Placental Pathology

The Basics and Practical Approach

Juan Putra, MD
Department of Pathology
Boston Children’s Hospital/ Harvard Medical School
 Outline

• Placental examination
– Indications
– Normal anatomy and histology
– Gross examination
– Selected pathology
– Pathology report examples
Why send placentas to pathology?

• To identify findings that are:

– Relevant to the immediate care of the mother or baby
– Predictive of possible recurrence that could guide care in
subsequent pregnancies
– Helpful to explain adverse pregnancy outcomes
– Important in medicolegal investigation of perinatal
mortality and long-term morbidity
When do we examine placenta?
Maternal condition

Fetal condition

Meserve EE et al. In: Diagnostic Gynecologic and Obstetric Pathology. 2017

Naeye RL: Disorders of the placenta, fetus and neonate: diagnosis and clinical significance. St. Louis, 1992, Mosby.
Normal anatomy and histology

Placental disk

Umbilical cord

https://library.med.utah.edu/WebPath/PLACHTML/PLAC031.html
Normal anatomy and histology

L.M. Ernst et al. (eds.), Color Atlas of Fetal and Neonatal Histology.2011
Umbilical cord

L.M. Ernst et al. (eds.), Color Atlas of Fetal and Neonatal Histology.2011
6 weeks

L.M. Ernst et al. (eds.), Color Atlas of Fetal and Neonatal Histology.2011
14 weeks

L.M. Ernst et al. (eds.), Color Atlas of Fetal and Neonatal Histology.2011
21 weeks

L.M. Ernst et al. (eds.), Color Atlas of Fetal and Neonatal Histology.2011
32 weeks

L.M. Ernst et al. (eds.), Color Atlas of Fetal and Neonatal Histology.2011
39 Weeks

L.M. Ernst et al. (eds.), Color Atlas of Fetal and Neonatal Histology.2011
6 6 14

21 32 39

21 39
Gross examination

Meserve EE et al. In: Diagnostic Gynecologic and Obstetric Pathology. 2017

 Gross description

• Placental weight
• Placental disk dimensions
• Description of umbilical cord
• Description of membrane
• Description of the placental disk
– Fetal surface
– Maternal surface
– Lesions (infarct, hemorrhage, thrombus, etc)
Significance of placental weight

Meserve EE et al. In: Diagnostic Gynecologic and Obstetric Pathology. 2017

Yee Khong T et al. Arch Pathol Lab Med. 2016;140:698–713
How many sections to submit?

+ FOCAL LESIONS
Meserve EE et al. In: Diagnostic Gynecologic and Obstetric Pathology. 2017
Meserve EE et al. In: Diagnostic Gynecologic and Obstetric Pathology. 2017
 Chorioaminonitis
Opaque membrane

Meserve EE et al. In: Diagnostic Gynecologic and Obstetric Pathology. 2017

Prolonged meconium staining
Green membrane

Meserve EE et al. In: Diagnostic Gynecologic and Obstetric Pathology. 2017

Marginal and membranous cord insertion

Meserve EE et al. In: Diagnostic Gynecologic and Obstetric Pathology. 2017

 Hypercoiled and hypocoiled umbilical cord

Normal: 2 coils per 10 cm

Yee Khong T et al. Arch Pathol Lab Med. 2016;140:698–713
 Abruptio placenta
Large retroplacental blood

https://library.med.utah.edu/WebPath/PLACHTML/PLAC072.html
Placental infarction

https://library.med.utah.edu/WebPath/PLACHTML/PLAC023.html
Extensive perivillous fibrin

Meserve EE et al. In: Diagnostic Gynecologic and Obstetric Pathology. 2017

 Selected placental pathology

• Amniotic fluid infection

• Infectious cases:
– Candida sp.
– Listeria sp.
– Cytomegalovirus
• Fetal vascular malperfusion
• Villous hypervascular lesions
Amniotic fluid infection

Chorioamnionitis
 Intrauterine infection

• Four main routes:

– Ascending infection from cervix, vagina, and
perineum (most common)
– Hematogeneous maternal-to-fetal spread
– Iatrogenic (via invasive techniques)
– Retrograde spread (through fallopian tubes)
 Acute chorioamnionitis

• The most common histologic diagnosis made in

placentas sent for histologic evaluation
– 67% preterm placentas
– 21-24% term placentas

• Associated complications:
– 66-75% of women are asymptomatic
– Maternal or fetal sepsis
– Premature membrane rupture
• Preterm labor
– Adverse long-term neurodevelopmental outcome
 Histology

• Maternal inflammatory response

– Subchorionitis
– Chorioaminonitis
• Fetal inflammatory response
– Umbilical phlebitis, arteritis
– Necrotizing funisitis
Migration of neutrophils

Kim CJ et al. Am J Obstet Gynecol. 2015; 213: S29-52

Maternal inflammatory response

Subchorionitis Acute chorioamnionitis

Yee Khong T et al. Arch Pathol Lab Med. 2016;140:698–713

Fetal inflammatory response

Umbilical phlebitis Umbilical arteritis

Kim CJ et al. Am J Obstet Gynecol. 2015; 213: S29-52

Fetal inflammatory response

Funisitis (perivasculitis)
Kim CJ et al. Am J Obstet Gynecol. 2015; 213: S29-52
Yee Khong T et al. Arch Pathol Lab Med. 2016;140:698–713;
 Selected placental pathology

• Amniotic fluid infection

• Infectious cases:
– Candida sp.
– Listeria sp.
– Cytomegalovirus
• Fetal vascular malperfusion
• Villous hypervascular lesions
Mode of placental/neonatal infection

Infectious agent Ascending Hematogeneous

Bacteria • Group B Streptococcus • Listeria sp.
• Escherichia coli • Treponema sp.

Viruses Rare • Cytomegaloviruses

• Parvovirus B19

Parasites Rare • Toxoplasmosis

• Trypanosoma cruzi
Fungi • Candida sp.
 Candida infection

• 80% due to Candida albicans

• 20-50% of pregnant women have candidal
colonization
• Identification of Candida funisitis in a premature
placenta is critical  neonatology should be notified
– Prematurity <28 weeks  increased incidence of
disseminated disease and mortality
• Ancillary test: GMS
 Umbilical cord

GMS
Meserve EE et al. In: Diagnostic Gynecologic and Obstetric Pathology. 2017
 Listeria infection
• Food-borne illness, unpasteurized milk products and
deli meats
• Facultative anaerobic, motile, gram-positive
• May account for up to 3% of 2nd trimester abortions
• Amniotic fluid appears meconium-stained, even in
extreme prematurity
Listeria sp. – parenchymal microabscess

https://library.med.utah.edu/WebPath/PLACHTML/PLAC034.html
Meserve EE et al. In: Diagnostic Gynecologic and Obstetric Pathology. 2017
 CMV infection

• Most common congenital viral infection (1-2%

newborns)
• 85-90% of infected infants are asymptomatic
• Leading cause of brain injury and sensorineural
hearing loss in children
• CNS involvement, pancytopenia, prematurity,
hydrops, IUFD and IUGR
• Ancillary test: immunostain and PCR
 CMV infection
Hydrops (edema) Viral inclusions

https://library.med.utah.edu/WebPath/PLACHTML/PLAC083.html
 Selected placental pathology

• Amniotic fluid infection

• Infectious cases:
– Candida sp.
– Listeria sp.
– Cytomegalovirus
• Fetal vascular malperfusion
• Villous hypervascular lesions
 Fetal vascular malperfusion
• Obstruction in fetal blood flow secondary to:
– Umbilical cord abnormalities
– Hypercoagulability
– Fetal cardiac dysfunctions (hypoxia)
• Fetal vascular malperfusion has been associated with:
– Fetal growth restriction
– Intrauterine fetal demise
– Thromboembolic events/necrosis of multiple fetal organs
– Obstetric complications (nonreassuring fetal heart tracing,
need for emergency delivery procedures)
 Fetal vascular malperfusion

• Pathologic findings consistent with fetal vascular

malperfusion:
– Vascular intramural fibrin deposition and thrombosis
– Stem vessel obliteration/fibromuscular sclerosis
– Vascular ectasia
– Segmental avascular villi
– Villous stromal-vascular karyorrhexis
 Possible etiologies

Marginal insertion
Hypercoiled cord

Heider A. Arch Pathol Lab Med. 2017; 141(11): 1484-9

 Thrombus in chorionic vessels

Stem vessel obliteration Fibrin thrombus

Heider A. Arch Pathol Lab Med. 2017; 141(11): 1484-9
 Avascular villi

Terminal villi showing total loss of villous capillaries and bland hyaline fibrosis of the villous stroma

Yee Khong T et al. Arch Pathol Lab Med. 2016;140:698–713

Villous Stromal-Vascular Karyorrhexis

Three or more foci of 2 to 4 terminal villi showing karyorrhexis of fetal cells (nucleated erythrocytes,
leukocytes, endothelial cells, and/or stromal cells) with preservation of surrounding trophoblast

Heider A. Arch Pathol Lab Med. 2017; 141(11): 1484-9

Yee Khong T et al. Arch Pathol Lab Med. 2016;140:698–713
 Selected placental pathology

• Amniotic fluid infection

• Infectious cases:
– Candida sp.
– Listeria sp.
– Cytomegalovirus
• Fetal vascular malperfusion
• Villous hypervascular lesions
– Chorangioma
– Chorangiosis
 Chorangioma

• Placental hemangioma
• Incidence rate: 0.5-1% of all placentas
• Develops during 32-37 weeks gestation
• Size matters
– Small – asymptomatic
– Medium and large – fetal growth restriction
• Preterm delivery
• Fetal hydrops (arteriovenous shunting)
• Platelet trapping (fetal thrombocytopenia, hemorrhage)
Chorangioma

http://www.webpathology.com/image.asp?n=3&Case=581
 Chorangiosis

• >10 fields of placental parenchyma with >10 terminal

villi, each containing >10 capillaries
• Adaptive response to chronic placental
underperfusion
– Diabetes
– Eclampsia
– Higher elevations
– Anemia
• Clinical significance is unclear
Chorangiosis

Meserve EE et al. In: Diagnostic Gynecologic and Obstetric Pathology. 2017

 Pathology report example

Placenta, delivery:
• Small mature placenta (306 gm), less than 10th
percentile for gestational age of 37 weeks
• Inflammation characteristic of amniotic fluid
infection:
– Maternal inflammatory response:
• Acute chorioamnionitis
– Fetal inflammatory response:
• Umbilical cord vasculitis
• Chorionic plate vasculitis
 Pathology report example

Singleton placenta, removal following fetal demise

at 21 weeks:
• Immature placenta (127 grams), within normal weight for
21 weeks
• Features of fetal vascular malperfusion:
– Hypercoiled trivascular umbilical cord (25.5 cm) with focal
torsion (predisposing condition)
– Chorionic and stem vessel ectasia, widespread
– Stem vessel obliteration, widespread
– Avascular villi, multifocal
– Normoblastemia
• Abundant villous trophoblast pseudoinclusions
Thank you