Williams Obstertics, Twenty-Second Edition - Page 619 630
Williams Obstertics, Twenty-Second Edition - Page 619 630
Williams Obstertics, Twenty-Second Edition - Page 619 630
Pathological Examination
Abnormal Shape or Implantation
Circulatory Disturbances
Placental Inflammation
Chorioangioma(Hemangioma)
Chorioamnionitis
Other Abnormalities
Incidence : remarkably constant
20% of almost 250,000women delivered during the
past 20years - in Parkland Hospital
Preterm fetuses seldom pass meconium.
<38 wks : uncommon
>42 wks : increase to 25~30%
Staining of the amnion can be obvious within 1~3hours after
meconium passage
Although more prolonged exposure results in staining of the the
chorion, umbilical cord and decidua, meconium passage cannot
be timed or dated accurately – Benirschke and Kaufmann(2000)
Study Meconium Passage(%)
Eden and associates(1987)
39weeks 14
40weeks 19
42weeks 26
>42weeks 29
Usher and colleagues(1988)
39-40 weeks 15
41 weeks 27
42 weeks or greater 32
Steer and co-workers(1989)
<36 weeks 3
36-39 weeks 13
40-41 weeks 19
42 weeks or greater 23
Clinical significance
: perinatal morbidity and mortality↑
- by Nathan and co-workers in Parkland Hospital, 1994-
- perinatal mortality - 1.5 : 0.3 per 1000
- severe fetal acidemia (cord arterial pH < 7.0) - 7 : 3 per
1000
- cesarean delivery : doubled (14% : 7%)
: neonatal morbidity and mortality ↑
- meconium aspiration syndrome (10% of exposed infants)
: serious maternal risk ↑
- associated with amnionic fluid embolism
→ increases maternal mortality from cardiorespiratory failure
and consumptive coagulopathy
- Puerperal metritis : 4 times
Imflammation of the fetal membranes is usually manifestation of
imtrauterine infection
Associated with prolonged membrane rupture and long labor
Characteristic
: clouding of the membranes
foul odor (depending on bacterial species and concentaraion )
Definition
: mono-and polymorphonuclear leukocytes infiltrate the chorion,
the resulting microscopical finding - cells origin : maternal
Leudocytes are found in amnionic fluid (amnionitis) or the
umbilical cord(funisitis) - cell origin : fetus
< 20 wks almost all polymorphonuclear leukocytes : maternal
origin
> 20 wks: Inflammatory response : maternal & fetal
Preterm deliveries : m/c
Accordign to some investigators these findings of
inflammation may be nonspecific and are not always
associated with other evidence of fetal or maternal
infection
Management
: antimicrobial administration and expedient delivery
Hypocoiled cords
: increase in various adverse outcomes in fetuses
- meconium staining, preterm birth and fetal distress
Hypercoiled cords
: higher incidence of preterm delivery and cocaine abuse in
one
with hypercoiled cords
- Rana and associates (1995) -
The umbilical cord
: typically contains two arteries and a single vein
Risk factors
: in women with diabetes, epilepsy, preeclampsia, antepartum
hemorrhage, oligohydramnios and hydramnios
→ increased incidence
Prognosis
- fetal prognosis
: depends on whether the two-vessel cord is associated with
other
abnormalities or whether it is an isolated finding
- Perinatal prognosis
: two-vessel umbilical cord is an isolated sonographic finding
→ better
Budorick and co-workers (1995)
: no abnormal karyotypes and only one echocardiographic
abnormality in 31 fetuses with a two-vessel cord
Catanzarite (1995)
- two of 46 fetuses : lethal chromosomal abnormalities
- 1/3 of 46 fetuses : tracheoesophageal fisrula
When a two vessel cord is a nonisolated finding
- aneuploid ≥ ½ - Budorick and associates (2001) –
- renal aplasia, limb-reduction defects, atresia of hollow organs
in such fetuses, suggesting a vascular etiology
- Pavlopoulos and colleagues (1998) –
Significance : unknown
Cord insertion
: usually inserted at or near the center of the fetal surface of the
placenta
Furcate insertion
Marginal insertion
Velamentous insertion
Vasa Previa
Anomalities Definition incidence Significance
Furcate insertion Umbilical vessels separate from the Rare
cord substance before their
insertion into the placenta
Margnial Inserion Battledore placenta 7% at term Cord being pulled off
: cord insertion at the placental during delivery of the
margin placenta
Stricture
More serious
Most infants with this finding are stillborn
Associated with an extreme focal deficiency in Wharton jelly
In monoamnionic twinning, a significant fraction of the high
perinatal mortality rate is attributed to entwining of the
umbilical cords before labor
accumulations of blood are associated with short
cords, trauma and entanglement
Causes Derived from remnants of the Result from liquefaction of Wharton jelly
umbilical vesicle or the
allantois
Placenta and cord – including the number of vessels-
should be examined grossly following all deliveries
Perinatal death
Preterm delivery
Fetal growth abnormalities
Fetal malformations
Hydrops
Any other fetal disorders
Multiple pregnancy
Maternal disorders
Gross placental lesions
Circumvallate(left) and cricummarginate(right) variaties of extrachorial placentas
Anomaly of Placental site
Velamentous Insertion
Internal cx os