PLACENTAL DISORDERS

dr. Benny Hasan, SpOG

Depart. of Obstetrics - Gynecology

Medicine School of Padjadjaran University
Bandung

PLACENTAL DISORDERS
I. Diseases and Abnormalities of the Fetal
Membranes
1. Diseases of the Chorioamnion
2. Disorders of Amniotic Fluid Volume

II. Diseases and Abnormalities of the Placenta

1.
2.
3.
4.
5.

Abnormalities of Placentation
Circulatory Disturbances
Abnormalities of the Umbilical Cord (Funis)
Gestational Trophoblastic Diseases
Other Tumours of the Placenta

PLACENTAL DISORDERS
Diseases and Abnormalities of the Fetal
Membranes
Diseases of the Chorioamnion
Meconium Staining
Chorioamniotis
Amnionitic Cysts
Amnion Nodosum
Amnionic Bands

Diseases of the Chorioamnion

Meconium Staining
7 - 22 %
Uncommon
Increases

< 38 weeks
> 40 weeks

NMR 3.3 % (1.7 % in non-staining)

Cesarean delivery was doubled

NM associated with meconium aspiration

Gambar : Meconium staining

Diseases of the Chorioamnion

Chorioamnionitis

Intrauterine infection, prolong membrane

rupture, long labor

Microscopical finding, MN and PMN

lecocytes infiltrate the chorion

Unexplained cases of ruptured membranes

and/or preterm labor associated with occult
chorioamnionitis

Diseases of the Chorioamnion

Amnionic cysts
Fusion of amnionic folds with subsequent
retention of fluid

Diseases of the Chorioamnion

Amnion Nodosum
Squamous
metaplasia of
the amnion
Amnionic
caruncles

Diseases of the Chorioamnion

Amnionic Bands

Amnion disruption
bands/string
formation adhere to the fetus and impaire
growth and development

Can cause intra uterine amputation

PLACENTAL DISORDERS
Diseases and abnormalities of the fetal
membranes
Disorders of amnionic fluid volume
Oligohydramnios
< 500 ml
Hydramnios, polyhydramnios > 2000 ml
Chronic
Acute
Measurement of Amnionic Fluid
Phelan and Colleagues (1987) :
Amnionic Fluid Index (Ultrasonic Method)
Adding the vertical depths of the longest pocket in
each of four equal uterine quadrant
Hydramnios : > 24 cm
Inaccurate to diagnosis oligohydramnios

TYPICAL AMNIONIC FLUID VOLUME

Weeks
Fetus
Amnionic
Percent
Gestation
(g)
(ml)
Fluid

Placenta
(g)

Fluid

16

100

100

200

50

28

1000

200

1000

45

36

2500

400

900

24

40

3300

500

800

17

Hydramnios

Causes :
Associated to fetal malformation
- CNS i.e anencephaly, spina bifida
- GIT i.e esophageal atresia
- Perinatal mortality increase

Pathogenesis
- Increase of amnionic fluid production
- Disturbance of volume control mechanism

Hydramnios

Symptoms

Purely mechanical causes and result

principally from pressure exerted within and
around the overdistended uterus upon
adjacent organs

Diagnosis

Uterine enlargement in association with

difficulty inpalpating fetal small parts and in
hearing fetal heart tones

DD : ascites, a large ovarian cyst

Can be made by ultrasonic evaluation

Hydramnios

Prognosis
Higher perinatal mortality rate :
fetal malformation, preterm labor,
cord prolapse erythroblastosis

Maternal complication : placental

abruption, uterine dysfunction, post
partum hemorrhage

Hydramnios

Management
Minor degrees rarely require treatment
Moderate degrees with dyspnea,
abdominal pain, ambulation difficulty need
hospitalization
- amniocentesis
- amniotomy
- indomethacin therapy :
1.5 to 3 mg/kg per day

Oligohydramnios
Marks and Divon (1992) : Amnionic fluid index < 5
cm
Risk of cord compression
fetal distress
Early onset oligohydramnios
- Associated to obstruction of fetal urinary tract
or renal agenesis
anuria
- Chronic leak from a defect in the membranes
- Fetal prognosis is poor
- Pulmonary hypoplasia :
- thoracic compression
- lack of fetal breathing movements
- failure to retain amnionic fluid or increased

Oligohydramnios

Oligohydramnios in late pregnancy

Increased cesarean delivery

Fetal heart decelerations and meconium

Amnio infusion

Infusion of crystalloid to replace

pathologically diminised amnionic fluid has
most often been used during labor to
prevent umbilical cord compression
Infusion of isotonic fluid by amniocentesis
for ultrasonic fetal evaluation

PLACENTAL DISORDERS
Diseases and abnormalities of the placenta
Abnormalities of placentation

Multiple placenta with a single fetus

Succenturiate placenta
Ring shaped placenta
Membranaceous placenta
Fenestrated placenta
Extrachorial placenta
Large placenta
Placental polyp

PLACENTA BIPARTITA
OR BILOBED
PLACENTA

ACCESORIES
PLACENTA

TRIPLE PLACENTA

EXTRACHORIAL PLACENTA
Circumvalate placenta

EXTRACHORIAL PLACENTA
Circummarginate placenta

CORD INSERTION
Velamoentous insertion

PLACENTAL DISORDERS
Diseases and abnormalities of the placenta
Circulatory disturbances

Placental infarcts
Placental calcification
Villous (fetal) artery thrombosis
Clinical significance
Hypertrophic lesions of the chorionic villi
Microscopic placental abnormalities
Placental inflamation

PLACENTA INFARCTS

PLACENTAL INFARCTS
Red Brown Infarcts

PLACENTAL DISORDERS
Diseases and abnormalities of the placenta
Abnormalities of the umbilical cord (funis)

Cord length
Absence of one umbilical artery
congenital anomalies
Cord coiling
Four-vessel cord
Cord insertion : - marginal insertion
- velamentous insertion
- vasa previa

PLACENTAL DISORDERS
Diseases and abnormalities of the placenta
Abnormalities of the umbilical cord (funis)

Cord abnormalities capable of impending

blood flow : - knots of the cord
- loops of the cord
- edema
- torsion
- stricture
- hematoma
- cysts

FALSE KNOT

TRUE KNOT

PLACENTAL DISORDERS
Diseases and abnormalities of the placenta
Gestational trophoblastic diseases
Other tumours of the placenta
- Chorioangioma (Hemangioma)
- Tumor metastatic to the placenta