PLACENTAL ABNORMALITIES

NORMAL TERM PLACENTA

• Weight: 470 grams
• Shape: Round to oval
• Diameter: 22 cm
• Central thickness: 2.5 cm
• Width: 2-4 cm
Composition: • Maternal surface: adherent to myometrium
• Umbilical cord (2 arteries, 1 vein) • Fetal surface: shiny, exposed to amniotic fluid and
• Placental disc chorionic plat
• Extraplacental membranes

ABNORMALITIES IN SHAPE AND SIZE

Abnormality
Placenta Bipartite/Bilobate
Placenta
Triplex/Multilobate
Succenturiate Placenta
Placenta Membranacea
Ring-Shaped Placenta
Placenta Fenestrate
Placentomegaly
Appearance Complications
Separate, nearly equally sized discs Incomplete division. Vessels
from both lobes unite to form
3 or more equally sized lobes the umbilical cord.
1 or more smaller accessory lobes that develop from a distance at Vasa Previa – can l/t fetal
the periphery of the main placenta hemorrhage
All or nearly all of the membranes and uterine cavity are covered by Associated w/ placenta previa or
functioning villi accrete → hemorrhage
Antepartum & postpartum bleeding
Has a partial or complete ring of placental tissue.
Fetal growth restriction
Missing central portion of placental disc. Chorionic plate still intact. Mistaken as retained placenta.
• Placental thickness > 40mm d/t striking villous enlargement →
contains blood and fibrin
• Maternal etiologies: Diabetes, severe anemia
• Fetal etiologies: Hydrops, anemia, syphilis, toxoplasmosis,
parvovirus CBV

EXTRACHORIAL PLACENTATION
• The fetal membranes do not insert at the edge of the placenta but rather at some point inwards.
• Result: Chorionic plate (fetal) is smaller than the basal plate (maternal) [normal: basal plate is wider]
• Chorionic plate periphery thickened, opaque, gray-white
circular ridge composed of a double fold of chorion and
CIRCUMVALATTE amnion.
placenta • Cross section: Appear as two “shelves”
• US: Thick linear band of echoes extending from one
placental edge to the other
• Chorion and amnion are folded upon themselves at the
placental margin leaving a part of the placenta uncovered at
the periphery.
CIRCUMMARGINATE
• Central depression on the fetal surface surrounded by a
placenta
greyish white thickened ring at the periphery
• Fibrin and old hemorrhage – lie between the placental
disc and the overlying amniochorion

ABNORMAL PLACENTAL LOCATION

PLACENTA PREVIA Placenta covers the opening of the cervix
ABNORMAL PLACENTAL ADHERENCE: PLACENTA ACCRETE, INCRETA, PERCRETA
• Variations of trophoblastic invasion of the myometrium
PLACENTA ACCRETE Superficial attachment to myometrium

PLACENTA INCRETA Deeper invasion of myometrium

PLACENTA Placenta can invade even outside the myometrium (ex.

PERCRETA bladder, lateral side to uterine blood vessels) s

CIRCULATORY DISTURBANCES (MATERNAL BLOOD FLOW DISRUPTION)

Generalities Lesions
• Slowing of maternal blood flow WITHIN the intervillous White or yellow, firm, round, elevated
Subchorionic Fibrin Deposition
space plaques on the fetal surface

Pervillous Fibrin Deposition
Maternal Floor Infarction
Subchorionic Infarct
Intervillous Thrombus
Placental infarctions
Placental Vessel Thrombosis
Hematoma
Fetal Vascular Malperfusion
Villous Vascular Lesions
Subamnionic Hematoma
Placental Calcifications
Hypertrophic Lesions of
Chorionic Villi
Placental Inflammation
Syncytial Knots
• Stasis of maternal blood flow AROUND an individual
villous → ↓ villous oxygenation → necrosis of
Small, yellow-white placental nodules
syncytiotrophoblast.
• FGR – if deposition affects > 25% of villi
• Dense fibrinoid layer within the placental basal plate →
Thick, yellow or white, firm corrugated
impedes maternal blood flow into the intervillous space
surface
• Risks: Miscarriage, IUGR, preterm delivery, stillbirth
Found underneath the chorionic plate, extends
downwards to the intervillous space
Round, oval collections
• Collection of coagulated maternal blood
Red – recent; white to yellow - older
• Causes elevated MSAFP
Vary in size (up to several cm)
• Most common; may be normal or pathologic
• Location: Placental margin (90%) Calcification
• Occlusion of maternal uteroplacental circulation → Fibrinoid degeneration of trophoblast
diminished flow to intervillous space → infarction → Ischemic infarction
placental abruption
Stem artery (fetal circulation) is occluded Sharply demarcated area of vascualrity
Retroplacental – b/w placenta and adjacent decidua (ex.
placenta abruptio) Sonographically:
Marginal (Subchorionic) – b/w chorion and decidua at • 1st week after hemorrhage:
placental periphery Hyperechoic to isoechoic
Subamnionic – b/w placenta and amnion (beneath • 1 – 2 weeks after hemorrhage:
amnion, above chorionic plate) hypoechoic
Massive Subchorionic hematoma (Breus mole) – along • After 2 weeks: Anechoic
the roof of the intervillous place, beneath the chorionic plate
FETAL BLOOD FLOW DISRUPTION
• FETAL VESSEL THROMBOSIS – portions of villus DISTAL to the obstruction become infarcted
and nonfunctional
• If many villi are affected: fetal growth restriction, stillbirth, nonreassuring fetal heart rate patterns
• CHORANGIOSIS - ↑ number of capillaries within terminal villi (≥ 10 capillaries in ≥ 10 villi in ≥ 10
fields viewed through 10x lens)
• FOCAL CHORANGIOSIS - ↑ capillaries in a significant portion, NOT diffusely
• CHORANGIOMATOSIS - ↑ capillary in stem villi, NOT in terminal villi
B/w placenta and amnion (chorionic plate and amnion)
OTHERS
• Calcium salts deposition on maternal surface in basal plate → seen as hyperechoic deposits
• Risk factors: smoking, higher maternal serum calcium levels
Striking enlargement of chorionic villi
• (+) Degenerative and necrotic changes
• Bacteria invade fetal surface of placenta
• Clumps of syncytial nuclei → project into intervillous space
• Represents apoptosis, begins after 32 weeks
 PLACENTAL TUMORS
Chorioangioma (Hemangioma) Tumors Metastatic to Placenta
• Only BENIGN tumor of placenta • Maternal malignant tumors rarely metastasize to the placenta
• ↑ Maternal serum AFP • Most common:
• Components: Resemble blood vessels and stroma of chorionic villi ✓ Melanoma – most common
• Small: asymptomatic ✓ Leukemia
• Large (> 5cm) – arteriovenous shunting within the placenta → ✓ Lymphoma
high-output heart failure, hydrops, fetal death ✓ Breast cancer
• Diagnosis: Grayscale and color Doppler, MSAFP level, Kleihauer- • Tumors usually confined to intervillous space
Betke stain
• US: Well-circumscribed, rounded, predominantly hypoechoic,
seen near the chorionic plate, protruding into the amniotic cavity
• Management: Reduced blood flow to tumor, vessel occlusion,
ablation

ABNORMALITIES OF THE MEMBRANES

Meconium Staining Chorioamnionitis
• Risk increases at >42 weeks • Infection of chorionic plate and umbilical cord
• (+) Staining of amnion: 1 – 3 hours → chorion, umbilical cord → • Routes of infection:
decidua ✓ Ascending infection: from LGT
• Fetal hypoxia → anal sphincter relaxation and fetal gasping ✓ Hematogenous spread from maternal blood
→ aspiration of meconium in utero → Meconium Aspiration ✓ Direct spread from endometrium or FT
Syndrome ✓ Swallowing
Small Amniotic Cyst Amnion Nodosum
• Fusion of amnionic folds with subsequent fluid retention • HALLMARK OF OLIGOHYDRAMNIOS
• Small, light tan nodules fixed to the amnion → may be scraped off
• Made up of: vernix caseosa with hair, sebum, desquamated
squames
Amnionic Band Sequence Amnionic Sheets
• D/t disruption of amnion. Amnion bands tether, constrict and • Normal amniochorion draped over preexisting uterine synechia
amputate fetal parts • Pose little fetal risk
• Consequence: Fetal intrauterine amputation

ABNORMALITES OF THE UMBILICAL CORD

• Influenced by amniotic fluid, volume, fetal mobility, heredity Long cord can l/t:
Cord length • Short cord: • Maternal distress
(40 – 70cm) ✓ Associated w/ oligohydramnios, slow fetal movement • Delivery complications
✓ Can l/t: FGR, malformation, fetal and fetal death • Fetal distress, anomalies, mortality
• Predictive fetal marker
Cord Diameter • Lean → poor fetal growth
• Large diameter → macrosomia
HYPERCOILING (UCI >90th percentile)
• Umbilical Coiling Index (UCI) – # of complete coils per 1
• FGR
cm of cod length
Cord Coiling • Intrapartum fetal acidosis & asphyxia
• HYPOCOILING (UCI <10th percentile) → fetal distress,
• Preterm delivery
meconium staining, preterm birth, fetal demise
• Cocaine abuse
• Most common aberration
Single Umbilical Artery • Etiology: ATROPHY of normal umbilical artery
(SUA) • Detection: Ultrasound at 17 – 36 weeks AOG
• Associated w/: spontaneous abortion, renal aplasia, limb-reduction defects, atresia of hollow organs
• Connection b/w 2 umbilical arteries 3 cm from the cord’s insertion to the placenta
Hyrtl Anastomosis
• Function: Equalize pressures between the arteries → improves placental perfusion (not seen in SUA)
• Umbilical artery fails to split (fused shared lumen) during embryological development → Complete or
Fused Umbilical Artery Partial
• Not associated w/ congenital anomalies
IMPENDS BLOOD FLOW
False Knots True Knots
• Knobs protruding from the cord • Can cause fetal hypoxia → death
KNOTS • Etiology: Focal redundancies and folding of • Etiology: active fetal movement
umbilical vessel or Wharton jelly • US: “hanging noose” sign
• NO clinical significance • Increased risk of stillbirth, FHR abnormalities
 • Etiology: Coiling around various fetal parts during movement
LOOPS • NUCHAL CORD – looped around neck
• Can cause deceleration during labor → associated w/ ↓ umbilical artery pH
• Presenting part: Umbilical cord
Funic Presentation • Can present with: Cord prolapse, FHR abnormalities
• Delivery: CS
• Focal narrowing of the diameter of the cord, develops near the cord insertion site
Cord Stricture • Pathologic features at narrow segment: (-) Wharton jelly & stenosis/obliteration of cord vessels
• Fetus is stillborn

ABNORMALITIES OF CORD INSERTION

• Battledore placenta
Marginal Insertion
• Cord inserts at the MARGIN of the placenta
• Umbilical vessels lose Wharton jelly SHORTLY BEFORE insertion → covered only by amnion sheath →
Furcate Insertion prone to compression, twisting, thrombosis
• Umbilical vessels branch like tines of a fork before the cord inserts into the chorionic plate (fetal side)
• The last few centimeters of the umbilical cord entering the placenta are lose Wharton jelly.
Vilamentous Insertion
• The vessels are “exposed” and covered only by the fetal membranes.
• Vessels lie between the cervix and the presenting fetal part
• Complications:
Vasa Previa
✓ Laceration of vessels with cervical dilatation or membrane rupture → l/t rapid fetal exsanguination
✓ Vessel compression → fetal anoxia

Figure (left to right): Marginal insertion, Furcate insertion, Vilamentous insertion, Vasa previa

VASCULAR
• Rare; occurs AFTER rupture of umbilical vein (usually) → hemorrhages into Wharton jelly
Hematoma • US: Hypoechoic mass that lack blood flow
• Can l/t: Stillbirth, intrapartum abnormal FHR pattern
True Cysts Pseudocysts
• Remnants of allantoic or vitelline ducts lined by • From local degeneration of Wharton jelly
Cysts
epithelium • Occurs ANYWHERE along the cord
• Found near insertion site of cord
• Rare
Umbilical Cord Vessel
• Most common: Venous thrombosis (70%) – has lower perinatal mortality
Thrombosis
• Arterial thrombosis - FGR
Umbilical Vein Varix Umbilical Artery Aneurysm
• Marked focal dilation • Rare
• Develop within the intra-amnionic or fetal intra- • D/t congenital thinning of the arterial wall with
abdominal portion of the umbilical vein diminished support from Wharton jelly
Vessel Dilatation • Increased risk for: IUFD, structural anomalies, • Location: At or near the placental insertion point
aneuploidy of the cord
• Common complications: varix rupture or • Associated with: SUA, Trisomy 21
thrombosis, compression of umbilical artery, fetal • Complication: Compression of umbilical vein →
cardiac failure fetal death

• Result of: Trophoblastic aging or infection

Degenerative Placental
• Smokers, increases as pregnancy progresses
Lesions
• Deliver within 38 – 39 WEEKS, should NOT be > 40 weeks
 Normal (central)
insertion of UC

Bilobar placenta with

central insertion of
umbilical cord

Placenta
circumvallate with
marginal insertion

Velamentous
insertion

Sources:
• Chismis buddy trans
• Doc L cheatsheet
• Williams 26th ed
• NCBI
• https://www.humpath.com/spip.php?article4673