Pathology of the Human Placenta - Home - Springer978-1-4757-4193-3/1.pdf · Pathology of the Human Placenta Second Edition . Kurt Benirschke Peter Kaufmann Pathology of the Human

Pathology of the Human Placenta

Second Edition

Kurt Benirschke Peter Kaufmann

Pathology of the Human Placenta Second Edition

With 613 Illustrations in 685 Parts

Springer Science+Business Media, LLC

Kurt Benirschke, MD Professor of Pathology and Reproductive Medicine, University of California, San Diego, University Medical Center, San Diego, California 92103-1990, USA

Professor Dr. med. Peter Kaufmann Institut fiir Anatomie der Medizinischen Fakultăt , Rheinisch-Westfâlische Technische Hochschule Aachen, 5100 Aachen, FRG

Library of Congress Cataloging-in-Publication Data Benirschke, Kurt.

Pathology of the human placenta 1 Kurt Benirschke, Peter Kaufmann. - 2nd ed.

p. cm. Includes bibliographical references.

ISBN 978-1-4757-4195-7 ISBN 978-1-4757-4193-3 (eBook) DOI 10.1007/978-1-4757-4193-3 Softcover reprint ofthe hardcover 2nd edition 1990

1. Placenta-Diseases. I. Kaufmann, Peter, 1942- . II. Title. [DNLM: 1. Placenta-pathology. WQ 212 B467p)

RG59l.B38 1990 616.3'4-dc20 DNLM/DLC 90-9659

© 1990Springer Science+Business Media New York

Originally published by Springer-Verlag New York Inc in 1990. Ali rights reserved. This work may not be translated or copied in whole or in pari without the writ­ten permission of the publisher (Springer Science+Business Media, LLC ), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, com­puter software, or by similar or dissimilar methodology now known or hereafter developed is for­bidden. The use of general descriptive names, trade names, trademarks, etc., in this publication, even if the former are not especially identified, is not tobe taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act , may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsi­bility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

Typeset by Publishers Service of Montana, Bozeman, Montana.

9 8 7 6 5 4 3 2 l

Preface

Most obstetricians and pediatricians would agree that the examination of the placenta often helps to explain abnormal neonatal outcome. As early as in 1892, Ballantyne wrote that

A diseased foetus without its placenta is an imperfect specimen, and a description of a foetal malady, unless accompanied by a notice of the placental condition, is incom­plete. Deductions drawn from such a case cannot be considered as conclusive, for in the missing placenta or cord may have existed the cause ofthe disease and death. Dur­ing intrauterine life the foetus, the membranes, the cord and the placenta form an organic whole, and disease of any part must react upon and affect the others.

Similar thoughts were succinctly detailed in Price's development of his con­cept of the "Prenatal Biases" as they affected twins, admonishing us also that placental study is a sine qua non for a more perfect understanding of fetal development (1950). Despite all this in our past, great resistance still exists to perform the task of placental examination routinely, and for many the placenta has remained a mysterious organ.

In 1967 Shirley G. Driscoll and I, therefore, wrote the chapter on placental pathology for the German Handbook of Pathology, the Henke-Lubarsch. Because there seemed to be a need for wider dissemination of the text, this was reprinted by Springer-Verlag New York, but it soon became unavailable. Since then, several books on placental pathology have been written, in French, German, and English (Philippe, Fox, Perrin, Lavery, Becker & Roeckelein) , and much more interest has been accorded this "so readily avail­able but poorly studied" organ. A new journal (Placenta) has appeared, and numerous chemical and pathological studies have been conducted. Regular Placenta Conferences have been held by the Rochester Trophoblast Confer­ence Series and the European Placenta Group, and the enigma of placental non-rejection has been tackled by numerous investigators. Some new infor­mation is being gathered continuously, and there will be no possible way to write a definitive text for some time to come.

The decision to rewrite this original text was made because of this con­stantly newly created knowledge, the fact that, in the past five years, the placenta has become a focal point of many litigations for cerebral palsy and fetal death , and because the anatomic pathologist performing surgical patho­logical diagnosis still has problems when faced with the task of having to

v

vi

undertake a decisive examination of this organ. Moreover, I have continued to collect material and have had the good fortune to be associated with many inquiring minds, the dysmorphologists (Drs. Kenneth L. Jones and his wife Marilyn) and ultrasonographers/radiologists (Drs. George R. Leopold and Dolores Pretorius; David K. Edwards) who continue to challenge me and require that I provide explanations for perinatal deaths and abnormalities. Having examined all placentas of all deliveries in the institutions with which I was affiliated over the past two decades, I have gathered a large amount of material to digest. Regrettably, Shirley Driscoll does not have the time to par­ticipate in the review of this material. Instead, Professor Peter Kaufmann agreed to write the normal anatomical and histological aspects of placental structure and development. The magnifications of illustrations are given as originally supplied. Many have been cropped to fit the space requirements and thus deviate slightly from the originals.

The text was written with WordPerfect 5.0. References are available from the authors on diskette, if desired.

I (KB) am indebted to many people, foremost to my wife for her understand­ing and patience with me and this task. The publisher, with many of its people, has been gracious and patient. My colleagues at the university, secretaries, computer consultants and other persons who have all helped gather data are gratefully acknowledged. It is also a pleasure to give special thanks to Mr. M. Graves, my photographic assistant, for his never-ending patience with the numerous requests I have made of him. Many students and colleagues have graciously read most chapters and they have made many helpful suggestions and corrections for which I am grateful. Last but not least I am most grateful to Dr. Geoffrey Altshuler, Oklahoma City, for many stimulating discussions and for his willingness to read and correct most pages of this manuscript. He undertook this with endless patience and friendship.

PK gratefully acknowledges the artistic help of W. Graulich and the photo­graphic assistance of G. Bock and U. Kaufmann. The histological and elect­ron-microscopic pictures are based on material processed by L. Philippens, D. Seelis, B. Witte, and Uta Zahn. Many of his former and current scientific coworkers have considerably contributed to the information presented here. In particular, Drs. Mario Castellucci, Irmgard Classen-Linke, Georg Kosanke, Arne Kotowski, Rudolf Leiser, Michael Luckhardt, Judith Muehl­hauser, Iris Scheffen, and Gertfried Schweikhart must be mentioned. Their scientific collaboration was the basis for PK's contribution. Finally, PK is grateful for the secretarial assistance of J. Jacobs, M. Kaufmann, and B. Witte.

Kurt Benirschke La Jolla, California

References

Peter Kaufmann Aachen, Federal Republic of Germany 1990

Ballantyne, J.W.: The diseases and deformities of the foetus. Vol. I. Oliver and Boyd, Edinburgh, 1892.

Becker, V., and Roeckelein, G. Pathologic der plazenta und des abortes. Springer­Verlag, Heidelberg, 1989.

Benirschke, K., and Driscoll, S.G.: The pathology of the human placenta. Springer­Verlag, New York, 1967.

Preface

Preface vii

Fox, H.: Pathology of the placenta. W.B. Saunders Co. , Philadelphia, 1978. Lavery, J.P., ed.: The human placenta. Clinical perspectives. Aspen Publishers, Rock­

ville, Maryland, 1987. Perrin, V.D.K., ed.: Pathology of the placenta. Churchill Livingstone, New York,

1984. Philippe, E.: Pathologie Foeto-Placentaire. Masson, Paris, 1986. Price, B.: Primary biases in twin studies: Review of prenatal and natal differences­

producing factors in monozygotic pairs. Am. J. Hum. Genet. 2:293-352, 1950.

Contents

Preface. . ............... . ....................... .. ... v

1. Placental Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Placental shapes · Types of matemofetal interdigitation Matemofetal barrier · Matemofetal blood flow interrelations · Placental types and phylogeny

2. Early Development of the Human Placenta . . . . . . . . . . . . 13 Prelacunar stage · Lacunar stage · Early villous stages

3. Basic Structure of the Villous Trees . . . . . . . . . . . . . . . . . . 22 Syncytiotrophoblast · Syncytium or multinucleated giant cells? · Syncytial plasmalemmas and microvilli · Zonal layering of syncytioplasm · Syncytiotrophoblastic cytoskeleton · Specialized regions of the villous surface · Epithelial plates · Syncytial lamellae covering Langhans' cells · Syncytiotrophoblast with prevailing rough endoplasmic reticulum · Syncytiotrophoblast with prevailing smooth endoplasmic reticulum · Syncytial knots, sprouts, bridges, and stromal trophoblastic buds · Transtrophoblastic channels · Plasma protrusions · Villous cytotrophoblast (Langhans' cells) · Langhans' cells as precursors of the syncytiotrophoblast · Langhans' cell types · Nematosomes Endocrine activity of the Langhans' cells · Functional aspects of syncytial fusion · Langhans' cells and gestational pathology Regulation of cytotrophoblastic proliferation and fusion Trophoblastic basal lamina · Connective tissue · Mesenchymal cells · Reticulum cells · Fibroblasts · Myofibroblasts · Connective tissue fibers · Development and structure of fetal villous vessels · Origin of the hemangioblastic

cells · Capillary formation during early pregnancy · Role of macrophages in vasculogenesis · Basic structure of the vessel walls

IX

x Contents

4. Hofbauer Cells M. Castellucci and P. Kaufmann . . . . . . . . . . . . . . . . . . . . . 71 First descriptions Morphology Occurrence and distribution Origin Immunological aspects Other free connective tissue cells

5. Architecture of Normal Villous Trees . . . . . . . . . . . . . . . . . 81 Structure of villous types Stem villi Immature intermediate villi Mature intermediate villi Terminal villi Mesenchymal villi Differentiation and maturation of the villous types Development of the mesenchymal villi Development and fate of immature intermediate villi Development of stem villi Development of the mature intermediate villi Development of the terminal villi Angioarchitecture of villi Vascular arrangement in immature villi Larger vessels of stem villi Paravascular capillary net of stem villi Vessel arrangement in mature intermediate and terminal villi Sinusoids of terminal villi Capillary growth as related to the development of terminal villi Intervillous space as related to the villous trees Fetomaternal flow interrelations

6. Three-Dimensional Aspects of Villous Maldevelopment 114 Villous cross-sectional features Villous maldevelopment Normal mature placenta Synchronous villous immaturity Persisting villous immaturity and rhesus incompatibility Terminal villi deficiency Maternal diabetes mellitus Villous hypermaturity Preeclampsia, hypertensive disorders, and placentas at high altitudes Prolonged pregnancy Classification of vil-lous maldevelopment

7. Placental Membranes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Development Amnion Amnionic epithelium (different cell types or cell degeneration) Cytological and functional aspects of the arnnionic epithelium Chromosomal determinations Cellular metaplasia and glycogen Amnionic mesoderm Clinical and research applications Chorion laeve Intermediate (spongy) layer Chorionic mesoderm Trophoblast layer Decidua Molecular aspects of the connective tissue of the membranes Physical properties of the membranes Cysts, tumors, and hemorrhage Amnionic fluid embolism · Meconium Gastroschisis Amnion nodosum Arnnionic bands Extramembranous pregnancy

8. Umbilical Cord and Major Fetal Vessels. . . . . . . . . . . . . . . 180 Structure Vessels Allantois Omphalomesenteric duct Innervation Spiral turns of the cord Length of the cord Abnormal length, nuchal cord Site of cord insertion Furcate cord insertion Velamentous cord insertion Placental surface vessels Cysts and edema

Contents

Single umbilical artery · Persisting umbilical vein · Placental transfusion · Knots · False knots · Strictures Rupture · Hematoma · Varices and aneurysms · Thrombosis of the umbilical vessels · Thrombosis of the placental vascular tree · Tumors of the umbilical cord

xi

9. Nonvillous Parts of the Placenta . . . . . . . . . . . . . . . . . . . . . 244 Extravillous trophoblast and origin of the X cells · Nomenclature · Origin · Composition of the extravillous trophoblast population · Types of extravillous cytotrophoblast Placental site giant cells · Multinucleated trophoblastic giant cells Syncytiogenesis · Secretory activities of extravillous cytotrophoblast · Decidua · Structural aspects of decidualization · G cell · Granular cell · Extracellular matrix · Functional relevance · Decidual degeneration · Chorionic plate · Development · Structure at term · Amnion · Spongy layer · Chorionic mesoderm · Primary cytotrophoblast · Langhans' fibrinoid layer · Marginal zone Subchorial closing ring · Trabeculae · Marginal sinus · Basal plate · Trophoblastic shell and development of the basal plate · Layers of the basal plate at term · Development of uteroplacental vessels · Number and position of the uteroplacental vessels · Structure of the uteroplacental arteries · Structure of uteroplacental veins · Intraarterial trophoblast · Functional aspects of uteroplacental vessels · Septa · Cell islands · Cell columns · Cysts and Breus' mole

10. Fibrinoid and Calcification . . . . . . . . . . . . . . . . . . . . . . . . . 306 Fibrinoid · Definition · Subchorial fibrinoid: Langhans' stria · Perivillous fibrinoid · Intravillous fibrinoid · Fibrinoid deposits in

11.

12.

cell islands and placental septa · Superficial fibrinoid of the basal plate: Rohr's stria · Uteroplacental fibrinoid of the basal plate: Nitabuch's stria · Intramural fibrinoid of uteroplacental arteries and veins · Fibrinoid in smooth chorion · Conclusion concerning fibrinoid · Calcification

Characterization of the Developmental Stages Additional data and discussion

Macroscopic Features of the Delivered Placenta

328

351

13. Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355 Macroscopic examination · Storage · Selection ·

14.

Photography · Examination · Placentas of multiple births ·

Fixation

Placental Shape Aberrations Site of placental attachment · Volumetric growth · Abnormal shapes ("errors in outline") · Placenta previa ·

367

xii

Placenta accreta 0 Placenta increta and percreta 0 Placenta membranacea 0 Placenta in ectopic pregnancy 0 Placenta in abdominal pregnancy ° Circumvallate placenta (extrachorial, circummarginate placentas)

15 0 Involution 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 398

Involution of the placental site 0 Subinvolution polyps 0 Involution of a remaining placenta

Placental

160 Pathology of Maternal Floor Infarction 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 406

170 Erythroblastosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 412

Placental pathology in erythroblastosis

180 Hydrops Fetalis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 423

a-Thalassemia ° Fetal hemorrhage ° Fetal tumors 0

Congenital anomalies and hydrops ° Congenital heart disease ° Cardiac arrhythmias 0 Nephrotic syndrome Parvovirus anemia 0 Hydrops of unknown etiology

190 Transplacental Hemorrhage 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 443

200

Transplacental blood and cell transfer 0 Hemorrhage 0

Technique for identification of fetal red blood cells 0

Significant transplacental hemorrhage ° Fetal consequences of massive hemorrhage across the placenta 0 Placenta in transplacental hemorrhage 0 Other fetal blood elements passing through the placenta 0 Mother to fetus transfer of cells

Fetal Storage Disorders 460

210 Maternal Diseases Complicating Pregnancy 0 0 0 0 0 0 0 0 0 0 0 0 465

Maternal diseases 0 Scleroderma 0 Dermatomyositis 0

Ehlers-Danlos syndrome 0 Rheumatoid arthritis 0 Periarteritis nodosa o Takayasu's arteritis 0 Myositis ossificans o Acute renal failure 0 Renal transplantation ° Acute fatty liver of pregnancy

Cholestasis of pregnancy 0 Hyperemesis gravidarum 0 Alcohol Cocaine and crack 0 Heroin ° LSD 0 Smoking 0

Methotrexate 0 Irradiation ° Maternal heart disease Hyperlipemias 0 J.Urious congenital syndromes 0 Sarcoidosis Cystinosis 0 Gaucher's disease 0 Pheochromocytoma 0

Hematological disorders 0 Sickle cell anemia 0 Idiopathic thrombocytopenia o Thrombotic thrombocytopenic purpura 0

Leukoagglutinins 0 von Willebrand's disease ° Factor VII deficiency 0 Hemorrhagic hereditary telangiectasia 0 Protein C deficiency ° Folate deficiency 0 Anemia 0 High altitude ° Fetal Letterer-Siwe's disease 0 Endocrine disorders 0 Thyroid diseases ° Cushing's disease 0 Diabetes during pregnancy Trauma 0 Transplacental fetal bleeding 0 Abruptio placentae Amniocentesis 0 Therapeutic abortion ° Cesarean section °

Contents

Contents xm

Automobile accidents · Maternal neoplasms · Malignant

melanoma · Fetal giant pigmented nevi · Breast carcinoma

Solid tumors · Multiple myeloma · Hodgkin's disease

Hemangioma of the uterus · Leukemia

22. Hypertensive Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499 Animal models Placental pathology of preeclampsia Decidual arteriopathy Infarcts Abruptio placentae · Fetal effects of abruptio placentae · Other placental changes in preeclampsia Etiology of toxemia and PIH

23. Lupus Erythematosus and Lupus Anticoagulant. . . . . . . . . 530 Lupus erythematosus Lupus anticoagulant

24. Infectious Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 542 Chorioamnionitis Macroscopic appearance · Microscopic appearance · General considerations of chorioamnionitis · Specific microorganisms · Neisseria gonorrhoeae · Group B streptococci Group A P-hemolytic streptococci · Streptococcus

pneumoniae Haemophilus injluenzae · Diplococcus

pneumoniae Salmonella typhi · Shigella sonnei · Clostridium

perfringens Diphtheroids · Corynebacterium kutscheri

Fusobacterium neocrophorum · Bacteroides fragilis · Campylobacter (Vibro) fetus · Streptobacillus monilifonnis

Gardnerella vagina/is · Ureaplasma urealyticum · Tularemia

Brucellosis · Leprosy Tuberculosis Listeriosis Mycoplasma hominis and Ureaplasma urealyticum · Chlamydia trachomatis · Bacterial vaginosis Syphilis Necrotizing funisitis Other spirochetal diseases Fungus infections Virus infections and villitides Cytomegalovirus infections Herpes simplex virus infection · Varicella (chickenpox) · Epstein-Barr virus · Smallpox, vaccinia, alastrim, parvovirus B 19 · Enteroviruses · Influenza, mumps, rabies · Hepatitis · Rubella · HIV infection · Toxoplasmosis Chagas' disease Babesiosis, trichomoniasis Malaria Other parasitic infections Villi tis of unknown etiology

25 . Multiple Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 636 Zygosity Placenta in the study of zygosity Causes of multiple births and incidence Third type of twin Twinning incidence · Superfetation and superfecundation Vascular anatomy of twin placentas Monoamnionic, monochorionic twin placenta · Diamnionic, monochorionic twin placenta Diamnionic, dichorionic twin placenta Vanishing twin phenomenon · Fetus papyraceus "Transfusion syndrome" Acardiac twins Conjoined twins Sacrococcygeal teratoma, epignathus Congenital anomalies Cytogenetics and "heterokaryotypic MZ twins" Chimerism, mosaicism Whole-body

xiv Contents

chimerism 0 Triplets and higher multiple births 0 Twins in abortion and ectopic pregnancy 0 Morbidity and mortality 0 Hormones in twin pregnancy

260 Abortion, Placentas of Trisomies, and Immunological Considerations of Recurrent Reproductive Failure 0 0 0 0 0 0 0 754

Anatomical findings 0 Summary of placental findings in chromosomally defined abortions 0 Trisomies 0 Polyploidies Monosomy 0 Induced abortions 0 Incomplete abortion Placenta in chorionic villous sampling 0 Trisomic placentas 0 Other findings 0 Recurrent or habitual abortion

27 0 Molar Pregnancies 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 782

280

Hydatidiform moles 0 Incidence 0 Genetics 0 Morphology Other attributes 0 Deportation ° Chorioadenoma destruens (invasive mole) 0 Therapy 0 Ectopic moles 0 Partial hydatidiform mole 0 Mole and fetus 0 PHM with twin gestation

Choriocarcinoma Choriocarcinoma "in situ" and choriocarcinoma with pregnancy o Trophoblastic pseudotumors 0

Ultrastructure 0 Antigenic studies 0 Epidemiology Endocrine aspects 0 Ectopic choriocarcinomas; tumors in men ° Therapy ° Choriocarcinoma in animals Choriocarcinoma in cell lines and genetics

816

29 0 Benign Tumors 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 841

300

Angiomas 0 Other benign tumors ° Chorangiosis, chorangiomatosis

Legal Considerations Twins 0 Inflammation ° The green placenta 0 Vascular abnormalities 0 Umbilical cord 0 Placental color 0 Other types of pathology

852

310 Glossary 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 863

Index 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 867