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Abnormalities of placenta and cord

Presentation by Shrooti Shah M.Sc. Nursing Batch 2011

Objectives
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Discuss abnormalities of placenta. Explain abnormalities related to length of cord. Describe abnormalities of cord impending blood flow. Discuss abnormalities related to membranes.

Placenta Succenturiata

One (usual) or more small lobes of placenta, size of cotyledon, may be placed at varying distances from the placental margin. In cases of absence of communicating blood vessels, it is called placenta spuria. Incidence: 3%

Clinical significance
If the succenturiate lobe is retained, following birth of the placenta, it may lead to: 1. Postpartum haemorrhage 2. Subinvolution 3. Uterine sepsis 4. Polyp formation

exploration of the uterus and removal of the lobe under general anaesthesia is to be done. .Treatment Whenever the diagnosis of missing lobe is made.

Placental extrachoralis Two types are described: 1. . Circumvallate placenta Placenta marginata 2.

Circumvallate placenta .

 .Morphology  The fetal surface is divided into a central depressed zone surrounded by a thickened white ring which is usually complete.  Vessels radiate from the cord insertion as far as the ring and then disappear from view. The peripheral zone outside the ring is thicker and the edge is elevated and rounded.

Clinical significance There is increased chance of: Abortion  Hydrorrhoea gravidarum  Antepartum haemorrhage  IUGR baby  Preterm delivery  Retained placenta or membranes  .

.Placenta Marginata A thin fibrous ring is present at the margin of the chorionic plate where the fetal vessels appear to terminate.

Placenta membranecae .

Imperfect separation in the third stage. Chance of retained placenta is more and manual removal becomes difficult.   .Clinical significance  Enroachment of some part over the lower segment.

 They are much more likely with placenta previa or with implantation over a prior uterine incision or perforation. . increta and perceta  These abnormalities are serious variations in which trophoblastic tissues invade the myometrium to varying depths.Placenta accreta.

Placenta accreta. increta and perceta .

Placenta accreta The condition is usually associated when the placenta is implanted in lower segment (Placenta praevia)  or over the previously injured sites as in caesarean section  dilatation and curettage operation  manual removal  myomectomy  .

.Diagnosis The diagnosis is only made  during attempted manual removal when the plane of cleavage between the placenta and uterine wall cannot be made out. colour Doppler and MRI have all been valuable in the diagnosis.  Ultrasound imaging.

shock.Pathological confirmation Absence of decidua basalis  Absence of Nitabuch’s fibrinoid layer  Varying degree of penetration of the villi into the muscle bundle (increta) or upto the serosal layer(percreta).  The risk includes hemorrhage. infection and rarely inversion of the uterus. .

the cord may be absent and the placenta may be attached to the liver as in exomphalus. .Cord abnormalities Abnormal length of cord Short cord  Less than 20cm or commonly relative due to entanglement of the cord round any fetal part.  In exceptional circumstances.

Prevent descent of the presenting part specially during labour Separation of normally situated placenta Favour malpresentation Acute inversion Fetal growth restriction Intrapartum distress Failure of external version Two fold risk of death . 7. 2. 6. 8. 4.Clinical significance: 1. 5. 3.

Long cord Clinical Significance  cord prolapse  cord entanglement round the neck or the body  True knot  False knots .

63 percent in liveborns.92 percent in perinatal deaths. and 3 percent in twins.  It is more common in twins and in babies born of diabetic mothers or in polyhydraminos. .Single Umbilical artery  Incidence of a single artery to be 0. 1.

Renal and genital anomalies. There is increased chance of abortion. prematurity.Single umbilical artery  It is frequently associated with congenital malformation of the fetus (10-20%). Trisomy 18 are common. IUGR and increased perinatal mortality  .

a single umbilical artery is detected by routine sonographic screening. Normal umbilical cord Single Umbilical Cord .Single umbilical artery  In many cases.

. otherwise.  If associated with low implantation of the placenta. there is chance of cord compression in vaginal delivery leading to fetal anoxia or even death. it has got little clinical significance.Cord insertion Battledore placenta  The cord is attached to the margin of the placenta.

Velamentous placenta  The umbilical vessels spread within the membranes at a distance from the placental margin. velamentous insertion develops in more commonly with placenta previa and multifetal gestations. which they reach surrounded only by a fold of amnion. Although their incidence is approximately 1 percent.  .

.Vasa praevia  If the leash of blood vessels happen to traverse through the membranes overlying the internal os. infront of the presenting part. the condition is called vasa praevia.

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urgent delivery is essential either vaginally or by caesarean section.Management  In the presence of fetal bleeding. If the baby is dead.  The infant’s haemoglobin is estimated and if necessary.  . blood transfusion be carried out. vaginal delivery is awaited.

each with cord leaving it. .Bipartite placenta Two complete and separate parts are present. The bipartite cord joins short distance from the two parts of the placenta.

Tripartite placenta  A tripartite placenta is similar but with three distinct parts. .

. with no clinical significance.Cord Abnormalities Capable of Impeding Blood Flow Knots False Knots  False knots appear as knobs protruding from the cord surface and are focal redundancies of a vessel or Wharton jelly.

 The risk of stillbirth is increased five. and these are more common in monoamnionic twins.True knot Active fetal movements create cord knotting.  Incidence : approximately 1 percent.to tenfold.  .

2 to 0.Loops  The cord frequently becomes around portions of the fetus. two loops in 2.5 percent  .5 to 5 percent. coiled  Those looped around the neck are termed a nuchal cord several large studies have reported one loop of nuchal cord in 20 to 34 percent of deliveries. and three loops in 0.

Loops  As labor progresses. contractions may compress the cord vessels and create fetal heart rate decelerations that persist until the contraction ceases. .

. Funic presentation may be identified antenatally with sonography and with color flow Doppler.Funic presentation    Cord prolapse or fetal heart rate abnormalities is an associated labor finding. If present during labor. cesarean delivery is typically indicated.

 Absence of Wharton jelly and stenosis or obliteration of cord vessels at the narrow segment are characteristic pathological features. Most fetuses are stillborn.Umbilical Cord Stricture  This is a focal narrowing of the cord diameter that typically develops in the area of fetal umbilical insertion .  .

usually of the umbilical vein. with effusion of blood into the cord. trauma. and entanglement.Hematoma  Associated with short cords. They may result from a varix rupture. May be caused by umbilical vessel venipuncture   .

Cysts   True cysts are epithelium-lined remnants of the allantois and may co-exist with a persistently patent urachus. the more common pseudocysts form from local degeneration of Wharton jelly. . In contrast.

Moreover.  . pseudocysts persisting beyond this can be associated with structural and chromosomal anomalies defects.Clinical significance  Single umbilical cord cysts found in the first trimester tend to resolve completely. especially trisomy 18 and 13. whereas multiple cysts may portend miscarriage or aneuploidy.

Thrombosis  Intrauterine thrombosis of umbilical cord vessels is a rare event.  . 20 percent are venous and arterial. and 10 percent are arterial thromboses. Approximately 70 percent are venous.

More-prolonged exposure results in staining of the chorion. Staining of the amnion can be obvious within 1 to 3 hours after meconium passage.   . and decidua. umbilical cord. and incidences range from 12 to 20 percent.Abnormalities of the Membranes Meconium Staining  The presence of meconium in amnionic fluid is relatively common.

vagal stimulation produced by cord or head compression may be associated with meconium passage in the absence of fetal distress. Lastly. and low Apgar scores . Secondly. in most fetuses. meconium passage is prevented by tonic anal sphincter contraction and by lack of intestinal peristalsis. nonreassuring fetal heart rate patterns. meconium passage is also associated with fetal acidosis.Passage of meconium    First.

Ascending infection from the lower genital tract Hematogenous spread Direct spread from the endometrium or fallopian tube And iatrogenic contamination during invasive procedures. 4. 2. .Chorioamnionitis  Routes of infection include 1. 3.

It is considered a hallmark of prolonged and severe oligohydramnios.  . light-tan nodules on the amnion that overlies the placenta.Other abnormalities  Amnion nodosum is a placental lesion consisting of numerous small.

.Amnionic bands  Amnionic bands are caused when disruption of the amnion leads to formation of bands or strings that entrap the fetus and impair growth and development of the involved structure.

Cunningham.References 1. Sixth edition. 2. Calcutta. India. Fraser DM. Edinburgh. Bloom etal. India. Jaypee Brothers Medical publishers (P) ltd.C. Textbook of obstetrics. Churchill Livingstone: 2003. McGraw Hill companies: 2010. Dutta D. United states of America. Cooper MA. A comprehensive textbook of midwifery. Leveno. New Central Book agency (P) Ltd: 2004. Myles Textbook of Midwives. Second edition. William’s obstetrics. 23rd edition. 3. 4. . Jacob A. Fourteenth edition.