Pathology of the Human Placenta 6/e

Pathology of the Human Placenta remains the most comprehensive and authoritative text in the field. It provides
extensive information on the normal placenta, encompassing physiology, metabolism, and endocrinology, and covers
placental diseases in great detail. The conditions discussed include shape aberrations, villous alterations and
maldevelopment, erythroblastosis fetalis and hydrops fetalis, transplacental hemorrhage, fetal storage disorders,
diverse maternal diseases, and infectious diseases. Further chapters are devoted to abortions, molar pregnancies,
trophoblastic neoplasms, benign tumors, and multiple pregnancies. Legal considerations are carefully explored, and this
new edition also includes a completely new chapter on artificial reproductive technology. In other respects, too, the
book has been extensively revised and expanded, with wide-ranging updates that reflect the most recent progress in the
field. Some 800 illustrations are included, many of them in color. The detailed index has been further improved and
tables updated. Pathology of the Human Placenta will be of enormous value to pathologists and obstetrician-
gynecologists alike.

Content Level ?Professional/practitioner

Keywords ?genetics - molecular biology - pathology - placenta

Related subjects ?Gynecology - Pathology


ix
Contents
1 Examination of the Placenta. . . . . . . . . . . . 1
1.1 Macroscopic Examination. . . . . . . . . . . 1
1.2 Storage. . . . . . 1
1.3 Selection. . . . . 2
1.4 Photography. . 2
1.5 Examination. . 2
1.6 Placentas of Multiple Births. . . . . . . . . . 6
1.7 Fixation. . . . . 8
1.8 Stereological Analysis. . . . . . . . . . . . . . 9
1.9 mRNA and Microarray Analyses. . . . . . 9
1.10 Special Procedures. . . . . . . . . . . . . . . . . 9
References. . . . . . . . 10
2 Macroscopic Features of the Delivered Placenta . . . . . 13
2.1 Fetal Surface. 13
2.2 Maternal Surface. . . . . . . . . . . . . . . . . . 14
2.3 The Terms 밊etal Placenta?and 밠aternal Placenta?. . . . . . . . . . . . . . . . . . . 14
References. . . . . . . . 15
3 Microscopic Survey17
3.1 Typical Histological Features of the First Trimester Placenta . . . . . . . . . . . . . 17
3.2 Typical Histological Features of the Third Trimester Placenta . . . . . . . . . . . . 23
4 Placental Types. . . 27
4.1 Placental Shapes. . . . . . . . . . . . . . . . . . . 28
4.2 Types of Maternal-Fetal Interdigitation. 29
4.3 Maternal-Fetal Interface. . . . . . . . . . . . . 30
4.4 Maternal-Fetal Blood Flow Interrelations . . . . . . . . 31
4.5 Placental Types and Phylogeny. . . . . . . 32
4.6 Genomic Imprinting. . . . . . . . . . . . . . . . 35
4.7 Human Placenta. . . . . . . . . . . . . . . . . . . 36
4.8 Animal Models37
References. . . . . . . . 37
5 Early Development of the Human Placenta41
5.1 The Origin of Trophoblast. . . . . . . . . . . 41
5.2 Prelacunar Stage. . . . . . . . . . . . . . . . . . . 41
5.3 Lacunar Stage. 44
5.4 Early Villous Stages. . . . . . . . . . . . . . . . 45
5.5 Histiotrophic Nutrition. . . . . . . . . . . . . . 46
5.6 Villus Regression and Formation of the Defi nitive Placenta . . . . . . . . . . . . . . 48
5.7 The Amnion and Yolk Sac. . . . . . . . . . . 50
References. . . . . . . . 51
x Contents
6 Basic Structure of the Villous Trees. . . . . . . 55
6.1 Syncytiotrophoblast. . . . . . . . . . . . . . . . 55
6.1.1 Microvillous Surface. . . . . . . . 55
6.1.2 Basal Surface. . . . . . . . . . . . . . 61
6.1.3 Organelles.. . . . . . . . . . . . . . . . 61
6.1.4 Nuclei63
6.1.5 Cytoskeleton. . . . . . . . . . . . . . . 64
6.1.6 Enzymes. . . . . . . . . . . . . . . . . . 64
6.1.7 Glycogen. . . . . . . . . . . . . . . . . 65
6.1.8 Specialized Regions of the Villous Surface 66
6.1.9 Syncytial Sprouts and Knots. . 67
6.1.10 Intervillous Bridges. . . . . . . . . 69
6.1.11 Transtrophoblastic Channels. . 70
6.2 Villous Cytotrophoblast (Langhans?Cells) . . . . . . . 70
6.2.1 Villous Cytotrophoblast Cell Types . . . . . . 71
6.2.2 Cytotrophoblast Fusion. . . . . . 73
6.2.3 Junctional Proteins. . . . . . . . . . 74
6.2.4 Endogenous Retroviral Glycoproteins . . . . 74
6.2.5 Externalization of Phosphatidylserine . . . . 76
6.2.6 Reorganization of the Cytoskeleton . . . . . . 76
6.2.7 Reorganization of the Plasma Membranes . 77
6.2.8 Overview. . . . . . . . . . . . . . . . . 77
6.3 Syncytiotrophoblast Regeneration and Repair . . . . . 78
6.3.1 Trophoblast Apoptosis. . . . . . . 79
6.3.2 Trophoblastic Basement Membrane . . . . . . 80
6.3.3 Connective Tissue. . . . . . . . . . 81
6.3.4 Matrix Components of the Villous Stroma 83
6.4 Villous Macrophages (Hofbauer Cells). 84
6.4.1 Origin and Distribution. . . . . . 84
6.4.2 Functions. . . . . . . . . . . . . . . . . 85
6.5 Other Free Connective Tissue Cells. . . . 86
6.5.1 Fetal Vasculature. . . . . . . . . . . 86
6.5.2 Stem Villous Arteries. . . . . . . . 86
6.5.3 Fetal Capillaries. . . . . . . . . . . . 87
6.5.4 Vasomotor Control. . . . . . . . . . 88
6.5.5 Lymphatics. . . . . . . . . . . . . . . . 89
6.6 Fibrinoid of the Villous Trees. . . . . . . . 89
6.6.1 Perivillous Fibrinoid. . . . . . . . . 89
6.6.2 Intravillous Fibrinoid. . . . . . . . 89
References. . . . . . . . 89
7 Architecture of Normal Villous Trees. . . . . 101
7.1 Classifi cation of Villous Types. . . . . . . 101
7.1.1 Stem Villi. . . . . . . . . . . . . . . . . 102
7.1.2 Immature Intermediate Villi. . . 104
7.1.3 Mature Intermediate Villi. . . . . 106
7.1.4 Terminal Villi. . . . . . . . . . . . . . 106
7.1.5 Mesenchymal Villi. . . . . . . . . . 109
7.2 Differentiation and Growth of Villous Types . . . . . . 110
7.2.1 Formation of Mesenchymal Villi . . . . . . . . 110
7.2.2 Differentiation of Mesenchymal Villi . . . . 111
7.2.3 Development of the Terminal Villi . . . . . . . 112
7.3 Angioarchitecture of Villi. . . . . . . . . . . 113
7.3.1 Vascular Arrangement in Immature Villi . . 113
7.3.2 Larger Vessels of Stem Villi. . . 113
Contents xi
7.3.3 Paravascular Capillary Net of Stem Villi . . 113
7.3.4 Arrangement of Vessels in Mature Intermediate and Terminal Villi . 115
7.3.5 Sinusoids of Terminal Villi. . . 117
7.4 General Aspects of Placental Vasculogenesis and Angiogenesis . . . . . . . . . . 117
7.4.1 Vasculogenesis (Day 15?2). . 118
7.4.2 Angiogenesis and Vascular Remodeling (Day 32 to Week 40) . . . . . 121
7.5 Molecular Regulation of Vasculogenesis and Angiogenesis . . . . . . . . . . . . . . 121
7.5.1 Vascular Endothelial Growth Factor . . . . . 124
7.5.2 Placental Growth Factor. . . . . . 124
7.5.3 Angiopoietins. . . . . . . . . . . . . . 125
7.5.4 Fibroblast Growth Factor. . . . . 125
7.5.5 Homeobox Genes. . . . . . . . . . . 125
7.6 Oxygen and Oxygen-Controlled Growth Factors as Regulators
of Villous and Vascular Development. . 126
7.6.1 Oxygen Sensing by Placental Tissues . . . . 128
7.6.2 Evidence for Oxygen-Controlled Fetoplacental Angiogenesis . . . . . 130
7.6.3 Oxygen and Villous Trophoblast . . . . . . . . 131
7.6.4 Oxygen and Villous Stroma. . . 133
7.6.5 Oxygen and Intervillous Circulation . . . . . 133
7.6.6 The Lobular Arrangement of the Villous Trees . . . . . . . . . . . . . . . . . 134
7.6.7 The Intervillous Clefts. . . . . . . 136
7.7 Histopathological Importance of Inhomogeneity of Villous Trees . . . . . . . . . 137
7.8 Fetomaternal Flow Interrelations. . . . . . 137
References. . . . . . . . 138
8 Characterization of the Developmental Stages . . . . . . . 145
8.1 Stages of Development. . . . . . . . . . . . . 145
References. . . . . . . . 155
9 Nonvillous Parts and Trophoblast Invasion157
9.1 Extravillous Trophoblast. . . . . . . . . . . . 157
9.1.1 Origins of Extravillous Trophoblast and Cell Columns . . . . . . . . . . . 157
9.1.2 Stages of Extravillous Trophoblast Differentiation
Along the Invasive Pathway. . . 160
9.1.3 Proliferative Stem Cells. . . . . . 161
9.1.4 Migratory Cells of the Cell Column. . . . . . 161
9.1.5 Cytotrophoblastic Shell. . . . . . 162
9.1.6 Invasive Interstitial Extravillous Trophoblast Cells . . . . . . . . . . . . . . 162
9.1.7 Multinucleated Placental-Bed Giant Cells . 164
9.1.8 Endovascular Trophoblast. . . . 164
9.1.9 Proteinases, Activators, and Inhibitors Involved
in Trophoblast Invasion. . . . . . 165
9.1.10 Cytokines and Hormones Controlling Differentiation
and Invasion of Extravillous Trophoblast . 166
9.1.11 Nitric Oxide, Carbon Monoxide, and Trophoblast Invasion . . . . . . . 169
9.1.12 MHC Class I Molecules. . . . . . 171
9.1.13 Oxygen-Mediated Regulation of the Invasive Pathway . . . . . . . . . . . 172
9.1.14 Failure of Extravillous Trophoblast Invasion
in Pathological Pregnancies. . . 174
9.1.15 Endocrine Activities of Extravillous Trophoblast . . . . . . . . . . . . . . . 175
9.2 Decidua. . . . . 175
9.2.1 Composition of Decidua. . . . . 176
9.2.2 Endometrial Stromal Cells and Decidual Cells . . . . . . . . . . . . . . . . . 176
9.2.3 Endocrine and Paracrine Aspects of Decidua . . . . . . . . . . . . . . . . . . 177
9.2.4 Uterine Natural Killer Cells (UNK Cells) . 178
xii Contents
9.2.5 Macrophages. . . . . . . . . . . . . . 179
9.2.6 Dendritic Cells. . . . . . . . . . . . . 180
9.2.7 B Cells and T Cells. . . . . . . . . 180
9.2.8 Regulatory T Cells. . . . . . . . . . 180
9.2.9 Endometrial Glands. . . . . . . . . 181
9.2.10 Decidual Extracellular Matrix. 181
9.3 Fibrinoid. . . . . 182
9.3.1 Localization of Fibrinoid Subtypes . . . . . . 182
9.3.2 Functions of Fibrinoid. . . . . . . 183
9.4 Calcifi cation. . 185
9.5 Chorionic Plate187
9.5.1 Development. . . . . . . . . . . . . . 187
9.5.2 Structure at Term. . . . . . . . . . . 188
9.5.3 Amnion. . . . . . . . . . . . . . . . . . . 188
9.5.4 Spongy Layer. . . . . . . . . . . . . . 189
9.5.5 Chorionic Mesoderm. . . . . . . . 189
9.5.6 Extravillous Cytotrophoblast. . 189
9.5.7 Langhans?Fibrinoid Layer. . . . 190
9.6 Marginal Zone190
9.6.1 Subchorial Closing Ring. . . . . 190
9.6.2 Marginal Sinus. . . . . . . . . . . . . 190
9.7 Basal Plate. . . 191
9.7.1 Development of the Basal Plate191
9.7.2 Layers of the Basal Plate at Term . . . . . . . 191
9.8 Uteroplacental Vessels. . . . . . . . . . . . . . 194
9.8.1 The Anatomy of the Uteroplacental Vasculature . . . . . . . . . . . . . . . . 194
9.8.2 Establishment of the Maternal Arterial Circulation . . . . . . . . . . . . . . 195
9.8.3 Number and Position of the Uteroplacental Vessels . . . . . . . . . . . . . 196
9.8.4 Importance of Physiological Changes of Uteroplacental Arteries . . . 196
9.8.5 Stages of Physiological Changes in Uteroplacental Arteries . . . . . . . 198
9.8.6 Structure of Uteroplacental Veins . . . . . . . 200
9.8.7 Septa. 200
9.8.8 Cell Islands. . . . . . . . . . . . . . . . 202
9.9 Pathology of Trophoblast Invasion. . . . 204
9.9.1 Placenta Accreta. . . . . . . . . . . . 204
9.9.2 Placenta Increta and Percreta. . 207
9.9.3 Uterine Rupture. . . . . . . . . . . . 210
9.9.4 Placenta in Ectopic (Tubal) Pregnancy . . . 211
9.9.5 Placenta in Abdominal Pregnancy . . . . . . . 213
9.9.6 Cysts and Breus?Mole. . . . . . . 214
9.9.7 Maternal Floor Infarction. . . . . 218
9.9.8 Decidual Degeneration. . . . . . . 222
References. . . . . . . . 223
10 Involution of Implantation Site: Retained Placenta . . . 241
10.1 Involution of the Placental Site. . . . . . . 241
10.2 Subinvolution. 243
10.3 Placental Polyps. . . . . . . . . . . . . . . . . . . 244
10.4 Involution of a Remaining Placenta. . . . 247
References. . . . . . . . 248
11 Anatomy and Pathology of the Placental Membranes . 249
11.1 Overview. . . . 249
11.1.1 Development.. . . . . . . . . . . . . . 250
11.1.2 Amnion. . . . . . . . . . . . . . . . . . . 253
Contents xiii
11.2 Amnionic Epithelium: Different Cell Types and Cell Degeneration . . . . . . . 254
11.3 Cytological and Functional Aspects of the Amnionic Epithelium. . . . . . . . . 255
11.3.1 Amnionic Fluid. . . . . . . . . . . . 258
11.3.2 Chromosomal Determinations259
11.4 Cellular Metaplasia and Glycogen. . . . 260
11.5 Amnionic Mesoderm. . . . . . . . . . . . . . 261
11.5.1 A Medley of Themes. . . . . . . 262
11.5.2 Clinical and Research Applications . . . . . 263
11.6 Chorion Laeve. . . . . . . . . . . . . . . . . . . 263
11.7 Intermediate (Spongy) Layer. . . . . . . . 264
11.8 Chorionic Mesoderm. . . . . . . . . . . . . . 264
11.9 Trophoblast Layer. . . . . . . . . . . . . . . . 265
11.10 Decidua. . . . 266
11.11 Tensile Properties of the Membranes. . 267
11.12 Pathology of the Membranes. . . . . . . . 268
11.12.1 Preterm Rupture of the Membranes . . . 268
11.12.2 Cysts, Tumors, and Hemorrhage . . . . . . 269
11.12.3 Amnionic Fluid Embolism. . 272
11.12.4 Meconium. . . . . . . . . . . . . . . 274
11.12.5 Gastroschisis. . . . . . . . . . . . . 283
11.12.6 Epidermolysis Bullosa. . . . . 284
11.12.7 Amnion Nodosum. . . . . . . . 285
11.12.8 Amnionic Bands. . . . . . . . . . 287
11.12.9 Limb-Body Wall Defect. . . . 293
11.12.10 Extramembranous Pregnancy293
References. . . . . . . . 295
12 Anatomy and Pathology of the Umbilical Cord . . . . . . 309
12.1 Development309
12.2 Amnionic Epithelium. . . . . . . . . . . . . . 311
12.3 Wharton뭩 Jelly.. . . . . . . . . . . . . . . . . . 311
12.4 Structure of Umbilical Vessels. . . . . . . 312
12.4.1 Innervation. . . . . . . . . . . . . . 313
12.4.2 Contractility of Umbilical Vessels . . . . . 314
12.4.3 Hyrtl Anastomosis, False Knots, and Hoboken Nodes . . . . . . . . . 315
12.4.4 Allantois. . . . . . . . . . . . . . . . 317
12.4.5 Omphalomesenteric Duct. . . 318
12.5 Spiral Turns of the Cord. . . . . . . . . . . . 321
12.6 Length of the Cord. . . . . . . . . . . . . . . . 324
12.6.1 Abnormal Length, Nuchal Cord . . . . . . . 325
12.6.2 Site of Cord Insertion. . . . . . 330
12.6.3 Furcate Cord Insertion. . . . . 331
12.6.4 Velamentous Cord Insertion. 331
12.7 Placental Surface Vessels. . . . . . . . . . . 336
12.8 Nucleated Red Blood Cells (NRBCs). 339
12.9 Cysts and Edema. . . . . . . . . . . . . . . . . 339
12.10 Single Umbilical Artery. . . . . . . . . . . . 341
12.11 Placental Transfusion. . . . . . . . . . . . . . 344
12.12 Knots. . . . . . 345
12.13 False Knots. . 346
12.14 Strictures. . . 346
12.15 Rupture. . . . . 348
12.16 Hematoma. . 349
12.17 Varices and Aneurysms. . . . . . . . . . . . 351
12.18 Thrombosis of the Umbilical Vessels. . 354
xiv Contents
12.19 Thrombosis of the Placental Vascular Tree . . . . . . 357
12.20 Tumors of the Umbilical Cord. . . . . . . 362
References. . . . . . . . 363
13 Placental Shape Aberrations. . . . . . . . . . . . 377
13.1 Site of Placental Attachment. . . . . . . . 377
13.2 Volumetric Growth. . . . . . . . . . . . . . . . 379
13.3 Abnormal Shapes (밇rrors in Outline?379
13.4 Placenta Previa. . . . . . . . . . . . . . . . . . . 382
13.5 Placenta Membranacea.. . . . . . . . . . . . 386
13.6 Circumvallate Placenta (Extrachorial, Circummarginate Placentas) . . . . . . . 387
References. . . . . . . . 390
14 Histopathological Approach to Villous Alterations . . . 395
14.1 Microscopic Evaluation. . . . . . . . . . . . . 395
14.1.1 Assessment of Villous Maturation . . . . . . 395
14.1.2 Placental Insuffi ciency. . . . . . 397
14.1.3 Examination of Fetal Stem Vessels . . . . . . 398
14.1.4 Examination of the Fetal Capillary Bed . . 399
14.1.5 Villous Architecture and Fibrinoid . . . . . . 399
14.1.6 Intervillous Space, Infarcts. . . 400
14.1.7 Abruptio Placentae. . . . . . . . . 401
14.2 Major Histopathological Findings. . . . 401
14.2.1 Syncytiotrophoblast. . . . . . . . 401
14.2.2 Knotting of the Syncytiotrophoblast . . . . . 402
14.2.3 Langhans?Cells. . . . . . . . . . . 402
14.2.4 Vasculosyncytial Membranes. 403
14.2.5 Trophoblastic Basement Membrane . . . . . 403
14.2.6 Perivillous Fibrinoid. . . . . . . . 403
14.2.7 Intravillous Fibrinoid. . . . . . . 403
14.2.8 Villous Calcifi cation. . . . . . . . 403
14.2.9 Stem Vessels. . . . . . . . . . . . . . 404
14.2.10 Nucleated Red Blood Cells. . . 405
14.2.11 Villous Capillarization. . . . . . 405
14.2.12 Stromal Architecture and Stromal Fibrosis . . . . . . . . . . . . . . . . . . . 406
14.2.13 Hofbauer Cells (Macrophages)406
14.2.14 Infl ammatory Changes. . . . . . 406
14.2.15 Villous Edema or Immaturity. 407
References. . . . . . . . 409
15 Villous Maldevelopment. . . . . . . . . . . . . . . . 411
15.1 Three-Dimensional Interpretation of Two-Dimensional Sections . . . . . . . . . 411
15.2 Syncytial Knotting: Artifact or Meaningful Pathological Finding? . . . . . . . . 411
15.3 Classifi cation of Villous Maldevelopment . . . . . . . 414
15.4 Cases of Villous Maldevelopment. . . . 416
15.4.1 Synchronous Villous Immaturity . . . . . . . 416
15.4.2 Persisting Villous Immaturity and Rhesus Incompatibility . . . . . . . 417
15.4.3 Normal Mature Placenta. . . . . 417
15.4.4 Preterm Villous Maturation and Villous Hypermaturity . . . . . . . . . . 419
15.4.5 Prolonged Pregnancy. . . . . . . 419
15.4.6 Placentas at High Altitude and Maternal Anemia . . . . . . . . . . . . . . . 420
15.4.7 Intrauterine Growth Restriction . . . . . . . . 421
15.4.8 Maternal Diabetes Mellitus. . . 423
References. . . . . . . . 425
Contents xv
16 Erythroblastosis Fetalis and Hydrops Fetalis . . . . . . . . 429
16.1 Erythroblastosis Fetalis. . . . . . . . . . . . 429
16.2 Placental Pathology in Erythroblastosis430
16.2.1 Nonimmune Hydrops. . . . . . . 436
16.2.2 a-Thalassemia. . . . . . . . . . . . . 437
16.3 Fetal Hemorrhage. . . . . . . . . . . . . . . . . 439
16.3.1 Fetal Tumors. . . . . . . . . . . . . . 440
16.4 Congenital Anomalies and Hydrops Fetalis . . . . . . 443
16.5 Congenital Heart Disease. . . . . . . . . . . 444
16.6 Cardiac Arrhythmias. . . . . . . . . . . . . . 445
16.7 Nephrotic Syndrome. . . . . . . . . . . . . . 445
16.8 Parvovirus Anemia and Other Causes of Myocarditis . . . . . . . . . . . . . . . . . . 446
16.8.1 Hydrop s of Unknown Etiology450
References. . . . . . . . 452
17 Transplacental Hemorrhage, Cell Transfer, Trauma . 461
17.1 Transplacental Blood and Cell Transfer461
17.2 Trauma. . . . . 461
17.3 Placenta in Hemorrhage. . . . . . . . . . . . 466
17.4 Technique for Identifi cation of Fetal Red Blood Cells . . . . . . . . . . . . . . . . . 467
17.5 Signifi cant Transplacental Hemorrhage471
17.6 Fetal Consequences of Massive Hemorrhage
Across the Placenta. . . . . . . . . . . . . . . 473
17.7 Nucleated Fetal Blood Elements Passing Through the Placenta . . . . . . . . . . 477
17.8 Mother to Fetus Transfer of Cells. . . . 478
References. . . . . . . . 479
18 Fetal Storage Disorders. . . . . . . . . . . . . . . . 487
References. . . . . . . . 492
19 Maternal Diseases Complicating Pregnancy: Diabetes, Tumors,
Preeclampsia, Lupus Anticoagulant. . . . . . 495
19.1 Maternal Diseases. . . . . . . . . . . . . . . . 495
19.1.1 Scleroderma. . . . . . . . . . . . . . 495
19.1.2 Dermatomyositis. . . . . . . . . . . 496
19.1.3 Ehlers뺻anlos Syndrome. . . . 496
19.1.4 Rheumatoid Arthritis. . . . . . . 496
19.1.5 Acute Fatty Liver of Pregnancy . . . . . . . . 497
19.1.6 Hyperemesis Gravidarum. . . . 497
19.1.7 Smoking. . . . . . . . . . . . . . . . . 499
19.1.8 Hodgkin뭩 Disease. . . . . . . . . 500
19.1.9 Irradiation. . . . . . . . . . . . . . . . 501
19.1.10 Hypercholesterolemia. . . . . . . 501
19.1.11 Pruritus Gravidarum. . . . . . . . 201
19.1.12 Pheochromocytoma. . . . . . . . 502
19.1.13 Hematological Disorders. . . . 502
19.1.14 Endocrine Disorders. . . . . . . . 505
19.1.15 Diabetes Mellitus During Pregnancy . . . . 506
19.1.16 Maternal Neoplasms. . . . . . . . 509
19.2 Hypertensive Disorders. . . . . . . . . . . . 513
19.2.1 Preeclampsia. . . . . . . . . . . . . . 513
19.2.2 Animal Models. . . . . . . . . . . . 514
19.2.3 Placental Pathology of Preeclampsia . . . . 514
19.2.4 Decidual Arteriopathy. . . . . . . 515
xvi Contents
19.2.5 Infarcts. . . . . . . . . . . . . . . . . . 519
19.2.6 Abruptio Placentae. . . . . . . . . 522
19.2.7 Fetal Effects of Abruptio Placentae . . . . . 526
19.2.8 Other Placental Changes in Preeclampsia . 526
19.2.9 Etiology of Toxemia, Pregnancy-Induced
Hypertension, or Preeclampsia529
19.3 Lupus Erythematosus and Lupus Anticoagulant . . 532
19.3.1 Lupus Erythematosus. . . . . . . 532
19.3.2 Lupus Anticoagulant. . . . . . . . 536
References. . . . . . . . 539
20 Infectious Diseases. 557
20.1 Chorioamnionitis. . . . . . . . . . . . . . . . . 557
20.1.1 Macroscopic Appearance. . . . 557
20.1.2 Microscopic Appearance. . . . 559
20.1.3 General Considerations of Chorioamnionitis . . . . . . . . . . . . . . . . . . 572
20.1.4 Specifi c Microorganisms.. . . . 575
20.2 Leprosy. . . . . 581
20.3 Tuberculosis. 582
20.4 Listeriosis. . . 583
20.5 Actinomyces. 586
20.6 Mycoplasma Hominis and Ureaplasma Urealyticum . . . . . . . . . . . . . . . . . . 586
20.7 Chlamydia trachomatis and C. psittaci587
20.8 Bacterial Vaginosis. . . . . . . . . . . . . . . . 589
20.9 Syphilis. . . . . 589
20.10 Necrotizing Funisitis. . . . . . . . . . . . . . 592
20.11 Other Spirochetal Diseases. . . . . . . . . 595
20.12 Fungus Infections. . . . . . . . . . . . . . . . . 595
20.13 Virus Infections and Villitides. . . . . . . 599
20.13.1 Cytomegalovirus Infection. . 599
20.13.2 Herpes Simplex Virus Infection . . . . . . . 603
20.13.3 Varicella (Chickenpox). . . . . 607
20.13.4 Epstein뺹arr Virus. . . . . . . . 608
20.13.5 Smallpox, Vaccinia, Alastrim, and Parvovirus B19 . . . . . . . . . . . . 608
20.13.6 Enteroviruses. . . . . . . . . . . . 609
20.13.7 Infl uenza, Mumps, and Rabies . . . . . . . . 610
20.13.8 Hepatitis. . . . . . . . . . . . . . . . 610
20.13.9 Rubella (German Measles) and Other Viral Infections . . . . . . . . . 612
20.13.10 Rubeola: Measles. . . . . . . . . 612
20.13.11 Human Immunodefi ciency Virus (HIV) Infection . . . . . . . . . . . . . 613
20.14 Toxoplasmosis. . . . . . . . . . . . . . . . . . . 614
20.15 Kala-Azar. . . 618
20.16 Chagas?Disease. . . . . . . . . . . . . . . . . . 618
20.17 Babesiosis, Trichomoniasis, Rickettsia, and Ehrlichia . . . . . . . . . . . . . . . . . 619
20.18 Malaria. . . . . 620
20.19 Other Parasitic Infections. . . . . . . . . . . 621
20.20 Villitis of Unknown Etiology (VUE). . 622
References. . . . . . . . 629
21 Abortion, Placentas of Trisomies, and Immunological
Considerations of Recurrent Reproductive Failure . . . 657
21.1 Anatomical Findings. . . . . . . . . . . . . . 659
21.2 Summary of Placental Findings in Chromosomally Defi ned Abortions . . . . 662
21.2.1 Trisomies. . . . . . . . . . . . . . . . 662
21.2.2 Polyploidies. . . . . . . . . . . . . . 664
Contents xvii
21.2.3 Monosomy X. . . . . . . . . . . . . 665
21.2.4 Induced Abortion. . . . . . . . . . 666
21.3 Incomplete Abortion. . . . . . . . . . . . . . 670
21.4 Placenta in Chorionic Villus Sampling671
21.5 Trisomic Placentas. . . . . . . . . . . . . . . . 674
21.5.1 Chemical Markers and Trisomy . . . . . . . . 676
21.6 Recurrent or Habitual Abortion. . . . . . 677
References. . . . . . . . 679
22 Molar Pregnancies687
22.1 Incidence. . . 688
22.2 Genetics. . . . 690
22.3 Recurrent Hydatidiform Moles. . . . . . 695
22.4 Complete Hydatidiform Moles. . . . . . 696
22.5 Partial Hydatidiform Mole. . . . . . . . . . 700
22.6 Other Attributes. . . . . . . . . . . . . . . . . . 703
22.7 Deportation. . 705
22.8 Invasive Mole (Chorioadenoma Destruens) . . . . . . 706
22.9 Therapy. . . . 708
22.10 Ectopic Moles.. . . . . . . . . . . . . . . . . . . 709
22.11 Complete Mole and Coexistent Fetus. 709
22.12 PHM with Twin Gestation. . . . . . . . . . 711
References. . . . . . . . 713
23 Trophoblastic Neoplasms. . . . . . . . . . . . . . . 723
23.1 Choriocarcinoma. . . . . . . . . . . . . . . . . 723
23.1.1 Intraplacental Choriocarcinoma (Choriocarcinoma 밒n Situ?
and Choriocarcinoma Coincident with Pregnancy . . . . . . . . . . . . . . 728
23.1.2 Chorangiocarcinoma. . . . . . . 730
23.2 Lesions of Extravillous Trophoblast: Exaggerated Placental Site,
Placental Site Nodule, Placental Site Trophoblastic Tumor (PSTT),
and Epithelioid Trophoblastic Tumor (ETT) . . . . . 731
23.3 Ultrastructure of Trophoblastic Tumors735
23.4 Antigenic Studies of Trophoblastic Tumors. . . . . . 735
23.5 Epidemiology of Choriocarcinoma. . . 736
23.6 Endocrine Aspects of GTN. . . . . . . . . 737
23.7 Ectopic Choriocarcinomas: Tumors in Men . . . . . 738
23.8 Therapy of GTN. . . . . . . . . . . . . . . . . . 739
23.9 Choriocarcinoma in Animals. . . . . . . . 740
23.10 Choriocarcinoma in Cell Lines and Genetics. . . . . 740
References. . . . . . . . 741
24 Benign Tumors and Chorangiosis. . . . . . . . 747
24.1 Chorangiomas. . . . . . . . . . . . . . . . . . . 747
24.2 Other Benign Tumors. . . . . . . . . . . . . . 754
24.3 Chorangiosis and Chorangiomatosis. . 754
24.4 Mesenchymal Dysplasia and the Beckwith-Wiedemann Syndrome . . . . . . . 756
References. . . . . . . . 756
25 Multiple Pregnancies. . . . . . . . . . . . . . . . . . 761
25.1 Zygosity. . . . 761
25.2 The Placenta in the Study of Zygosity. 764
25.3 Causes of Multiple Births and Incidence . . . . . . . . 769
25.4 Third Type of Twin. . . . . . . . . . . . . . . 774
xviii Contents
25.5 Twinning Incidence. . . . . . . . . . . . . . . 776
25.6 Superfetation and Superfecundation. . 778
25.7 Vascular Anatomy of Twin Placentas.. 778
25.8 Monoamnionic Monochorionic Twin Placenta . . . 784
25.9 Diamnionic Monochorionic Twin Placenta . . . . . . 798
25.10 Diamnionic, Dichorionic Twin Placenta . . . . . . . . 800
25.11 Vanishing Twin Phenomenon. . . . . . . . 801
25.12 Fetus Papyraceus. . . . . . . . . . . . . . . . . 805
25.13 Twin-to-Twin Transfusion Syndrome. 811
25.14 Amniopatch. 825
25.15 Acardiac Twins. . . . . . . . . . . . . . . . . . . 826
25.16 Conjoined Twins. . . . . . . . . . . . . . . . . 835
25.17 Sacrococcygeal Teratoma, Epignathus. 838
25.18 Congenital Anomalies. . . . . . . . . . . . . 840
25.19 Cytogenetics and 밐eterokaryotypic MZ Twins?. 842
25.20 Chimerism, Mosaicism. . . . . . . . . . . . 843
25.21 Whole-Body Chimerism. . . . . . . . . . . 845
25.22 Triplets and Higher Multiple Births. . . 846
25.23 Twins in Abortion and Ectopic Pregnancy . . . . . . . 851
25.24 Morbidity and Mortality. . . . . . . . . . . . 853
25.25 Hormones in Twin Pregnancy. . . . . . . 855
References. . . . . . . . 855
26 Legal Considerations. . . . . . . . . . . . . . . . . . 883
26.1 Twinning Problems. . . . . . . . . . . . . . . 886
26.2 Infl ammation888
26.3 The Green Placenta. . . . . . . . . . . . . . . 889
26.4 Vascular Abnormalities. . . . . . . . . . . . 890
26.5 Umbilical Cord. . . . . . . . . . . . . . . . . . . 891
26.6 Placental Villous Color. . . . . . . . . . . . 892
26.7 Other Types of Pathology. . . . . . . . . . . 893
References. . . . . . . . 895
27 Artifi cial Reproductive Technology (ART). 897
27.1 Placental Pathology with ART. . . . . . . 899
27.2 Monozygosity and Monochorionicity Following ART . . . . . . . . . . . . . . . . . 900
27.3 Chimerism. . 901
27.4 Confi ned Placental Mosaicism. . . . . . . 901
27.5 Imprinting. . . 901
27.6 Immunology. 902
References. . . . . . . . 902
Appendix.. . 907
Index.. . . . . 925
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