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Objective: The value of using customized birth-weight centiles to improve the diagnostic accuracy for fetal growth restriction (FGR), in comparison with using population-based charts, remains a matter of debate. One potential explanation for the conflicting data is that most studies used measures of perinatal mortality and morbidity as proxies for placenta-mediated FGR, many of which are not specific and may be confounded by other factors such as prematurity. The aim of this study was to compare the diagnostic accuracy of small-for-gestational age (SGA) at birth, defined according to customized vs population-based charts, for associated abnormal placental pathology., Methods: This was a secondary analysis of data from a prospective cohort study on risk factors for placenta-mediated complications and abnormal placental pathology in low-risk nulliparous women. All placentae were sent for detailed histopathological examination by two perinatal pathologists. The primary exposure was SGA, defined as birth weight < 10 th centile for gestational age using either a customized (SGA cust ) or a population-based (SGA pop ) birth-weight reference. The outcomes of interest were one of three types of abnormal placental pathology associated with FGR: maternal vascular malperfusion (MVM), chronic villitis and fetal vascular malperfusion (FVM). Adjusted relative risks (aRR) with 95% CIs were estimated using modified Poisson regression analysis, with adjustment for smoking, body mass index and aspirin treatment., Results: A total of 857 nulliparous women met the study criteria. The proportions of infants identified as SGA based on the customized and population-based charts were 12.6% (108/857) and 11.4% (98/857), respectively. A diagnosis of SGA using either customized or population-based charts was associated with an increased risk of any placental pathology (aRR, 3.04 (95% CI, 2.29-4.04) and 1.60 (95% CI, 1.10-2.31), respectively) and MVM pathology (aRR, 12.33 (95% CI, 6.60-23.03) and 5.29 (95% CI, 2.87-9.76), respectively). SGA cust , but not SGA pop , was also associated with an increased risk for chronic villitis (aRR, 1.85 (95% CI, 1.07-3.18)) and FVM pathology (aRR, 2.48 (95% CI, 1.25-4.93)). SGA cust had a higher detection rate for any placental pathology (30.3% vs 17.1%; P < 0.001), MVM pathology (63.2% vs 39.5%; P = 0.003) and chronic villitis (20.8% vs 8.3%; P = 0.007) than did SGA pop , for a similar false-positive rate. This was mainly the result of a higher detection rate for abnormal pathology in the white and East-Asian subgroups and a lower false-positive rate for abnormal pathology in the South-Asian subgroup by SGA cust than by SGA pop . In addition, pregnancies in the SGA cust group, but not those in the SGA pop group, were more likely to be complicated by preterm birth and a low 5-min Apgar score than were the corresponding non-SGA group., Conclusion: These findings suggest that customized birth-weight centiles may be superior to population-based birth-weight centiles in detecting FGR that is due to underlying placental disease. © 2020 International Society of Ultrasound in Obstetrics and Gynecology., (© 2020 International Society of Ultrasound in Obstetrics and Gynecology.)

Background: Placental mesenchymal dysplasia (PMD) is a rare vascular and connective placental anomaly, which is often associated with severe fetal and/or maternal complications. The diversity of presentation of PMD challenges diagnosis and effective pregnancy management., Objective: We aimed to review cases presenting at 7 tertiary centers worldwide over the last decade and to study the occurrence of obstetric and neonatal complications., Study Design: Pathology databases from 7 tertiary hospitals were screened for cases of PMD (between 2007-2017). Pregnancy history, outcomes and ultrasound images were then reviewed for each case., Results: Twenty-two cases of PMD were identified. Mean gestational age at diagnosis was 23 weeks (16-39 weeks). Prenatal biochemical screening was abnormal in 8 cases (36%). Of the 12 cases that underwent invasive genetic testing, 4 were abnormal. Six patients (27%) developed maternal complications (preeclampsia/gestational hypertension). Fetal growth restriction was identified in 11 cases (50%) and fetal death in 4 (18%). Four (18%) pregnancies were terminated, 9/14 (64%) delivered preterm and only three (14%) progressed normally. Fourteen babies were born alive; 5 (35%) died in the first sixty-one days after birth, 5 (35%) had transient thrombopenia and 1 (7%) had developmental delay at last follow-up. Our series identified four potential new associations with PMD: placental triploidy mosaicism, CHARGE syndrome, fetal pleuropulmonary blastoma and fetal skeletal dysplasia., Conclusions: PMD was substantially under-diagnosed before delivery in this cohort. Sonographers, fetal medicine specialists, obstetricians and pathologists should all suspect PMD in cases of an enlarged placenta and should look for fetal abnormalities. Diagnostic genetic testing should be discussed to exclude partial molar pregnancy. Close pregnancy follow-up is indicated due to the high risk of associated fetal or maternal adverse outcomes., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Introduction: Although early and late fetal growth restriction have been suggested to be distinct entities, the optimal gestational age cut-off that differentiates the two conditions is currently unclear and has been arbitrarily set in previous studies between 32 and 37 weeks. We aimed to use placental pathology findings to determine that optimal gestational age cut-off between early and late fetal growth restriction., Material and Methods: A retrospective cohort study of all women with singleton gestation who gave birth to a neonate diagnosed as small-for-gestational age (small-for-gestational age, defined as birthweight <10th percentile for gestational age) at a tertiary referral center between January 2001 and December 2015, and for whom placental pathology was available. Placental abnormalities were classified into lesions associated with maternal vascular malperfusion (MVM), fetal vascular malperfusion, placental hemorrhage and chronic villitis. Placental findings were analyzed as a function of gestational age at birth. The analysis was repeated in the subgroups of women without hypertensive complications of pregnancy (to reflect changes associated with isolated small-for-gestational age) and of neonates with severe small-for-gestational age (defined as birthweight <5th percentile), which are more likely to represent true fetal growth restriction., Results: A total of 895 women met the inclusion criteria. The only histological finding that changed with gestational age was MVM pathology, which decreased in frequency with increasing gestational age. We identified a considerable drop in the rate of MVM lesions at 33 weeks of gestation. The rate of MVM pathology in placentas of infants born before 33 0/7  weeks was significantly higher than that observed in placentas of infants born at 33 0/7  weeks or longer: 71.6% vs 27.4%, P < 0.001 for ≥2 MVM lesions, and 35.5% vs 3.5%, P < 0.001 for ≥3 MVM lesions. These findings persisted in the subgroups of women without hypertensive complications of pregnancy (n = 662) and of neonates with severe small-for-gestational age (n = 464)., Conclusions: Using placental pathology as a direct measure of the mechanisms underlying fetal growth restriction, the optimal gestational age at birth cut-off which differentiates early from late fetal growth restriction appears to be 33 0/7  weeks., (© 2018 Nordic Federation of Societies of Obstetrics and Gynecology.)

Introduction: In singletons, the pathogenesis of hypertensive disorders of pregnancy (HDP) is attributed to abnormal placentation, characterized by maternal vascular malperfusion (MVM) lesions. Whether MVM plays a similar role in twin pregnancies is unclear. The purpose of the study was to compared placental pathology findings between dichorionic-twin and singleton pregnancies complicated by HDP., Methods: Retrospective cohort study of women with dichorionic-twin or singleton pregnancies complicated by HDP who gave birth in a single tertiary center between 2001 and 2015. Placental abnormalities were classified into lesions associated with MVM, fetal vascular malperfusion, placental hemorrhage and chronic villitis. Placental findings and neonatal outcomes were compared between twin and singleton pregnancies., Results: A total of 144 women with twins and 768 women with a singleton pregnancy met the inclusion criteria. Compared with HDP singletons, twins with HDP had higher mean birth weights, were less likely to be small for gestational age and be born at <34 and at <32 weeks. Twins had lower odds for placental weight below <10th percentile (aOR 0.49, 95%CI 0.33-0.71), for MVM pathology (aOR 0.28, 95%CI 0.20-0.39) and for fetal vascular malperfusion pathology (aOR 0.65, 95%CI 0.45-0.93). These finding remained significant in the subpopulation of early onset HDP (<34 weeks) and small for gestational newborn., Discussion: Our findings support the hypothesis that MVM are less relevant to the pathogenesis of HDP in twin pregnancies and suggest that other placental or non-placental factors are responsible for the increased risk of HDP in twin pregnancies., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Purpose: Invasive placentation is one of the most important causes of postpartum hemorrhage and Cesarean hysterectomies (CHyst). The optimal mode of anesthesia in the management of these patients remains uncertain. The purpose of this study was to review the impact of mode of anesthesia on maternal and neonatal outcomes in women with invasive placentation undergoing Cesarean delivery (CD)., Methods: A retrospective cohort study was conducted in women with invasive placentation who delivered at our hospital during 2000-2012. Patients' charts and electronic health records were searched for relevant data, including obstetric and anesthetic procedures, blood loss, use of resuscitation fluids, and neonatal and maternal complications. Based on the initial planned mode of anesthesia (i.e., general or regional) for CD, comparisons were made between groups for maternal blood loss and transfusion, respiratory complications, and neonatal Apgar scores., Results: Of the 50 women with confirmed invasive placentation, 25 (50%) underwent elective CD, while the remaining 25 (50%) had unplanned CD; 36 (72%) required CHyst. Surgery for 34 (68%) patients commenced under regional anesthesia (RA), and surgery for 16 (32%) patients commenced under general anesthesia (GA). In women who received GA vs RA, there was no difference in mean (SD) blood loss [3,206 (3,777) mL vs 1,906 (1096) mL, respectively; mean difference, 1,300 mL; 95% confidence interval (CI), -739 to 3,339 mL; P = 0.20] or median [IQR] blood transfusion (4 [0-6] units vs 2 [0-4] units, respectively; median difference, 2 units; 95% CI, 0 to 4 units; P = 0.16). In neonates of women who received only RA before delivery vs those who received GA prior to delivery, significantly higher median [IQR] Apgar scores were observed at both one minute (8 [8-9] vs 3 [0-5], respectively; median difference, 5; 95% CI, 3 to 8; P < 0.001) and five minutes (9 [9-9] vs 7 [0-9], respectively; median difference, 2; 95% CI, 1 to 9; P < 0.001). Postoperative respiratory complications were more common with GA (6%) than with RA (0%) (P = 0.03)., Conclusion: Having safely performed two-thirds of our cases of CHyst under RA, our study suggests that RA, when compared with GA, is associated with no differences in blood loss or blood transfusion, superior neonatal outcome, and fewer respiratory complications. This suggests that RA can be considered a primary mode of anesthesia for such cases.

The placenta is the essential organ of mammalian pregnancy and errors in its development and function are associated with a wide range of human pathologies of pregnancy. Genome sequencing has led to methods for investigation of the transcriptome (all expressed RNA species) using microarrays and next-generation sequencing, and implementation of these techniques has identified many novel species of RNA including: micro-RNA, long noncoding RNA, and circular RNA. These species can physically interact with both each other and regulatory proteins to modify gene expression and messenger RNA to protein translation. Transcriptome analysis is actively used to investigate placental development and dysfunction in pathologies ranging from preeclampsia and fetal growth restriction to preterm labor. Genome-wide gene expression analysis is also being applied to identify prognostic and diagnostic biomarkers of these disorders. In this comprehensive review we summarize transcriptome biology, methods of isolation and analysis, application to placental development and pathology, and use in diagnostic analysis in maternal blood. Key information for analysis methods is organized into quick reference tables where current analysis techniques and tools are cited and compared. We have created this review as a practical guide and starting reference for those interested in beginning an investigation into the transcriptome of the placenta., (Crown Copyright © 2015. Published by Elsevier Inc. All rights reserved.)

Objectives: To review the association between ultrasound findings, placental pathology, and prognosis in pregnancies complicated by massive subchorionic thrombohematoma (MTH)/Breus' mole., Method: We identified 14 cases of MTH from January 2004 to December 2012. MTH was defined by >1 cm thickness hematoma and extensive (≥50%) involvement of the fetal surface of the placenta. Patient information, details of initial presentation, and perinatal outcome were obtained from the manual and electronic chart records. Ultrasound findings were related to pregnancy outcomes and associated placental pathology. Participants were stratified on the basis of birth outcome into survivors (live births, n = 7) and nonsurvivors (neonatal deaths or intrauterine fetal deaths/termination of pregnancy, n = 7)., Results: All 14 cases of MTH were suspected on ultrasound and confirmed by pathology assessment. All cases in the nonsurvivor group had abnormal umbilical artery (UA) Doppler waveforms compared with none in the survivors (p = 0.02). All cases in the nonsurvivor group had extreme preterm deliveries (p = 0.02). Birth weight was significantly reduced in the nonsurvivor group (p = 0.001), and 5/7 cases were diagnosed with severe intrauterine growth restriction, compared with none in the survivor group (p = 0.02)., Conclusion: Massive subchorionic thrombohematoma/Breus' mole may be diagnosed in the second trimester by ultrasound assessment of the placenta. Normal fetal growth and UA Doppler waveforms are associated with perinatal survival., (© 2013 John Wiley & Sons, Ltd.)

Background: Pregnancy complications such as pre-eclampsia and eclampsia, intrauterine growth restriction and placental abruption are thought to have a common origin related to abnormalities in the development and function of the placenta., Objectives: To compare, using the best available evidence, the benefits and harms of antenatal antithrombotic therapy to improve maternal or infant health outcomes in women considered at risk of placental dysfunction, when compared with other treatments, placebo or no treatment., Search Methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (17 July 2012)., Selection Criteria: Randomised controlled trials comparing antenatal antithrombotic therapy (either alone or in combination with other agents) with placebo or no treatment, or any other treatment in the antenatal period to improve maternal or infant health outcomes in women considered at risk of placental dysfunction., Data Collection and Analysis: Two review authors evaluated trials under consideration for appropriateness for inclusion and methodological quality without consideration of their results according to the prestated eligibility criteria. We used a fixed-effect meta-analysis for combining study data if the trials were judged to be sufficiently similar. We investigated heterogeneity by calculating I² statistic, and if this indicated a high level of heterogeneity among the trials included, we used a random-effects model., Main Results: Our search strategy identified 18 reports of 14 studies for consideration. The original review included five studies (484 women) which met the inclusion criteria, with a further five studies included in the updated review, involving an additional 655 women. The overall quality of the included trials was considered fair to good.Nine studies compared heparin (alone or in combination with dipyridamole or low-dose aspirin) with no treatment; and one compared trapidil (triazolopyrimidine).While this review identified the use of heparin to be associated with a statistically significant reduction in risk of perinatal mortality (six studies; 653 women; risk ratio (RR) 0.40; 95% confidence intervals (CI) 0.20 to 0.78), preterm birth before 34 (three studies; 494 women; RR 0.46; 95% CI 0.29 to 0.73) and 37 (five studies; 621 women; RR 0.72; 95% CI 0.58 to 0.90) weeks' gestation, and infant birthweight below the 10th centile for gestational age (seven studies; 710 infants; RR 0.41; 95% CI 0.27 to 0.61), there is a lack of reliable information available related to clinically relevant, serious adverse infant health outcomes, which have not been reported to date., Authors' Conclusions: While treatment with heparin for women considered to be at particularly high risk of adverse pregnancy complications secondary to placental insufficiency was associated with a statistically significant reduction in risk of perinatal mortality, preterm birth before 34 and 37 weeks' gestation, and infant birthweight below the 10th centile for gestational age when compared with no treatment for women considered at increased risk of placental dysfunction, to date, important information about serious adverse infant and long-term childhood outcomes is unavailable.

Objective: The aims of this study were to develop a nomogram of umbilical cord diameter (UCD) for pathologic examination of the placenta, to identify the umbilical cord components responsible for variations in UCD, and to examine the relationship between UCD and other placental pathologic features and perinatal outcome., Study Design: We prospectively collected 497 umbilical cords between 18 and 41 weeks' gestation over a 1-year period. Fresh-tissue UCD were grouped according to gestational age and compared to sonographic and histological measurements. Associations between UCD percentile and placental pathologic findings or obstetrical outcomes were examined., Results: Mean UCD increased with gestational age until a plateau at 1.0 cm in the third trimester, a value that was 0.56 cm less than sonographic measurements prior to delivery and 0.17 cm greater than UCD measured histologically. Umbilical cord components varied with UCD percentile, with umbilical vessel area increased in thick cords (p < 0.001) and Wharton's jelly area reduced in thin cords (p = 0.002). Thin umbilical cords were associated with at least one pathologic histological placental finding (p = 0.02), low placental weight (p < 0.001), single umbilical artery (p = 0.02), marginal cord insertion (p = 0.01), and low infant birth weight (p < 0.001)., Conclusions: This study provides reference curves for post-delivery UCD from 18 to 41 weeks' gestation for use by perinatal pathologists. We show that increased UCD is a function of increased umbilical blood vessel volume and decreased UCD is a function of decreased Wharton's jelly volume. UCD shows a strong association with placental and infant birth weight., (Crown Copyright © 2012. Published by Elsevier Ltd. All rights reserved.)

Background: Sudden infant death syndrome (SIDS) is postulated to be a developmental disorder originating during fetal life in utero. Knowledge regarding the intrauterine environment in which SIDS infants develop is, however, inadequate and how the placenta develops prior to a SIDS event has not been studied., Aim: To investigate the morphological development of the placenta obtained from full-term infants who subsequently succumbed to SIDS., Study Design: To estimate the percentage and total volumes of the chorionic villi and villous trophoblast membrane using stereological techniques., Subjects: Placentas were obtained retrospectively from normal birthweight (SIDS-NBW n=18) and small-for-gestational age (SIDS-SGA, n=14) infants who had succumbed to SIDS, and compared to either control (n=8) or SGA placentas (n=7), respectively., Results: SIDS-NBW placentas displayed evidence of augmented villous growth shown by significantly greater volumes of placental chorionic villi (gas-exchanging (GE) villi) in comparison to controls; this was not observed for SIDS-SGA placentas. However, both SIDS-NBW and SIDS-SGA placentas displayed significantly greater volumes of the cytotrophoblast (CT) (SIDS-NBW only), syncytiotrophoblast (SIDS-SGA only) and syncytial knots (SCT-K) and those displaying apoptotic syncytial nuclei (AP SCT-K). In contrast, SGA placentas displayed significantly reduced volumes of chorionic villi, GE villi and the villous trophoblast indicating a SIDS-specific effect associated with augmented placental growth., Conclusions: Our findings provide initial evidence that placental abnormality, although not necessarily causative, may precede a subset of SIDS cases supporting the hypothesis that the origins of SIDS begin during fetal life in utero., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objectives: Since pregnancies with a male fetus have higher perinatal complications attributed to placental dysfunction, including severe pre-eclampsia and intrauterine growth restriction, the objective of our study was to formally evaluate placental pathology for a placental origin of these sex-specific differences., Design: Retrospective study at Mount Sinai Hospital in Toronto, Canada. Identification of 262 singleton pregnancies affected by severe pre-eclampsia and/or intrauterine growth restriction who delivered between 22 and 32 weeks' gestation from 2000 to 2010. Detailed placental pathology was reviewed, and data from 140 pregnancies with male fetuses were compared with 122 pregnancies with female fetuses. A comparison group of 40 unaffected pregnancies who delivered in the same gestational range was used to determine baseline rates of placental pathology., Main Outcome Measured: Detailed placental pathology, including placental development/differentiation, velamentous umbilical cord insertion, maternal-fetal interface pathology, villous infarction, hemorrhagic lesions, villous development, and fetal vascular under-perfusion., Results: Impaired placental development and differentiation was equally common amongst males (73/140, 52.1%) and females (69/122, 56.6%). Male placentas exhibited significantly higher rates of chronic deciduitis (17.9% vs. 9.0%; relative risk [RR] 1.98, 95% confidence interval [CI] 1.02-3.86) and velamentous umbilical cord insertion (9.5% vs. 1.7%; RR 5.66, 95% CI 1.30-24.6), and a significantly lower frequency of villous infarction (55.4% vs. 73.7%; RR 0.75, 95% CI 0.62-0.90) than female placentas. No significant differences were noted for other lesions., Conclusions: Fetal sex exerts a differential effect on the placental pathology that mediates severe pre-eclampsia and/or IUGR. Placental pathology at birth may provide insight into the mechanisms linking adverse in utero events with long-term adult disease since, for example, a male tendency to an inflammatory pathology at the maternal-fetal interface may be linked to the excess risk of coronary artery disease., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Although in recent years placental pathology has been the subject of a wealth of detailed descriptions and diagnostic categorization, systematic correlation of these conditions with the pathology of stillbirth has not been attempted. We examine the relationship between specific inflammatory, maternal, and fetal vascular pathologies and the central nervous system pathology and histological indicators of fetal compromise. Our design was a retrospective case series of 37 3rd-trimester intrauterine fetal deaths. In general, mixed placental pathologies were the rule, with three quarters of the placentas demonstrating combinations of maternal vascular pathology, fetal vascular pathologies, umbilical cord abnormalities, or inflammatory lesions. The range of brain pathology was limited to acute, severe congestion, white matter edema, and neuronal karyorrhexis (pontosubicular necrosis with or without neuronal karyorrhexis at other sites). Established periventricular leukomalacia was present in only 2 cases. The presence of neuronal karyorrhexis or white matter gliosis was correlated with the presence of a high-grade inflammatory lesion and with fetal thymic involution. Neuronal karyorrhexis, but not white matter gliosis, correlated as well with histologically established fetal vascular lesions in the placenta, even once the effect of inflammation was accounted for. Gliosis also correlated with inflammation, meconium staining, and thymic involution. Central nervous system injury may be the end result of complex placental pathologies, and neuronal injury may be a consequence of the fetal inflammatory response. The correspondence between the time courses of histological features of chorioamnionitis, neuronal karyorrhexis, and thymic involution points to irreversible central nervous system injury being common 12-48 hours prior to in utero demise.

In contrast to thrombi and haematomas at other body sites, thrombi in the placental intervillous space are not traditionally known to undergo organisation. This report presents 11 examples of a form of organising thrombotic process that develops as a plaque on the foetal aspect of the basal plate. Originally identified in the placenta of a foetus showing severe intrauterine growth restriction, further examples of this lesion, which we term a 'basal plate plaque', show a spectrum of placental involvement. Small lesions appear to occur at points of localised stasis at the basal plate (eg, at edges of anchoring villi or in small basal plate depressions). Large areas of involvement, as seen in the original case, may be pathological markers of more generalised disturbances in placental circulation or of hypercoagulability in the intervillous space. Large basal plate plaques may therefore prove to be diagnostically significant and should be reported.

Within the placenta, most centrally placed intervillous thrombi are thought to form at sites of foetomaternal haemorrhage, while parabasally located intervillous thombi have been linked to maternal vascular disease. To determine whether parabasally located haemorrhagic lesions were morphologically heterogeneous, the authors performed a retrospective review of 25 placentas with thrombohaematomas occurring in the vicinity of the basal plate. Using morphological criteria, two lesions were distinguished: (1) the parabasally located intervillous thrombus, which had all the morphological features of more centrally located intervillous thrombi; and (2) the rounded intraplacental haematoma. Rounded intraplacental haematomas form as a result of disruption of vasculopathic decidual arterioles in a setting of maternal vascular underperfusion and are thus aetiologically distinct from classically described intervillous thrombi.

Background: Pregnancy complications such as pre-eclampsia and eclampsia, intrauterine growth restriction and placental abruption are thought to have a common origin related to abnormalities in the development and function of the placenta., Objectives: To compare, using the best available evidence, the benefits and harms of antenatal antithrombotic therapy to improve maternal or infant health outcomes in women considered at risk of placental dysfunction, when compared with other treatments, placebo or no treatment., Search Strategy: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2010)., Selection Criteria: Randomised controlled trials comparing antenatal antithrombotic therapy (either alone or in combination with other agents) with placebo or no treatment, or any other treatment in the antenatal period to improve maternal or infant health outcomes in women considered at risk of placental dysfunction., Data Collection and Analysis: Two review authors evaluated trials under consideration for appropriateness for inclusion and methodological quality without consideration of their results according to the prestated eligibility criteria. We used a fixed-effect meta-analysis for combining study data if the trials were judged to be sufficiently similar. We investigated heterogeneity by calculating I(2) statistic, and if this indicated a high level of heterogeneity among the trials included we used a random-effects model., Main Results: Our search strategy identified 14 reports of 10 studies for consideration, of which five met the inclusion criteria, involving 484 women. Four studies compared heparin (alone or in combination with dipyridamole) with no treatment; and one compared trapidil (triazolopyrimidine). While there were no statistically significant differences identified for the primary outcomes following heparin treatment, it was associated with a reduction in the risk of pre-eclampsia, eclampsia, and infant birthweight less than the 10th centile for gestational age., Authors' Conclusions: The review identified no significant differences for the primary outcomes perinatal mortality, preterm birth less than 34 weeks' gestation, and childhood neurodevelopmental handicap, although the number of studies and participants was small. While treatment with heparin appears promising with a reduction in pre-eclampsia, eclampsia, and infant birthweight less than the 10th centile for gestational age, the number of studies and participants included was small, and to date important information about serious adverse infant and long-term childhood outcomes is unavailable. Further research is required.

Massive perivillous fibrin deposition (MPFD) and maternal floor infarction (MFI) of the placenta are rare related conditions associated with poor perinatal outcome including antepartum stillbirth. The diseases are characterized by pathologic accumulation of fibrinoid deposits that surround the placental villi (in the case of MFI predominantly in the basal regions adjacent to the decidual plate). These findings suggest either overproduction and/or defective clearance of fibrinoid within the intervillous space. Recently genetic polymorphisms of the plasminogen activator inhibitor-1 (PAI-1) gene have been found in association with impaired fibrinolysis in the pelvis predisposing to endometriosis. We hypothesized that polymorphisms in one or more of four genes that regulate fibrinolysis were associated with MPFD and MFI placentas. We retrospectively identified 20 consecutive cases of MPFD/MFI from our placental pathology database and generated 2 random gestational age-matched controls for each case. Clinical charts were reviewed. DNA was extracted from archived paraffin blocks of placental tissue from cases and controls. Single nucleotide repeat polymorphisms (SNPs) in loci within PAI-1 gene, thrombin activated fibrinolysis inhibitor (TAFI) gene, plasminogen activator urokinase (u-PA) gene and plasminogen activator tissue (t-PA) gene were studied using PCR methods. Outcomes in the study group included perinatal death (8), preterm IUGR (6), preeclampsia (4) and only 3 normal term deliveries. A spectrum of placental ultrasound abnormalities was observed. No SNP polymorphism was found to associate with MPFD/MFI. MPFD/MFI are associated with significant abnormal perinatal outcomes but have not been shown to be mediated by polymorphisms in candidate genes that are predicted to impair fibrinolysis in our study.

Background: Placenta percreta, invasion of placental tissue through the uterine wall, is a rare but potentially fatal complication of pregnancy. Historically, the diagnosis was made at laparotomy, usually during Caesarean hysterectomy., Case: We describe a case of placenta percreta, in which the placenta was allowed to remain fixed to the uterine wall. Antenatal ultrasound and magnetic resonance imaging techniques were used to establish the diagnosis and guide clinical management. Elective postoperative uterine artery embolization down balloon catheters was used to prevent postpartum hemorrhage and to promote involution and shedding of the placenta. After 6 months, the uterus had involuted to the nonpregnant state., Conclusion: New diagnostic imaging techniques may be used to guide conservative management of placenta percreta, thereby maintaining fertility and avoiding hemorrhage, blood transfusion, and hysterectomy.

Objectives: To screen women with uteroplacental insufficiency between 18 and 26 weeks' gestation for sonographic evidence of destructive placental lesions, to observe the effect of low molecular-weight heparin (LMWH) in these cases, and to compare the outcome with similar but untreated controls., Methods: We screened 180 women at high risk for placental damage using 16-week maternal serum screening (alpha-fetoprotein and human chorionic gonadotropin), placental shape and texture, and uterine artery Doppler waveforms at the 18-20-week level II examination. Serial gray-scale examinations of placental texture were performed at 22, 24 and 26 weeks. LMWH was offered to women with ultrasound evidence of destructive placental lesions in the absence of intrauterine growth restriction and/or pre-eclampsia., Results: We prospectively identified six women (3.3%) with abnormal maternal serum screening and uterine artery Doppler in whom abnormal placental texture (echogenic cystic lesions) suggestive of destructive lesions in the placental parenchyma was found either at the 18-20-week ultrasound examination (n = 4), or by 26 weeks of gestation (n = 2). All six received LMWH and had live births (gestational age at delivery, 33-37 weeks; birth weight, 1000-3200 g). A further 14 women were referred with similar multiparameter evidence of placental damage at or after 26 weeks, outside the screening study. All had significant fetal growth restriction and were therefore not offered heparin. In 9/14 cases there was a perinatal death. Ischemic and/or thrombotic placental pathology was confirmed in each case, but no maternal thrombophilia disorders were identified in the 20 women., Conclusions: Integrated biochemical and ultrasound testing of placental function at 16-20 weeks of gestation, followed by serial placental gray-scale ultrasound, may be an effective method of identifying a subset of pregnancies at high risk of adverse pregnancy outcome due to destructive lesions in the placental parenchyma. This strategy of identifying thrombo-occlusive placental lesions before the development of pregnancy complications may prove useful in the design of trials to study the effectiveness of LMWH in the prevention of clinical complications resulting from thrombo-occlusive placental disease., (Copyright 2004 ISUOG. Published by John Wiley & Sons, Ltd.)

Objective: To examine the relationship between umbilical cord insertion site, placental pathology and adverse pregnancy outcome in a cohort of normal and complicated pregnancies. Methods: Sonographic measurement of the cord insertion and detailed placental pathology were performed in 309 participants. Associations between cord insertion site, placental pathology and adverse pregnancy outcome (pre‐eclampsia, preterm birth, small‐for‐gestational age) were examined. Results: A total of 93 (30%) participants were identified by pathological examination to have a peripheral cord insertion site. Only 41 of the 93 (44%) peripheral cords were detected by prenatal ultrasound. Peripherally inserted cords were associated significantly (P < 0.0001) with diagnostic placental pathology (most commonly with maternal vascular malperfusion (MVM)); of which 85% had an adverse pregnancy outcome. In cases of isolated peripheral cords, without placental pathology, the incidence of adverse outcome was not statistically different when compared to those with central cord insertion and no placental pathology (31% vs 18%; P = 0.3). A peripheral cord with an abnormal umbilical artery (UA) pulsatility index (PI) corresponded to an adverse outcome in 96% of cases compared to 29% when the UA‐PI was normal. Conclusions: This study demonstrates that peripheral cord insertion is often part of the spectrum of findings of MVM disease and is associated with adverse pregnancy outcome. However, adverse outcome was uncommon when there was an isolated peripheral cord insertion and no placental pathology. Therefore, additional sonographic and biochemical features of MVM should be sought when a peripheral cord is observed. © 2023 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

The article presents a guideline on the diagnosis and management of placenta praevia and placenta accreta. Topics include the risk factors for women with placenta praevia or a low-lying placenta, including caesarean delivery, assisted reproductive technology and maternal smoking, the role and the risks of transvaginal scanning, and optimisation of the delivery of women with placenta praevia.

Serious placental insufficiency results in perinatal death or preterm birth from ischemic-thrombotic pathology, a process which has its origins in placental maldevelopment in the first trimester. A proportion of at-risk pregnancies may be identified from abnormalities in first or second trimester serum screening data, uterine artery Doppler waveforms or placental shape and texture at the time of the 18–20-week anatomical examination. In combination, these tests may be capable of recognizing a subset of at-risk pregnancies with 50% positive predictive values. Early recognition before fetal viability affords opportunities to direct women to regional perinatal care centres for enhanced maternal–fetal surveillance, corticosteroids to enhance fetal lung maturation, prophylactic measures to prevent pre-eclampsia and optimal decision making around the time of delivery. The creation of regional screening programs to use screening data with a placental focus is likely to be cost-effective, because existing patterns of care are utilized. More importantly, this strategy can direct women to participate in clinical research programs designed to reduce morbidity and mortality from this common group of conditions. [ABSTRACT FROM AUTHOR]

Despite the increasing use of ultrasound in obstetrics, the task of accurately identifying fetuses at risk of stillbirth from chronic placental diseases continues to elude us (Kingdom et al. I Am J Obstet Gynecol i 2018;218:S803-17). They demonstrate elegantly that over a 33-year period the lower birthweight centiles for term deliveries have increased, in association with progressively higher rates of iatrogenic birth. It is only prior to 30 weeks of gestation that the relationship between stillbirth and an EFW of <5th centile is robust. [Extracted from the article]