The Placenta Its Membranes and the Umbilical Cord

The human placenta is a highly sophisticated organ of interface between mother and fetus, often referred to as the "gate-keeper to the fetus." Careful examination of the placenta, its membranes, and the umbilical cord can prove to be a valuable aid in the diagnosis and treatment of the neonate. Gross examination of the placenta takes five minutes, and more sophisticated examination should be considered when there is poor pregnancy outcome, recognizable malformations or abnormalities, multiple gestation, extremes of amniotic fluid volume, severe intrauterine growth retardation, short umbilical cord (< 32 cm), and profound acidemia. The maternal surface of the placenta (decidual plate) is soft, spongy and dark red; and the fetal surface (chorionic plate) is shiny and steel blue to gray. The placenta, membranes, and umbilical cord weigh approximately 400 to 600 g at birth. The ratio of fetal to placental size increases with gestation, being less than or equal to 1:1 at prior to three months, 4:1 at four to six months, and 6:1 at term. Abnormalities in structure can result in an inefficient transport of oxygen and nutrients to the developing baby. Despite this importance, it is one of the least understood and investigated human organs.

Common Placental Abnormalities
Figure 1.1. A succenturiate (accessory) lobe is common and has no effect on the fetus. This occurs in about 3 to 5% of deliveries. Its importance arises from the fact that it may be retained within die uterus and cause postpartum bleeding. (Sotelo-Avila, C.)
Soogdiere Die See
Figure 1.2. Anodier example of a succenturiate lobe. Note that this is very small and the diagnosis can easily be missed if die placenta is not examined carefully. (Singer, D.)
Bipartite Placenta

Figure 1.3. Fetal surface of a bipartite or bilobed placenta (placenta duplex). The two parts of die placenta are of nearly equal size and this occurs in about 1% of deliveries. Note that the lobes are separated by membranes. The umbilical cord may insert into one or other lobe, or may insert between die two.

Figure 1.3. Fetal surface of a bipartite or bilobed placenta (placenta duplex). The two parts of die placenta are of nearly equal size and this occurs in about 1% of deliveries. Note that the lobes are separated by membranes. The umbilical cord may insert into one or other lobe, or may insert between die two.

Figure 1.4. A close-up of the same placenta. The risk to the infant is that the vessels crossing the membranes may rupture, resulting in massive blood loss. It is suggested that this condition arises as a result of superficial implantation of the ovum.

Figure 1.4. A close-up of the same placenta. The risk to the infant is that the vessels crossing the membranes may rupture, resulting in massive blood loss. It is suggested that this condition arises as a result of superficial implantation of the ovum.

Circummarginate Placenta

Figure 1.5. Another example of a placenta duplex showing the maternal surface.

Figure 1.6. In a circumvallate (circummarginate) placenta the fetal surface may be reduced if decidual tissue has made its way between die amnion and chorion. This appears as a yellow, peripheral, hyalinized fold circumscribing the edge of the chorionic plate. This type of placenta has been reported to be a cause of antepartum bleeding and premature labor.

Figure 1.5. Another example of a placenta duplex showing the maternal surface.

Bipartite Placenta Image Placenta Membranacea

Figure 1.7. This is an example of placenta membranacea (placenta diffusa). These placentas are rare.

The ovum implants too deeply, the villae of the chorion fail to regress, and the placental tissue develops over the entire surface of the chorion. The placenta is very thin and is associated with poor fetal growth and antepartum hemorrhage. There may be previa type bleeding.

Antepartum Hemorrhage

Figure 1.8. Transillumination of the same placenta shows the thinness of this type of placenta and that islets of placental tissue are present throughout the membranes. Pregnancy rarely goes to term and fetal death is common. If pregnancy continues to term, placenta accreta may occur. In this condition, there is failure of separation of the placenta during the third stage of labor and there may be severe postpartum hemorrhage.

Severe Birth Asphyxia Neonatorum

Figure 1.9. An annular ("girdle" or ring-shaped) is a rare form of placenta which resembles a segment of a hollow cylinder. Sometimes a complex ring of placental tissue is seen. More commonly a portion of the ring undergoes atrophy resulting in a placenta which is approximately horseshoe-shaped. This type of placenta is probably a variant of placenta membranacea. Its clinical significance is uncertain but it appears to be associated with a high incidence of both ante-and postpartum bleeding. The fetus is often small for gestational age. (Connor, S.)

Figure 1.10. This otherwise normal placenta shows the presence of an intrauterine contraceptive device, indicating that it did not prevent pregnancy.

Premature Placenta Gross Photo

Figure 1.11. In premature separation of die placenta (abruptio placentae) there may be massive bleeding of maternal origin. Note the massive blood loss on the left of the maternal surface of die placenta. In these cases, there may be severe fetal asphyxia or death. The infant in this case had blood in stool (melena neonatorum) at birth. This was shown to be ingested maternal blood by the Apt test.

Figure 1.12. Another example of abruptio placentae. A large abruptio placentae may result in poor growth of the infant and fetal blood loss.

Placenta Maternal Surface

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Chorangioma

Figure 1.13. Fetal surface of a placenta with a large chorangioma (hemangioma of the placenta). These infants may present with severe nonimmune hydrops fetalis. The majority of cases of hydrops fetalis are now due to nonimmune causes.

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Placenta Hydrops

Figure 1.14. Maternal surface of the same placenta. Note the placental enlargement due to die chorangioma and edema. If the placenta is not examined, this cause of nonimmune hydrops fetalis may be missed.

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Calcified Placenta

Figure 1.15. A calcified, small placenta. This infant had severe intrauterine growth retardation at term as a result of poor fetal nutrition.

Figure 1.16. In velamentous insertion of the cord the umbilical vessels traverse the fetal membranes unsupported by either die umbilical cord or by placental tissue. If tearing of these unsupported vessels occurs before or during delivery, it can result in massive fetal blood loss.

Ragged Membranes Placenta

Figure 1.17. Another example of velamentous insertion of die cord. Note the vessels traversing die membranes before inserting into the fetal surface of the placenta. The vessels, lying in loose unsupported tissue, may easily stretch and tear, especially if they cross the cervical os and result in vasa previa with massive blood loss. (Sotelo-Avila, C.)

Vasa Previa

Figure 1.18. An example of velamentous insertion of the cord. Note the large vessels exposed in the membranes before they insert into the placental tissue, a section of which is shown at the top. Velamentous insertion of the cord occurs in 0.5 to 1% of singleton births, in 7% of twin births, and in 30 to 40% of triplet births. (Sotelo-Avila, C.)

Nuchal Umbilical Cord

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Baby Born Vasa Previa

Figure 1.19. Transillumination of the placenta shown in Figure 1.18. (Sotelo-Avila, C.)

Stripping The Fetal Membranes

Figure 1.20. Fetus born in a caul. Note that the membranes completely surround the fetus and that the umbilical cord (nuchal cord) encircles the neck twice. A cord around the neck once occurs in about 20%, and twice in about 2% of pregnancies. Whether the cord causes any problems depends on its tightness around the neck. (Klima, T.)

Figure 1.19. Transillumination of the placenta shown in Figure 1.18. (Sotelo-Avila, C.)

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Born The Caul

Figure 1.20. Fetus born in a caul. Note that the membranes completely surround the fetus and that the umbilical cord (nuchal cord) encircles the neck twice. A cord around the neck once occurs in about 20%, and twice in about 2% of pregnancies. Whether the cord causes any problems depends on its tightness around the neck. (Klima, T.)

Figure 1.21. Note the petechiae of the face and head and the subconjunctival hemorrhages in this infant who had a long cord around the neck. The normal umbilical cord is 40 to 60 cm long. Long cords (>70 cm) are more apt to be looped around the neck or an extremity of the fetus or to have true knots. Extremely short cords (<30 cm) may lead to abruptio placentae, inversion of the uterus, and intrafunicular hemorrhage (bleeding within the umbilical cord).

Abruptio Placentae

Figure 1.22. This cord was extremely long and wrapped around die left wrist and several times around the neck resulting in intrauterine death and birth of a stillborn infant. A long umbilical cord has usually been stretched by the movement of an extremely active fetus.

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Active Fetus

Figure 1.23. Intrauterine deadi as a result of a long umbilical cord which wrapped around the neck and then the left leg. As the infant moved in utero, he strangled himself.

Figure 1.22. This cord was extremely long and wrapped around die left wrist and several times around the neck resulting in intrauterine death and birth of a stillborn infant. A long umbilical cord has usually been stretched by the movement of an extremely active fetus.

Figure 1.23. Intrauterine deadi as a result of a long umbilical cord which wrapped around the neck and then the left leg. As the infant moved in utero, he strangled himself.

Figure 1.24. A

long umbilical cord can encircle an extremity and leave recognizable grooves (furrows) with or without skin ulceration. These are not associated with a poor outcome. In this infant, the cord encircled the right knee very tightly and interfered with the circulation distally.

Neck Immobility

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Umbilical Cord Ulceration

Figure 1.25. The severe umbilical cord constriction proximally resulted in intrauterine death of this fetus. (Finegold, M.)

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Hemorrhage Infants From Placenta

Figure 1.26. A hematoma of the umbilical cord (intrafunicular hemorrhage) resulted from a short umbilical cord. Short umbilical cords are associated with extreme intrauterine immobility, such as in the fetal akinesia syndrome.

Figure 1.27. A true knot in the umbilical cord of this fetus resulted in intrauterine death. The incidence of true knots in the umbilical cord is 0.1 to 1%, and is strongly associated with long cords and other markers of vigorous fetal activity. It is associated with about 10% of stillbirths. The knots must be very tight to obstruct blood flow. At the site of a long standing knot, such as in this fetus, there is a loss of Wharton's jelly and a constriction of umbilical vessels. Wharton's jelly probably prevents umbilical cord blood vessel compression by diffusing the pressure exerted by knots. The jelly is also slippery and this makes it difficult to maintain a knot.

Figure 1.28. An example of two true knots in the umbilical cord in an infant who was normal at birth.

Umbilical Cord Knot

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Figure 1.29. Close up of the true knot to the right in Figure 1.28. Note diat the Wharton's jelly is normal and that there is no constriction of the cord. This is, therefore, a recent knot. A previously loose knot may be suddenly tightened as the infant descends during delivery.

Figure 1.30. This umbilical cord transection during amniocentesis occurred several years ago, before ultrasound was used to determine the position of the amnio-centesis needle. There was considerable blood loss.

Centesis Needle

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Umbilical Cord UltrasoundSingle Umblical Artery

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Figure 1.33. The diagnosis of single umbilical artery is made by examining a section through the surface of the umbilical cord. This anomaly is present in 0.7 to 1.0% of single placentas and in 3 to 7.0% of multiple birth placentas. The incidence is low in black infants, but is increased in infants with associated congenital malformations. Further investigation is recommended if a single umbilical artery is associated with one other major anomaly.

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Trisomy13and18 Org

Figure 1.34. A histologic section of an umbilical cord with a single umbilical artery. Note that the thick-walled vessel is the artery and the thin-walled vessel is the vein. It may be associated with abnormal cord length, velamentous cord insertion, or circumvallate placenta. The finding of other congenital malformations is not specific for any one organ system. Cardiac, renal, gastrointestinal, and skeletal malformities have been described. There is an increased incidence of a single umbilical artery in trisomy 13 and 18.

Figure 1.34. A histologic section of an umbilical cord with a single umbilical artery. Note that the thick-walled vessel is the artery and the thin-walled vessel is the vein. It may be associated with abnormal cord length, velamentous cord insertion, or circumvallate placenta. The finding of other congenital malformations is not specific for any one organ system. Cardiac, renal, gastrointestinal, and skeletal malformities have been described. There is an increased incidence of a single umbilical artery in trisomy 13 and 18.

Umbilical Single Artery
Figure 1.35. Note the markedly enlarged, edematous umbilical cord due to excess Wharton's jelly in an infant of a diabetic mother. These cords are very friable and tear easily.

Figure 1.36. A thrombosed vessel in an umbilical cord with little Wharton's jelly. Trauma to the cord is more common when there is a lack of Wharton's jelly. The lack of Wharton's jelly is seen more commonly in postmature infants. A thrombosed vessel in the umbilical cord may compromise fetal well-being.

Figure 1.36. A thrombosed vessel in an umbilical cord with little Wharton's jelly. Trauma to the cord is more common when there is a lack of Wharton's jelly. The lack of Wharton's jelly is seen more commonly in postmature infants. A thrombosed vessel in the umbilical cord may compromise fetal well-being.

Postmature Umbilical Cord

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Umbilical Cord Fluid

Figure 1.39. This infant has a large cyst in the umbilical cord. The chemical composition of the fluid in this cyst was that of serum rather than urine. These cysts are thought to arise from the allan-tois.

Figure 1.37. This thin, narrow umbilical cord with total lack of Wharton's jelly was present at birth in an infant with postmatu-rity and oligohydramnios. Cord compression is probably more frequent with a narrow cord, perhaps because the Wharton's jelly does not "cushion" the cord.

Figure 1.38. A drying umbilical cord 4 days after birth. Note that as the cord dries, the Wharton's jelly disappears rapidly.

Figure 1.39. This infant has a large cyst in the umbilical cord. The chemical composition of the fluid in this cyst was that of serum rather than urine. These cysts are thought to arise from the allan-tois.

Figure 1.40. Another example of an umbilical cord cyst which is thought to arise from the allantois. These cysts are of no clinical signif-

Figure 1.40. Another example of an umbilical cord cyst which is thought to arise from the allantois. These cysts are of no clinical signif-

Umbilical Cord Cyst

Figure 1.41. Omphalitis and funisitis in an umbilical cord. Omphalitis is an acute inflammation of the skin surrounding the umbilicus. Funisitis is an acute inflammation of the umbilical cord itself. It results from bacteria or mycoplasma in the amniotic fluid attracting fetal neutrophils to migrate out of the umbilical cord vessels. It can be associated with necrosis and calcium deposits within the cord.

Figure 1.41. Omphalitis and funisitis in an umbilical cord. Omphalitis is an acute inflammation of the skin surrounding the umbilicus. Funisitis is an acute inflammation of the umbilical cord itself. It results from bacteria or mycoplasma in the amniotic fluid attracting fetal neutrophils to migrate out of the umbilical cord vessels. It can be associated with necrosis and calcium deposits within the cord.

Calcium Deposits Skull
Figure 1.42. Histologic section of an umbilical cord showing funisitis. Note the marked inflammatory reaction surrounding an artery in the cord itself. (Sotelo-Avila, C.)
Calcium Deposits Placenta

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One Vein Umbilical Cord
Figure 1.43. Histologic section of an umbilical cord showing marked inflammatory reaction and bacterial colonies (intensely stained blue areas) surrounding a vein in the cord itself.

Figure 1.44. Histologic section of the umbilical cord in an infant with congenital listerio-sis. Note the gram positive organisms on the surface of the umbilical cord.

Figure 1.45. Histologic section of funisitis occurring as a result of a catheter in situ in an umbilical vessel.

Figure 1.46. The external surface of the umbilical cord shows cheesy white areas similar to thrush which suggest the diagnosis of congenital candidiasis. (Sotelo-Avila, C.)

Figure 1.47. A histologic section of the umbilical cord of the same infant showing funisitis with the hyphae of Candida which are stained pink. (Sotelo-Avila, C.)

Figure 1.46. The external surface of the umbilical cord shows cheesy white areas similar to thrush which suggest the diagnosis of congenital candidiasis. (Sotelo-Avila, C.)

Funisitis Placenta

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Figure 1.48. External surface of an umbilical cord with yellowish brown areas on the external surface which suggest the diagnosis of congenital candidiasis. (Fanaroff, A.)

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Fetus Papyraceus Microscopy

Figure 1.49. Fetal surface of a placenta showing chorioamnioni-tis. Normally, the fetal surface of a placenta is shiny and clear with a prominent vascular pattern. In chorioamnionitis the fetal surface appears dull and opaque with an obscure vascular pattern. The amniotic fluid is cloudy, and the placenta, membranes, and amni-otic fluid may have a foul odor. Aspiration in this infected milieu by the fetus may result in neonatal pneumonia, sepsis and/or neonatal meningitis.

Figure 1.49. Fetal surface of a placenta showing chorioamnioni-tis. Normally, the fetal surface of a placenta is shiny and clear with a prominent vascular pattern. In chorioamnionitis the fetal surface appears dull and opaque with an obscure vascular pattern. The amniotic fluid is cloudy, and the placenta, membranes, and amni-otic fluid may have a foul odor. Aspiration in this infected milieu by the fetus may result in neonatal pneumonia, sepsis and/or neonatal meningitis.

Figure 1.50. Histologic section of the placenta showing chorioamnionitis. Factors associated with increased risk of placental infection include premature and prolonged rupture of the membranes, prolonged labor, placenta previa, and multiple births. Bacterial infections are more common than viral and fungal infections.

Figure 1.51. Histologic section of a placenta with cyto-megalovirus infection. Note the typical "owl's eye" inclusions in the villae. Viral agents reach the fetus by hematogenous dissemination and traverse the placental villae. Since viral lesions tend to be microscopic, gross examination of the placenta is not helpful. (Finegold, M.)

Figure 1.52. Histologic section of a placenta with congenital syphilis. Note the numerous spirochetes. (Finegold, M.)

Figure 1.53. The presence of meconium staining of the amniotic fluid occurs with fetal distress and postmaturity. Meconium staining of the placenta may occur within 1 hour. In cases of chorioamnionitis, the fetal surface may be green; in listeriosis, diere may be brown or chocolate staining of the amniotic fluid with similar staining of the placenta. (Finegold, M.)

Figure 1.52. Histologic section of a placenta with congenital syphilis. Note the numerous spirochetes. (Finegold, M.)

Congenital Listeriosis Placenta

Figure 1.54. Infant with a large "garment" nevus (bathing trunk nevus). Note the marked breakdown and ulceration of the skin.

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Figure 1.54. Infant with a large "garment" nevus (bathing trunk nevus). Note the marked breakdown and ulceration of the skin.

Trunk Nevus

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Figure 1.55. Gross section of placenta showing multiple nevi in the same infant shown in Figure 1.54- This emphasizes the importance of examining the placenta in infants born with such abnormalities. (Sotelo-Avila, C.)

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4IF ■

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"Bf j i.

IHbl.

Figure 1.56. Histologic section of melanoma cells from the placenta of the same infant shown in Figure 1.54 and 1.55. Similarly lesions can be seen in the placenta of infants with congenital neuroblas-toma. (Sotelo-Avila, C.)

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SSf iMHi IP i il

Ll^KNte mi Jf

Figure 1.57. Squamous metaplasia of the amnion. In this placenta with squamous metaplasia, the amnion is stripped from the membranes. Note the concentric appearance of these nodules and their frequent umbilica-tion. The amnion is squamous and these areas of metaplasia form with maturity. Note die tiny nodules of keratin irregularly present on the fetal surface.

Figure 1.57. Squamous metaplasia of the amnion. In this placenta with squamous metaplasia, the amnion is stripped from the membranes. Note the concentric appearance of these nodules and their frequent umbilica-tion. The amnion is squamous and these areas of metaplasia form with maturity. Note die tiny nodules of keratin irregularly present on the fetal surface.

Figure 1.58. Histologic section of the amnion showing the squamous metaplasia. Squamous metaplasia differs from amnion nodosum in that the lesions cannot be separated readily, whereas the nodules in amnion nodosum can be picked off of the underlying amnion leaving a semi-transparent, saucer-shaped depression with somewhat ragged edges.

Figure 1.59. Typical amnion nodosum in one twin. This twin was an acardiac monster having no urinary tract. The amnion is rough and shows numerous fine granules which are whitish, opaque, and uniform in size. Frequently the nodules are more irregular in size and slightly yellowish brown. It is unusual to see this degree of amnion nodosum. The other twin was normal.

Figure 1.60. Another example of amnion nodosum in a twin placenta. Note the normal umbilical cord and placenta on the right and the small umbilical cord with a thrombosed vessel on the left. This was a twin-twin transfusion syndrome and the twin on the left became a fetus papyraceus. The amnion nodosum lesions are whitish, opaque, and uniform in size.

Fetus Papyraceus Histology

Figure 1.60. Another example of amnion nodosum in a twin placenta. Note the normal umbilical cord and placenta on the right and the small umbilical cord with a thrombosed vessel on the left. This was a twin-twin transfusion syndrome and the twin on the left became a fetus papyraceus. The amnion nodosum lesions are whitish, opaque, and uniform in size.

Fetus Papyraceus

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Figure 1.61. Histologic section of a placenta and membranes showing amnion nodosum on the left and chorioamnioni-tis on the right in an infant with renal dysgenesis and hypoplastic lungs.

Vernix Caseosa And Histological
Figure 1.62. High-power histo-logic section of amnion nodosum which consists of lanugo, vernix caseosa, and squamous epithelial cells. With marked oligohydram-nios, the fetal skin rubs against the fetal surface of the placenta and produces these lesions.
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Responses

  • Luke
    Now talking about human placenta what chemical methodology can be used to dissolve the placenta and kill the odor too
    5 years ago
  • ulrich
    What causes retained placenta?
    6 years ago
  • NEBYAT DEMSAS
    Is umbilical cord blood stained is common for 20 days baby?
    5 years ago
  • catherine
    What membranes form the umbilical cords?
    5 years ago
  • Melilot Boffin
    Are the placenta and umbilical cord the same?
    5 years ago
  • marianna
    What are the membranes on the placenta?
    5 years ago
  • Yorda
    How common is placenta separation?
    5 years ago
  • ZULA HABTE
    What is strippong membranes?
    5 years ago
  • lennie
    How to stripping membrane?
    5 years ago
  • andrea neustadt
    What causes a short umbilical cord and a calcified placenta.?
    4 years ago
  • dorothy
    Does umbilical cord funisitis cause asphyxia?
    4 years ago
  • Julia Peters
    What is bipartite placenta?
    2 years ago
  • Lioba
    What is stripping membranes?
    2 years ago
  • Chris
    What is strippong the membrane?
    11 months ago
  • Sven
    What does membrane strippong mean in lpregnancy?
    6 months ago
  • john
    What do you mean by umbilical cord in case of chorio allantoic placenta?
    5 months ago
  • albert
    What does the absence of whartons jelly signifies in a placenta?
    1 month ago
  • Jodi Walker
    Can umbilical cord wrapped around neck in womb?
    1 month ago
  • kaarlo
    Can the foetus kill himself with the cord?
    6 days ago

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