Sunday, March 18, 2012, 7:30 PM
Convention Centre 217-219
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Beyond Chorioamnionitis: What You Didn’t Know
You Were Missing During Placental Examination
Oklahoma City, OK
Univ of Alabama
In accordance with ACCME guidelines regarding disclosure, the USCAP policy requires that faculty members who have a significant financial or other relationship with a commercial company, entity, or service (which will be discussed in this Symposium) must disclose this to attendees. The Academy also requires that speakers disclose any products that are not labeled for the use under discussion. The speakers listed below have indicated they have nothing to disclose.
Ona M. Faye-Petersen, Univ of Alabama, Birmingham, AL
Amy Heerema McKenney, Stanford University, Stanford, CA
Philip J. Katzman, University of Rochester Medical Center, Rochester, NY
Linda Ernst, Northwestern University, Chicago, IL
Monique De Paepe, Women & Infants Hospital, Providence, RI
Clinical histories are displayed below.
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Submitted by: Ona M. Faye-Petersen -
Univ of Alabama, Birmingham, AL
A 27-year old previously healthy primigravida was noted to have a thick-appearing placenta on a routine prenatal ultrasonogram at 13 weeks of gestation, based on her last menstrual period date and fundal height. The fetal nuchal translucency measurement was 1.0 mm, no structural fetal anomalies were identified, and amniotic fluid index (AFI) was normal.
She was followed by frequent ultrasonograms, and the placenta exhibited a few, enlarging, hypoechoic, “honey comb” areas and irregular thickenings interspersed with more normal appearing areas; AFIs continued to be within normal ranges. Initially the patient had declined a karyotypic analysis, but consented to an amniocentesis at 18 weeks, to rule out triploidy; a normal female, 46,XX karyotype was returned. A correlative maternal serum alpha-fetoprotein level was returned at >2.5 multiples of the median. Subsequent ultrasonograms revealed a structurally normal fetus, but fetal intrauterine growth restriction (IUGR), and an enlarged placenta, without evidence of high velocity blood flow (shunting) in the cystic appearing areas were observed. These placental abnormal areas were largely on and/or near the chorionic plate. As the gestation progressed, the disproportionate ratio of placentomegaly to fetal size began to increase, and color Doppler interrogation of umbilical arterial end-diastolic blood flow revealed decreased to near absence of flow, at 28 weeks. At this time, a cesarean section delivery, for fetal non-reassuring heart rate and absent end-diastolic blood flow, was accomplished. An edematous but small appearing, 600 g (617 – 1111 g expected) female infant had Apgar scores of 5, 5, and 6 at one, five, and ten minutes, respectively, and was admitted to the newborn intensive care unit with respiratory distress. The placenta was manually extracted and partially disrupted but exhibited large, tortuous vessels in the cord and on the chorionic plate, and was 420 g (210 – 331 g expected.) Several had thrombi (Gross images in Fig. 1,2). Serial sections of the placenta showed markedly ectatic single and often tortuous clustered chorionic plate and stem villous vessels; the parenchymal ectatic vessels ranged from 0.5 to 2.0 cm in diameter (Fig 1,2). There were also parenchymal cystic vesicles filled clear serous to cloudy mucinous fluid, which were 0.5 to 1.5 cm in diameter (Fig. 3,4.) Fig. 5-11 show representative histologic sections, from this placenta.
Submitted by: Amy Heerema McKenney -
Stanford University, Stanford, CA
A 43 year old G8P5025 presented at 32 and 1/7 weeks gestation with vaginal bleeding and preterm labor. A 2nd trimester fetal ultrasound had demonstrated duodenal atresia, pelviectasis and polyhydramnios. The patient declined amniocentesis. She delivered with clinical concern for placental abruption and the placenta was submitted to pathology for examination.
The trimmed placental disc weight was 370 grams. The umbilical cord measured 10 cm in length by 1.4 cm in diameter. It inserted eccentrically, contained three vessels, demonstrated normal coiling and had no knots or other gross lesions. The membranes inserted normally at the disc margin. The chorionic plate vasculature showed normal dispersion, and demonstrated no calcifications. The maternal surface demonstrated an adherent clot, consistent with the delivery observations of retroplacental hemorrhage. The parenchyma showed compression deep to the retroplacental hemorrhage, but no other lesions. Microscopic examination showed large vessel fetal thrombotic vasculopathy with unusually cellular thrombi.
Submitted by: Philip J. Katzman -
University of Rochester Medical Center, Rochester, NY
A 39 year old G1P0 woman was admitted for induction of labor due to chronic hypertension at term. A 3200 gram female infant was born after vacuum-assisted vaginal delivery. The placenta required manual removal. The 282 gram placenta appeared disrupted and possibly incomplete. The submitted slide is a section from the placenta.
Case 3 - Slide 1
Submitted by: Linda Ernst -
Northwestern University, Chicago, IL
A 34-year old gravid3, para0111 female presented to labor and delivery at 25 5/7ths weeks of gestation after she was noted to have high blood pressure (160/105 mmHg) on a prenatal visit. She denied headache, vision changes, right upper quadrant pain, and edema. She had not experienced vaginal bleeding, uterine contractions, or loss of fluid. She reported normal fetal movement. An ultrasonogram demonstrated a normal amniotic fluid volume index, but estimated fetal weight at <5th percentile, and absent umbilical arterial end-diastolic blood flow.
The patient’s first pregnancy ended in spontaneous abortion several years ago. Her second pregnancy, which occurred about one year prior to the index pregnancy, had been complicated by severe pre-eclampsia, necessitating an induced delivery at 27 weeks of gestation. After that delivery, the mother had persistent hypertension, and she was treated with lisinopril. When she again became pregnant, her medication was switched to labetolol.
The patient received steroids and magnesium and was monitored with daily non-stress tests on the antepartum service. On the third day of her stay, at 26 weeks of gestation, a cesarean section delivery was performed, due to non-reassuring fetal heart rate tracings. Apgar scores were 1, 5, and 8, at one, five and ten minutes, respectively. The infant’s birth weight was 445 g (<3rd percentile). Head circumference was 18.5 cm (<3rd percentile), and length was 30 cm (<3rd percentile).
The placenta was sent to pathology for examination. It weighed 221 g (175-280 g expected.) See gross (Figs. 1-2) and microscopic (Figs. 3-8) images of the placenta. A virtual slide from the previous pregnancy, one year prior, is also included (virtual slide #1)
Case 4 - Slide 1
Submitted by: Monique De Paepe -
Women & Infants Hospital, Providence, RI
26-year-old primigravida presented at 14 weeks gestation with a twin pregnancy. Ultrasound examination revealed a single placental disc with a thin dividing membrane between two same-sex fetuses. Follow-up prenatal ultrasonograms between 15 and 17 weeks demonstrated appropriate and concordant fetal growth. At 19 weeks, the mother presented with breathing difficulties. Ultrasound revealed severe polyhydramnios of twin A, while twin B had no discernable amniotic fluid. Amnioreduction was performed (1,500 mL of amniotic fluid was removed from twin A). At 20 weeks gestation, polyhydramnios was again seen in twin A. Doppler ultrasound examination revealed reversed end-diastolic flow in the umbilical artery of twin B. Anhydramnios was still present, and the bladder could not be visualized. Twin A had a dilated right ventricle and grade I tricuspid regurgitation. A decision was made to proceed with fetoscopic laser ablation of the intertwin anastomoses. One day after the laser ablation procedure, twin A no longer had tricuspid regurgitation, although the heart remained subjectively dilated. A small bladder was seen in twin B, and Doppler ultrasound revealed intermittent absent end-diastolic flow in the umbilical artery. At 23 weeks gestation, dual fetal demise was diagnosed. Delivery was induced. The placenta weighed 325 g (between 75th and 90th percentile for a 23-week twin placenta). Gross images of the placenta are shown in Figures 1-4. The cord of twin B had a velamentous insertion and was avulsed (Fig. 1). Several suspected laser ablation sites were detected upon gross examination (Fig. 2). Vascular injection studies were performed to delineate the superficial chorionic vasculature (Fig. 3). No connections were noted between the two vascular beds, but several occluded vessels were seen crossing the equator between the two twin circulations (Fig. 4). Histologic sections of side A showed relatively large and focally edematous chorionic villi (Fig. 5), while side B showed small, hypoplastic villi (Fig. 6). Sections of the laser ablation sites revealed necrotic and thrombosed chorionic plate vessels (Fig. 7-8), focally associated with clusters of avascular villi (Fig. 9).
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