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The '''placenta''' feeds the developing baby, breathes for it and disposes of its waste. | [[Image:Human_placenta.jpg|thumb|right|A placenta (fetal aspect) with attached umbilical cord. (WC/Asturnut)]] | ||
The '''placenta''' feeds the developing baby, breathes for it and disposes of its waste. | |||
=Clinical= | The organ is one that seems to be left behind; at least one review suggests it isn't done so well by general pathologists.<ref name=pmid12033960>{{Cite journal | last1 = Sun | first1 = CC. | last2 = Revell | first2 = VO. | last3 = Belli | first3 = AJ. | last4 = Viscardi | first4 = RM. | title = Discrepancy in pathologic diagnosis of placental lesions. | journal = Arch Pathol Lab Med | volume = 126 | issue = 6 | pages = 706-9 | month = Jun | year = 2002 | doi = 10.1043/0003-9985(2002)1260706:DIPDOP2.0.CO;2 | PMID = 12033960 }}</ref> | ||
''Placental pathology'' redirects to this article. | |||
=Clinical= | |||
==Examination of the placenta== | ==Examination of the placenta== | ||
*Most placentas are ''not'' examined by a pathologist. | *Most placentas are ''not'' examined by a pathologist. | ||
===Indications for exam by pathology=== | |||
Some indications for exam by a pathologist: | Some indications for exam by a pathologist: | ||
*Abnormalities in the: | *Abnormalities in the: | ||
Line 10: | Line 16: | ||
*#*Bad fetal outcome. | *#*Bad fetal outcome. | ||
*#*Suspected or known congenital abnormalities ''or'' chromosomal abnormalities. | *#*Suspected or known congenital abnormalities ''or'' chromosomal abnormalities. | ||
*#*[[IUGR]]. | |||
*#Mother: | *#Mother: | ||
*#*Infection/suspected infection. | *#*Infection/suspected infection. | ||
*#*Pre-term labour. | *#*Pre-term labour. | ||
*#*Maternal disease (e.g. SLE, coagulopathy). | *#*Maternal disease (e.g. [[SLE]], coagulopathy). | ||
*#*Complicated pregnancy (preclampsia, pregnancy induced hypertension, gestational diabetes). | *#*Complicated pregnancy (preclampsia, pregnancy induced hypertension, gestational diabetes). | ||
*#Placenta: | *#Placenta: | ||
*#*Unusual gross characteristics.<ref name=pmid9518951>{{cite journal |author=Yetter JF |title=Examination of the placenta |journal=Am Fam Physician |volume=57 |issue=5 |pages=1045–54 |year=1998 |month=March |pmid=9518951 |doi= |url=}}</ref> | *#*Unusual gross characteristics.<ref name=pmid9518951>{{cite journal |author=Yetter JF |title=Examination of the placenta |journal=Am Fam Physician |volume=57 |issue=5 |pages=1045–54 |year=1998 |month=March |pmid=9518951 |doi= |url=}}</ref> | ||
A more detailed list is given by Hargitai et al.<ref name=pmid15280396>{{cite journal |author=Hargitai B, Marton T, Cox PM |title=Best practice no 178. Examination of the human placenta |journal=J. Clin. Pathol. |volume=57 |issue=8 |pages=785–92 |year=2004 |month=August |pmid=15280396 |pmc=1770400 |doi=10.1136/jcp.2003.014217 |url=}}</ref> | A more detailed list is given by Hargitai et al.<ref name=pmid15280396>{{cite journal |author=Hargitai B, Marton T, Cox PM |title=Best practice no 178. Examination of the human placenta |journal=J. Clin. Pathol. |volume=57 |issue=8 |pages=785–92 |year=2004 |month=August |pmid=15280396 |pmc=1770400 |doi=10.1136/jcp.2003.014217 |url=}}</ref> and Chang.<ref>URL: [http://smj.sma.org.sg/5012/5012ra1.pdf http://smj.sma.org.sg/5012/5012ra1.pdf]. Accessed on: 11 February 2011.</ref> | ||
====Most common==== | |||
Most common reasons for submitting a placenta to pathology:<ref>Sherman C. 8 February 2011.</ref> | |||
# Prematurity. | |||
# PROM / possible [[chorioamnionitis]]. | |||
# Multiple gestation. | |||
==Bleeding in late pregnancy== | ==Bleeding in late pregnancy== | ||
DDx of bleeding in late pregnancy: | DDx of bleeding in late pregnancy: | ||
*Placental abruption (most common). | *[[Placental abruption]] (most common). | ||
*Placenta previa. | *Placenta previa. | ||
*Vasa previa (fetus losing blood). | *Vasa previa (fetus losing blood). | ||
==Clinical screening tests== | ==Clinical screening tests== | ||
{{main|Pregnancy}} | |||
*PAPP-A - low values seen in aneuploidy.<ref>URL: [http://www.ncbi.nlm.nih.gov/sites/entrez?Db=gene&Cmd=ShowDetailView&TermToSearch=5069 http://www.ncbi.nlm.nih.gov/sites/entrez?Db=gene&Cmd=ShowDetailView&TermToSearch=5069]. Accessed on: 7 July 2010.</ref> | *PAPP-A - low values seen in aneuploidy.<ref>URL: [http://www.ncbi.nlm.nih.gov/sites/entrez?Db=gene&Cmd=ShowDetailView&TermToSearch=5069 http://www.ncbi.nlm.nih.gov/sites/entrez?Db=gene&Cmd=ShowDetailView&TermToSearch=5069]. Accessed on: 7 July 2010.</ref> | ||
==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= | =Normal histology= | ||
==Villi== | ==Villi== | ||
{{Main|Chorionic villi}} | {{Main|Chorionic villi}} | ||
This is dealt with in a separate article that also covers the types of trophoblast (cytotrophoblast, syncytiotrophoblast, intermediate trophoblast). | This is dealt with in a separate article that also covers the types of trophoblast ([[cytotrophoblast]], [[syncytiotrophoblast]], intermediate trophoblast). | ||
==Cord== | ==Cord== | ||
Line 55: | Line 76: | ||
==Membranes== | ==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=== | ===Amnion=== | ||
General: | General: | ||
Line 80: | Line 107: | ||
*Has blood vessels. | *Has blood vessels. | ||
*Opposed to "trophoblastic X cells" on side opposite of amnion.<ref name=Ref_H4P2_974>{{Ref H4P2|974}}</ref> | *Opposed to "trophoblastic X cells" on side opposite of amnion.<ref name=Ref_H4P2_974>{{Ref H4P2|974}}</ref> | ||
**Beneath of the "trophoblastic X cells" is ''decidua'' (mnemonic ''NEW'' = nucleus central, eosinophilic, well-defined cell border), which is maternal tissue. | **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.<ref name=pmid21393870>{{Cite journal | last1 = Narasimha | first1 = A. | last2 = Vasudeva | first2 = DS. | title = Spectrum of changes in placenta in toxemia of pregnancy. | journal = Indian J Pathol Microbiol | volume = 54 | issue = 1 | pages = 15-20 | month = | year = | doi = 10.4103/0377-4929.77317 | PMID = 21393870 |URL = http://www.ijpmonline.org/article.asp?issn=0377-4929;year=2011;volume=54;issue=1;spage=15;epage=20;aulast=Narasimha }}</ref><ref>URL: [http://zulekhahospitals.com/uploads/files/Sub-chorionic.pdf http://zulekhahospitals.com/uploads/files/Sub-chorionic.pdf]. Accessed on: 17 August 2012.</ref> | |||
***The pathologic counterpart of this is ''[[perivillous fibrin deposition]]''. | |||
Image: | |||
*[http://www.ijpmonline.org/viewimage.asp?img=IndianJPatholMicrobiol_2011_54_1_15_77317_u5.jpg Subchorionic fibrin deposition (ijpmonline.org)]. | |||
==Common terms== | ==Common terms== | ||
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***Membranous or velamentous (veil-like) insertion. | ***Membranous or velamentous (veil-like) insertion. | ||
****Vessels separate/branch prior to reaching placental disc. | ****Vessels separate/branch prior to reaching placental disc. | ||
***Furcate insertion - | ***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). | **Knots (false vs. true). | ||
***False knots are nothing to worry about -- look like a knot but aren't really one. | ***False knots are nothing to worry about -- look like a knot but aren't really one. | ||
Line 112: | Line 149: | ||
***Normal: 2 arteries, 1 vein. | ***Normal: 2 arteries, 1 vein. | ||
*Membranes - shiny & translucent - normal (green, opaque/dull - chorioamnionitis). | *Membranes - shiny & translucent - normal (green, opaque/dull - chorioamnionitis). | ||
**Attachment: marginal (normal), circummarginate (inside edge), | **Attachment (insertion): marginal (normal), circummarginate (inside edge), [[circumvallate placenta|circumvallate]] (folding on self). | ||
**Site of rupture - if obvious; low point of rupture suggests low-lying placenta. | **Site of rupture - if obvious; low point of rupture suggests low-lying placenta. | ||
*Placental disc. | *Placental disc. | ||
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Notes: | Notes: | ||
*Parenchymal nodules - a brief DDx: | *Parenchymal nodules - a brief DDx: | ||
**White: infarct (chronic), thrombi, chorangioma, perivillous fibrin deposition. | **White: [[placental infarct|infarct]] (chronic), thrombi, [[chorangioma]], [[perivillous fibrin deposition]]. | ||
**Red: infarct (acute), thrombi. | **Red: infarct (acute), thrombi. | ||
==Sections== | ==Sections== | ||
#Cord two sections. | #Cord two sections. | ||
#Membranes (rolled). | #Membranes (rolled), two rolls or more.<ref name=pmid19061291>{{cite journal |author=Winters R, Waters BL |title=What is adequate sampling of extraplacental membranes?: a randomized, prospective analysis |journal=Arch. Pathol. Lab. Med. |volume=132 |issue=12 |pages=1920–3 |year=2008 |month=December |pmid=19061291 |doi= |url=}}</ref> | ||
#Cord at insertion + disc. | #Cord at insertion + disc. | ||
#Placenta - full thickness (maternal and fetal surface). | #Placenta - full thickness (maternal and fetal surface). | ||
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Appearance:<ref name=Ref_Lester461>{{Ref Lester|461}}</ref> | Appearance:<ref name=Ref_Lester461>{{Ref Lester|461}}</ref> | ||
*Normal - shiny. | *Normal - shiny. | ||
* | *[[Chorioamnionitis]] - opaque/dull. | ||
*Meconium - green. | *Meconium - green. | ||
*Amnion nodosum - yellow patches. | *[[Amnion nodosum]] - yellow patches. | ||
**Some describe 'em as white.<ref>CS. 7 February 2011.</ref> | **Some describe 'em as white.<ref>CS. 7 February 2011.</ref> | ||
==Placental mass== | ==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:<ref>AFIP Placental pathol. ISBN: 1-881041-89-1. P.312</ref> | Placental mass by gestational age:<ref>AFIP Placental pathol. ISBN: 1-881041-89-1. P.312</ref> | ||
{| class="wikitable" | {| class="wikitable" | ||
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===Linear regression - placental mass-gestational age=== | ===Linear regression - placental mass-gestational age=== | ||
Based on the table in the AFIP book<ref>AFIP Placental pathol. ISBN: 1-881041-89-1. P.312</ref> | Based on the table in the AFIP book<ref>AFIP Placental pathol. ISBN: 1-881041-89-1. P.312</ref> one can generate the following regression lines: | ||
{| class="wikitable" | {| class="wikitable" | ||
| ||'''50%''' ||'''10%''' ||'''90%''' | | ||'''50%''' ||'''10%''' ||'''90%''' | ||
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*The change in mass/week is approximately linear and equal to 300 grams / 14 weeks ~ 20 grams/week. | *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). | *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.<ref>{{cite book |author= Fox, Harold; Sebire, Neil J. |title=[http://www.amazon.com/Pathology-Placenta-Major-Problems/dp/1416025928/ref=sr_1_fkmr0_1?ie=UTF8&qid=1297259619&sr=1-1-fkmr0 Pathology of the Placenta (Major Problems in Pathology)]|publisher=Saunders |location= |year=2007 |pages= 559-561 |edition=3rd |isbn=978-1416025924 |oclc= |doi= |accessdate=}}</ref> | |||
***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:<ref>URL: [http://quizlet.com/5793113/ob-flash-cards/ http://quizlet.com/5793113/ob-flash-cards/]. Accessed on: 13 January 2012.</ref> | |||
*Maternal [[diabetes]] - esp. poorly controlled.<ref name=pmid2771897>{{Cite journal | last1 = Clarson | first1 = C. | last2 = Tevaarwerk | first2 = GJ. | last3 = Harding | first3 = PG. | last4 = Chance | first4 = GW. | last5 = Haust | first5 = MD. | title = Placental weight in diabetic pregnancies. | journal = Placenta | volume = 10 | issue = 3 | pages = 275-81 | month = | year = | doi = | PMID = 2771897 }}</ref> | |||
*Maternal [[anemia]]/low maternal iron stores.<ref>{{Cite journal | last1 = Hindmarsh | first1 = PC. | last2 = Geary | first2 = MP. | last3 = Rodeck | first3 = CH. | last4 = Jackson | first4 = MR. | last5 = Kingdom | first5 = JC. | title = Effect of early maternal iron stores on placental weight and structure. | journal = Lancet | volume = 356 | issue = 9231 | pages = 719-23 | month = Aug | year = 2000 | doi = | PMID = 11085691 }}</ref> | |||
*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==== | |||
<pre> | |||
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. | |||
</pre> | |||
===Placental growth restriction=== | |||
*[[AKA]] ''placenta small for gestational age''. | |||
*''Small placenta'' redirects here. | |||
Associations: | |||
*Maternal vascular disease, e.g. [[hypertrophic decidual vasculopathy|hypertension]]. | |||
*Fetal malformations. | |||
====Sign out==== | |||
<pre> | |||
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, BIRTH: | |||
- PLACENTA SMALL FOR GESTATIONAL AGE (160 GRAMS -- TRIMMED, POST-FIXATION WEIGHT). | |||
- THREE VESSEL UMBILICAL CORD WITHIN NORMAL LIMITS. | |||
- FETAL MEMBRANES WITHIN NORMAL LIMITS. | |||
- 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. | |||
</pre> | |||
=Overview of placental pathology= | =Overview of placental pathology= | ||
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==Common entities/diagnoses== | ==Common entities/diagnoses== | ||
*Normal. | *Normal. | ||
*Chorioamnionitis. | *[[Chorioamnionitis]]. | ||
*Placental abruption. | *[[Placental abruption]]. | ||
*Meconium. | *[[Meconium]]. | ||
*Hypertensive changes. | *Hypertensive changes. | ||
=Sign | =Sign out= | ||
What should be commented on... | What should be commented on... | ||
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***Fetal. | ***Fetal. | ||
*Membranes. | *Membranes. | ||
**Membranitis? | **[[Membranitis]]? | ||
**Chorioamnionitis? | **[[Chorioamnionitis]]? | ||
*Cord: | *Cord: | ||
**3 vessel? | **3 vessel? | ||
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Mnemonic: ''chorio, cord, vessels, villi (maturity, infarction)''. | Mnemonic: ''chorio, cord, vessels, villi (maturity, infarction)''. | ||
==Normal placenta== | |||
<pre> | |||
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, BIRTH: | |||
- THREE VESSEL UMBILICAL CORD WITHIN NORMAL LIMITS. | |||
- FETAL MEMBRANES WITHIN NORMAL LIMITS. | |||
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI WITHIN NORMAL LIMITS. | |||
</pre> | |||
===C-section=== | |||
<pre> | |||
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, CAESAREAN SECTION: | |||
- THREE VESSEL UMBILICAL CORD WITHIN NORMAL LIMITS. | |||
- FETAL MEMBRANES WITHIN NORMAL LIMITS. | |||
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI WITHIN NORMAL LIMITS. | |||
</pre> | |||
=Cord pathology= | =Cord pathology= | ||
*Two vessel cord. | *[[Two vessel cord]]. | ||
*Hypercoiling/Hypocoiling. | *Hypercoiling/Hypocoiling. | ||
*Abnormal insertion. | *Abnormal insertion. | ||
*Cord | *[[Cord knot]]s (true vs. false). | ||
*Strictures. | *Strictures. | ||
*Hematoma. | *Hematoma. | ||
*Hemangioma. | *[[Hemangioma]]. | ||
*Benign cyst. | *Benign cyst. | ||
==Two vessel cord== | ==Two vessel umbilical cord== | ||
*[[AKA]] | *[[AKA]] ''two vessel cord''. | ||
*[[AKA]] ''single umbilical artery''. | |||
{{Main|Two vessel umbilical cord}} | |||
* | |||
==Insertion== | ==Insertion== | ||
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*Increased risk of vasa previa.<ref name=pmid20872421>{{cite journal |author=Hasegawa J, Farina A, Nakamura M, ''et al.'' |title=Analysis of the ultrasonographic findings predictive of vasa previa |journal=Prenat. Diagn. |volume=30 |issue=12-13 |pages=1121–5 |year=2010 |month=December |pmid=20872421 |doi=10.1002/pd.2618 |url=}}</ref> | *Increased risk of vasa previa.<ref name=pmid20872421>{{cite journal |author=Hasegawa J, Farina A, Nakamura M, ''et al.'' |title=Analysis of the ultrasonographic findings predictive of vasa previa |journal=Prenat. Diagn. |volume=30 |issue=12-13 |pages=1121–5 |year=2010 |month=December |pmid=20872421 |doi=10.1002/pd.2618 |url=}}</ref> | ||
== | ====Sign out==== | ||
<pre> | |||
PLACENTA, UMBILICAL CORDS AND FETAL MEMBRANES, BIRTH: | |||
- THREE VESSEL UMBILICAL CORD WITH A VELAMENTOUS INSERTION, OTHERWISE WITHIN NORMAL LIMITS. | |||
- FETAL MEMBRANES WITHIN NORMAL LIMITS. | |||
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI WITHIN NORMAL LIMITS. | |||
</pre> | |||
==Umbilical knot== | |||
*[[AKA]] ''umbilical cord knot''. | |||
*[[AKA]] ''cord knot''. | |||
*[[AKA]] ''true knot''. | |||
===General=== | ===General=== | ||
*Prevalence ~1.25%.<ref name=pmid12012287>{{cite journal |author=Airas U, Heinonen S |title=Clinical significance of true umbilical knots: a population-based analysis |journal=Am J Perinatol |volume=19 |issue=3 |pages=127–32 |year=2002 |month=April |pmid=12012287 |doi=10.1055/s-2002-25311 |url=}}</ref><ref name=Ref_WMSP>{{Ref WMSP|464}}</ref> | *Prevalence ~1.25%.<ref name=pmid12012287>{{cite journal |author=Airas U, Heinonen S |title=Clinical significance of true umbilical knots: a population-based analysis |journal=Am J Perinatol |volume=19 |issue=3 |pages=127–32 |year=2002 |month=April |pmid=12012287 |doi=10.1055/s-2002-25311 |url=}}</ref><ref name=Ref_WMSP>{{Ref WMSP|464}}</ref> | ||
*Increase risk of stillbirth; odds ratio 3.93.<ref name=pmid12012287/> | *Increase risk of [[stillbirth]]; odds ratio 3.93.<ref name=pmid12012287/> | ||
===Gross=== | ===Gross=== | ||
Line 298: | Line 408: | ||
===Microscopic=== | ===Microscopic=== | ||
Features: | Features: | ||
*+/-Thrombi. | *+/-[[thrombosis|Thrombi]]. | ||
**Fibrin deposition. | **Fibrin deposition. | ||
*+/-Lines of Zahn. | *+/-Lines of Zahn. | ||
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*Rare ~ 1/5500. | *Rare ~ 1/5500. | ||
*Mortality ~50% is severe. | *Mortality ~50% is severe. | ||
=Membranes= | =Membranes= | ||
*Squamous metaplasia. | *Squamous metaplasia. | ||
*Chorioamnionitis - see ''infection'' section. | *[[Chorioamnionitis]] - see ''infection'' section. | ||
==Amnion nodosum== | ==Amnion nodosum== | ||
{{Main|Amnion nodosum}} | |||
==Placental meconium== | |||
{{Main|Placental meconium}} | |||
==Squamous metaplasia of the amnion== | |||
===General=== | ===General=== | ||
* | *Benign common finding thought to be of no clinical significance.<ref name=Ref_WMSP463>{{Ref WMSP|463}}</ref> | ||
* | **One case report suggesting an association with [[chorioamnionitis]].<ref>{{Cite journal | last1 = Chew | first1 = RH. | last2 = Silberberg | first2 = BK. | title = Possible association of acute inflammatory exudate in chorioamnionitis and amniotic squamous metaplasia. | journal = Am J Clin Pathol | volume = 93 | issue = 4 | pages = 582-5 | month = Apr | year = 1990 | doi = | PMID = 2321592 }}</ref> | ||
*Needs to be separated from amnion nodosum - '''important'''.<ref>CS. 7 February 2011.</ref> | |||
===Gross=== | ===Gross=== | ||
Features:<ref name=pmid18081444>{{Cite journal | last1 = Adeniran | first1 = AJ. | last2 = Stanek | first2 = J. | title = Amnion nodosum revisited: clinicopathologic and placental correlations. | journal = Arch Pathol Lab Med | volume = 131 | issue = 12 | pages = 1829-33 | month = Dec | year = 2007 | doi = 10.1043/1543-2165(2007)131[1829:ANRCAP]2.0.CO;2 | PMID = 18081444 }}</ref> | |||
*White (or yellow) plaques - irregular outline. | |||
DDx: | |||
*[[Amnion nodosum]] - small (~1-5 mm), round, classically yellow. | |||
Images: | |||
*[http://www.archivesofpathology.org/action/showFullPopup?id=i1543-2165-131-12-1829-f01&doi=10.1043%2F1543-2165%282007%29131%5B1829%3AANRCAP%5D2.0.CO%3B2 Amnion nodosum & squamous metaplasia of the amnion (archivesofpathology.org)].<ref name=pmid18081444/> | |||
<!-- annoying use of '[' and ']' - had to go find escape characters here: http://www.w3schools.com/tags/ref_urlencode.asp --> | |||
===Microscopic=== | ===Microscopic=== | ||
Features: | Features:<ref name=pmid18081444/> | ||
* | *Dense, paucicellular (pink) compact keratin - '''key feature'''. | ||
Image: [http:// | Image: | ||
*[http://flylib.com/books/2/953/1/html/2/43%20-%20Placenta_files/DA10C43FF29.png Squmous metaplasia of the amnion (flylib.com)].<ref>URL: [http://flylib.com/books/en/2.953.1.49/1/ http://flylib.com/books/en/2.953.1.49/1/]. Accessed on: 10 January 2011.</ref> | |||
== | ==Circumvallate placenta== | ||
*[[AKA]] ''circumvallate insertion of the membranes''. | |||
===General=== | ===General=== | ||
* | *May be associated with [[placental abruption]].<ref name=pmid18226129>{{Cite journal | last1 = Suzuki | first1 = S. | title = Clinical significance of pregnancies with circumvallate placenta. | journal = J Obstet Gynaecol Res | volume = 34 | issue = 1 | pages = 51-4 | month = Feb | year = 2008 | doi = 10.1111/j.1447-0756.2007.00682.x | PMID = 18226129 }}</ref> | ||
* | |||
Note: | |||
*Membranes usually attach to the edge of the placenta. | |||
===Gross=== | ===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: | DDx: | ||
* | *[[Circummarginate placenta]]. | ||
Images: | Images: | ||
*[http:// | *[http://library.med.utah.edu/nmw/mod2/Tutorial2/pics/circumvallate.jpg Circumvallate placenta - partial and complete (utah.edu)]. | ||
*[http://library.med.utah.edu/WebPath/jpeg2/PLAC027.jpg Circumvallate placenta (utah.edu)]. | |||
* | |||
=Twin placentas= | =Twin placentas= | ||
Line 403: | Line 494: | ||
*Twin-to-twin transfusion syndrome. | *Twin-to-twin transfusion syndrome. | ||
= | =Placental disc= | ||
== | ==Villous edema== | ||
===General=== | |||
*Non-specific finding. | |||
*Reported in associated with congenital adrenal hyperplasia for the stem villi.<ref name=pmid11045335>{{Cite journal | last1 = Furuhashi | first1 = M. | last2 = Oda | first2 = H. | last3 = Nakashima | first3 = T. | title = Hydrops of placental stem villi complicated with fetal congenital adrenal hyperplasia. | journal = Arch Gynecol Obstet | volume = 264 | issue = 2 | pages = 101-4 | month = Sep | year = 2000 | doi = | PMID = 11045335 }}</ref> | |||
===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.<ref name=pmid11045335/> | |||
DDx: | |||
*[[Chorioamnionitis]]. | |||
*Fetal edema. | |||
* | *Idiopathic (no cause apparent). | ||
* | *[[Placental villous immaturity]]. | ||
* | |||
Image: | |||
* | *[http://www.med.yale.edu/obgyn/kliman/placenta/articles/EOR_Placenta/Image19.gif villous edema (yale.edu)].<ref>URL: [http://www.med.yale.edu/obgyn/kliman/placenta/articles/EOR_Placenta/Trophtoplacenta.html http://www.med.yale.edu/obgyn/kliman/placenta/articles/EOR_Placenta/Trophtoplacenta.html]. Accessed on: 28 May 2011.</ref> | ||
=== | ==Placental villous immaturity== | ||
{{Main|Placental villous immaturity}} | |||
==Villous hypoplasia== | |||
* | *[[AKA]] ''terminal villus deficiency''.<ref name=Ref_Placenta346>{{Ref Placenta|346}}</ref> | ||
{{Main|Villous hypoplasia}} | |||
=== | =Diseases of the placental attachment= | ||
==Placenta creta== | |||
Includes ''placenta accreta'', ''placenta increta'', and ''placenta percreta''. | |||
{{Main|Placenta creta}} | |||
==Placental abruption== | |||
{{Main|Placental abruption}} | |||
= | =Inflammatory pathologies= | ||
==General<ref name=Ref_PBoD1106>{{Ref PBoD|1106}}</ref> | ===Overview of infections=== | ||
General:<ref name=Ref_PBoD1106>{{Ref PBoD|1106}}</ref> | |||
*Infection usually ascending, i.e. from vagina up through cervix. | *Infection usually ascending, i.e. from vagina up through cervix. | ||
** | **Associated with intercourse. | ||
*Hematogenous rare - manifest as villitis. | *Hematogenous rare - manifest as villitis. | ||
**Think ''[[TORCH infections]]'' (toxoplasmosis, others ([[syphilis]], TB, listeriosis), rubella, cytomegalovirus, herpes simplex virus). | **Think ''[[TORCH infections]]'' ([[toxoplasmosis]], others ([[syphilis]], [[TB]], listeriosis), rubella, [[cytomegalovirus]], [[herpes simplex virus]]). | ||
*Funisitis usually follows chorioamnionitis. | *Funisitis usually follows chorioamnionitis. | ||
**Inflammatory cells in umbilical cord are fetal (trivia). | **Inflammatory cells in umbilical cord are fetal (trivia). | ||
===Types | ====Types==== | ||
By site:<ref name=Ref_PBoD1106>{{Ref PBoD|1106}}</ref> | |||
*Fetal membranes: chorioamnionitis, membranitis.<ref name=Ref_Sternberg4_2311>{{Ref Sternberg4|2311}}</ref> | *Fetal membranes: chorioamnionitis, membranitis.<ref name=Ref_Sternberg4_2311>{{Ref Sternberg4|2311}}</ref> | ||
*Umbilical cord: funisitis. | *Umbilical cord: funisitis. | ||
*Placenta: placentitis, villitis. | *Placenta: placentitis, villitis. | ||
==Grading | ==Membranitis== | ||
:''Chorionitis'' redirects here. | |||
===General=== | |||
*Early [[chorioamnionitis]].<ref>{{Cite journal | last1 = Vedovato | first1 = S. | last2 = Zanardo | first2 = V. | title = [Chorioamnionitis and inflammatory disease in the premature newborn infant]. | journal = Minerva Pediatr | volume = 62 | issue = 3 Suppl 1 | pages = 155-6 | month = Jun | year = 2010 | doi = | PMID = 21090086 }}</ref> | |||
*Controversial.{{fact}} | |||
===Microscopic=== | |||
Features: | |||
*[[PMN]]s 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'':<ref name=Ref_Sternberg4_2311>{{Ref Sternberg4|2311}}</ref> | |||
# PMNs - decidua only. | # PMNs - decidua only. | ||
# PMNs - in subamniotic tissue. | # PMNs - in subamniotic tissue. | ||
# 1 or 2 + [[necrosis]] in decidua or chorion/subamniotic tissue. | # 1 or 2 + [[necrosis]] in decidua or chorion/subamniotic tissue. | ||
===Sign out=== | |||
<pre> | |||
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, CESAERIAN SECTION: | |||
- FETAL MEMBRANES WITH CHORIONITIS. | |||
- THREE VESSEL UMBILICAL CORD WITH VASCULITIS. | |||
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI. | |||
</pre> | |||
====Waffle==== | |||
<pre> | |||
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, BIRTH: | |||
- FETAL MEMBRANES WITH MECONIUM-LADEN MACROPHAGES AND ABUNDANT DECIDUAL NEUTROPHILS | |||
SUSPICIOUS FOR EARLY CHORIONITIS. | |||
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI. | |||
- THREE VESSEL UMBILICAL CORD WITHIN NORMAL LIMITS. | |||
</pre> | |||
==Chorioamnionitis== | |||
{{Main|Chorioamnionitis}} | |||
Umbilical cord vasculitis | ==Umbilical cord vasculitis== | ||
{{Main|Umbilical cord vasculitis}} | |||
==Funisitis== | |||
{{Main|Funisitis}} | |||
*Inflammation of Wharton's jelly - the connective tissue of the umbilical cord. | |||
==Acute villitis== | |||
{{main|Acute villitis}} | |||
==Villitis of unknown etiology== | ==Villitis of unknown etiology== | ||
* | {{Main|Villitis of unknown etiology}} | ||
==Chronic intervillitis== | |||
*[[AKA]] ''chronic intervillositis''.<ref name=pmid8215826>{{Cite journal | last1 = Jacques | first1 = SM. | last2 = Qureshi | first2 = F. | title = Chronic intervillositis of the placenta. | journal = Arch Pathol Lab Med | volume = 117 | issue = 10 | pages = 1032-5 | month = Oct | year = 1993 | doi = | PMID = 8215826 }}</ref> | |||
===General=== | ===General=== | ||
*Rare. | |||
* | *Massive chronic intervillitis - associated [[IUGR]], spontaneous abortion, perinatal fetal death.<ref name=pmid17088773>{{Cite journal | last1 = Rota | first1 = C. | last2 = Carles | first2 = D. | last3 = Schaeffer | first3 = V. | last4 = Guyon | first4 = F. | last5 = Saura | first5 = R. | last6 = Horovitz | first6 = J. | title = [Perinatal prognosis of pregnancies complicated by placental chronic intervillitis]. | journal = J Gynecol Obstet Biol Reprod (Paris) | volume = 35 | issue = 7 | pages = 711-9 | month = Nov | year = 2006 | doi = | PMID = 17088773 }}</ref> | ||
*Recurs. | |||
===Microscopic=== | ===Microscopic=== | ||
Features:<ref name= | Features:<ref name=pmid8215826/><ref name=pmid17088773/> | ||
* | *Intervillous inflammatory cells: | ||
* | **Lymphocytes. | ||
**Histiocytes. | |||
*Fibrinoid deposition. | |||
Images | ====Images==== | ||
<gallery> | |||
*[ | Image:Intervillitis_-_intermed_mag.jpg | Intervillitis - intermed. mag. (WC) | ||
Image:Intervillitis_-_very_high_mag.jpg | Intervillitis - very high mag. (WC) | |||
</gallery> | |||
==Chronic deciduitis== | |||
*[[AKA]] plasma cell deciduitis. | |||
{{Main|Chronic deciduitis}} | |||
= | =Placental infarction= | ||
==True infarcts== | ==True infarcts== | ||
{{Main|Placental infarct}} | |||
==Perivillous fibrin deposition== | |||
*Abbreviation ''PFD''. | |||
===General=== | ===General=== | ||
* | *Thought to be an immunologic problem - resulting in platelet activation and fibrin deposition.<ref name=pmid12066949>{{Cite journal | last1 = Sebire | first1 = NJ. | last2 = Backos | first2 = M. | last3 = Goldin | first3 = RD. | last4 = Regan | first4 = L. | title = Placental massive perivillous fibrin deposition associated with antiphospholipid antibody syndrome. | journal = BJOG | volume = 109 | issue = 5 | pages = 570-3 | month = May | year = 2002 | doi = | PMID = 12066949 }}</ref> | ||
*May be associated with [[diabetes mellitus]].<ref name=Ref_Placenta327>{{Ref Placenta|327}}</ref> | |||
===Gross=== | ===Gross=== | ||
*Pale (white). | |||
* | *Firm. | ||
*White fibrous sepatae. | |||
* | |||
* | |||
===Microscopic=== | ===Microscopic=== | ||
Features: | 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 [[Basics#Nuclear destruction words|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: | |||
* | *[http://path.upmc.edu/cases/case75.html APLA syndrome (upmc.edu)]. | ||
=== | ===Sign out=== | ||
====Thrombi==== | |||
<pre> | |||
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, BIRTH: | |||
- THREE VESSEL UMBILICAL CORD WITHIN NORMAL LIMITS. | |||
- FETAL MEMBRANES WITHIN NORMAL LIMITS. | |||
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI AND THREE LARGE INTERVILLOUS | |||
THROMBI (BLOCKS A7-A9). | |||
</pre> | |||
== | ==Maternal floor infarction== | ||
* | *Abbreviated ''MFI''. | ||
** | *Formally ''placental maternal floor infarction''. | ||
*[[AKA]] ''massive perivillous fibrin deposition''.<ref name=Ref_Placenta367>{{Ref Placenta|367}}</ref> | |||
{{Main|Maternal floor infarction}} | |||
=Fetal disease= | =Fetal disease= | ||
==Fetal thrombotic vasculopathy== | ==Fetal thrombotic vasculopathy== | ||
*Abbreviated ''FTV''. | |||
* | *A large number of terms are used for this including:<ref name=pmid19237859>{{Cite journal | last1 = Marchetti | first1 = D. | last2 = Belviso | first2 = M. | last3 = Fulcheri | first3 = E. | title = A case of stillbirth: the importance of placental investigation in medico-legal practice. | journal = Am J Forensic Med Pathol | volume = 30 | issue = 1 | pages = 64-8 | month = Mar | year = 2009 | doi = 10.1097/PAF.0b013e318187387e | PMID = 19237859 }}</ref> | ||
* | **''Fibrinous vasculosis''. | ||
**''Fibromuscular sclerosis''. | |||
**''Fetal artery stem thrombosis''. | |||
*The multitude of terms reflects the confusion about this finding and that it has numerous etiologies.<ref name=pmid19237859/> | |||
* | {{Main|Fetal thrombotic vasculopathy}} | ||
** | |||
* | |||
* | |||
==Hemorrhagic endovasculitis== | ==Hemorrhagic endovasculitis== | ||
Line 576: | Line 699: | ||
=Maternal disease= | =Maternal disease= | ||
==Hypertensive changes== | ==Hypertensive changes== | ||
===General=== | |||
Associated pathologic changes:<ref name=pmid6754249>{{cite journal |author=Soma H, Yoshida K, Mukaida T, Tabuchi Y |title=Morphologic changes in the hypertensive placenta |journal=Contrib Gynecol Obstet |volume=9 |issue= |pages=58–75 |year=1982 |pmid=6754249 |doi= |url=}}</ref> | |||
*Placental infarcts. | *Placental infarcts. | ||
*Increased syncytial knots. | *Increased syncytial knots. | ||
Line 587: | Line 707: | ||
*Thickening of the trophoblastic basement membrane. | *Thickening of the trophoblastic basement membrane. | ||
=== | ===Microscopic=== | ||
Features:<ref name= | Features:<ref name=pmid6754249>{{cite journal |author=Soma H, Yoshida K, Mukaida T, Tabuchi Y |title=Morphologic changes in the hypertensive placenta |journal=Contrib Gynecol Obstet |volume=9 |issue= |pages=58–75 |year=1982 |pmid=6754249 |doi= |url=}}</ref> | ||
* | *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.<ref>Sherman, C. 7 February 2011.</ref> | ||
Images: | Images: | ||
*[http:// | *[http://www.pathxchange.org/case/19711 Pregnancy-induced hypertension (pathxchange.org)]. | ||
==Hypertrophic decidual vasculopathy== | |||
:[[AKA]] ''decidual vasculopathy''. | |||
{{Main|Hypertrophic decidual vasculopathy}} | |||
==HELLP syndrome== | ==HELLP syndrome== | ||
{{Main|HELLP syndrome}} | |||
==Malaria== | |||
{{Main|Malaria}} | |||
===General=== | ===General=== | ||
* | *Uncommon in Canada. | ||
* | *May lead to fetal demise. | ||
===Microscopic=== | ===Microscopic=== | ||
Feature: | |||
* | *[[RBC]]s with basophilic dots ~1-2 micrometres. | ||
====Image==== | |||
<gallery> | |||
Image:Maternal_malaria_placenta_-_very_high_mag.jpg | Maternal malaria - very high mag. (WC) | |||
</gallery> | |||
=Tumours= | =Tumours= | ||
{{main|Gestational trophoblastic disease}} | {{main|Gestational trophoblastic disease}} | ||
==Chorangioma== | ==Chorangioma== | ||
{{Main|Chorangioma}} | |||
==Chorangiomatosis== | |||
===General=== | ===General=== | ||
*[[ | Associated with: | ||
*Preeclampsia. | |||
*[[IUGR]]. | |||
=== | ===Gross=== | ||
* | *Multiple tan nodules. | ||
=== | ===Microscopic=== | ||
Features: | Features: | ||
* | *Multiple chorangiomas - the difference between chorangioma and chorangiomatosis is not well defined.<ref>URL: [http://path.upmc.edu/cases/case655/dx.html http://path.upmc.edu/cases/case655/dx.html]. Accessed on: 28 January 2012.</ref> | ||
Images: | |||
*[http://path.upmc.edu/cases/case655.html Chorangiomatosis - several images (upmc.edu)]. | |||
==Chorangiosis== | |||
{{Main|Chorangiosis}} | |||
=Other= | |||
==Fetus papyraceus== | |||
*May be spelled ''foetus papyraceus''. | |||
*[[AKA]] ''fetus compressus''. | |||
{{Main|Fetus papyraceus}} | |||
==Placental mesenchymal dysplasia== | |||
*Abbreviated ''PMD''. | |||
{{Main|Placental mesenchymal dysplasia}} | |||
=Placental cysts and pseudocysts= | |||
Types:<ref name=Ref_Placenta219-220>{{Ref Placenta|219-220}}</ref> | |||
*Amnionic epithelial inclusion cyst (amniotic cyst). | |||
*[[Epidermal inclusion cyst]] - lined by keratinized squamous epithelium. | |||
*Chorionic cyst ([[AKA]] chorionic pseudocyts). | |||
*Cell island cyst. | |||
Other considerations:<ref name=pmid12054300>{{Cite journal | last1 = Brown | first1 = DL. | last2 = DiSalvo | first2 = DN. | last3 = Frates | first3 = MC. | last4 = Davidson | first4 = KM. | last5 = Genest | first5 = DR. | title = Placental surface cysts detected on sonography: histologic and clinical correlation. | journal = J Ultrasound Med | volume = 21 | issue = 6 | pages = 641-6; quiz 647-8 | month = Jun | year = 2002 | doi = | PMID = 12054300 }}</ref> | |||
*Hematoma. | |||
*Fibrin-lined pseudocyst. | |||
General:<ref name=pmid12054300/> | |||
*Usually good outcome. | |||
*Large cysts (>4.5 cm) or multiple cysts (>3) are associated with [[IUGR]]. | |||
Images: | |||
*[http:// | *[http://www.jultrasoundmed.org/content/21/6/641/F5.expansion.html Subchorionic cysts (jultrasoundmed.org)].<ref name=pmid12054300/> | ||
=See also= | =See also= | ||
Line 648: | Line 797: | ||
*[[Pregnancy]]. | *[[Pregnancy]]. | ||
*[[Gestational trophoblastic disease]]. | *[[Gestational trophoblastic disease]]. | ||
*[[TORCH infections]]. | |||
=References= | =References= | ||
{{reflist|2}} | {{reflist|2}} | ||
=Recommended reading= | =Recommended reading= | ||
Line 660: | Line 808: | ||
=External links= | =External links= | ||
*[http://emedicine.medscape.com/article/262470-overview Cord complications (emedicine.medscape.com)]. | *[http://emedicine.medscape.com/article/262470-overview Cord complications (emedicine.medscape.com)]. | ||
*[http://www.palpath.com/MedicalTestPages/placenta2.htm Placenta notes (palpath.com)]. | |||
[[Category:Placenta]] |
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