PLACENTAL

ABNORMALITIES
Normal Placenta
- Weight: 470g
- Shape and Size: round to oval with 22cm diameter
o Central thickness – 2.5cm
- Composition:
o Placental disc
o Extraplacental membranes
o Three-vessel umbilical cord
- Maternal Surface – basal plate
o Clefts
 Divides the placenta into portions
(cotyledons)
 Site of internal septa which extend into
the intervillous space
- Fetal Surface – chorionic plate
o Where the umbilical cord inserts (at the center)
o Covered by thin amnion
- Increases in thickness during pregnancy (1mm per week)
but does not exceed 40mm
Abnormalities of the Placenta
o Placentomegaly - >40mm thickness; secondary SHAPE AND SIZE
to: Complication
 Maternal DM Bilobate - Placenta form as a
 Severe maternal anemia Placenta/ separate, nearly
 Fetal hydrops Bipartite equally sized disc
 Infection (syphilis, toxoplasma, CMV) placenta/ - Cord inserts
Placenta Duplex between two
 Collections of blood or fibrin
placental lobes
- Sonographic findings:
(either on a
o Homogenous and 2-4cm thick
connecting
o Lies against the myometrium and indents into the chorionic bridge or
amniotic sac intervening
o Retroplacental space (<1-2cm) is a hyperechoic membranes)
area that separates the myometrium from its

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Multilobate - Contains 3 or more -
basal plate placenta equally sized lobes
Succenturiate - Small accessory - Vasa previa
lobe lobes (if vessels
- Develops at a overlie the
distance from the cervix)
main placenta - Fetal
hemorrhage
- Postpartum
uterine atony
and

Williams Obstetrics 24th Edition

hemorrhage
Placenta - Fetal membranes - Placenta
membranacea are covered by a previa or
functioning villi accreta
- Hemorrhage
Ring-shaped - Variant of - Ante/post
placenta placenta partum
membranacea bleeding
- Placenta is annular - Fetal-growth
restriction
Placenta - Central portion of - Prompts
fenestrate a placental disc is search for a
missing retained
- Involves only villous placental
tissue (chorionic cotyledon
plate intact)

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EXTRACHORIAL PLACENTATION
- Chorionic plate fails to extend to the periphery of the
placenta
- Chorionic plate smaller than the basal plate
Circummarginate - Fibrin and old
placenta hemorrhage lie
between the placenta
and the overlying
amniochorion
Circumvallate - Peripheral chorion is a
placenta thickened, opaque,
gray-white circular
ridge composed of
double fold of chorion
and amnion (appears
as shelf on cross-
section)
PLACENTA ACCRETA, INCRETA, AND PERCRETA
- Develops when trophoblast invades the myometrium to
varying depths causing abnormal adherence
- Factors that increases incidence: Placenta previa and Prior
uterine incision or prforation
- Complication: torrential hemorrhage
CIRCULATORY DISTURBANCES
- 30% of placental villi can be lost without untoward fetal
effects
Maternal Blood Flow Disruption
Subchorionic - Caused by slowing of
Fibrin maternal blood flow
Deposition within the intervillous
space with subsequent
fibrin deposition
- Lesion: white or yellow
firm plaques on the
fetal surface
Preivillous - Caused by maternal
Fibrin blood flow stasis around
Deposition individual villus
Maternal Floor - Dense fibrinoid layer
Infarction within the placental
basal plate
- Associated with
thrombophillias
Intervillous - Collection of
thrombus coagulated maternal
blood normally found in
the intervillous space
mixed with fetal blood
from a break in a villus
Infarction - Associated with
preeclampsia or lupus
anticoagulant
Hematoma - Retroplacental:
between placenta and
adjacent decidua
- Marginal
(subchorionic):
between chorion and
decidua at the
periphery; no clinical
consequence
- Subchorial (Breus Mole):
along the roof of the
intervillous space and
beneath the chorionic
plate
- Subamnionic: fetal
vessel origin
PLACENTAL CALCIFICATION
- most commonly deposited on the basal plate
- grow with advancing gestation
- Associated with:
o Nulliparity
o Smoking
o High socioeconomic status
o Inc. maternal s. calcium
PLACENTAL TUMORS
Chorioangioma
Increased - Benign
risk of - Have components similar to blood vessels and stroma of
antepartum
the chorionic villi
bleeding
- Diagnostics:
and
preterm o MSAFP
birth o Sonogram: well circumscribed, rounded,
predominantly hypoechoic lesion near the
chorionic surface
o Increased blood flow by color Doppler –
distinguishes other placental masses
- Small: asymptomatic
- Large (>5cm) associated with significant AV shunting that
can cause fetal anemia and hydrops
Tumors metastatic to the Placenta
- Rare but most commonly:
o Melanoma***
o Leukemia
o Lymphoma
o Breast cancer
- Tumor cells usually are confined within the intervillous
space
Abnormalities of the Membranes
Meconium Staining
- Staining of the amnion obvious within 1-3hrs
- Passage of meconium cannot be timed or dated
accurately
Chorioamnionitis
- d/t prolonged membrane rupture
Miscarriage,
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fetal-growth - organisms initially infect the chorion and adjacent decidua
restriction, in the area overlying the internal os  full thickness
preterm del, involvement  chorioamnionitis  spread along the
stillbirths chorioamniotic plate  inflammation of the chorionic
Elevated s. AFP plate and of umbilical cord  funitis
- fetal infection:
o Hematogenous spread maternal bacteremia
o Aspiration or swallowing of infected amniotic fluid
o Direct contact wth infected amniotic fluid
- Possible explanation for unexplained cases of:
Placental Ruptured membranes
Williams Obstetrics 24th Edition
o
insufficiency
o Preterm labor
- Grossly: membrane clouding accompanied by a foul odor
Miscarriage
Amnion nodosum
Placental - Numerous small, light tan nodules on the amnion overlying
abruption – large the chorionic plate
retroplacental - Contains deposits of fetal squames and fibrin
hematoma - Reflects prolonged and severe oligohydramnios
Amniotic Band Sequence
Fetal-growth - Anatomic fetal disruption sequence caused by bands of
restriction amnion that entrap fetal structures and impair growth and
development
Preterm delivery - Etiology:
o Early rupture of amnion  adherence of fetus to
Adherent the underlying sticcky chorion
placenta
- Involves:
o Extremities  limb-reduction
o Cranium  encephalocele 2
Amniotic Sheet o 2nd tri placenta previa
- Formed by normal amniochorion draped over a - Examiner occasionally able to palpate of directly see a
preexisting uterine synechia tubular fetal vessel in the membranes overlying the
- Slight risk for preterm membrane rupture and placental presenting part
abruption - Diagnosis
Transvigal USD
Abnormalities of the Umbilical Cord o
o Color Doppler interrogation of the placental site
Normal:
insertion
- Length:
- Management
o 40-70 cm (some 32-100cm)
o Elective CS delivery at 34-35wks
o Influenced by amniotic fluid volume and fetal
Furcate Insertion
mobility
- Cord connection onto the placental disc is central, but
- Cord diameter – predictive marker for fetal outcomes
umbilical vessels loss their protective Wharton jelly shortly
- Umbilical vessels
before they insert
o spiral through the cord in a left-twisting direction
- Prone to:
o 2 thick-walled arteries
o Compression
o 1 thin, larger umbilical vein
o Twisting
- Umbilical coiling index:
Knots
o Via antepartum sonogram: 0.4
True Knots
o Via postpartum actual measurement: 0.2
- caused by fetal movements
Length
- common in monoamniotic twins
- Short Cords
- Complications: In singleton: Inc risk of Stillbirth (4-10x)
o Associated with
False Knots
 Fetal growth restrictions
- No clinical significance
 Congenital malformations
- Focal redundancies of a vessel or Wharton jelly
 Intrapartum distress
Strictures
 Increased risk of death (2x)
- Focal narrowing of its diameter
- Long Cords
- Usually develops near the fetal cord insertion
o Associated with:
- Pathological features:
 Cord entanglement
o absence of Wharton jelly
 Prolapse
o obliteration of cord vessels at the narrow segment
 Fetal anomalies, acidemia, and demise
Cord Loops
 Macrosomia
- cause: coiling around various fetal parts during movement
Coiling
- Common in longer cords
- Hypocoiling – linked with fetal demise
- Complication
- Hypercoiling – fetal-growth restriction and intrapartum fetal
o FHR decelerations and Low umbilical artery pH
acidosis
Vascular
- Both have been reported in the setting of:
Cord Hematoma
o Trisomic fetus
- Associated with:
Single umbilical artery

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o
o Abnormal cord length
Vessel Number
o Umbilical vessel aneurysm
- Most common abnormality: single umbilical artery
o Trauma; Entanglement
o When seen, aneuploidy risk is increased
o Umbilical vessel venipuncture; Funitis
o Most common anomalies associated:
- Usually the umbilical vein
 CVS and Genitourinary
Cord Vessel thromboses
- Fused umbilical artery with a shared lumen
- 70% venous; 20% both; 10% arterial
o Associated with marginal or velamentous cord
- Arterial thromboses have higher perinatal morbidity and
insertion
mortality and associated with fetal-growth restrictions, fetal
Remnants and Cysts
acidosis, stillbirth
True Cyst – epithelium-lined remnants of the allantoic or vitelline

Williams Obstetrics 24th Edition

Umbilical Vein Varix
ducts
- Marked focal dilatation that can be within either
Pseudocysts*** - local degeneration of of Wharton jelly
intraamniotic or fetal intraabdominka portion of the umb
Insertion
vein
Marginal Insertion/ battledore placenta
- Complication:
- Cord anchors at the placental margin
o Rupture or thrombosis
- More frequent with multifetal pregnancy
o Compression of umb artery
Velamentous Insertion
o Fetal cardiac failure (d/t inc preload)
- Umbilical vessels spread within the membranes at a
Umbilical artery aneurysm
distance from the placental margin
- Congenital thinning of the vessels wall with diminished
- Vessels are vulnerable to compression  fetal
support from Wharton jelly
hypoperfusion and acidemia
- Most form at or near the cords placental insertion (where
- Commonly seen with placenta previa and multifetal
support is absent)
gestations
- Associated with:
Vasa previa
o Single umb artery
- Variant of velamentous insertion
o Trisomy 18
- Vessels within the membranes overlie the cervical os
o AFV abnormalities fetal-grwoth restrictions
- Risk factors:
o Stillbirth 3
o Bilobate or succenturiate placenta