2 Placenta - Libre Pathology

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Placenta
From Libre Pathology
The placenta feeds the developing baby, breathes for it and

disposes of its waste.
The organ is one that seems to be left behind; at least one

review suggests it isn't done so well by general pathologists.[1]
Placental pathology redirects to this article.
Contents
1 Clinical A placenta (fetal aspect) with attached umbilical
1.1 Examination of the placenta cord. (WC/Asturnut)
1.1.1 Indications for exam by pathology
1.1.1.1 Most common
1.2 Bleeding in late pregnancy
1.3 Clinical screening tests
1.4 Abbreviations
2 Normal histology
2.1 Villi
2.2 Cord
2.2.1 Omphalomesenteric duct remnant
2.2.2 Allantoic duct remnant
2.2.3 Vitelline artery remnant
2.3 Membranes
2.3.1 Amnion
2.3.2 Chorion
2.4 Common terms
3 Grossing
3.1 General
3.2 Sections
3.3 Placental membranes
3.4 Placental mass
3.4.1 Linear regression - placental mass-
gestational age
3.4.2 What to remember...
3.4.3 Placentomegaly
3.4.3.1 Sign out
3.4.4 Placental growth restriction
3.4.4.1 Sign out
4 Overview of placental pathology
4.1 Approach
4.2 Common entities/diagnoses
5 Sign out
5.1 Normal placenta
5.1.1 C-section
6 Cord pathology
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6.1 Two vessel umbilical cord

6.2 Insertion
6.2.1 Marginal insertion
6.2.2 Velamentous insertion
6.2.2.1 Sign out
6.3 Umbilical knot
6.3.1 General
6.3.2 Gross
6.3.3 Microscopic
6.4 Coiling
6.5 Cord hematoma
7 Membranes
7.1 Amnion nodosum
7.2 Placental meconium
7.3 Squamous metaplasia of the amnion
7.3.1 General
7.3.2 Gross
7.3.3 Microscopic
7.4 Circumvallate placenta
7.4.1 General
7.4.2 Gross
8 Twin placentas
9 Placental disc
9.1 Villous edema
9.1.1 General
9.1.2 Microscopic
9.2 Placental villous immaturity
9.3 Villous hypoplasia
10 Diseases of the placental attachment
10.1 Placenta creta
10.2 Placental abruption
11 Inflammatory pathologies
11.1 Overview of infections
11.1.1 Types
11.2 Membranitis
11.2.1 General
11.2.2 Microscopic
11.2.2.1 Grading membranitis
11.2.3 Sign out
11.2.3.1 Waffle
11.3 Chorioamnionitis
11.4 Umbilical cord vasculitis
11.5 Funisitis
11.6 Acute villitis
11.7 Villitis of unknown etiology
11.8 Chronic intervillitis
11.8.1 General
11.8.2 Microscopic
11.8.2.1 Images
11.9 Chronic deciduitis
12 Placental infarction
12.1 True infarcts
12.2 Perivillous fibrin deposition
12.2.1 General
12.2.2 Gross
12.2.3 Microscopic
12.2.4 Sign out
12.2.4.1 Thrombi
12.3 Maternal floor infarction
13 Fetal disease
13.1 Fetal thrombotic vasculopathy
13.2 Hemorrhagic endovasculitis
13.2.1 General
13.2.2 Microscopic
14 Maternal disease
14.1 Hypertensive changes
14.1.1 General
14.1.2 Microscopic
14.2 Hypertrophic decidual vasculopathy
14.3 HELLP syndrome
14.4 Malaria
14.4.1 General
14.4.2 Microscopic
14.4.2.1 Image
15 Tumours
15.1 Chorangioma
15.2 Chorangiomatosis
15.2.1 General
15.2.2 Gross
15.2.3 Microscopic
15.3 Chorangiosis
16 Other
16.1 Fetus papyraceus
16.2 Placental mesenchymal dysplasia
17 Placental cysts and pseudocysts
18 See also
19 References
20 Recommended reading
21 External links
Clinical
Examination of the placenta
Most placentas are not examined by a pathologist.
Indications for exam by pathology
Some indications for exam by a pathologist:
Abnormalities in the:
1. Fetus:
Bad fetal outcome.
Suspected or known congenital abnormalities or chromosomal abnormalities.
IUGR.
2. Mother:
Infection/suspected infection.
Pre-term labour.
Maternal disease (e.g. SLE, coagulopathy).
Complicated pregnancy (preclampsia, pregnancy induced hypertension, gestational diabetes).
3. Placenta:
Unusual gross characteristics.[2]
A more detailed list is given by Hargitai et al.[3] and Chang.[4]
Most common
Most common reasons for submitting a placenta to pathology:[5]
1. Prematurity.
2. PROM / possible chorioamnionitis.
3. Multiple gestation.
Bleeding in late pregnancy

DDx of bleeding in late pregnancy:
Placental abruption (most common).

Placenta previa.
Vasa previa (fetus losing blood).
Clinical screening tests

Main article: Pregnancy
PAPP-A - low values seen in aneuploidy.[6]
Abbreviations
C/S = Caesarean section.
LSCS = lower segment C-section.
FTP = failure to progress.
PROM = premature rupture of membranes.
PPROM = preterm premature ruptures of membranes.
IUGR = intrauterine growth restriction.
IOL = induction of labour.
Normal histology
Villi
Main article: Chorionic villi
This is dealt with in a separate article that also covers the types of trophoblast (cytotrophoblast,
syncytiotrophoblast, intermediate trophoblast).
Cord
Omphalomesenteric duct remnant
AKA vitelline duct.

Benign embryologic remnant.
Features:
Duct with benign looking cuboidal epithelium.
Allantoic duct remnant
Benign embryologic remnant.
Features:
Duct with benign looking flat epithelium.
Vitelline artery remnant
Features:
Small artery in the cord.
Membranes
Fetus to mother:
Amnion - thin layer: one cell layer, basement membrane, connective tissue.
Cleft - artifactual - empty space.
Chorion - vascular.
Decidua (maternal tissue) - may contain obsolete chorionic villi; place to look for hypertensive changes.
Amnion
General:
Next to fetus, surrounds amniotic fluid, avascular.
Characteristics:
Characterized by a single layer of cells.[7]

Cuboidal/squamoid shape.
Eosinophilic cytoplasm.
Central nucleus.
Squamous metaplasia may be seen at cord insertion.
Basement membrane.
'Compact layer'.[7]
'Fibroblastic layer'.[7]
Chorion
General:
Surrounds amnion.
Characteristics:
Layers:[8]
'Reticular layer' - cellular (inner aspect).
'Pseudo-basemement membrane'.
'Outer trophoblastic layer'.
Has blood vessels.
Opposed to "trophoblastic X cells" on side opposite of amnion.[7]
Beneath of the "trophoblastic X cells" is decidua (mnemonic NEW = nucleus central, eosinophilic,
well-defined cell border), which is maternal tissue.
Note:
Fibrin deposition may be found deep to the chorion - known as subchorionic fibrin deposition.
Gross: subchorionic, white/yellow, laminated, classically has a triangular-shape with the base of
triangle parallel to fetal aspect of disc.
Arises due to localized stasis of the inter-villous maternal blood.
Focal small deposits are considered to be a normal finding - seen in ~15% of cases.[9][10]
The pathologic counterpart of this is perivillous fibrin deposition.
Image:
Subchorionic fibrin deposition (ijpmonline.org) (http://www.ijpmonline.org/viewimage.asp?img=IndianJPat

holMicrobiol_2011_54_1_15_77317_u5.jpg).
Common terms
Chorionic plate - fetal aspect of placenta.
Basal plate - maternal aspect of placenta.
Has extravillous trophoblast.
Place to look for maternal vessels.
Grossing
This is often very quick. The gross is quite important, as some things cannot be diagnosed microscopically.
General
Dimensions:
Disc.
Length of cord, diameter of cord.
Accessory lobes - dimensions.
Two lobes of equal size + cord arises in between = bilobate placenta.
Mass (weight).
Should be done 'trimmed' (cord cut-off, membrane cut-off).
Should be done when placenta is "fresh", i.e. not fixed -- as mass tables are based on fresh state.
Umbilical cord
Attachment.
Location: central, eccentric, marginal.
Marginal attachment assoc. with hypertension[11]
Membranous or velamentous (veil-like) insertion.
Vessels separate/branch prior to reaching placental disc.
Furcate insertion - blood vessels separate before reaching placenta disc/not surrounded by
Wharton's jelly - vessels more exposed to trauma (risk for vasa previa).
Knots (false vs. true).
False knots are nothing to worry about -- look like a knot but aren't really one.
Twisting/coiling - 1-3 coils/10 cm is normal.
Number of vessels.
Normal: 2 arteries, 1 vein.
Membranes - shiny & translucent - normal (green, opaque/dull - chorioamnionitis).
Attachment (insertion): marginal (normal), circummarginate (inside edge), circumvallate (folding on
self).
Site of rupture - if obvious; low point of rupture suggests low-lying placenta.
Placental disc.
Fetal surface - normal is shinny.
Dull in chorioamnionitis.
Maternal surface
Are the cotyledons intact?
Adherent clot?
Parenchyma - after sectioning:
White vs. red nodules.
Notes:
Parenchymal nodules - a brief DDx:

White: infarct (chronic), thrombi, chorangioma, perivillous fibrin deposition.
Red: infarct (acute), thrombi.
Sections
1. Cord two sections.
2. Membranes (rolled), two rolls or more.[12]
3. Cord at insertion + disc.
4. Placenta - full thickness (maternal and fetal surface).
Sections should not be taken at the margin of the disc.
Placental membranes
Appearance:[13]
Normal - shiny.
Chorioamnionitis - opaque/dull.
Meconium - green.
Amnion nodosum - yellow patches.
Some describe 'em as white.[14]
Placental mass
It is considered routine to obtain a mass for the placenta. This is usually done when the placenta is fresh and with
the membranes and cord trimmed, as most tables of placental mass were created with these parameters.
Placental mass by gestational age:[15]
Gest. Age/Percentile 25% 50% 75%

32 weeks 275 g 318 g 377 g
36 weeks 369 g 440 g 508 g
40 weeks 440 g 501 g 572 g
Linear regression - placental mass-gestational age
Based on the table in the AFIP book[16] one can generate the following regression lines:
50% 10% 90%

slope (g/week) 21.58088235 19.70588235 25.40196078
y-intercept (g) -357.4558824 -397.2352941 -366.7254902
Pearson (r) 0.988670724 0.988268672 0.982206408
placental mass = slope x gestational age + intercept
What to remember...
Extrapolated from the linear regression (see above):
50% at term = 500 grams.

50% at 26 weeks = 200 grams.
The change in mass/week is approximately linear and equal to 300 grams / 14 weeks ~ 20 grams/week.
The spread in mass between 10% and 90%, crudely estimated, is 200 grams (for GA=26-40).
Notes:
Is it required?
Sebire and Fox have advocated abandoning the practise of obtaining a placental mass, due to the large
number of uncontrolled variables inherent in these measures. Instead, they have advocated using
mushy descriptors such as "small", "average" and "large", which require experience in examining the
organ.[17]
In the context of quality, a measure (even if somewhat flawed) is probably more reproducible
and objective than arbitrary descriptors which require experience and a continuing case volume
to calibrate.
Placentomegaly
AKA large placenta.
Associations:[18]
Maternal diabetes - esp. poorly controlled.[19]

Maternal anemia/low maternal iron stores.[20]
Fetal malformations.
Neoplasms of the placenta, e.g. chorangioma.
Twin-twin transfusion syndrome.
Chronic intrauterine infections, e.g. syphilis, toxoplasmosis, cytomegalovirus.
Lame causes of a heavy placenta:
Dates wrong - error in determining the estimated date of confinement.

Adherent blood clot.
Comment:
Most of causes seem to have one thing in common:

There is a decreased oxygen delivery to the fetus.
Sign out
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, CESAERIAN SECTION:

- LARGE PLACENTA (819 GRAMS -- TRIMMED, POST-FIXATION WEIGHT).
- FETAL MEMBRANES WITHIN NORMAL LIMITS.
- THREE VESSEL UMBILICAL CORD WITHIN NORMAL LIMITS.
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI.
Placental growth restriction
AKA placenta small for gestational age.

Small placenta redirects here.
Associations:
Maternal vascular disease, e.g. hypertension.

Fetal malformations.
Sign out
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, BIRTH:

- PLACENTA SMALL FOR GESTATIONAL AGE (160 GRAMS -- TRIMMED, POST-FIXATION WEIGHT).
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI WITH:
-- OLD CENTRAL TRANSMURAL INFARCT (1.7 CM MAXIMAL DIMENSION).
COMMENT:
The 10th percentile placental mass (pre-fixation) for 34 weeks and 2 days is approximately 390 grams.
Overview of placental pathology

Approach
The pathology of the placenta is diverse and is not easy to group.
It terms of remembering things. It is probably easiest to take a combined anatomical, etiologic and morphologic
approach.
Anatomical basis:
Cord.
Membranes.
Disc.
Etiologic:
Congential.
Infectious.
Neoplastic.
Endocrine.
Trauma.
Vascular.
Degenerative.
Autoimmune.
Toxic.
Idiopathic.
Compartmental:
Vasculature.
Membranes.
Parenchyma:
Maternal part (decidua).
Fetal part (villi, cord).
Common entities/diagnoses
Normal.
Chorioamnionitis.
Placental abruption.
Meconium.
Hypertensive changes.
Sign out
What should be commented on...
Placenta:
Maturity of villi (2nd or 3rd trimester).
Infarction?
Subchorionic less important than maternal aspect.
Peripheral aspect of placental disc less important than central region of disc.
Blood vessels.
Maternal.
Fetal.
Membranes.
Membranitis?
Chorioamnionitis?
Cord:
3 vessel?
Vasculitis/inflammation?
Mnemonic: chorio, cord, vessels, villi (maturity, infarction).
Normal placenta
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI WITHIN NORMAL LIMITS.
C-section
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, CAESAREAN SECTION:

Cord pathology
Two vessel cord.
Hypercoiling/Hypocoiling.
Abnormal insertion.
Cord knots (true vs. false).
Strictures.
Hematoma.
Hemangioma.
Benign cyst.
Two vessel umbilical cord

AKA two vessel cord.
AKA single umbilical artery.
Main article: Two vessel umbilical cord
Insertion
Marginal insertion
Definition:
The umbilical cord is attached to the placental disc at its margin.
Prevalence:
Approximately 12% of placentas.[21]

Relevance:
None according to WMSP.[21]

In theory, the cord, dependent on its relation to the internal os, is at greater risk of injury (leading to
vasa previa) and compression (fetal hypoxia). A retrospective study found cord position in relation to
the internal os is predictive for vasa previa.[22]
Velamentous insertion
Definition:
The umbilical cord inserts into the fetal membranes.[21]

The vessels are not protected by Wharton's jelly.
Wharton's jelly = the connective tissue surrounding the vessels in the cord.
Details:[21]
3/4 of the time the vessel also branch; in the remaining 1/4 the vessels stay together.
Relevance:
Increased risk of vasa previa.[22]
Sign out
PLACENTA, UMBILICAL CORDS AND FETAL MEMBRANES, BIRTH:

- THREE VESSEL UMBILICAL CORD WITH A VELAMENTOUS INSERTION, OTHERWISE WITHIN NORMAL LIMITS.
Umbilical knot
AKA umbilical cord knot.
AKA cord knot.
AKA true knot.
General
Prevalence ~1.25%.[23][24]
Increase risk of stillbirth; odds ratio 3.93.[23]
Gross
Work-up:[24]
Diameter measures and colour on both sides of the knot.

Knot should be untied to assess for deformation of Wharton's jelly.
Sections from both sides of the knot - to look for thrombi.
Note:
False knots (large diameter - focally) are common - they cannot be untied.
Microscopic
Features:
+/-Thrombi.
Fibrin deposition.
+/-Lines of Zahn.
Images:
Lines of Zahn (utah.edu) (http://library.med.utah.edu/WebPath/ATHHTML/ATH031.html).

Lines of Zahn (ucsf.edu) (http://pathhsw5m54.ucsf.edu/case9/image94.html).
Coiling
Hypo- and hypercoiling are both considered problematic.[21]
Normal: 1-3 coils/10 cm.[25]
Associated with cord stricture, which is usu. at the fetal end of the cord.[26]
Notes:
There is little uniformity in how coiling is assessed in the medical literature - though 10% and 90% are
considered the cut-points for normal.[27]
What are the 10% and 90% cut-points? They are not given in WMSP. UT access to a journal article[28]
that might have it is screwed-up.
Cord hematoma
Features:[26]
Rare ~ 1/5500.
Mortality ~50% is severe.
Membranes
Squamous metaplasia.
Chorioamnionitis - see infection section.
Amnion nodosum
Main article: Amnion nodosum
Placental meconium
Main article: Placental meconium
Squamous metaplasia of the amnion

General
Benign common finding thought to be of no clinical significance.[29]

One case report suggesting an association with chorioamnionitis.[30]
Needs to be separated from amnion nodosum - important.[31]
Gross
Features:[32]
White (or yellow) plaques - irregular outline.
DDx:
Amnion nodosum - small (~1-5 mm), round, classically yellow.
Images:
Amnion nodosum & squamous metaplasia of the amnion (archivesofpathology.org) (http://www.archivesofp

athology.org/action/showFullPopup?id=i1543-2165-131-12-1829-f01&doi=10.1043%2F1543-2165%28200
7%29131%5B1829%3AANRCAP%5D2.0.CO%3B2).[32]
Microscopic
Features:[32]
Dense, paucicellular (pink) compact keratin - key feature.
Image:
Squmous metaplasia of the amnion (flylib.com) (http://flylib.com/books/2/953/1/html/2/43%20-%20Placent

a_files/DA10C43FF29.png).[33]
Circumvallate placenta
AKA circumvallate insertion of the membranes.
General
May be associated with placental abruption.[34]
Note:
Membranes usually attach to the edge of the placenta.
Gross
Fetal membranes attach to the fetal surface of the placenta away from the margin of the placental disc.
Classification:
Partial - not circumferential.

Complete.
DDx:
Circummarginate placenta.
Images:
Circumvallate placenta - partial and complete (utah.edu) (http://library.med.utah.edu/nmw/mod2/Tutorial2/pi

cs/circumvallate.jpg).
Circumvallate placenta (utah.edu) (http://library.med.utah.edu/WebPath/jpeg2/PLAC027.jpg).
Twin placentas
Main article: Twin placentas
These are often submitted... even if they are normal. In these specimens, usually, the chorion is the key.
It covers:
Monozygotic vs. dizygotic twins.

Twin-to-twin transfusion syndrome.
Placental disc
Villous edema
General
Non-specific finding.
Reported in associated with congenital adrenal hyperplasia for the stem villi.[35]
Microscopic
Features:
"Swiss chesse-like" appearance / bubbly appearance.

Usually patchy and focal.
Note:
Cistern formation is reported in the stem villi in association with congenital adrenal hyperplasia.[35]
DDx:
Chorioamnionitis.
Fetal edema.
Idiopathic (no cause apparent).
Placental villous immaturity.
Image:
villous edema (yale.edu) (http://www.med.yale.edu/obgyn/kliman/placenta/articles/EOR_Placenta/Image19.

gif).[36]
Placental villous immaturity

Main article: Placental villous immaturity
Villous hypoplasia
AKA terminal villus deficiency.[37]
Main article: Villous hypoplasia
Diseases of the placental attachment

Placenta creta
Includes placenta accreta, placenta increta, and placenta percreta.
Main article: Placenta creta
Placental abruption
Main article: Placental abruption
Inflammatory pathologies
Overview of infections
General:[38]
Infection usually ascending, i.e. from vagina up through cervix.

Associated with intercourse.
Hematogenous rare - manifest as villitis.
Think TORCH infections (toxoplasmosis, others (syphilis, TB, listeriosis), rubella, cytomegalovirus,
herpes simplex virus).
Funisitis usually follows chorioamnionitis.
Inflammatory cells in umbilical cord are fetal (trivia).
Types
By site:[38]
Fetal membranes: chorioamnionitis, membranitis.[39]

Umbilical cord: funisitis.
Placenta: placentitis, villitis.
Membranitis
Chorionitis redirects here.
General
Early chorioamnionitis.[40]
Controversial.[citation needed]
Microscopic
Features:
PMNs in the decidua.

+/-PMNs in subamniotic tissue.
+/-Necrosis in decidua or chorion/subamniotic tissue.
Note:
Plasma cells in the decidua = chronic deciduitis.
DDx:
Chorioamnionitis.
Grading membranitis
Sternberg:[39]
1. PMNs - decidua only.

2. PMNs - in subamniotic tissue.
3. 1 or 2 + necrosis in decidua or chorion/subamniotic tissue.
Sign out
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, CESAERIAN SECTION:

- FETAL MEMBRANES WITH CHORIONITIS.
- THREE VESSEL UMBILICAL CORD WITH VASCULITIS.
Waffle

- FETAL MEMBRANES WITH MECONIUM-LADEN MACROPHAGES AND ABUNDANT DECIDUAL NEUTROPHILS
SUSPICIOUS FOR EARLY CHORIONITIS.
Chorioamnionitis
Main article: Chorioamnionitis
Umbilical cord vasculitis

Main article: Umbilical cord vasculitis
Funisitis
Main article: Funisitis
Inflammation of Wharton's jelly - the connective tissue of the umbilical cord.
Acute villitis
Main article: Acute villitis
Villitis of unknown etiology

Main article: Villitis of unknown etiology
Chronic intervillitis
AKA chronic intervillositis.[41]
General
Rare.
Massive chronic intervillitis - associated IUGR, spontaneous abortion, perinatal fetal death.[42]
Recurs.
Microscopic
Features:[41][42]
Intervillous inflammatory cells:

Lymphocytes.
Histiocytes.
Fibrinoid deposition.
Images
Intervillitis - intermed. Intervillitis - very high

mag. (WC) mag. (WC)
Chronic deciduitis
AKA plasma cell deciduitis.
Main article: Chronic deciduitis
Placental infarction
True infarcts
Main article: Placental infarct
Perivillous fibrin deposition

Abbreviation PFD.
General
Thought to be an immunologic problem - resulting in platelet activation and fibrin deposition.[43]

May be associated with diabetes mellitus.[44]
Gross
Pale (white).
Firm.
White fibrous sepatae.
Microscopic
Features:
Acellular eosinophilic material around formed villi.

Obliteration of intervillous space.
Intervillous distance increased vis-a-vis normal - key feature.
Notes:
Nuclei of villi are usually preserved.

Villi may have secondary infarction, i.e. there may be nuclear destruction (karyolysis, karyorrhexis,
pyknosis).
DDx:
Placental infarction - loss of nuclei in the villi (below the edge of the lesion).
Massive perivillous fibrin deposition (maternal floor infarct).
Images:
APLA syndrome (upmc.edu) (http://path.upmc.edu/cases/case75.html).
Sign out
Thrombi

- PLACENTAL DISC WITH THIRD TRIMESTER VILLI AND THREE LARGE INTERVILLOUS
THROMBI (BLOCKS A7-A9).
Maternal floor infarction

Abbreviated MFI.
Formally placental maternal floor infarction.
AKA massive perivillous fibrin deposition.[45]
Main article: Maternal floor infarction
Fetal disease
Fetal thrombotic vasculopathy
Abbreviated FTV.
A large number of terms are used for this including:[46]
Fibrinous vasculosis.
Fibromuscular sclerosis.
Fetal artery stem thrombosis.
The multitude of terms reflects the confusion about this finding and that it has numerous etiologies.[46]
Main article: Fetal thrombotic vasculopathy
Hemorrhagic endovasculitis
Abbreviated HEV.
General
Associated with stillbirth.[47]
Microscopic
Features:[48]
Walls of the (fetal) placental blood vessels (in the villi) are disrupted.
+/-Intraluminal necrotic debris.
RBC fragmentation.
Maternal disease
Hypertensive changes
General
Associated pathologic changes:[49]
Placental infarcts.
Increased syncytial knots.
Hypovascularity of the villi.
Cytotrophoblastic proliferation.
Thickening of the trophoblastic basement membrane.
Microscopic
Features:[49]
Enlarged endothelial cells - fetal capillaries.

Atherosis of the spiral arteries - placental bed (maternal).
Notes:
One should look for the changes in the membrane roll, not the maternal surface.[50]
Images:
Pregnancy-induced hypertension (pathxchange.org) (http://www.pathxchange.org/case/19711).
Hypertrophic decidual vasculopathy

AKA decidual vasculopathy.
Main article: Hypertrophic decidual vasculopathy
HELLP syndrome
Main article: HELLP syndrome
Malaria
Main article: Malaria
General
Uncommon in Canada.
May lead to fetal demise.
Microscopic
Feature:
RBCs with basophilic dots ~1-2 micrometres.
Image
Maternal malaria - very

high mag. (WC)
Tumours
Main article: Gestational trophoblastic disease
Chorangioma
Main article: Chorangioma
Chorangiomatosis
General
Associated with:
Preeclampsia.
IUGR.
Gross
Multiple tan nodules.
Microscopic
Features:
Multiple chorangiomas - the difference between chorangioma and chorangiomatosis is not well defined.[51]
Images:
Chorangiomatosis - several images (upmc.edu) (http://path.upmc.edu/cases/case655.html).
Chorangiosis
Main article: Chorangiosis
Other
Fetus papyraceus
May be spelled foetus papyraceus.
AKA fetus compressus.
Main article: Fetus papyraceus
Placental mesenchymal dysplasia

Abbreviated PMD.
Main article: Placental mesenchymal dysplasia
Placental cysts and pseudocysts

Types:[52]
Amnionic epithelial inclusion cyst (amniotic cyst).

Epidermal inclusion cyst - lined by keratinized squamous epithelium.
Chorionic cyst (AKA chorionic pseudocyts).
Cell island cyst.
Other considerations:[53]
Hematoma.
Fibrin-lined pseudocyst.
General:[53]
Usually good outcome.

Large cysts (>4.5 cm) or multiple cysts (>3) are associated with IUGR.
Images:
Subchorionic cysts (jultrasoundmed.org) (http://www.jultrasoundmed.org/content/21/6/641/F5.expansion.ht

ml).[53]
See also
Chorionic villi.
Endometrium.
Pregnancy.
Gestational trophoblastic disease.
TORCH infections.
References
PMID 21393870 (http://www.ncbi.nlm.nih.gov/pubme
1. Sun, CC.; Revell, VO.; Belli, AJ.; Viscardi, RM. (Jun d/21393870).
2002). "Discrepancy in pathologic diagnosis of 10. URL: http://zulekhahospitals.com/uploads/files/Sub-
placental lesions.". Arch Pathol Lab Med 126 (6): 706- chorionic.pdf. Accessed on: 17 August 2012.
9. doi:10.1043/0003- 11. J Anat. Soc. India 49(2) 149-152 (2000). Available at:
9985(2002)1260706:DIPDOP2.0.CO;2 (http://dx.doi.or http://www.indmedica.com/anatomy/aindex1.cfm?
g/10.1043%2F0003-9985%282002%291260706%3AD anid=41. Accessed on: January 21, 2009.
IPDOP2.0.CO%3B2). PMID 12033960 (http://www.nc 12. Winters R, Waters BL (December 2008). "What is
bi.nlm.nih.gov/pubmed/12033960). adequate sampling of extraplacental membranes?: a
2. Yetter JF (March 1998). "Examination of the placenta". randomized, prospective analysis". Arch. Pathol. Lab.
Am Fam Physician 57 (5): 1045–54. PMID 9518951 (h Med. 132 (12): 1920–3. PMID 19061291 (http://www.n
ttp://www.ncbi.nlm.nih.gov/pubmed/9518951). cbi.nlm.nih.gov/pubmed/19061291).
3. Hargitai B, Marton T, Cox PM (August 2004). "Best 13. Lester, Susan Carole (2005). Manual of Surgical
practice no 178. Examination of the human placenta" Pathology (2nd ed.). Saunders. pp. 461. ISBN 978-
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC17704 0443066450.
00/). J. Clin. Pathol. 57 (8): 785–92. 14. CS. 7 February 2011.
doi:10.1136/jcp.2003.014217 (http://dx.doi.org/10.113 15. AFIP Placental pathol. ISBN: 1-881041-89-1. P.312
6%2Fjcp.2003.014217). PMC 1770400 (http://www.pu 16. AFIP Placental pathol. ISBN: 1-881041-89-1. P.312
bmedcentral.gov/articlerender.fcgi?tool=pmcentrez&art 17. Fox, Harold; Sebire, Neil J. (2007). Pathology of the
id=1770400). PMID 15280396 (http://www.ncbi.nlm.ni Placenta (Major Problems in Pathology) (http://www.a
h.gov/pubmed/15280396). mazon.com/Pathology-Placenta-Major-Problems/dp/14
//www.ncbi.nlm.nih.gov/pmc/articles/PMC1770400/. 16025928/ref=sr_1_fkmr0_1?ie=UTF8&qid=1297259
4. URL: http://smj.sma.org.sg/5012/5012ra1.pdf. 619&sr=1-1-fkmr0) (3rd ed.). Saunders. pp. 559-561.
Accessed on: 11 February 2011. ISBN 978-1416025924.
5. Sherman C. 8 February 2011. 18. URL: http://quizlet.com/5793113/ob-flash-cards/.
6. URL: http://www.ncbi.nlm.nih.gov/sites/entrez? Accessed on: 13 January 2012.
Db=gene&Cmd=ShowDetailView&TermToSearch=5069. 19. Clarson, C.; Tevaarwerk, GJ.; Harding, PG.; Chance,
Accessed on: 7 July 2010. GW.; Haust, MD.. "Placental weight in diabetic
7. Sternberg, Stephen S. (1997). Histology for pregnancies.". Placenta 10 (3): 275-81. PMID 2771897
Pathologists (2nd ed.). Lippincott Williams & Wilkins. (http://www.ncbi.nlm.nih.gov/pubmed/2771897).
pp. 974. ISBN 978-0397517183. 20. Hindmarsh, PC.; Geary, MP.; Rodeck, CH.; Jackson,
8. Sternberg, Stephen S. (1997). Histology for MR.; Kingdom, JC. (Aug 2000). "Effect of early
Pathologists (2nd ed.). Lippincott Williams & Wilkins. maternal iron stores on placental weight and
pp. 977. ISBN 978-0397517183. structure.". Lancet 356 (9231): 719-23.
9. Narasimha, A.; Vasudeva, DS.. "Spectrum of changes PMID 11085691 (http://www.ncbi.nlm.nih.gov/pubme
in placenta in toxemia of pregnancy.". Indian J Pathol d/11085691).
Microbiol 54 (1): 15-20. doi:10.4103/0377-4929.77317 21. Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D
(http://dx.doi.org/10.4103%2F0377-4929.77317). (2008). The Washington Manual of Surgical Pathology
(1st ed.). Lippincott Williams & Wilkins. pp. 464. 35. Furuhashi, M.; Oda, H.; Nakashima, T. (Sep 2000).
ISBN 978-0781765275. "Hydrops of placental stem villi complicated with fetal
22. Hasegawa J, Farina A, Nakamura M, et al. (December congenital adrenal hyperplasia.". Arch Gynecol Obstet
2010). "Analysis of the ultrasonographic findings 264 (2): 101-4. PMID 11045335 (http://www.ncbi.nlm.
predictive of vasa previa". Prenat. Diagn. 30 (12-13): nih.gov/pubmed/11045335).
1121–5. doi:10.1002/pd.2618 (http://dx.doi.org/10.100 36. URL:
2%2Fpd.2618). PMID 20872421 (http://www.ncbi.nlm. http://www.med.yale.edu/obgyn/kliman/placenta/articles
nih.gov/pubmed/20872421). Accessed on: 28 May 2011.
23. Airas U, Heinonen S (April 2002). "Clinical 37. Baergen, Rebecca N. (2011). Manual of Pathology of
significance of true umbilical knots: a population-based the Human Placenta (2nd ed.). Springer. pp. 346.
analysis". Am J Perinatol 19 (3): 127–32. ISBN 978-1441974938.
doi:10.1055/s-2002-25311 (http://dx.doi.org/10.1055% 38. Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson;
2Fs-2002-25311). PMID 12012287 (http://www.ncbi.nl Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K.
m.nih.gov/pubmed/12012287). (2005). Robbins and Cotran pathologic basis of disease
24. Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 1106.
(2008). The Washington Manual of Surgical Pathology ISBN 0-7216-0187-1.
(1st ed.). Lippincott Williams & Wilkins. pp. 464. 39. Mills, Stacey E; Carter, Darryl; Greenson, Joel K;
ISBN 978-0781765275. Oberman, Harold A; Reuter, Victor E (2004).
25. CS. 7 February 2011. Sternberg's Diagnostic Surgical Pathology (4th ed.).
26. Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D Lippincott Williams & Wilkins. pp. 2311. ISBN 978-
(2008). The Washington Manual of Surgical Pathology 0781740517.
(1st ed.). Lippincott Williams & Wilkins. pp. 465. 40. Vedovato, S.; Zanardo, V. (Jun 2010). "
ISBN 978-0781765275. [Chorioamnionitis and inflammatory disease in the
27. Khong TY (December 2010). "Evidence-based premature newborn infant].". Minerva Pediatr 62 (3
pathology: umbilical cord coiling". Pathology 42 (7): Suppl 1): 155-6. PMID 21090086 (http://www.ncbi.nl
618–22. doi:10.3109/00313025.2010.520309 (http://dx. m.nih.gov/pubmed/21090086).
doi.org/10.3109%2F00313025.2010.520309). 41. Jacques, SM.; Qureshi, F. (Oct 1993). "Chronic
PMID 21080869 (http://www.ncbi.nlm.nih.gov/pubme intervillositis of the placenta.". Arch Pathol Lab Med
d/21080869). 117 (10): 1032-5. PMID 8215826 (http://www.ncbi.nl
28. PMID 16076615. m.nih.gov/pubmed/8215826).
29. Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D 42. Rota, C.; Carles, D.; Schaeffer, V.; Guyon, F.; Saura,
(2008). The Washington Manual of Surgical Pathology R.; Horovitz, J. (Nov 2006). "[Perinatal prognosis of
(1st ed.). Lippincott Williams & Wilkins. pp. 463. pregnancies complicated by placental chronic
ISBN 978-0781765275. intervillitis].". J Gynecol Obstet Biol Reprod (Paris) 35
30. Chew, RH.; Silberberg, BK. (Apr 1990). "Possible (7): 711-9. PMID 17088773 (http://www.ncbi.nlm.nih.
association of acute inflammatory exudate in gov/pubmed/17088773).
chorioamnionitis and amniotic squamous metaplasia.". 43. Sebire, NJ.; Backos, M.; Goldin, RD.; Regan, L. (May
Am J Clin Pathol 93 (4): 582-5. PMID 2321592 (http:// 2002). "Placental massive perivillous fibrin deposition
www.ncbi.nlm.nih.gov/pubmed/2321592). associated with antiphospholipid antibody syndrome.".
31. CS. 7 February 2011. BJOG 109 (5): 570-3. PMID 12066949 (http://www.nc
32. Adeniran, AJ.; Stanek, J. (Dec 2007). "Amnion bi.nlm.nih.gov/pubmed/12066949).
nodosum revisited: clinicopathologic and placental 44. Baergen, Rebecca N. (2011). Manual of Pathology of
correlations.". Arch Pathol Lab Med 131 (12): 1829-33. the Human Placenta (2nd ed.). Springer. pp. 327.
doi:10.1043/1543- ISBN 978-1441974938.
2165(2007)131[1829:ANRCAP]2.0.CO;2 (http://dx.do 45. Baergen, Rebecca N. (2011). Manual of Pathology of
i.org/10.1043%2F1543-2165%282007%29131%5B182 the Human Placenta (2nd ed.). Springer. pp. 367.
9%3AANRCAP%5D2.0.CO%3B2). PMID 18081444 ISBN 978-1441974938.
(http://www.ncbi.nlm.nih.gov/pubmed/18081444). 46. Marchetti, D.; Belviso, M.; Fulcheri, E. (Mar 2009). "A
33. URL: http://flylib.com/books/en/2.953.1.49/1/. case of stillbirth: the importance of placental
Accessed on: 10 January 2011. investigation in medico-legal practice.". Am J Forensic
34. Suzuki, S. (Feb 2008). "Clinical significance of Med Pathol 30 (1): 64-8.
pregnancies with circumvallate placenta.". J Obstet doi:10.1097/PAF.0b013e318187387e (http://dx.doi.org/
Gynaecol Res 34 (1): 51-4. doi:10.1111/j.1447- 10.1097%2FPAF.0b013e318187387e).
0756.2007.00682.x (http://dx.doi.org/10.1111%2Fj.144 PMID 19237859 (http://www.ncbi.nlm.nih.gov/pubme
7-0756.2007.00682.x). PMID 18226129 (http://www.n d/19237859).
cbi.nlm.nih.gov/pubmed/18226129). 47. Stevens NG, Sander CH (October 1984). "Placental
hemorrhagic endovasculitis: risk factors and impact on
pregnancy outcome". Int J Gynaecol Obstet 22 (5): 50. Sherman, C. 7 February 2011.
393–7. PMID 6151926 (http://www.ncbi.nlm.nih.gov/p 51. URL: http://path.upmc.edu/cases/case655/dx.html.
ubmed/6151926). Accessed on: 28 January 2012.
48. Sander CM, Gilliland D, Akers C, McGrath A, Bismar 52. Baergen, Rebecca N. (2011). Manual of Pathology of
TA, Swart-Hills LA (February 2002). "Livebirths with the Human Placenta (2nd ed.). Springer. pp. 219-220.
placental hemorrhagic endovasculitis: interlesional ISBN 978-1441974938.
relationships and perinatal outcomes". Arch. Pathol. 53. Brown, DL.; DiSalvo, DN.; Frates, MC.; Davidson,
Lab. Med. 126 (2): 157–64. PMID 11825110 (http://w KM.; Genest, DR. (Jun 2002). "Placental surface cysts
ww.ncbi.nlm.nih.gov/pubmed/11825110). detected on sonography: histologic and clinical
49. Soma H, Yoshida K, Mukaida T, Tabuchi Y (1982). correlation.". J Ultrasound Med 21 (6): 641-6; quiz
"Morphologic changes in the hypertensive placenta". 647-8. PMID 12054300 (http://www.ncbi.nlm.nih.gov/
Contrib Gynecol Obstet 9: 58–75. PMID 6754249 (htt pubmed/12054300).
p://www.ncbi.nlm.nih.gov/pubmed/6754249).
Recommended reading
Langston C, Kaplan C, Macpherson T, et al. (May 1997). "Practice guideline for examination of the
placenta: developed by the Placental Pathology Practice Guideline Development Task Force of the College
of American Pathologists". Arch. Pathol. Lab. Med. 121 (5): 449–76. PMID 9167599 (http://www.ncbi.nlm.
nih.gov/pubmed/9167599).
Baergen, Rebecca N. (2005). Manual of Benirschke and Kaufmann's Pathology of the Human Placenta (htt
p://www.amazon.com/Manual-Benirschke-Kaufmanns-Pathology-Placenta/dp/0387220895/ref=sr_1_1?ie=
UTF8&qid=1297169019&sr=8-1) (1st ed.). Springer. ISBN 978-0387220895.
External links
Cord complications (emedicine.medscape.com) (http://emedicine.medscape.com/article/262470-overview).
Placenta notes (palpath.com) (http://www.palpath.com/MedicalTestPages/placenta2.htm).
Retrieved from "https://librepathology.org/w/index.php?title=Placenta&oldid=48989"
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12019/4/ Placenta - Libre Pathology

The placenta feeds the developing baby, breathes for it and

The organ is one that seems to be left behind; at least one

Placental pathology redirects to this article.

6.1 Two vessel umbilical cord

Indications for exam by pathology

Some indications for exam by a pathologist:

A more detailed list is given by Hargitai et al.[3] and Chang.[4]

Most common reasons for submitting a placenta to pathology:[5]

Bleeding in late pregnancy

Placental abruption (most common).

Clinical screening tests

PAPP-A - low values seen in aneuploidy.[6]

AKA vitelline duct.

Duct with benign looking cuboidal epithelium.

Allantoic duct remnant

Benign embryologic remnant.

Duct with benign looking flat epithelium.

Vitelline artery remnant

Small artery in the cord.

Next to fetus, surrounds amniotic fluid, avascular.

Characterized by a single layer of cells.[7]

Subchorionic fibrin deposition (ijpmonline.org) (http://www.ijpmonline.org/viewimage.asp?img=IndianJPat

Parenchymal nodules - a brief DDx:

Placental mass by gestational age:[15]

Gest. Age/Percentile 25% 50% 75%

Linear regression - placental mass-gestational age

50% 10% 90%

placental mass = slope x gestational age + intercept

Extrapolated from the linear regression (see above):

50% at term = 500 grams.

Maternal diabetes - esp. poorly controlled.[19]

Lame causes of a heavy placenta:

Dates wrong - error in determining the estimated date of confinement.

Most of causes seem to have one thing in common:

PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, CESAERIAN SECTION:

Placental growth restriction

AKA placenta small for gestational age.

Maternal vascular disease, e.g. hypertension.

PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, BIRTH:

Overview of placental pathology

Mnemonic: chorio, cord, vessels, villi (maturity, infarction).

PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, CAESAREAN SECTION:

Two vessel umbilical cord

Main article: Two vessel umbilical cord

The umbilical cord is attached to the placental disc at its margin.

Approximately 12% of placentas.[21]

None according to WMSP.[21]

The umbilical cord inserts into the fetal membranes.[21]

Increased risk of vasa previa.[22]

PLACENTA, UMBILICAL CORDS AND FETAL MEMBRANES, BIRTH:

Diameter measures and colour on both sides of the knot.

Lines of Zahn (utah.edu) (http://library.med.utah.edu/WebPath/ATHHTML/ATH031.html).

Squamous metaplasia of the amnion

Benign common finding thought to be of no clinical significance.[29]

White (or yellow) plaques - irregular outline.

Amnion nodosum - small (~1-5 mm), round, classically yellow.

Amnion nodosum & squamous metaplasia of the amnion (archivesofpathology.org) (http://www.archivesofp

Dense, paucicellular (pink) compact keratin - key feature.

Squmous metaplasia of the amnion (flylib.com) (http://flylib.com/books/2/953/1/html/2/43%20-%20Placent

May be associated with placental abruption.[34]

Membranes usually attach to the edge of the placenta.

Partial - not circumferential.

Circumvallate placenta - partial and complete (utah.edu) (http://library.med.utah.edu/nmw/mod2/Tutorial2/pi