99  Chorioangioma

JACLYN M. COLETTA  |  MARY E. D’ALTON

Introduction
Chorioangiomas are the most common histologic type of placental
tumor. They are usually well circumscribed, vascular, and pre-
dominantly hypoechoic, ranging from microscopic to several
centimeters in diameter.1

Disease
PREVALENCE AND EPIDEMIOLOGY
Chorioangiomas are found in 0.5% to 1% of placentas examined
at delivery.2 Microangiomas are the most common but are less
likely to cause any fetal or maternal complications and will often
go undetected. Masses greater than 5 cm, also known as larger
or giant chorioangiomas, however, are found in 1 : 10,000 to
3 : 10,000 pregnancies.1
Fig. 99.1  Two-dimensional image demonstrating the homogeneous
placenta with a well-circumscribed, hypoechoic mass along the anterior
ETIOLOGY AND PATHOPHYSIOLOGY surface.

Histologically, there are two main types of chorioangiomas:

angiomatous (formed from numerous blood vessels), and cellular
(formed by loose mesenchymal tissue).3 Large tumors often
contain degenerative changes such as necrosis, calcification, and
myxoid changes.3 They are formed by excessive proliferation of
blood vessels in chorionic villi and are perfused by the fetal
circulation.1 The size, therefore, determines the amount of fetal
blood that is sequestered within the tumor and increases the
risk for fetal complications.

MANIFESTATIONS OF DISEASE
Clinical Presentation
Chorioangiomas over 4–5 cm in maximum diameter, or multiple
smaller chorioangiomas, have been associated with adverse
perinatal outcomes, including intrauterine growth restriction,
polyhydramnios leading to preterm labor and preterm delivery,
and placental abruption.4 Fetal complications include high-output
failure, thrombocytopenia due to platelet sequestration, feto-
maternal hemorrhage, disseminated intravascular coagulopathy,
and potentially, fetal or neonatal demise.4
Imaging Techniques and Findings
Ultrasound.  Most chorioangiomas are small, intraplacental,
singular tumors, and are often not identified on ultrasound (US)
as they do not cause any complications. In addition, it is difficult
to differentiate these tumors from other placental lesions.3 They
generally can appear as well-circumscribed, hypoechoic lesions
compared to the surrounding placental tissue3 (Fig. 99.1). Large
tumors can be of variable shapes and can contain fibrous septae.4
The use of Doppler is helpful in the evaluation since this is a
Fig. 99.2  Color Doppler demonstrating blood flow along the surface
of the mass.
vascular lesion with prominent blood flow5 (Fig. 99.2). It can
also estimate the degree of vascularity as increased vascularity
would increase the risk for fetal complications. This may help
in differentiating it from a hematoma or fibrin collection that
would not have any significant blood flow.5 Prapas et al. retro-
spectively reviewed cases of a suspected chorioangioma over a
9-year period.5 As the grayscale appearance of a chorioangioma
is indistinguishable from placental hemorrhage, they confirmed
the utility of color flow mapping and pulsed Doppler for diag-
nosis.5 In addition, color Doppler imaging can also confirm
vascular channels that are continuous with the fetal circulation,
ruling out other diagnoses such as degenerated myoma, placental
teratoma, or incomplete hydatidiform mole.5 Previous research
has shown the benefit of color Doppler for identifying a discrete

437
438 PART 10  Placenta and Cord
“feeding vessel,” especially in cases when prenatal therapy is being
considered.
Magnetic Resonance Imaging.  Placental magnetic resonance
imaging has been reported as being used as an adjunct to US
placental imaging, though it is not necessary for diagnosis.6
Differential Diagnosis From
Imaging Findings
The differential diagnosis of solid placental masses includes
placental hemorrhage, placental teratoma, partial hydatidiform
mole, degenerated myoma, and maternal tumor metastatic to the
placenta.7 As chorioangiomas are vascularized tumors, the use
of color and pulsed Doppler can aid in the differentiation.5
Synopsis of Treatment Options
PRENATAL
Antenatal management depends on the size of the tumor and the
presence of fetal compromise. Once the diagnosis is suspected,
US surveillance is initially recommended every 2 to 3 weeks,
followed by surveillance on a weekly basis beginning at 32 weeks.
As the hemodynamic changes have been reported to progress
rapidly, Doppler evaluation of the fetal circulation, as well as fetal
echocardiography, is recommended.1,2 Asymptomatic cases can
be managed conservatively, and if fetal growth is normal and
there are no signs of fetal compromise, spontaneous delivery at
term is reasonable. The management of symptomatic or compli-
cated chorioangiomas is primarily dependent on fetal symptoms
and gestational age.1 Previous cases have been treated with
indomethacin and digoxin given to the mother.8 These treatments
were successful in cases with maternal mirror hydrops and cardiac
failure. In 1996, Quintero et al. attempted direct treatment of a
large chorioangioma by endoscopic-guided ligation and bipolar
electrocautery of the feeding vessel.9 Although the procedure
itself was considered successful, the fetus died 3 days later.9 Nicolini
et al. performed a less invasive procedure of percutaneous
sonographic-guided chemosclerosis using absolute alcohol. 10
These initial cases resulted in a good outcome; however, several
other authors have employed the same technique without success.
Embolization of the chorioangioma using microcoils and enbu-
crilate have also been reported but have resulted in fetal demise.11,12
Finally, endoscopic-assisted laser coagulation of feeding vessels
has been attempted in few cases with mixed results. Improvement
of current techniques and more research is necessary to determine
the risks and benefits of intervention.13,14
POSTNATAL
Given the risk for significant neonatal anemia and thrombocy-
topenia in cases of a large chorioangioma, delivery at a tertiary
center with access to immediate neonatology evaluation is
recommended.
KEY POINTS
• Chorioangiomas are the most common benign tumor of the
placenta.
• They are usually well circumscribed, vascular, and
predominantly hypoechoic, ranging from microscopic to
several centimeters in diameter.
• Chorioangiomas over 4–5 cm in maximum diameter have
been associated with adverse perinatal outcomes including
intrauterine growth restriction, polyhydramnios, fetomaternal
hemorrhage, fetal anemia, disseminated intravascular
coagulopathy, platelet sequestration, and neonatal
hypoalbuminemia.
• After diagnosis, US surveillance every 2 to 3 weeks is
recommended, followed by surveillance on a weekly basis
after 32 weeks to monitor for complications.
• Multiple medical and surgical interventions have been
employed with unclear benefits.
SUGGESTED READINGS
Amer HZ, Heller DS. Chorioangioma and related vascular lesions of the
placenta—a review. Fetal Pediatr Pathol. 2010;29(4):199-206.
Fan M, Skupski D. Placental chorioangioma: literature review. J Perin Med.
2013;42(3):273-279.
Sepulveda W, Alcalde JL, Schnapp C, et al. Perinatal outcome after prenatal
diagnosis of placental chorioangioma. Obstet Gynecol. 2003;102:1028.
Wattar B, Hillman S, Marton T, et al. Placenta chorioangioma: a rare case and
systematic review of literature. J Matern Fetal Neonatal Med.
2014;27(10):1055-1063.
Zalel Y, Weisz B, Gamzu R, et al. Chorioangiomas of the placenta. J Ultrasound
Med. 2002;21:909-913.
Zanardini C, Papageorghiou A, Bhide A, et al. Giant placental chorioangioma:
natural history and pregnancy outcome. Ultrasound Obstet Gynecol.
2010;35:332-336.
All references are available online at
www.expertconsult.com.

REFERENCES
1. Wattar B, Hillman S, Marton T, et al. Placenta chorioangioma: a rare case
and systematic review of literature. J Matern Fetal Neonatal Med.
2014;27(10):1055-1063.
2. Fan M, Skupski D. Placental chorioangioma: literature review. J Perin Med.
2013;42(3):273-279.
3. Amer HZ, Heller DS. Chorioangioma and related vascular lesions of the
placenta—a review. Fetal Pediatr Pathol. 2010;29(4):199-206.
4. Zanardini C, Papageorghiou A, Bhide A, et al. Giant placental chorioangioma:
natural history and pregnancy outcome. Ultrasound Obstet Gynecol.
2010;35:332-336.
5. Prapas N, Liang RI, Hunter D, et al. Color Doppler imaging of placental
masses: differential diagnosis and fetal outcome. Ultrasound Obstet Gynecol.
2000;16:559-563.
6. Zaidi SF, Moshiri M, Osman S, et al. Comprehensive imaging review of
abnormalities of the placenta. Ultrasound Q. 2016;32:25-42.
7. Benirschke K, Kaufman P. Pathology of the Human Placenta: Benign Tumors.
New York: Springer-Verlag; 1995:pp709-pp718.
99  Chorioangioma 438.e1
8. Kriplani A, Abbi M, Bannerjee N, et al. Indomethacin therapy in the treatment
of polyhydramnios due to placental chorioangioma. J Obstet Gynaecol Res.
2001;27:245-248.
9. Quintero RA, Reich H, Romero R, et al. In utero endoscopic devascularization
of a large chorioangioma. Ultrasound Obstet Gynecol. 1996;8:48.
10. Nicolini U, Zuliani G, Caravelli E, et al. Alcohol injection: a new method
of treating placental chorioangiomas. Lancet. 1999;353:1674-1675.
11. Sepulveda W, Alcalde JL, Schnapp C, et al. Perinatal outcome after prenatal
diagnosis of placental chorioangioma. Obstet Gynecol. 2003;102:1028.
12. Zalel Y, Weisz B, Gamzu R, et al. Chorioangiomas of the placenta. J Ultrasound
Med. 2002;21:909-913.
13. Lau TK, Leung TY, Yu SC, et al. Prenatal treatment of chorioangioma by
microcoil embolisation. BJOG. 2003;110:70-73.
14. Lau TK, Yu SC, Leung TY, et al. Prenatal embolisation of a large chorio-
angioma using enbucrilate. BJOG. 2005;112:1002-1004.