Difference between revisions of "Placenta"

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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.
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*#*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:
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====Most common====
====Most common====
Most common reasons for submitting a placenta to pathology:<ref>CS. 8 February 2011.</ref>
Most common reasons for submitting a placenta to pathology:<ref>Sherman C. 8 February 2011.</ref>
# Prematurity.
# Prematurity.
# PROM / possible chorioamnionitis.  
# PROM / possible [[chorioamnionitis]].  
# Multiple gestation.
# 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>


{{main|Pregnancy}}
==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==
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==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:  
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*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 - vessel run on fetal surface (more exposed to trauma).
***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.
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***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), circumvallated (folding on self).
**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.


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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.
*Choriomnionitis - opaque/dull.
*[[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>


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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> I generated the following regression lines:
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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*Is it required?
*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>   
**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 almost certainly more reproducible than arbitrary descriptors which require experience and a continuing case volume to calibrate.
***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-out=
=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 knots (true vs. false).
*[[Cord knot]]s (true vs. false).
*Strictures.
*Strictures.
*Hematoma.
*Hematoma.
*Hemangioma.
*[[Hemangioma]].
*Benign cyst.
*Benign cyst.


==Two vessel cord==
==Two vessel umbilical cord==
*[[AKA]] single umbilical artery.
*[[AKA]] ''two vessel cord''.
 
*[[AKA]] ''single umbilical artery''.
===Associations===
{{Main|Two vessel umbilical cord}}
*Associated with congenital abnormalities, esp. cardiac - '''key point'''.<ref name=Ref_WMSP464>{{Ref WMSP|464}}</ref>
**Thought to be an acquired defect (as prevalence is lower in early in gestation).
*May be seen in association of other cord abnormalities (e.g. marginal insertion, velamentous insertion).
*In apparently well (liveborn) infants it is associated with (occult) renal abnormalities, specifically vesico-ureteric reflux; there is no evidence for other abnormalities.<ref name=pmid15613529>{{cite journal |author=Srinivasan R, Arora RS |title=Do well infants born with an isolated single umbilical artery need investigation? |journal=Arch. Dis. Child. |volume=90 |issue=1 |pages=100–1 |year=2005 |month=January |pmid=15613529 |pmc=1720078 |doi=10.1136/adc.2004.062372 |url=}}</ref>
*Associated with maternal diabetes.<ref name=pmid7997408>{{cite journal |author=Lilja M |title=Infants with single umbilical artery studied in a national registry. 3: A case control study of risk factors |journal=Paediatr Perinat Epidemiol |volume=8 |issue=3 |pages=325–33 |year=1994 |month=July |pmid=7997408 |doi= |url=}}</ref>
 
Image:
*[http://www.glowm.com/resources/glowm/graphics/figures/v2/1070/05b.jpg SUA (glown.com)].<ref>URL: [http://www.glowm.com/?p=glowm.cml/section_view&articleid=151 http://www.glowm.com/?p=glowm.cml/section_view&articleid=151]. Accessed on: 8 January 2011.</ref>


==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>


==Knots==
====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===
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===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.
Image: [http://flylib.com/books/2/953/1/html/2/43%20-%20Placenta_files/DA10C43FF12.png Hematoma (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>


=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===
*Associated with (long-standing) oligohydramnios.<ref>URL: [http://library.med.utah.edu/WebPath/PLACHTML/PLAC042.html http://library.med.utah.edu/WebPath/PLACHTML/PLAC042.html]. Accessed on: 12 January 2011.</ref>
*Benign common finding thought to be of no clinical significance.<ref name=Ref_WMSP463>{{Ref WMSP|463}}</ref>
*Should be separated from ''squamous metaplasia of amnion''.
**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===
*Yellow patch or yellow nodules.
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>
**Some think they are white.<ref>CS. 7 February 2011.</ref>
*White (or yellow) plaques - irregular outline.


Image: [http://www.webpathology.com/image.asp?n=2&Case=659 Amnion nodosum (webpathology.com)].
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/>
*Simple epithelium of amnion replaced by (non-keratinizing) stratified squamous epithelium.
*Dense, paucicellular (pink) compact keratin - '''key feature'''.


Image: [http://www.webpathology.com/image.asp?case=659&n=3 Amnion nodosum (webpathology.com)].
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>


==Passage of meconium==
==Circumvallate placenta==
*[[AKA]] ''circumvallate insertion of the membranes''.
===General===
===General===
*Associated with fetal distress.
*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>
*Small amount - at term - is considered to be normal.
 
Note:
*Membranes usually attach to the edge of the placenta.


===Gross===
===Gross===
*Green/green discolourization.
*Fetal membranes attach to the fetal surface of the placenta away from the margin of the placental disc.  
 
===Microscopy===
Features:<ref>ALS. 6 Febraury 2009.</ref>
*Meconium histiocytes - '''key feature'''.
**Macrophages with brown fine granular pigment.
*Pseudostratified epithelium (amnion) - low power.
*Amnion - columnar morphology (normally cuboidal).
*"Drop-out" of individual amnion cells / loss of individual cells.


Time of meconium passage:<ref name=pmid2413412>{{cite journal |author=Miller PW, Coen RW, Benirschke K |title=Dating the time interval from meconium passage to birth |journal=Obstet Gynecol |volume=66 |issue=4 |pages=459–62 |year=1985 |month=October |pmid=2413412 |doi= |url=}}</ref>
Classification:
*<1 h - no staining of membranes.
*Partial - not circumferential.
*1-3 h - amnion is stained.
*Complete.
*>3 h - chorion is stained.


DDx:
DDx:
*Hemosiderin-laden macrophages.
*[[Circummarginate placenta]].
**This is sorted-out with an iron stain -- see below.
 
Notes:
*The above time course is disputed - in vitro experiments suggest it is considerably longer.<ref name=pmid19031358>{{cite journal |author=Funai EF, Labowsky AT, Drewes CE, Kliman HJ |title=Timing of fetal meconium absorption by amnionic macrophages |journal=Am J Perinatol |volume=26 |issue=1 |pages=93–7 |year=2009 |month=January |pmid=19031358 |doi=10.1055/s-0028-1103028 |url=}}</ref>
 


Images:
Images:
*[http://commons.wikimedia.org/wiki/File:Meconium-laden_macrophages_high_mag.jpg Meconium-laden macrophages - high mag. (WC)].
*[http://library.med.utah.edu/nmw/mod2/Tutorial2/pics/circumvallate.jpg Circumvallate placenta - partial and complete (utah.edu)].
*[http://commons.wikimedia.org/wiki/File:Meconium-laden_macrophages_intermed_mag.jpg Meconium-laden macrophages - intermed. mag. (WC)].
*[http://library.med.utah.edu/WebPath/jpeg2/PLAC027.jpg Circumvallate placenta (utah.edu)].
 
===Special stains===
*Hemosiderin +ve in hemosiderin-laden macrophages.
*PAS +ve in meconium-laden macrophages.<ref name=pmid11268705>{{cite journal |author=Povýsil C, Bennett R, Povýsilová V |title=CD 68 positivity of the so-called meconium corpuscles in human foetal intestine |journal=Cesk Patol |volume=37 |issue=1 |pages=7–9 |year=2001 |month=January |pmid=11268705 |doi= |url=}}</ref>
 
Useful to differentiate hemosiderin-laden macrophages and meconium laden macrophages:
*Hemosiderin stain -- +ve for old blood.
**Prussian-blue stain = hemosiderin stain.<ref>{{cite journal |author=Sienko A, Altshuler G |title=Meconium-induced umbilical vascular necrosis in abortuses and fetuses: a histopathologic study for cytokines |journal=Obstet Gynecol |volume=94 |issue=3 |pages=415?0 |year=1999 |month=September |pmid=10472870 |doi= |url=}}</ref>
 
Notes:
*PAS-D -- +ve in meconium... though may rarely stain hemosiderin.
*Meconium contains bile.<ref>{{cite journal |author=Sienko A, Altshuler G |title=Meconium-induced umbilical vascular necrosis in abortuses and fetuses: a histopathologic study for cytokines |journal=Obstet Gynecol |volume=94 |issue=3 |pages=415?0 |year=1999 |month=September |pmid=10472870 |doi= |url=}}</ref>
 
==Squamous metaplasia==
*Benign common finding - no clinical significance.<ref name=Ref_WMSP463>{{Ref WMSP|463}}</ref>
*Needs to be separated from amnion nodosum.<ref>CS. 7 February 2011.</ref>
 
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>


=Twin placentas=
=Twin placentas=
Line 417: Line 494:
*Twin-to-twin transfusion syndrome.
*Twin-to-twin transfusion syndrome.


=Diseases of the placental attachment=
=Placental disc=
==Placenta acreta/percreta/increta==
==Villous edema==
Placenta attaches to the uterus deeper than it should.
===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/>


==Placental abruption==
DDx:
===General===
*[[Chorioamnionitis]].
Classic clinical manifestations:<ref name=pmid16752262>{{cite journal |author=Tikkanen M, Nuutila M, Hiilesmaa V, Paavonen J, Ylikorkala O |title=Clinical presentation and risk factors of placental abruption |journal=Acta Obstet Gynecol Scand |volume=85 |issue=6 |pages=700–5 |year=2006 |pmid=16752262 |doi=10.1080/00016340500449915 |url=}}</ref>
*Fetal edema.
*Vaginal bleeding (~70%).
*Idiopathic (no cause apparent).
*Abdominal pain (~50%).
*[[Placental villous immaturity]].
*Fetal heart rate abnormalities (~70%).


Sign-out:
Image:
*Pathologists should sign-out this as "focal adherent retroplacental hematoma".
*[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>
**The pathologic findings may be due to abruption or manual removal of the placenta.


===Gross===
==Placental villous immaturity==
Features:<ref>CS. 7 February 2011.</ref>
{{Main|Placental villous immaturity}}
*Large adherent blood clot.
*Disc depression on maternal side.


Notes:
==Villous hypoplasia==
*Loosely attached clot less convincing.
*[[AKA]] ''terminal villus deficiency''.<ref name=Ref_Placenta346>{{Ref Placenta|346}}</ref>
*Central haemorrhage is the most worrisome.
{{Main|Villous hypoplasia}}


===Microscopic===
=Diseases of the placental attachment=
Features:
==Placenta creta==
#Decidual hemorrhage.
Includes ''placenta accreta'', ''placenta increta'', and ''placenta percreta''.
#*Blood in the decidua.
{{Main|Placenta creta}}
#Intravillous hemorrhage, [[AKA]] villous stromal hemorrhage.
#*"Bags of blood" - blood outside of vessels in the villi.
#**Should not be confused with congested villi.


Notes:
==Placental abruption==
*There are '''no''' definitive microscopic findings for placental abruption.
{{Main|Placental abruption}}
*Intravillous hemorrhage is non-specific - may arise in the following: early placental infarct, cord compression, abdominal trauma.


=Inflammatory pathologies=
=Inflammatory pathologies=
==Infection==  
===Overview of infections===  
General:<ref name=Ref_PBoD1106>{{Ref PBoD|1106}}</ref>
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.
**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 (by site)<ref name=Ref_PBoD1106>{{Ref PBoD|1106}}</ref>===
====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 infection (chorioamnionitis, membranitis, funisitis)==
==Membranitis==
Membranitis:<ref name=Ref_Sternberg4_2311>{{Ref Sternberg4|2311}}</ref>
:''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.


Chorioamnionitis:<ref name=Ref_Sternberg4_2311>{{Ref Sternberg4|2311}}</ref>
===Sign out===
# placental chorionic plate only.
<pre>
# 1 + subamniotic tissue.
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, CESAERIAN SECTION:
# 1 or 2 + necrosis or abscess.
- FETAL MEMBRANES WITH CHORIONITIS.
- THREE VESSEL UMBILICAL CORD WITH VASCULITIS.
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI.
</pre>


Sternberg separates ''vasculitis'' and ''funisitis'' without really explaining the terms<ref name=Ref_Sternberg4_2311>{{Ref Sternberg4|2311}}</ref> -- I presume:
====Waffle====
''vasculitis'' = inflammation of vessels in the umbilical cord.
<pre>
''funisitis'' = inflammation of the cord (vessels and Wharton jelly).
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>


Umbilical cord vasculitis:<ref name=Ref_Sternberg4_2311>{{Ref Sternberg4|2311}}</ref>
==Chorioamnionitis==
* +0.5 for each vessel.
{{Main|Chorioamnionitis}}
* +0.5 for each vessel with severe involvement.


Umbilical funisitis:<ref name=Ref_Sternberg4_2311>{{Ref Sternberg4|2311}}</ref>
==Umbilical cord vasculitis==
# Focal inflammation.
{{Main|Umbilical cord vasculitis}}
# Diffuse inflammation.
# Necrosis - in vessels or Wharton jelly.


Note: There is no such thing as ''chorionitis''.<ref>ALS. February 2009.</ref>
==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==
*Abbreviated ''VUE''.
{{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===
Features:<ref name=pmid17889674>{{cite journal |author=Redline RW |title=Villitis of unknown etiology: noninfectious chronic villitis in the placenta |journal=Hum. Pathol. |volume=38 |issue=10 |pages=1439–46 |year=2007 |month=October |pmid=17889674 |doi=10.1016/j.humpath.2007.05.025 |url=}}</ref>
*Rare.
*Usually term placenta.
*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>
*Prevalence: 5% to 15% of all placentas.
*Recurs.
*Associated with:
**Intrauterine growth restriction.
**Recurrent reproductive loss/adverse outcomes in subsequent pregnancies -- '''key point'''.
***Recurrence in up 37% of cases.<ref name=pmid20604650>{{cite journal |author=Feeley L, Mooney EE |title=Villitis of unknown aetiology: correlation of recurrence with clinical outcome |journal=J Obstet Gynaecol |volume=30 |issue=5 |pages=476–9 |year=2010 |pmid=20604650 |doi=10.3109/01443611003802339 |url=}}</ref>
 
Etiology:
*Unknown - as the name of the entity suggests.
**Suspected to be immune-mediated.
 
===Microscopic===
===Microscopic===
Features:<ref name=pmid17889674/>
Features:<ref name=pmid8215826/><ref name=pmid17088773/>
*Lymphocytes in villous stroma - '''key feature'''.
*Intervillous inflammatory cells:
**Usually focal/patchy.
**Lymphocytes.
**Lymphocytes: maternal derivation, T-lymphocytes -- mostly CD8-positive.
**Histiocytes.
*+/-Intervillositis (lymphocytes between villi).
*Fibrinoid deposition.
*+/-Histiocytes.
*'''No''' plasma cells - this suggests an infectious etiology.<ref>CS. 7 February 2011.</ref>
**Plasma cells may be seen in the decidua -- these can be ignored.


Notes:
====Images====
*Neutrophils are usually absent. A significant number of 'em is suggestive of an infectious villitis.
<gallery>
*Infective villitis is usu. B-cell predominant.
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}}


Images:
=Placental infarction=
*[http://jcp.bmj.com/content/61/12/1254/F6.large.jpg VUE (bmj.com)].<ref>URL: [http://jcp.bmj.com/content/61/12/1254.abstract http://jcp.bmj.com/content/61/12/1254.abstract]. Accessed on: 11 January 2011.</ref>
*[http://farm4.static.flickr.com/3501/3954021698_84a3542b43.jpg VUE (flickr.com)].<ref>URL: [http://www.flickr.com/photos/jian-hua_qiao_md/3954021698/ http://www.flickr.com/photos/jian-hua_qiao_md/3954021698/]. Accessed on: 11 January 2011.</ref> **CHECK**
 
=Infarction=
==True infarcts==
==True infarcts==
===General===
{{Main|Placental infarct}}
*Associated with retroplacental hematoma.
 
===Gross===
Features:<ref name=Ref_WMSP465>{{Ref WMSP|465}}</ref>
*Early - red.
*Late - white/grey.
 
Images:
*[http://pathweb.uchc.edu/eatlas/gyn/681b.htm Placental infarcts (pathweb.uchc.edu)].
*[http://library.med.utah.edu/WebPath/PLACHTML/PLAC044.html Placental infarcts (med.utah.edu)].
 
===Microscopic===
Features:
#Necrosis of villi; hyaline material (acellular eosinophilic material) replaces the stroma of the villi.
#Loss of intervillous space.<ref name=Ref_WMSP465>{{Ref WMSP|465}}</ref>
#*Villi appear to be crowded.<ref>{{Ref PBoD|1109}}</ref>
#**Normal spacing is ~1x smallest villus or larger.
#***In perivillous fibrin deposition - spacing usu. larger than normal.
#Prominent syncytial knots.
#Thickened trophoblastic basement membrane (below [[cytotrophoblast]]s).
#+/-Changes seen in decidual vasculopathy:
#*Acute atherosis (vaguely like [[atherosclerosis]]).
#**[[Fibrinoid necrosis]].
#**Vessel wall lipid deposition.
 
Images:
*[http://pathweb.uchc.edu/eatlas/gyn/1203b.htm Recent infarct (pathweb.uchc.edu)].
*[http://path.upmc.edu/cases/case75/images/micro1.jpg Placental infarct (umpmc.edu)].<ref>URL: [http://path.upmc.edu/cases/case75/micro.html http://path.upmc.edu/cases/case75/micro.html]. Accessed on: 6 January 2011.</ref>
*[http://www.mda-sy.com/pathology/PLACHTML/PLAC024.HTM Placental infarct - necrotic villi (mda-sy.com)].
 
===Significant infarcts===
*> 3cm --or-- central location --or-- in 1st or 2nd trimester.
**Small foci are accepted in term placentae - typically at periphery.


==Perivillous fibrin deposition==
==Perivillous fibrin deposition==
*Massive perivillous fibrin deposition is assoc. with anti-phospholipid antibody (APLA) syndrome.<ref name=pmid12066949>{{cite journal |author=Sebire NJ, Backos M, Goldin RD, Regan L |title=Placental massive perivillous fibrin deposition associated with antiphospholipid antibody syndrome |journal=BJOG |volume=109 |issue=5 |pages=570–3 |year=2002 |month=May |pmid=12066949 |doi= |url=http://www3.interscience.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=1470-0328&date=2002&volume=109&issue=5&spage=570}}</ref>
*Abbreviation ''PFD''.
**APLA is assoc. with recurrent miscarriage - can be treated with heparin + ASA.<ref name=pmid12066949/>
===General===
*Thought to be an immunologic problem - resulting in platelet activation and fibrin deposition.<ref name=pmid12066949/>
*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===
Line 575: Line 643:
*White fibrous sepatae.
*White fibrous sepatae.


===Microscopy===
===Microscopic===
Features:
Features:
*Acellular eosinophilic material around formed villi.
*Acellular eosinophilic material around formed villi.
Line 582: Line 650:


Notes:
Notes:
*Nuclei of villi are usu. preserved.
*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).
*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==
===General===
*Abbreviated ''FTV''.
*May cause IUGR.
*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>  
*Associated with cerebral palsy and common in perinatal deaths.<ref name=pmid10414494>{{cite journal |author=Kraus FT, Acheen VI |title=Fetal thrombotic vasculopathy in the placenta: cerebral thrombi and infarcts, coagulopathies, and cerebral palsy |journal=Hum. Pathol. |volume=30 |issue=7 |pages=759–69 |year=1999 |month=July |pmid=10414494 |doi= |url=}}</ref>
**''Fibrinous vasculosis''.
 
**''Fibromuscular sclerosis''.
===Microscopic===
**''Fetal artery stem thrombosis''.
Features:
*The multitude of terms reflects the confusion about this finding and that it has numerous etiologies.<ref name=pmid19237859/>
*Thrombus in the fetal vasculature +/- recanalization.  
{{Main|Fetal thrombotic vasculopathy}}
**Eosinophilic (light pink on H&E), moderately granular intravascular material (fibrin) with layering.
 
Images:
*[http://jcp.bmj.com/content/61/12/1254/F8.large.jpg FTV (bmj.com)].<ref>URL: [http://jcp.bmj.com/content/61/12/1254.abstract http://jcp.bmj.com/content/61/12/1254.abstract]. Accessed on: 12 January 2011.</ref>
*[http://gut.bmj.com/content/41/3/354/F3.large.jpg Thrombus - rat (bmj.com)].<ref>URL: [http://gut.bmj.com/content/41/3/354.full http://gut.bmj.com/content/41/3/354.full]. Accessed on: 12 January 2011.</ref>


==Hemorrhagic endovasculitis==
==Hemorrhagic endovasculitis==
Line 627: Line 713:


Notes:
Notes:
*One should look for the changes in the membrane roll, not the maternal surface.<ref>CS. 7 February 2011.</ref>
*One should look for the changes in the membrane roll, not the maternal surface.<ref>Sherman, C. 7 February 2011.</ref>
 
Images:
*[http://www.pathxchange.org/case/19711 Pregnancy-induced hypertension (pathxchange.org)].


==Hypertrophic decidual vasculopathy==
==Hypertrophic decidual vasculopathy==
===General===
:[[AKA]] ''decidual vasculopathy''.
*A change seen in hypertension.
{{Main|Hypertrophic decidual vasculopathy}}


===Microscopic===
==HELLP syndrome==
Features:<ref name=pmid18641412>{{Cite journal  | last1 = Roberts | first1 = DJ. | last2 = Post | first2 = MD. | title = The placenta in pre-eclampsia and intrauterine growth restriction. | journal = J Clin Pathol | volume = 61 | issue = 12 | pages = 1254-60 | month = Dec | year = 2008 | doi = 10.1136/jcp.2008.055236 | PMID = 18641412 }}</ref>
{{Main|HELLP syndrome}}
*Mild or moderate:
*#Perivascular inflammatory cells.
*#+/-Vascular thrombosis.
*#Smooth muscle hypertrophy.
*#Endothelial hyperplasia.
*#*Above two lead to narrowing of the decidual spiral arteries<ref>AFIP - Placental Pathology. P.122. ISBN: 1-881041-89-1. 2004.</ref> -- '''key feature'''.
*Severe:<ref name=pmid18641412/>
*#Atherosis of maternal blood vessels.
*#*Foamy macrophages within vascular wall.
*#Fibrinoid necrosis of vessel wall (amorphous eosinophilic material vessel wall).


General:
==Malaria==
*Seen in intrauterine growth restriction (IUGR).
{{Main|Malaria}}
 
Images:
*[http://commons.wikimedia.org/wiki/File:Hypertrophic_decidual_vasculopathy_intermed_mag.jpg HDV - intermed. mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Hypertrophic_decidual_vasculopathy_low_mag.jpg HDV - low mag. (WC)].
 
==HELLP syndrome==
===General===
===General===
*Diagnosed clinically.
*Uncommon in Canada.
*Pathologically not the same as ''severe preclampsia''.<ref name=pmid18362224>{{cite journal |author=Vinnars MT, Wijnaendts LC, Westgren M, Bolte AC, Papadogiannakis N, Nasiell J |title=Severe preeclampsia with and without HELLP differ with regard to placental pathology |journal=Hypertension |volume=51 |issue=5 |pages=1295–9 |year=2008 |month=May |pmid=18362224 |doi=10.1161/HYPERTENSIONAHA.107.104844 |url=}}</ref>
*May lead to fetal demise.
 
Definition:
*'''H''' = hemolysis.
*'''EL''' = elevated liver enzymes.
*'''LP''' = low platelets.


===Microscopic===
===Microscopic===
Features:<ref name=pmid7966086>{{cite journal |author=Ornstein MH, Rand JH |title=An association between refractory HELLP syndrome and antiphospholipid antibodies during pregnancy; a report of 2 cases |journal=J. Rheumatol. |volume=21 |issue=7 |pages=1360–4 |year=1994 |month=July |pmid=7966086 |doi= |url=}}</ref>
Feature:
*Thrombotic microangiopathic vasculopathy.
*[[RBC]]s with basophilic dots ~1-2 micrometres.
**In essence: severe ''hypertrophic decidual vasculopathy''. (???)


====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===
*[[Hamartoma]]-like growth in the placenta consisting of [[blood vessel]]s.<ref name=pmid20594143>{{cite journal |author=Amer HZ, Heller DS |title=Chorangioma and related vascular lesions of the placenta--a review |journal=Fetal Pediatr Pathol |volume=29 |issue=4 |pages=199–206 |year=2010 |pmid=20594143 |doi=10.3109/15513815.2010.487009 |url=}}</ref>
Associated with:
 
*Preeclampsia.
Epidemiology:
*[[IUGR]].
*Often benign/insignificant; large lesions (>4 cm<ref name=pmid20594143>{{cite journal |author=Amer HZ, Heller DS |title=Chorangioma and related vascular lesions of the placenta--a review |journal=Fetal Pediatr Pathol |volume=29 |issue=4 |pages=199–206 |year=2010 |pmid=20594143 |doi=10.3109/15513815.2010.487009 |url=}}</ref> or >5 cm<ref name=pmid21234259>{{cite journal |author=Lež C, Fures R, Hrgovic Z, Belina S, Fajdic J, Münstedt K |title=Chorangioma placentae |journal=Rare Tumors |volume=2 |issue=4 |pages=e67 |year=2010 |pmid=21234259 |pmc=3019602 |doi=10.4081/rt.2010.e67 |url=}}</ref>) or multiple lesions are significant.
*May be association with:
**Fetal maternal haemorrhage.
**Hydrops.
**[[IUGR]].
*Incidence: ~1 in 100 placentas.<ref name=pmid20594143/>


===Gross===
===Gross===
*White lesions.
*Multiple tan nodules.
**Occasionally red lesions.


===Microscopic===
===Microscopic===
Features:<ref name=pmid20594143/>
Features:
*Mass of capillaries - '''key feature'''.
*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>
*+/-High cellularity.
*+/-Degenerative changes.


Images:
Images:
*[http://commons.wikimedia.org/wiki/File:Chorangioma_-_intermed_mag.jpg Chorangioma - intermed. mag. (WC)].
*[http://path.upmc.edu/cases/case655.html Chorangiomatosis - several images (upmc.edu)].
*[http://commons.wikimedia.org/wiki/File:Chorangioma_-_low_mag.jpg Chorangioma - low mag. (WC)].
 
==Chorangiosis==
{{Main|Chorangiosis}}
 
=Other=
==Fetus papyraceus==
*May be spelled ''foetus papyraceus''.
*[[AKA]] ''fetus compressus''.
{{Main|Fetus papyraceus}}


Notes:
==Placental mesenchymal dysplasia==
*Must be differentiated from chorangiomatosis (assoc. with preeclampsia & IUGR) and chorangiosis (assoc. with maternal [[diabetes mellitus]]).<ref name=pmid20594143/>
*Abbreviated ''PMD''.
{{Main|Placental mesenchymal dysplasia}}


==Chorangiosis==
=Placental cysts and pseudocysts=
===General===
Types:<ref name=Ref_Placenta219-220>{{Ref Placenta|219-220}}</ref>
*Should not be confused with chorangioma.
*Amnionic epithelial inclusion cyst (amniotic cyst).
*Rare.
*[[Epidermal inclusion cyst]] - lined by keratinized squamous epithelium.
*Chorionic cyst ([[AKA]] chorionic pseudocyts).
*Cell island cyst.


Associations:
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>
*Maternal hypoxia:
*Hematoma.
**Smoking.
*Fibrin-lined pseudocyst.
**Altitude.
**Diabetes.


===Microscopic===
General:<ref name=pmid12054300/>
Features:
*Usually good outcome.
*Increased blood vessels in the terminal villi.
*Large cysts (>4.5 cm) or multiple cysts (>3) are associated with [[IUGR]].
*Not well circumscribed.


Notes:
Images:
*Usually not seen on gross pathology.
*[http://www.jultrasoundmed.org/content/21/6/641/F5.expansion.html Subchorionic cysts (jultrasoundmed.org)].<ref name=pmid12054300/>


=See also=
=See also=
Line 728: Line 801:
=References=
=References=
{{reflist|2}}
{{reflist|2}}
[[Category:Gynecology]]


=Recommended reading=
=Recommended reading=
Line 737: 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]]

Latest revision as of 15:27, 10 May 2018

A placenta (fetal aspect) with attached umbilical cord. (WC/Asturnut)

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.

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:

Clinical screening tests

  • 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

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]

Image:

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:

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]

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]

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).
- 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.

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

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.
  • Cord:
    • 3 vessel?
    • Vasculitis/inflammation?

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

Normal placenta

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.

C-section

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.

Cord pathology

Two vessel umbilical cord

  • AKA two vessel cord.
  • AKA single umbilical artery.

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.
- FETAL MEMBRANES WITHIN NORMAL LIMITS.
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI WITHIN NORMAL LIMITS.

Umbilical knot

  • AKA umbilical cord knot.
  • AKA cord knot.
  • AKA true knot.

General

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:

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

Amnion nodosum

Placental meconium

Squamous metaplasia of the amnion

General

  • Benign common finding thought to be of no clinical significance.[29]
  • Needs to be separated from amnion nodosum - important.[31]

Gross

Features:[32]

  • White (or yellow) plaques - irregular outline.

DDx:

Images:

Microscopic

Features:[32]

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

Image:

Circumvallate placenta

  • AKA circumvallate insertion of the membranes.

General

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:

Images:

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:

Image:

Placental villous immaturity

Villous hypoplasia

  • AKA terminal villus deficiency.[37]

Diseases of the placental attachment

Placenta creta

Includes placenta accreta, placenta increta, and placenta percreta.

Placental abruption

Inflammatory pathologies

Overview of infections

General:[38]

Types

By site:[38]

  • Fetal membranes: chorioamnionitis, membranitis.[39]
  • Umbilical cord: funisitis.
  • Placenta: placentitis, villitis.

Membranitis

Chorionitis redirects here.

General

Microscopic

Features:

  • PMNs in the decidua.
  • +/-PMNs in subamniotic tissue.
  • +/-Necrosis in decidua or chorion/subamniotic tissue.

Note:

DDx:

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.
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI.

Waffle

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.

Chorioamnionitis

Umbilical cord vasculitis

Funisitis

  • Inflammation of Wharton's jelly - the connective tissue of the umbilical cord.

Acute villitis

Villitis of unknown etiology

Chronic intervillitis

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

Chronic deciduitis

  • AKA plasma cell deciduitis.

Placental infarction

True infarcts

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:

Images:

Sign out

Thrombi

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).

Maternal floor infarction

  • Abbreviated MFI.
  • Formally placental maternal floor infarction.
  • AKA massive perivillous fibrin deposition.[45]

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]

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:

Hypertrophic decidual vasculopathy

AKA decidual vasculopathy.

HELLP syndrome

Malaria

General

  • Uncommon in Canada.
  • May lead to fetal demise.

Microscopic

Feature:

  • RBCs with basophilic dots ~1-2 micrometres.

Image

Tumours

Chorangioma

Chorangiomatosis

General

Associated with:

Gross

  • Multiple tan nodules.

Microscopic

Features:

  • Multiple chorangiomas - the difference between chorangioma and chorangiomatosis is not well defined.[51]

Images:

Chorangiosis

Other

Fetus papyraceus

  • May be spelled foetus papyraceus.
  • AKA fetus compressus.

Placental mesenchymal dysplasia

  • Abbreviated PMD.

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:

See also

References

  1. Sun, CC.; Revell, VO.; Belli, AJ.; Viscardi, RM. (Jun 2002). "Discrepancy in pathologic diagnosis of placental lesions.". Arch Pathol Lab Med 126 (6): 706-9. doi:10.1043/0003-9985(2002)1260706:DIPDOP2.0.CO;2. PMID 12033960.
  2. Yetter JF (March 1998). "Examination of the placenta". Am Fam Physician 57 (5): 1045–54. PMID 9518951.
  3. Hargitai B, Marton T, Cox PM (August 2004). "Best practice no 178. Examination of the human placenta". J. Clin. Pathol. 57 (8): 785–92. doi:10.1136/jcp.2003.014217. PMC 1770400. PMID 15280396. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1770400/.
  4. URL: http://smj.sma.org.sg/5012/5012ra1.pdf. Accessed on: 11 February 2011.
  5. Sherman C. 8 February 2011.
  6. URL: http://www.ncbi.nlm.nih.gov/sites/entrez?Db=gene&Cmd=ShowDetailView&TermToSearch=5069. Accessed on: 7 July 2010.
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