Manual of Pathology of the Human Placenta (eBook)

Rebecca N. Baergen, MD is Professor of Clinical Pathology and Laboratory Medicine and the Chief of Perinatal and Pediatric Pathology, Weill-Medical College of Cornell University and New York-Presbyterian Hospital, New York NY.

Manual of Pathology of the Human Placenta 3
Foreword 7
Preface to the First Edition 9
Preface to the Second Edition 11
Contents 13
Section I:Approach to the Specimen 15
Chapter 1: Evaluation of the First-Trimester Products of Conception 16
General Considerations 16
Macroscopic Examination 17
Cytogenetics, Flow Cytometry, and Other Special Studies 19
Submission of Microscopic Sections 21
Microscopic Examination 22
Therapeutic or Induced Abortion 22
Spontaneous Abortions 23
Suggestions for Examination and Report 24
Selected References 25
Chapter 2: Evaluation of the Second-Trimester Products of Conception 26
General Considerations 26
Macroscopic Examination and Description 27
Special Procedures 30
Submission of Microscopic Sections 31
Microscopic Description, Diagnosis, and Report 33
Selected References 33
Chapter 3: Macroscopic Evaluation of the Second- and Third-Trimester Placenta 35
Selection of Placentas for Pathologic Examination 35
Examination of All Placentas 36
Selection Based on Consensus Indications 36
Initial Selection with Storage of Remaining Placentas 36
Gross Examination of All Placentas with Microscopic Examination on Selected Placentas 36
Storage 37
Macroscopic Examination 37
Instruments 37
Procedure for Examination 39
Normal Macroscopic Appearance 42
Suggested Gross Description 45
Submission of Microscopic Sections 45
Fixation 46
Special Procedures 46
Selected References 54
Chapter 4: Microscopic Evaluation of the Second- and Third-Trimester Placenta 55
Approach to the Specimen 55
Routine and Special Stains 57
Immunohistochemical Markers 58
Selected References 67
Section II:Development and Normal Histology 68
Chapter 5: Early Placental Development 69
General Considerations 69
Prelacunar Stage: Day 1–8 Postconception 69
Lacunar Stage: Day 8–13 Postconception 71
Primary Chorionic Plate 71
Lacunar System 72
Trophoblastic Shell 72
Early Villous Stage: Day 13–28 Postconception 72
Second Month and Beyond 73
Development of the Fetal Membranes 74
Development of the Umbilical Cord 77
Selected References 78
Chapter 6: Chorionic Villi: Histology and Villous Development 79
Histology 79
Syncytiotrophoblast 80
Syncytial Knots, Sprouts, and Bridges 82
Villous Cytotrophoblast (Langhans’ Cells) 84
Villous Stroma 84
General Considerations of Villous Development and Villous Types 85
Mesenchymal Villi 87
Immature Intermediate Villi 88
Stem Villi 89
Mature Intermediate Villi 90
Terminal Villi 91
Selected References 92
Chapter 7: Overview and Microscopic Survey of the Placenta 94
Introduction 94
Overview and Microscopic Survey of First-Trimester Placenta 95
Overview and Microscopic Survey of Second- and Third-Trimester Placenta 98
Chorionic Plate 101
Villous Structures 102
Nonvillous Structures 103
Basal Plate 106
Marginal Zone 108
Anatomy of the Intervillous Space 110
Calcification, Mineralization, and Pigment 110
Fetal Membranes 112
Amnion 113
Chorion Laeve 114
Trophoblast Layer 115
Decidua 115
Structure and Histology of the Umbilical Cord 115
Umbilical Vessels 116
Selected References 116
Chapter 8: Extravillous Trophoblast, Trophoblastic Invasion, and Fibrinoid 118
General Considerations 118
Extravillous Trophoblast 118
Trophoblastic Stem Cells 120
Proliferative Phenotype 121
Invasive Phenotype 121
Interstitial Phenotype 122
Multinucleated Extravillous Trophoblast 123
Decidua 123
Fibrinoid 125
Uteroplacental Vessels and Physiologic Conversion 126
Selected References 127
Section III:Multiple Gestation 128
Chapter 9: Multiple Gestation: General Aspects 129
General Considerations 129
Zygosity 130
Incidence 130
Twin Placentation 130
Pathogenesis 133
Clinical Features and Implications 134
Examination of the Placenta in Multiple Gestation 135
Gross Examination 135
Examination of Vascular Anastomoses 138
Diamnionic–Dichorionic Twin Placenta 140
Diamnionic–Monochorionic Twin Placenta 140
Monoamnionic–Monochorionic Twin Placenta 141
Suggestions for Examination and Report 146
Selected References 146
Chapter 10: Multiple Gestation: Twin Variants and Related Conditions 148
Vanishing Twin and Fetus Papyraceous 148
Clinical Features and Implications 148
Pathogenesis 149
Pathologic Features 149
Suggestions for Examination and Report 149
Acardiac Twins 150
Pathogenesis 152
Pathologic Features 153
Clinical Features and Implications 153
Suggestions for Examination and Report 155
Conjoined Twins 155
Pathogenesis 155
Pathologic Features 156
Suggestions for Examination and Report 157
Twin Variants 158
Triplets and Higher Multiple Births 159
Suggestions for Examination and Report 160
Twin-to-Twin Transfusion 160
Chronic Twin-to-Twin Transfusion 160
Pathogenesis 160
Pathologic Features 161
Clinical Features and Implications 162
Treatment Considerations 165
Acute Twin-to-Twin Transfusion 165
Pathogenesis 165
Clinical Features and Implications 166
Acute on Chronic Twin-to-Twin Transfusion 166
Suggestions for Examination and Report 166
Chimerism and Mosaicism 167
Heterokaryotypic Monozygotic Twins 167
Sacrococcygeal Teratoma and Epignathus 168
Selected References 168
Section IV:Abnormalities of the Placenta 170
Chapter 11: Abortion and the Placenta in Chromosomal Anomalies 171
General Considerations 171
Induced Abortions 172
Clinical Features and Implications 172
Pathologic Features 173
Spontaneous Abortions 175
Pathogenesis 176
Clinical Features and Implications 176
Pathologic Features 177
Recurrent or Habitual Abortion 180
Chromosomal Anomalies 180
Trisomies 180
Other Chromosomal Anomalies 182
Ancillary Testing 184
Suggestions for Examination and Report 186
Confined Placental Mosaicism, Uniparental Disomy, and Imprinting 186
Confined Placental Mosaicism 187
Uniparental Disomy 187
Imprinting 187
Selected References 188
Chapter 12: Postpartum Hemorrhage, Subinvolution of the Placental Site, and Placenta Accreta 190
General Considerations 190
Uterine Atony 191
Pathogenesis 191
Pathologic Features 191
Suggestions for Examination and Report 193
Retained Placental Tissue and Involution of the Placental Site 193
Normal Involution of the Placental Site 193
Subinvolution of the Placental Site 195
Pathogenesis 195
Pathologic Features 195
Suggestions for Examination and Report 196
Postpartum Endometritis 196
Suggestions for Examination and Report 196
Placenta Accreta, Placenta Increta, and Placenta Percreta 197
Clinical Features and Implications 197
Pathogenesis 198
Pathologic Features 199
Pitfalls in Diagnosis: 201
Suggestions for Examination and Report 203
Placental Polyp 204
Suggestions for Examination and Report 204
Involution of a Retained Placenta 205
Suggestions for Examination and Report 205
Selected References 207
Chapter 13: Placental Shape Aberrations 208
General Considerations 208
The Multilobate Placenta 209
The Bilobed Placenta 209
Succenturiate Lobes (Accessory Lobes, Placenta Succenturiata) 209
Pathogenesis 209
Clinical Features and Implications 211
Suggestions for Examination and Report 212
Circumvallate and Circummarginate Placentas 212
Pathologic Features 212
Clinical Features and Implications 213
Pathogenesis 215
Extramembranous Pregnancy 216
Pathogenesis 216
Pathologic Features 217
Clinical Features and Implications 217
Suggestions for Examination and Report 218
Placenta Membranacea (Placenta Diffusa) 219
Suggestions for Examination and Report 219
Miscellaneous Shape Abnormalities 220
Placenta Previa 221
Pathogenesis 221
Pathologic Features 221
Clinical Features and Implications 222
Suggestions for Examination and Report 222
Selected References 222
Chapter 14: Pathology of the Fetal Membranes 224
Cysts and Tumors 224
Pathologic Features 224
Pathogenesis 228
Clinical Features and Implications 228
Suggestions for Examination and Report 228
Embryonic Remnants 228
Vernix Caseosa 230
Hematomas and Breus’ Mole 231
Subamnionic Hematoma 231
Retromembranous Hematoma 233
Subchorionic Hematoma and Breus’ Mole 233
Pathologic Features 233
Clinical Features and Implications 234
Suggestions for Examination and Report 235
Meconium and Other Pigments 236
Pathologic Features 236
Pathogenesis 239
Clinical Features and Implications 239
Suggestions for Examination and Report 241
Gastroschisis 241
Squamous Metaplasia 242
Amnion Nodosum 242
Pathogenesis 242
Pathologic Features 243
Clinical Features and Implications 243
Suggestions for Examination and Report 245
Amnionic Bands 245
Pathogenesis 245
Pathologic Features 246
Clinical Features and Implications 249
Suggestions for Examination and Report 251
Selected References 251
Chapter 15: Pathology of the Umbilical Cord 252
Embryonic Remnants 252
Allantoic Duct Remnants 252
Pathogenesis 252
Pathologic Features 253
Clinical Features and Implications 253
Omphalomesenteric Duct Remnants 253
Pathogenesis 253
Pathologic Features 254
Clinical Features and Implications 254
Suggestions for Examination and Report 255
Umbilical Cord Coiling, Torsion, and Stricture 256
Pathogenesis 256
Pathologic Features 256
Clinical Features and Implications 258
Suggestions for Examination and Report 259
Umbilical Cord Length 259
Pathologic Features 259
Pathogenesis 260
Clinical Features and Implications 260
Cord Diameter 261
Suggestions for Examination and Report 262
Cord Entanglement and Cord Prolapse 263
Clinical Features and Implications 263
Pathologic Features 264
Umbilical Cord Knots 264
Pathologic Features 264
Clinical Features and Implications 265
Suggestions for Examination and Report 267
Cord Insertion 267
Velamentous and Marginal Cord Insertion 267
Pathologic Features 267
Pathogenesis 272
Clinical Features and Implications 272
Furcate Cord Insertion 272
Interpositional Cord Insertion 273
Suggestions for Examination and Report 273
Single Umbilical Artery 273
Pathologic Features 273
Clinical Features and Implications 274
Pathogenesis 275
Supernumerary Vessels 275
Suggestions for Examination and Report 275
Thrombosis of Umbilical Vessels 275
Pathologic Features 275
Pathogenesis 276
Clinical Features and Implications 277
Suggestions for Examination and Report 277
Tumors 277
Hemangiomas 277
Teratomas 278
Miscellaneous Cord Lesions 278
Suggestions for Examination and Report 282
Selected References 282
Section V:Disease Processes and the Placenta 283
Chapter 16: Infectious Diseases 284
General Considerations 284
Ascending Infection and Acute Chorioamnionitis 285
Pathogenesis 285
Acute Chorioamnionitis and Preterm Delivery 286
Incompetent Cervix 286
“Clinical” Acute Chorioamnionitis 287
Pathologic Features 287
Maternal Response, Fetal Response, and Fetal Infection 290
Subacute Chorioamnionitis 293
Suggestions for Examination and Report 294
Specific Microorganisms 294
Group B Streptococcus 295
Clinical Features and Implications 295
Pathologic Features 295
Listeriosis 296
Clinical Features and Implications 296
Pathogenesis 296
Pathologic Features 296
Escherichia coli 297
Fusobacterium 298
Clostridia 298
Mycoplasma 299
Chlamydia 299
Bacterial Vaginosis 300
Candida Species 300
Clinical Features and Implications 300
Pathologic Features 300
Suggestions for Examination and Report 302
Chronic Villitis 302
Syphilis 302
Pathogenesis 302
Pathologic Features 302
Cytomegalovirus 304
Clinical Features and Implications 304
Pathogenesis 305
Pathologic Features 305
Herpes Simplex Virus 307
Pathogenesis 307
Pathologic Features 307
Clinical Features and Implications 307
Parvovirus B19 307
Clinical Features and Implications 307
Pathologic Features 309
Mycobacteria 310
Toxoplasma 310
Pathogenesis 310
Clinical Features and Implications 311
Pathologic Features 311
Malaria 312
Pathogenesis 312
Clinical Features and Implications 312
Pathologic Features 312
Suggestions for Examination and Report 313
Villitis of Unknown Etiology 313
Pathogenesis 313
Pathologic Features 314
Clinical Features and Implications 316
Suggestions for Examination and Report 316
Chronic Chorioamnionitis 316
Suggestions for Examination and Report 317
Chronic Intervillositis 317
Suggestions for Examination and Report 318
Selected References 322
Chapter 17: Maternal Diseases Complicating Pregnancy 323
General Considerations 323
Connective Tissue Disorders 324
Renal Disease 324
Liver Disease 325
Cardiac Disease 326
Hematologic Disorders 326
Sickle Cell Anemia 326
Clinical Features and Implications 326
Pathologic Features 326
Other Hematologic Disorders 327
Thyroid Disease 328
Diabetes Mellitus 328
Clinical Features and Implications 328
Pathologic Features 329
Miscellaneous Conditions 330
Maternal Drug Use 331
Tobacco 331
Clinical Features and Implications 331
Pathogenesis 331
Pathologic Features 331
Alcohol 331
Cocaine 331
Miscellaneous Therapeutic Medications 332
Suggestions for Examination and Report 332
Selected References 335
Chapter 18: Placental Malperfusion 337
General Considerations 337
Preeclampsia and Gestational Hypertension 338
Clinical Features and Implications 338
Pathologic Features 339
Decidual Vascular Changes 339
Infarcts 343
Abruptio Placentae 346
Villous Maldevelopment and Syncytial Knotting 346
Villous Maldevelopment and Hypoxia: 348
Terminal Villus Deficiency: Villous Hypoplasia: 348
Other Placental Changes in Preeclampsia 349
Pathogenesis 351
Lupus Erythematosus 351
Clinical Features and Implications 351
Pathologic Features 352
Lupus Anticoagulant and Antiphospholipid Antibodies 352
Clinical Features and Implications 352
Pathologic Features 353
Thrombophilias 353
Clinical Features and Implications 353
Pathologic Features 354
Suggestions for Examination and Report 354
Selected References 354
Chapter 19: Miscellaneous Placental Lesions 356
Intervillous Thrombi 356
Pathogenesis 356
Pathologic Features 357
Suggestions for Examination and Report 359
Intravillous Hemorrhage 359
Suggestions for Examination and Report 359
Retroplacental Hematoma and Abruptio Placentae 360
Pathogenesis 360
Clinical Features and Implications 360
Pathologic Features 361
Suggestions for Examination and Report 363
Chorangiosis and Chorangiomatosis 363
Chorangiosis 364
Pathologic Features 364
Pathogenesis 365
Clinical Features and Implications 365
Suggestions for Examination and Report 366
Chorangiomatosis 366
Sec18_19 366
Suggestions for Examination and Report 366
Fibrinoid Deposition 367
Normal Perivillous Fibrinoid 367
Maternal Floor Infarction and Massive Perivillous Fibrin Deposition 368
Pathogenesis 368
Pathologic Features 369
Clinical Features and Implications 370
Suggestions for Examination and Report 376
Placental Mesenchymal Dysplasia 373
Clinical Features and Implications 373
Pathogenesis 374
Pathologic Features 374
Suggestions for Examination and Report 372
Villous Edema and Villous Immaturity 376
Suggestions for Examination and Report 376
Selected References 377
Chapter 20: Placental Abnormalities in Fetal Conditions 379
Hydrops Fetalis 379
Immune Hydrops 380
Pathogenesis 380
Pathologic Features 380
Clinical Features and Implications 382
Hematologic Disorders 383
Clinical Features and Implications 383
Pathologic Features 384
Trauma 384
Miscellaneous Causes of Fetal Hydrops 385
Suggestions for Examination and Report 386
Fetomaternal Hemorrhage 386
Pathogenesis 386
Pathologic Features 386
Clinical Features and Implications 387
Suggestions for Examination and Report 389
Fetal Nucleated Red Blood Cells 389
Suggestions and Examples for Report 389
Transplacental Passage of Cellular Elements 390
Fetal Metabolic Storage Disorders 390
Pathologic Features 390
Specific Disorders 392
Suggestions for Examination and Report 393
Placental Changes in Intrauterine Fetal Demise 393
Suggestions for Examination and Report 396
Selected References 399
Chapter 21: Fetal Thrombotic Vasculopathy 401
General Considerations 401
Thrombosis in the Fetal Circulation 402
Pathologic Features 402
Thrombosis 402
Avascular Villi 402
Intimal Fibrin Cushions 403
Fibromuscular Sclerosis 404
Hemorrhagic Endovasculopathy: Villous Stromal Karyorrhexis 405
Pathogenesis 408
Clinical Features and Implications 411
Suggestions for Examination and Report 412
Selected References 412
Section VI: Neoplasms and GestationalTrophoblast Disease 413
Chapter 22: Neoplasms 414
General Considerations 414
Primary Placental Neoplasms 414
Chorangioma (Angioma) 414
Pathogenesis 414
Pathologic Features 415
Clinical Features and Implications 419
Chorangiocarcinoma 419
Suggestions for Examination and Report 420
Leiomyoma 420
Endometrial Stromal Lesions 420
Teratomas Versus Acardiac Twinning 420
Hepatocellular Adenoma 421
Heterotopia 421
Suggestions for Examination and Report 421
Maternal Neoplasms Metastatic to the Placenta 421
Clinical Features and Implications 421
Pathologic Features 422
Suggestions for Examination and Report 423
Fetal Neoplasms Metastatic to the Placenta 423
Malignant Fetal Tumors 423
Benign “Metastatic” Lesions 425
Suggestions for Examination and Report 425
Selected References 425
Chapter 23: Hydatidiform Moles 426
General Considerations 426
Hydatidiform Moles 427
Pathogenesis 427
Incidence and Epidemiologic Factors 429
Complete Hydatidiform Moles 430
Pathologic Features 430
Embryonic and Fetal Tissue in Complete Hydatidiform Moles 432
Clinical Features and Implications 433
Early Complete Hydatidiform Moles 435
Biparental Complete Hydatidiform Moles 435
Ectopic Molar Pregnancy 436
Partial Hydatidiform Mole 436
Pathologic Features 436
Clinical Features and Implications 437
Differential Diagnosis 437
Hydropic Abortus Versus Partial Mole 438
Partial Mole Versus Complete Mole 438
Early Mole Versus Hydropic Abortus Versus Partial Mole 439
Partial Mole Versus Twin Pregnancy with Complete Mole 439
Ancillary Testing 440
Suggestions for Examination and Report 441
Invasive Hydatidiform Mole 442
Pathogenesis 442
Pathologic Features 442
Clinical Features and Implications 442
Suggestions for Examination and Report 443
Selected References 445
Chapter 24: Choriocarcinoma 446
General Considerations 446
Clinical Features and Implications 446
Pathologic Features 448
Metastasis 451
Choriocarcinoma-In Situ: Placental Choriocarcinoma 451
Pathogenesis 451
Pathologic Features 452
Clinical Features and Implications 454
Suggestions for Examination and Report 455
Selected References 456
Chapter 25: Lesions of Extravillous Trophoblast 457
General Considerations 457
Placental-Site Nodule 458
Clinical Features and Implications 458
Pathologic Features and Pathogenesis 458
Exaggerated Placental Site 460
Clinical Features and Implications 460
Pathologic Features 460
Placental-Site Trophoblastic Tumor 461
Clinical Features 461
Pathologic Features 461
Clinical Implications 464
Differential Diagnosis 465
Differential Diagnosis: PSTT Versus Lesions of EVT 466
Differential Diagnosis: PSTT Versus Choriocarcinoma 466
Differentiation of PSTT from Other Tumors 467
Epithelioid Trophoblastic Tumor 467
Clinical Features and Implications 467
Pathologic Features 467
Extrauterine Lesions of Extravillous Trophoblast 467
Suggestions for Examination and Report 468
Selected References 470
Section VII: Legal Considerationsand New Directions 471
Chapter 26: Legal Considerations 472
General Considerations 472
The Placenta in Litigation 473
Twinning Problems 474
Inflammatory Processes 475
Acute Chorioamnionitis 475
Chronic Villitis 475
Vascular Abnormalities 476
Fetal Thrombotic Vasculopathy 476
Umbilical Cord 477
Meconium – the “Green” Placenta 477
Uteroplacental Malperfusion 478
Abruptio Placentae 478
Infarcts 479
Miscellaneous 479
Maternal Floor Infarction – Massive Perivillous Fibrin Deposition 479
Chorangiosis 480
Nucleated Red Blood Cells 480
Placental Pallor 480
Villous Changes 481
Timing of Fetal Death 481
Conclusion 482
Selected References 482
Chapter 27: New Directions: What is New in Placental Studies? 483
References 489
Appendix AAbbreviations and Definitions 491
Appendix B 495
Index 520