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PLACENTA
PLACENTAL CALCIFICATION
Is a normal physiological process that occurs during pregnancy.According to some it has no
pathological /clinical significance.Others however associate various types of calcification to
significant conditions .Grading of placenta is based on calcifications.

Grade 0:smooth chorionic plate devoid of undulations and calcified areas.Normally placenta
upto 29wks is grade 0.

PL
PL

Grade 0 Placenta(PL) Grade I Placenta(PL)


Arrow-Uneven placental texture

Grade I:Scattered calcific spots with subtle undulations of chorionic plate.

Grade II: Calcific areas seen in the basal plate.Calcific septa from chorionic plate approach
basal plate.(without reaching it) dividing placenta into incomplete cotyledons.

Grade III placenta.Prominent calcifications


seen in Basal plate(arrows) &septa(arrowheads)

Grade III:Mature Placenta:Marked undulations of the chorionic plate and calcific areas
extend from chorionic plate to the basal layer dividing placenta into cotyledons.Centre of
cotyledons has sonoluscent areas.

SIGNIFICANCE OF GRADING
Two portions of placenta may have different grades and highest grade is assigned.

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According to Hopper grade I placenta before 27 wks, grade II before 32 wks and grade III
before 34 wks have high incidence of pre-ecclampsia and IUGR. BPD of 8.7 cm or less with
gradeIII placenta—chances of IUGR are increased by 8.5 times. Grade III placenta is
associated with complete lung maturity.However if a grade III placenta is found earlier in
pregnancy it is not a 100% reliable marker of fetal lung maturity.
BPD of 9.2 cm or more corelates with lung maturity because it tends to exclude early
gestational age.Placental changes may be delayed in D.mellitus and Rh sensitization.
Changes are accelerated in IUGR and hypertension.

LESIONS OF PLACENTA(Normal)
Present as hypo-echoic or anechoic lesions.Include:
1.Subchorionic fibrin deposition
2. Intervillous thrombosis

Subchorionic fibrin deposition-Multiple Maternal Lakes(arrows)P-placenta


subchorionic anechoic/hyperechoic
lesions (Arrows)

3. Perivillous fibrin deposition &maternal lakes


4.Infarcts.
On ultrasound these sonolucent spaces cannot be distinguished from one another.Only
histologically these lesions can be differentiated.These lesions are common and usually
insignificant.However the number and size of these lesions increase with the duration of
pregnancy and in some pathologic conditions such as Rh iso-immunization ,severe toxemia
and maternal hypertension.

RETROPLACENTAL AREA:shows veins which drain blood from the placenta.

Retroplacental veins(arrowheads).P-Placenta

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CONTRACTIONS OF PLACENTA:
Transient myometrial thickening results from normal uterine contractions(Braxton-Hick’s)
which are imperceptible to the mother .These contractions most commonly occur in second
trimester but can be seen earlier.Contraction causes localized thickening of placenta and /or
myometrium.A contraction may mimic Pl. previa and should be followed over
time(rescanning within 30 min. to 1 hr) to exclude that diagnosis.It should also be
distinguished from leiomyoma which will not change its shape on rescanning.

PLACENTA CRETA:
Focal or diffuse deficiency of decidua basalis.3 categories:
1.Pl.accreta vera: where villi invade the superficial part of myometrium.
2.Pl.increta: Here the myometrium is invaded even in deeper layers.
3.Pl.percreta:villi invade the myometrium completely and further cross it so as to reach the
serosa.
Increased incidence in patients with previous C.S. and uterine scars.
Ultrasound—Absence or significant decrease of usual retroplacental hypo-echoic
zone(representing decidua basalis) is seen.On U/S placenta accreta & increta cannot be
distinguished ,however placenta percreta can be diagnosed by seeing the thinning of the uterine -
bladder interface with protrusion of placental tissue into the bladder lumen.
In all the varieties of placenta creta multiple maternal lakes may be seen.

Placenta increta-There is absence of retroplacental myometrium in the lower part of placenta(curved arrow)
Retro placental myometrium is seen in the upper part (Arrowhead).Arrow shows maternal lake.F-Fetus.

• In women with placenta previa, an abnormally adherent placenta is suspected when


there is an absent decidual interface between the placenta and the myometrium.
Another sign is the presence of unusually dilated vessels at the placental site

large dilated blood vessels in the anterior


uterine wall, which is suggestive of placenta
accreta.

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Placenta percreta-Placenta invading bladder wall(between arrows) Increased blood flow seen in the same area

B
ANTEPARTUM HEMORRAGE:

Bleeding from placenta previa and abruptio placentae usually occurs at or close to term, while
retroplacental or marginal hemorrhage may occur as early as the first trimester.

Retroplacental Hemorrhage & Submembranous hemorrhage


Retroplacental hemorrhage may manifest itself in three ways: (1) external bleeding without
formation of a significant intrauterine hematoma; (2) formation of a retroplacental or
marginal hematoma with or without external bleeding and (3) formation of a submembranous
hematoma at a distance from the placenta, with or without external bleeding Sonographic
examination in cases of antepartum bleed will be negative if most of the bleeding is external.

A retroplacental or submembranous hematoma will appear as a hypoechoic or complex


collection at sonography.
In early pregnancy subchorionic hematoma may be distinguished from nonfused amnion by
evaluating the thickness of the membrane.The membrane above a subchorionic hematoma is

F
thicker than the amnion. Small hematomas of less than

Submembranous hematoma(H) d/d Old submembranous hematoma


Unfused Amnion(arrowhead)

60 c.c. are not associated with increased risk of miscarriage. Disseminated intravascular
coagulation may occur in cases of large,chronic retroplacental hematomas as a result of tissue
breakdown.

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Submembranous hematoma(H).F-fetus Retroplacental bleed(H) P-placenta;F-Fetus

ABRUPTIO PLACENTAE:-
It is premature seperation of placenta . Clinically the pt. may have any of the following
signs: vaginal bleeding,preterm labour, abdominal pain,features of fetal distress or maternal
shock.Maternal hypertension is seen in 50% of cases. Other risk factors include previous h/o
of abruption,premature delivery,presence of fibroid, placenta previa and exposure to drugs
eg. Cocaine.
There are two types of abruptio placenta 1) Retroplacental abruption-It is a severe high
pressure bleed due to rupture of spiral arteries. 2) Marginal abruption-It is milder type of low
pressure bleed and occurs due to tears of marginal veins. Placental seperation is very little
and the bleed usually collects beneath the membranes ( sub-membranous bleed ) away from
the placenta.

ULTRASOUND- In Retroplacental bleed placenta will appear enlarged with presence of


ill-defined echogenic retroplacental collection . This echogenic area of acute bleed will
decrease in echogenicity with the passage of time and will also be more sharply demarcated
from placental tissue.
Marginal abruption shows seperation of small area of placental edge and usually hypoechoic
area of submembranous bleed adjacent to separated placenta.

Abruptio Placenta H-hematoma;P-Placenta Abruptio(late).Hematoma resolving

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Low lying placenta:is the one which is within 2 cm of the internal os but not covering it.

PLACENTA PREVIA

Placenta previa, in which the placenta covers part or all of the internal cervical os, is a
common cause of bleeding in the third trimester although it occurs in less than 1% of
deliveries. While diagnosing placenta previa it is important to define Internal Os.The
endocervical canal is seen on sonogram as a line of increased or decreased echogenicity.The
superior termination of endocervical canal is the Internal os.

Placenta previa-

Placenta previa is often overdiagnosed in the first two trimesters, because it is commonly
mimicked by two conditions:
1.Overfilling of the urinary bladder
2.Contractions.(suspected if myometrial wall is greater than 1.5cm).
Thus if placentaprevia is suspected it is important to re examine the patient after voiding and
/or after approximately half an hour has passed

False Pl. previa- Prevoiding. P- Placenta B-Bladder Postvoiding

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Uterine contraction Contraction passed

Obscured (by fetal head ) placenta previa . In such cases two techniques used to define the
lower margin of placenta :1.Elevation of presenting part by abdominal palpation 2. By raising
the foot end of the bed.
Presently the better way to document placenta previa in such cases is by:
TRANSLABIAL OR TRANSVAGINAL SCANNING
TVS is superior to both Transabdominal & Translabial scanning in diagnosing placenta
previa.

Translabial scan CompletePlacenta previa Transvaginal Scan

Succenturiate Lobe

Accessory lobe caused by failure of normal villous atrophy.


Connected to main lobe by membrane having foetal vascular supply.
Significance-1.Vessels may rupture during labour causing foetal death.
2.Retention of lobe may lead to PPH or infection.
D/D-Uterine contraction.
Lateral Placenta

Succenturiate Lobe(S)
PL-Placenta main

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