Difference between revisions of "Placenta"

Jump to navigation Jump to search

Placenta (view source)

Revision as of 15:27, 10 May 2018

2,371 bytes removed ,  15:27, 10 May 2018
→‎What to remember...
(→‎Infection: wikify)
 
(261 intermediate revisions by 2 users not shown)
Line 1: Line 1:
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.
Line 11: Line 16:
*#*Bad fetal outcome.
*#*Bad fetal outcome.
*#*Suspected or known congenital abnormalities ''or'' chromosomal abnormalities.
*#*Suspected or known congenital abnormalities ''or'' chromosomal abnormalities.
*#*[[IUGR]].
*#Mother:
*#Mother:
*#*Infection/suspected infection.
*#*Infection/suspected infection.
*#*Pre-term labour.
*#*Pre-term labour.
*#*Maternal disease (e.g. SLE, coagulopathy).
*#*Maternal disease (e.g. [[SLE]], coagulopathy).
*#*Complicated pregnancy (preclampsia, pregnancy induced hypertension, gestational diabetes).
*#*Complicated pregnancy (preclampsia, pregnancy induced hypertension, gestational diabetes).
*#Placenta:
*#Placenta:
Line 22: Line 28:


====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==
Line 94: Line 108:
*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==
Line 118: Line 142:
***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.
Line 125: Line 149:
***Normal: 2 arteries, 1 vein.
***Normal: 2 arteries, 1 vein.
*Membranes - shiny & translucent - normal (green, opaque/dull - chorioamnionitis).
*Membranes - shiny & translucent - normal (green, opaque/dull - chorioamnionitis).
**Attachment: marginal (normal), circummarginate (inside edge), 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.
Line 138: Line 162:
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.


Line 151: Line 175:
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>


Line 172: Line 196:


===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%'''
Line 196: Line 220:
*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=
Line 230: Line 301:
==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...


Line 247: Line 318:
***Fetal.
***Fetal.
*Membranes.
*Membranes.
**Membranitis?
**[[Membranitis]]?
**Chorioamnionitis?
**[[Chorioamnionitis]]?
*Cord:
*Cord:
**3 vessel?
**3 vessel?
Line 254: Line 325:


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.
Line 265: Line 352:
*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==
Line 302: Line 381:
*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>
Line 318: Line 408:
===Microscopic===
===Microscopic===
Features:
Features:
*+/-Thrombi.
*+/-[[thrombosis|Thrombi]].
**Fibrin deposition.
**Fibrin deposition.
*+/-Lines of Zahn.
*+/-Lines of Zahn.
Line 339: Line 429:
*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.
 
DDx:
*[[Amnion nodosum]] - small (~1-5 mm), round, classically yellow.


Image: [http://www.webpathology.com/image.asp?n=2&Case=659 Amnion nodosum (webpathology.com)].
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===
Classification:
Features:<ref>ALS. 6 Febraury 2009.</ref>
*Partial - not circumferential.
*Meconium histiocytes - '''key feature'''.
*Complete.
**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:
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 427: Line 498:
===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:  
**Chorioamnionitis, fetal edema, idiopathic (no cause apparent).
*[[Chorioamnionitis]].
*Fetal edema.
*Idiopathic (no cause apparent).
*[[Placental villous immaturity]].


Image:
Image:
*[http://www.med.yale.edu/obgyn/kliman/placenta/articles/EOR_Placenta/Image19.gif villous edema (yale.edu)].<ref>URL: [http://www.med.yale.edu/obgyn/kliman/placenta/articles/EOR_Placenta/Trophtoplacenta.html http://www.med.yale.edu/obgyn/kliman/placenta/articles/EOR_Placenta/Trophtoplacenta.html]. Accessed on: 28 May 2011.</ref>
*[http://www.med.yale.edu/obgyn/kliman/placenta/articles/EOR_Placenta/Image19.gif villous edema (yale.edu)].<ref>URL: [http://www.med.yale.edu/obgyn/kliman/placenta/articles/EOR_Placenta/Trophtoplacenta.html http://www.med.yale.edu/obgyn/kliman/placenta/articles/EOR_Placenta/Trophtoplacenta.html]. Accessed on: 28 May 2011.</ref>
==Placental villous immaturity==
{{Main|Placental villous immaturity}}
==Villous hypoplasia==
*[[AKA]] ''terminal villus deficiency''.<ref name=Ref_Placenta346>{{Ref Placenta|346}}</ref>
{{Main|Villous hypoplasia}}


=Diseases of the placental attachment=
=Diseases of the placental attachment=
==Placenta acreta/percreta/increta==
==Placenta creta==
Placenta attaches to the uterus deeper than it should.
Includes ''placenta accreta'', ''placenta increta'', and ''placenta percreta''.
{{Main|Placenta creta}}


==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=
==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.
# PMNs - decidua only.
===General===
# PMNs - in subamniotic tissue.
*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>
# 1 or 2 + [[necrosis]] in decidua or chorion/subamniotic tissue.
*Controversial.{{fact}}


Chorioamnionitis:<ref name=Ref_Sternberg4_2311>{{Ref Sternberg4|2311}}</ref>
===Microscopic===
# placental chorionic plate only.
Features:
# 1 + subamniotic tissue.
*[[PMN]]s in the decidua.  
# 1 or 2 + necrosis or abscess.
*+/-PMNs in subamniotic tissue.
*+/-Necrosis in decidua or chorion/subamniotic tissue.


Sternberg separates ''vasculitis'' and ''funisitis'' without really explaining the terms<ref name=Ref_Sternberg4_2311>{{Ref Sternberg4|2311}}</ref> -- I presume:
Note:
''vasculitis'' = inflammation of vessels in the umbilical cord.
*Plasma cells in the decidua = [[chronic deciduitis]].
''funisitis'' = inflammation of the cord (vessels and Wharton jelly).


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


Umbilical funisitis:<ref name=Ref_Sternberg4_2311>{{Ref Sternberg4|2311}}</ref>
====Grading membranitis====
# Focal inflammation.
''Sternberg'':<ref name=Ref_Sternberg4_2311>{{Ref Sternberg4|2311}}</ref>
# Diffuse inflammation.
# PMNs - decidua only.
# Necrosis - in vessels or Wharton jelly.
# PMNs - in subamniotic tissue.
# 1 or 2 + [[necrosis]] in decidua or chorion/subamniotic tissue.


Note: There is no such thing as ''chorionitis''.<ref>ALS. February 2009.</ref>
===Sign out===
<pre>
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, CESAERIAN SECTION:
- FETAL MEMBRANES WITH CHORIONITIS.
- THREE VESSEL UMBILICAL CORD WITH VASCULITIS.
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI.
</pre>


==Villitis of unknown etiology==
====Waffle====
*Abbreviated ''VUE''.
<pre>
PLACENTA, UMBILICAL CORD AND FETAL MEMBRANES, BIRTH:
- FETAL MEMBRANES WITH MECONIUM-LADEN MACROPHAGES AND ABUNDANT DECIDUAL NEUTROPHILS
  SUSPICIOUS FOR EARLY CHORIONITIS.
- PLACENTAL DISC WITH THIRD TRIMESTER VILLI.
- THREE VESSEL UMBILICAL CORD WITHIN NORMAL LIMITS.
</pre>


===General===
==Chorioamnionitis==
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>
{{Main|Chorioamnionitis}}
*Usually term placenta.
*Prevalence: 5% to 15% of all placentas.
*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:
==Umbilical cord vasculitis==
*Unknown - as the name of the entity suggests.
{{Main|Umbilical cord vasculitis}}
**Suspected to be immune-mediated.


===Microscopic===
==Funisitis==
Features:<ref name=pmid17889674/>
{{Main|Funisitis}}
*Lymphocytes in villous stroma - '''key feature'''.
*Inflammation of Wharton's jelly - the connective tissue of the umbilical cord.
**Usually focal/patchy.
**Lymphocytes: maternal derivation, T-lymphocytes -- mostly CD8-positive.
*+/-Intervillositis (lymphocytes between villi).
*+/-Histiocytes.


Notes:
==Acute villitis==
*Lymphocytes are smaller and stain darker than the cells of the villi. (???)
{{main|Acute villitis}}
*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>CS. 7 February 2011.</ref>
**Plasma cells may be seen in the decidua -- these can be ignored.


==Villitis of unknown etiology==
{{Main|Villitis of unknown etiology}}


Images:
==Chronic intervillitis==
*[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>
*[[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>
*[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> **CHECK**
*[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>


=Infarction=
==True infarcts==
===General===
===General===
*Associated with retroplacental hematoma.
*Rare.
 
*Massive chronic intervillitis - associated [[IUGR]], spontaneous abortion, perinatal fetal death.<ref name=pmid17088773>{{Cite journal  | last1 = Rota | first1 = C. | last2 = Carles | first2 = D. | last3 = Schaeffer | first3 = V. | last4 = Guyon | first4 = F. | last5 = Saura | first5 = R. | last6 = Horovitz | first6 = J. | title = [Perinatal prognosis of pregnancies complicated by placental chronic intervillitis]. | journal = J Gynecol Obstet Biol Reprod (Paris) | volume = 35 | issue = 7 | pages = 711-9 | month = Nov | year = 2006 | doi =  | PMID = 17088773 }}</ref>
===Gross===
*Recurs.
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===
===Microscopic===
Features:
Features:<ref name=pmid8215826/><ref name=pmid17088773/>
#Necrosis of villi; hyaline material (acellular eosinophilic material) replaces the stroma of the villi.
*Intervillous inflammatory cells:
#Loss of intervillous space.<ref name=Ref_WMSP465>{{Ref WMSP|465}}</ref>
**Lymphocytes.
#*Villi appear to be crowded.<ref>{{Ref PBoD|1109}}</ref>
**Histiocytes.
#**Normal spacing is ~1x smallest villus or larger.
*Fibrinoid deposition.
#***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:
====Images====
*[http://pathweb.uchc.edu/eatlas/gyn/1203b.htm Recent infarct (pathweb.uchc.edu)].
<gallery>
*[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>
Image:Intervillitis_-_intermed_mag.jpg | Intervillitis - intermed. mag. (WC)
*[http://www.mda-sy.com/pathology/PLACHTML/PLAC024.HTM Placental infarct - necrotic villi (mda-sy.com)].
Image:Intervillitis_-_very_high_mag.jpg | Intervillitis - very high mag. (WC)
</gallery>
==Chronic deciduitis==
*[[AKA]] plasma cell deciduitis.
{{Main|Chronic deciduitis}}


===Significant infarcts===
=Placental infarction=
*> 3cm --or-- central location --or-- in 1st or 2nd trimester.
==True infarcts==
**Small foci are accepted in term placentae - typically at periphery.
{{Main|Placental infarct}}


==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 600: 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 607: 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 652: 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===
==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).
 
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:
*[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==
==Malaria==
{{Main|Malaria}}
===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).
*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>
*[[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]].
**Altshuler criteria: "a minimum of 10 villi, each with 10 or more vascular channels, in 10 or more areas of 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/>
***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:
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/>
*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>


=See also=
=See also=
Line 758: Line 801:
=References=
=References=
{{reflist|2}}
{{reflist|2}}
[[Category:Gynecology]]


=Recommended reading=
=Recommended reading=
Line 767: 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]]
Michael
48,790

edits

Retrieved from "https://librepathology.org/wiki/Special:MobileDiff/6129...48989"

Navigation menu