PLACENTA PLACENTA Dr.DOAA IRAQIDr.DOAA IRAQI

Normal placentaNormal placenta

US image shows a US image shows a placenta that is placenta that is relatively relatively homogeneous in homogeneous in echo-texture.echo-texture.

The retroplacental The retroplacental clear space is clear space is hypoechoichypoechoic (arrowheads). (arrowheads).

Normal placentaNormal placenta Normal placentaNormal placenta. . ((aa)) US US image shows a placentaimage shows a placenta ((PP))

that is relatively that is relatively homogeneous in echohomogeneous in echo--

texturetexture.. TheThe retroplacental clear retroplacental clear

spacespace is hypoechoic is hypoechoic ((arrowheadsarrowheads). ). ((bb)) Sagittal Sagittal singlesingle--shot fast spinshot fast spin--echo echo ((SSFSESSFSE) ) T2-weighted MR T2-weighted MR

image shows a placentaimage shows a placenta ((PP)) with intermediate signal with intermediate signal

intensityintensity. . The dark line The dark line represents the represents the

retroplacental clear space retroplacental clear space ((arrowheadsarrowheads).).

subchorionic cyst of the placentasubchorionic cyst of the placenta. . Also known as membranous cyst, Also known as membranous cyst,

chorionic cystchorionic cystcystic lesion of the cystic lesion of the

placenta, just placenta, just below the below the placental surfaceplacental surface.. Few mobile echoes Few mobile echoes were seen within were seen within the lesionthe lesion. . This This finding is generally finding is generally considered to be considered to be clinically of little clinically of little significancesignificance. .

Velamentous insertion of Velamentous insertion of umbilical cord into placentaumbilical cord into placenta

These color These color doppler images doppler images show show the umbilical the umbilical cord inserting into cord inserting into the placental the placental membranesmembranes before before reaching the reaching the placental tissue placental tissue properproper. .

Vesicular mole Vesicular mole ((also called Molar also called Molar pregnancy or Hydatidiform molepregnancy or Hydatidiform mole) ) in in

1st trimester1st trimester Sonography of the uterus Sonography of the uterus

was done in this 1st was done in this 1st trimester pregnancytrimester pregnancy. . aa) ) Hyperechoic mass in Hyperechoic mass in the uterine cavity with the uterine cavity with multiple cystic spaces multiple cystic spaces within itwithin it.. bb) ) Uterus is Uterus is enlarged enlarged ((bulkybulky) ) cc) ) The The myometrium is hypoechoic myometrium is hypoechoic compared to the contents compared to the contents of the uterine cavityof the uterine cavity. . These These appearances can be appearances can be likened to a likened to a ""snowstormsnowstorm""

Vesicular moleVesicular mole

Vesicular moleVesicular moleCT image of a patient with a CT image of a patient with a

ββ--hCG level of 620,000 hCG level of 620,000 mIUmIU//mL shows :mL shows :

a predominantly a predominantly lowlow--attenuation mass in the attenuation mass in the uterus with heterogeneous uterus with heterogeneous foci of internal foci of internal enhancementenhancement..

Pathologic examination Pathologic examination demonstrated a complete demonstrated a complete mole mole without myometrial without myometrial invasioninvasion. .

enlarged ovary with theca enlarged ovary with theca lutein cystslutein cysts.. CT can be CT can be used to assess for invasion used to assess for invasion by gestational by gestational trophoblastic diseasetrophoblastic disease. .

Placental calcificationPlacental calcification This 3rd trimester This 3rd trimester

pregnancy shows pregnancy shows extensive calcification extensive calcification of the basal plate of the basal plate ((uterine or maternal uterine or maternal surfacesurface) ) of the of the placentaplacenta. . Clinically Clinically and pathologically, and pathologically, calcific changes of calcific changes of placenta have no placenta have no significancesignificance. .

Placenta-GradingPlacenta-Grading

Grade 0Grade 0Late 1st trimester-Late 1st trimester-

early 2nd early 2nd trimestertrimester

UniformUniform moderate moderate echogenicityechogenicity

SmoothSmooth chorionic chorionic plate without plate without indentationsindentations

Grade 1Grade 1Grade 1Grade 1 Mid 2nd trimester –Mid 2nd trimester –

early 3rd trimester early 3rd trimester (~18-29 wks)(~18-29 wks)

Subtle (thin) Subtle (thin) indentationsindentations of of chorionic plate.chorionic plate.

Small, diffuse Small, diffuse calcificationscalcifications (hyperechoic) randomly (hyperechoic) randomly dispersed in placentadispersed in placenta

Grade 2Grade 2Grade 2Grade 2 Late 3rd trimester Late 3rd trimester

(~30 wks to delivery)(~30 wks to delivery) Larger indentationsLarger indentations

along chorionic platealong chorionic plate Larger calcificationsLarger calcifications in in

a “dot-dash” a “dot-dash” configuration along configuration along the basilar platethe basilar plate

Grade 3Grade 3Grade 3Grade 3 39 wks – post dates39 wks – post dates Complete indentations of chorionicComplete indentations of chorionic

plate through to the basilar plate plate through to the basilar plate creating “cotyledons” (portions of creating “cotyledons” (portions of placenta separated by the placenta separated by the indentations)indentations)

More irregular calcificationsMore irregular calcifications with with significant shadowingsignificant shadowing

May signify placental dysmaturity May signify placental dysmaturity which can cause IUGRwhich can cause IUGR

Associated with smoking, chronic Associated with smoking, chronic hypertension, SLE, diabeteshypertension, SLE, diabetes

placental chorioangiomaplacental chorioangioma Sonography of the placenta Sonography of the placenta

in this 16 week pregnancy in this 16 week pregnancy shows shows a large, solid mass, a large, solid mass, that is non calcific and that is non calcific and shows mild vascularity shows mild vascularity (vascular) and excludes (vascular) and excludes placental hematomaplacental hematoma. . and and shows many cystic spaces shows many cystic spaces within itwithin it.. This tumor of the This tumor of the placenta lies close to the placenta lies close to the cord insertion sitecord insertion site. . Ultrasound images of this Ultrasound images of this type of placental mass are type of placental mass are highly suggestive of highly suggestive of placental chorioangiomaplacental chorioangioma..

placental chorioangiomaplacental chorioangioma

Succenturiate placentaSuccenturiate placenta

Succenturiate placentaSuccenturiate placenta

Succenturiate placentaSuccenturiate placentaThis was a 3rd trimester pregnancy This was a 3rd trimester pregnancy

showing part of the placenta along showing part of the placenta along the anterior wall of the uterus the anterior wall of the uterus (SUCCENT PL), and the main part of (SUCCENT PL), and the main part of the placenta along the posterior wall the placenta along the posterior wall (PL). (PL). The sucenturiate lobe of The sucenturiate lobe of placenta is connected to the main placenta is connected to the main placenta by a string of blood vessels.placenta by a string of blood vessels.

Circumvallate placentaCircumvallate placentaCircumvallate placentaCircumvallate placenta

Circumvallate placentaCircumvallate placenta Infolding of the margins of the Infolding of the margins of the

placentaplacenta.. This condition is a normal variant and is This condition is a normal variant and is produced due to the fact that in this case, the chorionic plate produced due to the fact that in this case, the chorionic plate ((fetal surfacefetal surface) ) of the placenta is smaller than the basal plate of the placenta is smaller than the basal plate ((surface in contact with the uterine wall or deciduasurface in contact with the uterine wall or decidua) ) of the of the placenta with resultant shouldering or infoldingplacenta with resultant shouldering or infolding/ / rolling of the rolling of the placental marginsplacental margins.. This condition is called This condition is called circumvallate placenta and usually circumvallate placenta and usually causes causes no harm to the fetusno harm to the fetus. . However, However, it can it can sometimes be associated with sometimes be associated with increased chances of placental increased chances of placental abruption and hemorrhage.abruption and hemorrhage.

Circumvallate placentaCircumvallate placenta

Placental venous lakePlacental venous lake

Placental venous lakePlacental venous lakeThis placenta, in a 28 week pregnancy shows This placenta, in a 28 week pregnancy shows

a large hypoechoic a large hypoechoic ((almost anechoicalmost anechoic)), , measuring 5 x 3.5 cmsmeasuring 5 x 3.5 cms. . in sizein size. . Some Some particulate matter was seen flowing through particulate matter was seen flowing through this area, which was closer to the fetal this area, which was closer to the fetal surface of the placentasurface of the placenta. . These ultrasound These ultrasound images suggest a typical appearance of a images suggest a typical appearance of a large venous lake in the placentalarge venous lake in the placenta.. Color Color Doppler image showed no major flow Doppler image showed no major flow pattern within this placental lakepattern within this placental lake. . The fine, The fine, echogenic strands within the lesion appear echogenic strands within the lesion appear to be nothing more than artefacts produced to be nothing more than artefacts produced by slow flowing blood within the lesionby slow flowing blood within the lesion. .

Placenta previaPlacenta previa

Placenta previaPlacenta previa

The above ultrasound and color Doppler images The above ultrasound and color Doppler images show the lower margin of the placenta partially show the lower margin of the placenta partially covering the internal os, suggesting covering the internal os, suggesting partial partial placenta previaplacenta previa..

Placenta previaPlacenta previa One point to be noted is that placenta previa One point to be noted is that placenta previa

is diagnosed in the 2nd and 3rd trimester of is diagnosed in the 2nd and 3rd trimester of pregnancy, and that normal uterine pregnancy, and that normal uterine contractions can cause the placenta to be contractions can cause the placenta to be ""pushedpushed" " lower down its normal position, lower down its normal position, creating an appearance of placenta previa creating an appearance of placenta previa ((a a false positive diagnosis of placenta previafalse positive diagnosis of placenta previa).). Hence it is advisable to repeat the Hence it is advisable to repeat the ultrasound scan after 30 minutes to exclude ultrasound scan after 30 minutes to exclude a false diagnosis of this conditiona false diagnosis of this condition..

Placenta previaPlacenta previa This ultrasound image shows This ultrasound image shows

the placenta completely the placenta completely covering the internal os , covering the internal os , thus diagnostic of thus diagnostic of complete placenta complete placenta previaprevia..

Follow up ultrasonography is Follow up ultrasonography is advisable in all cases of advisable in all cases of placenta previa, to look for placenta previa, to look for ascent of the placenta to a ascent of the placenta to a higher position due to the higher position due to the growth of the uterusgrowth of the uterus.. Such Such cases of placenta previa cases of placenta previa ((both partial and completeboth partial and complete) ) are are in danger of hemorrhage in danger of hemorrhage ((antepartumantepartum) ) and are and are advised rest to prevent thisadvised rest to prevent this..

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placental abruptionplacental abruption . .

Crescent of Crescent of avascularavascular low low echogenicity echogenicity between placenta between placenta and uterine wall and uterine wall consistent withconsistent with placental placental abruptionabruption. .

placental abruptionplacental abruption

Retained products of Retained products of conceptionconception/ / retained placentaretained placenta

Retained products of Retained products of conceptionconception/ / retained placentaretained placenta

The above ultrasound images show The above ultrasound images show a post partum uterus on a post partum uterus on transabdominal sonographytransabdominal sonography. . There is a hyperechoic There is a hyperechoic mass within the endometrial cavity measuring 8 x 5 mass within the endometrial cavity measuring 8 x 5 cmscms.. The color Doppler ultrasound image shows poor The color Doppler ultrasound image shows poor vascularity of the mass and the endometriumvascularity of the mass and the endometrium..

note that the endometrial mass is eccentric within the cavitynote that the endometrial mass is eccentric within the cavity- - the the anterior myometrium is thicker whilst the posterior wall of the anterior myometrium is thicker whilst the posterior wall of the uterus is thinneruterus is thinner. . The placenta was not expelled at the time of The placenta was not expelled at the time of deliverydelivery..

Absence of vascularity or poor flow does not rule out Absence of vascularity or poor flow does not rule out retained products of conceptionretained products of conception/ / retained placentaretained placenta..

The single most important sign of retained products of The single most important sign of retained products of conception is the large endometrialconception is the large endometrial massmass. . Other signs Other signs of retained placenta or products include complex fluid of retained placenta or products include complex fluid or thickened endometrium or thickened endometrium ((more than 10 mmmore than 10 mm..((..

Bilobed placentaBilobed placenta: (: (bilobate bilobate placenta)placenta)

Bilobed placentaBilobed placenta: : bilobate bilobate placentaplacenta

Bilobed placentaBilobed placenta: (: (bilobate bilobate placenta)placenta)

This is a 3rd trimester pregnancy with This is a 3rd trimester pregnancy with ultrasound images showing ultrasound images showing two parts two parts of the placenta along the anterior of the placenta along the anterior and posterior walls of the uterus, and posterior walls of the uterus, connected by a thin bridge of connected by a thin bridge of placental tissueplacental tissue.. This kind of This kind of sonographic appearance is typical of sonographic appearance is typical of bilobed placentabilobed placenta. .

Twin gestationsTwin gestations T sign in a T sign in a

MonochorionicMonochorionic--diamniotic Twin diamniotic Twin GestationGestation

Twin peak sign in Twin peak sign in DICHORIONICDICHORIONIC--DIAMNIOTIC DIAMNIOTIC TWIN GESTATIONSTWIN GESTATIONS..

Twin gestationsTwin gestations

Placental hematomaPlacental hematoma aa)) US image shows a US image shows a

rounded collection of rounded collection of mixedmixed--echogenicityechogenicity material material ((arrowheadsarrowheads) ) deep to the chorion deep to the chorion along the lateral margin along the lateral margin of the placentaof the placenta. .

There is There is no internal no internal Doppler signal to Doppler signal to suggest blood flowsuggest blood flow.. This This appearance is appearance is consistent with a consistent with a subchorionic subchorionic hematomahematoma. . ((bb

placenta accretaplacenta accreta)) US images show US images show disruption of the disruption of the

normal hypoechoic normal hypoechoic myometrium myometrium ((black black arrowheadsarrowheads) ) by invading by invading placental tissue placental tissue ((white white arrowheadsarrowheads). ). BB = = bladderbladder, , PP = = placentaplacenta. . ((bb)) Sagittal SSFSE MR Sagittal SSFSE MR image shows intermediateimage shows intermediate--signalsignal--intensity placental tissue intensity placental tissue ((arrowheadarrowhead) ) invading the normal invading the normal dark myometriumdark myometrium ((MM)) in the in the lower uterine segment, findings lower uterine segment, findings consistent with placenta accretaconsistent with placenta accreta. . ((cc)) Sagittal SSFSE MR image Sagittal SSFSE MR image shows obliteration of the normal shows obliteration of the normal dark myometriumdark myometrium ((MM)) posteriorly, posteriorly, with placental tissue of with placental tissue of heterogeneous signal intensity heterogeneous signal intensity ((arrowheadsarrowheads) ) penetrating the full penetrating the full thickness of the uterine wallthickness of the uterine wall. . This This appearance is indicative of appearance is indicative of placenta percretaplacenta percreta. .

placenta accretaplacenta accretaUS images show disruption of the US images show disruption of the

normal hypoechoic myometrium normal hypoechoic myometrium ((black arrowheadsblack arrowheads) ) by invading by invading placental tissue placental tissue ((white white arrowheadsarrowheads). ). BB = = bladderbladder, , PP = = placentaplacenta. . ((bb)) Sagittal SSFSE MR Sagittal SSFSE MR image shows intermediateimage shows intermediate--signalsignal--intensity placental tissue intensity placental tissue ((arrowheadarrowhead) ) invading the normal invading the normal dark myometriumdark myometrium ((MM)) in the in the lower uterine segment, findings lower uterine segment, findings consistent with placenta accretaconsistent with placenta accreta. . ((cc)) Sagittal SSFSE MR image Sagittal SSFSE MR image shows obliteration of the normal shows obliteration of the normal dark myometriumdark myometrium ((MM)) posteriorly, with placental tissue posteriorly, with placental tissue of heterogeneous signal intensity of heterogeneous signal intensity ((arrowheadsarrowheads) ) penetrating the full penetrating the full thickness of the uterine wallthickness of the uterine wall. . This appearance is indicative of This appearance is indicative of placenta percretaplacenta percreta. .

placenta accretaplacenta accreta US images show disruption of the US images show disruption of the

normal hypoechoic myometrium normal hypoechoic myometrium ((black arrowheadsblack arrowheads) ) by invading by invading placental tissue placental tissue ((white white arrowheadsarrowheads). ). BB = = bladderbladder, , PP = = placentaplacenta. . ((bb)) Sagittal SSFSE MR Sagittal SSFSE MR image shows intermediateimage shows intermediate--signalsignal--intensity placental tissue intensity placental tissue ((arrowheadarrowhead) ) invading the normal invading the normal dark myometriumdark myometrium ((MM)) in the in the lower uterine segment, findings lower uterine segment, findings consistent with placenta accretaconsistent with placenta accreta. . ((cc)) Sagittal SSFSE MR image Sagittal SSFSE MR image shows obliteration of the normal shows obliteration of the normal dark myometriumdark myometrium ((MM)) posteriorly, with placental tissue posteriorly, with placental tissue of heterogeneous signal intensity of heterogeneous signal intensity ((arrowheadsarrowheads) ) penetrating the full penetrating the full thickness of the uterine wallthickness of the uterine wall. . This appearance is indicative of This appearance is indicative of placenta percretaplacenta percreta. .