GESTATIONAL

AND PLACENTAL
DISORDERS
JANET LIM-DY, M.D., F,PSP
December 5 & 6, 2007

PLACENTA

Chorio-amnion
membrane

15-20 cm
indiameter

Umbilical cord

Normal placenta

450-600
gms

Normal placenta- maternal side

PLACENTAL MATURATION

FEATURES OF
NORMAL VILLI
MATURATION:

1. Progressive
diminution in villous
size & stromal content
2. Presence of blood
vessels
3. Syncytial knots
4. Cytotrophoblastic
layer disappears

Syncitial knots

Mature placenta with syncitial knots intervillous fibrin

Syncitial knots in mature villi

NONNEOPLASTIC
PLACENTAL
DISORDERS

HYDROPIC PLACENTA

Extremely pallor appearance

Large and thick placentas with coarse
villous structures
Villi are large,edematous, w/ dec. fetal
vessels
Seen in polyhydramnios ,
erythroblastosis fetalis, CMV, fetal renal
vein thrombosis or tumors of placenta

HYDROPIC PLACENTA

NORMAL PLACENTA

PLACENTAL INFARCTS

Represents area of villous necrosis

due to local obstruction of the maternal
utero-placental circulation
Color reflects age of the lesion: dark red
lesions are recent, while paler lesions
are older
Assoc : toxemia , essential HPN, Rh
incompatibility, nontoxic antepartum hge

INFARCTS

Based on maternal
surface; common at
margins
More solid than
adjacent tissue &
appear granular
Red to white
Early infarcts: villous
congestion &
collapse w/ loss of
intervillous space
Old infarcts: fibrin
deposition in
intervillous space

PLACENTAL INFARCTS

Non-infarcted area

Infarcted area

Placental infarcts

PLACENTA ACCRETA,
INCRETA, PERCRETA
Abnormal adherence of the placenta
to the uterine wall
Partial or complete absence of
decidual plate (placental villi adhere
directly or invade myometrium)
Deficient in endometrial
desidualization

PLACENTA ACCRETA
Associated conditions:

Previous CS
Hx of uterine curettage scarring ,
infection , leiomyoma

Complications :

Post-partum bleeding -> secondary to

failure of placental separation
Assoc with placenta previa ( 60 % )

PLACENTA PERCRETA

CHORIONIC VILLI

MYOMETRIUM

PLACENTA ACCRETA

PLACENTA PREVIA
Placenta

implants in the lower

uterine segment or cervix
Placenta may get in the way of
progressively dilated cervical
opening
Complications : antepartum
bleeding and premature labor

LOW LYING PLACENTA

PLACENTA PREVIA

Toxemia of Pregnancy
Symptoms

complex
characterized HPN, proteinuria
and edema (preeclampsia)
Occurs in 6% of pregnant women
Last trimester and primiparas
Eclampsia severe form
convulsions and DIC

Pathogenesis:
Abnormality of placentations
placental ischemia
uteroplacental perfusion stimulation
of vasoconstrictor substances and
inhibition of vasodilators
HPN, DIC and organ damage follows

Morphology:
1.
2.
3.

4.
5.
6.
7.

Placental infarct (larger & numerous)

Retroplacental hematomas
Intervillous fibrin deposition, and
prominent syncytial knotting , villous
hypovascularity
Fibrinoid necrosis of the uterine vessel wall and
intimal lipid deposit ** ( acute atherosis)
Liver = subcapsular hemorrhage and periportal
hemorrhagic necrosis
Kidneys = fibrin thrombi in glomeruli renal
cortical necrosis
Brain = hemorrhages and thrombosis

PLACENTA IN TOXEMIA OF PREGNANCY

ATHEROSIS OF THE ENDOTHELIUM

PREGNANCY INDUCED HPN

TOXEMIA

Clinical course :
starts 32nd wks. AOG
insidious on set
HPN,edema,proteinuria,headache
and visual disturbances
Bed rest,balanced diet and anti
hypertensives
Pregnancy termination - definitive
treatment

Placental infections :

Types of placental infection :

Fetal

membranes chorio-amnionitis
Umbilical cord funisitis
Chorionic villi villitis

Route of infection :
1. Ascending infection via birth canal
most common ;usually bacterial
2. Hematogenous ( transplacental )

PLACENTAL VILLITIS

CHORIOAMNIONITIS
Ascending infection with neutrophilic
infiltration of the membranes
Opacification of the membranes
Yellow-green coloration due to
myeloperoxidase from neutrophils
May be foul-smelling (anaerobic)

CHORIOAMNIONITIS

surface opacity
Involves surface
and peripheral
membranes
Usual agents:
bacteria
Premature labor
and PROM

CHORIO-AMNIONITIS

NORMAL

FUNISITIS

MATURE BILOBATE
PLACENTA

Two distinct lobes of roughly equal

proportion, separated by fetal membranes
Umbilical cord inserts between the two
lobes
Clinical significance/ associations :

multiparity , advanced maternal age , infertility

placenta previa, first trimester bleeding
excessive placental adhesions

BILOBED PLACENTA

ACCESSORY LOBE OR
SUCCENTURIATE LOBE

Small , discrete masses of placental

tissues are separated from the main
placenta
Clinical significance :

trauma to vessel fetal hge

thrombotic, thrombo-embolic events
retained placenta after delivery
placenta previa
increase tendency to infarct

ACCESSORY LOBE

ACCESSORY LOBE OR SUCCENTURIATE LOBE

BATTLEDOR PLACENTA
True marginal insertion
Slightly smaller babies on the
average
Less mobile and more prone to
compromise

MARGINAL INSERTION

VELAMENTOUS
INSERTION

Insertion of the cord into free

membranes
1% of deliveries
Paucity of vessel surface, vessel
ramifications growth retardation

VELAMENTOUS INSERTION OF U.C.

MULTIPLE
GESTATIONS

Twin Pregnancies

Arise from fertilization of two ova

( dizygotic ) or from division of one
fertilized ovum ( monozygotic )
Information with regard to type of
twinning
Three types :
Dichorionic diamniotic
Monochorionic, diamniotic
Monochorionic , monoamniotic

CHORIONICITY

- 2 placentas
- single shared placenta
- 2 separate fertilized eggs
- 1 fertilized egg splits early
- Chorionic tx in dividing memb
- no chorionic tx in dividing
forms ridge on surface membranes
- Thick & opaque memb - thin & delicate membranes
- Placental surface disrupted - easily separated
when attempt to separate

DICHORIONIC

MONOCHORIONIC

HIGHER MULTIPLE
BIRTHS

 COMPLICATION

Twin- twin transfusion in

which placental vascular
anastomoses create an
abnormal sharing of fetal
circulations through
shunting

Ectopic Pregnancy

Fetal implantation at any site other than

a normal uterine location
Occur in 1 out of 150 pregnancies
Location :
Fallopian tube
Ovary
Abdominal cavity
Cornual area

Ectopic Pregnancy
Predisposing factors :
PID
Peritubal adhesions
Endometriosis
Leiomyomas
Previous surgery
50 % FTs are normal

ECTOPIC
PREGNANCY

Abortion
Incidence
Etiology

of 15 40 %

Infections : Listeria, campylobacter ,

Sy, toxoplasma , rubella
2. Mechanical disturbance : myomas ,
cervical incompetence
3. Endocrine diseases
4. Immunologic mechanisms : ( autoimmune , ABO incompatibility )
5. Chromosomal abnormalities
1.

Diagnosis of abortion :
Identification of :
fetus or fetal parts
chorionic villi *
trophoblasts and *decidual tissues
gestational sac or placental parts
( cord, membranes )

Gestational
Trophoblastic Disease
Spectrum of tumor characterized by
proliferation of pregnancy - associated
trophoblastic tissue of progressive
malignant potential
Types :
1.Hydatidiform mole (H. mole)
2. Invasive mole

3.choriocarcinoma

Modified WHO classification of

Gestational Trophoblastic diseases

Hydatidiform mole
Complete
Partial
Invasive mole
Choriocarcinoma
Placental site trophoblastic tumor
Epithelioid trophoblastic tumor
Miscellaneous trophoblastic lesions
Exaggerated placental site
Placental site nodule

Hydatidiform mole

Characterized by cystic swelling of

chorionic villi with variable trophoblastic
proliferations
Precursor lesion of choriocarcinoma
Usually seen in the 4th 5th month of
pregnancy
Occur at any age

PARTIAL
HYDATIDIFORM MOLE
Hydropic villi are admixed with normal
villi
sometimes with fetal parts
Trophoblastic proliferation around the
hydropic villi is mild and focal
Volume of the placental tissue is normal
Results from fertilization of an egg with
1diploid or 2 haploid sperm
Triploid

Normal

PARTIAL MOLE

HYDROPHIC VILLI

PARTIAL H MOLE

COMPLETE
HYDATIDIFORM MOLE

Voluminous vesicular grape-like clusters, 12cm

Result from fertilization of an empty egg by 1
or 2 sperm (androgenetic)
Diploid
No fetal parts
Diffuse villous hydropic swelling, avascular,
with cisterns
Trophoblastic (cyto- and syncytio-)
proliferation with atypia

COMPLETE
HYDATIDIFORM MOLE

Incidence of 1 : 2000 deliveries

Higher incidence in Southeast Asia
Phil incidenec of 1 : 173 deliveries
Increase incidence in :
older than 30 yrs
vit A deficiency
Hx of previous mole

Complete H mole
clinical features
Large uterus inappropriate for AOG
Increase association of toxemia ,
hyperthyroidism
Presents with AUB
Passage of thin watery fluid and grape
like masses
Elevated HCG titer

Large uterus

VESICLES

COMPLETE H MOLE

Grape-like
vessicles

AVASCULAR ,
EDEMATOUS
STROMA

TROPHOBLAST PROLIFERATION

COMPLETE H MOLE

Types of H mole
Features
Karyotype
Villous
edema
Troph prolif

Atypia
Serum HCG

Complete Mole
Mole
46,XX (46
XY)
all villi

Partial

Triploid
some villi

diffuse,
Focal,
circumferen slight
tial
often
absent
present
elevated
less
elevated

INVASIVE
HYDATIDIFORM MOLE

Molar tissues invading myometrium or

blood vessels, ( trophoblastic deportation )

Occurs in 16 % of complete H mole

Complication :
uterine perforation
trophoblastic embolization ( lungs,
vagina , etc )

INVASIVE
HYDATIDIFORM MOLE
Diagnosed on a hysterectomised
specimen
Irregular hemorrhagic lesion within
muscle bundles of myometrium
Must demonstrate hydropic villi
within myometrium

CHORIOCARCINOMA

Most aggressive form of GTD

Epithelial malignant neoplasm of trophoblastic cells
Most occur following complete H mole ( 1 : 40 )
May also be preceded by :
abortion ( 1 : 15,386 )
ectopic pregnancy ( 1 : 5,333)
term pregnancy ( 1 : 160,000)

CHORIOCARCINOMA
morphology :

Well-circumscribed dark red , hemorrhagic

necrotic mass
Dimorphic: cytotrophoblasts +
syncytiotrophoblasts with extensive
necrosis and hemorrhage
No chorionic villi identified *

Clinical Course
> irregular bleeding
> Markedly elevated HCG
> Hematogenous spread
lungs,vagina,brain ,liver and
kidney

LUTEIN
CYST

CHORIOCARCINOMA

CHORIOCARCINOMA

CHORIOCARCINOMA

CYTOTROPHOBLAST
SYNCITIOTROPHOBLAST

CHORIOCARCINOMA

METASTATIC
CHORIOCARCINOMA

PLACENTAL SITE
TROPHOBLASTIC TUMOR

PSTT
< 2% of GTD
Maybe preceded by normal
pregnancy,abortion,and or H. mole
Infiltration of the endomyometrium
by the intermediate trophoblast
Beta subunits of HCG is increased

PSTT

MERRY
CHRISTMAS !