Abnormalities of Placenta, Umbilical Cord & Membranes

By: Dr. Meyzadel Bergado

Abnormal Placentation
Multilobed placenta Bilobed or placenta bilobata
Incidence 2-8% of placentas Roughly equal size lobes are separated by a segment membranes Umbilical cord may insert in either of the lobes or in velamentous fashion or in between the lobes

Bilobed placenta

Pathogenesis: - Arise due to implantation in areas of decrease uterine perfusion - Example

-

Lateral implantation in between anterior and posterior walls of the uterus with one lobe on the other and one on the posterior wall

Other local factors leading to multilobulation:

Implantation over leiomyomas Area of previous surgeries In the cornu Over the cervical os

Succenturiate placenta
Incidence 5 % Results when one or more small accessory lobes are developed in the membranes at the a distance from the periphery of the main placenta

Succenturiate placenta

Membranaceous Placenta

All fetal membranes are covered by functioning villi and the placenta develops as a thin membranous structure occupying the entire periphery of the chorion

Extrachorial placenta

Circumvallate placenta

If fetal surface of placenta present a central depression surrounded by a thickened, grayish white ring When the ring coincides with placental margins Chorion and amnion are raised at the margin by interposed decidua & fibrin without folding the membranes

Circummarginate placenta

Placenta Accreta, increta, & percreta

Placenta accreta

Accounts for 75-78% Placenta attached directly to the muscles of the uterine wall
Accounts for 17% of cases Placenta extends into the uterine muscles 5-7% which extends through the entire wall of the uterus

Placenta increta

Placenta percreta

Placenta accreta
Incidence of 1 in 7,000 deliveries Incidence maybe increase because of the increase # of women with prev CS Risk factors:

Placenta previa Placental located underlying the previous uterine scar Multiple pregnancies Prev. D & C

Placental infarcts

of term pregnancies 2/3 pregnancies complicated by severe HPNsive disease Result from occlusion of maternal vascular supply Principal histopath features:

Fibrinoid degeneration of trophoblast Calcification Ischemic infarction from adhesion of spiral arteries

Degenerative lesions of placenta have 2 etiological factors:

Changes assoc with aging of trophoblast Impairment of uteroplacental circulation causing infarction

Placental calcification
Small calcareous nodules or plaques frequently observed on the maternal surface of the placenta Visualized in UTZ >33 weeks AOG

More than half of the placenta have some degree of calcification w/c increase until term

Villous (fetal) artery thrombosis

Thrombosis of a stem artery produces sharply demarcated area of avascularity Single artery thrombosis

(+) 4.5% of placenta from normal pregnancy (+)10% involving diabetic women

Thrombosis of single fetal stem artery will deprive only 5% of the villi of their blood supply

Abnormalities of umbilical cord

Length
Mean length at term 55-60 cm Vascular occlusion by thrombi & true knots Excessively short umbilical cords may be instruments in abruptio placenta & uterine inversion

Single umbilical artery

Absence of one umbilical artery

(+) 0.85% of all cords in singletons

About 30% of all infants with only one umbilical artery are assoc with congenital anomalies

Incidence from 18-68%

Infants with single-artery cord had

18% incidence of malformation 34% usually growth restricted 17% delivered preterm

Incidence is increase in newborn of women with

DM Epilepsy Preeclampsia Anterpartum hge Oligohydramnios Hydramnios

Velamentous insertion of umbilical cord

An abnormal condition in which umbilical vessel does not insert into the placental mass but instead, traverse the fetal membrane before it inserts into the umbilical cord Velamentous insertion

Used to describe the condition in which the umbilical cord inserts on the chorioamniotic membranes rather than on the placental mass 1.1% in singleton pregnancies 8.7% in twin gestations Spontaneous abortion

Incidence

33% between 9th & 12th wks AOG 26 % between 13th & 16th

Vasa previa
Assoc with velamentous insertion when some of the fetal vessels in the membrane cross the region of the internal os & occupy a position of the presenting part Condition in which bv may be lodged between fetus & entrance to the birth canal

Cord abnormalities

Knots

False knots
Result

from kinking of the vessels to accommodate length of cord from active fetal movement

True knots
Results

Torsion
Result of fetal movement, cord normally becomes twisted Marked torsion compromised fetal circulation

Loops
Coiling of cord around the neck Incidence of nuchal cord coil once 21%

Hematoma

Usually results from rupture of varix, usually of umbilical vein with effusion of blood into cord

Stricture
Most but not all infants with cord stricture are stillborn Assoc with an extreme focal deficiency in whartons jelly

Abnormalities of fetal mambranes & amniotic fluid

Meconium staining
Staining of amniotic membrane within 1-3 hrs after meconium passage Neonatal mortality rate

3.3%

in the group with meconium-stained membrane compared with 1.7% in those without stng

Chorioamnionitis
Inflammation of fetal membrane is a manifestation of an intrauterine infection Frequently assoc with prolonged membrane rupture and long labor (+) mononuclears & polymorphonuclear leukocytes infiltrating the chorion

Disorders of the amniotic fluid volume

Hydramnios
Defined as amniotic fluid index >24-25 cm mild moderate degrees = 2-3 L Incidence 1% of all pregnancies 2/3 idiopathic 1/3 is associated with fetal anomalies, maternal DM or multifetal gestation

Mild hydramnios
Defined as pockets measuring 8-11 cm in vertical dimension Present in 86% of cases with xsive fluid

Moderate hydramnios
Defined as pockets containing only small parts & measured 12-15 cms deep Present in 15%

Pathogenesis: Early in pregnancy

Amnionic cavity is filled with fluid similar in composition to ECF Transfer of H2O & other small molecules takes place not only across the amnion but thru the fetal skin Fetus begin to urinate, swallow & inspire amnionic fluid

During 1st half of pregnancy

2nd trimester

Symptoms:

Severe dyspnea edema Clinical findings

Diagnosis

Uterine enlargements in association with difficulty in palpating fetal small parts & in hearing FHT

By UTZ

Large amounts of amnionic fluid can always be demonstrated as an abnormally echo-free space between fetus & uterine wall or placenta

Prognosis
The more severe the hydramnios, the higher the perinatal mortality rate Maternal complication associated with hydramnios

Placental

abruption Uterine dysfunction Postpartum hge

Management

Amniocentesis
Principal

purpose is to relieve maternal distress is cord prolapse

Amniotomy
Disadvantage

Indomethacin therapy
Impairs

lung liquid production or enhances absorption Decrease fetal urine production Increase fluid movement across fetal membrane dose: 1.5-3 mg/kg/day Disadvantage

Potential closure of fetal ductus arteriosus

Oligohydramnios
Defined as amniotic fluid index of <5 cm Risk :

Cord

compression

Conditions freq associated with oligohydramnios

Fetal

Maternal

Chromosomal abn Cong anomalies Growth restriction Demise Postterm pregnancy Ruptured membranes

Uteroplacental insufficiency Hypertension Preeclampsia diabetes

Placenta

Drugs

Abruption Twin-twin transfusion

Prostaglandin synthetase inhibitors ACE inhibitors

idiopathic

Early-onset oligohydramnios
Almost always evident when there is obstruction of fetal urinary tract or renal agenesis Exposure to ACE inhibitors Fetal prognosis is poor

Pulmonary hypoplasia
Incidence @ birth : 1.1 1.4 in 1000 infants (+) when amnionic fluid is scant

3 possibilities that account for pulmonary hypoplasia

Thoracic compression Lack of fetal breathing movement decreases lung inflow Failure to retain amnionic fluid or increase outflow with impaired lung growth and development

Oligohydramnios in late pregnancy

Amnionic fluid volume diminishes normally after 35 weeks Significant oligohydramnios

Associated

with increased risk of adverse perinatal

outcomes Fivefold increased cesarean delivery rate

Thank u doctors & God bless