Path. Res. Pract. 186, 455-458 (1990)
Chorioangiomas of Intermediate Size and Intrauterine Growth Retardation D. R. Mucitelli, E. Z. Charles, and F. T. Kraus Department of Pathology, Sf. John's Mercy Medical Center, Sf. Louis, USA
SUMMARY
Very large chorioangiomas are a rare but well recognized cause of neonatal morbidity; while small ones are clinically insignificant. This study emphasizes that some chorioangiomas ofintermediate size may be causally related to intrauterine growth retardation, and that they may be surprisingly difficult to detect in the unfixed placenta.
Introduction Chorioangioma (hemangioma) is the most frequent benign tumor of the human placenta, occurring in approximately 1% of all pregnancies8, 18. Because the majority of these tumors are small, they usually have no clinical significance. Complications that have been clearly related to very large hemangiomas include polyhydramnios, premature labor, toxemia, abruptio placentae, neonatal cardiac failure, microangiopathic hemolytic anemia, and congenital anomalies of various types 2,4,8,9,10,17-19. The relationship between chorioangiomas and intrauterine growth retardation has been suggested by a number of individual case reports 11 , 13 and some larger studies 18 , but the statistical significance of this apparent relationship is usually lost when case control comparisons in larger series have been made 9,19. It is possible that chorioangiomas are causally related to intrauterine growth retardation, even when the chorioangiomas are not large enough to produce the more usual complications but still retain a significant size in comparison to the size of the placenta. We present here two instances of placenta chorioangioma associated with intrauterine growth retardation in which the chorioangiorna appears to represent the most significant etiologic abnormality in the gestation. Case Reports
Case 1 A 19 year old white primigravid woman was admitted for the induction of labor. Intrauterine growth retardation © 1990 by Gustav Fischer Verlag, Stuttgart
had been documented by serial ultrasound measurements which failed to identify any intraplacental lesions. A 2150 gram female was delivered from the vertex position at 37 weeks gestation. Apgar scores of 7 and 9 were recorded at one and five minutes respectively. She was 44.5 cm in length with a head circumference of 32.5 cm. No physical or neurological abnormalities were noted. The neonatal course was unremarkable. Physical examination was unremarkable apart from size compatible with a small-for-gestational age (SGA) infant. Laboratory studies including complete blood count (CBC) were normal. A platelet count was not done. At 29 months of age, she does not have dysmorphic features or psychomotor impairment.
Placental Examination: The trimmed placenta weighed 420 grams (50th percentile at 37 weeks 14 ) and measured 15.0 x 12.5 x 2.0 cm. Three blood vessels were present in the umbilical cord. At the first examination of cut sections of the unfixed placenta, no lesions were identified. After fixation, numerous circumscribed nodules of variable size became more readily identifiable because they now had a more solid consistency and a lighter grey color in contrast with the rest of the placenta (Fig. 1). In histologic sections, the hemangiomas were composed of crowded capillaries, and varied from 1 mm or less to 3 cm in greatest dimension (Fig. 2). More than 100 small areas of hemangioma were identified. As many as 15 hemangiomas could be counted on a single histologic section. Changes related to toxemia or inflammation were not identified. 0344-0338/90/0186-0455$3.50/0
456 . D. R. Mucitelli et al.
Fig. 1. Chorioangioma. Case 1. Gross photograph depicting infarct (open arrow) with adjacent ill-defined chorioangioma (closed arrow), recognized grossly only after formalin fixation.
Fig. 2. Chorioangioma. Case 1. Multiple, scattered foci of variable-sized chorioangiomas intermixed with numerous smaller chorionic villi. 7 x. Hematoxylin and eosin.
Case 2
Fig. 3. Chorioangioma. Case 2. Gross photograph of a section of placenta after formalin fixation showing unremarkable placental tissue (open arrow) with adjacent fleshy, firm, multilobated chorioangioma (closed arrow), recognized only after formalin fixation.
An 18 year old black women, gravida 1, at 34 weeks gestation presented 14 hours after premature rupture of membranes. An ultrasound examination performed on the day of admission revealed an abnormal growth profile indicating intrauterine growth retardation and a breech presentation, but no placental lesions were identified. Delivery was accomplished by Cesarean section. Operative findings in the mother included a unicornuate uterus, ectopic left kidney, and agenesis of the left fallopian tube and ovary. The right ovary and fallopian tube were intact. A male infant was delivered from the breech position. Apgar scores of 7 and 9 were recorded at one and five minutes respectively. He was 44.0 cm in length and weighed 1810 grams. The head circumference was 30.5 cm. The infant was initially tachypneic (respiratory rate> 70/min) and temporarily required oxygen. A chest radiograph showed prominent interstital markings and a structurally normal heart. Over a 24 hour period the requirement for supplemental oxygen environment declined, and the infant experienced no further respiratory problems. The physical examination was normal except for a 2.0 x 1.0 cm cutaneous angioma on the dorsal aspect of the right ankle. No congenital malformations were noted. Laboratory data including CBC were within normal limits. Placental Examination: The trimmed placenta weighed 375 grams (between the 50-75th percentile for a 34 week gestation 14 ) and measured 15.5 x 14.5 x 2.0 cm. The umbilical cord measured 27.5 cm in length and contained
Chorioangiomas and Intrauterine Growth Retardation . 457
Fig. 4. Chorioangioma. Case 2. Many capillary-sized vessels within a single chorioangioma. 90x. Hematoxylin and eosin.
three blood vessels. An ovoid well-demarcated mass 7.0 em in greatest diameter was found bulging beneath the fetal surface of the placenta. On cross section this mass was tan, with a lobulated appearance (Fig. 3). Histologically, the mass consisted of a network of numerous thin-walled vascular channels set in a very loose fibrous stroma (Fig. 4). Some of the vascular spaces contained red blood cells. Cellular areas without identifiable vascular channels were also present. Random sections from other areas of the placenta showed two small infarcts in contact with the decidual plate and thrombosis of one fetal stem artery. Discussion The most direct and dramatic pathologic effects attributable to chorioangiomas seem to occur only when the lesions are very large. These relationships would appear to be well established because such problems as neonatal cardiac failure, microangiopathic hemolytic anemia, and polyhydramnios can be related to effects of very large hemangiomas in other clinical situations. At the other extreme, very small hemangiomas appear to have no notable systemic effects whether they are located in the placenta or elsewhere. The chorioangiomas reported here are not as large as many of those reported as a cause of growth retardation, but they are significant in our opinion because they occurred in relatively small-sized placentas, at or near the 50th percentile by weight l4 . Most of the very large studies of chorioangioma have failed to note a relationship to intrauterine growth retardation, especially when all chorioangiomas are considered and compared with a control group of infants without
placentalchorioangioma. No chorioangiomas were listed in one study of 63 placentas associated with SGA newborns l . Nevertheless, as suggested by Wentworth l9 , there are some instances of intrauterine growth retardation in which a chorioangioma seems to be the only identifiable potential abnormality of significance. This idea is supported by individual case reports 11 , 13 and by the two cases in this report. Similarly, Wallenburg 18 noted that five in a series of thirteen instances of chorioangioma were associated with birth weights at or below the tenth percentile in his local area near Amsterdam. One larger, more recent histopathologic study of placentas in 151 instances of intrauterine growth retardation found three instances of chorioangioma as the apparent cause l6 ; in this series, other more common morphologic lesions, notably the vascular manifestations of hypertension, chronic inflammation, and hemorrhagic endovillitis appear to explain the intrauterine growth retardation in 90% of the cases. From our experience and the reports in the literature we conclude that chorioangioma can represent the primary basis of intrauterine growth retardation when the size relationships between the baby, the placenta, and the chorioangioma are appropriate. The basis of growth retardation would appear to be the result of shunting a significant proportion of placentofetal blood flow away from the villi thus reducing all forms of nutrient exchange. No direct or quantitative functional studies have been reported. While the largest chorioangiomas produce the most serious clinical problems, smaller lesions can also cause significant growth retardation and it is important not to overlook them. It seems likely that the severity of impaired growth is proportional to the size of the chorioangioma. There are several reports of identification of placental chorioangiomas by ultrasound techniques 3,5-7, 12, 15. These studies note that there is no contrast in echogenic characteristics of placental tissue and chorioangioma; the presence of a placental deformity in combination with the recognition of SGA infant is the usual basis for ultrasound diagnosis. As there was no placental deformity in the two cases presented here, even in retrospect the ultrasound images are interpreted as normal. Neither of the lesions in this report was recognized at the time of initial gross examination; others have noted the same difficultyI7-19. Our experience also emphasizes the importance of detailed and complete gross and histologic study of placentas associated with growth retardation because significant and extensive forms of multiple chorioangioma are easily overlooked on the basis of gross examination alone. The gross abnormalities can be especially subtle in the unfixed placenta.
Other Issues Chorioangiomas are conventionally subclassified8 according to three main histologic patterns. The angiomatous type, exemplified in this report, is composed of small capillary vessels crowded together with inconspicuous stroma. The cellular type is composed of masses of myxoid
458 . D. R. Mucitelli et al.
matrix through which many fibroblastic cells and a few vessels are scattered. Degenerate chorioangiomas have conspicuous hyalinized, calcific and necrotic foci. The relationship, if any, between chorioangiomas and villi that appear hypervascular or telangiectatic is not settled. The controversy about whether chorioangiomas are hamartomas or neoplasms is not resolved. The presence of various admixtures of non-vessel tissue components and the virtual absence of angiosarcoma as a placental lesion are more consistent with the concept of hamartoma. Components of trophoblast and smooth muscle are common, but wide variations in proportion occur. Simultaneous occurrance of hemangiomas in both fetus and placenta has been noted in several instances 8; in one study six times as often as in a control group with no hemangiomas 9 . A significant relationship to important congenital anomalities is possible but appears unlikely8,9. References 1 Altshuler G, Russell P, Ermocilla R (1975) The placental pathology of small-for-gestational age infants. Am J Obstet Gynecol121: 351-59 2 Asadourian LA, Taylor HB (1968) Clinical significance of placental hemangiomas. Obstet Gynecol31: 551-55 3 Asokan S, Chadalavada K, Gardi R, Sastry V (1978) Prenatal diagnosis of placental tumor by ultrasound. JCU 6: 180-1 4 Bauer CR, Fojaco RM, Bancalari E, Fernandez-Rocha L (1978) Microangiopathic hemolytic anemia and thrombocytopenia in a neonate associated with a large placental chorioangioma. Pediatrics 62: 574-77 5 Bruhwiler H, Schneitter J, Luscher KP (1986) Ultrasonic diagnosis of a giant chorioangioma of the placenta and fetal complications. Ultraschall Med 7: 245-7
6 Dao AH, Rogers CW, Wong SW (1981) Chorioangioma of the placenta: Report of 2 cases with ultrasound study in 1. Obstet Gynecol 57: 46S-9S 7 Engel K, Hahn T, Karschnia R (1981) Sonographic diagnosis of a placental tumor with high-grade intrauterine fetal development deficiency, increasing anhydramnia and subsequent fetal death. Geburtshilfe Frauenheilkd 41: 570-3 8 Fox H (1967) Vascular tumors of the placenta. Obstet Gynecol Surv 22: 697-711 9 Froehlich LA, Fujikura T, Fisher P (1971) Chorioangiomas and their clinical implications. Obstet Gynecol 37: 51-9 10 Jones CEM, Rivers RPA, Taghizadeh A (1972) Disseminated intravascular coagulation and fetal hydrops in a newborn infant in association with a chorioangioma of placenta. Pediatrics
50:901-7
11 King CR, Lovrien EW (1978) Chorioangioma of the placenta and intrauterine growth failure. J Pediatr 93: 1027-28 12 Liang ST, Woo JSK, Wong VCW (1982) Chorioangioma of the placenta: An ultrasonic study. Br J Obstet Gynaecol 89: 480-82 13 Mahmood K (1977) Small chorioangiomas and smallfor-gestational age baby. Am J Obstet Gynecol127: 440-42 14 Naeye RL (1987) Do placental weights have clinical significance? Hum Pathol18: 387-91 15 O'Malley BP, Toi A, deSa OJ, Williams GL (1981) Ultrasound appearances of placental chorioangioma. Radiology 138: 159-60 16 Rayburn W, Sander C, Compton A (1989) Histologic examination of the placenta in the growth-retarded fetus. Am J Perinatol 6: 58-61 17 Sieracki JC, Panke TW, Horvat BL, Perrin EV, Nanda B (1975) Chorioangiomas. Obstet Gynecol 46: 155-59 18 Wallenburg HCS (1971) Chorioangioma of the placenta. Obstet Gynecol Surv 26: 411-25 19 Wentworth P (1965) The incidence and significance of hemangioma of the placenta. Br J Obstet Gynaecol 72: 81-88
Received October 5, 1989 . Accepted in revised form December 20, 1989
Key words: Chorioangioma - Chorangioma - Placental hemangioma - Intrauterine growth retardation Frederick T. Kraus, M.D., Chairman, Department of Pathology, St. John's Mercy Medical Center, 615 South New Ballas Road, St. Louis, Missouri 63141-8221, USA
Chorioangiomas of Intermediate Size and Intrauterine Growth Retardation D. R. Mucitelli, E. Z. Charles, and F. T. Kraus Department of Pathology, Sf. John's Mercy Medical Center, Sf. Louis, USA
SUMMARY
Very large chorioangiomas are a rare but well recognized cause of neonatal morbidity; while small ones are clinically insignificant. This study emphasizes that some chorioangiomas ofintermediate size may be causally related to intrauterine growth retardation, and that they may be surprisingly difficult to detect in the unfixed placenta.
Introduction Chorioangioma (hemangioma) is the most frequent benign tumor of the human placenta, occurring in approximately 1% of all pregnancies8, 18. Because the majority of these tumors are small, they usually have no clinical significance. Complications that have been clearly related to very large hemangiomas include polyhydramnios, premature labor, toxemia, abruptio placentae, neonatal cardiac failure, microangiopathic hemolytic anemia, and congenital anomalies of various types 2,4,8,9,10,17-19. The relationship between chorioangiomas and intrauterine growth retardation has been suggested by a number of individual case reports 11 , 13 and some larger studies 18 , but the statistical significance of this apparent relationship is usually lost when case control comparisons in larger series have been made 9,19. It is possible that chorioangiomas are causally related to intrauterine growth retardation, even when the chorioangiomas are not large enough to produce the more usual complications but still retain a significant size in comparison to the size of the placenta. We present here two instances of placenta chorioangioma associated with intrauterine growth retardation in which the chorioangiorna appears to represent the most significant etiologic abnormality in the gestation. Case Reports
Case 1 A 19 year old white primigravid woman was admitted for the induction of labor. Intrauterine growth retardation © 1990 by Gustav Fischer Verlag, Stuttgart
had been documented by serial ultrasound measurements which failed to identify any intraplacental lesions. A 2150 gram female was delivered from the vertex position at 37 weeks gestation. Apgar scores of 7 and 9 were recorded at one and five minutes respectively. She was 44.5 cm in length with a head circumference of 32.5 cm. No physical or neurological abnormalities were noted. The neonatal course was unremarkable. Physical examination was unremarkable apart from size compatible with a small-for-gestational age (SGA) infant. Laboratory studies including complete blood count (CBC) were normal. A platelet count was not done. At 29 months of age, she does not have dysmorphic features or psychomotor impairment.
Placental Examination: The trimmed placenta weighed 420 grams (50th percentile at 37 weeks 14 ) and measured 15.0 x 12.5 x 2.0 cm. Three blood vessels were present in the umbilical cord. At the first examination of cut sections of the unfixed placenta, no lesions were identified. After fixation, numerous circumscribed nodules of variable size became more readily identifiable because they now had a more solid consistency and a lighter grey color in contrast with the rest of the placenta (Fig. 1). In histologic sections, the hemangiomas were composed of crowded capillaries, and varied from 1 mm or less to 3 cm in greatest dimension (Fig. 2). More than 100 small areas of hemangioma were identified. As many as 15 hemangiomas could be counted on a single histologic section. Changes related to toxemia or inflammation were not identified. 0344-0338/90/0186-0455$3.50/0
456 . D. R. Mucitelli et al.
Fig. 1. Chorioangioma. Case 1. Gross photograph depicting infarct (open arrow) with adjacent ill-defined chorioangioma (closed arrow), recognized grossly only after formalin fixation.
Fig. 2. Chorioangioma. Case 1. Multiple, scattered foci of variable-sized chorioangiomas intermixed with numerous smaller chorionic villi. 7 x. Hematoxylin and eosin.
Case 2
Fig. 3. Chorioangioma. Case 2. Gross photograph of a section of placenta after formalin fixation showing unremarkable placental tissue (open arrow) with adjacent fleshy, firm, multilobated chorioangioma (closed arrow), recognized only after formalin fixation.
An 18 year old black women, gravida 1, at 34 weeks gestation presented 14 hours after premature rupture of membranes. An ultrasound examination performed on the day of admission revealed an abnormal growth profile indicating intrauterine growth retardation and a breech presentation, but no placental lesions were identified. Delivery was accomplished by Cesarean section. Operative findings in the mother included a unicornuate uterus, ectopic left kidney, and agenesis of the left fallopian tube and ovary. The right ovary and fallopian tube were intact. A male infant was delivered from the breech position. Apgar scores of 7 and 9 were recorded at one and five minutes respectively. He was 44.0 cm in length and weighed 1810 grams. The head circumference was 30.5 cm. The infant was initially tachypneic (respiratory rate> 70/min) and temporarily required oxygen. A chest radiograph showed prominent interstital markings and a structurally normal heart. Over a 24 hour period the requirement for supplemental oxygen environment declined, and the infant experienced no further respiratory problems. The physical examination was normal except for a 2.0 x 1.0 cm cutaneous angioma on the dorsal aspect of the right ankle. No congenital malformations were noted. Laboratory data including CBC were within normal limits. Placental Examination: The trimmed placenta weighed 375 grams (between the 50-75th percentile for a 34 week gestation 14 ) and measured 15.5 x 14.5 x 2.0 cm. The umbilical cord measured 27.5 cm in length and contained
Chorioangiomas and Intrauterine Growth Retardation . 457
Fig. 4. Chorioangioma. Case 2. Many capillary-sized vessels within a single chorioangioma. 90x. Hematoxylin and eosin.
three blood vessels. An ovoid well-demarcated mass 7.0 em in greatest diameter was found bulging beneath the fetal surface of the placenta. On cross section this mass was tan, with a lobulated appearance (Fig. 3). Histologically, the mass consisted of a network of numerous thin-walled vascular channels set in a very loose fibrous stroma (Fig. 4). Some of the vascular spaces contained red blood cells. Cellular areas without identifiable vascular channels were also present. Random sections from other areas of the placenta showed two small infarcts in contact with the decidual plate and thrombosis of one fetal stem artery. Discussion The most direct and dramatic pathologic effects attributable to chorioangiomas seem to occur only when the lesions are very large. These relationships would appear to be well established because such problems as neonatal cardiac failure, microangiopathic hemolytic anemia, and polyhydramnios can be related to effects of very large hemangiomas in other clinical situations. At the other extreme, very small hemangiomas appear to have no notable systemic effects whether they are located in the placenta or elsewhere. The chorioangiomas reported here are not as large as many of those reported as a cause of growth retardation, but they are significant in our opinion because they occurred in relatively small-sized placentas, at or near the 50th percentile by weight l4 . Most of the very large studies of chorioangioma have failed to note a relationship to intrauterine growth retardation, especially when all chorioangiomas are considered and compared with a control group of infants without
placentalchorioangioma. No chorioangiomas were listed in one study of 63 placentas associated with SGA newborns l . Nevertheless, as suggested by Wentworth l9 , there are some instances of intrauterine growth retardation in which a chorioangioma seems to be the only identifiable potential abnormality of significance. This idea is supported by individual case reports 11 , 13 and by the two cases in this report. Similarly, Wallenburg 18 noted that five in a series of thirteen instances of chorioangioma were associated with birth weights at or below the tenth percentile in his local area near Amsterdam. One larger, more recent histopathologic study of placentas in 151 instances of intrauterine growth retardation found three instances of chorioangioma as the apparent cause l6 ; in this series, other more common morphologic lesions, notably the vascular manifestations of hypertension, chronic inflammation, and hemorrhagic endovillitis appear to explain the intrauterine growth retardation in 90% of the cases. From our experience and the reports in the literature we conclude that chorioangioma can represent the primary basis of intrauterine growth retardation when the size relationships between the baby, the placenta, and the chorioangioma are appropriate. The basis of growth retardation would appear to be the result of shunting a significant proportion of placentofetal blood flow away from the villi thus reducing all forms of nutrient exchange. No direct or quantitative functional studies have been reported. While the largest chorioangiomas produce the most serious clinical problems, smaller lesions can also cause significant growth retardation and it is important not to overlook them. It seems likely that the severity of impaired growth is proportional to the size of the chorioangioma. There are several reports of identification of placental chorioangiomas by ultrasound techniques 3,5-7, 12, 15. These studies note that there is no contrast in echogenic characteristics of placental tissue and chorioangioma; the presence of a placental deformity in combination with the recognition of SGA infant is the usual basis for ultrasound diagnosis. As there was no placental deformity in the two cases presented here, even in retrospect the ultrasound images are interpreted as normal. Neither of the lesions in this report was recognized at the time of initial gross examination; others have noted the same difficultyI7-19. Our experience also emphasizes the importance of detailed and complete gross and histologic study of placentas associated with growth retardation because significant and extensive forms of multiple chorioangioma are easily overlooked on the basis of gross examination alone. The gross abnormalities can be especially subtle in the unfixed placenta.
Other Issues Chorioangiomas are conventionally subclassified8 according to three main histologic patterns. The angiomatous type, exemplified in this report, is composed of small capillary vessels crowded together with inconspicuous stroma. The cellular type is composed of masses of myxoid
458 . D. R. Mucitelli et al.
matrix through which many fibroblastic cells and a few vessels are scattered. Degenerate chorioangiomas have conspicuous hyalinized, calcific and necrotic foci. The relationship, if any, between chorioangiomas and villi that appear hypervascular or telangiectatic is not settled. The controversy about whether chorioangiomas are hamartomas or neoplasms is not resolved. The presence of various admixtures of non-vessel tissue components and the virtual absence of angiosarcoma as a placental lesion are more consistent with the concept of hamartoma. Components of trophoblast and smooth muscle are common, but wide variations in proportion occur. Simultaneous occurrance of hemangiomas in both fetus and placenta has been noted in several instances 8; in one study six times as often as in a control group with no hemangiomas 9 . A significant relationship to important congenital anomalities is possible but appears unlikely8,9. References 1 Altshuler G, Russell P, Ermocilla R (1975) The placental pathology of small-for-gestational age infants. Am J Obstet Gynecol121: 351-59 2 Asadourian LA, Taylor HB (1968) Clinical significance of placental hemangiomas. Obstet Gynecol31: 551-55 3 Asokan S, Chadalavada K, Gardi R, Sastry V (1978) Prenatal diagnosis of placental tumor by ultrasound. JCU 6: 180-1 4 Bauer CR, Fojaco RM, Bancalari E, Fernandez-Rocha L (1978) Microangiopathic hemolytic anemia and thrombocytopenia in a neonate associated with a large placental chorioangioma. Pediatrics 62: 574-77 5 Bruhwiler H, Schneitter J, Luscher KP (1986) Ultrasonic diagnosis of a giant chorioangioma of the placenta and fetal complications. Ultraschall Med 7: 245-7
6 Dao AH, Rogers CW, Wong SW (1981) Chorioangioma of the placenta: Report of 2 cases with ultrasound study in 1. Obstet Gynecol 57: 46S-9S 7 Engel K, Hahn T, Karschnia R (1981) Sonographic diagnosis of a placental tumor with high-grade intrauterine fetal development deficiency, increasing anhydramnia and subsequent fetal death. Geburtshilfe Frauenheilkd 41: 570-3 8 Fox H (1967) Vascular tumors of the placenta. Obstet Gynecol Surv 22: 697-711 9 Froehlich LA, Fujikura T, Fisher P (1971) Chorioangiomas and their clinical implications. Obstet Gynecol 37: 51-9 10 Jones CEM, Rivers RPA, Taghizadeh A (1972) Disseminated intravascular coagulation and fetal hydrops in a newborn infant in association with a chorioangioma of placenta. Pediatrics
50:901-7
11 King CR, Lovrien EW (1978) Chorioangioma of the placenta and intrauterine growth failure. J Pediatr 93: 1027-28 12 Liang ST, Woo JSK, Wong VCW (1982) Chorioangioma of the placenta: An ultrasonic study. Br J Obstet Gynaecol 89: 480-82 13 Mahmood K (1977) Small chorioangiomas and smallfor-gestational age baby. Am J Obstet Gynecol127: 440-42 14 Naeye RL (1987) Do placental weights have clinical significance? Hum Pathol18: 387-91 15 O'Malley BP, Toi A, deSa OJ, Williams GL (1981) Ultrasound appearances of placental chorioangioma. Radiology 138: 159-60 16 Rayburn W, Sander C, Compton A (1989) Histologic examination of the placenta in the growth-retarded fetus. Am J Perinatol 6: 58-61 17 Sieracki JC, Panke TW, Horvat BL, Perrin EV, Nanda B (1975) Chorioangiomas. Obstet Gynecol 46: 155-59 18 Wallenburg HCS (1971) Chorioangioma of the placenta. Obstet Gynecol Surv 26: 411-25 19 Wentworth P (1965) The incidence and significance of hemangioma of the placenta. Br J Obstet Gynaecol 72: 81-88
Received October 5, 1989 . Accepted in revised form December 20, 1989
Key words: Chorioangioma - Chorangioma - Placental hemangioma - Intrauterine growth retardation Frederick T. Kraus, M.D., Chairman, Department of Pathology, St. John's Mercy Medical Center, 615 South New Ballas Road, St. Louis, Missouri 63141-8221, USA
