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DMST 315 OBGYN 3 > Placental Pathology > Flashcards

Placental Pathology Flashcards

1
Q

By 12 weeks of gestation, two distinct components of the placenta are recognizable, what are they?

A
  1. Fetal portion
  2. Maternal portion
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2
Q

What is another name for the fetal portion?

A

Chorion frondosum AKA chorionic plate

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3
Q

What is another name for the maternal portion?

A

Decidua basalia AKA basal plate

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4
Q

What is the two portions of the placenta held together by?

A

Anchoring stem villi at the Cytotrophoblastic shell

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5
Q

Projections of the decidua basalis is called what? What does it do?

A
  1. Placental septa
  2. Divides the placenta into compartments
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6
Q

What is a cotyledon?

A

Compartment of the placental septa

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7
Q

There are about ____ cotyledons in a placenta?

A

20

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8
Q

Basic texture of the placenta changes how during gestation?

A

Does not change with gestational age except for the deposition of calcium

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9
Q

Placental calcifications are present in >50% of placentas after how many weeks?

A

33 weeks

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10
Q

Calcium deposits are found primarily in what area?

A

Basal plate or septa, but may be seen in the subchorionic and previllous spaces

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11
Q

Amount of calcification is increased in patients with what three things?

A
  1. IUGR
  2. Hypertension
  3. Smoking
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12
Q

How many grades of the placenta are there?

A

4: Grade 0-3

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13
Q

What is a grade 0 placenta?

A

Homogenous, chorionic plate is straight

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14
Q

What does a grade 1 placenta look like?

A
  1. Scattered echogenic areas
  2. Subtle undulations
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15
Q

What does a grade 2 placenta look like? 2

A
  1. Indentations
  2. Linear echogenic areas
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16
Q

What does a grade 3 placenta look like? 3

A
  1. Indentations to basal layer
  2. Cystic areas
  3. Shadowing calcifications (after 36-38 weeks)
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17
Q

How do we document the placenta? What do we need to ensure during this process? 4

A
  1. Document the placental position in SAG and TRX.
  2. Measure from placental edge to the internal OS of the cervix
  3. Document the placental cord insertion in SAG and TRX
  4. Ensure there is only one placental mass
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18
Q

What do we need to assess during placental documentation?

A

Texture and thickness

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19
Q

During placental documentation we need to measure the placenta how?

A

From the placental edge to the internal OS of the cervix

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20
Q

The placenta should be a minimum of ________ away from the internal OS of the cervix?

A

2cm

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21
Q

The cord insertion for the placenta should be how far from the placental edge in both planes?

A

> 2cm

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22
Q

What is the shape of the placenta?

A

Flat and circular

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23
Q

How heavy is the placenta?

A

500-600 grams

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24
Q

How thick is the placenta?

A

1.5 - 4cm

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25
Q

The placenta grows how much a week in thickness?

A

1mm

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26
Q

When measuring the placenta, we do not include what in the measurement?

A

The myometrium or retroplacental complex

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27
Q

What is considered placentalmegaly?

A

> 4cm

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28
Q

What is the etiology of placentomegaly? 6

A
  1. Maternal diabetes
  2. Maternal anemia
  3. Hydrops
  4. Intrauterine infection
  5. Partial mole
  6. Chromosomal abnormalities
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29
Q

Thickness of the placenta usually depends on what?

A

Gestational age

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30
Q

What is considered a thin placenta?

A

<1.5 cm

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31
Q

Why do we normally have thin placenta?

A

Placenta insufficiency

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32
Q

What is the etiology of thin placenta? 2

A
  1. Vascular deficiency or infarction
  2. Pre-eclampsia
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33
Q

What are some pre-eclampsia signs that results in thin placentas? 3

A
  1. Hypertension
  2. Proteinuria
  3. Edema
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34
Q

Thin placenta may cause what?

A

IUGR

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35
Q

Intraplacental lesions have what type of clinical significance?

A

None

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36
Q

What are two examples of intraplacental lesions?

A
  1. Maternal lakes (Subchorionic fibrin deposition)
  2. Placental lakes (Perivillous fibrin deposition)
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37
Q

What are maternal lakes?

A

Sonolucent area adjacent to chorionic plate

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38
Q

What does maternal lakes result in?

A

Pooling and stasis of maternal blood

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39
Q

Often what type of flow is demonstrated in maternal lakes?

A

Rouleaux flow

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40
Q

What does placental lakes look like? What might be visualized with them?

A

Well defined intraplacental hypoechoic lesions in which rouleaux flow is sometimes visible.

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41
Q

What is placental lakes caused by?

A

Turbulence and stasis of maternal blood in intervillous space within secondary fibrin deposition

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42
Q

Placental lakes can be abnormal if seen in 1st trimester, why?

A

Due to association with placenta accreta spectrum and placental insufficiency

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43
Q

What are two examples of intraplacental lesions?

A
  1. Intervillous and subchorionic thrombus
  2. Septal cysts
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44
Q

What are intervillous and subchorionic thrombus caused by?

A

Fetal bleeding into intervillous space

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45
Q

What does intervillous and subchorionic thrombus contain? How do they appear?

A

Fibrin and appear as intraplacental hypoechic lesions

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46
Q

Where are intervillous and subchorionic thrombosis located?

A

Perivillous and subchorionic spaces

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47
Q

Intervillous sand subchorionic thrombus are thought to be how significant? What are they associated with?

A

Insignificant as well but are associated with RH isoimmunization cases

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48
Q

Septal cysts are located where?

A

Top of septa.

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49
Q

Septal cysts are thought to be a result from what?

A

Obstructed venous drainage

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50
Q

How does septal cysts appear?

A

Hypoechoic intraplacental lesions

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51
Q

What are placental infarcts?

A

Microscopic triangular shaped lesions on maternal side of placenta

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52
Q

What are placental infarcts due to? What does it lead to?

A

Obstruction of maternal blood flow leading to necrosis

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53
Q

In terms of placental infarcts, over 10% involvement of the placenta is considered what three things?

A
  1. Extensive and associated with IUGR
  2. Fetal hypoxia
  3. Fetal demise
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54
Q

Are placental infarcts generally seen on U/S?

A

No

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55
Q

Most placenta look how in the 1st and early second trimester?

A

Low

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56
Q

What can make the placenta look low?

A

Distended bladders

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57
Q

How does placenta previa appear? What are two other names for placenta previa?

A
  1. Low lying
  2. Marginal or partial placental previa
  3. Complete placenta previa
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58
Q

What is the clinical history for placenta previa?

A

Painless vaginal bleeding

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59
Q

What is a low lying placenta?

A

When the placenta is <2cm from the internal OS but not overlying it

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60
Q

What is a partial placenta previa?

A

Placenta touches the internal OS

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61
Q

What is a complete placental previa?

A

Placenta completely covers the internal OS

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62
Q

What do we need to do if the bladder is over distended when viewing the placenta previa?

A

Empty some bladder

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63
Q

When would we empty the bladder when look for placenta previa? 2

A
  1. If cervix looks longer than 4 cm
  2. Over distended
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64
Q

Why do we need to empty the bladder when we assess for placenta previa?

A

To asses for uterine contraction in cervix area

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65
Q

At the 18-20 week scan, if the placenta is <2cm from the internal os after a post void bladder assessment, what must be done? How long will they need to do this?

A
  1. The patient will return at 24-28 weeks for follow up
  2. Until the placenta migrates away from the internal OS by >2cm. Most do migrate but a few will continue to be low lying
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66
Q

What do we need to use with EV for placenta previa?

A

Use condom or non latex probe cover

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67
Q

What does EV for placenta previa require from sonographers?

A

Experience

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68
Q

What is required from the patient for a EV for placenta previa? 2

A
  1. No bleeding for 24 hours
  2. Empty bladder
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69
Q

What is the process of EV for placenta previa? 2

A
  1. Insert slowly under direct visualization
  2. Use little to no pressure against cervix
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70
Q

Where does the umbilical cord attachment to placenta insert?

A

At or near the center of placenta

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71
Q

What is a battledore?

A

Marginal cord insertion

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72
Q

Where is the cord of a battledore in terms of the placental edge?

A

<2cm

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73
Q

What can a battledore progress to?

A

Velamentous

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74
Q

What is a velamentou insertion?

A

Cord inserting into the chorionic membranes and then vessels track to placenta

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75
Q

With velamentous insertion, vessels are not protected by placenta or Wharton jelly, therefore more susceptible to what?

A

Rupture

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76
Q

Battledores and velamentous CI are associated with what? 4

A
  1. IUGR
  2. FHR abnormalities
  3. Placental abruption
  4. Preterm labour
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77
Q

What are some variations in shape for battledore s and velamentous CI? 3

A
  1. Succenturiate
  2. Extrachorial
  3. Membranacea
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78
Q

What are two different branches of extrachorial?

A
  1. Circummarginate
  2. Circumvallate
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79
Q

What is a succenturiate? 2

A
  1. Accessory lobe
  2. Separate piece of placenta connected to main placenta via vessels within membrane
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80
Q

Succenturiate are at a higher risk of what two things?

A
  1. Increased risk of retained products
  2. Increased risk of vasa previa
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81
Q

What are vasa previa in relation to succenturiate?

A

Vessels connecting placenta to succenturiate lobe going across cervix

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82
Q

What is a vasa previa?

A

Unprotected fetal vessels travelling in the membranes across the lower uterine segment of cervix

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83
Q

In terms of vasa previa, vessels may do what?

A

Rupture in labour or with rupture of membranes, carrying a high risk of fetal death

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84
Q

If Vasa previa is identified penatally, what is planned? What does this do for survival rate?

A

C-section is planned for 34-36 weeks and outcome is >97% survival rate

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85
Q

What are some risk factors for vasa previa? 3

A
  1. Velamentous or marginal CI into placenta
  2. Resolving placenta previa
  3. Succenturiate lobes of placenta
86
Q

What does a screening look like for vasa previa? 3

A
87
Q

What do we look for with vasa previa during evaluation of the lower uterine segment and cervix?

A

Bubbles and lines when evaluating the lower uterine segment and cervix

88
Q

Extrachorial placenta occurs when?

A

The chorionic plate does not extend to the edge of placenta. Chorionic membrane extends over placenta

89
Q

What are two types of Extrachorial placenta?

A
  1. Circummarginate
  2. Circumvallate
90
Q

What does Circummarginate looks like?

A

A flat ring at attachment to chorionic plate

91
Q

What does a Circumvallate look like? 2

A
  1. Fold in the membrane at site of attachment
  2. Placenta and fetal membranes fold back towards the chronic surface
92
Q

What are complications of Circumvallates? 3

A
  1. Increased risk of placental abruption
  2. Placental insufficiency (fetal IUGR)
  3. PRL hemorrhage at delivery
93
Q

In both Circummarginate and Circumvallate placentas the chorionic plate does not do what?

A

Extend to the edge of the placenta

94
Q

What is a synechiae?

A

Area of scarring in endometrium

95
Q

Compared to the rest of the uterus, what does the synechiae not do?

A

Stretch

96
Q

Synechiae leaves the appearance of what?

A

A membrane that just ends

97
Q

With a synechiae, we can see what in terms of fetal parts?

A

Fetal parts on both sides of membrane but fetus is not attached to it as it would in an amniotic band syndrome

98
Q

What are the potential complications of Circumvallate placenta? 5

A
  1. Placental rupture
  2. Placental insufficiency
  3. Hemorrhage
  4. IUGR
  5. Preterm labour
99
Q

What is the biggest concern for succenturiate lobes?

A

Vasa previa

100
Q

What is synechiae associated with?

A

Asherman’s syndrome

101
Q

What is a placenta membranacea?

A

Entire uterine surface is covered with placenta

102
Q

How does placenta membranacea form?

A

Due to failure of smooth chorion to compress and become the chorionic membrane in embryology

103
Q

How common is placenta membranacea?

A

Very rare

104
Q

What are some complications of placenta membranacea? 5

A
  1. Placenta previa
  2. IUGR
  3. Fetal demise
  4. Postpartum hemorrhage
  5. Retained tissue post delivery
105
Q

What might placental hemorrhage occur with in terms of placental abruption? 2

A
  1. Marginal
  2. Retroplacenta
106
Q

What are three different formation of placental abruption?

A
  1. External bleeding, no hematoma
  2. Retroplacental hematoma without external bleeding
  3. Subchorionic hematoma with or without bleeding
107
Q

Placenta abruption may be caused by what? 6

A
  1. Abdominal trauma
  2. Short umbilical cord
  3. PIH (pregnancy induced hypertension)
  4. Maternal vascular disease
  5. Maternal smoking and/or drug usage
  6. Fibroids
108
Q

What are symptoms of placental abruptions? 3

A
  1. Preterm labor contractions
  2. Bleeding
  3. PAIN
109
Q

What is the sonographic apeparence of placenta abruptions? 2

A
  1. Sonolucent or complex mass beneath chorionic membrane
  2. Placental thickening, often >5.5cm
110
Q

What are three examples of tumors in the placenta?

A
  1. Teratoma
  2. Chorioangioma
  3. Metastatic tumors
111
Q

What is a teratoma in a placenta?

A

A rare germ cell tumor

112
Q

What is a chorioangioma?

A

Vascular tumor, usually single

113
Q

What does a chorioangioma look like? 2

A
  1. Well defined solid/complex mass
  2. If large, may cause hydrops and heart failure
114
Q

How might metastatic tumors arrive in the placenta?

A

Metastatic tumours may spread to the placenta from mother or fetus, though rare

115
Q

What does PAS stand for?

A

Placenta Accreta Spectrum

116
Q

What is PAS?

A

When the placenta does not attach properly to the basalis but rather invades into and beyond the maternal basalis layer

117
Q

What are three types of PAS?

A
  1. Accreta
  2. Increta
  3. Precreta
118
Q

What happens with PAS Accreta?

A

Attaches to myometrim

119
Q

What does PAS Increta look like?

A

Invades into myometrium

120
Q

What does a PAS Precreta look like?

A

Invades through the myometrium to perimetrium and even beyond

121
Q

What are some risks of placenta Increta a or Precreta risks? 2

A
  1. Increased risk of having acreta after C section or other uterine surgery
  2. Increased risk of bleeding postpartum, because the placenta has invaded into the uterine wall it is difficult to remove at delivery
122
Q

Placenta Increta or Precreta may result in what at delivery?

A

Hysterectomy at delivery

123
Q

What are some common risks of accreta? 2

A
  1. Placenta previa (anterior placenta)
  2. Prior c-section
124
Q

What can accreta be associated with? 7

A
  1. Advanced maternal age
  2. Increased parity
  3. Uterine abnormalities
  4. Smoking
  5. Myomectomy
  6. Previous uterine surgery
  7. Previous D and C
125
Q

In terms of placenta Increta or Precreta, what is great question to ask if a patient is Graviida 2 or more?

A

have you had a C-section delivery

126
Q

What are some sonographic appearance or signs with accreta? 5

A
  1. Anterior placenta
  2. Presence of numerous lacunae
  3. Look for a “clear zone” between placenta wall in the retroplacental area
  4. Thin or imperceptible myometrium
  5. Bladder line loss
127
Q

In terms of accreta, what are some things we need to look for with anterior placenta? 2

A
  1. Low lying or anterior previa
  2. Previous c-section deliveries
128
Q

In terms of accreta, when we look for a “Clear zone” between placenta and uterine wall in the retroplacental area, what area some things we might see? 2 (abnormal and normal)

A
  1. Abnormal if this clear zone cannot be demonstrated
  2. Normal placental clear zone, applying pressure to the clear zone will disappear
129
Q

In terms of accreta, what constitute bladder line loss? 3

A
  1. Not as sharp or clear
  2. Lumpy or bumpy
  3. Bulges into the bladder
130
Q

What is diagnosis like for accreta on u/s? What can be seen?

A
  1. Difficult on U/S
  2. Only Anterior placenta
131
Q

What should we look for in terms of a diagnosis of accreta? What can help us look? 3

A
  1. Absent or severely thinned myometrium
  2. Extension to adjacent organs
  3. Use colour doppler
132
Q

What can be used to diagnose accreta in the case of ambiguous ultrasound findings?

A

MRI

133
Q

What does the umbilical cord develop from?

A

Connecting stock and yolk sac

134
Q

What is the vessel information in the umbilical cord?

A

2 arteries and 1 vein

135
Q

What is the umbilical cord vessels surrounded by?

A

Whartons jelly

136
Q

What is umbilical cords covered with?

A

Amnions

137
Q

How long is Umbilical Cord?

A

50-100cm long

138
Q

What is cord cysts remnants of?

A

Allantoic remnant

139
Q

How significant is cord cysts?

A

Transient and insignificant

140
Q

Multiple cord cysts can be associated with what? 3

A
  1. T18
  2. T13
  3. Increased risk of miscarriage
141
Q

What are two types of cord knots?

A

True or false knots

142
Q

False chord knots are due to what?

A

Cord kink or redundancy

143
Q

How Common are true knots?

A

Rare (<1% of pregnancy)

144
Q

Most true knots are what?

A

Lost

145
Q

What are risk factors of Cord knots? 3

A
  1. Long cord
  2. Polyhydraminos
  3. Excessive fetal movements
146
Q

What is a highly specific sign for true or false cord knots?

A

Hanging noose sign

147
Q

What can be used for further characterization of cord knots?

A

3D/4D

148
Q

What is a umbilical vein varix?

A

Intra-abdominal focal enlargement of the umbilical vein

149
Q

What might happen in umbilical vein varix?

A

Stasis may occur here and blood may clot

150
Q

What is umbilical vein varix associated with?

A

A higher incidence of adverse outcomes

151
Q

Label

A
152
Q

Label

A
153
Q

Label the image

A
154
Q

What does this image represent?

A

The placental appearance on u/s

155
Q

What does this image represent?

A

Grade 3 placenta

156
Q

What does these images represent?

A

SAG placenta and TRX placenta

157
Q

What does this image represent?

A

Placenta measurements: The placental edge to the internal OS of the cervix

158
Q

What does these images represent?

A

Placental documentation of the cord insertion

159
Q

What does this image represent?

A

Size and shape of the placenta in trans

160
Q

What does this image represent?

A

Placentomegaly

161
Q

What does this image represent?

A
  1. Maternal lakes
  2. Placental Lakes
162
Q

What does this image represent?

A

Placental Lakes

163
Q

What does this image represent?

A

Maternal lake

164
Q

What does this image represent?

A

Placental position with a distended bladder and the low lying placental bladder

165
Q

What does these images represent?

A

Placental Previa
A. Low lying <2cm from internal os
B. Marginal Previa
C. Partial Previa
D. Complete previa

166
Q

What does this image represent?

A

Low lying placenta - when the placenta is <2cm from the interlay OS but not overlying it

167
Q

What does this image represent?

A

Partial placental previa

168
Q

What does this image represent?

A

Complete placenta previa

169
Q

Label

A
170
Q

What does this image represent?

A

Low lying placenta

171
Q

What does this image represent?

A

Normal Transabdominal cervix at 18 weeks LMP

172
Q

What does this image represent?

A

Normal Endovaginal cervix at 18 weeks

173
Q

What does these images represent?

A
  1. Cord insertion into placenta
  2. Inserts at or near center of placenta
174
Q

What does these two images represent?

A
  1. Marginal CI (Battledore)
  2. Velamentous CI
175
Q

What does these images represent?

A

Marginal CI and Velamentous CI

176
Q

What does this image represent?

A

Succenturiate

177
Q

What does these images represent?

A

Succenturiate placenta

178
Q

What does these images represent?

A
  1. “Bubbles and Line” when evaluating the lower uterine segment and cervix for vasa previa
  2. Bubbles on the top row and lines on the second row
179
Q

What does this image represent?

A

Vasa previa arterial waveform, which matches fetal heart rate

180
Q

What does these images represent?

A

Vasa previa vs funic presentation

181
Q
A
182
Q

What does these images represent?

A
  1. Normal
  2. Circummarginate
  3. Circumvallate
183
Q

What does these images represent?

A

A. Circummarginate
B. Circumvallate

184
Q

What does these images represent?

A

Circumvallate

185
Q

What does this image represent?

A

Circumvallate

186
Q

What does this image represent?

A

Circumvallate

187
Q

What does this image represent?

A

Synechiae

188
Q

What does this image represent?

A

Synechiae

189
Q

What does this image represent?

A

Synechiae

190
Q

What does this image represent?

A

Synechiae

191
Q

What does this image represent?

A

Placenta membranacea

192
Q

What does these images represent?

A

Placenta abruption
A. External bleeding, no hematoma
B. Retroplacental hematoma without external bleeding
C. Subchorionic hematoma with or without bleeding

193
Q

What does this image represent?

A

Sonographic appearence of abruptions

194
Q

What does this image represent?

A

Amniotic hematoma

195
Q

What does this image represent?

A

Chorioangioma

196
Q

Label

A
  1. Normal creta
  2. Accreta
  3. Increta
  4. Percreta
197
Q

Label

A
198
Q

What does this image represent?

A

Clear zone

199
Q

What does this image represent?

A

Clear zone disappears with probe pressure
1. Clear zone is hypoechoic
2. Slight pressure the clear zone disappears. Normal placental bed

200
Q

What does this image represent?

A

Loss of clear zone due to invasive placenta

201
Q

What does this image represent?

A
202
Q

Label

A
203
Q

What does this image represent?

A

Umbilical cord

204
Q

What does this image represent?

A

2UA = 3 vessel cord

205
Q

What does this image represent?

A

Cord cyst

206
Q

What does this image represent?

A

Cord knots

207
Q

What does this image represent?

A

Umbilical vein varix

208
Q

What does this image represent?

A

Umbilical cord varix

209
Q

What is this?

A

Hanging noose sign for a cord knot

210
Q

What is a fecalith?

A

A 30 year old male whose sub type is Brian

  • Cheats on bench
  • Probably is a caffeine addiction
  • is a weaker sub type of the chuong variation
211
Q
A

DMST 315 OBGYN 3 (21 decks)

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