Fetal Development

Obstetrics Daphne Christy Labao, MD

September 12, 2019

Naegele Rule
• An EDC based on LMP can be quickly estimated
as follows:
o add 7 days to the irst day of the LMP
and subtract 3 months
o For example, if the irst day of the LMP
was October 5, the due date is 1 0-05
minus 3 (months) plus 7 (days) = 7-1 2,
or July 12 of the following year.

Embryofetal development
• embryologist describe this in ovulation age, or
Gestational age or menstrual age the time in days or weeks from ovulation
• the time elapsed since the first day of the last Postconceptional age
menstrual period (LMP), a time that actually • nearly identical to ovulation age
precedes conception.
• starting time, approximately 2 weeks before
ovulation and fertilization and nearly 3 weeks
EMBRYONIC DEVELOPMENT
before blastocyst implantation Embryonic Period
• term pregnancy averaging approximately 280 • Time which organogenesis takes place ! lasts 6
days, or 40 weeks between the first day of the weeks
LMP and birth • begins the third week from the LMP through
o corresponds to 9 and 1 13 calendar the eighth week age of gestation
months • during this period, embryonic disc is well
American College of Obstetricians and Gynecologists, defined
the American Institute of Ultrasound in Medicine, and • embryonic disc is well defined, and most
the Society for Maternal-Fetal Medicine (Reddy, 20 14) pregnancy tests that measure human chorionic
together recommend the following: gonadotropin (hCG) become positive by this
1. First-trimester sonography is the most accurate time
method to establish or reairm gestational age. • body stalk is now differentiated
2. In conceptions achieved with assisted- • There are villous cores in which angioblastic
reproductive technology, this gestational age is chorionic mesoderm can be distinguished and a
used. true intervillous space that contains maternal
3. If available, the gestational ages calculated from blood.
the LMP and from first-trimester sonography Zygote and Blastocyst Development
are compared, and the estimated date of • During the irst 2 weeks after ovulation and then
coninement (EDC) recorded and discussed with fertilization, the zygote-or preembryo-develops
the patient. to the blastocyst stage.
4. The best obstetrical estimate of gestational age • The blastocyst implants 6 or 7 days following
at delivery is recorded on the birth certiicate. fertilization .
The embryofetal crown-rump length in the first • The 58-cell blastocyst diferentiates into ive
trimester is accurate ±5 to 7 days. hus, if sonographic embryo-producing cells-the inner cel mass-and
assessment of gestational age difers by more than 5 the remaining 53 cells form placental
days prior to 9 weeks' gestation, or by more than 7 days trophoblast.
later in the irst trimester, the estimated delivery date is
changed.

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 Fetal Development
Obstetrics Daphne Christy Labao, MD
September 12, 2019

Embryo • Presence of heart beat

• Conceptus at the beginning of the third week e. 7th week
after ovulation and fertilization • Corresponds to 9 weeks after the onset of
LMP
Weeks and Development • embryonic period to fetal period
a. 3rd week transition
• fetal blood vessels in the chorionic villi • CRL –s 24 mm in length
appear • Most organ systems have developed
• Fetus enters a period of growth and
from your primary stem cells, you’ll see maturation
cytotropoblast going to f. End of the 8th week
synsichiotrophoblast • crown-rump length approximates 22 mm
secondary stem cell, there’s the extra • Fingers and toes are present, and the
embryonic going to the center of your arms bend at the elbows.
chorionic villi • upper lip is complete
tertiary stem villus, appearance of fetal • external ears form definitive elevations
on either side of the head

FETAL DEVELOPMENT AND PHYSIOLOGY
Gestational weeks and Development
a. 12 gestational weeks
• uterus palpable above the symphysis
blood vesselsin the chorionic villi pubis
b. 4th week • Rapid fetal growth
• a cardiovascular system has formed • crown-rump length = 5 to 6 cm
• circulation is established both between the • Centers of ossification appeared in most
embryo and the chorionic villi fetal bones, and the fingers and toes have
• neural plate forms, and it subsequently become differentiated
folds to form the neural tube • Skin and nails develop, and scattered
c. End of the 5th week menstrual cycle rudiments of hair appear
• chorionic sac ! approximately 1 cm in • external genitalia begins to show
diameter definitive signs of male or female gender
• embryo is 3 mm long and can be measured • fetus begins to make spontaneous
sonographically movements.
• arm and leg buds have developed b. 16 gestational weeks
• amnion is beginning to ensheathe the body • Fetal growth slows at this time.
stalk ! umbilical cord. • Crown-rump length = 12 cm
d. 6th week o sonographic crown-rump length is
• embryo ! approximately 9 mm long not measured beyond 13 weeks,
• neural tube has closed which corresponds to
o cranial end of the neural tube approximately 8.4 cm. Instead,
closes by 38 days from the LMP biparietal diameter, head
o caudal end closes by 40 days circumference, abdominal
circumference, and femur length
• Cardiac motion is almost always
are measured.
discernable sonographically

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 Fetal Development
Obstetrics Daphne Christy Labao, MD
September 12, 2019

• fetal weight = 150g • eyes open

o Fetal weight in the second and third • Nociceptors are present over all the
trimesters is estimated from a body
combination of these • neural pain system is developed
measurements • fetal liver and spleen ! important sites
• Eye movements begin at 16 to 18 weeks, for hemopoiesis.
coinciding with midbrain maturation. g. 28 gestational weeks
c. 18 gestational weeks • CRL = approximates 25 cm
• female fetus ! uterus is formed and • fetal weight ! about 1100 g
vaginal canalization begins • thin skin is red and covered with vernix
d. 20 gestational weeks caseosa
• in the male, testicles start to descend • Pupillary membrane has just
• First fetal movement or called quickening disappeared from the eyes
• Fetal weight ! somewhat more than 300 g • Peak ! Isolated eye blinking
• weight increases substantially in a linear • bone marrow ! major site of
manner. hemopoiesis
• fetus moves approximately every minute • Survival rate ! 90-percent without
and is active 10 to 30 percent of the day physical or neurological impairment
• Brown fat forms, and the fetal skin becomes h. 32 gestational weeks
less transparent • CRL ! approximating 28 cm
• Downy lanugo covers its entire body, and • Fetal weight ! about 1800 g
some scalp hair can be seen. • skin surface is still red and wrinkled
• Cochlear function develops between 22 and i. 36 gestational weeks
25 weeks! maturation continues for 6 • CRL ! averages about 32 cm
months after delivery. • fetal weight approximates 2800 g
• This is the midpoint of pregnancy as • body has become more round
estimated from the LMP. • Because of subcutaneous fat
• Quickening deposition, the body has become more
e. 24 gestational weeks rotund, and the previous wrinkled
• fetal weight = almost 700 g facies is now fuller
• fat deposition begins • Survival rate ! nearly 100-percent
• canalicular period of lung development j. 40 gestational weeks
o bronchi and bronchioles enlarge • fetus is now fully developed
and alveolar ducts develop, is • Considered term
nearly completed. • average CRL ! about 36 cm
• secretory type II pneumocytes have • average fetal weight !
initiated surfactant secretion approximates3500 g.
• fetus born at this time will attempt to *everyweek the fetus gains 200grams
breathe
o many will die ! terminal sacs have
not yet formed
o overall survival rate ! barely above
50 percent
o approximately 30 percent survive
without severe morbidity
f. 26 gestational weeks

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 Fetal Development
Obstetrics Daphne Christy Labao, MD
September 12, 2019

CENTRAL NERVOUS SYSTEM b. inferior third forms the spinal cord

c. spinal cord extends along the entire vertebral
DEVELOPMENT
column length, but after that it lags behind
Brain Development vertebral growth.
a. walls of the neural tube ! form the brain and
spinal cord
b. lumen ! ventricular system of the brain and
the central canal of the spinal cord
c. sixth week
• the cranial end of the neural tube forms
three primary vesicles
• Three primary vesicles
-Procencephalon
-Mesencephalon
-Rhombencephalon
d. seventh week
e. five secondary vesicles develop
• telencephalon—future cerebral d. During the third trimester, integration of
hemispheres nervous and muscular function proceeds
• diencephalon—thalami rapidly.
• mesencephalon—midbrain e. 8th week
• metencephalon—pons and cerebellum • Synaptic function is sufficiently
• myelencephalon—medulla developed by the to demonstrate
f. The end of the embryonic period signifies flexion of the neck and trunk
completion of primary and secondary f. 21 weeks
neuralization. • Ossification of the entire sacrum is
g. 3 to 4 months’ gestation sonographically visible
• Peak of neuronal proliferation g. 24 weeks ! spinal cord extends to S1 ! birth
h. 3 to 5 months to L3! adult to L1.
• Peak and occurrence of neuronal h. Spinal cord myelination
migration • begins at midgestation and continues
• characterized by movement of millions through the first year of life
of neuronal cells from their ventricular
and subventricular zones to areas of the CARDIOVASCULAR SYSTEM
brain in which they reside for life
Embryogenesis of the heart
i. Neuronal proliferation and migration proceed
• Complex
along with gyral growth and maturation
• straight cardiac tube is formed by the 23rd day
j. 6 months
• tube undergoes looping!chambers then fuse
• Myelination of the ventral roots of the
and form septa
cerebrospinal nerves and brainstem
• valves develop, and the aortic arch forms by
begins ! most myelination progresses
vasculogenesis
after birth


Spinal Cord Fetal Circulation
a. superior two thirds of the neural tube give rise • Fetal blood does not need to enter the
to the brain pulmonary vasculature to be oxygenated, most

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 Fetal Development
Obstetrics Daphne Christy Labao, MD
September 12, 2019

of the right ventricular output bypasses the *deoxygenated blood comes from your fetus, from
lungs. the fetus the deoxygenated blood will go thru the
• Fetal heart chambers work in parallel, not in umbilical arteries going to your placenta and will
series diffuse to the capillary network and will enter in the
o effectively supplies the brain and heart intervenous space where the blood will be
with more highly oxygenated blood oxygenated by the blood coming from the spiral
than the rest of the body. artery which is the maternal line that is oxygenated.
*Umbilical arteries carry deoxygenated blood to the
placenta and umbilical veins carry oxygenated blood
to the fetus.
*oxygenated blood will go to your umbilical vein
then will go to ductus venosus and to the portal
sinus. Portal sinus of the liver and the blood that
goes to the liver will be deoxygenated and it will go
thru inferior vena cava. In inferior vena cava, there












will be the mixed blood of oxygenated and
deoxygenated going to the right atrium. The
oxygenated blood will go thru the foramen ovale
going to the left atrium and left ventricle going to
the aorta supplying heart and brain. From the right
atrium, deoxygenated blood goes to the right
ventricle to pulmonary tracts to the ductus
arteriosus to aorta going down to hypogastic artery
and umbilical cord.

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 Fetal Development
Obstetrics Daphne Christy Labao, MD
September 12, 2019

*distal portion of the hypogastric artery becomes • The more distal portions of the hypogastric
the medial umbilical ligament (hypogastric artery arteries undergo atrophy and obliteration
undergo atrophy with 3 to 4 days after birth. within 3 to 4 days after birth. These become the
*intraabdominal umbilical vein becomes umbilical ligaments, whereas the
ligamentum teres intraabdominal remnants of the umbilical vein
*Ductus venosus becomes the ligamentum form the ligamentum teres.
venosum • The ductus venosus constricts by 10 to 96 hours
*Ductus Arteriosus becomes ligamentum after birth and is anatomically closed by 2 to 3
arteriosum weeks. This ultimately forms the ligamentum
• Oxygen and nutrient materials required for fetal venosum
growth and maturation are delivered from the
placenta by the single umbilical vein Difference in fetal and adult circulation
• The vein then divides into the ductus venosus • 3 shunts (ductus venosus, foramen ovale and
and the portal sinus. The ductus venosus is the ductus arteriosus) which allow oxygenated blood
major branch of the umbilical vein and traverses to bypass the right ventricle and pulmonary
the liver to enter the inferior vena cava directly. circulation and flow directly to the left ventricle
• Because it does not supply oxygen to the and aorta to supply the heart and brain
intervening tissues, it carries well-oxygenated • Ventricles of the fetal heart work in parallel as
blood directly to the heart. opposed to that of the adult heart which works in
• In contrast, the portal sinus carries blood to the sequence
hepatic veins primarily on the left side of the • Fetal cardiac aoutput per unit of weight is 3x
liver, and oxygen is extracted. The relatively higher than that of an adult at rest, !
deoxygenated blood from the liver then flows compensates for the low oxygen content of the
back into the inferior vena cava, which also fetal blood. ! ↑ cardiac output ! ↑ heart rate
receives more deoxygenated blood returning and low peripheral resistance
from the lower body. Blood flowing to the fetal
heart from the inferior vena cava, therefore,
consists of an admixture of arterial-like blood Fetoplacental Blood Volume
that passes directly through the ductus venosus • at term is approximately 125 mL/kg of fetal
and less well-oxygenated blood that returns weight
from most of the veins below the level of the • normal newborn have 78ml/kg
diaphragm.
• The oxygen content of blood delivered to the
heart from the inferior vena cava is thus lower
than that leaving the placenta.

Circulatory Changes at Birth
• After birth, the umbilical vessels, ductus
arteriosus, foramen ovale, and ductus venosus
normally constrict or collapse.
• With the functional closure of the ductus
arteriosus and the expansion of the lungs, blood
leaving the right ventricle preferentially enters
the pulmonary vasculature to become
oxygenated before it returns to the left heart.

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 Fetal Development
Obstetrics Daphne Christy Labao, MD
September 12, 2019

HEMOPOIESIS • 6 weeks
• demonstrable first in the yolk sac ! liver ! o final adult version of the α chain is
spleen and bone marrow. produced exclusively
• Both myeloid and erythroid cells are continually • functional difference between hemoglobins A
produced by progenitors that are from and F
hematopoietic stem cells • hemoglobin F bind more oxygen than do those
that contain nearly all hemoglobin A
Fetal Erythrocytes • Hemoglobin A binds 2,3-diphosphoglycerate
• first erythrocytes released into the fetal (2,3-DPG) more avidly than does hemoglobin F,
circulation are nucleated and macrocytic thus lowering the affinity of hemoglobin A for
• As fetal development progresses! more and oxygen
more of the circulating erythrocytes are smaller • last weeks of pregnancy
and nonnucleated o amount of hemoglobin F in fetal
• have a short life span, which progressively erythrocytes begins to decrease
lengthens to approximately 90 days at term ! • Term
↑ RBC production o approximately three fourths of total
• differ structurally and metabolically from those hemoglobin levels are hemoglobin F
in the adult • first 6 to 12 months of life
o more deformable, which serves to o hemoglobin F proportion continues to
offset their higher viscosity decline and eventually reaches the low
o contain several enzymes with levels found in adult erythrocytes.
appreciably different activities
• fetal hemoglobin concentrations rise across Coagulation Factors
pregnancy. • with the exception of fibrinogen, there are no
embryonic forms of the various hemostatic
Fetal Hemoglobin proteins
• tetrameric protein • 12 weeks
• composed of two copies of two different o fetus starts producing normal, adult-
peptide chains ! which determine the type of type procoagulant, fibrinolytic, and
hemoglobin produced anticoagulant proteins
o Because they do not cross the placenta ,
• embryonic and fetal life
o various α and β chain precursors are their concentrations at birth are
produced ! results in the serial markedly below the levels that develop
within a few weeks of life
production of several different
• Normal neonates
embryonic hemoglobin
o levels of factors II, VII, IX, X, XI, and of
• Fetal blood is first produced in the yolk sac
protein S, protein C, antithrombin, and
o hemoglobins Gower 1, Gower 2, and
plasminogen all approximate 50 % of
Portland are made.
adult levels
• Erythropoiesis moves to the liver
o levels of factors V, VIII, XIII, and
o fetal hemoglobin F is produced.
fibrinogen are closer to adult values
• hemopoiesis moves to the bone marrow
o Without prophylactic treatment, the
o adult-type hemoglobin A appears in
levels of vitamin K-dependent
fetal red blood cells
coagulation factors usually decrease
o present in progressively greater
even further during the first few
amounts as the fetus matures

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 Fetal Development
Obstetrics Daphne Christy Labao, MD
September 12, 2019

o days after birth. This decline is amplified RESPIRATORY SYSTEM

in breastfed infants and may lead to •Early neonatal outcome
newborn hemorrhage
− Lung maturation and biochemical
• Fetal fibrinogen indices of functional fetal lung maturity
o appears as early as 5 weeks are important predictors.
o same amino acid composition as adult
fibrinogen, however it has different ANATOMICAL MATURATION
properties
o It forms a less compressible clot, and
the fibrin monomer has a lower degree
of aggregation
• Although plasma fibrinogen
o levels at birth are less than those in
nonpregnant adults
o the protein is functionally more active
than adult fibrinogen
• Fetal Factor XIII
o Fibrin stabilizing factor
o Significantly reduced compared with
those in adults
• Cord Plasma
o There is low levels of plasminogen and
elevated fibrinolytic activity compared
with that of the maternal plasma
• Amniotic Fluid Thromboplastins & factor/s in
Wharton Jelly
• Combine to aid coagulation at the
umbilical cord puncture site.

Plasma Proteins
• Concentrations of plasma proteins all rise:
o Albumin Lung development proceeds along an
o lactic dehydrogenase established timetable that apparently cannot be
o aspartate aminotransferase hastened by antenatal or neonatal therapy
o γ-glutamyl transpeptidase four essential lung development stages
o alanine transferase • Pseudoglandular stage
• Conversely, prealbumin levels decline with o entails growth of the intrasegmental
gestational age. bronchial tree between the 5th and
• At birth 17th weeks.
o mean total plasma protein and albumin o During this period, the lung looks
concentrations in fetal blood are similar microscopically like a gland
to maternal levels • Canalicular stage
! this is important because o from 16 to 25 weeks, the bronchial
albumin binds unconjugated cartilage plates extend peripherally.
bilirubin to prevent kernicterus o Each terminal bronchiole gives rise to
in the newborn. several respiratory bronchioles, and

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 Fetal Development
Obstetrics Daphne Christy Labao, MD
September 12, 2019

each of these in turn divides into Pulmonary Surfactant

multiple saccular ducts. • keeps terminal sacs from collapsing ! terminal
• Terminal sac stage sacs must remain expanded despite the
o begins after 25 weeks pressure imparted by the tissue-to-air interface
o During this stage, alveoli give rise to • formed in type II pneumonocytes that line the
primitive pulmonary alveoli, that is, the alveoli
terminal sacs. o cells are characterized by multivesicular
o Simultaneously, an extracellular matrix bodies that produce the lamellar bodies
develops from proximal to distal lung in which surfactant is assembled
segments until term. • Late fetal life
• Alveolar stage o when the alveolus is characterized by a
o begins during the late fetal period and water-to-tissue interface, the intact
continues well into childhood. An lamellar bodies are secreted from the
extensive capillary network is built, the lung and swept into the amnionic fluid
lymph system forms, and type II during respiratory-like movements !
pneumocytes begin to produce fetal breathing
surfactant. • At birth with first breath,
o an air-to-tissue interface is established
At birth, only approximately 15% of the adult number of in the lung alveolus.
alveoli is present. Thus, the lung continues to grow, o Surfactant uncoils from the lamellar
adding more alveoli for up to 8 years. bodies and spreads to line the alveolus
! prevent alveolar collapse during
expiration
Conditions affecting Lung Maturity • Fetal lungs’ capacity to produce surfactant
• Fetal renal agenesis establishes lung maturity
o amnionic fluid is absent at the
beginning of lung growth! major Surfactant Composition
defects occur in all four developmental • Lipid
stages o 90% of surfactant's dry weight is lipid,
• Fetus with membrane rupture and subsequent specifically glycerophospholipids.
oligohydramnios before 20 weeks • Proteins
o exhibits nearly normal bronchial o account for the other 10 percent
branching and cartilage development • Glycerophospholipids
but has immature alveoli o 80% of the are phosphatidylcholines
• Membrane rupture after 24 weeks (lecithins)
o may have minimal long-term effect on o Dipalmitoylphosphatidylcholine (DPPC or
pulmonary structure PC)
" vitamin D − a specific lecithin, principal active
o thought to be important for several component that constitutes half of
aspects of lung development surfactant ! 8 to 15%
o Phosphatidylglycerol (PG) accounts for
another
o phosphatidylinositol (PI)

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 Fetal Development
Obstetrics Daphne Christy Labao, MD
September 12, 2019

Biosynthesis
• Takes place in the type II pneumocytes
• Apoproteins
o produced in the endoplasmic reticulum
o aid the forming and reforming of a
surface film
• Phospholipid
o primary surface tension-lowering
component of the surfactant
• Glycerophospholipids
o synthesized by cooperative interactions
of several cellular organelles.


Corticosteroids and Fetal Lung Maturation
• Fetal cortisol
o stimulates lung maturation and
surfactant synthesis.
• Corticosteroids
o Unlikely the only stimulus for
augmented surfactant formation
o However, when these are administered
at certain critical times, they may
improve preterm fetal lung maturation.


Breathing
• Fetal respiratory muscles develop early
• 11 weeks
o chest wall movements are detected
sonographically
• Beginning of the fourth month
o fetus engages in respiratory movement
sufficiently intense to move amnionic
fluid in and out of the respiratory tract.
• Some extrauterine events have effects on fetal
breathing, for example: maternal exercise
stimulates it.


NOTE: Yung audio same lang din po sa book, ganun
din sa ppt kaya wala masyadong blue and
red

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