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Placenta (view source)

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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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====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]].  
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==Abbreviations==
==Abbreviations==
*C/S = Caesarian section.
*C/S = Caesarean section.
*LSCS = lower segment C-section.
*LSCS = lower segment C-section.
*FTP = failure to progress.
*FTP = failure to progress.
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*PPROM = preterm premature ruptures of membranes.
*PPROM = preterm premature ruptures of membranes.
*IUGR = [[intrauterine growth restriction]].
*IUGR = [[intrauterine growth restriction]].
*IOL = induction of labour.


=Normal histology=
=Normal histology=
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**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>
**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]]''.
***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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===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===
===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>
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 [[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>
*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.
*Fetal malformations.
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===Placental growth restriction===
===Placental growth restriction===
*[[AKA]] ''placenta small for gestational age''.
*[[AKA]] ''placenta small for gestational age''.
*''Small placenta'' redirects here.
Associations:
Associations:
*Maternal vascular disease, e.g. [[hypertrophic decidual vasculopathy|hypertension]].
*Maternal vascular disease, e.g. [[hypertrophic decidual vasculopathy|hypertension]].
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====Sign out====
====Sign out====
<pre>
<pre>
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, CESAERIAN SECTION:
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, BIRTH:
- PLACENTA SMALL FOR GESTATIONAL AGE (160 GRAMS -- TRIMMED, POST-FIXATION WEIGHT).
- PLACENTA SMALL FOR GESTATIONAL AGE (160 GRAMS -- TRIMMED, POST-FIXATION WEIGHT).
- THREE VESSEL UMBILICAL CORD WITHIN NORMAL LIMITS.
- THREE VESSEL UMBILICAL CORD WITHIN NORMAL LIMITS.
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===C-section===
===C-section===
<pre>
<pre>
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, CAESARIAN SECTION:
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, CAESAREAN SECTION:
- THREE VESSEL UMBILICAL CORD WITHIN NORMAL LIMITS.
- THREE VESSEL UMBILICAL CORD WITHIN NORMAL LIMITS.
- FETAL MEMBRANES WITHIN NORMAL LIMITS.
- FETAL MEMBRANES WITHIN NORMAL LIMITS.
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*[[AKA]] ''two vessel cord''.
*[[AKA]] ''two vessel cord''.
*[[AKA]] ''single umbilical artery''.
*[[AKA]] ''single umbilical artery''.
 
{{Main|Two vessel umbilical cord}}
===Associations===
*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 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>
 
===Sign out===
<pre>
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, CAESARIAN SECTION:
- TWO VESSEL UMBILICAL CORD, NEGATIVE FOR INFLAMMATION.
- FETAL MEMBRANES WITH FOCAL PIGMENTED CELLS CONSISTENT WITH MECONIUM,
  NEGATIVE FOR APPARENT CHORIOAMNIONITIS.
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI WITHOUT APPARENT PATHOLOGY.
</pre>


==Insertion==
==Insertion==
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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=
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==Amnion nodosum==
==Amnion nodosum==
===General===
{{Main|Amnion nodosum}}
*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>
*Should be separated from ''squamous metaplasia of amnion''.
 
===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>
*Yellow nodules ~ 1-5 mm.
**Some think they are white.<ref>CS. 7 February 2011.</ref>
 
DDx:
*[[Squamous metaplasia of the amnion]] - large irregular patches, usu. white.
 
Images:
*[http://www.webpathology.com/image.asp?n=2&Case=659 Amnion nodosum (webpathology.com)].
*[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===
Features:<ref name=pmid18081444/>
*Stratified squamous epithelium - non-keratinizing ''or'' minimal keratin.
*Amorphous acidophilic (pink) debris.
 
Note:
*Normal amnion = simple epithelium.
 
Images:
*[http://www.webpathology.com/image.asp?case=659&n=3 Amnion nodosum (webpathology.com)].
*[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 -->


==Placental meconium==
==Placental meconium==
*[[AKA]] ''meconium staining''.
{{Main|Placental meconium}}
===General===
*Associated with fetal distress.
*Small amount - at term - is considered to be normal.
 
Other meconium-related pathology:
*[[Meconium peritonitis]].
*[[Meconium ileus]].
 
===Gross===
*Green/green discolourization.
 
===Microscopic===
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>
*<1 h - no staining of membranes.
*1-3 h - amnion is stained.
*>3 h - chorion is stained.
 
DDx:
*Hemosiderin-laden macrophages.
**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:
*[http://commons.wikimedia.org/wiki/File:Meconium-laden_macrophages_high_mag.jpg Meconium-laden macrophages - high mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Meconium-laden_macrophages_intermed_mag.jpg Meconium-laden macrophages - intermed. mag. (WC)].
 
===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>
 
===Sign out===
<pre>
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, BIRTH:
- FETAL MEMBRANES WITH MECONIUM-LADEN MACROPHAGES, NEGATIVE FOR CHORIOAMNIONITIS.
- THREE VESSEL UMBILICAL CORD WITHIN NORMAL LIMITS.
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI WITHIN NORMAL LIMITS.
</pre>
 
====Not definite====
<pre>
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, CESAERIAN SECTION:
- EARLY CHORIOAMNIONITIS.
- FETAL MEMBRANES WITH FOCAL AMNION CELL DROP-OUT AND RARE PIGMENTED
  CELLS SUGGESTIVE OF MECONIUM.
- THREE VESSEL UMBILICAL CORD WITHIN NORMAL LIMITS.
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI.
</pre>


==Squamous metaplasia of the amnion==
==Squamous metaplasia of the amnion==
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===Gross===
===Gross===
Features:<ref name=pmid18081444/>
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.
*White (or yellow) plaques - irregular outline.


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===General===
===General===
*Non-specific finding.
*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===
===Microscopic===
Features:
Features:
*"Swiss chesse-like" appearance / bubbly appearance.
*"Swiss chesse-like" appearance / bubbly appearance.
*Usu. patchy and focal.
*Usually patchy and focal.
 
Note:
*Cistern formation is reported in the stem villi in association with congenital adrenal hyperplasia.<ref name=pmid11045335/>


DDx:  
DDx:  
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*Fetal edema.
*Fetal edema.
*Idiopathic (no cause apparent).
*Idiopathic (no cause apparent).
*[[Placental villous immaturity]].


Image:
Image:
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==Placental villous immaturity==
==Placental villous immaturity==
*[[AKA]] ''distal villous immaturity'', [[AKA]] ''villous immaturity'', [[AKA]] ''villous dysmaturity''.<ref name=Ref_Placenta_375>{{Ref Placenta|375}}</ref>
{{Main|Placental villous immaturity}}
*Abbreviated ''PVI''.
 
===General===
Associated with:
*[[Diabetes mellitus]].<ref name=pmid1856519>{{Cite journal  | last1 = Arizawa | first1 = M. | last2 = Nakayama | first2 = M. | last3 = Kidoguchi | first3 = K. | title = [Correlation of placental villous immaturity and dysmaturity with clinical control of maternal diabetes]. | journal = Nihon Sanka Fujinka Gakkai Zasshi | volume = 43 | issue = 6 | pages = 595-602 | month = Jun | year = 1991 | doi =  | PMID = 1856519 }}</ref>
*[[Beckwith-Wiedemann syndrome]].
*Intrauterine fetal demise near term.<ref name=pmid15138817>{{Cite journal  | last1 = Stallmach | first1 = T. | last2 = Hebisch | first2 = G. | title = Placental pathology: its impact on explaining prenatal and perinatal death. | journal = Virchows Arch | volume = 445 | issue = 1 | pages = 9-16 | month = Jul | year = 2004 | doi = 10.1007/s00428-004-1032-2 | PMID = 15138817 }}</ref>


===Microscopic===
==Villous hypoplasia==
Features:<ref name=Ref_Placenta_375>{{Ref Placenta|375}}</ref>
*[[AKA]] ''terminal villus deficiency''.<ref name=Ref_Placenta346>{{Ref Placenta|346}}</ref>
*Increased numbers of (immature) intermediate villi (in relation to the gestational age) with:
{{Main|Villous hypoplasia}}
**Increased number of capillaries.
**Edema.
**Macrophages.
**Large diffusion distance (vessel-to-villous surface distance large).
*Less (mature) terminal villi.<ref name=pmid18382864>{{Cite journal  | last1 = Daskalakis | first1 = G. | last2 = Marinopoulos | first2 = S. | last3 = Krielesi | first3 = V. | last4 = Papapanagiotou | first4 = A. | last5 = Papantoniou | first5 = N. | last6 = Mesogitis | first6 = S. | last7 = Antsaklis | first7 = A. | title = Placental pathology in women with gestational diabetes. | journal = Acta Obstet Gynecol Scand | volume = 87 | issue = 4 | pages = 403-7 | month =  | year = 2008 | doi = 10.1080/00016340801908783 | PMID = 18382864 }}</ref>
 
DDx:
*[[Chorangiosis]].
 
Images:
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Placental_villous_immaturity_-_low_mag.jpg Placental villous immaturity - low mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Placental_villous_immaturity_-_intermed_mag.jpg Placental villous immaturity - intermed. mag. (WC)].


=Diseases of the placental attachment=
=Diseases of the placental attachment=
==Placenta creta==
==Placenta creta==
*What?
Includes ''placenta accreta'', ''placenta increta'', and ''placenta percreta''.
**Trophoblastic tissue deeper than it should be.
{{Main|Placenta creta}}
*Clinical?
**Postpartum hemorrhage leading to a hysterectomy.<ref name=pmid18514815>{{Cite journal  | last1 = Tantbirojn | first1 = P. | last2 = Crum | first2 = CP. | last3 = Parast | first3 = MM. | title = Pathophysiology of placenta creta: the role of decidua and extravillous trophoblast. | journal = Placenta | volume = 29 | issue = 7 | pages = 639-45 | month = Jul | year = 2008 | doi = 10.1016/j.placenta.2008.04.008 | PMID = 18514815 }}</ref>
*Pathogenesis?
**It is suspected that it arises as there is defect in the endometrium/myometrium -- ''not'' deep trophoblastic invasion.<ref name=pmid18514815/>
**Risk factors:<ref name=pmid23466142>{{Cite journal  | last1 = Wortman | first1 = AC. | last2 = Alexander | first2 = JM. | title = Placenta accreta, increta, and percreta. | journal = Obstet Gynecol Clin North Am | volume = 40 | issue = 1 | pages = 137-54 | month = Mar | year = 2013 | doi = 10.1016/j.ogc.2012.12.002 | PMID = 23466142 }}</ref>
***Placenta previa.
***Previous caesarian section.
 
Note:
*Normal: trophoblastic tissue attaches to the decidua.<ref name=Ref_Pathde_974>{{Ref Pathde|974}}</ref>
 
===Placenta accreta===
*Trophoblastic tissue (directly) adherent to the myometrium.<ref name=Ref_Pathde_974>{{Ref Pathde|974}}</ref>
 
Image:
*[http://library.med.utah.edu/WebPath/jpeg2/PLAC040.jpg Placenta accreta (med.utah.edu)].<ref>URL: [http://library.med.utah.edu/WebPath/EXAM/IMGQUIZ/plfrm.html http://library.med.utah.edu/WebPath/EXAM/IMGQUIZ/plfrm.html]. Accessed on: 3 December 2011.</ref>
 
===Placenta increta===
*Trophoblastic tissue extends into the myometrium.
 
===Placenta percreta===
*Trophoblastic tissue penetrates through the myometrium.


==Placental abruption==
==Placental abruption==
===General===
{{Main|Placental abruption}}
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>
*Vaginal bleeding (~70%).
*Abdominal pain (~50%).
*Fetal heart rate abnormalities (~70%).
 
Sign-out:
*Pathologists should sign-out this as "focal adherent retroplacental hematoma".
**The pathologic findings may be due to abruption or manual removal of the placenta.
 
===Gross===
Features:<ref>CS. 7 February 2011.</ref>
*Large adherent blood clot.
*Disc depression on maternal side.
 
Notes:
*Loosely attached clot less convincing.
*Central haemorrhage is the most worrisome.
 
===Microscopic===
Features:
#Decidual hemorrhage.
#*Blood in the decidua.
#Intravillous hemorrhage, [[AKA]] villous stromal hemorrhage.
#*"Bags of blood" - blood outside of vessels in the villi.
#**Should not be confused with congested villi.
 
Notes:
*There are '''no''' definitive microscopic findings for placental abruption.
*Intravillous hemorrhage is non-specific - may arise in the following: early placental infarct, cord compression, abdominal trauma.


=Inflammatory pathologies=
=Inflammatory pathologies=
Line 717: Line 549:


==Membranitis==
==Membranitis==
:''Chorionitis'' redirects here.
===General===  
===General===  
*Controversial. (???)
*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===
===Microscopic===
Line 728: Line 562:
Note:
Note:
*Plasma cells in the decidua = [[chronic deciduitis]].
*Plasma cells in the decidua = [[chronic deciduitis]].
DDx:
*[[Chorioamnionitis]].


====Grading membranitis====
====Grading membranitis====
Line 734: Line 571:
# 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==
===General===
*Associated with pre-term labour.<ref name=pmid22958008>{{Cite journal  | last1 = Martinelli | first1 = P. | last2 = Sarno | first2 = L. | last3 = Maruotti | first3 = GM. | last4 = Paludetto | first4 = R. | title = Chorioamnionitis and prematurity: a critical review. | journal = J Matern Fetal Neonatal Med | volume = 25 Suppl 4 | issue =  | pages = 29-31 | month = Oct | year = 2012 | doi = 10.3109/14767058.2012.714981 | PMID = 22958008 }}</ref>
**Classically described as due to an ascending infection.
*At term usually non-infectious.<ref name=pmid22412842>{{Cite journal  | last1 = Roberts | first1 = DJ. | last2 = Celi | first2 = AC. | last3 = Riley | first3 = LE. | last4 = Onderdonk | first4 = AB. | last5 = Boyd | first5 = TK. | last6 = Johnson | first6 = LC. | last7 = Lieberman | first7 = E. | title = Acute histologic chorioamnionitis at term: nearly always noninfectious. | journal = PLoS One | volume = 7 | issue = 3 | pages = e31819 | month =  | year = 2012 | doi = 10.1371/journal.pone.0031819 | PMID = 22412842 }}</ref>
Clinical features:
*Maternal fever.
*Premature rupture of membranes (PROM).
*Non-reassuring fetal heart rate (NRFHR).
Management:
*Antibiotics - usually ampicillin and gentamicin.<ref name=pmid20569811>{{Cite journal  | last1 = Tita | first1 = AT. | last2 = Andrews | first2 = WW. | title = Diagnosis and management of clinical chorioamnionitis. | journal = Clin Perinatol | volume = 37 | issue = 2 | pages = 339-54 | month = Jun | year = 2010 | doi = 10.1016/j.clp.2010.02.003 | PMID = 20569811 | PMC = 3008318 }}</ref>
===Gross===
*Fetal membranes dull/opaque.
===Microscopic===
Features:
*Neutrophils in the amnion.
**Amnion:
***The simple cuboidal epithelium and the paucicellular underlying connective tissue
***Separated from the chorion by an artefactual cleft.
Note:
*Severe cases may have umbilical cord vasculitis or [[funisitis]].
Images:
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Chorioamnionitis_-_low_mag.jpg Chorioamnionitis - low mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Chorioamnionitis_-_high_mag.jpg Chorioamnionitis - high mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Chorioamnionitis_-2-_very_high_mag.jpg Chorioamnionitis - very high mag. (WC)].
====Grading chorioamnionitis====
Chorioamnionitis:<ref name=Ref_Sternberg4_2311>{{Ref Sternberg4|2311}}</ref>
# placental chorionic plate only.
# 1 + subamniotic tissue.
# 1 or 2 + necrosis ''or'' abscess.


===Sign out===
===Sign out===
<pre>
<pre>
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, CESAERIAN SECTION:
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, CESAERIAN SECTION:
- CHORIOAMNIONITIS.
- FETAL MEMBRANES WITH CHORIONITIS.
- FETAL MEMBRANES NEGATIVE MECONIUM.
- THREE VESSEL UMBILICAL CORD WITH VASCULITIS.
- THREE VESSEL UMBILICAL CORD WITHIN NORMAL LIMITS.
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI.
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI.
- THROMBUS OF THE PLACENTAL DISC (1.3 CM - MAXIMAL DIMENSION).
</pre>
</pre>


==Umbilical cord vasculitis==
====Waffle====
===General===
*Usually seen together with [[chorioamnionitis]].
**May be described as the ''fetal response'' to chorioamnionitis.<ref name=pmid14749651/>
*Presence considered to be a good prognosticator.<ref name=pmid14749651>{{Cite journal  | last1 = Lahra | first1 = MM. | last2 = Jeffery | first2 = HE. | title = A fetal response to chorioamnionitis is associated with early survival after preterm birth. | journal = Am J Obstet Gynecol | volume = 190 | issue = 1 | pages = 147-51 | month = Jan | year = 2004 | doi = 10.1016/j.ajog.2003.07.012 | PMID = 14749651 }}
</ref>
 
===Microscopic===
Features:
*[[Neutrophil]]s in the vessels of the umbilical cord.
*Wharton's jelly without neutrophils.
 
Note:
*Umbilical vein involvement (umbilical phlebitis) precedes umbilical artery involvement (umbilical arteritis).<ref name=pmid21090086>{{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>
 
DDx:
*[[Funisitis]] - neutrophils also in the connective tissue of the umbilical cord (Wharton's jelly).
 
====Grading====
Umbilical cord vasculitis:<ref name=Ref_Sternberg4_2311>{{Ref Sternberg4|2311}}</ref>
* +0.5 for each vessel.
* +0.5 for each vessel with severe involvement.
 
==Funisitis==
===General===
*Usu. seen together with [[chorioamnionitis]].
 
===Microscopic===
Features:
*Neutrophils in the vessels of the umbilical cord and Wharton's jelly.
 
Note:
*Wharton's jelly = connective tissue of the umbilical cord.
 
DDx:
*[[Umbilical cord vasculitis]] - neutrophils only in the vessel wall.
 
====Grading funisitis====
Funisitis:<ref name=Ref_Sternberg4_2311>{{Ref Sternberg4|2311}}</ref>
# Focal inflammation.
# Diffuse inflammation.
# Necrosis - in umbilical vessels or Wharton jelly.
 
===Sign out===
<pre>
<pre>
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, BIRTH:
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, BIRTH:
- CHORIOAMNIONITIS.
- FETAL MEMBRANES WITH MECONIUM-LADEN MACROPHAGES AND ABUNDANT DECIDUAL NEUTROPHILS
- THREE VESSEL UMBILICAL CORD WITH FUNISITIS.
  SUSPICIOUS FOR EARLY CHORIONITIS.
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI.
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI.
- TWO THROMBI OF THE PLACENTAL DISC (LARGEST 0.9 CM - MAXIMAL DIMENSION).
- THREE VESSEL UMBILICAL CORD WITHIN NORMAL LIMITS.
</pre>
</pre>


==Acute villitis==
==Chorioamnionitis==
===General===
{{Main|Chorioamnionitis}}
*Rare.
 
*Typically viral - see ''[[TORCH infections]]''.
==Umbilical cord vasculitis==
{{Main|Umbilical cord vasculitis}}


===Microscopic===
==Funisitis==
Features:
{{Main|Funisitis}}
*[[Neutrophil]]s in the villous stroma - '''key feature'''.
*Inflammation of Wharton's jelly - the connective tissue of the umbilical cord.


Images:
==Acute villitis==
*[http://www.webpathology.com/image.asp?n=1&Case=579 Acute villitis (webpathology.com)].
{{main|Acute villitis}}
*[http://www.webpathology.com/image.asp?n=2&Case=579 Acute villitis (webpathology.com)].


==Villitis of unknown etiology==
==Villitis of unknown etiology==
*Abbreviated ''VUE''.
{{Main|Villitis of unknown etiology}}
 
===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>
*Usually term placenta.
*Prevalence: 5% to 15% of all placentas.
*Associated with:
**[[Intrauterine growth restriction]] (IUGR).
**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===
Features:<ref name=pmid17889674/>
*Lymphocytes in villous stroma - '''key feature'''.
**Usually focal/patchy.
**Lymphocytes: maternal derivation, T-lymphocytes -- mostly CD8-positive.
*+/-Intervillositis (lymphocytes between villi).
*+/-Histiocytes.
 
Notes:
*Lymphocytes are smaller and stain darker than the cells of the villi. (???)
*Neutrophils are usually absent.  A significant number of 'em is suggestive of an infectious villitis.
*Infective villitis is usu. B-cell predominant.
*'''No''' plasma cells - this suggests an infectious etiology.<ref>Sherman, C. 7 February 2011.</ref>
**Plasma cells may be seen in the decidua -- these can be ignored.
 
Images:
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Villitis_of_unknown_etiology_-_intermed_mag.jpg VUE - intermed. mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Villitis_of_unknown_etiology_-_very_high_mag.jpg VUE - very high mag. (WC)].
*www:
**[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 name=jian>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>
**[http://www.flickr.com/photos/jian-hua_qiao_md/3954022678/in/photostream/ VUE (flickr.com)].<ref name=jian>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>


==Chronic intervillitis==
==Chronic intervillitis==
Line 903: Line 619:
*Fibrinoid deposition.
*Fibrinoid deposition.


Images:
====Images====
*[http://commons.wikimedia.org/wiki/File:Intervillitis_-_intermed_mag.jpg Intervillitis - intermed. mag. (WC)].
<gallery>
*[http://commons.wikimedia.org/wiki/File:Intervillitis_-_very_high_mag.jpg Intervillitis - very high mag. (WC)].
Image:Intervillitis_-_intermed_mag.jpg | Intervillitis - intermed. mag. (WC)
 
Image:Intervillitis_-_very_high_mag.jpg | Intervillitis - very high mag. (WC)
</gallery>
==Chronic deciduitis==
==Chronic deciduitis==
*[[AKA]] plasma cell deciduitis.
*[[AKA]] plasma cell deciduitis.
 
{{Main|Chronic deciduitis}}
===General===
*Associated with preterm labour.<ref name=pmid18171100>{{Cite journal  | last1 = Edmondson | first1 = N. | last2 = Bocking | first2 = A. | last3 = Machin | first3 = G. | last4 = Rizek | first4 = R. | last5 = Watson | first5 = C. | last6 = Keating | first6 = S. | title = The prevalence of chronic deciduitis in cases of preterm labor without clinical chorioamnionitis. | journal = Pediatr Dev Pathol | volume = 12 | issue = 1 | pages = 16-21 | month =  | year =  | doi = 10.2350/07-04-0270.1 | PMID = 18171100 }}</ref>
 
===Microscopic===
Features:<ref name=pmid18171100/>
*Plasma cells within the decidua.
 
Notes:
*Decidua = maternal tissue.
 
Images:
*[http://commons.wikimedia.org/wiki/File:Chronic_deciduitis_-_intermed_mag.jpg Chronic deciduitis - intermed. mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Chronic_deciduitis_-_very_high_mag.jpg Chronic deciduitis - very high mag. (WC)].


=Placental infarction=
=Placental infarction=
==True infarcts==
==True infarcts==
{{Main|Infarction}}
{{Main|Placental infarct}}
===General===
*May be seen in conjunction with a retroplacental hematoma.
*Infarcts frequently associated with [[hypertension]].<ref>URL: [http://www.medind.nic.in/jae/t04/i1/jaet04i1p27.pdf http://www.medind.nic.in/jae/t04/i1/jaet04i1p27.pdf]. Accessed on: 16 April 2012.</ref><ref name=pmid11969346>{{Cite journal  | last1 = Becroft | first1 = DM. | last2 = Thompson | first2 = JM. | last3 = Mitchell | first3 = EA. | title = The epidemiology of placental infarction at term. | journal = Placenta | volume = 23 | issue = 4 | pages = 343-51 | month = Apr | year = 2002 | doi = 10.1053/plac.2001.0777 | PMID = 11969346 }}</ref>
 
Note: "[[Maternal floor infarct]]" is ''not'' a true infarct.<ref name=Ref_TPoSP178>{{Ref TPoSP|178}}</ref>
 
===Gross===
Features:<ref name=Ref_WMSP465>{{Ref WMSP|465}}</ref>
*Early - red.
*Late - white/grey.
 
====Significant infarcts====
*> 3cm --or-- central location --or-- in 1st or 2nd trimester.{{fact}}
**Small foci are accepted in term placentae - typically at periphery.
 
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:
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Placental_infarct_-_low_mag.jpg Placental infarct - low mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Placental_infarct_-_intermed_mag.jpg Placental infarct - intermed. mag. (WC)].
*www:
**[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)].


==Perivillous fibrin deposition==
==Perivillous fibrin deposition==
*Abbreviation ''PFD''.
*Abbreviation ''PFD''.
===General===
===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>
*May be associated with [[diabetes mellitus]].<ref name=Ref_Placenta327>{{Ref Placenta|327}}</ref>


Line 1,011: Line 674:
*Formally ''placental maternal floor infarction''.
*Formally ''placental maternal floor infarction''.
*[[AKA]] ''massive perivillous fibrin deposition''.<ref name=Ref_Placenta367>{{Ref Placenta|367}}</ref>
*[[AKA]] ''massive perivillous fibrin deposition''.<ref name=Ref_Placenta367>{{Ref Placenta|367}}</ref>
===General===
{{Main|Maternal floor infarction}}
*'''''Not''''' a true infact.
**It is really fibrin deposition.<ref name=Ref_TPoSP178>{{Ref TPoSP|178}}</ref>
 
Associations:
*[[Intrauterine growth restriction]] (IUGR).<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><ref name=pmid11910510>{{Cite journal  | last1 = Katzman | first1 = PJ. | last2 = Genest | first2 = DR. | title = Maternal floor infarction and massive perivillous fibrin deposition: histological definitions, association with intrauterine fetal growth restriction, and risk of recurrence. | journal = Pediatr Dev Pathol | volume = 5 | issue = 2 | pages = 159-64 | month =  | year =  | doi = 10.1007/s10024-001-0195-y | PMID = 11910510 }}</ref>
*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>
**APLA is associated with recurrent miscarriage - can be treated with heparin + ASA.<ref name=pmid12066949/>
*Pregnancy-induced [[hypertension]].<ref name=pmid8569189>{{Cite journal  | last1 = Kanfer | first1 = A. | last2 = Bruch | first2 = JF. | last3 = Nguyen | first3 = G. | last4 = He | first4 = CJ. | last5 = Delarue | first5 = F. | last6 = Flahault | first6 = A. | last7 = Nessmann | first7 = C. | last8 = Uzan | first8 = S. | title = Increased placental antifibrinolytic potential and fibrin deposits in pregnancy-induced hypertension and preeclampsia. | journal = Lab Invest | volume = 74 | issue = 1 | pages = 253-8 | month = Jan | year = 1996 | doi =  | PMID = 8569189 }}</ref>
 
===Gross===
Features:<ref name=Ref_Placenta368>{{Ref Placenta|368}}</ref>
*+/-Thickened placenta.
*Maternal aspect of placental disc irregular or lobulated appearance.
*+/-Yellowish discolourization.
 
===Microscopic===
Features:
*Extensive fibrin deposition around villi on maternal aspect - see: ''[[Perivillous fibrin deposition]]''.
**Described as having a "net-like" pattern.<ref name=Ref_Placenta368>{{Ref Placenta|368}}</ref>
**"Extensive" - either of the following:<ref name=pmid11910510/><ref>AFIP - Placental Pathology. P.135. ISBN: 1-881041-89-1. 2004.</ref>
**#Micro: one slide with >50% of villi involved.
**#*Gross: full thickness involvement.
**#Micro: maternal floor has at least 3 mm of fibrin on one slide.
**#*Gross: maternal floor diffusely involved.
 
DDx:
*[[Perivillous fibrin deposition]] - less perivillous fibrin.
*[[Placental infarction]].
 
Images:
*[http://www.flickr.com/photos/jian-hua_qiao_md/3987724630/ Maternal floor infarct (flickr.com)].
*[http://www.flickr.com/photos/jian-hua_qiao_md/3986970923/ Maternal floor infarct (flickr.com)].
*[http://path.upmc.edu/cases/case224.html Maternal floor infarct - several images (upmc.edu)].
 
===Sign out===
<pre>
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, BIRTH:
- THREE VESSEL UMBILICAL CORD WITHIN NORMAL LIMITS.
- FETAL MEMBRANES WITHIN NORMAL LIMITS.
- SMALL PLACENTAL DISC WITH MASSIVE PERIVILLOUS FIBRIN DEPOSITION, SEE COMMENT.
 
COMMENT:
Massive perivillous fibrin deposition (MPVFD) is associated with intrauterine
growth restriction (IUGR). MPVFD is described in association with in
anti-phospholipid antibody (APLA) syndrome, pregnancy-induced hypertension and
congenital infections. Perivillous fibrin deposition may be seen in diabetes.
 
There is no apparent infection. Changes suggestive of decidual vasculopathy
are not apparent. Changes suggestive of fetal thrombotic vasculopathy are
not identified.
</pre>


=Fetal disease=
=Fetal disease=
Line 1,072: Line 684:
**''Fetal artery stem thrombosis''.
**''Fetal artery stem thrombosis''.
*The multitude of terms reflects the confusion about this finding and that it has numerous etiologies.<ref name=pmid19237859/>
*The multitude of terms reflects the confusion about this finding and that it has numerous etiologies.<ref name=pmid19237859/>
===General===
{{Main|Fetal thrombotic vasculopathy}}
*May cause [[IUGR]].
*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>
 
===Microscopic===
Features:<ref name=pmid10414494>{{Cite journal  | last1 = Kraus | first1 = FT. | last2 = Acheen | first2 = 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 | month = Jul | year = 1999 | doi =  | PMID = 10414494 }}</ref>
*Thrombus in the fetal vasculature +/- recanalization.
**Eosinophilic (light pink on H&E), moderately granular intravascular material (fibrin) with layering.
*Clustered fibrotic villi without blood vessels - '''key feature'''.
**This is a chronic change.
 
Images:
*www:
**[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>
**[http://www.womenandinfants.org/fertilityandpregnancy/images/FTV.Fig.4a.jpg FTV - low mag. (womenandinfants.org)].<ref>URL: [http://www.womenandinfants.org/fertilityandpregnancy/current-topics-in-perinatal-pathology.cfm http://www.womenandinfants.org/fertilityandpregnancy/current-topics-in-perinatal-pathology.cfm]. Accessed on: 17 December 2012.</ref>
**[http://www.womenandinfants.org/fertilityandpregnancy/images/FTV.Fig.4b.jpg FTV - high mag. (womenandinfants.org)].
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Fetal_thrombotic_vasculopathy_-_intermed_mag.jpg FTV - intermed. mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Fetal_thrombotic_vasculopathy_-_high_mag.jpg FTV - high mag. (WC)].


==Hemorrhagic endovasculitis==
==Hemorrhagic endovasculitis==
Line 1,120: 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}}
*Seen in [[intrauterine growth restriction]] (IUGR).
 
===Microscopic===
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>
*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).
 
Note:
*''Smooth muscle hypertrophy'' can also be understood as ''lack of physiological conversion of spiral arteries of the uterus''.<ref name=pmid12848643>{{Cite journal  | last1 = Naicker | first1 = T. | last2 = Khedun | first2 = SM. | last3 = Moodley | first3 = J. | last4 = Pijnenborg | first4 = R. | title = Quantitative analysis of trophoblast invasion in preeclampsia. | journal = Acta Obstet Gynecol Scand | volume = 82 | issue = 8 | pages = 722-9 | month = Aug | year = 2003 | doi =  | PMID = 12848643 }}</ref>
 
Images:
*[[WC]]:
**[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)].
*www:
**[http://path.upmc.edu/cases/case75/images/micro2.jpg Atherosis (upmc.edu)].<ref>URL: [http://path.upmc.edu/cases/case75.html http://path.upmc.edu/cases/case75.html]. Accessed on: 2 January 2012.</ref>


==HELLP syndrome==
==HELLP syndrome==
===General===
{{Main|HELLP syndrome}}
*Diagnosed clinically.
*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>
 
Definition:
*'''H''' = hemolysis.
*'''EL''' = elevated liver enzymes.
*'''LP''' = low platelets.
 
===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>
*Thrombotic microangiopathic vasculopathy.
**In essence: severe ''hypertrophic decidual vasculopathy''. (???)


==Malaria==
==Malaria==
Line 1,175: Line 735:
*[[RBC]]s with basophilic dots ~1-2 micrometres.
*[[RBC]]s with basophilic dots ~1-2 micrometres.


Image:
====Image====
*[http://commons.wikimedia.org/wiki/File:Maternal_malaria_placenta_-_very_high_mag.jpg Maternal malaria - very high mag. (WC)].
<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==
===General===
{{Main|Chorangioma}}
*[[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>
 
Epidemiology:
*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.
**[[Fetal hydrops]].
**[[IUGR]].
*Incidence: ~1 in 100 placentas.<ref name=pmid20594143/>
 
===Gross===
*White lesions.
**Occasionally red lesions.
 
===Microscopic===
Features:<ref name=pmid20594143/>
*Mass of capillaries - '''key feature'''.
*+/-High cellularity.
*+/-Degenerative changes.
 
Images:
*[http://commons.wikimedia.org/wiki/File:Chorangioma_-_intermed_mag.jpg Chorangioma - intermed. mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Chorangioma_-_low_mag.jpg Chorangioma - low mag. (WC)].
 
Notes:
*Must be differentiated from [[chorangiomatosis]] (associated with preeclampsia & IUGR) and chorangiosis (assoc. with maternal [[diabetes mellitus]]).<ref name=pmid20594143/>


==Chorangiomatosis==
==Chorangiomatosis==
Line 1,227: Line 762:


==Chorangiosis==
==Chorangiosis==
===General===
{{Main|Chorangiosis}}
*Should not be confused with [[chorangioma]].
*Relative common among babies in ICU ~5%.<ref>URL: [http://www.bhj.org/journal/2009_5102_april/download/pg251-252.pdf http://www.bhj.org/journal/2009_5102_april/download/pg251-252.pdf]. Accessed on: 26 July 2011.</ref>
 
Associations:
*Maternal hypoxia:
**[[Smoking]].
**Altitude.
**Gestational [[diabetes]].<ref name=pmid18382864>{{Cite journal  | last1 = Daskalakis | first1 = G. | last2 = Marinopoulos | first2 = S. | last3 = Krielesi | first3 = V. | last4 = Papapanagiotou | first4 = A. | last5 = Papantoniou | first5 = N. | last6 = Mesogitis | first6 = S. | last7 = Antsaklis | first7 = A. | title = Placental pathology in women with gestational diabetes. | journal = Acta Obstet Gynecol Scand | volume = 87 | issue = 4 | pages = 403-7 | month =  | year = 2008 | doi = 10.1080/00016340801908783 | PMID = 18382864 }}</ref>
 
===Gross===
*Usually not seen on gross pathology.
 
===Microscopic===
Features:
*Increased blood vessels in the terminal villi.
**Altshuler criteria: "a minimum of 10 villi, each with 10 or more vascular channels, in 3 or more random, non-infarcted placental areas when using a ×10 ocular."<ref name=pmid6546343>{{Cite journal  | last1 = Altshuler | first1 = G. | title = Chorangiosis. An important placental sign of neonatal morbidity and mortality. | journal = Arch Pathol Lab Med | volume = 108 | issue = 1 | pages = 71-4 | month = Jan | year = 1984 | doi =  | PMID = 6546343 }}</ref><ref name=pmid11520290/><ref>URL: [http://path.upmc.edu/cases/case655/dx.html http://path.upmc.edu/cases/case655/dx.html]. Accessed on: 28 January 2012.</ref>
***The definition suffers from [[IPFitis]].
*Lesion ''not'' well circumscribed.
*Villi tend to be larger and have centrally placed blood vessels.<ref>E. Latta. 26 July 2011.</ref>
 
Notes:
*Normal villi have up to five vascular channels.<ref name=pmid11520290>{{Cite journal  | last1 = De La Ossa | first1 = MM. | last2 = Cabello-Inchausti | first2 = B. | last3 = Robinson | first3 = MJ. | title = Placental chorangiosis. | journal = Arch Pathol Lab Med | volume = 125 | issue = 9 | pages = 1258 | month = Sep | year = 2001 | doi = 10.1043/0003-9985(2001)1251258:PC2.0.CO;2 | PMID = 11520290 | url=http://www.archivesofpathology.org/doi/full/10.1043/0003-9985%282001%29125%3C1258:PC%3E2.0.CO;2}}</ref>
 
Images:
*[http://commons.wikimedia.org/wiki/File:Chorangiosis_-_intermed_mag.jpg Chorangiosis - intermed. mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Chorangiosis_-_high_mag.jpg Chorangiosis - high mag. (WC)].
 
===Sign out===
<pre>
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, CESAERIAN SECTION:
- THREE VESSEL UMBILICAL CORD WITHIN NORMAL LIMITS.
- FETAL MEMBRANES WITHIN MECONIUM STAINING OF THE AMNION, NEGATIVE FOR CHORIOAMNIONITIS.
- PLACENTAL DISC WITH:
-- CHORANGIOSIS.
-- FOCAL PERIVILLOUS FIBRIN DEPOSITION.
 
COMMENT:
Chorangiosis is a non-specific finding that may be associated with diabetes, smoking or high altitude.
</pre>


=Other=
=Other=
Line 1,272: Line 768:
*May be spelled ''foetus papyraceus''.
*May be spelled ''foetus papyraceus''.
*[[AKA]] ''fetus compressus''.
*[[AKA]] ''fetus compressus''.
 
{{Main|Fetus papyraceus}}
===General===
*Remnant of a dead fetus usu. from a twin pregnancy.
**No clinical consequence for mother and remaining fetus.
 
Clinical:<ref name=Ref_Placenta141>{{Ref Placenta|141}}</ref>
*Documented multiple gestation by imaging.
*Elevated AFP.
*May be a "fetal reduction" in the context of ''in vitro'' fertilization (IVF).
 
Note:
*"Papyraceus" = paper-like.
 
===Gross===
*Pale yellow flattened disk or plaque with a pigmented macule<ref name=Ref_Placenta141>{{Ref Placenta|141}}</ref> - on membranes or placental disc.
 
===Microscopic===
Features:
*Fetal structures - such as:
**Cartilage.
**Bone.
 
Images:
*[http://www.nejm.org/doi/full/10.1056/NEJMicm020196 Fetus papyraceus (nejm.org)].
*[http://path.upmc.edu/cases/case128.html Fetus papyraceus (upmc.edu)].
*[http://www.neonet.ch/en/03_Case_of_the_month/archive/11_dermatologic_disorders/2002_10.asp Fetus papyraceus (neonet.ch)].<ref>URL: [http://www.neonet.ch/en/03_Case_of_the_month/archive/11_dermatologic_disorders/2002_10.asp http://www.neonet.ch/en/03_Case_of_the_month/archive/11_dermatologic_disorders/2002_10.asp]. Accessed on: 3 January 2012.</ref>


==Placental mesenchymal dysplasia==
==Placental mesenchymal dysplasia==
*Abbreviated ''PMD''.
*Abbreviated ''PMD''.
===General===
{{Main|Placental mesenchymal dysplasia}}
*Very rare ~ 70 reported cases.<ref name=pmid16753607>{{Cite journal  | last1 = Pham | first1 = T. | last2 = Steele | first2 = J. | last3 = Stayboldt | first3 = C. | last4 = Chan | first4 = L. | last5 = Benirschke | first5 = K. | title = Placental mesenchymal dysplasia is associated with high rates of intrauterine growth restriction and fetal demise: A report of 11 new cases and a review of the literature. | journal = Am J Clin Pathol | volume = 126 | issue = 1 | pages = 67-78 | month = Jul | year = 2006 | doi = 10.1309/RV45-HRD5-3YQ2-YFTP | PMID = 16753607 }}</ref>
*Etiology unknown.


Associations:<ref name=pmid16753607/>
=Placental cysts and pseudocysts=
*[[IUGR]] ~ 50% of cases.
Types:<ref name=Ref_Placenta219-220>{{Ref Placenta|219-220}}</ref>
*Fetal demise ~ 40-45% of cases.
*Amnionic epithelial inclusion cyst (amniotic cyst).
*[[Beckwith-Wiedemann syndrome]].  
*[[Epidermal inclusion cyst]] - lined by keratinized squamous epithelium.
*Chorionic cyst ([[AKA]] chorionic pseudocyts).
*Cell island cyst.


===Gross===
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>
Features:<ref name=pmid23266781>{{Cite journal  | last1 = Rohilla | first1 = M. | last2 = Siwatch | first2 = S. | last3 = Jain | first3 = V. | last4 = Nijhawan | first4 = R. | title = Placentomegaly and placental mesenchymal dysplasia. | journal = BMJ Case Rep | volume = 2012 | issue = | pages = | month = | year = 2012 | doi = 10.1136/bcr-2012-007777 | PMID = 23266781 }}</ref>
*Hematoma.
*[[Placentomegaly]].
*Fibrin-lined pseudocyst.
*Grape-like vesicles.  


DDx - gross:
General:<ref name=pmid12054300/>
*[[Partial hydatidiform mole]].
*Usually good outcome.
*Large cysts (>4.5 cm) or multiple cysts (>3) are associated with [[IUGR]].


Image:
Images:
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3094260/figure/F3/ PMD (nih.gov)].<ref name=pmid21513565/>
*[http://www.jultrasoundmed.org/content/21/6/641/F5.expansion.html Subchorionic cysts (jultrasoundmed.org)].<ref name=pmid12054300/>
===Microscopic===
Features:<ref name=pmid21513565>{{Cite journal  | last1 = Umazume | first1 = T. | last2 = Kataoka | first2 = S. | last3 = Kamamuta | first3 = K. | last4 = Tanuma | first4 = F. | last5 = Sumie | first5 = A. | last6 = Shirogane | first6 = T. | last7 = Kudou | first7 = T. | last8 = Ikeda | first8 = H. | title = Placental mesenchymal dysplasia, a case of intrauterine sudden death of fetus with rupture of cirsoid periumbilical chorionic vessels. | journal = Diagn Pathol | volume = 6 | issue =  | pages = 38 | month =  | year = 2011 | doi = 10.1186/1746-1596-6-38 | PMID = 21513565 }}</ref>
*Stem villi with edema (hydropic changes) and few blood vessels.
*Paucivascular (few blood vessels) or avascular (terminal) villi.
 
Note:
*Stem villi = large villi with a fibrotic core and (fetal) arteries and veins.<ref name=pmid9260835>{{Cite journal  | last1 = Demir | first1 = R. | last2 = Kosanke | first2 = G. | last3 = Kohnen | first3 = G. | last4 = Kertschanska | first4 = S. | last5 = Kaufmann | first5 = P. | title = Classification of human placental stem villi: review of structural and functional aspects. | journal = Microsc Res Tech | volume = 38 | issue = 1-2 | pages = 29-41 | month =  | year =  | doi = 10.1002/(SICI)1097-0029(19970701/15)38:1/229::AID-JEMT53.0.CO;2-P | PMID = 9260835 }}</ref>
 
Image:
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3094260/figure/F5/ PMD (nih.gov)].<ref name=pmid21513565/>


=See also=
=See also=
Line 1,347: 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]]
[[Category:Placenta]]
Michael
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