Maternal circulation in the first-trimester human placenta—Myth or reality?

The classic theory of development of the uteroplacental and intervillous circulation determined that maternal blood enters the intervillous space in high-pressure streams from the early first trimester. This theory has recently been challenged and our hypothesis to be presented is that the intervillous circulation is not fully established until the end of the first trimester. Ex vivo studies of hysterectomy specimens have demonstrated that trophoblastic plugs obstruct blood flow into the intervillous space in early pregnancy and only at 12 to 13 weeks do these plugs become loose and allow for continuous maternal blood flow into the intervillous space. This concept is supported by many other experimental findings. In complicated early pregnancies the uteroplacental circulation demonstrates flow characteristics that are strikingly different from those of normal early pregnancies. In abnormal pregnancies increased flow within the intervillous space is demonstrated by color Doppler imaging. Our hypothesis supports other studies that have shown that the embryo favors an environment low in oxygen during early development and that oxygen levels in placental tissue are low in the early first trimester. The classic drawing of placental circulations is based on second- and third-trimester studies, and its applicability to the early first trimester should be revisited because we will show that new data support the hypothesis that the development of the early intervillous circulation is a progressive phenomenon.