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Arch. Gyn/ik. 221, 167-174 (1976)
Gynfikologie 9 J. F. Bergmann Vertag 1976
Ultrasonic Diagnosis of Placenta membranacea Juriy W. Wladimiroff, Henk C. S. Wallenburg, Peter v. d. Putten, and A. C. Drogendijk Department of Obstetrics and Gynecology, Academisch Ziekenhuis Rotterdam -- Dijkzigt, Erasmus University, Rotterdam, The Netherlands
Ultraschalldiagnose einer Placenta membranacea Summary. In this paper the first known case is presented in which an anteparturn diagnosis of placenta membranacea was made by ultrasound. A multiparous woman is presented with intermittent painless vaginal bleeding in the second trimester of pregnancy. Ultrasonic examination at 20 weeks' gestation revealed a gestational sac almost completely covered with placental tissue. At 26 weeks the patient delivered a dead, growth retarded fetus and an almost complete placenta membranacea. Key words: Placenta membranacea - Ultrasound - Placentography. Zusammenfassung. Es wird fiber den ersten bekannten Fall einer vor der Entbindung mittels Ultraschall diagnostizierten Placenta membranacea berichtet. Be/ einer Vielgeb/irenden traten im zweiten Schwangerschaftstrimenon intermittierende, schmerzlose Blutungen auf. Eine Ultraschalluntersuchung in der 20. Schwangerschaftswoche zeigte, dal3 fast die ganze Oberfl/iche der Eih/iute mit Zotten besetzt war. In der 26. Schwangerschaftswoche wurde die Frau von einem intra-uterin verstorbenen und wachstumretardierten Fetus entbunden. Die Nachgeburt wies eine fast v611ige Placenta membranacea auf.
Introduction Placenta membranacea or diffusa is a rare type of placental abnormality, in which the entire or greater part of the surface of the gestational sac is covered with functioning villi. In this communication the antepartum diagnosis of a placenta membranacea by means of ultrasound is reported.
Case Report A 28-year old Caucasian, gravida 3, para 2, with an expected date of confinement of April 29, 1975, was admitted on December 5, 1974, at 20 weeks' gestation, for evaluation of intermittent painless vaginal bleeding during the previous 5 weeks. Otherwise her prenatal course had been uneventful. The
Fig. 1. Ultrasonogram showing the gestational sac on a longitudinal section through the maternal umbilicus. M.UMB. = maternal umbilicus, S. = symphysis, M.B. = maternal urinary bladder, C. cervix, P.D. = largest diameter (2.4 cm) of placental disk, V.T. = villous tissue (placenta membranacea), F - fetus, B.C. = accumulation of blood clots
Fig. 2. Ultrasonogram showing transverse section of gestational sac halfway between maternal umbilicus and symphysis. M.ABD. = maternal abdomen, P.D. = placental disk, V.T. = villous tissue (placenta membranacea, diameter: 0.5 era), F ~ fetus
Ultrasonic Diagnosis of Placenta Membranacea
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Fig. 3. Posterior side of gestational sac shown upside down in a tank of water. O = opening of sac, A = area without any villous tissue on posterior side of sac, V.T. = villous tissue, P.T. = part of placental disk on anterior side of sac
obstetric history revealed a term spontaneous delivery in 1966 of a 3250 g live female infant and a second pregnancy in~1972 which for unknown reasons ended in intra-uterine fetal death during labor at 39 weeks' gestation. The further medical history was unremarkable. On admission gynecologic examination revealed a closed cervix, and slight sanguineous discharge. Fetal heart sounds were audible. Ultrasonic examination showed a fetal biparietal diameter of 4.20 cm, a value below the 5th percentile according to Campbell and N e w m a n ' s normal curve (Campbell and Newman, 1971). Longitudinal and transverse B-scan ultrasonograms (Fig. 1 and 2) revealed a placenta covering most of the anterior uterine wall and the uterine fundus. The largest diameter of the placental disk measured 2.4 cm. Ultrasonic examination of the gestational sac at the level of the internal cervical os was difficult due to accumulation of blood clots in this area. On the upper posterior side of the gestational sac a thin layer of villous tissue was observed, with a largest diameter of 0.7 cm. These findings on ultrasound lead to the diagnosis of placenta membranacea.
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Fig. 4. Microscopic picture of a longitudinal section through the placental disk (4a), placenta membranacea (4b) and part of the membranes devoid of any villi (4e). Hemotoxylin-eosin. Original magnification x 150
During her stay in the hospital the patient had recurrent vaginal bleeding. She was placed on complete bed rest and a Shirodkar cerclage was performed. After this there was no more visible vaginal bleeding but during the following weeks ultrasonic, scanning showed further accumulation of blood clots behind the internal cervical os and a poor increase in fetal biparietal diameter. The hemoglobin level fell to between 8 and 9 g percent and she was transfused with 10 U of packed cells. At 26 weeks' gestation, six weeks after admission, the patient suddenly developed a temperature of 39 ~ C and went into active labor. The Shirodkar eerclage was removed, which resulted in discharge of old, foul smelling blood clots. Intra-uterine infection was suspected, and intramuscular administration of ampicilline was started. On digital examination at 2 cm dilatation placental tissue was felt on the interior uterine wall, but the membranes right behind the internal os appeared free of villi. During labor fetal heart action ceased. After 3 h the patient gave birth to a stillborn female infant. The birth weight of 560 g was below the 10th percentile of Gruenwald's tables (Gruenwald, 1966); no congenital malformations were noticed. The gestational sac was delivered spontaneously and appeared almost entirely covered by placental tissue.
Ultrasonic Diagnosis of Placenta Membranacea
171
Intra- and postpartum blood loss was estimated at 200 ml. Within 4 h after delivery the patient's temperature returned to normal and she was discharged in good condition on the 7th postpartum day.
Examination of the Ptaeenta Gross examination of the placenta was performed with the gestationat sac suspended in a water bath, which allows conclusions on the previous intra-uterine position (Holzapfel, 1940). A distinct placental disk measuring 10 x 8 x 2 cm was seen on the anterior and part of the fundal side of the sac. On the posterior side the villous tissue varied from 0.2-0.7 cm in thickness. On the lower posterior side of the membranes an area of 6 x 8 cm, which included the site of the rupture, was devoid of villi (Fig. 3). The entire sac weighed 250 g. The umbilical cord was 40 cm long and inserted centrally on the placental disk. The maternal aspect of the ehorion showed adherent fresh and old blood clots. The macroscopic diagnosis was placenta membranacea. On histotogic examination the villi in the main placental disk appeared normal for the duration of gestation. The viIli contained a normal number of fetal vessels, the usual amount of stromal tissue and a normally developed syncyfiotr0phoblast (Fig. 4a). The villi in the placental tissue on the posterior side
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of the sac showed marked fibrosis with only few fetal vessels. The trophoblast presented numerous aggregations of syncytial nuclei, many villi were embedded in depositions of fibrinoid substance (Fig. 4b). No villous tissue could be demonstrated in the small area of membranes on the lower posterior side (Fig. 4c).
Discussion
Culp et al. (1973) reported a case of placenta membranacea diagnosed by arterial placentography. They state that ultrasonic placental localization would not have sufficient refinement to demonstrate placenta membranacea. Pryse-Davies et al. (1973) suggested that it should be possible to diagnose placenta membranacea by means of antepartum ultrasonic placentography. These authors presented a case of placenta membranacea which was only recognized after delivery, but re-examination of their antepartum ultrasonograms did indicate the presence of placenta membranacea.
Ultrasonic Diagnosis of Placenta Membranacea
173
In the present case an antepartum diagnosis of placenta membranacea was made on the basis of ultrasonograms. Ultrasonic scanning of the placenta did not establish the absence of villi on the lower posterior part of the gestationat sac at the level of the internal cervical os, apparently due to accumulation of blood clots in this area. According to the literature, continuous or repeated antepartum bleeding seems to be the main feature of placenta membranacea (Von Weiss, 1894; Finn, 1954; Culp et al., 1973; Pryse-Davies et al., 1973). Finn (1954) and Janowski and Granowitz (1961) presented altogether 3 cases, in which pregnancy had to be terminated by Cesarean section between the 20th and 27th week of pregnancy because of continuous loss of blood. Other obstetric complications that have been described are spontaneous abortion and complications in the third stage of labor like hemorrhage (Von Weiss, 1894; Benirschke and DriscoI1, 1967) and adherent placenta (Von Weiss, 1894; De Lee, 1902; Reinprecht, 1902). The cause of placenta membranacea is not clear. Many etiological factors have been suggested: previous episodes of endometritis (Von Weiss, 1894), poor blood supply in the decidua basalis, necessitating the persistence of villi on the chorion laeve; rich vascularization of the decidua capsularis (Eastman and Hellman, 1966); hypoplastic endometrium after intensive uterine curettement (Martius, 1971). In the case presented here, there is a distinct placental disk together with villous tissue covering the major part of the sac. Though the villi show fibrotic changes, the presence of patent fetal vessels indicates that they have been functional. The clustering of syncytial nuclei in syncytiaI knots which are observed in great number in this tissue could be attributed to hypoxia due to an insufficient utero-placental blood supply (Tominaga and Page, 1966). The association of a well-formed placental disk with placenta membranacea has previously been described by Pryse-Davies et al. (1973).
Acknowledgements.We are indebtedto Dr. J. C. J. Galliard,AssociateProfessorof Pathology, and Dr. I. Bakri, pathologist (Dept. of Pathology I, Erasmus University Rotterdam) for the macroscopic and microscopicexamination of the placenta.
References
Benirschke, K., Driscoll, S. G.: The Pathology of the Human Placenta, pp. 13--15. Berlin-HeidelbergNew York: Springer 1967 Campbell, S., Newman, G.: Growth of the fetal biparietal diameter during normal pregnancy. J. Obstet. Gynaec. Brit. Cwlth. 78, 513-519 (1971) Culp, W. C., Brian, R. N., Morettin, L. B.: Placenta membranacea. Radiology 108, 309-310 (1973) De Lee, J.: Placenta membranacea. American Journal of Obstetrics and Diseases of Women and Children 46, 530-531 (1902) Eastman, N. J., Hellman, L. M.: Williams Obstetrics. Thirteenth edition, p. 590. New York: AppletonCentury-Crofts 1966 Finn, J. L.: Placenta membranacea. Obstet. Gyneeol. 3, 438--440 (1954) Gruenwald, P.: Growth ofthe human fetus.I. Normal growth and its variation.Amer.J. Obstet. Gynec.94, 1112-1119 (1966) Holzapfel, G.: Ein Beitrag zur Frage des Plazentasitzes und seiner Besonderheiten. Zbl. Gyn/ik. 64, 645-658 (I940)
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Janowski, N. A., Granowitz, E. T.: Placenta membranacea. Obstet. Gynecol. 18, 206-212 (1961) Martius, H.: Lehrbuch der Geburtshilfe. Seventh Edition, p. 389. Stuttgart: Thieme 1971 Pryse-D avies, J., Dewhurst, C. J., Campbell, S.: Placenta membranacea. J. Obstet. Gynaec. Brit. Cwlth. 80, 1106-1110 (1973) Reinprecht, L.: Placenta membranacea. Zbl. Gyn/ik. 20, 73 (1902) Tominaga, T., Page, E. W.: Accommodation of the human placenta to hypoxia. Amer. J. Obstet. Gynec. 94, 679--691 (1966) Weiss, O. von: Placenta membranacea. Zbl. Gyn/ik. 3, 76--79 (1894)
Received September 10, 1975
Arch. Gyn/ik. 221, 167-174 (1976)
Gynfikologie 9 J. F. Bergmann Vertag 1976
Ultrasonic Diagnosis of Placenta membranacea Juriy W. Wladimiroff, Henk C. S. Wallenburg, Peter v. d. Putten, and A. C. Drogendijk Department of Obstetrics and Gynecology, Academisch Ziekenhuis Rotterdam -- Dijkzigt, Erasmus University, Rotterdam, The Netherlands
Ultraschalldiagnose einer Placenta membranacea Summary. In this paper the first known case is presented in which an anteparturn diagnosis of placenta membranacea was made by ultrasound. A multiparous woman is presented with intermittent painless vaginal bleeding in the second trimester of pregnancy. Ultrasonic examination at 20 weeks' gestation revealed a gestational sac almost completely covered with placental tissue. At 26 weeks the patient delivered a dead, growth retarded fetus and an almost complete placenta membranacea. Key words: Placenta membranacea - Ultrasound - Placentography. Zusammenfassung. Es wird fiber den ersten bekannten Fall einer vor der Entbindung mittels Ultraschall diagnostizierten Placenta membranacea berichtet. Be/ einer Vielgeb/irenden traten im zweiten Schwangerschaftstrimenon intermittierende, schmerzlose Blutungen auf. Eine Ultraschalluntersuchung in der 20. Schwangerschaftswoche zeigte, dal3 fast die ganze Oberfl/iche der Eih/iute mit Zotten besetzt war. In der 26. Schwangerschaftswoche wurde die Frau von einem intra-uterin verstorbenen und wachstumretardierten Fetus entbunden. Die Nachgeburt wies eine fast v611ige Placenta membranacea auf.
Introduction Placenta membranacea or diffusa is a rare type of placental abnormality, in which the entire or greater part of the surface of the gestational sac is covered with functioning villi. In this communication the antepartum diagnosis of a placenta membranacea by means of ultrasound is reported.
Case Report A 28-year old Caucasian, gravida 3, para 2, with an expected date of confinement of April 29, 1975, was admitted on December 5, 1974, at 20 weeks' gestation, for evaluation of intermittent painless vaginal bleeding during the previous 5 weeks. Otherwise her prenatal course had been uneventful. The
Fig. 1. Ultrasonogram showing the gestational sac on a longitudinal section through the maternal umbilicus. M.UMB. = maternal umbilicus, S. = symphysis, M.B. = maternal urinary bladder, C. cervix, P.D. = largest diameter (2.4 cm) of placental disk, V.T. = villous tissue (placenta membranacea), F - fetus, B.C. = accumulation of blood clots
Fig. 2. Ultrasonogram showing transverse section of gestational sac halfway between maternal umbilicus and symphysis. M.ABD. = maternal abdomen, P.D. = placental disk, V.T. = villous tissue (placenta membranacea, diameter: 0.5 era), F ~ fetus
Ultrasonic Diagnosis of Placenta Membranacea
169
Fig. 3. Posterior side of gestational sac shown upside down in a tank of water. O = opening of sac, A = area without any villous tissue on posterior side of sac, V.T. = villous tissue, P.T. = part of placental disk on anterior side of sac
obstetric history revealed a term spontaneous delivery in 1966 of a 3250 g live female infant and a second pregnancy in~1972 which for unknown reasons ended in intra-uterine fetal death during labor at 39 weeks' gestation. The further medical history was unremarkable. On admission gynecologic examination revealed a closed cervix, and slight sanguineous discharge. Fetal heart sounds were audible. Ultrasonic examination showed a fetal biparietal diameter of 4.20 cm, a value below the 5th percentile according to Campbell and N e w m a n ' s normal curve (Campbell and Newman, 1971). Longitudinal and transverse B-scan ultrasonograms (Fig. 1 and 2) revealed a placenta covering most of the anterior uterine wall and the uterine fundus. The largest diameter of the placental disk measured 2.4 cm. Ultrasonic examination of the gestational sac at the level of the internal cervical os was difficult due to accumulation of blood clots in this area. On the upper posterior side of the gestational sac a thin layer of villous tissue was observed, with a largest diameter of 0.7 cm. These findings on ultrasound lead to the diagnosis of placenta membranacea.
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Fig. 4. Microscopic picture of a longitudinal section through the placental disk (4a), placenta membranacea (4b) and part of the membranes devoid of any villi (4e). Hemotoxylin-eosin. Original magnification x 150
During her stay in the hospital the patient had recurrent vaginal bleeding. She was placed on complete bed rest and a Shirodkar cerclage was performed. After this there was no more visible vaginal bleeding but during the following weeks ultrasonic, scanning showed further accumulation of blood clots behind the internal cervical os and a poor increase in fetal biparietal diameter. The hemoglobin level fell to between 8 and 9 g percent and she was transfused with 10 U of packed cells. At 26 weeks' gestation, six weeks after admission, the patient suddenly developed a temperature of 39 ~ C and went into active labor. The Shirodkar eerclage was removed, which resulted in discharge of old, foul smelling blood clots. Intra-uterine infection was suspected, and intramuscular administration of ampicilline was started. On digital examination at 2 cm dilatation placental tissue was felt on the interior uterine wall, but the membranes right behind the internal os appeared free of villi. During labor fetal heart action ceased. After 3 h the patient gave birth to a stillborn female infant. The birth weight of 560 g was below the 10th percentile of Gruenwald's tables (Gruenwald, 1966); no congenital malformations were noticed. The gestational sac was delivered spontaneously and appeared almost entirely covered by placental tissue.
Ultrasonic Diagnosis of Placenta Membranacea
171
Intra- and postpartum blood loss was estimated at 200 ml. Within 4 h after delivery the patient's temperature returned to normal and she was discharged in good condition on the 7th postpartum day.
Examination of the Ptaeenta Gross examination of the placenta was performed with the gestationat sac suspended in a water bath, which allows conclusions on the previous intra-uterine position (Holzapfel, 1940). A distinct placental disk measuring 10 x 8 x 2 cm was seen on the anterior and part of the fundal side of the sac. On the posterior side the villous tissue varied from 0.2-0.7 cm in thickness. On the lower posterior side of the membranes an area of 6 x 8 cm, which included the site of the rupture, was devoid of villi (Fig. 3). The entire sac weighed 250 g. The umbilical cord was 40 cm long and inserted centrally on the placental disk. The maternal aspect of the ehorion showed adherent fresh and old blood clots. The macroscopic diagnosis was placenta membranacea. On histotogic examination the villi in the main placental disk appeared normal for the duration of gestation. The viIli contained a normal number of fetal vessels, the usual amount of stromal tissue and a normally developed syncyfiotr0phoblast (Fig. 4a). The villi in the placental tissue on the posterior side
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J.W. Wladimiroff et al.
of the sac showed marked fibrosis with only few fetal vessels. The trophoblast presented numerous aggregations of syncytial nuclei, many villi were embedded in depositions of fibrinoid substance (Fig. 4b). No villous tissue could be demonstrated in the small area of membranes on the lower posterior side (Fig. 4c).
Discussion
Culp et al. (1973) reported a case of placenta membranacea diagnosed by arterial placentography. They state that ultrasonic placental localization would not have sufficient refinement to demonstrate placenta membranacea. Pryse-Davies et al. (1973) suggested that it should be possible to diagnose placenta membranacea by means of antepartum ultrasonic placentography. These authors presented a case of placenta membranacea which was only recognized after delivery, but re-examination of their antepartum ultrasonograms did indicate the presence of placenta membranacea.
Ultrasonic Diagnosis of Placenta Membranacea
173
In the present case an antepartum diagnosis of placenta membranacea was made on the basis of ultrasonograms. Ultrasonic scanning of the placenta did not establish the absence of villi on the lower posterior part of the gestationat sac at the level of the internal cervical os, apparently due to accumulation of blood clots in this area. According to the literature, continuous or repeated antepartum bleeding seems to be the main feature of placenta membranacea (Von Weiss, 1894; Finn, 1954; Culp et al., 1973; Pryse-Davies et al., 1973). Finn (1954) and Janowski and Granowitz (1961) presented altogether 3 cases, in which pregnancy had to be terminated by Cesarean section between the 20th and 27th week of pregnancy because of continuous loss of blood. Other obstetric complications that have been described are spontaneous abortion and complications in the third stage of labor like hemorrhage (Von Weiss, 1894; Benirschke and DriscoI1, 1967) and adherent placenta (Von Weiss, 1894; De Lee, 1902; Reinprecht, 1902). The cause of placenta membranacea is not clear. Many etiological factors have been suggested: previous episodes of endometritis (Von Weiss, 1894), poor blood supply in the decidua basalis, necessitating the persistence of villi on the chorion laeve; rich vascularization of the decidua capsularis (Eastman and Hellman, 1966); hypoplastic endometrium after intensive uterine curettement (Martius, 1971). In the case presented here, there is a distinct placental disk together with villous tissue covering the major part of the sac. Though the villi show fibrotic changes, the presence of patent fetal vessels indicates that they have been functional. The clustering of syncytial nuclei in syncytiaI knots which are observed in great number in this tissue could be attributed to hypoxia due to an insufficient utero-placental blood supply (Tominaga and Page, 1966). The association of a well-formed placental disk with placenta membranacea has previously been described by Pryse-Davies et al. (1973).
Acknowledgements.We are indebtedto Dr. J. C. J. Galliard,AssociateProfessorof Pathology, and Dr. I. Bakri, pathologist (Dept. of Pathology I, Erasmus University Rotterdam) for the macroscopic and microscopicexamination of the placenta.
References
Benirschke, K., Driscoll, S. G.: The Pathology of the Human Placenta, pp. 13--15. Berlin-HeidelbergNew York: Springer 1967 Campbell, S., Newman, G.: Growth of the fetal biparietal diameter during normal pregnancy. J. Obstet. Gynaec. Brit. Cwlth. 78, 513-519 (1971) Culp, W. C., Brian, R. N., Morettin, L. B.: Placenta membranacea. Radiology 108, 309-310 (1973) De Lee, J.: Placenta membranacea. American Journal of Obstetrics and Diseases of Women and Children 46, 530-531 (1902) Eastman, N. J., Hellman, L. M.: Williams Obstetrics. Thirteenth edition, p. 590. New York: AppletonCentury-Crofts 1966 Finn, J. L.: Placenta membranacea. Obstet. Gyneeol. 3, 438--440 (1954) Gruenwald, P.: Growth ofthe human fetus.I. Normal growth and its variation.Amer.J. Obstet. Gynec.94, 1112-1119 (1966) Holzapfel, G.: Ein Beitrag zur Frage des Plazentasitzes und seiner Besonderheiten. Zbl. Gyn/ik. 64, 645-658 (I940)
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J . W . Wladimiroff et al.
Janowski, N. A., Granowitz, E. T.: Placenta membranacea. Obstet. Gynecol. 18, 206-212 (1961) Martius, H.: Lehrbuch der Geburtshilfe. Seventh Edition, p. 389. Stuttgart: Thieme 1971 Pryse-D avies, J., Dewhurst, C. J., Campbell, S.: Placenta membranacea. J. Obstet. Gynaec. Brit. Cwlth. 80, 1106-1110 (1973) Reinprecht, L.: Placenta membranacea. Zbl. Gyn/ik. 20, 73 (1902) Tominaga, T., Page, E. W.: Accommodation of the human placenta to hypoxia. Amer. J. Obstet. Gynec. 94, 679--691 (1966) Weiss, O. von: Placenta membranacea. Zbl. Gyn/ik. 3, 76--79 (1894)
Received September 10, 1975
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