of Turner syndrome are not as evident in
verely malformed (trisomy 13—includes defects of the lip, 45,X/46,XX mosaic females as in the usual 45,X females.
Although mosaicism usually results from nondisjunction, it genotype of the embryo and allow selection of a chromo-
can also occur through the loss of a chromosome by ana- somally healthy embryo for transfer. Preimplantation genet-
phase lagging; chromosomes separate normally, but one of ic diagnosis can be carried out 3 to 5 days after IVF of the
them is delayed in its migration and is eventually lost. oocyte. One or two cells (blastomeres) are removed from
the embryo and these cells are then analysed before transfer
into the uterus. The sex of the embryo can also be deter-
MULTIPLE GESTATIONS mined from one blastomere taken from a six- to eight-cell
dividing zygote, and analysed by polymerase chain reaction
In North America, twins naturally occur approximately once
and fluorescence in situ hybridisation techniques. This pro-
in every 85 pregnancies, triplets approximately once in 902
cedure has been used to detect female embryos during IVF
pregnancies, quadruplets once in 903 pregnancies and quin-
in cases in which a male embryo would be at risk of a serious
tuplets approximately once in every 904 pregnancies. Twins
X-linked disorder. The polar body may also be tested for dis-
that originate from two zygotes are dizygotic (DZ) twins
eases where the mother is the carrier (Fig. 2.15A).
whereas twins that originate from one zygote are monozy-
gotic (MZ) twins. Two-thirds of twins are DZ, with marked
racial differences whereas the incidence of MZ twinning is
approximately the same in all populations. DZ twins may be
of the same sex or different sexes and are no more alike Case Outcome
genetically than brothers or sisters born at different times.
Patient PG opted for noninvasive prenatal testing (NIPT)
The fetal membranes and placentas vary according to the
through cell-free DNA (cfDNA) screening. This testing was con-
origin of the twins. DZ twins always have two amnions and ducted approximately 3 weeks after her previous visit (8 weeks
two chorions, but the chorions and placentas may be fused. post conception—10 weeks gestational age). The test results
Anastomoses between blood vessels of fused placentas of demonstrated a high risk for trisomy 21 (Down syndrome).
DZ twins may result in erythrocyte mosaicism. MZ twins are A diagnostic chorionic villus sampling (CVS) was then per-
genetically identical; physical differences between MZ twins formed that confirmed the diagnosis of trisomy 21. PG opted to
are caused by environmental differences, chance variation continue the pregnancy. A later fetal ultrasound demonstrated
and uneven X-chromosome activation. MZ twinning usually enhanced nuchal translucency (Fig. 3.6), but no cardiovascu-
results from division of the embryoblast into two embryonic lar anomalies. The remainder of the pregnancy was uneventful,
primordia, with each embryo in its own amniotic sac but and PG delivered a baby girl at 38 weeks.
Additional reflection: What is the difference between
sharing the same chorionic sac and placenta (monochori-
a screening test and a diagnostic test? How is CVS per-
onic–diamniotic twin). Uncommonly, early separation of formed, at what gestational age, and with what possible
embryonic blastomeres (e.g., during the two-cell to eight- risks to fetus and the mother? What is a nuchal translu-
cell stages) results in MZ twins with two amnions, two cho- cency, and why was there a concern about cardiovascular
rions and two placentas that may or may not be fused. Twin anomalies?
transfusion syndrome occurs in as many as 10% to 15% of
monochorionic–diamniotic MZ twins. There is shunting of
arterial blood from one twin through unidirectional um-
bilical–placental arteriovenous anastomoses into the venous
circulation of the other twin. The donor twin is small, pale
and anaemic whereas the recipient twin is large and has
polycythaemia. In lethal cases, death results from anaemia
in the donor twin and congestive heart failure in the recipi-
ent twin. Late division of early embryonic cells, such as divi-
sion of the embryonic disc during the second week, results
in MZ twins that are in one amniotic sac and one chorionic
sac. A monochorionic–monoamniotic twin placenta is as-
sociated with fetal mortality rates that are higher by up to
10%, with the cause being cord entanglement. Because ul-
trasonographic studies are a common part of prenatal care,
it is known that early death and resorption of one member
of a twin pair is common. Triplets may be derived from one
zygote and be identical, two zygotes and consist of identical
twins and a singleton or three zygotes and be of the same sex
or of different sexes. The determination of twin zygosity is
done by molecular diagnosis.
PREIMPLANTATION GENETICS Fig. 3.6 Ultrasound of a fetus demonstrating an enhanced

nuchal translucency (arrow).
In couples with inherited genetic disorders and using
IVF, preimplantation genetic diagnosis can determine the
QUESTIONS
1. How many sperms would probably be deposited by a nor- c. neck

mal young adult male in the vagina during intercourse: d. main piece
a. 300,000 e. head
b. 3 million
c. 30 million 4. Morphologically abnormal sperm may cause:
d. 300 million a. monosomy
e. 3 billion b. congenital anomalies
c. trisomy
2. The secondary oocyte completes the second meiotic divi- d. abnormal embryos
sion: e. infertility
a. before ovulation
b. during ovulation BIBLIOGRAPHY
c. at fertilisation Jelin AC, Sagasser KG, Wilkins L. Prenatal genetic testing options. Pedi-
d. before birth atr Clin North Am 2019;66:281–93.
e. at puberty Bamberg C, Hecher K. Update on twin-to-twin transfusion syndrome.
Best Pract Res Clin Obstet Gynaecol 2019;58:55–65.
Katz DJ, Teloken P, Shoshany O. Male infertility – The other side of the
3. The sperm penetrates the zona pellucida, partially as-
equation. Aust Fam Physician 2017;46:641–6.
sisted by enzymes that are released from which portion
of the sperm:
a. middle piece
b. acrosome
4 Implantation and Week 2
endometrium. The window of implantation is relatively

Case Scenario brief, 2 to 3 days, and occurs during a restricted time pe-
riod, 6 to 10 days after ovulation and fertilisation—the mid-
A 32-year-old woman, having had two previous successful
pregnancies, presented to her family physician with unusually
secretory stage of the menstrual cycle. At this time, and
heavy menstruation. Her last normal menstrual period was ex- under the influence of progesterone and oestrogen, the
actly 2 months ago. She previously had a very regular cycle and cellular features of the endometrium are altered; pinopods
normal menstrual flow. She did not complain of any abdominal (microvilli) form on the epithelial cells, cellular vacuoles
pain. She has been on oral contraception for the past 3 years move towards the apical end of cells, the uterine connec-
and felt that she had been compliant. tive tissue is more oedematous, and some of the connec-
On physical examination, there was mild tenderness in her tive tissue cells accumulate large quantities of glycogen and
lower abdomen. Her blood pressure and heart rate were nor- lipids and expand in size, becoming the decidual cells (see
mal. Her haemoglobin level and white cell count were normal. Video 4.1).
Vaginal examination did not reveal any causes of bleeding al-
The syncytiotrophoblast and the blastocyst slowly implant
though her posterior fornix was tender on digital examination.
A pregnancy test was positive and an ultrasound examination
in the endometrium. Syncytiotrophoblastic cells displace
in the office revealed an empty uterine cavity and fluid present endometrial cells at the implantation site, reach the base-
in the rectouterine pouch (Fig. 4.1). ment membrane and then extend invadopodia between
She was sent immediately to the nearby hospital for further the cells, leading to degradation of the extracellular matrix.
care and treatment. This invasion allows the syncytiotrophoblast to reach the
Questions for reflection: How could the pregnancy test be vascular connective tissues and blood vessels. The syncy-
positive yet the woman is menstruating? Similarly, how could tiotrophoblast engulfs decidual cells to provide embryonic
she be pregnant yet the uterine cavity is empty? What kind nutrition. Some endometrial cells undergo apoptosis which
of fluid might be in the rectouterine pouch? What is your di- facilitates the invasion. Endometrial cell signalling also
agnosis and why? What further testing might be important?
helps to modulate the depth of penetration of the syncy-
tiotrophoblast. The blastocyst is completely embedded by
day 8 to 10. Initially the entry location is covered with fibrin
after which endometrial cells proliferate to cover the im-
plantation site.
Individual lacunae (Fig. 4.2) soon appear in the syn-
cytiotrophoblast. These become filled with a mixture of
maternal blood from the ruptured endometrial capillar-
ies and cellular debris of eroded uterine glands, provid-
ing nutritive material to the embryo. Communication of
the eroded endometrial capillaries with the lacunae in the
syncytiotrophoblast establishes the earliest uteroplacen-
tal circulation. Oxygenated blood passes into the lacunae
from the spiral endometrial arteries and poorly oxygenat-
ed blood is removed from them through the endometrial
veins.
In a 12-day embryo, adjacent syncytiotrophoblastic lacu-
nae have fused to form lacunar networks, the primordia
Fig. 4.1 Ultrasound image as per case.
of the intervillous spaces of the placenta. The endometrial
capillaries around the implanted embryo become congested
and dilated to form maternal sinusoids, thin-walled termi-
nal vessels that are larger than ordinary capillaries. The syn-
IMPLANTATION cytiotrophoblast erodes the sinusoids, and maternal blood
flows freely into the lacunar networks. The trophoblast
The mechanisms of implantation involve synchronisa- absorbs nutritive fluid from the lacunar networks, which is
tion between the invading blastocyst and a prepared transferred to the embryo.
18
CHAPTER 4 — Implantation and Week 2 19
Fig. 4.2 Timeline of development related to implantation and week 2 of development.
BILAMINAR EMBRYO
As implantation of the blastocyst progresses, the primordi-

um of the amniotic cavity appears in the embryoblast. Am-
niogenic cells, amnioblasts, separate from the epiblast and
form the amnion, which encloses the amniotic cavity. Con-
currently, morphological changes occur in the embryoblast
resulting in a flat, almost circular embryonic disc, which is
bilaminar (Fig. 4.3), consisting of the:
• epiblast—the thicker layer of high columnar cells related
to the amniotic cavity; and
• hypoblast—the thinner layer of small cuboidal cells adja-
cent to the exocoelomic cavity.
The pluripotent epiblast forms the floor of the amniotic
cavity and is continuous peripherally with the amnion. The
Fig. 4.3 Implanted blastocyst at 12 days. (Modified from Mitchell B,
hypoblast forms the roof of the exocoelomic cavity and is con- Sharma R. Embryology: An Illustrated Colour Text. 2nd ed. London:
tinuous with the thin exocoelomic membrane (Fig. 4.3). The Elsevier; 2009.)
exocoelomic membrane, together with the hypoblast, lines
the primary umbilical vesicle. The bilaminar embryonic disc
now lies between the amniotic cavity and umbilical vesicle. umbilical vesicle forms. This smaller vesicle is formed by ex-
Cells from the umbilical vesicle endoderm form a layer of traembryonic endodermal cells that migrate from the hypo-
connective tissue, the extraembryonic mesoderm which sur- blast inside the primary umbilical vesicle.
rounds the amnion and umbilical vesicle. The extraembry-
onic mesoderm increases and isolated coelomic spaces ap- DEVELOPMENT OF CHORIONIC SAC
pear within it which rapidly fuse to form the extraembryonic
coelom surrounding the amnion and umbilical vesicle (ex- The end of the second week is characterised by the appear-
cept where they are attached to the chorion by the connect- ance of primary chorionic villi (Fig. 4.4), that form columns
ing stalk). As the extraembryonic coelom forms, the primary with syncytial coverings. These cellular extensions grow into
umbilical vesicle decreases in size and a smaller secondary the syncytiotrophoblast forming primary chorionic villi, the
Molecular Biology Considerations

• MUC1, integrins (e.g., α1β1, HB-EGF)—implantation
(maternal factors)
• Wnt—endometrial receptivity
• L-selectin—apposition of blastocyst to endometrium (blas-
tocyst factor)
• Cx43—angiogenesis at implantation site
• miRs—communication between blastocyst and endome-
trium (blastocyst derived)
CLINICAL ISSUES
INHIBITION OF IMPLANTATION
The administration of progestins or antiprogestins (morn-
ing-after pills, a type of emergency contraceptive) for several
days beginning shortly after unprotected sexual intercourse,
inhibits ovulation and may also inhibit implantation of the
blastocyst. An intrauterine device (IUD) usually interferes
with implantation by causing a local uterine inflammatory
reaction. An IUD is typically a primary contraceptive but
may also be used for emergency contraception, by prevent-
ing fertilisation. Some IUDs contain progesterone, which is
slowly released and interferes with the development of the
endometrium so that implantation does not usually occur.
Fig. 4.4 Implanted embryo at 13 days. (Modified from Mitchell B, Other IUDs have a wrap of copper wire. Copper is directly
Sharma R. Embryology: An Illustrated Colour Text. 2nd ed. London: toxic to sperms and also causes uterine endothelial cells to
Elsevier; 2009.) produce substances that are toxic to sperms.
ECTOPIC IMPLANTATION
Implantation of blastocysts usually occurs in the superior
part of the body of the uterus.
However, blastocysts sometimes implant outside the uter-
us (ectopia). Between 95% to 98% of ectopic implantations
occur in the uterine tubes, most often in the ampulla and
isthmus. The incidence of ectopic pregnancy ranges from 1
Fig. 4.5 Details of the prechordal plate. (Modified from Moore KL, in 80 to 1 in 250 pregnancies, depending on many factors.
Persaud TVN, & Torchia MG. The Developing Human: Clinically Oriented In the United States, the frequency of ectopic pregnancy is
Embryology. 10th ed. Philadelphia: Elsevier; 2015.) approximately 2% of all pregnancies and rupture of a tubal
pregnancy is responsible for about 3% of pregnancy-related
first stage in the development of the chorionic villi of the deaths.
placenta. A woman with a tubal pregnancy has signs and symptoms
The extraembryonic coelom splits the extraembryonic of pregnancy but may also have abdominal pain and ten-
mesoderm into two layers: the extraembryonic somatic me- derness because of distention of the uterine tube, abnormal
soderm, lining the trophoblast and covering the amnion bleeding and pelvic peritonitis. The pain may be confused
and the extraembryonic splanchnic mesoderm, surround- with appendicitis if the pregnancy is in the right uterine
ing the umbilical vesicle (Fig. 4.4). The extraembryonic so- tube. Ectopic pregnancies produce β human chorionic go-
matic mesoderm and the two layers of trophoblast form the nadotropin (hCG) at a slower rate than normal pregnancies
chorion (wall of the chorionic sac). The embryo, amniotic so pregnancy testing may give false-negative results if per-
sac and umbilical vesicle are suspended in the chorionic formed too early.
sac by the connecting stalk. At 14 days, the hypoblastic cells Transvaginal ultrasonography is extremely helpful in the
in a discrete area of the embryonic disc become columnar early detection of ectopic tubal pregnancies.
and form the prechordal plate (Fig. 4.5); the site of the pri- There are several causes of tubal pregnancy, often related
mordial mouth. The prechordal plate serves as a signalling to factors that delay or prevent transport of the cleaving
centre for controlling development of cranial structures, in- zygote into the uterus. Such factors include mucosal ad-
cluding the forebrain and eyes. hesions in the uterine tube or from blockage of the tube
CHAPTER 4 — Implantation and Week 2 21
caused by scarring resulting from pelvic inflammatory dis- the nuclear DNA is paternal, and an embryo is absent but
ease. Unruptured tubal pregnancies may be managed medi- trophoblastic proliferation continues following implanta-
cally (intramuscular methotrexate) and/or surgically (lapa- tion. This proliferation produces excessively elevated levels
roscopic salpingotomy or salpingectomy) depending on the of hCG. A partial hydatidiform mole usually results from fer-
circumstances. Ectopic tubal pregnancies may result in rup- tilisation of a normal oocyte by two sperms—dispermy. Most
ture of the uterine tube and haemorrhage into the perito- women with molar pregnancies present with significant
neal cavity, followed by death of the embryo. Tubal rupture vomiting, vaginal bleeding, enlarging uterus and a failed
and haemorrhage are emergencies and a salpingectomy is pregnancy. Ultrasound can detect the delayed spontaneous
performed. abortion or anembryonic pregnancy. Molar pregnancies are
When blastocysts implant in the isthmus of the uterine most often treated by suction curettage followed by anti-D
tube, the tube tends to rupture earlier because this narrow prophylaxis.
part of the tube is relatively inflexible, and there is often Most hydatidiform moles are not cancerous. However
extensive bleeding. When blastocysts implant in the uter- some develop into invasive moles, which are locally invasive
ine (intramural) part of the tube they may develop beyond and nonmetastatic. In less than 5% of molar pregnancies,
8 weeks before rupture occurs. a choriocarcinoma develops. Choriocarcinomas are highly
Blastocysts that implant in the ampulla or on the fimbriae metastatic and can spread rapidly through the lymphatic
of the uterine tube may be expelled into the peritoneal cav- vessels or bloodstream to various sites such as the lungs, va-
ity, where they can implant in the rectouterine pouch. In gina, liver, bone, intestine and brain. Chemotherapy is the
exceptional cases, an abdominal pregnancy may continue treatment option of choice and, depending on the degree
to full term and the fetus may be delivered alive through a of metastases, radiation therapy and/or surgery may also be
laparotomy. Usually, however, the placenta attaches to the considered. These tumours can occur even following treat-
peritoneum or abdominal organs which causes considerable ment of a molar pregnancy, which is why follow-up testing
intraperitoneal bleeding. An abdominal pregnancy very sig- of hCG is important to ensure that hCG falls back to normal
nificantly increases the risk of maternal death from haemor- levels, indicating successful treatment of the molar preg-
rhage. nancy.
In rare cases of cervical implantations, the placenta be-
comes firmly attached to fibrous and muscular tissues of the
cervix, often resulting in bleeding, which requires subse-
Case Outcome
quent surgical intervention, such as hysterectomy.
The patient underwent a transvaginal ultrasound examination in
hospital confirming a left tubal pregnancy with likely hemoperito-
GESTATIONAL TROPHOBLASTIC DISEASES neum. Later that day, a diagnostic laparoscopy was performed.
Hemoperitoneum was confirmed resulting from a bleeding left
Molar pregnancies (1:1500 pregnancies), a type of gesta- tubal pregnancy in the area of the ampulla. All other structures
tional trophoblastic disease (GTD), are classified as either were normal. A left salpingectomy was performed with perito-
complete or partial. The main mechanisms for development neal lavage. The patient was discharged 24 hours later.
of complete hydatidiform moles include fertilisation of an Additional reflection: Did this patient exhibit the typical
oocyte with an absent or inactive pronucleus followed by du- presentation for tubal pregnancy? Is the rate of tubal preg-
plication (monospermic mole) or fertilisation of an empty nancy changing and, if so, what might be some reasons?
oocyte by two sperms (dispermic mole). Most complete hy-
datidiform moles are monospermic, the genetic origin of
QUESTIONS
1. The wall of the chorionic sac is composed of: 3. The most common location for an ectopic pregnancy is:
a. cytotrophoblast and syncytiotrophoblast a. on the ovary
b. two layers of trophoblast lined by extraembryonic so- b. in the peritoneal cavity
matic mesoderm c. in the superior cervix
c. trophoblast and the exocoelomic membrane d. in the isthmus of the uterine tube
d. two layers of trophoblast and extraembryonic e. in the ampulla of the uterine tube
splanchnic mesoderm
e. amniotic sac and the umbilical vesicle 4. Which of the following is correct as it relates to gesta-
tional trophoblastic diseases:
2. The amniotic cavity if found between the trophoblast a. Most complete hydatidiform moles are monospermic
and the: b. Most partial hydatidiform moles are typically monospermic
a. extraembryonic mesoderm c. There is continued growth of the embryo although
b. inner cell mass the trophoblast undergoes involution
c. exocoelomic membrane d. Unless treated immediately, most hydatidiform moles
d. connecting stalk become choriocarcinomas
e. chorion e. In most cases, women with hydatidiform moles are
asymptomatic
BIBLIOGRAPHY Fukui Y, Hirota Y, Matsuo M, et al. Uterine receptivity, embryo attach-

ment, and embryo invasion: Multistep processes in embryo implanta-
Committee on Practice Bulletins – Gynecology. Practice Bulletin No. tion. Reprod Med Biol 2019;18:234–40.
193. Tubal Ectopic Pregnancy. American College of Obstetrics and Su R-W, Fazleabas AT. Implantation and establishment of pregnancy
Gynecology; 2018. in human and nonhuman primates. Adv Anat Embryol Cell Biol
Cuman C, Van Sinderen M, Gantier MP, et al. Human blastocyst 2015;216:189–213.
secreted microRNA regulate endometrial epithelial cell adhesion.
EBioMedicine 2015;2:1528–35.
Weeks 3 to 8—General 5
Organogenesis
systems and most of the cardiovascular system. Excluding

Case Scenario the head and limbs, mesoderm is the source of all connec-
tive tissues, including cartilage, bones, tendons, ligaments,
A 47-year-old woman (JM) presented to her family physician
dermis and stroma (connective tissue) of internal organs
with heavy menstrual bleeding and abdominal cramping. She
was concerned because bleeding during her period is usually (see Video 5.1).
lighter, and there were more clots than she had seen previ- The first morphological sign of gastrulation is the forma-
ously. Also, the timing of her periods had been erratic over the tion of the primitive streak on the dorsal surface of the epi-
past few months and she was concerned that she might have blast of the bilaminar embryonic disc. By the beginning of the
cancer; her mother had died at age 55 years of ovarian can- third week, this thickened linear band of epiblast (Fig. 5.2)
cer. JM reported no other symptoms. Her past obstetric history appears caudally in the median plane of the embryonic disc
was nulligravida. She is sexually active. Physical examination and results from the proliferation and movement of cells
was normal (blood pressure 118/76 mmHg, heart rate 78 beats of the epiblast to the median plane of the embryonic disc.
per minute, respiratory rate 17 breaths per minute, temperature The appearance of the primitive streak delineates cranio-
36.8° C) except for slight distention of the abdomen and very
caudal axis, cranial and caudal ends, dorsal and ventral sur-
mild lower pelvic tenderness. Moderate active bleeding was
noted during pelvic examination. The cervix was open; there faces, and right and left sides of the embryo. As the streak
was no cervical or adnexal tenderness. Haematology, blood elongates by addition of cells to its caudal end, the cranial
chemistry and urinalysis were all within normal limits. end proliferates to form the primitive node. Concurrently, a
Questions for reflection: Might JM be approaching narrow furrow, the primitive groove, develops in the primi-
menopause? How would this be clinically evaluated? What tive streak that is continuous with a small depression in the
diagnostic tests might be appropriate for her? Why? Are primitive node, the primitive pit. The primitive groove and
the JM symptoms typical for ovarian cancer? What other pit result from the invagination of epiblastic cells. Later,
diagnoses might be considered? cells leave the deep surface of the primitive streak (Fig. 5.3)
and form mesenchyme – a connective tissue consisting of
small, spindle-shaped cells loosely arranged in an extracel-
lular matrix of sparse collagen fibres. Some mesenchyme
GASTRULATION forms mesoblast (undifferentiated mesoderm), which pro-
duces intraembryonic mesoderm. The primitive streak ac-
Gastrulation is the beginning of morphogenesis (develop- tively forms mesoderm until the early part of the fourth
ment of body form) and is the most significant event oc- week; thereafter, production of mesoderm slows down. Cells
curring during the third week. During gastrulation the from the epiblast, as well as from the primitive node and
bilaminar embryonic disc is converted into a trilaminar other parts of the primitive streak, displace the hypoblast,
embryonic; the three germ layers develop, which are pre- forming embryonic endoderm in the roof of the umbilical
cursors of all embryonic tissues. At the same time, the ax- vesicle. The cells remaining in the epiblast create the em-
ial orientation of the embryo is established. Extensive cell bryonic ectoderm.
shape changes, rearrangement, movement and alterations Caudal to the primitive streak, the cloacal membrane
in adhesive properties contribute to the process of gastrula- indicates the future site of the anus. The embryonic disc re-
tion. Each of the three germ layers (ectoderm, mesoderm mains bilaminar here because the embryonic ectoderm and
and endoderm) gives rise to specific tissues and organs. For endoderm are fused. The primitive streak undergoes regres-
instance, embryonic ectoderm gives rise to the epidermis, sive changes and disappears by the end of the fourth week.
central and peripheral nervous systems, eyes and internal
ears, neural crest cells, and many connective tissues of the
head. Embryonic endoderm is the source of the epithelial
linings of the respiratory and alimentary (digestive) tracts, NOTOCHORD
including the glands opening into the gastrointestinal tract
and glandular cells of associated organs such as the liver Mesodermal cells migrate cranially from the primitive node
and pancreas. Embryonic mesoderm gives rise to all skel- and pit to form a median cord, the notochordal process
etal muscles, blood cells, the lining of blood vessels, all (Fig. 5.4), which then develops a lumen, the notochordal
visceral smooth muscular coats, serosal linings of all body canal. The notochordal process grows in a cranial direction
cavities, ducts and organs of the reproductive and excretory in between the ectoderm and endoderm until it reaches
23
Fig. 5.1 Timeline of development related to general organogenesis.
notochord. Mesenchymal cells from the primitive streak

and notochordal process also migrate laterally and cranially,
until they reach the margins of the embryonic disc and be-
come continuous with the extraembryonic mesoderm cover-
ing the amnion and umbilical vesicle. Other mesenchymal
cells also migrate cranially and around the prechordal plate
where they form cardiogenic mesoderm.
By the middle of the third week, intraembryonic meso-
derm separates the ectoderm and endoderm everywhere ex-
cept at the oropharyngeal membrane, in the median plane
cranial to the primitive node where the notochordal process
is located, and at the cloacal membrane.
The primitive pit continues to develop and extend into
the notochordal process, forming the notochordal canal.
The floor of the notochord and the underlying embryonic
endoderm fuse and gradually undergo apoptosis (Fig. 5.5A),
resulting in the formation of confluent openings in the floor
of the notochordal process. This brings the notochordal ca-
nal into communication with the umbilical vesicle and re-
sults in the loss of the floor of the notochordal canal. The
notochordal process then becomes a flattened, grooved
notochordal plate. Beginning at the cranial end, the noto-
chordal plate cells proliferate and undergo infolding, which
creates the notochord (Fig. 5.5B). The notochord further
Fig. 5.2 Dorsal view of a 16-day embryo. (From Mitchell B, Sharma R. defines the primordial longitudinal axis of the embryo, gives
Embryology: An Illustrated Colour Text. 2nd ed. London: Elsevier; 2009.
some rigidity to the embryo, provides signals for develop-
Fig. 1.7.)
ment of axial musculoskeletal structures and the central
nervous system, and contributes to the intervertebral discs.
the prechordal plate where the ectoderm and endoderm The developing notochord induces the overlying embryonic
are fused. Prechordal mesoderm is formed from mesen- ectoderm to thicken and form the neural plate, the primor-
chymal population of neural crest origin, rostral to the dium of the central nervous system (CNS).
CHAPTER 5 — Weeks 3 to 8—General Organogenesis 25
Fig. 5.3 Drawing of a transverse cut of the cranial half of the embryo
to show migration of mesenchymal cells. (From Mitchell B, Sharma R.
Embryology: An Illustrated Colour Text. 2nd ed. London: Elsevier; 2009.
Fig. 1.8.)
Fig. 5.5 (A) Drawing of the median section of an 18-day embryo

showing apoptosis of floor of notochordal process. (B) Drawing of the
transverse section of a slightly older embryo showing formation of the
notochord and neural plate. (Modified from Moore KL, Persaud TVN,
& Torchia MG. The Developing Human: Clinically Oriented Embryology.
10th ed. Philadelphia: Elsevier; 2015. Fig. 4.9.)
Fig. 5.4 Drawing of the median section of a 16-day embryo showing

developing notochordal process. (Modified from Moore KL, Persaud
TVN, & Torchia MG. The Developing Human: Clinically Oriented Embryol-
ogy. 10th ed. Philadelphia: Elsevier; 2015. Fig. 4.8B.)
Fig. 5.6 Drawing of the transverse section of the embryo. (Modified
from Mitchell B, Sharma R. Embryology: An Illustrated Colour Text. 2nd
NEURULATION ed. London: Elsevier; 2009. Fig. 1.10A.)
Neurulation is the process that forms the neural plate, neu- folds (Fig. 5.6). The neural folds become particularly promi-
ral folds, and then closure of the folds to form the neural nent at the cranial end of the embryo and are the first signs
tube. Neurulation is completed by the end of the fourth of brain development. By day 21, the neural folds have be-
week, when closure of the caudal neuropore occurs. gun to fuse, converting the neural plate into the neural tube
The notochord induces the overlying embryonic ecto- (Fig. 5.7), the primordium of the brain vesicles and spinal
derm to form the neuroectoderm—an elongated plate of cord. The neural tube soon separates from the surface ecto-
thickened epithelial cells that gives rise to the CNS, the derm, the latter of which differentiates into the epidermis.
brain, spinal cord and various other structures, including Neurulation is completed during the fourth week.
those of the eye. As the notochord elongates, the neural Selected neuroectodermal cells on the crest of the merg-
plate broadens and eventually extends cranially as far as the ing neural folds undergo epithelial-to-mesenchymal transi-
oropharyngeal membrane. Over time, the neural plate ex- tion and migrate away. As the neural tube separates from the
tends beyond the notochord. surface ectoderm, these neural crest cells form a flattened
Around day 18, the neural plate invaginates along its irregular mass, the neural crest, between the neural tube
central axis to form a neural groove with bilateral neural and the overlying surface ectoderm (Fig. 5.7). The neural
Fig. 5.7 Transverse section of the 22-day-old embryo showing neu-

ral tube and neural crest. (Modified from Moore KL, Persaud TVN, &
Torchia MG. The Developing Human: Clinically Oriented Embryology.
10th ed. Philadelphia: Elsevier; 2015. Fig. 17.1F.)
crest soon separates into right and left parts that shift to the
dorsolateral aspects of the neural tube. Neural crest cells dif-
ferentiate and migrate widely. Neural crest cells give rise to
the spinal ganglia (dorsal root ganglia) and ganglia of the
autonomic nervous system. Ganglia of cranial nerves V, VII,
IX and X are also partly derived from neural crest cells. In
addition, neural crest cells form the neurolemma sheaths
of peripheral nerves and contribute to the formation of the
leptomeninges, the arachnoid mater and pia mater. Neural
crest cells also contribute to the formation of pigment cells,
the suprarenal medulla and many other tissues and organs.
SOMITES
In addition to forming the notochord, cells derived from

the primitive node form the paraxial mesoderm. This cell
population appears as a thick, longitudinal column of cells
continuous with the intermediate mesoderm and with the
extraembryonic mesoderm covering the umbilical vesicle
and amnion. Toward the end of the third week, the paraxial Fig. 5.8 (A) Transverse section of a 20-day-old embryo showing lo-
mesoderm differentiates, condenses and in a craniocaudal cation of somite. (B) Dorsal view of an embryo (approximately 22 days)
sequence begins to divide into paired cuboidal bodies, the showing five pairs of somites. (Modified from Moore KL, Persaud TVN,
somites (Fig. 5.8A). The somites are located on each side of & Torchia MG. The Developing Human: Clinically Oriented Embryology.
the developing neural tube. By the end of the fifth week, 42 10th ed. Philadelphia: Elsevier; 2015. Figs 4.10, 5.6)
to 44 pairs are present. The somites form distinctive surface
elevations (Fig. 5.8B) on the embryo. Somites give rise to The formation of the embryonic vascular system involves
most of the axial skeleton and associated musculature, as vasculogenesis, the formation of new vascular channels by
well as to the adjacent dermis of the skin. The first pair of assembly of individual angioblasts (endothelial cell precur-
somites appears a short distance caudal to the site at which sors) and angiogenesis, the formation of new vessels by bud-
the otic placode forms. Motor axons from the developing ding from preexisting vessels. Blood vessel formation begins
spinal cord innervate muscle cells in the somites. when mesenchymal cells differentiate into angioblasts which
aggregate to form isolated angiogenic cell clusters, or blood
islands. The angioblasts flatten to form endothelial cells
PRIMITIVE CIRCULATORY SYSTEM that arrange themselves around the blood island cavities,
forming the endothelium. Many of these cavities soon fuse
At the end of the second week, embryonic nutrition is de- to form networks of endothelial channels (vasculogenesis).
rived from maternal blood by diffusion through the extra- Additional vessels sprout into adjacent areas (angiogenesis)
embryonic coelom and umbilical vesicle. Shortly after, blood and fuse with other vessels forming communicating chan-
vessel formation begins in the extraembryonic mesoderm nels. The mesenchymal cells surrounding the primordial
of the umbilical vesicle, connecting stalk and chorion, and endothelial blood vessels differentiate into the muscular
then in the embryo. Early formation of the cardiovascular and connective tissue elements of the vessels.
system is correlated with the urgent need for blood vessels Haematogenesis occurs through specialised endothelial
to provide oxygen and nourishment to the embryo from the cells (hemangiogenic epithelium) of blood vessels as they
maternal circulation. grow on the umbilical vesicle and allantois and later in
specialised sites along the dorsal aorta of the embryo. Pro- organ system to reach a functional state. Motion of the pri-
genitor blood cells also arise directly from hemangiopoietic mordial heart can be detected using ultrasonography dur-
stem cells. Blood formation begins in the embryo in the fifth ing the fourth week.
week, first along the aorta and then in the liver, and later in
the spleen, bone marrow and lymph nodes.
The heart and great vessels form from mesenchymal cells CHORIONIC VILLI
in the cardiogenic area. Paired, longitudinal endothelial-
lined channels (endocardial heart tubes) develop during Shortly after primary chorionic villi appear at the end of the
the third week and fuse to form a primordial heart tube, second week, they begin to branch and become invested
which joins with blood vessels in the embryo, connecting with mesenchymal cells. These secondary chorionic villi
the stalk, chorion and umbilical vesicle to form a primordi- (Fig. 5.9A) cover the entire surface of the chorionic sac.
al cardiovascular system (Fig. 5.9B). By the end of the third Some of these mesenchymal cells soon differentiate into cap-
week, blood is circulating, and the heart begins to beat on illaries and blood cells, converting the secondary villi into
the 21st or 22nd day. The cardiovascular system is the first tertiary villi (Fig. 5.9B). The capillaries in these chorionic
Fig. 5.9 (A) Drawing of a sagittal section of an embryo (16 days) showing secondary villi. (B) Drawing of a sagittal section of an embryo (21 days)
tertiary villi. (Modified from Mitchell B, Sharma R. Embryology: An Illustrated Colour Text. 2nd ed. London: Elsevier; 2009. Fig. 2.2B.)
villi fuse to form arteriocapillary networks which connect

with the embryonic heart through further vessel differentia-
tion, including vessels in the stalk. By the end of the third
week, embryonic blood begins to flow slowly through the
capillaries in the chorionic villi. Oxygen and nutrients in the
maternal plasma in the intervillous spaces diffuse through
the walls of the villi and enter the embryo’s blood. Carbon
dioxide and waste products diffuse from blood in the fetal
capillaries through the wall of the chorionic villi into the
maternal blood.
Concurrently, cytotrophoblastic cells of the chorionic villi
proliferate and extend through the syncytiotrophoblast to
form an extravillous cytotrophoblastic shell which gradually
surrounds the chorionic sac and attaches it to the endome-
trium. Villi that attach to the maternal tissues through the
cytotrophoblastic shell are called stem or anchoring villi.
The villi that grow from the sides of the stem villi are called
branch villi, through which the main exchange of material
between the blood of the mother and embryo takes place.
The branch villi are bathed in continually changing mater-
nal blood in the intervillous space.
FOLDING
Establishment of body form requires folding of the trilami-

nar embryonic disc into a somewhat cylinder-shaped em-
bryo. Folding occurs in the median and horizontal planes
and results from rapid growth of the embryo (Fig. 5.10A–C).
Folding at the cranial and caudal ends and sides of the em-
bryo occurs simultaneously, and it results in the cranial and
caudal regions migrating ventrally, as the embryo elongates
cranially and caudally (see Video 5.2).
Fig. 5.10 (A) Drawing of a sagittal section of the cranial end of the
CRANIAL FOLDING embryo. The arrows indicates cranial folding and movement of the
septum transversum, heart and other structures moving onto the ven-
At the beginning of the fourth week, the developing brain
tral surface of the embryo. (B) Drawing of a sagittal section of the
projects dorsally into the amniotic cavity. It grows cranially caudal end of the embryo. The arrows indicates caudal folding and
beyond the oropharyngeal membrane and overhangs the movement of the cloacal membrane and primordial hindgut onto the
developing heart beginning the head folding. At the same ventral surface of the embryo. (C) Drawing of a transverse section
time, the septum transversum, primordial heart, pericar- of the embryo. Arrows indicate bilateral folding and initiation of the
dial coelom and oropharyngeal membrane migrate onto envelopment of a portion of the umbilical vesicle into the embryo.
the ventral surface of the embryo (Fig. 5.10A). During this (Modified from Moore KL, Persaud TVN, & Torchia MG. The Developing
folding, part of the endoderm of the umbilical vesicle is Human: Clinically Oriented Embryology. 10th ed. Philadelphia: Elsevier;
incorporated into the embryo as the foregut. After head 2015. Figs 5.2, 5.4, 5.1C3.)
folding, the septum transversum lies caudal to the heart,
where it subsequently develops into the central tendon of
HORIZONTAL PLANE FOLDING
the diaphragm.
Lateral folding is produced by the rapidly growing spinal
cord and somites. The primordia of the ventrolateral ab-
CAUDAL FOLDING
dominal wall fold toward the median plane (Fig. 5.10C),
This results primarily from growth of the distal part of the rolling the edges of the embryonic disc ventrally and form-
neural tube. The caudal eminence (tail region) projects over ing a roughly cylindrical embryo. As the abdominal wall
the cloacal membrane, the future site of the anus. During forms, part of the endoderm germ layer is incorporated into
caudal folding (Fig. 5.10B), part of the endodermal germ the embryo as the midgut. Initially, there is a wide connec-
layer is incorporated into the embryo as the hindgut. The tion between the midgut and umbilical vesicle; however, af-
terminal part of the hindgut soon dilates slightly to form ter lateral folding, the connection is reduced, forming an
the cloaca, the rudiment of the urinary bladder and rectum. omphaloenteric duct. The region of attachment of the am-
The connecting stalk (primordium of the umbilical cord) nion to the ventral surface of the embryo is also reduced to
is now attached to the ventral surface of the embryo, and a relatively narrow umbilical region. As the umbilical cord
the allantois, or the diverticulum of the umbilical vesicle, is forms from the connecting stalk, ventral fusion of the later-
partially incorporated into the embryo. al folds reduces the region of communication between the
intraembryonic and extraembryonic coelomic cavities to a of spontaneous abortions of embryos occur during the first
narrow communication. As the amniotic cavity expands and trimester. The true frequency of early spontaneous abor-
obliterates most of the extraembryonic coelom, the amnion tion is difficult to establish because it often occurs before
forms the epithelial covering of the umbilical cord. a woman is aware that she is pregnant, but rates of 50% to
70% have been reported. A spontaneous abortion occurring
several days after the first missed period is very likely to be
Molecular Biology Considerations mistaken for a delayed menstruation. More than half of all
known spontaneous abortions result from chromosomal ab-
• BMPs, FGFs, Shh, Tbx16, Tgifs and Wnts—gastrulation
• Wnt3a, Wnt5a and FGFs—germ cell layer fates
normalities of the embryo. The higher incidence of early
• TGF-β (nodal), veg T and Wnt—endoderm specification spontaneous abortions in older women probably results
• TGF-β superfamily, BMP4—mesoderm formation from the increasing frequency of nondisjunction during oo-
• WNT, FGF, NOTCH, HOX, Tbx6—somite formation genesis. Spontaneous abortions that result from failure of
• Wnt/β-catenin—neural crest development blastocysts to implant may result from a poorly developed
• FOXD3, SNAIL2, SOX9, SOX10—differentiation and endometrium and immune intolerance; however, in many
migration neural crest cells cases, there are probably lethal chromosomal abnormalities
• Delta-Notch signalling—craniocaudal sequencing of in the embryo. There is a higher incidence of spontaneous
somite formation abortion of fetuses with neural tube defects, cleft lip and
• Fit1—anastomosis of primitive vessels
cleft palate. After 10 gestational weeks, 25% to 40% of spon-
taneous abortions are related to fetal causes, 25% to 35% to
placental causes and 5% to 10% to maternal causes, with the
remainder unexplained.
CLINICAL ISSUES
TERATOMA CHORDOMAS
Remnants of the primitive streak may persist and give rise A chordoma is a rare malignancy that may form from vesti-
to a sacrococcygeal teratoma, a type of germ cell tumour gial remnants of the notochord. Approximately one-third of
that may be benign or malignant. By definition, the tumours chordomas occur at the base of the cranium and extend to
contain tissues derived from all three germ layers in vary- the nasopharynx. Chordomas grow slowly and may infiltrate
ing stages of differentiation, as they arise from pluripotent adjacent bone and soft tissues.
cell lines. Sacrococcygeal teratomas are the most common
congenital tumour in neonates and have an incidence of
approximately 1 in 35,000 with a 4:1 preponderance in Case Outcome
females. The teratomas are usually diagnosed on routine
antenatal ultrasonography, with about 70% being benign. Measurement of serum β human chorionic gonadotropin (ß-
Usually, teratomas are promptly surgically excised, with hCG) showed a level of 12,200 mIU/mL. A transvaginal ultra-
the prognosis dependent on many factors. These presacral sound was carried out, demonstrating an apparent abnormal
tumours may cause intestinal or urinary obstruction, and gestational sac within the cervical canal. Based on the clinical
work-up, JM was diagnosed with an incomplete spontaneous
surgical excision of such masses can have long-term sequelae
abortion.
in terms of normal function of these systems. Additional reflection: In what clinical situations would
either expectant, medical or surgical treatment be recom-
SPONTANEOUS ABORTION mended for an incomplete spontaneous abortion? What
would you recommend as treatment, if any, for JM and
Spontaneous abortion (miscarriage) is pregnancy loss that why? What are the most common reasons for spontane-
occurs within the first 12 completed weeks of pregnancy ous abortion?
and has a frequency of 25% to 30%. Approximately 80%
QUESTIONS
1. Which of the following is correct as it relates to 2. During neurulation:

gastrulation? a. the notochord forms the neural plate and neural
a. The formation of the primitive groove is the first folds
morphologic sign of gastrulation b. the notochord induces the endoderm to form neuro-
b. The primitive streak follows the formation of the endoderm
primitive groove and is formed by hypoblast cells c. the neural folds first begin to fuse by day 28
c. Some cells of the primitive streak leave its deep sur- d. neural crest cells are formed by epithelial-to-
face to form mesenchyme mesenchymal transition of neuroectoderm
d. Cells from the hypoblast as well as from the primitive e. neural crest cells form and remain adjacent to the
streak displace the hypoblast to form the ectoderm neural tube
e. The primitive node is formed at the caudal end of the
primitive streak.
BIBLIOGRAPHY Vijayraghavan DS, Davidson L. Mechanics of neurulation: From classi-

cal to current perspectives on the physical mechanics that shape, fold,
Behera MA, Price TM. Abnormal (dysfunctional) uterine bleed- and form the neural tube. Birth Defects Res 2017;109(2):153–68.
ing. Medscape. http://emedicine.medscape.com/article/257007. Yoon HM, Byeon SJ, Hwang JY, et al. Sacrococcygeal teratomas in
December 7, 2018. newborns: a comprehensive review for the radiologists. Acta Radiol
Dupin E, Calloni GW, Coelho-Aguiar JM, Le Douarin NM. The issue of 2018;59:236–46.
the multipotency of the neural crest cells. Dev Biol 2018; 444 Suppl
1:S47–59.
Placentation and Membranes 6
the placenta are attached by the cytotrophoblastic shell, the
Case Scenario external layer of trophoblastic cells on the maternal surface
of the placenta. The chorionic villi are attached firmly to the
An anxious 34-year-old woman (TJ), 6-weeks pregnant, pres-
decidua basalis through this shell. Endometrial arteries and
ents to the emergency department with vaginal bleeding that
had begun 5 hours earlier. TJ described mild lower quadrant veins pass freely through gaps in the cytotrophoblastic shell
abdominal pain, but no other symptoms. Six months previous- and enter the intervillous space (Fig. 6.3). As chorionic villi
ly, she had had a spontaneous abortion at 8 weeks gestation. invade the decidua basalis, decidual tissue is eroded to en-
Otherwise, her past medical history was unremarkable. TJ was large the intervillous space. The placental septa, which proj-
taking no medications, did not smoke and denied any alcohol ect towards the chorionic plate, divide the fetal part of the
or illicit drug use. placenta into cotyledons, each consisting of two or more stem
All vital signs were normal. Abdominal examination demon- villi and many branch villi. By the end of the fourth month,
strated no tenderness or distension, and normal bowel sounds. the decidua basalis is almost entirely replaced by cotyledons.
The uterus was not palpable. Pelvic examination demonstrated As the conceptus enlarges, the decidua capsularis bulges
a closed cervical os; scant blood was noted in the vaginal vault
into the uterine cavity and becomes greatly attenuated. The
with no active bleeding. The remainder of the physical examina-
tion was unremarkable. decidua capularis eventually fuses with the decidua parieta-
Haematology and blood chemistry results were normal. Uri- lis on the opposing uterine wall, obliterating the uterine cav-
nalysis revealed no white cells, a few red blood cells and a few ity. By 22 to 24 weeks the decidua capsularis degenerates
bacteria (nitrite, ketones and glucose were all negative). Serum β because of reduced vascularisation, allowing the smooth
human chorionic gonadotrophin (β-hCG) was 17,230 mIU/mL. chorion to fuse with the decidua parietalis.
An ultrasound examination using an endovaginal probe was Initially, when trophoblastic cells invade the uterine spi-
conducted and demonstrated two fluid-filled structures in the ral arteries, these cells create plugs within the arteries. The
uterus measuring 1.7 cm × 0.8 cm and 2.2 cm × 0.5 cm. The plugs allow only maternal plasma to enter the intervillous
remainder of the ultrasound examination was normal. space. As a result, there is a net negative oxygen gradient
Questions for reflection: Does a previous spontaneous
created. Elevated oxygen levels during the early stages of
abortion increase the risk for future spontaneous abor-
tions? What is the significance of the red blood cells and development can be deleterious to the embryo. By 11 to
bacteria in the urine sample and the β-hCG result? What is 14 weeks, the plugs begin to break down, maternal whole
the significance of a closed cervix on pelvic examination? blood begins to flow and oxygen concentrations increase.
What could the two fluid-filled structures represent? The intervillous space (Fig. 6.3) of the placenta, which
by 11 to 14 weeks contains maternal blood, results from the
coalescence and enlargement of the lacunar networks. The
intervillous space is partially divided into compartments by
PLACENTATION AND MEMBRANES placental septa. Maternal blood enters the intervillous space
from the spiral endometrial arteries in the decidua basalis.
The placenta, a fetomaternal organ, is comprised of a fetal The intervillous space is drained by endometrial veins. The
part that develops from the chorionic sac and a maternal numerous branch villi are continuously bathed with mater-
part derived from the decidua basalis (the part of the en- nal blood in the intervillous space. The branch chorionic
dometrium that is deep to the conceptus). Early develop- villi provide a large surface area for exchange across the very
ment of the placenta is characterised by rapid proliferation thin placental membrane, consisting of extrafetal tissues, in-
of trophoblast and development of the chorionic sac and terposed between the fetal and maternal circulations. Until
chorionic villi. By the end of the third week, the basic com- approximately 20 weeks, the placental membrane consists of
ponents necessary for physiological exchanges between the four layers: syncytiotrophoblast, cytotrophoblast, connective
mother and embryo are established. tissue of the villi and endothelium of fetal capillaries. After
Chorionic villi cover the entire chorionic sac until the be- the 20th week, the cytotrophoblastic cells disappear over
ginning of the eighth week (Fig. 5.8). As the chorionic sac large areas of the villi, leaving only thin patches of syncytio-
grows, the villi associated with the decidua capsularis (decid- trophoblast. As a result, the placental membrane then con-
ua overlying the embryo) become compressed, necrotic and sists of three layers in most areas, and in some sites the pla-
degenerate, producing the smooth chorion. The villi of the cental membrane becomes markedly attenuated. At these
decidua basalis then rapidly proliferate, branch and enlarge, sites, the syncytiotrophoblast comes into direct contact with
which forms the villous chorion (Fig. 5.9A). The placenta the endothelium of the fetal capillaries to form a vasculosyn-
typically has a discoid shape. The fetal and maternal parts of cytial placental membrane.
31
Fig. 6.1 Timeline of development related to placentation and formation of membranes.
ed blood in the capillaries passes into thin-walled veins that

PLACENTA AND IMMUNITY follow the chorionic arteries to the site of attachment of the
umbilical cord. Here they converge to form the umbilical
The fetal parts of the placenta contain both paternal and vein and carry oxygen-rich blood to the fetus.
maternal genes and therefore must be protected from the The maternal blood in the intervillous space enters
maternal immune system to prevent rejection. Although evi- through 80 to 100 spiral endometrial arteries (Fig. 6.3) in
dence continues to be discovered about the immune mecha- the decidua basalis, which eject blood at a considerably
nisms necessary, there is some evidence to indicate: higher pressure than that in the intervillous space. As a re-
• syncytiotrophoblast lacks major histocompatibility (MHC) sult, blood spurts towards the chorionic plate and then flows
antigens and thus does not evoke rejection responses slowly over the branch villi, allowing exchange. The intervil-
• local immunosuppressor molecules, PGE2, TGF-β and in- lous space of the mature placenta contains approximately
terleukin 10, help to block activation of maternal T cells 150 mL of blood, which is replenished three or four times
and natural killer (NK) cells per minute. The maternal blood eventually returns through
• activated maternal leukocytes are destroyed by apoptosis- the endometrial veins to the maternal circulation.
inducing ligands present on the trophoblast
• complement regulatory proteins protect the placenta
from complement-mediated destruction PLACENTAL FUNCTION AND
• there is silencing of key maternal T cell-attracting inflam- TRANSPORTATION
matory chemokine genes in decidual stromal cells.
The placenta has several main functions including metabo-
lism, transportation of gases and nutrients, endocrine secre-
FETAL AND MATERNAL PLACENTAL tion, protection and excretion, all of which are essential for
CIRCULATION maintaining pregnancy and normal fetal development.
Particularly during early pregnancy, the placenta synthe-
Deoxygenated blood from the fetus is carried to the pla- sises glycogen, cholesterol and fatty acids, which serve as
centa through the paired umbilical arteries (Fig. 6.3). The sources of nutrients and energy for the fetus. These are also
umbilical arteries divide into radially dispersed, branching required for transport and endocrine secretion activities.
chorionic arteries that enter the chorionic villi, forming an The placenta has a number of protective mechanisms,
extensive arteriocapillary–venous network. This network such as DNA methylation, which allow it to react to various
brings the fetal blood extremely close to the maternal blood, environmental conditions (e.g., hypoxia) and exposures
separated only by the placental membrane. The reoxygenat- that may occur and minimise any impact on the fetus.
CHAPTER 6 — Placentation and Membranes 33
Fig. 6.3 Schematic drawing of a transverse section through a full-

term placenta showing the relationship between the fetal and maternal
parts of the placenta. (Modified from Mitchell B, Sharma R. Embryology:
An Illustrated Colour Text. 2nd ed. London: Elsevier; 2009. Fig. 2.6A.)
There are other ways that cells may transfer across the
placental membrane. Erythrocytes (maternal or fetal) can
enter the fetal or maternal circulation through small defects
in the placental membrane. Maternal leukocytes may cross
under their own power. Some bacteria and protozoa such as
Toxoplasma gondii create placental lesions and then cross the
membrane through the resulting defects.
Fig. 6.2 Drawing of a sagittal section of a uterus at 16 weeks show- Water and gases cross the placental membrane by simple
ing the various membranes and placental structures. (Modified from diffusion. The quantity of oxygen reaching the fetus is pri-
Mitchell B, Sharma R. Embryology: An Illustrated Colour Text. 2nd ed. marily limited by blood flow (maternal or fetal) rather than
London: Elsevier; 2009. Fig. 2.1.) oxygen diffusion. Glucose produced by both the mother
and the placenta is quickly transferred by facilitated (ac-
tive) diffusion mediated primarily by glucose transporter
1 (GLUT1). Amino acids are actively transported across
There are only very few substances, endogenous or exog-
the placental membrane; for most amino acids, the plasma
enous, that are unable to pass through the placental mem-
concentrations in the fetus are higher than in the mother.
brane; it acts as a true barrier only when a molecule is of
Water-soluble vitamins cross the placental membrane more
a certain size, configuration and charge. Some substances
quickly than fat-soluble vitamins. Unconjugated steroid hor-
present in the maternal circulation only pass through the
mones cross the placental membrane quite freely. Protein
placental membrane in quantities insufficient to affect the
hormones (e.g., insulin) reach the fetus in only very small
fetus. Most drugs and other substances in the maternal
amounts, except thyroxine and triiodothyronine which en-
blood plasma pass through the placental membrane and
ter by slow transfer. Electrolytes are freely exchanged across
enter the fetal blood plasma. Almost all materials are trans-
the placental membrane in significant quantities, each type
ported across this membrane by one of the following four
at its own rate. Transferrin crosses the placental membrane
main transport mechanisms:
(placental receptors) and carries iron to the embryo/fetus.
• simple diffusion—passive transport characteristic of sub- Urea and uric acid pass through the placental membrane by
stances moving from areas of higher to lower concentra- simple diffusion. Conjugated bilirubin is easily transported.
tion until equilibrium The immaturity of the fetal immune system means that
• facilitated diffusion—transport through electrical gradi- only small quantities of antibodies are produced. However,
ents requiring a transporter but no energy some degree of passive immunity is provided by the transfer
• active transport—passage of ions or molecules across a of maternal IgG gamma globulins by transcytosis, beginning
cell membrane against a concentration gradient and re- at 16 weeks and peaking at 26 weeks.
quires energy (e.g., ATP) The amount of drugs or metabolites crossing the placen-
• pinocytosis—a form of endocytosis where the material is tal membrane is controlled by the maternal blood concen-
a small amount of extracellular fluid and usually reserved tration and the blood flow through the placenta because
for large molecules most such compounds cross by simple diffusion. Most drugs
used for the management of labour readily cross the pla- the umbilical vesicle, forming the umbilical cord. In addi-
cental membrane. Viruses may pass through the placental tion, blood vessels, initially two veins and two arteries, are
membrane and cause fetal infection. Microorganisms such integrated into the umbilical cord through the processes
as Treponema pallidum and T. gondii also cross the placental of angiogenesis and vasculogenesis. By the end of the fifth
membrane. week, the umbilical cord has blood flowing in these vessels.
The placenta synthesises progesterone and oestrogens. The right umbilical vein becomes obliterated by the sixth
The syncytiotrophoblast produces oestrogen and protein week, leaving a single vein, two arteries and the remnant
hormones including chorionic gonadotropin (hCG), cho- of the umbilical vesicle, the allantois. The two arteries typi-
rionic somatomammotropin (hCS) and chorionic thy- cally form a helical structure around the vein. Close to the
rotropin (hCT). hCG maintains the corpus luteum, hCS placenta, there is also an anastomosis between the two arter-
causes decreased maternal glucose utilisation and increased ies; it is thought that this acts as a pressure equaliser. The
maternal free fatty acids whereas hCT appears to function structure of the umbilical cord and patency of the blood ves-
similarly to thyroid-stimulating hormone. sels are supported by special connective tissue (Wharton’s
jelly). At term, the cord is typically 50 to 60 cm long (range
of 30–100 cm), with a diameter of approximately 8 mm. In
AMNIOTIC CAVITY AND FLUID most cases, the umbilical cord connects to the centre of the
placenta, but less commonly it may also connect closer to
The amniotic sac that surrounds the developing embryo the margin.
and fetus contains amniotic fluid.
Because the amniotic sac enlarges faster than the chori-
onic sac, the amnion and smooth chorion fuse to form the Molecular Biology Considerations
amniochorionic membrane which, in turn, fuses with the
• HLX, MSX2 and DLX3—expressed in the trophoblast induce
decidua capsularis. It is the amniochorionic membrane that
trophoblastic invasion and regulate placental development
ruptures during labour. The amnion also forms the epithe- • MAP2K1, MAP2K2 and Gcm1—in trophoblast stem cells
lial covering of the umbilical cord. regulate the branching process of the stem villi
Initially, amniotic fluid is derived from maternal tissue • EGF, TGF-α, amphiregulin, VEGF—stimulation of cytotro-
and interstitial fluid by diffusion from the decidua parieta- phoblast cell production
lis; diffusion of fluid from blood in the intervillous space • TGF-β—binding leucine-rich proteoglycan decorin (DCN) re-
through the chorionic plate; tissue fluid from the fetus duces cytotrophoblast migration and invasiveness
(before skin keratinisation); and fluid secreted by the fe- • Human placental methylome—selectively regulates maternal
tal gastrointestinal and respiratory tracts, with the latter and fetal exchanges; also controls fetal growth and
contributing approximately 350 mL/day. During the 11th development
week, the fetus begins to excrete urine into the amniotic
cavity, with more than 0.5 L added daily, late in pregnancy.
The total volume of amniotic fluid is approximately 30 mL
at 10 weeks, 350 mL at 20 weeks and 700 to 1000 mL by CLINICAL ISSUES
37 weeks.
The exchange of water content in amniotic fluid occurs HYPERTENSIVE DISORDERS OF PREGNANCY
continuously through the amniochorionic membrane into
the maternal tissue fluid and then enters through uterine PREECLAMPSIA AND ECLAMPSIA
capillaries. Such an exchange also happens via fetal blood, Development of new hypertension (≥140 mmHg systolic or
through the umbilical cord and chorionic plate on the fetal ≥90 mmHg diastolic) after the 20th week of gestation in an
surface of the placenta. Amniotic fluid is also swallowed and otherwise normotensive woman is considered preeclampsia.
absorbed by the fetal digestive tracts, passing into the fetal It usually includes proteinuria. With increasing severity, it
bloodstream, with the waste products crossing the placental may also include thrombocytopenia, reduced liver or kid-
membrane into the maternal blood. Any excess water in the ney function, pulmonary oedema or cerebral and/or vi-
fetal blood is excreted by the fetal kidneys and returned to sual symptoms. The origin of preeclampsia appears to be
the amniotic sac through urination. multifactorial; the primary pathology being a hypoinvasive
placenta and compromised uterine angiogenesis leading
to reduced placental perfusion and production of toxins
UMBILICAL CORD that attack the maternal vasculature. The renal angiotensin
system has also been implicated. Preeclampsia is a leading
Early in development the bilaminar embryo is surrounded cause of maternal morbidity and may lead to fetal malnu-
by extraembryonic mesoderm, formed by the endodermal trition, fetal growth restriction, miscarriage or fetal death.
cells of the umbilical vesicle. At approximately 10 days, Eclampsia is diagnosed when seizures occur, without previ-
apoptosis occurs in the extraembryonic mesoderm, causing ous history, in a woman with preeclampsia. Eclampsia is a
extraembryonic coelomic spaces to appear, which soon co- leading cause of maternal mortality.
alesce resulting in the bilaminar embryo being suspended
within what will become the chorionic cavity. The embryo GESTATIONAL HYPERTENSION
remains attached to the developing placenta by the con- Gestational hypertension is defined as the development of
necting stalk. As the embryo develops, the amniotic sac en- hypertension (≥140 mmHg systolic or ≥90 mmHg diastolic),
larges and envelopes the connecting stalk and a portion of without proteinuria, after the 20th week of gestation.
Another random document with
no related content on Scribd:
Mr. R. (reads from the newspaper emphatically). “One of the
richest papers on the woman question that has ever emanated from
an official source is the opinion of Solicitor Rayner on the question
whether licenses should be granted women to command
steamboats. He says: ‘Instead of being master in name, while some
one else performs the duties, why does she not let some one else be
master in name? She would not stand her watch at night in the cold.
She would not enforce the discipline on a Mississippi steamer. She
would not tramp to the rooms of shippers and consigners to do the
banking business—’”
Mary (interrupting). Why! that is just what I have been doing for
the last five months.
Mr. R. (reads on). “‘All the accounts concur in describing the lady
who makes this application as one of high character, business
qualifications, and highest worth. But, in the application of what is
with me a principle, the higher the character and worth, the greater
my difficulty in asking that the license asked for to command a
Mississippi steamboat be granted. Because it would be assigning a
position to woman which God, in his providence, never intended her
to fill.
K. Rayner, Solicitor of the Treasury.’”
(Holds out paper to her.)
Mary. What does he mean? I am sure God has permitted me to fill
this position, and (reverently) if He had not permitted it, and helped
me, too, I never could have done it so well. How unjust this man is!
Oh, Mr. Rayner! can you not comprehend that, when a woman can
do a man’s work, she ought to have the legal right? (Comes forward,
takes the paper, and reads to herself. To him) But see, Mr. Romberg.
Here is something else about it; something from the Secretary of the
Treasury. (Reads) “The United States Revised Statutes say that
whenever any person applies to be licensed, the inspectors shall
diligently inquire as to the character of the person, whether male or
female. I see no reason, then, in unwritten or in written law, why
Mistress Miller may not lawfully demand an examination; and, if she
proves herself duly qualified, have a license to serve as master of a
vessel. Let the local inspectors carefully examine her, and if they are
satisfied that she can be safely intrusted with the duties and
responsibilities of a master of a steam vessel, let them grant her a
license, according to section 4439.
Chas. J. Folger, Secretary of the Treasury.”
Bless him for that! He may make it all right. You see, Mr. Romberg,
it is not fully decided. I may get the license yet. (Phus looks up from
his book.) I have been examined; and when I told the inspectors all
about that large boat that got stuck up the river, near Cairo, and that
we had the chance to take off the loaded barges, and how I had
them made fast to us, took the wheel myself, turned the big boat
round, and carried her safely into Cairo, they looked surprised
enough. And one of them said that I did seem to be qualified. Phus
remembers it, the visit of the inspectors; don’t you, Phus?
Phus (jumping up and putting his whole hand in the book for a
mark). O, yes, mis’! dem two gem’man, one wid de black bandanna
on he hat, de oder wid de gaiters! De las’ one, he say, “You culled
pusson, tel’ me troo, your mis’ she no bos’ dis boat?” I say, “Yaas,
saar!” Den de one wid de black bandanna, he say, “But de mate, he
de real cap’n; he stan’ at w’eel, steer, an’ tak’ car’ ob injyne, don’
he?”
Mary. What did you tell him?
Phus. I sez, “No! On’y when mis’ restin’, an’ it’s cam (calm), an’
dere ain’t no snags nor be-yous. She bos’, she steer, she watch
injyne. Pats, he on’y shovel coal, ’bey orders. On’y he mad
sometime, an’ he say he not be bos’ by wimmin. Den de one wid de
gaiters, he say, “You nig tell de trute; she raal cap’n? She bos’
ebryting?” I say, “Yas, saar-e! ebryting! She bos’ steamboat. She
bos’ Pats. She bos’ Hank and me—Phus—dat’s me W’y! mis’ could
bos’ you, bos’ de President ’nited States, be cap’n ob ebrybody.”
Den dey bof laf, an’ I help’ ’em obe de gang-plank.
Mary (sitting). Oh, Phus! you tried to prove too much. But you
make me laugh, in spite of my troubles.
Phus. I does my bes’, mis’. (Sits down, r., and reads.)
Mr. R. The other owners say, and the newspapers, too, that you
have no chance; and we are all so certain of it that we have agreed
not to take away the boat if you do get the license.
Mary. Do you think yourselves so certain as that? Very well. But I
have faith to believe that you will all wish that you had not made that
promise, unless you really want me to have the boat.
Mr. R. Oh, madam! we’ve no notion you’ll get it. The other owners
scorn the idea of a woman captain, and so do I. It’s ridiculous!
(Walks about.)
Phus (reading to himself). W’ot did Meelissee scramded—no—
squeemed for? ’coz she felt a col’ han’ on her fourhed? Golly! wos
she ’f’aid o’ dat? (Reads) Oh! she was alone in de dark, in de bed,
an’ couldn’t see nobody! I should ’a’ thought she would ’a’
squeemed. (Looks all around in a frightened manner.)
Mr. R. (seating himself near Mary). When did you hear from your
husband last?
Mary. Not for a long time. I can’t think what the reason is. I
expected to find a letter here, but haven’t received any. Phus!
Phus (jumping up in terror, and then relieved). Oh! it’s on’y mis’.
Yaas! yaas!
Mary. Phus, you go to the post-office, and see if there are any
letters. The post-man may not know that we have come in.
Phus. Yaas, mis’. (Puts book on the wheel-house, and exit l.)
Mr. R. He went out with a fishing-fleet, didn’t he, from Gloucester?
Mary. Yes; why?
Mr. R. Well, there have been a good many fishing-boats lost
lately, down at the Banks, that went from Gloucester. What was the
name of his boat?
Mary. The Betsey Ludgitt, Captain Zabulon Miller.
Mr. R. That’s the name of one of them, I think. Here’s the shipping
list. It says (he reads), “Several vessels strayed from the fleet, and
have not been heard from since. It is feared that they are lost.
Among them is the Betsey Ludgitt, Captain Zab—”
Mary (rising in alarm). Merciful Heaven! it cannot be! I should
have heard; something would have told me if such a dreadful thing
had happened to William. I cannot believe it.
Mr. R. He may be safe; but the probabilities are that he is lost.
Mary. Oh! do not say that again. I cannot and will not believe it.
(Goes to the hammock, and bends over it.)
Mr. R. (approaching Mary in an insinuating way). My dear—
madam, if anything should happen to your husband, remember
(smiling) that you have a warm friend in me. I will give you as good a
home as there is on the river, and take your child, too. Yes! yes! I’ll
take your child.
Mary (turning suddenly upon him). Give me a home? Take my
child? What do you mean?
Mr. R. Why, I mean that I’ll marry you!
Mary. Marry me? Who gave you the right to say you’d marry me,
or take my baby? William’s child! How dare you!
Mr. R. I don’t see as you can help yourself. You need the
protection of a man. You can’t have the boat; and you certainly can’t
get a living around here, with your hands tied by that young one. And
you’re too pretty a woman—(Tries to take her hand.)
Mary. (indignantly). Sir! you’ve said enough! You may own my
boat, and you may have the power to take her from me; but you
cannot have the wife of Captain William Miller. I tell you, sir, that I
would rather beg my way home from door to door, with my child in
my arms,—yes, I would starve,—before I would be the wife of any
man but my own husband. Dead or alive, it makes no difference to
me. He is still my husband!
Mr. R. (aside). Those down-East women beat the world. The
spunk they show—Yankee grit they call it—it’s amazing! But, Gad! it
makes her look handsomer than ever. (To her, insinuatingly) You
may change your mind; but, whether you do or not, remember that I
will always be your friend. (Smiling.)
Mary. Sir! I shall never change my mind; and I forbid you ever to
mention this subject to me again. I want no such friendship as yours.
Good-morning! (Turns from him, and goes to the hammock.)
Mr. R. (apologetically). Well, I’m sure I—(Aside) Gad! I want her
more than ever. (To her) You know I said if you did get the license,
we won’t take away the boat. I’m sure you ought not to complain of
that!
Mary (without turning). Very well, sir—then, there is nothing more
to say. Good-morning.
Mr. R. (shamefacedly). Er-er-good-morning. (Exit r.)
Mary (scornfully). So this is the way men protect women! Wretch!
To dare to speak so to me!
(Re-enter Phus, R.)
Phus. O, mis’! dere’s an ol’ gemmen an’ young maars on de warf,
an’ dey bof ax for you.
Mary. Why, who can they be? Ask them to come on deck.
Phus (at r.). Dis way! Dis way!
(Captain Gandy, outside, sings.)
“On Springfield maount’ins there did dwell

A lovelye youth an’ known full well—”
Mary (in great surprise). Father Gandy!

(Enter Capt. G. at r., with J. Q. A., in the uniform of a railroad-train
boy, with a basket on his arm.)
Mary. Why, father! Where did you come from? And John Quincy
Adams! (Rushes into his arms, spilling the basket.)
J. Q. A. Here! Here! What are you about, spilling all my
spondulics! (Puts down his basket, and takes off his hat.)
Mary. Dear, dear father! where in the world did you come from?
(Throws her arms round him.)
Capt G. Why! from hum, o’ coorse. Whar else should I hail from?
Mary (eagerly). Oh, father! do you know anything about William? I
haven’t heard from him for two months, and I can’t think what the
reason is. You don’t suppose anything could have happened to him,
do you?
Capt. G. Oh! wal, no—I guess not. I saw by the Herald that Zab
Miller’s skewner had strayed from the rest on ’em; but he knows wot
he’s abaout. He ain’t a-gwine ter tell all Glowchester where them
skewls o’ haulibaout hide. (Pats her on the shoulder.) Don’t yer worry
abaout that! There ain’t no telegraph poles on them fishin’ graounds,
an’ the post-man don’t drop in every day in them diggin’s, an’ there
ain’t no delivery if yer do write, nuther.
Mary. I can’t help worrying; and yet I know he must be safe. But,
father, how did you happen to come?
Capt. G. Wal, yer marm was so worrited abaout your trouble that
she made me start off; coz she sed I could act as cap’n, if that was
all the gov’ment wanted, be “master in name” (she read it in the
Globe), so’s you could keep the boat. (Shoves hat on back of head,
puts hands in pockets, and walks about, sailor fashion.)
J. Q. A. I was the first one to think of coming. And I went to Boston
on Jim Rosson’s engine, and got a chance as train-boy to New York.
And when marm found out I was bound to come, she said pup
should go, too. I wanted to come and punch old Romberg’s head.
(Walks about and inspects everything.)
Mary. But where did you get the money to come with, father? and,
John (to J. Q. A.), who paid your fare from New York?
J. Q. A. Why! I paid myself, of course. What do you take me for?
When I got to New York I got another chance as train-boy, all the
way through; and I’ve peddled out water in a big-nosed coffee-pot
from Annisport to New Orleans. And sold books, too! And prize
packages, and things, and magazines. (Calls) “Harper’s! December
Harper’s! Baby Pathfinder! Puck! Peanuts! Gum drops? (Offers his
basket to Mary.)
Mary. You funny boy!
Capt. G. Well, yer see, yer marm—
Mary (interrupting). Sit down, father. (Offers him a camp-stool.)
Capt. G. No, I just ’s lives stand. (Leans against railing.) Yer marm
took boarders all summer, an’ she made me take that money. She
said ’twould never do any more good; an’, then, Leafy Jane, she’s
l’arnt the millinger’s trade, an’ she giv’ me some o’ hern.
J. Q. A. I tried to get a pass for him, part way, at least; but them
railroad men are so mean they’ll never help a fellow along.
Capt. G. Haow is little Nate?
Mary. Oh! he’s all right! Here he is, father. Come and see him.
(They go together to the hammock.) He hasn’t been sick a day this
summer. The dear little fellow! He grows like a weed.
J. Q. A. (at the hammock, aside). A pig weed, I s’pose.
Capt. G. Yer see, Mary, yer trouble has set me ter thinkin’; an’
when you wrote they was goin’ to take away yer boat, just cos yer
was a woman, by the great horn spoon, I was mad: for yer a Gandy
cl’ar through, a sea-cap’n born like all the rest on us. And I’ve made
up my mind that wimmin’s rights must be worth suthin’ to wimmin, as
well as men’s rights to men. An’, as old Pete Rosson said, when he
felt so bad about yer losing the boat, “Sence a woman can’t allus hev
her husband or her father tew take care on her, she ort to have the
right to take care o’ herself, an’ then she can use it or not, as she
wants tew.” An’ so I begin to think that I don’t care if we do let ’em
vote.
J. Q. A. (examining the wheel). Cracky! you can’t make me believe
that. I shall vote in five years, and I’m sure I don’t want Leafy Jane
taggin’ after me to the poles. ’Tain’t any place for girls.
Capt. G. Stop yer gab! Wait till yer ten year older an’ then if yer up
for see-lectman, yer’ll be glad enuf ter have tem vote for yaou!
J. Q. A. Wouldn’t I make a healthy selectman? Yes, I guess not!
Capt. G. An’—an’, Mary, I want to tell yer suthin’ else. I gin in
about yer mother’s caarf, an’ went an’ bought her back. To be sure,
she ain’t a caarf no longer, but a good likely heifer; but yer mother
sez the principle ’s just as good as if she was jest born, or as old as
Methuselum. An’ she’s tickled enuf abaout it, an’ she said men ain’t
so bad arter all, if yer can onny make ’em see what is wimmin’s jest
dues.
(Enter Phus, l.)
Phus. Oh, mis’! dere’s a s’prise for yer, a golly big one!
Mary. A surprise! What is it?
Phus. Dere’s two ladies talking to Hank; an’ one looks so peart, so
peart, oh, Lor’! (Turns to r. Aside) I wan’ tell her de res’. O, golly! I
can’t keep in.
Mary. Talking to Hank? Some of his lady friends, I suppose.
Phus. O, yes! I forgets. Dey wants ter see you, dey say, and Hank
say he bring’d ’em in.
(Enter Hank, r., in a stage sailor suit, with Mrs. Gandy and Leafy
Jane, the latter very stylishly dressed.)
Mary. Mother! Leafy Jane! (Rushes to them.) Well, this is a
surprise, I should think.
Capt. G. (in great surprise). I vum to vummy, I am beat now!
Phus. Wot I tole yer? Wot I tol yer, mis’? (Aside.) But de odder
one’s bigger!
Capt. G. Waal, I swan to man, Lorany! you’ve got ahead on us this
time. (Goes up to her) Tarnation! haow glad I am ter see yer!
Mary. Why, Leafy Jane, how you’ve grown!
J. Q. A. Yes, and she feels bigger’n you do, and puts on a plaguy
sight more airs. She wants father (she calls him par) to put an e in
Gandy, ’cause she says it’s more genteel.—And say! she don’t lithp
(lisp) any more; the customers laughed at her so for saying “yeth,
thir.”
Capt. G. (to Mrs. G.). Where in the world ’d you come from?
Mrs. G. (deliberately sitting, and removing bonnet, mitts, etc.).
Waal, Nathan, we heerd of an exertion train daown here, at
redooced rates; an’ the boarders,—one on ’em’s writin’ a book,—an’
wanted to be quiet,—said they’d take the haouse furnished for tew
months, and pay in advance. And so Leafy an’ me come right along.
She’s made a lot o’ bunnits this fall on her own accaount, so she’s
quite a haress (heiress).
L. J. Oh, mar!
Mrs. G. Yer see, par, we hadn’t time to write after we’d made up
our mind to start, an’ we cum a leetle sooner’n we should ef it hadn’t
’a’ been for comin’ with—er—with—
L. J. (whispers warningly). Why, mar!
Mrs. G.—with the exertionists. (Aside). Why in the world don’t he
come? I’m tired o’ keepin’ it in. He said he onny wanted to go ter the
bank. (To Mary) An’ then I was afraid you or the baby—why! where
is the baby? Do les see him!
Mary. He’s asleep, mother. Here, come and see him. Isn’t he a
darling? (They go to the hammock.)
L. J. Oh, Mary, what made you name the baby Nathan? I wish you
had called him Herbert, Ernest, or Montmorenci. It’s so much more
genteel.
J. Q. A. Montmorenci Miller! Cracky! wouldn’t that be tony?
L. J. (scornfully). Tony! (Walks off with Hank to the wheel-house.)
Mrs. G. (To Mary) We tole yer young man that looks so much like
Fred Douglass not ta tell yer who we was.
J. Q. A. Marm won’t say “colored man.”
Mrs. G. No, I won’t; I’m sick o’ readin’ on’t in the newspapers.
They’re allus sayin’ such a man, colored, had his leg took off, or
died, or suthin’. What difference does it make, I should like to know,
whether he’s colored or not! He’s hurt all the same, ain’t he? an’ he’s
a man, tew, all the same, ain’t he?
Phus (aside). Golly! I shall bust!
Mary (to Mrs. G.). How long can you stay? a good while, I hope.
Hank (steps forward, drawls). I think we must start in about three
weeks from Monday, if all the signs come right. (To Mary) You see
the excursion don’t last only till then.
Mary (in surprise). We must start! What in the world does this
mean?
Hank. Wal, you see, Leafy and me, we’ve been a-writin’ back and
forth sence the cap’n told me I’d better; an’ she’s agreed to hev me,
an’ go an’ live down to Nantucket. Grandfather’s old, and my marm
wants me to come home an’ settle down an’ see to things. She says
she’s tired o’ housekeeping, and wants to see some young folks
round.
J. Q. A. (To L. J.). ’Fore I’d marry a cook! Anybody that feels as big
as you do. Cookie Mudgitt! How are you, Mrs. Cookie Mudgitt!
Capt. G. Hold your yorp! Hundreds of big men hev ben cooks.
There was the most worshipful G. M. of aour Masonic Lodge, he
used to be cook in Annisport Jail, an’ now he’s a ’surance man, an’
lives in a tarnal big haouse. An’, then, there was a feller cooked on a
ranch five year’, an’ they sent him to Congress.
Mary. Oh, Hank! what shall we do without you?
Hank. I tho’t o’ that. But a nice French Creole feller is takin’ my
place to-day; an’ if he does well, p’r’aps you’ll keep him. If not, I’ll
find somebody else afore we go.
Mary (to L. J.). When are you going to be married?
L. J. (loftily). As soon as we have made the needed preparations.
Henry will explain.
J. Q. A. (to Hank). Then, that’s what you’re so rigged up for, ain’t
it, Bub? in all them sailor slops. You look like a royal tar, a regular old
Britisher.
Hank (sheepishly). Why, yes; you see, Leafy, she likes it. But as
soon as the weddin’ is over (she wants me to be married in ’em here
on the boat), I mean to put the whole rig away in my sea-chist, with
them blasted books that deluded me into goin’ to sea; an’ that will be
the last of my bein’ a sailor. I’ve had enough of it. Darn the bunks! I
want to sleep on a first-rate feather-bed the rest of my life.
L. J. Law! Henry. How you do talk!
Hank. It’s a fact, Leafy, so there! (He goes up to her and tries to
kiss her.)
L. J. (pushing him away). There! that will do, Henry. That’s seven
times to-day since I came.
Hank. Is it? Well, ’tain’t any too many, anyhow!
J. Q. A. You great galloot! Catch me ever being such a fool. Say!
what kind of a necktie you going to wear?
Hank. Oh, a stunner! blue and yallar, I guess. (Looks at L. J.)
Sha’n’t I, Leafy?
L. J. (with dignity). No, Henry; you must have one to match my
dress.
J. Q. A. (to L. J.). ’Fore I’d go taggin’ way down to New Orleans
after a husband!
L. J. You’ll have to tag all round the world before you’ll find any
one fool enough to wed you.
J. Q. A. I don’t think I shall ever “wed.” My affections have been
blighted by a fair damsel from Chicago. She had large feet.
Mrs. G. Stop, John Quincy! Yer as sarsy daown here as yer was
ter hum; ain’t ye l’arnt nothin’ by travellin’?
(Phus, who has been examining J. Q. A.’s basket, attracted by the
peanuts, puts his hand in his pocket for money to buy some, and,
feeling a letter there, draws it forth.)
Phus. Golly, I forgets dat let’! Mis’! mis’! here’s a let’; seems it
mus’ be dat licens’. Yes! see dis great t’ing on it, big as a hoe-cake
and red as a ’simmon.
Mary (eagerly). Give it to me! (Breaks the seal and hastily reads.)
New Orleans, Feb. 8, 1884.
Mrs. Mary Miller: Dear madam, I take great pleasure in
forwarding to you a captain’s license, for a Mississippi steamboat,
granted according to the decision of Secretary Folger, under Section
4439 of the Revised Statutes of the United States.
Very Respectfully,
Daniel Dumont.
Supervising Inspector-General.
(Mary bursts into tears, and sits down.)
Phus. Is it, mis’? Is it de licens’?
Mary (rising proudly, and holding it out). Yes, it is my license; and
I am Captain Mary Miller! (Hands paper to Capt. G.)
Hank. Hurrah! Three cheers for Captain Mary Miller!
J. Q. A. And a Tiger-r-r-rrr!
(Patsy looks in, then enters and listens).
Capt. G. I thought Charles J. Folger ’d hev the rights on’t.
Mrs. G. Them Folgers could allus be depended on to do the right
thing; believed in ekality from the beginnin’. Old Ben Franklin was
one on ’em, and Lucreshy Mott. They ain’t a bit like some o’ them
Nantucket Halletts—allus on the wrong side of ekality.
Phus. Lor’ bress Cap’n Mary Miller, cap’n of de Keyhole’s Bride.
(Seizes his banjo, sings uproariously, and dances about.)
Bress de men at Washington,—’Lijah cum down,

Dat made a woman cap’n,—’Lijah cum down.
But bress above dem all,—’Lijah cum down.
Good Seketelly Folger,—’Lijah cum down.
May de charyott ob Erlijah swing him softly up to (Slower) Heben,
An’ Mary Miller’s blessin’ be his eberlastin’ crown.
Mrs. G. (to him, aside). You go’n see ef he ain’t a-comin’. I can’t
hold in much longer. (Exit Phus, r.)
Patsy. Faix, mum, I’ll shthay wid ye as lang as ye varnt.
Mary. But, Patsy, if you do stay, you must expect to obey orders.
Patsy. For sure, mum; I shpects to ’bey a raal laycensed cap’n.
(Goes to wheel and sits by it.)
Mary. And now I am captain of my own vessel in name as well as
in reality. God bless Secretary Folger! He has saved us from want,
protected our little home, and given a woman the right to be captain
of her own boat. If William were only here!
Phus (entering in great excitement). Oh, mis’! here’s de biggest
s’prise in de worl’! (Beckoning.) Dis way! Dis way!
(Enter Captain Miller, l. All rise.)
Capt. M. Mary!
Mary. My dear William! I knew you would come back! (Embraces
him.)
Capt. M. Of course, my darling wife. Why shouldn’t I come back?
Mary. Why, the papers said your vessel had drifted from the rest,
and—
Capt. M. That is true. But we drifted to some purpose, for we
struck a splendid school of halibut, and we stayed till we filled up.
That’s the reason I did not write. And when we landed, I ran up to
Annisport, and found Mother Gandy and Leafy Jane wanted to come
with me, and so we all came along together.
(Shakes hands all round, returns to Mary.)
Mary. But, William, where have you been all this time?
Capt. M. Oh, I had to go to the bank for father to pay the interest
on a note—
Mrs. G. But we thought we’d come right along—
Mary. Why didn’t you tell me, mother?
Mrs. G. William told me not to. He wanted to s’prise yer.
J. Q. A. She thought she wouldn’t “tell you all at once, for fear you
couldn’t bore it.”
Phus. I seen de cap’n at de pos’-office. He say, “How Mis Miller?” I
say, “Bos’, an’ de baby, too.” Golly, wa’n’t it a big s’prise?
Mary. See, William, here’s my license as captain. I sent to
Washington for a license, and here it is. (Shows it to him.)
Mrs. G. Think of aour Mary’s bein’ a cap’n. Haow lucky! An’,
naow, if anything happens to you, William, she can allus get a livin’,
’cos she can manage her own boat.
J. Q. A. Yes, and she can paddle her own canoe.
L. J. John Quincy Adams Gandy, how very vulgar!
Capt. G. (to William). What’ll you do, neaow Mary’s made capt’n?
Haow’ll you git along?
Mary. Oh, we’ll both be captains.
Capt. M. No! She shall be captain still; and I’ll be her mate. It won’t
be the first time a man has sailed through life under the orders of a
brave and true-hearted woman,—nor the last, I hope. And so,
Captain Mary Miller, I salute you. (Makes a naval salute.)
Phus. Wid a kiss! wid a kiss! Mars cap’n, kiss mis’ cap’n.
Capt. M. Yes, to please you, my good fellow (and myself also), it
shall be with a kiss. (Kisses her hand). My captain!
Disposition of characters:
r. c. l.
Capt. G. Mrs. G. Hank and L. J.
Capt. M. and Mary.
J. Q. A. Phus.
*** END OF THE PROJECT GUTENBERG EBOOK CAPTAIN
MARY MILLER ***
Updated editions will replace the previous one—the old editions

will be renamed.
Creating the works from print editions not protected by U.S.

copyright law means that no one owns a United States copyright
in these works, so the Foundation (and you!) can copy and
distribute it in the United States without permission and without
paying copyright royalties. Special rules, set forth in the General
Terms of Use part of this license, apply to copying and
distributing Project Gutenberg™ electronic works to protect the
PROJECT GUTENBERG™ concept and trademark. Project
Gutenberg is a registered trademark, and may not be used if
you charge for an eBook, except by following the terms of the
trademark license, including paying royalties for use of the
Project Gutenberg trademark. If you do not charge anything for
copies of this eBook, complying with the trademark license is
very easy. You may use this eBook for nearly any purpose such
as creation of derivative works, reports, performances and
research. Project Gutenberg eBooks may be modified and
printed and given away—you may do practically ANYTHING in
the United States with eBooks not protected by U.S. copyright
law. Redistribution is subject to the trademark license, especially
commercial redistribution.
START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE
PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK
To protect the Project Gutenberg™ mission of promoting the

free distribution of electronic works, by using or distributing this
work (or any other work associated in any way with the phrase
“Project Gutenberg”), you agree to comply with all the terms of
the Full Project Gutenberg™ License available with this file or
online at www.gutenberg.org/license.
Section 1. General Terms of Use and

Redistributing Project Gutenberg™
electronic works
1.A. By reading or using any part of this Project Gutenberg™
electronic work, you indicate that you have read, understand,
agree to and accept all the terms of this license and intellectual
property (trademark/copyright) agreement. If you do not agree to
abide by all the terms of this agreement, you must cease using
and return or destroy all copies of Project Gutenberg™
electronic works in your possession. If you paid a fee for
obtaining a copy of or access to a Project Gutenberg™
electronic work and you do not agree to be bound by the terms
of this agreement, you may obtain a refund from the person or
entity to whom you paid the fee as set forth in paragraph 1.E.8.
1.B. “Project Gutenberg” is a registered trademark. It may only

be used on or associated in any way with an electronic work by
people who agree to be bound by the terms of this agreement.
There are a few things that you can do with most Project
Gutenberg™ electronic works even without complying with the
full terms of this agreement. See paragraph 1.C below. There
are a lot of things you can do with Project Gutenberg™
electronic works if you follow the terms of this agreement and
help preserve free future access to Project Gutenberg™
electronic works. See paragraph 1.E below.
1.C. The Project Gutenberg Literary Archive Foundation (“the
Foundation” or PGLAF), owns a compilation copyright in the
collection of Project Gutenberg™ electronic works. Nearly all the
individual works in the collection are in the public domain in the
United States. If an individual work is unprotected by copyright
law in the United States and you are located in the United
States, we do not claim a right to prevent you from copying,
distributing, performing, displaying or creating derivative works
based on the work as long as all references to Project
Gutenberg are removed. Of course, we hope that you will
support the Project Gutenberg™ mission of promoting free
access to electronic works by freely sharing Project
Gutenberg™ works in compliance with the terms of this
agreement for keeping the Project Gutenberg™ name
associated with the work. You can easily comply with the terms
of this agreement by keeping this work in the same format with
its attached full Project Gutenberg™ License when you share it
without charge with others.
1.D. The copyright laws of the place where you are located also
govern what you can do with this work. Copyright laws in most
countries are in a constant state of change. If you are outside
the United States, check the laws of your country in addition to
the terms of this agreement before downloading, copying,
displaying, performing, distributing or creating derivative works
based on this work or any other Project Gutenberg™ work. The
Foundation makes no representations concerning the copyright
status of any work in any country other than the United States.
1.E. Unless you have removed all references to Project

Gutenberg:
1.E.1. The following sentence, with active links to, or other

immediate access to, the full Project Gutenberg™ License must
appear prominently whenever any copy of a Project
Gutenberg™ work (any work on which the phrase “Project
Gutenberg” appears, or with which the phrase “Project
Gutenberg” is associated) is accessed, displayed, performed,
viewed, copied or distributed:
This eBook is for the use of anyone anywhere in the United

States and most other parts of the world at no cost and with
almost no restrictions whatsoever. You may copy it, give it
away or re-use it under the terms of the Project Gutenberg
License included with this eBook or online at
www.gutenberg.org. If you are not located in the United
States, you will have to check the laws of the country where
you are located before using this eBook.
1.E.2. If an individual Project Gutenberg™ electronic work is

derived from texts not protected by U.S. copyright law (does not
contain a notice indicating that it is posted with permission of the
copyright holder), the work can be copied and distributed to
anyone in the United States without paying any fees or charges.
If you are redistributing or providing access to a work with the
phrase “Project Gutenberg” associated with or appearing on the
work, you must comply either with the requirements of
paragraphs 1.E.1 through 1.E.7 or obtain permission for the use
of the work and the Project Gutenberg™ trademark as set forth
in paragraphs 1.E.8 or 1.E.9.
1.E.3. If an individual Project Gutenberg™ electronic work is

posted with the permission of the copyright holder, your use and
distribution must comply with both paragraphs 1.E.1 through
1.E.7 and any additional terms imposed by the copyright holder.
Additional terms will be linked to the Project Gutenberg™
License for all works posted with the permission of the copyright
holder found at the beginning of this work.
1.E.4. Do not unlink or detach or remove the full Project

Gutenberg™ License terms from this work, or any files
containing a part of this work or any other work associated with
Project Gutenberg™.

Ebook Concise Clinical Embryology An Integrated Case Based Approach PDF Full Chapter PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ebook Concise Clinical Embryology An Integrated Case Based Approach PDF Full Chapter PDF

Uploaded by

Copyright:

Available Formats

Concise Clinical Embryology: an

Integrated, Case-Based Approach -

Unlock your eBook today.

For technical assistance:

Mark G. Torchia, DipBT, MSc, PhD

T.V.N. (Vid) Persaud MD, PhD, DSc, FRCPath (Lond.), FAAA

CONCISE CLINICAL EMBRYOLOGY:

Copyright © 2021 by Elsevier, Inc. All rights reserved.

Library of Congress Control Number: 2020951836

Content Strategist: Jeremy Bowes

Printed in United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

2 Reproductive Organs and Gametogenesis 4 9 Development of the Body Cavities, Diaphragm,

14 Teratogenesis and Birth Defects 107

Multiple Choice Question Answers 112

Video 3.1 Fertilisation 12 Video 9.3 Pharyngeal Apparatus 64

Video 3.2 Blastocyst 12 Video 9.4 Face and Palate 66

Video 4.1 Implantation 18 Video 10.1 Nervous System 71

Video 5.1 Gastrulation 23 Video 10.2 Eyes 76

Video 5.2 Folding 28 Video 10.3 Ears 78

Video 8.1 Heart 44 Video 11.1 Gastrointestinal 82

Video 8.2 Vascular 49 Video 12.1 Urinary 89

Video 9.1 Body Cavities 58 Video 12.2 Reproductive System 91

Video 9.2 Respiratory System 61 Video 13.1 Limbs 101

tissues of the uterus and vagina (endometrium and mucosa,

(internal), myometrium (middle muscular) and perime-

The ovaries are oval-shaped glands adjacent to the uterus

progresses only to metaphase. If a sperm penetrates the sec-

MENSTRUAL CYCLE by the corpus luteum stimulates the glandular epithelium

Molecular Biology Considerations NONDISJUNCTION

CLINICAL ISSUES Case Outcome

genital tract. Oocytes are usually fertilised within 12 hours

Fig. 3.1 Timeline of development related to fertilisation.

many women who are sterile to have children. Since 1978,

IN VITRO FERTILISATION AND EMBRYO TRANSFER INTRACYTOPLASMIC SPERM INJECTION

the treatment of couples in whom typical IVF has failed, or

ASSISTED IN VIVO FERTILISATION

Most pregnancy tests are based on the detection or measure-

AUTOSOMAL TRISOMY MOSAICISM

PREIMPLANTATION GENETICS Fig. 3.6 Ultrasound of a fetus demonstrating an enhanced

1. How many sperms would probably be deposited by a nor- c. neck

endometrium. The window of implantation is relatively

Fig. 4.2 Timeline of development related to implantation and week 2 of development.

As implantation of the blastocyst progresses, the primordi-

Molecular Biology Considerations

BIBLIOGRAPHY Fukui Y, Hirota Y, Matsuo M, et al. Uterine receptivity, embryo attach-

systems and most of the cardiovascular system. Excluding

Fig. 5.1 Timeline of development related to general organogenesis.

notochord. Mesenchymal cells from the primitive streak

Fig. 5.5 (A) Drawing of the median section of an 18-day embryo

Fig. 5.4 Drawing of the median section of a 16-day embryo showing

Fig. 5.7 Transverse section of the 22-day-old embryo showing neu-

In addition to forming the notochord, cells derived from

villi fuse to form arteriocapillary networks which connect

Establishment of body form requires folding of the trilami-

1. Which of the following is correct as it relates to 2. During neurulation:

BIBLIOGRAPHY Vijayraghavan DS, Davidson L. Mechanics of neurulation: From classi-

Fig. 6.1 Timeline of development related to placentation and formation of membranes.

ed blood in the capillaries passes into thin-walled veins that

Fig. 6.3 Schematic drawing of a transverse section through a full-

“On Springfield maount’ins there did dwell

Mary (in great surprise). Father Gandy!

Bress de men at Washington,—’Lijah cum down,