Ultrasound Imaging of Placenta

Embryology and placental development.
Normal placenta.
Placental abnormalities.
Morphologic abnormalities.
Miscellaneous.
Conclusion.

1. SONOGRAPHIC EVALUATION OF PLACENTA By Dr Vishwanath R S Vydehi Hospital, Bengaluru Unrestricted

2. Embryology and placental development. Normal placenta. Placental abnormalities. Morphologic abnormalities. Miscellaneous. Conclusion.

3. http://classes.midlandstech.edu/carterp/Courses/bio211/chap28/chap28.htm

4. http://classes.midlandstech.edu/carterp/Courses/bio211/chap28/chap28.htm

5. http://classes.midlandstech.edu/carterp/Courses/bio211/chap28/chap28.htm

6. http://classes.midlandstech.edu/carterp/Courses/bio211/chap28/chap28.htm

7. http://classes.midlandstech.edu/carterp/Courses/bio211/chap28/chap28.htm

8. By Wolfgang Moroder

9. Hypoechoic myometrium Subplacental clear space

10. Dot Dash

11. PLACENTAL LAKES/LACUNAE

12. PLACENTAL VOLUME Rumack4thedn

13. Placental Vascularity and Doppler ultrasound http://classes.midlandstech.edu/carterp/Courses/bio211/chap28/chap28.htm

14. CHORIOAMNIOTIC SEPARATION

15. PLACENTAL ABNORMALITIES Placenta previa Placenta accreta Abruptio placenta Placental infarction Placental masses Morphologic abnormalities

16. PLACENTA PREVIA Implantation in LUS. Normally – 2 cms from the OS. Incidence – 0.5% Bleeding – Hallmark Accurate diagnosis – vital. not before 15 weeks. Trans abdominal, if unclear Transvaginal.

17. Complete placenta previa http://radiopaedia.org/articles/placenta-previa

18. Marginal placenta

19. Low lying placenta

20. Placenta accreta: Definition: Chorionic villi attach to myometrium . Villi invade past maternal decidua layer . Types : Accreta - Attaches to myometrium. Doesn’t invade. Increta –Invades into myometrium. Percreta – Invades past uterine serosa into organs. http://embryology.med.unsw.edu.au/Notes/placenta2.htm

21. Risk Factors: Prior uterine surgery. Placenta previa. Unexplained elevated MS-AFP levels. Advancing maternal age. Clinical Manifestations: Profuse haemorrhage after delivery. Inability to separate placenta from uterus. Life-threatening.

22. Sonographic findings : Coexisting placenta previa- adherent portion low in uterus. Loss of normal hypoechoic retroplacental-myometrial interface. Thinning or disruption of the hyperechoic sub vesicular uterine serosa. Presence of focal exophytic masses. Numerous placental lakes. Color doppler findings: Diffuse lacunar blood flow, Dilated vascular channels Absence of normal subplacenal venous flow Demonstration of vessels crossing the placental- myometrial disruption site.

23. Placental infarction: Focal or throughout. – Vascular etiology. Maternal floor infarction- Fibrinoid deposition. Infarcts >3 cms – perinatal mortality . Focal

24. Sonographic findings : Hyperechoic placental mass or placental thickening. Subchorionic cysts. Infarctions due to maternal vascular disease – echogenic, rimmed cystic lesions within placenta. Early identification – Anticoagulation therapy with heparin .

25. Chorioangioma: Most common benign tumor – 1% Most are asymptomatic. Large (>5cms)– High output fetal cardiac failure, Anemia, Hydrops and death. Well circumscribed solid tumours. Hypoechoic to hyperechoic. Color/power doppler –Increased flow. Interventions – Injection of thrombogenic material Microcoil embolization. Endoscopic laser devascularization.

26. Morphologic placental abnormalities: Circumvallate placenta: Chorionic plate( fetal surface) is smaller than basal plate (surface interacting the uterus) Rolling and shouldering of the placental margins. Complete(rare) – Adverse neonatal outcomes. Partial- Quite common.

27. Succenturiate lobe/accessory lobe: Single or multiple in addition to main lobe. Incidence – 6% Concern- Retained accessory lobe. Vascular connection b/n main and accessory lobe

28. Bilobed placenta: Two similar sized placental lobes with vascular connection. Umbilical cord - might insert into the membranes between lobes. Complications: Vasaprevia. Post partum hemorrhage.

29. Umbilical cord: Length: Cord length varies. Extremes of length – short, excessive cord length. Diameter : Marker for chromosomal abnormalities. 1 st trimester – Cord diameter = Fetal size. Small diameter- Pregnancy loss. 2 nd and 3 rd trimester- Whartons’s jelly – largest contributer Area of Wharton's jelly – fetal biometry upto 32 wks. Larger cord- aneuploidy. Thin cord – IUGR.

30. Absent umbilical cord twists/uncoiled cord: Single umbilical arteries Multiple gestations Fetal demise Preterm delivery Aneuploidy Marginal/ velamentous insertion

31. Umbilical cord cysts: All cord cysts – Associated with structural and chromosomal defect. So a detailed structural survey needed. Cysts in 1 st trimester – resolve without sequelae. Trisomies 13 and 18 – most common anomalies.

32. Cord insertion into placenta: Velamentous insertion : Into membranes. Not into disc. Incidence – 1%. Risks: IUGR, Preterm delivery, congenital anomalies Low Apgar scores, neonatal death & retained placenta.

33. Marginal cord insertion: Humpath.com - Human pathology 7% of all singleton. Not associated with IUGR or preterm delivery. Vasa previa.

34. Vasa previa: Cord vessels overlying internal os. Small amount of blood loss –fetal death. Velamentous and marginal cord insertions. Sonographically: Fetal vessel identified overlying os. Pulsed wave doppler identifies fetal artery 3D power doppler assists in identifying. Not to equate cord in the LUS or overlying the cervix Freely floating. Careful attention to detail and follow-up might be needed.

35. Retained products of conception: Abnormal bleeding. Risks: 2 nd trimester spontaneous abortion Extreme preterm birth MTP Placenta accreta. Sonographically: Echogenic endometrial mass Lack of flow doesn’t exclude RPOC Calcifications in mass- Highly suggestive of RPOC.

36. CONCLUSION: Multiple placental abnormalities can be detected on prenatal sonography. Basic anatomy and physiology of the placenta should be understood so that abnormal findings can be acknowledged to achieve best possible outcome for the mother and baby.

37. Rumack 4 th Edition- Diagnostic ultrasound. www.rsna.org Placenta Accreta:Spectrum of US and MR Imaging Findings1, W. Christopher Baughman, MD • Jane E. Corteville , MD • Rajiv R. Shah, MD. Humpath.com - Human pathology – Placenta Specimens. www.radiopedia.org . http://classes.midlandstech.edu/carterp/Courses/bio211/chap28/chap28.htm - Embryology slides. References:

38. THANK YOU