PARTURITION AND LACTATION

PARTURITION

Active labor is characterized by a dramatic increase in the number of oxytocin receptors in the
myometrium. Once begun, the process appears to be self-perpetuating. The level of maternal
catecholamines increases, resulting in the liberation of free fatty acids, including arachadonic acid; there
is also an increase in the level of maternal or fetal cortisol, which decreases the production of uterine
smooth muscle prostacyclin. It is unlikely that oxytocin is the initiator of labor despite the fact that
oxytocin receptors are present in the myometrium and increase before labor, and it stimulates decidual
prostaglandin E2 and prostaglandin F2a production. Therefore, the prostaglandins (PG) are thought to
play the central role. For years, it has been known that rupture, stripping or infection of the fetal
membranes, as well as instillation of hypertonic solutions into the amniotic fluid, results in the onset of
labor. These facts have led to the hypothesis that a fetal-amniotic fluid-fetal membrane complex is a
metabolically active unit that triggers the onset of labor. Evidence supporting a causative role of
prostaglandins in the labor process is present since PGs induce myometrial contractions in all stages of
gestation. However, direct evidence relating endogenous PGs to labor is not clear. Important to this
hypothesis is the understanding that at least one mechanism in the onset of parturition is the release of
stored precursors of PGs from the fetal membranes. The major precursor for PGs is arachadonic acid,
which is stored in glycerophospholipids. The fetal membranes are enriched with two major
glycerophospholipids, phosphatidylinositol and phosphatidylethanolamine. As gestation advances, the
progressively increasing levels of estrogen stimulate the storage, in fetal membranes, of these
glycerophospholipids containing arachadonic acid. A series of fetal membrane lipases, including
phospholipase A2 and Phospholipase C control the release of arachadonic acid from storage in fetal
membrane phospholipids. Once in a free state, arachadonic acid is available for conversion to PG.
Additional factors that augment and accentuate the normal process of labor include the liberation of
corticosteroid by the mother and fetus, resulting in a decrease in the production of myometrial
prostacyclin, a smooth muscle relaxant. There is no reduction in maternal or fetal progesterone levels
during spontaneous labor. Undoubtedly, progesterone is important in uterine quiescence because in the
first trimester removal of the corpus luteum leads rapidly to myometrial contractions . Likewise, labor
ensues following the administration of progesterone receptor antagonists in the third trimester. The
anti-progesterone agents occupy progesterone receptors and inhibit the action of progesterone, which
is clearly essential for maintenance of uterine quiescence. Yet, progesterone administration to women,
except for very large doses, does not suppress uterine contractions once begun. The ratios of estradiol
and progesterone in various animal models are closely related to the stimulation of myometrial gap-
junction formation. With decreasing progesterone relative to estradiol, gap junctions permit cell-cell
communication for theSynchronized myometrial smooth muscle contractions required for labor.
Progesterone and the estrogens are antagonistic in the parturition process. Progesterone produces
uterine relaxation, stabilizing lysosomal membranes and inhibiting prostaglandin synthesis and release.
By contrast, estrogens destabilize lysosomal membranes and augment the synthesis of prostaglandin
and their release . Although gradual increase in umbilical cord DHEAS and maternal estriol occurs
toward term, there is no corresponding drop in either fetal or maternal progesterone concentrations.
The roles of estrogen include regulation of events leading to parturition because pregnancies are often
prolonged when estrogen levels in maternal blood and urine are low, as in placental sulfatase deficiency
or when associated with anencephaly. Feto-placental estrogens are closely linked to myometrial
irritability, contractility, and labor. In primates, estrogens ripen the cervix, initiate uterine activity, and
established labor. Estrogens also increase the sensitivity of the myometrium to oxytocin by augmenting
prostaglandin biosynthesis. Because placental release of estrogens is linked to the fetal hypothalamus,
pituitary, adrenals, and placenta the fetal pituitary adrenal axis appears to fine-tune parturition timing in
part through its effect on estrogen production.

In human studies, there is a correlation in uterine activity with circulating maternal estrogens and
progesterone as labor approaches. There is firm evidence of increasing, rhythmical fetal adrenal and
placental steroid output over the 5 weeks just before term that is important in preparing human
pregnancy for the final cascade of oxytocin and prostaglandins that stimulate labor.

Parturition – control

· Parturition requires myometrial contractions and cervical softening.

· The myometrium is a functional syncytium (coupled by gap junctions) so contractions are coordinated.
Contractions occur because action potentials cause Ca2+ influx; oestrogen-primed myometrium shows
pacemaker potentials, which initiate Aps if they are large enough. Prostaglandins liberate Ca2+ from
intracellular binding sites. Oxytocin increases the rate of Ca2+ influx and lowers the excitation threshold
of the myocyte.

· Cervical softening. The cervix has a high connective tissue content – collagen bundles in a proteoglycan
matrix. Cervical softening occurs because there is a loss of collagen and an increase in
glycosoaminoglycans (GAGs), specifically keratan sulphate. (This does not bind collagen well; dermatan
sulphate does, so the increased keratan:dermatan sulphate ratio may explain the “loosening” of the
collagen.) Prostaglandins (PGE2; PGF2alpha ) increase cervical compliance.

· The endometrium is probably the most important site of prostaglandin (PG) synthesis. Remember that
PGs are local hormones. The enzyme PLA2 is critical in PG synthesis. The estrogen:progesterone ratio
controls both PG synthesis (high E:P ---- high prostaglandin synthesis) and also PG release : estradiol
oxytocin receptors in the endometrium ---- more PG release · Oxytocin is a peptide synthesized in
hypothalamic neurons and transported along their axons to the posterior pituitary. It is released in
response to tactile stimulation of the reproductive tract, esp. The cervix, and increases myometrial
contractility (the Ferguson reflex). This reflex is facilitated by a high O:P ratio

Relaxin is a polypeptide hormone made by the corpus luteum and secreted throughout most of
pregnancy. It causes relaxation of the interpubic ligament, so the pubic symphysis can separate to some
extent. (This can cause considerable discomfort during pregnancy.) Its precise action in the human is not
certain, but in addition to ligamentous relaxation it may also inhibit myometrial activity, inhibit oxytocin
secretion and facilitate cervical softening. It therefore helps to maintain pregnancy but gets things ready
for parturition.

Parturition – timing

· Human pregnancy normally lasts 40 weeks from the date of the last menstrual period.1 Forty weeks is
“full term”. Labor is considered premature if it occurs before 37 weeks’ completed gestation; after 42
weeks pregnancy is considered prolonged. (Prematurity is not the same as low birth weight, though
obviously premature babies tend to be small.)

Parturition – timing

· Human pregnancy normally lasts 40 weeks from the date of the last menstrual period.1 Forty weeks is
“full term”. Labor is considered premature if it occurs before 37 weeks’ completed gestation; after 42
weeks pregnancy is considered prolonged. (Prematurity is not the same as low birth weight, though
obviously premature babies tend to be small.)

· Human: unclear. Simple anencephaly (= no head and no CRH) does not necessarily prolong pregnancy;
nor does fetal adrenal hypoplasia; infusion of ACTH or synthetic glucocorticoids does not induce
parturition. (Nevertheless, cortisol does rise in late pregnancy.) It seems that the onset of labor is not
critically dependent on fetal adrenal activity

– And there are no clear and consistent changes in placental estrogen synthesis at term. The E:P
ratio does rise, but the change is neither abrupt nor universal. Might local steroid receptor
changes be having the same effect? Unproven. PGF2 levels do rise in amniotic fluid before
labour, and rise throughout parturition. So the changes in cortisol and PGF2alpha are the same
as in sheep and goats, but the control mechanisms are unknown.

Dates always refer to the LMP, which is a useful clinical convention, but note that this means the true
gestation (from ovulation) is 38 weeks.

Parturition – mechanism
· From ~36 weeks, the uterus occasionally contracts, weakly – Braxton-Hicks contractions. They can be
felt – the uterus hardens. The head descends into the pelvis late in pregnancy, and “engages” there.

· Cervical ripening consists of softening, effacement (its length is obliterated) and dilatation.

· Labor begins when (a) uterine contractions are regular and (b) there is progressive dilatation of the
cervix. Labor is divided into three stages.

· First stage of labor. From the onset of labor to full dilatation of the cervix (10 cm). Mean duration ~8h
(primagravidae2) or ~5h (multiparous woman). The myometrium contracts, generating intrauterine
pressures of 50–75 mmHg. The wave of excitation spreads down from the fundus of the uterus. As the
muscle contracts, it also retracts

– It does not relax back to its original length (brachystasis). The lower uterine segment is far less
muscular than the rest; no point squeezing at the bottom.

· Pain relief in labour – nitrous oxide (tricky to use correctly because time to action is slow – need to
inhale before it hurts), TENS (transcutaneous electrical nerve stimulation; doesn’t work well for serious
pain), intramuscular pethidine (mild opiate: if the baby gets some, it will come out doped up and with
respiratory suppression, and will need naloxone before it starts to breathe), epidural anaesthesia
(excellent but tricky to put in during contractions, involving as it does inserting a large needle
temporarily into the epidural space; a plastic cannula is then left behind to infuse local anaesthetic
around the nerve roots). Women who have pethidine and then an epidural have a tendency to fall
asleep! Why?

· Monitoring in labor – cardiotocography is routine (monitors uterine contractions and fetal heart rate).
More invasive monitoring, such as fetal scalp blood sampling, possible but avoided.

· The fetus is metabolically vulnerable during parturition: its own systems are not yet functioning, and
maternal support is dwindling. Prolonged labor can result in fetal distress.

· Second stage. From full cervical dilatation to delivery of the fetus. Average duration 40 min
(primagravidae) or 20 min (multiparae). The uterus continues to contract and force the fetus through
the cervix. The head has been flexing continuously throughout labor. It rotates internally (usually from
facing sideways to facing backwards). The head then extends as it passes through the perineum, and
rotates externally to face sideways again. The shoulders appear (anterior, then posterior) and finally, the
trunk is delivered by lateral flexion.

· At this point, the umbilical cord would be clamped3 and cut, the baby slapped around a bit until it
turns pink (operating on lungs now, so O2 tension rises to normal levels) and makes some noise, dried,
weighed, tagged, injected with vitamin K, etc.

· Third stage. From delivery of the baby to delivery of the placenta. About 15 min.

· The puerperium is the 6 weeks following birth (hence puerperal fever, now rare)

Lactogenesis – Initiation of Lactation

Lactogenesis is the term meaning the initiation of lactation. This it the process of functional
differentiation which mammary tissue undergoes when changing from a nonlactating to a lactating
state. This process is normally associated with the end of pregnancy and around the time of parturition.
Because lactogenesis is particularly dependent upon a specific set of hormones (called the Lactogenic
Complex of hormones), mammary tissue from most states of the nonlactating mammary gland also can
be made to undergo some degree of lactogenesis by administration of high amounts of those hormones,
even in nonpregnant animals.

Defining Principles of Lactogenesis

Lactogenesis is a series of cellular changes whereby mammary epithelial cells are converted from a
nonsecretory state to a secretory state.

Lactogenesis occurs by a two stage process :

1. Cytologic and enzymatic differentiation of alveolar epithelial cells. This coincides with very
limited milk synthesis and secretion before parturition. Cytological changes associated with
stage 1 of lactogenesis are described below. Enzymatic changes include increased synthesis of
acetyl CoA carboxylase, fatty acid synthetase, and other enzymes associated with lactation, and
increases in the uptake transporter systems for amino acids, glucose, and other substrates for
milk synthesis. Note that synthesis of a-lactalbumin, and therefore, lactose synthesis does not
begin until stage 2 of lactogenesis. Stage 1 of lactogenesis coincides with the formation of
colostrum and immunoglobulin uptake (see The Neonate and Colostrum Lesson).
2. Copius secretion of all milk components. In the cow this begins about 0-4 days before
parturition and extends through a few days postpartum. It is not until the release of the
inhibitory effects of progesterone on lactogenesis (about 2 days prepartum in many mammals)
and the stimulation by the very high blood concentrations of prolactin and glucocorticoids
associated with parturition, that copious milk secretion begins (stage 2 of lactogenesis). One
exception to this timing is in women. The drop in blood progesterone concentration does not
occur in women until parturition, so that the full impact of stage 2 of lactogenesis sometimes
does not occur until about 2 days postpartum. In pigs and mice, stage 2 of lactogenesis is
occurring immediately prior to and at the time of parturition. It is difficult to get any mammary
secretion out of a sow until parturition, whereas in the cow, substantial mammary secretion
volume can be collected up to several days prepartum.

Points to consider : During late pregnancy the mammary gland develops the capacity to make
milk, but copius milk secretion does not take place until near parturition.

The mammary gland seems to be locked into a state where milk secreting cells are present in
late pregnancy, but copius milk secretion cannot take place. In fact, low levels of caseins and ß-
lactoglobulin are synthesized in the mammary cells during roughly the last third of pregnancy.
Milk fat accumulates in the cells and alveoli during the final few days of pregnancy. However,
there is little synthesis of a-lactalbumin until the immediate peripartum period.

** Lactose synthesis is the key to milk secretion. **

Hormones associated with parturition (decreasing progesterone and increases in glucocorticoid
and prolactin) lead to transcription of the a-lactalbumin gene (see diagram below). The a-
lactalbumin mRNA is translated at the RER and the a-lactalbumin protein interacts with
galactosyltransferase in the Golgi apparatus in synthesis of lactose (see Lactose Synthesis
Lesson). Synthesis of lactose osmotically draws water into the Golgi apparatus and secretory
vesicles. This process allows for secretion of large amounts of milk and is the most obvious
manifestation of stage 2 of lactogenesis. At the same time, synthesis of other milk components
is increased.

Hormonal Changes Associated With Lactogenesis

Number of hormonal changes are occurring in the mother’s blood around the time of
parturition. Some of these hormonal changes are specifically involved in lactogenesis. From the
figure, progesterone decreases starting a few days prepartum. Estrogen starts to peak
prepartum, which in turn stimulates the periparturitent prolactin secretion. The periparurient
prolactin peak is very important to the entire process of lactogensis, especially in initiating
copius milk secretion (stage 2 of lactogenesis). Glucocorticoids also peak at parturition. And,
there is a growth hormone peak associated with parturition. The content of a-lactalbumin in the
mammary tissue is an indicator of lactogenesis.

Progesterone Involvement in Lactogenesis

** Progesterone is the key negative regulator of lactogenesis.
Progesterone has a negative (inhibitory) effect on lactogenesis. It may hold lactogenesis in check
until just prior to parturition.
Progesterone suppresses the peripartum onset of synthesis of lactose, a-lactalbumin and casein,
as well as the PRL-induced synthesis of these constituents.
If progesterone concentrations in theblood are reduced during the peripartum period, then the
synthesis of mammary enzymes and milk proteins is increased.
Blood concentrations of progesterone normally decrease about 2 days prepartum.
Progesterone also may compete with glucocorticoid for glucocorticoid receptors in the
mammary cells.
High progesterone concentrations during pregnancy may occupy glucocorticoid receptors until
near parturition.

Both insulin and the IGFs may be involved in glucose uptake by the mammary cells. This glucose
uptake is of critical importance for lactose synthesis. Insulin also may be directly involved in
expression of milk protein genes.

Glucocorticoids
Glucocorticoids are required in vitro for full initiation of milk secretion. There may be several
roles of glucocorticoids in lactogenesis. They seem to be involved in development of the RER
and other ultrastructural changes in the cells required for massive protein synthesis. They also
may be directly involved in transcription of the casein and a-lactalbumin genes.
Galactopoiesis
Maintenance of Lactation
Galactopoeisis is the maintenance of lactation once lactation has been established. The role of
milk removal complicates interpretation of the hormonal requirements for milk synthesis.
Without frequent emptying of the mammary gland, milk synthesis will not persist in spite of
adequate hormonal status. Conversely, maintenance of intense suckling or milking stimulus will
not maintain lactation indefinitely. Nevertheless, suckling or actual removal of milk is required
to maintain lactation.

Changes in mammary cell numbers (by growth or by cell death) and yield per cell are regulated
in part by galactopoietic hormones and in part by local mammary factors. Both the hormonal
and the local factors are regulated by milk removal.

Prolactin
Prolactin is a primary component of the galactopoietic complex of hormones.

There is a milking-induced or nursing-induced release of PRL (see graph below; adapted from
Tucker 1994). This surge of PRL (green line in the graph) is small compared with the peripartum
surge of PRL associated with lactogenesis; about a 3-fold increase over non-stimulated PRL
concentrations (blue hatched line). However, the milking-induced PRL surge is a direct link
between the act of nursing or milk removal and the galactopoietic hormones involved in
 maintaining lactation. The surge occurs over a period of about a half of an hour after milking or
nursing.

Growth Hormone

Nursing causes increased release of GH from the pituitary. Blood GH decreases with advancing
lactation. Thyroid Releasing Hormone (TRH) is the hypothalamic hormone which stimulates release
of Thyroid Stimulating Hormone (TSH) from the pituitary. TRH can also release GH from the
pituitary. The release of GH from the pituitary in response to TRH administration also decreases with
advancing lactation.

Adrenal Corticoids

*** are essential for maintenance of lactation.

Adrenal glucocorticoids can inhibit lactation at high doses. However, at lower doses (resulting in
more physiological blood concentrations) exogenous glucocorticoid stimulates milk yield in humans
in early lactation and prevents the expected decline in milk yield in later lactation.

Thyroid Hormones

*** are essential for maximal secretion of milk.

Feeding thyroprotein (iodinated casein) to cows increases milk yield by 10 % in early lactation and by
15-20% in late lactation.

Milk Composition

Water

Water content of milk is dependent upon the synthesis of lactose. Without some water in the milk,
milk would be a viscous secretion composed mostly of lipid and protein and would be extremely
difficult to remove from the gland. Upon birth, the mammalian neonate is not able to seek out its
own water supply and would dehydrate rapidly without the water component of milk.

Carbohydrate

Lactose is the major carbohydrate in the milk of most species. Lactose is a disaccharide composed of
the monosaccharides D-glucose and D-galactose, joined in a ß-1,4-glycosidic linkage. The chemical
name for lactose is 4-0-ß-D-galactopyranosyl-D-glucopyranose. It is essentially unique to milk,
although it has been identified in the fruit of certain plants. Of the mammalian species where
information is available, only some marsupials have an alternative sugar other than lactose, and
those sugars are generally trisaccharides of glucose and galactose.

Lactose plays a major role in milk synthesis. It is the major osmole in milk and the process of
synthesis of lactose is responsible for drawing water into the milk as it is being formed in the
mammary epithelial cells. Because of the close relationship between lactose synthesis and the
amount of water drawn into milk, lactose content is the least variable component of milk

Milk Fat

The fat component of milk is composed of a complex mixture of lipids. Triglycerides are the major
type of lipid in milk fat. Triglycerides are composed of three fatty acids covalently bound to a
glycerol molecule by ester bonds. Milk fat is the major source of lipid used by the neonate mammal
for accumulating body adipose in the initial days after birth. Most mammalian neonates are born
with little body adipose that might be used for insulation or as a source of stored energy. A few days
after birth most neonates begin to be able to metabolize milk fat as an energy source.

Milk fat is secreted from mammary epithelial cells as fat globules which are primarily composed of a
globule of triglyceride surrounded by a lipid bilayer membrane with some similarities to the apical
membrane of the epithelial cells. This fat globule membrane helps to stabilize the fat globules in an
emulsion within the aqueous environment of milk . Lipid has a lower buoyant density than water, so
when raw milk is centrifuged the fat rises to the top resulting in the cream layer. There are so many
fat globules that they also carry some of the milk protein to the top, so cream also contains a small
amount of protein in addition to the milk fat component; this protein component contributes to the
whipping characteristics of cream.

Milk Protein

The total protein component of milk is composed of numerous specific proteins. The primary group
of milk proteins are the caseins. There are 3 or 4 caseins in the milk of most species; the different
caseins are distinct molecules but have similarities in structure. Caseins have an amino acid
composition which is important for growth and development of the nursing young. Caseins are fairly
easily digestible in the intestine compared with many other food proteins available. This high
quality, easily digestible protein in cow milk is one of the key reasons why milk is such an important
human food.

Casein is composed of several similar proteins which form a multi-molecular, granular structure
called a casein micelle. In addition to casein molecules, the casein micelle contains water and salts
(mainly calcium and phosphorous). Some enzymes are associated with casein micelles, too. The
micellar structure of casein in milk is an important part of the mode of digestion of milk in the
stomach and intestine, the basis for many of the milk products industries. Casein is one of the most
abundant organic components of milk, along with the lactose and milk fat. Individual molecules of
casein alone are not very soluble in the aqueous environment of milk. However, the casein micelle
granules are maintained as a colloidal suspension in milk. If the micellar structure is disturbed, the
micelles may come apart and the casein may come out of solution, forming the gelatinous material
called the curd. This is part of the basis for formation of all non-fluid milk products. Because the
casein micelle is in suspension, it can be separated from the rest of milk by centrifugation at a very
high speed.

There are many whey proteins in milk and the specific set of whey proteins found in mammary
secretions varies with the species, the stage of lactation, the presence of an intramammary
infection, and other factors.. The major whey proteins are ß-lactoglobulin and a-lactalbumin. a-
Lactalbumin is an important protein in the synthesis of lactose and its presence is central to the
process of milk synthesis. ß-Lactoglobulin's function is not known. Other whey proteins are the
immunoglobulins (antibodies; especially high in colostrum) and serum albumin (a serum protein).
Whey proteins also include a long list of enzymes, hormones, growth factors, nutrient transporters,
disease resistance factors, and others. Caseins are highly digestible in the intestine and are a high
quality source of amino acids. Most whey proteins are relatively less digestible in the intestine,
although all of them are digested to some degree. When substantial whey protein is not digested
fully in the intestine, some of the intact protein may stimulate a localized intestinal or a systemic
immune response. This is sometimes referred to as milk protein allergy and is most often thought to
be caused by ß-lactoglobulin. Milk protein allergy is only one type of food protein allergy.

Minerals

The major minerals found in milk are calcium and phosphorous. These minerals are required in large
quantities by the rapidly growing neonate for bone growth and development of soft tissues. They
are both mostly associated with the casein micelle structure..

Other Components in Milk

Milk contains all the major vitamins. The fat soluble vitamins A, D, E, and K, are found primarily in
the milk fat; milk has only limited amounts of vitamin K. The B vitamins are found in the aqueous
phase of milk

Milk always contains leukocyte cells, also known as somatic cells. The concentration of leukocytes in
milk varies with the species (human milk has relatively high somatic cell counts; cow milk from
healthy glands has low somatic cell counts), infection status of the gland, and stage of lactation.

Milk has numerous other components, many of which are grouped in the major biochemical
components listed above. These may include bioactive factors such as hormones and growth
factors, enzymes, cellular proteins, and others.