SlideShare a Scribd company logo
1 of 93
Download to read offline
Placenta pathology associated with
   maturation abnormalities and
   late intra uterine foetal death.

        PETER G.J. NIKKELS
   Dept. of Pathology UMC Utrecht,
            the Netherlands
Anatoom Frederick Ruysch, J. van Neck 1683
Perinatal death
• Perinatal death occurs in 1,5% of all birth

• Frequency of stillbirth in western Europe approximately 2,2-4,4 /
  1000 life birth

• Riskfactors:
  multiple pregnancy, prematurity, first or second pregnancy,
  hypertension or pre-eclampsia of the mother, congenital
  abnormalities (20-40%) and inflammation
Causes of IUFD
• Placenta or umbilical cord pathology                                          62%
• Congenital abnormalities                                                      17%
• Intra-uterine infection                                                        2%
• Trauma                                                                         1%
• Miscellaneous (tumors, storage disorder) 3%
• Unexplained (12/47 no placenta)                                               15%

•   Horn et al. Identification of the causes of intrauterine death during 310 consecutive autopsies.
    European Journal of Obstetrics & Gynaecology and Reproductive Biology 113 (2004), 134-8.

    University Hospital Leipzig, IUFD from 22-42 6/7 weeks.
Causes of IUFD
• Placenta or umbilical cord pathology                                                     62%
• Utero-placental pathology                                         38%
• Dysmaturity of parenchym                                          23%
• Inflammation                                                      14%
• Umbilical cord                                                    22%
           (Compression, bleeding, haematoma)
• Miscellaneous                                                     3%
           (TTTS, chorangioma etc.)
•   Horn et al. Identification of the causes of intrauterine death during 310 consecutive autopsies.
    European Journal of Obstetrics & Gynaecology and Reproductive Biology 113 (2004), 134-8.

    University Hospital Leipzig, IUFD van 22-42 6/7 weeks.
Main cause of IUFD
Disturbance in delivering oxygen to the foetus
• Not enough or loss of parenchyma
  –   Small placenta
                             Placental bed pathology
  –   Placental infarcts
  –   Chronic inflammation
  –   Foetal thrombosis
• Diffusion distance too long
  – Fibrin deposition
  – Abnormal maturation
• Umbilical cord pathology
Normal development of
 the placenta parenchyma




• Placenta: the fastest growing
  organ of the human body

• from 1 tot 5 x 1010 cells in 38
  weeks
Placental weight
Ratio of placental weight and foetal weight
Normal development of placental parenchyma
FIRST TRIMESTER
     – In first 12 weeks only mesenchymal villi
     – Development of immature intermediate villi with two layers of
       trophoblast
     – Development of stem villi with central fibrous core


                                                       Amniotic cavity
Yolk sac
Normal 13 weeks
Normal 13 weeks
Normal maturation of placental parenchyma

• SECOND TRIMESTER

  – Parenchyma consists of immature intermediate villi, there is
    some development of mature intermediate villi

  – Largest variation in villus shape and diameter

  – Mesenchymal stroma alongside stem villi disappears and
    occasionally some fibrinoid material can be seen
Normal 23 weeks
Normal 23 weeks
Normal 25 weeks
Normal 25 weeks
Normal 31 weeks
Normal 31 weeks
Normal maturation of the placental parenchyma

• THIRD TRIMESTER

  – Development of terminal villi

  – At 40 weeks 40% of the villous volume are terminal villi

  – Terminal villi have syncytio-vascular membranes

  – Stem villi are covered with fibrinoid material
Normal 35 weeks
Normal 35 weeks
Normal 40 weeks
Normal 40 weeks
Pathology of the_placenta_-_lecture
Abnormal maturation of the placenta parenchyma



• Accelerated maturation




• Delayed maturation and dysmaturity
Accelerated maturation
• Utero-placental pathology
  decreased blood flow to the placenta due to abnormalities in spiral
  arteries
  maternal hypertension or pre-eclampsia
  Sometimes also abnormalities in vessels in the membranes or in the
  decidua (acute atherosis)

• Multiple pregnancy placenta (two or more)

• Recipient of the twin-transfusion syndrome
Pathology of the_placenta_-_lecture
Normal spiral arteries
Multinucleated trophoblast
Spiral artery
Pathology of the_placenta_-_lecture
Acute atherosis in artery of membranes
Accelerated maturation histology

• Premature formation of terminal villi with syncytio-vascular
  membranes
• Stem villi with aspect normal for pregnancy duration

• Distal villous hypoplasia with long slender villi and increased space
  between villi



• Hyperchromasia of trophoblast

• Increased syncytial knotting
Pathology of the_placenta_-_lecture
NRBC
Pathology of the_placenta_-_lecture
Other abnormalities of utero-placental /
         placental bed pathology
• Infarcts

• (partial) solutio


• (Massive) subchorionic haematoma

• Intervillus thrombi / haematoma
Recent infarct
Old infarct with central hemorrhage
Accelerated maturation

• Recipiënt of twin-twin transfusion syndrome


• CS at 30 weeks because of worsening foetal condition after
  multiple amniotic drainage
recipiënt   30 weeks   donor
Delayed maturation and dysmaturity
Less terminal villi as expected.
From 30 weeks onwards terminal villi recognisable.
At 40 weeks 40% of the villi are terminal villi.

• Maternal diabetes
• Macrosomia without diabetes
• Chronic villitis
• Defective placental maturation
• Congenital and / or chromosomal abnormality
• Donor of twin-twin transfusion syndrome
• Foetal anaemia of low colloid osmotic pressure
• Foetal cardiac decompensation
Delayed maturation, maternal diabetes

• Small groups of immature villi and hydropic villi

• Chorangiosis

• Fibrinoid necrosis of the villous stroma




• Increase of NRBCs
Pathology of the_placenta_-_lecture
Pathology of the_placenta_-_lecture
NRBC
Pathology of the_placenta_-_lecture
Variable maturation example 1




                Bichorionic twin placenta at 38 weeks

Small placental part                heavy placental part
Main cause of IUFD
Disturbance in delivering oxygen to the foetus
• Not enough or loss of parenchyma
  –   Small placenta
                             Placental bed pathology
  –   Placental infarcts
  –   Chronic inflammation
  –   Foetal thrombosis
• Diffusion distance too long
  – Fibrin deposition
  – Abnormal maturation
• Umbilical cord pathology
Loss of parenchyma, chronic inflammation
Severe villitis of unknown etiology
• Destruction of villi, less mature
• Infiltrate with macrophages and T-cells
• High recurrence risk of IUGR and IUFD

     – Recently some case reports with favorable outcome
       after treatment with corticosteroids and antitrombotics


Boog et al. J Gynecol Obstet Biol Reprod (Paris). 2006 Jun;35(4):396-404. [Combining corticosteroid and
aspirin for the prevention of recurrent villitis or intervillositis of unknown etiology]
Pathology of the_placenta_-_lecture
CD 68   CD 3
Loss of parenchyma, chronic inflammation
Chronic intervillositis
• Massive histiocytic infiltrate in maternal
  compartment
• Perinatal mortality 29%, IUGR 77%
• High recurrence risk of abortion, IUGR and IUFD

     – Recently some case reports of favorable outcome after
       treatment with corticosteroids and antitrombotics

Boog et al. J Gynecol Obstet Biol Reprod (Paris). 2006 Jun;35(4):396-404. [Combining corticosteroid and
aspirin for the prevention of recurrent villitis or intervillositis of unknown etiology]
Pathology of the_placenta_-_lecture
Pathology of the_placenta_-_lecture
CD 68   CD 3
Loss of parenchyma, foetal trombosis
• Groups of avascular villi
• Histology similar as in IUFD
• Incidence
  –   Normal placenta’s                 2%
  –   Placenta’s with overcoiled cord   20%
  –   Pre-eclampsia                     20-30%
  –   Macrosomia without DM             30-40%
• Occasionally in association with CMV or
  trombophilia disorder
Pathology of the_placenta_-_lecture
Pathology of the_placenta_-_lecture
Pathology of the_placenta_-_lecture
Pathology of the_placenta_-_lecture
Pathology of the_placenta_-_lecture
CMV
Diffusion distance too long, fibrin

Gitter infarct, maternal floor infarct
• Massive perivillous fibrin deposition

• High recurrence risk

• High risk of IUGR and IUFD

• Sometimes associated with VUE
Pathology of the_placenta_-_lecture
Pathology of the_placenta_-_lecture
Pathology of the_placenta_-_lecture
Diffusion distance too long, maturation

Defective placental maturation
• Absence of terminal villi, no syncytio-vascular
  membranes
• Occurs after 35-36 weeks GA
• No IUGR
• Severe hypoxia and increase of NRBC’s at the
  end of pregnancy
Stallmach et al. Rescue by birth: defective placental maturation and
late fetal mortality. Obstet Gynecol. 2001 Apr;97(4):505-9.
Pathology of the_placenta_-_lecture
Pathology of the_placenta_-_lecture
IUFD at 39 weeks GA           IUFD at 40 weeks GA
Placenta with normal weight   Placenta with low normal weight
Other placental causes of IUFD
Haemorrhage: feto-maternal transfusion
  – Usually no abnormalities visible in the placenta


Inflammation
  – Ascending infection: e.g. bacterial
     • Chorioamnionitis and funisitis
     • Acute villitis and microabscesses
  – Haematogenous infection: e.g. viral, toxoplasmosis
     • Chronic villitis
Placenta abnormalities and time of death
Time between death    abnormalities in the placenta
and birth
6-36      hr          Nuclear dust in foetal circulation and
                        villous stroma
12       hr           Degeneration of smooth muscle cells
                        of the umbilical cord vessel wall
2        days         Focal obliteration of vessels in the
                        placental parenchyma
2        weeks        Extensive obliteration of vessels and
                        villous stromal fibrosis
IUFD 6-36 hr




               Nuclear dust
IUFD 12 hr -




               Degeneration of smooth muscle
IUFD 12 hr -




                                                 granulocytes




               Degeneration of smooth muscle cells
IUFD 2 days - weeks
IUFD 2 days - weeks




                      Loss of basophilia in smooth muscle cells
IUFD 2 days - weeks
IUFD 2 days - weeks
Umbilical cord pathology
• Too short, too long
• Knots
• Strangulation
• Thrombosis
• Haemangioma
• Meconium induced necrosis
• Coiling
Pathology of the_placenta_-_lecture
Too long with true knot
strangulation
Cord coiling
• Umbilical cord: Wharton’s jelly, usually two arteries and
  a vein
• Wharton’s jelly: hyaluronic acid, chondroitin sulphate,
  collagen
• Vessels: form a helix,
• Normal coiling approximately between 1 and 3 coils per
  10 cm
• Abnormal coiling associated with severe perinatal
  morbidity and mortality
Umbilical cord with   Umbilical cord with
undercoiling          overcoiling
Cord coiling
Study of 885 placenta from UMCU, de Laat et al.

                       Undercoiled cords



   IUFD
   Apgarscore < 7 after 5 minutes
   Congenital / chromosomal abnormality
   Trisomie (13 / 18 / 21)
   Premature birth, not corrected
   Premature birth corrected for amnionitis
   Single umbilical artery

                                              0.1          0.5    1               5   10   20 30

                                                           Odds Ratio (95% CI)

  de Laat et al. Umbilical coiling index in normal and complicated pregnancies.
  Obstet Gynecol. 2006 May;107(5):1049-55.
Cord coiling
Study of 885 placenta from UMCU, de Laat et al.

                         Overcoiled cords



   IUFD
   asfyxia
   Umbilical arteriel pH < 7.05
   IUGR
   Trisomie (13 / 18 / 21)
   Congenital / chromosomal abnormality
   Single umbilical artery

                                              0.1          0.5    1            5    10    20 30

                                                          Odds Ratio (95% CI)

          de Laat et al. Umbilical coiling index in normal and complicated pregnancies.
          Obstet Gynecol. 2006 May;107(5):1049-55.
Pathology of the_placenta_-_lecture
Cord coiling and mortality
              Perinatal   Congenital   Solutio, small   Unknown
              Mortality   anomaly      placenta or
                                       prematurity
Undercoiled   44 %        48 %         40 %             12 %
(133)         58/133      28/58        23/58            7/58

Normal        22 %        46 %         49 %             5%
(492)         110/492     51/110       53/110           6/110

Overcoiled    38 %        39 %         24 %             37 %
(99)          38/99       15/38        9/38             14/38
Pathology of the_placenta_-_lecture
Pathology of the_placenta_-_lecture
HAVE FUN WITH YOUR PLACENTAS
     PETER NIKKELS

More Related Content

What's hot

Gross pathology of breast tumors (3)
Gross pathology of breast tumors (3)Gross pathology of breast tumors (3)
Gross pathology of breast tumors (3)Neema Tiwari
 
T cell lymphomas - By Dr MULUKALA SWETHA
T cell lymphomas - By Dr MULUKALA SWETHAT cell lymphomas - By Dr MULUKALA SWETHA
T cell lymphomas - By Dr MULUKALA SWETHASwetha Mulukala
 
Liquid based cytology | Abdul Quddus
Liquid based cytology | Abdul QuddusLiquid based cytology | Abdul Quddus
Liquid based cytology | Abdul QuddusAbdul Quddus
 
Gestational trophoblastic disease
Gestational trophoblastic disease Gestational trophoblastic disease
Gestational trophoblastic disease Nandakanta Mahanta
 
Gestational trophoblastic disease
Gestational trophoblastic diseaseGestational trophoblastic disease
Gestational trophoblastic diseaseShahin Hameed
 
The Paris System for Reporting Urinary Cytology
The Paris System for Reporting Urinary CytologyThe Paris System for Reporting Urinary Cytology
The Paris System for Reporting Urinary CytologyRawa Muhsin
 
Disorders of pregnancy and placental pathology
Disorders of pregnancy and placental pathologyDisorders of pregnancy and placental pathology
Disorders of pregnancy and placental pathologyDr Prakriti Shukla
 
Uterine arteriovenous malformation Acquired Dr Mamta Lekhi
Uterine arteriovenous malformation Acquired Dr Mamta LekhiUterine arteriovenous malformation Acquired Dr Mamta Lekhi
Uterine arteriovenous malformation Acquired Dr Mamta LekhiLifecare Centre
 
Pathologic Reporting of breast specimens
Pathologic Reporting of breast specimensPathologic Reporting of breast specimens
Pathologic Reporting of breast specimensMalini Goswami
 
Follicular thyroid differential diagnosis
Follicular thyroid differential diagnosisFollicular thyroid differential diagnosis
Follicular thyroid differential diagnosisVikram Prabhakar
 
Ectopic pregnancy PBL
Ectopic pregnancy PBLEctopic pregnancy PBL
Ectopic pregnancy PBLThidanai K.
 
Benign lesion of the uterus
Benign lesion of the uterusBenign lesion of the uterus
Benign lesion of the uterussakinah43
 
Bethesda system for cervix cytology
Bethesda system for cervix cytologyBethesda system for cervix cytology
Bethesda system for cervix cytologyRavi Kumar Meena
 

What's hot (20)

Gross pathology of breast tumors (3)
Gross pathology of breast tumors (3)Gross pathology of breast tumors (3)
Gross pathology of breast tumors (3)
 
T cell lymphomas - By Dr MULUKALA SWETHA
T cell lymphomas - By Dr MULUKALA SWETHAT cell lymphomas - By Dr MULUKALA SWETHA
T cell lymphomas - By Dr MULUKALA SWETHA
 
Minimal residual disease
Minimal residual diseaseMinimal residual disease
Minimal residual disease
 
Tissue microarray
Tissue microarrayTissue microarray
Tissue microarray
 
Renal pediatric tumors
Renal pediatric tumorsRenal pediatric tumors
Renal pediatric tumors
 
Liquid based cytology | Abdul Quddus
Liquid based cytology | Abdul QuddusLiquid based cytology | Abdul Quddus
Liquid based cytology | Abdul Quddus
 
Gestational trophoblastic disease
Gestational trophoblastic disease Gestational trophoblastic disease
Gestational trophoblastic disease
 
Gestational trophoblastic disease
Gestational trophoblastic diseaseGestational trophoblastic disease
Gestational trophoblastic disease
 
The Paris System for Reporting Urinary Cytology
The Paris System for Reporting Urinary CytologyThe Paris System for Reporting Urinary Cytology
The Paris System for Reporting Urinary Cytology
 
Disorders of pregnancy and placental pathology
Disorders of pregnancy and placental pathologyDisorders of pregnancy and placental pathology
Disorders of pregnancy and placental pathology
 
germ cell tumours of ovary
germ cell tumours of ovarygerm cell tumours of ovary
germ cell tumours of ovary
 
Bethesda system for reporting
Bethesda system for reportingBethesda system for reporting
Bethesda system for reporting
 
Uterine arteriovenous malformation Acquired Dr Mamta Lekhi
Uterine arteriovenous malformation Acquired Dr Mamta LekhiUterine arteriovenous malformation Acquired Dr Mamta Lekhi
Uterine arteriovenous malformation Acquired Dr Mamta Lekhi
 
Pancreas cytology
Pancreas cytologyPancreas cytology
Pancreas cytology
 
Pathologic Reporting of breast specimens
Pathologic Reporting of breast specimensPathologic Reporting of breast specimens
Pathologic Reporting of breast specimens
 
Follicular thyroid differential diagnosis
Follicular thyroid differential diagnosisFollicular thyroid differential diagnosis
Follicular thyroid differential diagnosis
 
Fungus in histopathology
Fungus in histopathologyFungus in histopathology
Fungus in histopathology
 
Ectopic pregnancy PBL
Ectopic pregnancy PBLEctopic pregnancy PBL
Ectopic pregnancy PBL
 
Benign lesion of the uterus
Benign lesion of the uterusBenign lesion of the uterus
Benign lesion of the uterus
 
Bethesda system for cervix cytology
Bethesda system for cervix cytologyBethesda system for cervix cytology
Bethesda system for cervix cytology
 

Similar to Pathology of the_placenta_-_lecture

Similar to Pathology of the_placenta_-_lecture (20)

Care in Pregnancies Subsequent to Stillbirth or Perinatal Death
Care in Pregnancies Subsequent to Stillbirth or Perinatal DeathCare in Pregnancies Subsequent to Stillbirth or Perinatal Death
Care in Pregnancies Subsequent to Stillbirth or Perinatal Death
 
ectopic-.pptx
ectopic-.pptxectopic-.pptx
ectopic-.pptx
 
Preterm labour seminar
Preterm labour seminarPreterm labour seminar
Preterm labour seminar
 
Ante partum haemorrhage
Ante partum haemorrhageAnte partum haemorrhage
Ante partum haemorrhage
 
MULTIPLE PREGNANCY revision 2.pptx
MULTIPLE PREGNANCY revision 2.pptxMULTIPLE PREGNANCY revision 2.pptx
MULTIPLE PREGNANCY revision 2.pptx
 
MSc Embryo implantation lecture
MSc Embryo implantation lectureMSc Embryo implantation lecture
MSc Embryo implantation lecture
 
Multiple pregnancy by Dr taimur afridi
Multiple pregnancy  by Dr taimur afridiMultiple pregnancy  by Dr taimur afridi
Multiple pregnancy by Dr taimur afridi
 
Obstateric emergencies
Obstateric emergenciesObstateric emergencies
Obstateric emergencies
 
Obstateric emergencies
Obstateric emergenciesObstateric emergencies
Obstateric emergencies
 
obestateric emergency
obestateric emergencyobestateric emergency
obestateric emergency
 
Lecture 10 Multifetal pregnancy
Lecture 10 Multifetal pregnancyLecture 10 Multifetal pregnancy
Lecture 10 Multifetal pregnancy
 
MFG
MFGMFG
MFG
 
PLACENTA ACCRETA SPECTRUM DISORDERS.pptx
PLACENTA ACCRETA SPECTRUM DISORDERS.pptxPLACENTA ACCRETA SPECTRUM DISORDERS.pptx
PLACENTA ACCRETA SPECTRUM DISORDERS.pptx
 
multiple pregnancy.pptx
 multiple pregnancy.pptx multiple pregnancy.pptx
multiple pregnancy.pptx
 
Multiple pregnancy
Multiple pregnancyMultiple pregnancy
Multiple pregnancy
 
ECTOPIC PREGNANCY-1.ppt
ECTOPIC PREGNANCY-1.pptECTOPIC PREGNANCY-1.ppt
ECTOPIC PREGNANCY-1.ppt
 
SREEHARSHA p.k.pptx
SREEHARSHA p.k.pptxSREEHARSHA p.k.pptx
SREEHARSHA p.k.pptx
 
Maternal death autopsy
Maternal death autopsyMaternal death autopsy
Maternal death autopsy
 
Prom
PromProm
Prom
 
Amniotic fluid disorder prof.salah
Amniotic fluid disorder prof.salahAmniotic fluid disorder prof.salah
Amniotic fluid disorder prof.salah
 

More from Celso Silva

Resposta celso caso hospital aliança pps red 09 2012
Resposta celso caso hospital aliança pps red 09 2012Resposta celso caso hospital aliança pps red 09 2012
Resposta celso caso hospital aliança pps red 09 2012Celso Silva
 
Caso extra de uropatologia
Caso extra de uropatologiaCaso extra de uropatologia
Caso extra de uropatologiaCelso Silva
 
Immortal Women Essays In Medical Eponyms Ii
Immortal Women Essays In Medical Eponyms IiImmortal Women Essays In Medical Eponyms Ii
Immortal Women Essays In Medical Eponyms IiCelso Silva
 
Dcis Breast Invasive
Dcis Breast InvasiveDcis Breast Invasive
Dcis Breast InvasiveCelso Silva
 
The Pathology Of Endometriosis
The Pathology Of EndometriosisThe Pathology Of Endometriosis
The Pathology Of EndometriosisCelso Silva
 
Caso GinecolóGico
Caso GinecolóGicoCaso GinecolóGico
Caso GinecolóGicoCelso Silva
 
Medical Foreign Bodies
Medical  Foreign  BodiesMedical  Foreign  Bodies
Medical Foreign BodiesCelso Silva
 
Mediastinal Pathology Compartmental Approach
Mediastinal  Pathology  Compartmental  ApproachMediastinal  Pathology  Compartmental  Approach
Mediastinal Pathology Compartmental ApproachCelso Silva
 
Unknow Primary Ca
Unknow Primary CaUnknow Primary Ca
Unknow Primary CaCelso Silva
 
Melanoma Lipoblastic Cell Type
Melanoma Lipoblastic Cell TypeMelanoma Lipoblastic Cell Type
Melanoma Lipoblastic Cell TypeCelso Silva
 

More from Celso Silva (13)

Resposta celso caso hospital aliança pps red 09 2012
Resposta celso caso hospital aliança pps red 09 2012Resposta celso caso hospital aliança pps red 09 2012
Resposta celso caso hospital aliança pps red 09 2012
 
Lobisomen
LobisomenLobisomen
Lobisomen
 
Caso extra de uropatologia
Caso extra de uropatologiaCaso extra de uropatologia
Caso extra de uropatologia
 
Immortal Women Essays In Medical Eponyms Ii
Immortal Women Essays In Medical Eponyms IiImmortal Women Essays In Medical Eponyms Ii
Immortal Women Essays In Medical Eponyms Ii
 
Dcis Breast Invasive
Dcis Breast InvasiveDcis Breast Invasive
Dcis Breast Invasive
 
Dorothy Reed
Dorothy ReedDorothy Reed
Dorothy Reed
 
The Pathology Of Endometriosis
The Pathology Of EndometriosisThe Pathology Of Endometriosis
The Pathology Of Endometriosis
 
Caso GinecolóGico
Caso GinecolóGicoCaso GinecolóGico
Caso GinecolóGico
 
Medical Foreign Bodies
Medical  Foreign  BodiesMedical  Foreign  Bodies
Medical Foreign Bodies
 
Mediastinal Pathology Compartmental Approach
Mediastinal  Pathology  Compartmental  ApproachMediastinal  Pathology  Compartmental  Approach
Mediastinal Pathology Compartmental Approach
 
Snc Who 2007
Snc Who 2007Snc Who 2007
Snc Who 2007
 
Unknow Primary Ca
Unknow Primary CaUnknow Primary Ca
Unknow Primary Ca
 
Melanoma Lipoblastic Cell Type
Melanoma Lipoblastic Cell TypeMelanoma Lipoblastic Cell Type
Melanoma Lipoblastic Cell Type
 

Recently uploaded

How to Customise Quotation's Appearance Using PDF Quote Builder in Odoo 17
How to Customise Quotation's Appearance Using PDF Quote Builder in Odoo 17How to Customise Quotation's Appearance Using PDF Quote Builder in Odoo 17
How to Customise Quotation's Appearance Using PDF Quote Builder in Odoo 17Celine George
 
ASTRINGENTS.pdf Pharmacognosy chapter 5 diploma in Pharmacy
ASTRINGENTS.pdf Pharmacognosy chapter 5 diploma in PharmacyASTRINGENTS.pdf Pharmacognosy chapter 5 diploma in Pharmacy
ASTRINGENTS.pdf Pharmacognosy chapter 5 diploma in PharmacySumit Tiwari
 
3.14.24 The Selma March and the Voting Rights Act.pptx
3.14.24 The Selma March and the Voting Rights Act.pptx3.14.24 The Selma March and the Voting Rights Act.pptx
3.14.24 The Selma March and the Voting Rights Act.pptxmary850239
 
Riti theory by Vamana Indian poetics.pptx
Riti theory by Vamana Indian poetics.pptxRiti theory by Vamana Indian poetics.pptx
Riti theory by Vamana Indian poetics.pptxDhatriParmar
 
AUDIENCE THEORY - PARTICIPATORY - JENKINS.pptx
AUDIENCE THEORY - PARTICIPATORY - JENKINS.pptxAUDIENCE THEORY - PARTICIPATORY - JENKINS.pptx
AUDIENCE THEORY - PARTICIPATORY - JENKINS.pptxiammrhaywood
 
Research Methodology and Tips on Better Research
Research Methodology and Tips on Better ResearchResearch Methodology and Tips on Better Research
Research Methodology and Tips on Better ResearchRushdi Shams
 
Auchitya Theory by Kshemendra Indian Poetics
Auchitya Theory by Kshemendra Indian PoeticsAuchitya Theory by Kshemendra Indian Poetics
Auchitya Theory by Kshemendra Indian PoeticsDhatriParmar
 
Material Remains as Source of Ancient Indian History & Culture.ppt
Material Remains as Source of Ancient Indian History & Culture.pptMaterial Remains as Source of Ancient Indian History & Culture.ppt
Material Remains as Source of Ancient Indian History & Culture.pptBanaras Hindu University
 
Plant Tissue culture., Plasticity, Totipotency, pptx
Plant Tissue culture., Plasticity, Totipotency, pptxPlant Tissue culture., Plasticity, Totipotency, pptx
Plant Tissue culture., Plasticity, Totipotency, pptxHimansu10
 
BÀI TẬP BỔ TRỢ TIẾNG ANH 11 THEO ĐƠN VỊ BÀI HỌC - CẢ NĂM - CÓ FILE NGHE (GLOB...
BÀI TẬP BỔ TRỢ TIẾNG ANH 11 THEO ĐƠN VỊ BÀI HỌC - CẢ NĂM - CÓ FILE NGHE (GLOB...BÀI TẬP BỔ TRỢ TIẾNG ANH 11 THEO ĐƠN VỊ BÀI HỌC - CẢ NĂM - CÓ FILE NGHE (GLOB...
BÀI TẬP BỔ TRỢ TIẾNG ANH 11 THEO ĐƠN VỊ BÀI HỌC - CẢ NĂM - CÓ FILE NGHE (GLOB...Nguyen Thanh Tu Collection
 
VIT336 – Recommender System - Unit 3.pdf
VIT336 – Recommender System - Unit 3.pdfVIT336 – Recommender System - Unit 3.pdf
VIT336 – Recommender System - Unit 3.pdfArthyR3
 
LEAD6001 - Introduction to Advanced Stud
LEAD6001 - Introduction to Advanced StudLEAD6001 - Introduction to Advanced Stud
LEAD6001 - Introduction to Advanced StudDr. Bruce A. Johnson
 
Arti Languages Pre Seed Send Ahead Pitchdeck 2024.pdf
Arti Languages Pre Seed Send Ahead Pitchdeck 2024.pdfArti Languages Pre Seed Send Ahead Pitchdeck 2024.pdf
Arti Languages Pre Seed Send Ahead Pitchdeck 2024.pdfwill854175
 
3.14.24 Gender Discrimination and Gender Inequity.pptx
3.14.24 Gender Discrimination and Gender Inequity.pptx3.14.24 Gender Discrimination and Gender Inequity.pptx
3.14.24 Gender Discrimination and Gender Inequity.pptxmary850239
 
Dhavni Theory by Anandvardhana Indian Poetics
Dhavni Theory by Anandvardhana Indian PoeticsDhavni Theory by Anandvardhana Indian Poetics
Dhavni Theory by Anandvardhana Indian PoeticsDhatriParmar
 
AI Uses and Misuses: Academic and Workplace Applications
AI Uses and Misuses: Academic and Workplace ApplicationsAI Uses and Misuses: Academic and Workplace Applications
AI Uses and Misuses: Academic and Workplace ApplicationsStella Lee
 
Alamkara theory by Bhamaha Indian Poetics (1).pptx
Alamkara theory by Bhamaha Indian Poetics (1).pptxAlamkara theory by Bhamaha Indian Poetics (1).pptx
Alamkara theory by Bhamaha Indian Poetics (1).pptxDhatriParmar
 
The First National K12 TUG March 6 2024.pdf
The First National K12 TUG March 6 2024.pdfThe First National K12 TUG March 6 2024.pdf
The First National K12 TUG March 6 2024.pdfdogden2
 

Recently uploaded (20)

How to Customise Quotation's Appearance Using PDF Quote Builder in Odoo 17
How to Customise Quotation's Appearance Using PDF Quote Builder in Odoo 17How to Customise Quotation's Appearance Using PDF Quote Builder in Odoo 17
How to Customise Quotation's Appearance Using PDF Quote Builder in Odoo 17
 
ASTRINGENTS.pdf Pharmacognosy chapter 5 diploma in Pharmacy
ASTRINGENTS.pdf Pharmacognosy chapter 5 diploma in PharmacyASTRINGENTS.pdf Pharmacognosy chapter 5 diploma in Pharmacy
ASTRINGENTS.pdf Pharmacognosy chapter 5 diploma in Pharmacy
 
3.14.24 The Selma March and the Voting Rights Act.pptx
3.14.24 The Selma March and the Voting Rights Act.pptx3.14.24 The Selma March and the Voting Rights Act.pptx
3.14.24 The Selma March and the Voting Rights Act.pptx
 
Riti theory by Vamana Indian poetics.pptx
Riti theory by Vamana Indian poetics.pptxRiti theory by Vamana Indian poetics.pptx
Riti theory by Vamana Indian poetics.pptx
 
AUDIENCE THEORY - PARTICIPATORY - JENKINS.pptx
AUDIENCE THEORY - PARTICIPATORY - JENKINS.pptxAUDIENCE THEORY - PARTICIPATORY - JENKINS.pptx
AUDIENCE THEORY - PARTICIPATORY - JENKINS.pptx
 
Research Methodology and Tips on Better Research
Research Methodology and Tips on Better ResearchResearch Methodology and Tips on Better Research
Research Methodology and Tips on Better Research
 
Auchitya Theory by Kshemendra Indian Poetics
Auchitya Theory by Kshemendra Indian PoeticsAuchitya Theory by Kshemendra Indian Poetics
Auchitya Theory by Kshemendra Indian Poetics
 
t-test Parametric test Biostatics and Research Methodology
t-test Parametric test Biostatics and Research Methodologyt-test Parametric test Biostatics and Research Methodology
t-test Parametric test Biostatics and Research Methodology
 
Material Remains as Source of Ancient Indian History & Culture.ppt
Material Remains as Source of Ancient Indian History & Culture.pptMaterial Remains as Source of Ancient Indian History & Culture.ppt
Material Remains as Source of Ancient Indian History & Culture.ppt
 
Plant Tissue culture., Plasticity, Totipotency, pptx
Plant Tissue culture., Plasticity, Totipotency, pptxPlant Tissue culture., Plasticity, Totipotency, pptx
Plant Tissue culture., Plasticity, Totipotency, pptx
 
BÀI TẬP BỔ TRỢ TIẾNG ANH 11 THEO ĐƠN VỊ BÀI HỌC - CẢ NĂM - CÓ FILE NGHE (GLOB...
BÀI TẬP BỔ TRỢ TIẾNG ANH 11 THEO ĐƠN VỊ BÀI HỌC - CẢ NĂM - CÓ FILE NGHE (GLOB...BÀI TẬP BỔ TRỢ TIẾNG ANH 11 THEO ĐƠN VỊ BÀI HỌC - CẢ NĂM - CÓ FILE NGHE (GLOB...
BÀI TẬP BỔ TRỢ TIẾNG ANH 11 THEO ĐƠN VỊ BÀI HỌC - CẢ NĂM - CÓ FILE NGHE (GLOB...
 
VIT336 – Recommender System - Unit 3.pdf
VIT336 – Recommender System - Unit 3.pdfVIT336 – Recommender System - Unit 3.pdf
VIT336 – Recommender System - Unit 3.pdf
 
LEAD6001 - Introduction to Advanced Stud
LEAD6001 - Introduction to Advanced StudLEAD6001 - Introduction to Advanced Stud
LEAD6001 - Introduction to Advanced Stud
 
Arti Languages Pre Seed Send Ahead Pitchdeck 2024.pdf
Arti Languages Pre Seed Send Ahead Pitchdeck 2024.pdfArti Languages Pre Seed Send Ahead Pitchdeck 2024.pdf
Arti Languages Pre Seed Send Ahead Pitchdeck 2024.pdf
 
3.14.24 Gender Discrimination and Gender Inequity.pptx
3.14.24 Gender Discrimination and Gender Inequity.pptx3.14.24 Gender Discrimination and Gender Inequity.pptx
3.14.24 Gender Discrimination and Gender Inequity.pptx
 
Dhavni Theory by Anandvardhana Indian Poetics
Dhavni Theory by Anandvardhana Indian PoeticsDhavni Theory by Anandvardhana Indian Poetics
Dhavni Theory by Anandvardhana Indian Poetics
 
AI Uses and Misuses: Academic and Workplace Applications
AI Uses and Misuses: Academic and Workplace ApplicationsAI Uses and Misuses: Academic and Workplace Applications
AI Uses and Misuses: Academic and Workplace Applications
 
Problems on Mean,Mode,Median Standard Deviation
Problems on Mean,Mode,Median Standard DeviationProblems on Mean,Mode,Median Standard Deviation
Problems on Mean,Mode,Median Standard Deviation
 
Alamkara theory by Bhamaha Indian Poetics (1).pptx
Alamkara theory by Bhamaha Indian Poetics (1).pptxAlamkara theory by Bhamaha Indian Poetics (1).pptx
Alamkara theory by Bhamaha Indian Poetics (1).pptx
 
The First National K12 TUG March 6 2024.pdf
The First National K12 TUG March 6 2024.pdfThe First National K12 TUG March 6 2024.pdf
The First National K12 TUG March 6 2024.pdf
 

Pathology of the_placenta_-_lecture

  • 1. Placenta pathology associated with maturation abnormalities and late intra uterine foetal death. PETER G.J. NIKKELS Dept. of Pathology UMC Utrecht, the Netherlands
  • 2. Anatoom Frederick Ruysch, J. van Neck 1683
  • 3. Perinatal death • Perinatal death occurs in 1,5% of all birth • Frequency of stillbirth in western Europe approximately 2,2-4,4 / 1000 life birth • Riskfactors: multiple pregnancy, prematurity, first or second pregnancy, hypertension or pre-eclampsia of the mother, congenital abnormalities (20-40%) and inflammation
  • 4. Causes of IUFD • Placenta or umbilical cord pathology 62% • Congenital abnormalities 17% • Intra-uterine infection 2% • Trauma 1% • Miscellaneous (tumors, storage disorder) 3% • Unexplained (12/47 no placenta) 15% • Horn et al. Identification of the causes of intrauterine death during 310 consecutive autopsies. European Journal of Obstetrics & Gynaecology and Reproductive Biology 113 (2004), 134-8. University Hospital Leipzig, IUFD from 22-42 6/7 weeks.
  • 5. Causes of IUFD • Placenta or umbilical cord pathology 62% • Utero-placental pathology 38% • Dysmaturity of parenchym 23% • Inflammation 14% • Umbilical cord 22% (Compression, bleeding, haematoma) • Miscellaneous 3% (TTTS, chorangioma etc.) • Horn et al. Identification of the causes of intrauterine death during 310 consecutive autopsies. European Journal of Obstetrics & Gynaecology and Reproductive Biology 113 (2004), 134-8. University Hospital Leipzig, IUFD van 22-42 6/7 weeks.
  • 6. Main cause of IUFD Disturbance in delivering oxygen to the foetus • Not enough or loss of parenchyma – Small placenta Placental bed pathology – Placental infarcts – Chronic inflammation – Foetal thrombosis • Diffusion distance too long – Fibrin deposition – Abnormal maturation • Umbilical cord pathology
  • 7. Normal development of the placenta parenchyma • Placenta: the fastest growing organ of the human body • from 1 tot 5 x 1010 cells in 38 weeks
  • 8. Placental weight Ratio of placental weight and foetal weight
  • 9. Normal development of placental parenchyma FIRST TRIMESTER – In first 12 weeks only mesenchymal villi – Development of immature intermediate villi with two layers of trophoblast – Development of stem villi with central fibrous core Amniotic cavity Yolk sac
  • 12. Normal maturation of placental parenchyma • SECOND TRIMESTER – Parenchyma consists of immature intermediate villi, there is some development of mature intermediate villi – Largest variation in villus shape and diameter – Mesenchymal stroma alongside stem villi disappears and occasionally some fibrinoid material can be seen
  • 19. Normal maturation of the placental parenchyma • THIRD TRIMESTER – Development of terminal villi – At 40 weeks 40% of the villous volume are terminal villi – Terminal villi have syncytio-vascular membranes – Stem villi are covered with fibrinoid material
  • 25. Abnormal maturation of the placenta parenchyma • Accelerated maturation • Delayed maturation and dysmaturity
  • 26. Accelerated maturation • Utero-placental pathology decreased blood flow to the placenta due to abnormalities in spiral arteries maternal hypertension or pre-eclampsia Sometimes also abnormalities in vessels in the membranes or in the decidua (acute atherosis) • Multiple pregnancy placenta (two or more) • Recipient of the twin-transfusion syndrome
  • 32. Acute atherosis in artery of membranes
  • 33. Accelerated maturation histology • Premature formation of terminal villi with syncytio-vascular membranes • Stem villi with aspect normal for pregnancy duration • Distal villous hypoplasia with long slender villi and increased space between villi • Hyperchromasia of trophoblast • Increased syncytial knotting
  • 35. NRBC
  • 37. Other abnormalities of utero-placental / placental bed pathology • Infarcts • (partial) solutio • (Massive) subchorionic haematoma • Intervillus thrombi / haematoma
  • 39. Old infarct with central hemorrhage
  • 40. Accelerated maturation • Recipiënt of twin-twin transfusion syndrome • CS at 30 weeks because of worsening foetal condition after multiple amniotic drainage
  • 41. recipiënt 30 weeks donor
  • 42. Delayed maturation and dysmaturity Less terminal villi as expected. From 30 weeks onwards terminal villi recognisable. At 40 weeks 40% of the villi are terminal villi. • Maternal diabetes • Macrosomia without diabetes • Chronic villitis • Defective placental maturation • Congenital and / or chromosomal abnormality • Donor of twin-twin transfusion syndrome • Foetal anaemia of low colloid osmotic pressure • Foetal cardiac decompensation
  • 43. Delayed maturation, maternal diabetes • Small groups of immature villi and hydropic villi • Chorangiosis • Fibrinoid necrosis of the villous stroma • Increase of NRBCs
  • 46. NRBC
  • 48. Variable maturation example 1 Bichorionic twin placenta at 38 weeks Small placental part heavy placental part
  • 49. Main cause of IUFD Disturbance in delivering oxygen to the foetus • Not enough or loss of parenchyma – Small placenta Placental bed pathology – Placental infarcts – Chronic inflammation – Foetal thrombosis • Diffusion distance too long – Fibrin deposition – Abnormal maturation • Umbilical cord pathology
  • 50. Loss of parenchyma, chronic inflammation Severe villitis of unknown etiology • Destruction of villi, less mature • Infiltrate with macrophages and T-cells • High recurrence risk of IUGR and IUFD – Recently some case reports with favorable outcome after treatment with corticosteroids and antitrombotics Boog et al. J Gynecol Obstet Biol Reprod (Paris). 2006 Jun;35(4):396-404. [Combining corticosteroid and aspirin for the prevention of recurrent villitis or intervillositis of unknown etiology]
  • 52. CD 68 CD 3
  • 53. Loss of parenchyma, chronic inflammation Chronic intervillositis • Massive histiocytic infiltrate in maternal compartment • Perinatal mortality 29%, IUGR 77% • High recurrence risk of abortion, IUGR and IUFD – Recently some case reports of favorable outcome after treatment with corticosteroids and antitrombotics Boog et al. J Gynecol Obstet Biol Reprod (Paris). 2006 Jun;35(4):396-404. [Combining corticosteroid and aspirin for the prevention of recurrent villitis or intervillositis of unknown etiology]
  • 56. CD 68 CD 3
  • 57. Loss of parenchyma, foetal trombosis • Groups of avascular villi • Histology similar as in IUFD • Incidence – Normal placenta’s 2% – Placenta’s with overcoiled cord 20% – Pre-eclampsia 20-30% – Macrosomia without DM 30-40% • Occasionally in association with CMV or trombophilia disorder
  • 63. CMV
  • 64. Diffusion distance too long, fibrin Gitter infarct, maternal floor infarct • Massive perivillous fibrin deposition • High recurrence risk • High risk of IUGR and IUFD • Sometimes associated with VUE
  • 68. Diffusion distance too long, maturation Defective placental maturation • Absence of terminal villi, no syncytio-vascular membranes • Occurs after 35-36 weeks GA • No IUGR • Severe hypoxia and increase of NRBC’s at the end of pregnancy Stallmach et al. Rescue by birth: defective placental maturation and late fetal mortality. Obstet Gynecol. 2001 Apr;97(4):505-9.
  • 71. IUFD at 39 weeks GA IUFD at 40 weeks GA Placenta with normal weight Placenta with low normal weight
  • 72. Other placental causes of IUFD Haemorrhage: feto-maternal transfusion – Usually no abnormalities visible in the placenta Inflammation – Ascending infection: e.g. bacterial • Chorioamnionitis and funisitis • Acute villitis and microabscesses – Haematogenous infection: e.g. viral, toxoplasmosis • Chronic villitis
  • 73. Placenta abnormalities and time of death Time between death abnormalities in the placenta and birth 6-36 hr Nuclear dust in foetal circulation and villous stroma 12 hr Degeneration of smooth muscle cells of the umbilical cord vessel wall 2 days Focal obliteration of vessels in the placental parenchyma 2 weeks Extensive obliteration of vessels and villous stromal fibrosis
  • 74. IUFD 6-36 hr Nuclear dust
  • 75. IUFD 12 hr - Degeneration of smooth muscle
  • 76. IUFD 12 hr - granulocytes Degeneration of smooth muscle cells
  • 77. IUFD 2 days - weeks
  • 78. IUFD 2 days - weeks Loss of basophilia in smooth muscle cells
  • 79. IUFD 2 days - weeks
  • 80. IUFD 2 days - weeks
  • 81. Umbilical cord pathology • Too short, too long • Knots • Strangulation • Thrombosis • Haemangioma • Meconium induced necrosis • Coiling
  • 83. Too long with true knot
  • 85. Cord coiling • Umbilical cord: Wharton’s jelly, usually two arteries and a vein • Wharton’s jelly: hyaluronic acid, chondroitin sulphate, collagen • Vessels: form a helix, • Normal coiling approximately between 1 and 3 coils per 10 cm • Abnormal coiling associated with severe perinatal morbidity and mortality
  • 86. Umbilical cord with Umbilical cord with undercoiling overcoiling
  • 87. Cord coiling Study of 885 placenta from UMCU, de Laat et al. Undercoiled cords IUFD Apgarscore < 7 after 5 minutes Congenital / chromosomal abnormality Trisomie (13 / 18 / 21) Premature birth, not corrected Premature birth corrected for amnionitis Single umbilical artery 0.1 0.5 1 5 10 20 30 Odds Ratio (95% CI) de Laat et al. Umbilical coiling index in normal and complicated pregnancies. Obstet Gynecol. 2006 May;107(5):1049-55.
  • 88. Cord coiling Study of 885 placenta from UMCU, de Laat et al. Overcoiled cords IUFD asfyxia Umbilical arteriel pH < 7.05 IUGR Trisomie (13 / 18 / 21) Congenital / chromosomal abnormality Single umbilical artery 0.1 0.5 1 5 10 20 30 Odds Ratio (95% CI) de Laat et al. Umbilical coiling index in normal and complicated pregnancies. Obstet Gynecol. 2006 May;107(5):1049-55.
  • 90. Cord coiling and mortality Perinatal Congenital Solutio, small Unknown Mortality anomaly placenta or prematurity Undercoiled 44 % 48 % 40 % 12 % (133) 58/133 28/58 23/58 7/58 Normal 22 % 46 % 49 % 5% (492) 110/492 51/110 53/110 6/110 Overcoiled 38 % 39 % 24 % 37 % (99) 38/99 15/38 9/38 14/38
  • 93. HAVE FUN WITH YOUR PLACENTAS PETER NIKKELS