Abnormalities of the Placenta

Dr. Cayabyab-Chapter outline

Some Indications for Placental Pathological
Examination
Maternal Indications
Abruption
Antepartum infection with fetal risks
Anti-CDE alloimmunization
Cesarean hysterectomy
Oligohydramnios or hydramnios
Peripartum fever or infection
Preterm delivery
Postterm delivery
Severe trauma
Suspected placental injury
Systemic disorders with known effects
Thick or viscid meconium
Unexplained late pregnancy bleeding
Unexplained or recurrent pregnancy
complications
Fetal and Neonatal Indications
Admission to an acute care nursery
Birth weight 10th or 95th percentile
Fetal anemia
Fetal or neonatal compromise
Neonatal seizures
Hydrops fetalis
Infection or sepsis
Major anomalies or abnormal karyotype
Multifetal gestation
Stillbirth or neonatal death
Vanishing twin beyond the first trimester
Placental Indications
Gross lesions
Marginal or velamentous cord insertion
Markedly abnormal placental shape or size
Markedly adhered placenta
Term cord < 32 cm or > 100 cm
Umbilical cord lesions
NORMAL PLACENTA
Measurement
Weight
Diameter
Central thickness
Round to oval shape

470gms
22cm
2.5cm

Composed of:
1. Placental disc
2. Extraplacental membranes
3. 3 vessel umbilical cord(AVA)
Maternal surface
Is the basal plate

Divided by clefts into portionstermed

COTYLEDONS
These cleft marks(cotyledons) is the site of
internal septa, w/c extend into the
intervillous space.
Fetal Surface
Is the Chorionic plate-into w/c the
umbilical cord inserts, typically in the
center.
The chorionic plate and its vessels are
covered by thin amnion, which can be
easily peeled away from a postdelivery
specimen.

SONOGRAPHICALLY
Placenta is homogenous
2-4cm thick
Lies against the myometrium
Indents into the amnionic sac
During sonographic exams,you can
examine:
1. Placental location
2. Relationship to the internal cervical os
3. Umbilical cord is imaged
4. Fetal and placental insertion sites
examined
5. Vessels counted
Retroplacental space
A hypoechoic area that separates the
myometrium form the placentas basal
plate and measures less than 1-2 cm.
ABNORMALITIES of PLACENTA
Placentas may infrequently form as
separate , nearly equally sized disc.
1. Bilobate Placenta
Also known as bipartite placenta/placenta
duplex
Cord inserts between the two placental
lobes- either into
a. connecting chorionic bridge or into
b. intervening membranes
2. Multibilobate
Placenta containing 3 or more equally
sized lobes
Rare
3. Succenturiate lobes
One or more small accessory lobes
May develop in the membranes at a
distance from the main placenta
These lobes have vessels that course
through the membranes
Located on the anterior uterine wall across
the amnionic cavity

If these vessels overlie the cervix to

create a vasa previa, they can cause
dangerous fetal hemorrhage if torn.
Accessory lobe may also be retained in the
uterus after delivery and causes
1. postpartum uterine atony and;
2. hemorrhage.

Placenta Membranacea
All or nearly all of the membranes are
covered with villi
These placenta may give rise to serious
hemorrhage because of associated
placenta previa or accreta.
Ring shaped Placenta
May be a variant of membranacea
Placenta is annular and a partial or
complete ring of placental tissue is
present
Associated with greater likelihood of
antepartum and postpartum bleeding and
fetal growth restriction.
Placenta Fenestrata
Central portion of placental disc is missing
There is actual hole in the placenta, but
more often, the defect involves only
villous tissue and the chorionic plate
remains intact.
Erroneously prompt a search for retained
placental cotyledons.
During pregnancy, Normal placenta increases its
thickness at a rate of approximately 1mm per
week and does not exceed 40mm.
Placentomegaly defines those thicker than
40mm and commonly results from striking villous
enlargement.
May result from collections of blood and
fibrin like:
a. Perivillous fibrin deposition
b. Intervillous or subchronic thrombosis
c. Large retroplacental hematomas
Secondary to:
a. Maternal diabetes
b. Severe maternal hernia
c. Fetal hydrops or infection caused by:
1. Syphilis
2. Toxoplasmosis
3. Cytomegalovirus (CMV)
Less common
a. Villi are enlarged and edematous and fetal
parts are present
b. Such as in cases of partial mole/complete
mole

Cystic Vesicles
Seen with placental mesenchymal
dysplasia
Rare condition
Correspond to enlarged stem villi, but
unlike moar pregnancy, there is not
excessive trophoblast proliferation.
ExtraChorial Placentation(EP)
The chorionic plate normally extends to
the periphery of the placenta and has a
diameter similar to that of basal plate.
But with EP, chorionic plate fails to extend
to this periphery and leads to chorionic
plate that is smaller than basal plate.
Most pregnancies with EP have normal
outcome
1. Circummarginate placenta
Fibrin and old hemorrhage lie between the
placenta and the overlying amniochorion

2. Circumvallate placenta
The peripheral chorion is a thickened,
opaque, gray white circular ridge
composed of a double fold of chorion and
amnion.
Sonographically=double fold can be seen
as thick as linear band of echoes
extending from one placental edge to the
other.
On cross section, it appears as SHELF
This is important because its location may
help to differentiate this shelf from
amnionic bands and amnionic sheets.
Associated with increased risk for
antepartum bleeding and preterm birth.
Placenta Accreta,Increta,Percreta
TORRENTIAL HEMORRAGE is a frequent
Complication
Placenta Accrete Syndromes
Abnormally implanted, invasive or
adhered placenta
To grow from adhesion or coaslescence, to
adhere or to become attached to.
Any placental implantation with
abnormally firm adherence to
myometrium because of partial or total
absence of the decidua basalis and
imperfect development of the fibrinoid or
NITABUCH layer.
Potentially cause hemorrhage
Etiopathogenesis

Placental villi are anchored to muscle

fibers rather than decidual cells.
Decidual deficiency then prevents normal
placental separation after delivery
Cytotrophoblast may control decidual
invasion through factors such as
angiogenesis and growth expression.
Tissue specimen showed
hyperinvasiveness, constitutional
endometrial defect.
Increased vulnerability of the decidua to
trophoblast invasion ff incision into the
decidua.

Classification by depth of trophoblastic growth

1. PLACENTA ACCRETA-80%
Indicates that villi are attached to the
myometrium
2. PLACENTA INCRETA-15%
Villi actually invade the myometrium
3. PLACENTA PERCRETA-5%
Villi penetrate through the myometrium
and or through the serosa
Total placenta accreta
Abnormal adherence may involve all
lobules
Focal placenta accreta
All or part of a single lobule is abnormally
attached
Acretta Syndrome leading cause of:
1. Intractable postpartum hemorrhage
2. Emergency peripartum hysterectomy
Risk factors
1. Associated previa
2. Prior cesarean delivery
3. Classical hysterotomy-eccrete placenta
4. Myomectomy-low risk
5. the risk for accrete syndromes was
increased eightfold with MSAFP levels >
2.5 MoM, and it was increased fourfold
when maternal free -hCG levels were >
2.5 MoM.
Cesarean Scar pregnancy
an adverse outcome before the fetal is
viable in placenta accreta.
Clinical presentation
in 1st and 2nd triaccreta syndrome +
placenta previa=hemorrhage
absence of placenta previa= accreta may
not be identified until 3rd stage of labor
when an adhered placenta is encountered.

Use MRI or sonography

Management
Surgical, anesthesia and blood blanking
Timing of delivery-deliver the baby until
36 weeks or later
Preoperative arterial catheterization
Cesarean delivery and hysterectomy
Circulatory Disturbances
Placenta is a target organ of maternal
disease
Placental perfusion disorders can be grouped
into/
1. Hose in which there is disrupted maternal
blood flow or within the intervillous space
2. Those with disturbed fetal blood flow
through the villi.
1. Subchorionic fibrin deposition
2. Perivillous fibrin deposition
3. Intervillous thrombosis.May be a focal
sonolucensis w/n the placenta.
4. In the absence of maternal or fetal
complications, isolated placental
sonoluceincies are considered incidental
finding.
Maternal blood flow disruption
1. Subchorionic fibrin deposition
Caused by slowing of maternal
blood flow within the intervillous
space with subsequent fibrin
deposition.
Blood stasis specifically occurs in
the subchorionic area
Lesions are commonly seen as
white or yellow firm plaques on
fetal surface.
2. Perivillous fibrin deposition
Stasis around the villous
Results in fibrin deposition and can
lead to diminished villous
oxygenation and
syncytiotrophoblastic necrosis.
These visible small yellow white
placental nodules are considered to
be normal placental aging.
Maternal floor infarction
Extreme variant of perivillous fibrinoid
deposition
Dense fibrinoid layer within the placental
basal plate and is erroneously termed an
infarction.

Lesion has a thick white firm corrugated

surface that impedes normal maternal
blood flow into intervillous space.
Associated with :
a. Miscarriages
b. Fetal growth restriction
c. Preterm delivery
d. Stillbirths
e. Lupus anticoagulant
f. Maternal thrombophilias
They create thixker basal plate

Intervillous thrombus
Collection of coagulated maternal blood
normally found in the intervillous space
mixed with fetal blood from a break in a
villous,
Round or oval collections vary in size up to
several centimeters
They appear red if recent or white- yellow
if older
Develop at any placental depth.
NOT associated with adverse fetal
sequelae
Can cause elevated maternal serum alpha
fetoprotein levels.
Infarction
Chorionic villi themselves receives oxygen
solely from maternal circulation suplied to
the intervillous space.
Any utroplacental disease that diminishes
or obstructs this supply can result in
infarction of individual villus.
These are common lesions in mature
placentas and are benign in limited
numbers.
If numerous, placental insufficeincy can
develop
When they are thick , centrally located
and randomly distributed.
Associated with:
a. Preecclampsia
b. Lupus anticoagulant
Hematoma
Maternal-placental-fetal unit can develop a
number of hematoma types include:
a. Retroplacental hematoma
b/w placenta and adjacent
decidua
b. marginal hematoma
b/w chorion and decidua at the
placental periphery
kown as subchorionic
hemorrhage
c. subchorial thrombosis

also known as Breus Mole

along the roof of the intervillous
space and beneath the chorioic
plate.
d. Subamnionic hematoma
These are fetal vessel origin
and found beneath the amnion
but above the chorionic plate.
Sonographically,
These hematomas resemble a crescent
shaped fluid collection that is:
a. hyperechoic to isoechoic in the first
week after hemorrhage
b. hypoechoic at 1-2 weeks
c. anechoic after 2 weeks
most subchorioic hematomas visible
sonographically are fairly small and of no
clinical consequence
extensive retroplacental, margeinal and
subchorial collections asoociated with:
a. higher rates of miscarriages
b. placental abruption
c. fetal growth restriction
d. preterm delivery
e. adherent placenta
placental abruption is a large
clinically retroplacental
hematoma.
Fetal thrombotic vasculopathy
these are deoxygenated fetal
blood flows from the two
umbilical arteries into the
arteries within the chorionic
plate that divide and send
branches out across the
placental surface.
These eventually supply
individual stem villi and their
thrombosis wil obstruct fetal
bloow flow distal to the
obstruction
Affected portions of the villus
become infarcted and
nonfunctional.
Thrombi in limited numbers are
normally found in mature
placentas, but these may be
clinically significant if many villi
become infacrted.
Subamnionic hematoma
These hematomas lie b/w the placenta
and amnion

 Most often are acute events during third

stage labor when cord traction ruptures a
vessel near the cord insertion.
Chronic lesions may cause fetomaternal
hemorrhage or fetal growth restriction
Through doppler- shows absence of
internal blood flow that permits
differentiation of hematomas from other
placental masses.
Placental Calcification
Calcium salts may be deposited
throughout the placenta, but are most
common on the basal plate
Associated with:
a. Nulliparity
b. Smoking
c. Higher socioeconomic status
d. Increasing maternal serum calcium
levels.
e. Cacification can be seen
sonographically
Placental tumors
1. Gestational trophoblastic disease
2. Chorioangioma
Benign tumors
Similar to blood vessels and stroma
of the chorionic villus
A.k.a chorangioma
Incidence approx.1%
Elevated maternal serum alpha
fetoprotein( MSAFP)- impt
diagnostic finding
Well circumscribed,rounded,
predominantly hypoechoic lesion
near the chorionic surface and
protruding into the amnionic cavity.
Doppler differentiate from:
a. Hematoma
b. Partial hydatidiform mole
c. Teratoma
d. Metastases and
e. Leiomyoma.
Small chorioangiomas are usually
asymptomatic
Large tumors measuring >5 cm,
associated with significant
arteriovenous shunting within fluid
abnormalities. And fetal growth
restriction
Some had treated these through
interdicting excessive blood flow
using vessel occlusion or ablation.
Tumors metastatic to the placenta
a. Malignant tumors rarely metastasize to
the placenta

b. Most common:
a. Melanomas
b. Leukemia
c. Lymphomas
d. Breast cancer
c. Tumor cells usually are confined within the
intervillous space.
d. As a result: metastasis to the fetus is
uncommon but is most often seen with
MELANOMA.
ABNORMALITIES of the MEMBRANES
1. Meconium Staining
Fetal passage of meconium before or
during labor is common with cited
incidences that range from 12-20 percent.
2. Chorioamnionitis
Non genital tract flora can colonize and
infect membranes, umbilical cord, fetus.
Bacteria most commonly ascend after
prolonged membranes rupture and during
labor to cause infection
Organisms initially infect the chorion and
infect the chorion and adjacent decidua in
the area overlying the internal os.
Progression leads to full thickness
involvement of the membraneschorioamnionitis.
Inflammation of the chorionic plate and
umbilical cord- funisitis
Fetal infection may result from
hematogenous spread if the mother has
bacteremia
But mote likely from :
a. Aspiration
b. Swallowing
c. Direct contact with infected amnionic
fluid.
Most commonly there is microscopic or
occult chorioamnionitis
In some cases, infection characterized by
membrane clouding accompanied by foul
odor that depends on bacterial species.
Other membrane abnormalities
1. Amnion Nodosum
Characterized by numeous small,
light-tan nodules on the amnion
overlying the chorionic plate.
These may be scraped off the fetal
surface and contain deposits of
fetal squames and fibrin that
reflect prolonged and severe
oligohydramnios.
Amnionic band sequence
An anatomic fetal disruption
sequence caused by bands
of am ion that entrap fetal

stuctures and impair their

growth and development.
Amnionic bands
commonly involve the
extremities to cause limb
reduction defects and more
subtle deformations.
They may also affect fetal
structures such as cranium
causing
encephalophalocele.
Amnionic sheet is formed
by normal amniochroiron
draped over a preexisting
uterine synechia.

ABNORMALITIES OF THE UMBILICAL CORD

1. Length
40-70 cm
very few measure <32 or >100 cm
cord length is influenced by
amnionic fluid volume and fetal
mobility.
Short cord may be associated with:
a. Fetal growth restriction
b. Congenital malformations
c. Intrapartum distress
d. Two fold risk of death.
Excessive long cords are more
likely to be linked with:
a. Cord entanglement
b. Prolapse
c. Fetal anomalies
d. Acidemia
e. Demise
Cord diameter has been used as a
predictive marker for fetal
outcomes
Link lean cords with poor fetal
growth and large diameter cords
with macrosomia.
Coiling
Umbilical vessels spiral through the cord in
a sinistral that is left twisting direction.
Umbilical coiling index- number of
complete coils per centimeter of cord
length
Normal antepartum index sonographically
is 0.4 contrast with normal value of 0.2
Hypocoiling
Linked with fetal demise
Hypercoiling
Associated with fetal growth restriction
and intrapartum fetal acidosis

Both have been reported in the setting of

trisomic fetuses and with single umbilical
artery..
Vessel number
The usual arrangement of two thick walled
arteries and one thin, larger umbilical vein
is altered.
The most common aberration is that of
single umbilical artery
Cord vessel number is a component of
standard prenatal ultrasound examination.
Most commonly described anomalies are
cardiovascular and genitourinary.
Single artery has been associated with
fetal growth restriction in some.
Remnants and Cysts
Embryos in early development initially
have two umbilical veins.remnants of
vitelline duct, allantoic dicut and
embryonic vessels.
Cyst are occasionally are found along
the course of the cord.
True cyst are epithelium-lined
remnants of the allantoic or vitelline
ducts and tend to be located closer of
the fetal insertion site.
Multiple cyst may portend miscarriage
and aneuploidy.
Cyst persisting beyond this time are
asoociated with a risk for structural
defects and chromosomal anomalies.
Insertion
The cord normally inserts centrally into
the placental disc, but eccentric, marginal
or velamentous insertions arevariants.
Marginal and velamentous are important
in that the cord or vessels may be torn
during labor and delivery.
Marginal insertion or battledore placentacord anchors at the placental margin
More frequent with:
a. Multifetal pregnancy
b. Assisted reproductive technology
c. Assoc. weight discordance

Velamentous insertion
Umbilical vessels spread within the
membranes at a distance from the
placental margin surrounded by
fold of amnion
As a result: vessels are vulnerable
to compression leading to fetal
hypoperfusion and academia.
Commonly seen in placenta previa
and multifetal gestations

Fureate insertions
Cord connection onto the placental
disc is central but umbilical vessels
lose their protection.
Prone to compression, twisting, and
thrombosis.
Vasa Previa
Dangerous variation of
velamentous insertion in w/c the
vessels within membranes overlie
the cervical os.
The vessels can be interposed b/w
the cervix and the presenting fetal
part.
Risk factors:
a. Bilobate
b. Succenturiate placentas
c. 2nd tri placenta previa

True knots
Caused by fetal movements
Common and dangerous in monoamnionic
twins
Assoc. with singleton fetuses
False knots

No clinical significance and appear as

knobs protruding from the cord surface
These are focal redundancies of a vessel
or Wharton jelly.

Cord stricture
Focal narrowing of its diameter that
usually develops near the fetal cord
insertion.
Feature: absence of wharton jelly and
stenosis or obliteration of cord vessels at
the narrow segment.
Cord loops
Frequent encountered and are caused by
coiling around various fetal parts during
movement.
Nuchal cord is common.and have mod to
severe variable heart decelerations and
assoc with lower umbilical artery pH.
Cord Hematomas
Uncommon
Assoc with abnormal cord length, vessel
aneurysm, trauma entanglement,
umbilical vessel puncture and funisitis
Complications: rupture or thrombosis,
compression of the umbilical artery, fetal
cardiac failure due to increased preload.