notice of faculty disclosure hurry, it’s placenta time to ... · redline ,pediatrdev pathol2008...
TRANSCRIPT
![Page 1: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/1.jpg)
1
Hurry, It’s Placenta Time
Janice M. Lage, MDMedical University of South Carolina, Charleston, SC
Notice of Faculty DisclosureIn accordance with ACCME guidelines, any individual in a positionto influence and/or control the content of this CME activity hasdisclosed all relevant financial relationships within the past 12months with commercial interests that provide products and/orservices related to the content of this CME activity.
The individual below has responded that she has no relevantfinancial relationship with commercial interest to disclose:
Janice M. Lage, MD, FASCP
![Page 2: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/2.jpg)
2
Fetoplacental circulation� Two circulatory systems
� Maternal-from spiral arteries in decidua, around villi, intervillous space, back via sinuses
� Fetal- through umbilical cord, chorionic plate vessels on surface of placenta, down stem villi to secondary and tertiary villi, reverse to cord
Mature Placenta-- Gross Anatomy
� Placental disc (villi)� Fetal surface, chorionic plate, umbilical cord� Maternal surface, decidua
� Umbilical cord (2 arteries and 1 vein)� Placental membranes: amnion, chorion, and decidua
![Page 3: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/3.jpg)
3
Mature Placenta: Maternal and Fetal Surfaces
Succenturiatelobe
Normal Umbilical Cord� 45-55 cm normal � 32/35-70 cm, range� left:right spiral twist 4-
7:1, 0.21 coils/cm� Short, <30 cm, decr fetal
motion, IUGR, incr perinatal mortality, neurologic abn, decr IQ, seizures
� Long cord, >70 cm, thrombosis and congestion, associated with hyperactivity syndromes
![Page 4: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/4.jpg)
4
Umbilical Cord Insertion� Normal, eccentric� Marginal, battledore� Membranous, velamentous-compression injury� Associated with multiple gestations, congenital syndromes (4x), diabetes mellitus (4x), adv maternal age (2x), smoking
� Neurologic abnormalities (2x), hyperactive syndromes (2-3 x)
� Catastrophic fetal blood loss with rupture, most frequent in ruptured vasa previa:� velamentous cord vessels overlying cervical os,
trauma causes exanguination
![Page 5: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/5.jpg)
5
Abnormalities of Umbilical Cord
� False knot� True knot—1% of all deliveries, inconsequential
� Occlusive true knot � Cause of fetal death in utero due to thrombosis or hemorrhage
� Indentation when untied� Edematous cord on placental side due to umbilical vein obstruction
True and False Cord Knots
![Page 6: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/6.jpg)
6
Umbilical Cord Thrombus
Single umbilical artery� Single umbilical artery—1% of deliveries
� Associated with renal anomalies and major congenital anomalies (2x)
� Stillbirth (4x)� Intrauterine growth retardation, preterm delivery (2x)
Persistent vitelline vessels/cord angioma
![Page 7: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/7.jpg)
7
Histopathologic Lesions of the Placenta� Infections-maternal/fetal/both� Structural lesions:
� Hemorrhages/thrombi/abruptions� Infarcts
� Reactive changes:� Pigment: meconium, hemosiderin� Upstream occlusions/downstream effects (dam on a
river)� Chronic inflammatory lesions� Chronic fibrinoid depositions� Failure of the placenta to deliver
Cerebral Palsy in Term Infants:159 medicolegal case reviews
� Clinical/sentinel events (20%)� Severe, large fetoplacental vascular lesions (34%)� Chronic placental dysfunction (22%)� Subacute/chronic hypoxia (15%)� Idiopathic (8%)Redline ,Pediatr Dev Pathol 2008 11:456-464
Placental lesions associated with neurologic impairment in >37 wks� Severe fetal chorioamnionitis
� Severe fetal chorionic vasculitis with:� Subintimal expansion� Dissolution of individual smooth muscle cells
� Extensive avascular villi� Diffuse chorioamnionic hemosiderosis
� Chronic peripheral separation� Macrophages with hemosiderin, 1-3 days (3-8 days in
other tissues, Redline)� Redline, O’Riordan, Arch Path Lab Med 2000,
124:1785-1791)
Severe fetal placental vascular lesions in term infants with neurologic impairment:
� Fetal thrombotic vasculopathy (avascular villi)
� Chronic obliterative villitis� Severe fetal vasculitis� Meconium-associated fetal vascular necrosis
� 51% of cases/10% controls� 52% of cases had one/more lesion(s)� Redline 2005, Am J Obstet Gynecol 192:452
![Page 8: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/8.jpg)
8
Infections of umbilical cord� Acute funisitis, various vessels, associated with chorioamnionitis� Long-standing acute funisitis calcifies and becomes necrotic� Lymphoplasmacytic funisitis is associated with syphilis or herpes simplex infections� Candidal funisitis
Candidal Funisitis
![Page 9: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/9.jpg)
9
Circummarginate membrane insertion (extrachorial)
� 4% (3-25%) of placentas to some degree� Major fetal malformations� Decidual necrosis
Circumvallate membrane insertion (extrachorial)� 6% (2-18%) of
placentas to some degree
� Multiparity� Early fluid loss� Intrauterine growth
retardation (IUGR)� Pre-eclampsia� Bleeding disorders
during pregnancy –chorionic hemosiderosis
� Decidual necrosis
Amnionic band
�Slight fluid loss-- no sequelae�Ongoing loss of much fluid-- amnionic bands form, webs of amniochorion entrap fetal parts …amputation, malformation, deformations
Abnormalities of membranes� Amnion nodosum� Severe oligohydramnios
� Due to prolonged, premature rupture of membranes� Due to marked decreased urine production
� Poor fetal lung development� Congenital absence of kidneys, ureters, urethra, obstruction, such as a posterior urethral valve
� Ulceration of amnion, deposits of squames and vernix on denuded amnion
![Page 10: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/10.jpg)
10
Amnion nodosum:severe oligohydramnios Amnion nodosum
Meconium� Meconium release, acute, turns fetal membranes green initially, then cord: � Amnion, 1-3 hours� Chorion, 3-6 hours� Decidua, 3-6 hours� Cord and chorionic plate, > 6 hours
![Page 11: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/11.jpg)
11
Abnormalities of membranes and chorionic plate � Chronic meconium exposure� After 16 hours gets apoptosis of smooth muscle cells of cord—meconium associated vasonecrosis (really apoptosis)� Longer, membranes turn yellow
� Eventually meconium disappears
Meconium-associated vascular necrosis� Altshuler, 1989, necrosis of smooth muscle, vasoconstriction of cord vein� King, Redline, et al, Hum pathol 2004:35:412-7� Myocytes of chorionic blood vessels exposed to meconium exhibit apoptotic changes, like pyknotic nuclei in heart
Need picture of apoptotic smooth muscle chorionic plate
![Page 12: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/12.jpg)
12
Hemosiderin and hematoidinPlacental Inflammations
and Infections� Two types of placental infections:� Ascending infection, most common type, bacterial, associated with or causes PROM� acute chorioamnionitis� maternal neutrophils in membranes
� Hematogenous infection, bacterial or viral, including syphilis, listeriosis, toxoplasmosis, candida, rubella, CMV, HSV, parvovirus, mycoplasma, � villitis, acute or chronic
Chorioamnionitis
Chorionic vasculitis: Fetal neutrophils and eosinophils headed for amnionic sac
![Page 13: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/13.jpg)
13
![Page 14: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/14.jpg)
14
T-cell and eosinophilic chorionic vasculitis, Jacques et al. Ped Dev Pathol 2011;14:198-205� CD3 + T cells and
eosinophils� To intervillous space in
23.5%� To amnionic cavity in
15.7%� No specific direction in
60.8%� Asso with villitis of
unknown origin and avascular villi
Chronic villitis� Lymphocytes, plasma cells and histiocytes in villi
� Maternal in origin� May result in villous sclerosis or massive intervillositis
Granulomatous villitis
![Page 15: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/15.jpg)
15
Parvovirus
![Page 16: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/16.jpg)
16
Placental Parenchymal Lesions� Infarcts� 5-15%, esp if central, associated with pre-eclampsia, diabetes, lupus erythematosis, uteroplacental insufficiency� Fetal complications: intrauterine growth retardation (IUGR), fetal distress, intrauterine fetal demise (IUFD)
![Page 17: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/17.jpg)
17
Infarct and surrounding accelerated maturation Infarcts, aging
Placental Parenchymal Lesions� Thrombi
� Intervillous� Fetal and maternal blood, 6/1000 births� Associated with fetomaternal hemorrhage,
isoimmunization, erythroblastosis, SLE, antiphospholipid antibodies, trauma, vigorous fetal movements; check Kleihauer-Betke
� Retroplacental� Retromembranous
INTERVILLOUS OR INTRAVILLOUS THROMBUS
MARGINAL HEMATOMA
RETROPLACENTAL HEMATOMA
SUBAMNIONIC HEMATOMA--TRACTION
MASSIVE SUBCHORIONIC THROMBOSIS, BREUS’ MOLE
![Page 18: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/18.jpg)
18
Maternal floor infarction� Misnomer� Extreme form of perivillous fibrin deposition� Gross: white, firm, stiff placenta� Diffuse involvement of maternal surface basal plate extending upward into overlying villi
Maternal floor infarction� Gitterinfarkt, German literature--gridlike� Fibrin obliterates normal space between villi (intervillous space) in which maternal blood percolates� Area of involvement removed from the overall placental function: no exchange of nutrients, oxygen, waste products
![Page 19: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/19.jpg)
19
Maternal floor infarction
Massive perivillous fibrin deposition
Massive perivillousfibrin
![Page 20: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/20.jpg)
20
Villous vascular lesions� Increased vascularity� Localized-chorangioma � Diffuse-chorangiosis, chorangiomatosis� Thrombi, intimal cushions� Muscularization of stem veins� Acute arteritis
� Obliteration of flow� Hemorrhagic endovasculitis� Fetal artery thrombosis-downstream
![Page 21: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/21.jpg)
21
Chorangioma; diffuse or localized
Chorangiosis� Increased villous blood vessels
� >10 loops/10 villi/ medium power field in 3 or more areas
� Often > 20 capillaries
� Large for gestational age, delayed villous maturation, diabetic
![Page 22: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/22.jpg)
22
Fibrin thrombi and intimal fibrin cushion Villous stem vessels
� Muscularization of stem vein walls
� Seen in reversed end diastolic blood flow doppler studies
Villous vascular lesions
Acute arteritisFetal artery thrombosis
avascular villifetal thrombotic vasculopathy
Fetal thrombotic vasculopathy (extensive avascular villi)
� Redline and Pappin, Hum Pathol 1995; 26:80-85
� Avascular villi conforming to a single villous tree, smaller blood vessels
� Greater than 2.5% of total villi
� Foci in multiple sections
� Single lesion greater than 0.25 cm squared
� IUGR, monitoring abnormalities, oligohydramnios, and maternal coagulopathy
![Page 23: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/23.jpg)
23
Hemorrhagic endovasculitis� Thrombosis and recanalization of chorionic/villous stem vessels� Increased perinatal morbidity and mortality� Abnormalities of neonatal growth and development
Hemorrhagic endovasculitis
Hemorrhagic endovasculitis—Associated clinical conditions in livebirth and stillbirth� Chronic villitis of unknown etiology� Chorionic vessel thrombi� Increased fetal nucleated rbc’s� Meconium staining� Maternal hypertension
Villous adrenal cortical nodule
![Page 24: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/24.jpg)
24
Placental abruption� Acute� Due to inflamed decidual vessels, deciduitis and decidual necrosis, or hypertensive rupture
� Trauma, acute chorioamnionitis, congenital anomalies, pre-eclampsia, smoking
� Outcome: risk of stillbirth, preterm delivery, neonatal death
� Life-threatening, generally quick in evolution
Acute placental abruption
Placental abruption� Chronic� Retroplacental or marginal sinus bleed� May be life-threatening, generally slow in evolution� Retroplacental hemorrhage indents placenta, hemosiderin laden macrophages, clot turns brown and stringy
![Page 25: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/25.jpg)
25
Decidual vasculopathyDecidual vasculopathy—Acute atherosis� Associated with pre-eclampsia, PIH, chronic hypertension, lupus erythematosus, less commonly, DM� Acute vascular rejection of transplanted kidney� Fibrinoid necrosis, foamy macrophages, lymphocytes� Results in placental infarcts
![Page 26: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/26.jpg)
26
![Page 27: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/27.jpg)
27
Changes in maternal blood vessels with hypertensive disorders� Normal spiral arteries-->
� Decidual medial hypertrophy�
Abnormal placental adherence� Placenta accreta-abnormal placental adherence, clinical and/or pathologic diagnoses, myometrium attached to maternal surface of placenta
� Placenta increta-often hysterectomy, villi within myometrium
� Placenta percreta-always hysterectomy, villi on uterine serosa
Placenta increta/percreta
![Page 28: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/28.jpg)
28
Pregnancy and Placenta
Janice M. Lage, MD, FASCPMedical University of South
Carolina
Come on people, one more hill and then we’re finished!
![Page 29: Notice of Faculty Disclosure Hurry, It’s Placenta Time to ... · Redline ,PediatrDev Pathol2008 11:456-464 Placental lesions associated with neurologic impairment in >37 wks Severe](https://reader034.vdocuments.mx/reader034/viewer/2022051800/5ad105b67f8b9a92258b8ffc/html5/thumbnails/29.jpg)
29
Life-Threatening Placental Lesions
� Abruptio placentae (extensive)� Placental infarction (extensive)� Knotted umbilical cord� Umbilical vascular thrombosis� Ruptured vasa previa� Chorionic vascular thrombosis (extensive)
� Giant chorangioma� Choriocarcinoma