Finally! A concise yet complete, easy-to-use reference guide designed to be used everyday in the delivery room and in the Surgical Pathology gross room, by everyone charged with gross placental examination. Obstetricians, general practitioners, pathologists, residents, nurse midwives, OB nurses, physician assistants and pathologists' assistants will benefit from its contents. Its unique clinical-pathological correlation approach allows quick review of the possible placental findings associated with specific maternal and fetal conditions, and the fetal consequences thereof, a focus which is also helpful for those providing prenatal care.
Section I. Clinicopathological Correlations is the "driving force" of the guide. It is divided into chapters based upon the maternal, fetal and placental indications for placental examination. Each indication is subsequently concisely described by its Definition, Clinical Associations, Gross Features, Microscopic Features, Etiology and Significance. For clarification of features of the normal and the abnormal placenta, turn to Section II. Placental Pathology. For an explanation of terminology used in prenatal clinical histories, turn to Section III. Clinical Definitions. In recent years, the placenta has played an increasingly important role in litigation, particularly in cases on behalf of neurologically impaired children. To review the placenta's impact on litigation, turn to Section IV. Legal Implications. Additionally, there are over 70 commonly used abbreviations, 23 clinical and pathological tables and 41 schematics, illustrations and photomicrographs. The user friendly table of contents and index provide quick and easy access to desired information, cross referenced through out all sections of the guide.
For example, a patient presents with the following clinical history: 38 year old woman, Gravida 2, Para 1, Fullterm 0, Preterm 0, Abortion 1, 36 weeks gestation, 1 pack/day cigarette smoker for 20 years, third trimester bleeding, questionable IUGR, Cesarean section for partial placenta previa.
Can't remember what IUGR stands for? Turn to Abbreviations: IUGR, page 1: "Intrauterine Growth Retardation."
To review causes of third trimester bleeding, turn to Section III: Chapter 13 Clinical Definitions: Hemorrhage, Third Trimester, page 129: "Is an ominous complication of pregnancy although bleeding in late pregnancy is not uncommon. 10-15% of cases require medical attention. Third trimester bleeding is a major cause of maternal death, and perinatal morbidity and mortality. Most serious bleeding (2-3% of pregnancies, 30% of third trimester hemorrhage) is due to abruptio placenta or placenta previa. Other less common causes include: 1) circumvallate placenta (more commonly a major cause of 2nd trimester hemorrhage and fetal death); 2) abnormal blood clotting mechanisms; 3) uterine rupture. Most blood loss due to placental accidents is maternal; fetal blood loss is possible, particularly with placental laceration. Bleeding from ruptured vasa previa is the only cause of pure fetal hemorrhage."
Placental examination reveals low placental weight, retroplacental hematoma/abruptio placentae and numerous infarcts.
Want more information about abruptio placentae? Turn to Section II: Placental Pathology, Chapter 9 Maternal Surface (Basal Plate): Abruptio Placentae, page 81: "In cases of abruptio placentae, a clinical condition in which the placenta separates from the uterine wall before delivery (placental abruption), the basal plate should be inspected for blood clot. In very acute abruption (25-50% of cases) there may be no grossly appreciable abnormality. Adherent, sometimes laminated blood clot, occasionally dissecting into adjacent parenchyma, may be seen with a recent abruption. The clot of an older abruption is firm, dry and stringy, and eventually brown. The placental tissue overlying and adjacent to the adherent blood clot may be: a) dark red due to villous hemorrhage - an early abruption; b) thinned out, over a "saucer-like" depression; or c) depressed, firm and pale with a several day old infarct."
How does the patient's smoking history affect all this? Turn to Section I: Clinicopathological Correlation, Chapter 2 Maternal Indications: Smoking, page 33: Clinical Associations: The older the woman the greater the risk; increased risk for antepartum hemorrhage secondary to abruptio placentae or placenta previa, premature rupture of membranes and preterm labor. Gross Features: may see abruptio placentae, circumvallate placenta, thin umbilical cord, single umbilical artery, chorioamnionitis as a consequence of premature rupture of membranes, fetal stem vessel lesions, changes associated with placenta previa and large infarcts. Microscopic Features: may also see: fetal stem vessel lesions, marginal decidual necrosis, parenchymal and vascular changes of ischemia, increased basal lamina thickness beneath the trophoblastic covering of the villi, decreased density of terminal villi blood vessels and "cobblestone" appearance of the umbilical artery endothelial cells with leakage of plasma and red blood cells into the subendothelial spaces. Etiology. Smoking causes decreased prostacyclin and increased thromboxane synthesis (which alters fetal and maternal circulations toward vasoconstriction), increased platelet aggregation and decreased blood flow. Necrosis of the decidua at the placental margin, due to vascular changes inhibiting blood flow, and microinfarcts are sometimes the nidus for placental abruptions. Significance. Smoking a single cigarette reduces uteroplacental blood flow for 5-15 minutes, which may be long enough to produce decidual necrosis and small placental infarcts, putting the fetus at risk for premature delivery or death. The increased thickness of the basement membrane and decreased density of terminal villi blood vessels, may impose a barrier to the placental-fetal passage of nutrients and oxygen. This may explain why infants of cigarette smokers often have lower birth weights and higher hemoglobin levels at birth than the infants of nonsmokers. Although smokers have a lower incidence of hypertension and pre-eclampsia before and during pregnancy, the fetus is at greater risk for threatened or late spontaneous abortion, diminished breathing movements and increased perinatal mortality. Smoking increases the risk for placenta previa; it correlates with the number of years a woman has smoked and not with smoking during pregnancy. Because smoking accelerates the sclerotic narrowing of small uterine arteries and arterioles, blood flow to many parts of the endometrium is reduced. Later, when the blastocyst is "looking" for a place to implant, these affected areas of endometrium appear less hospitable, therefore the blastocyst implants low in the uterus, where the placenta may cover the cervical os.
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This reference guide cuts across medical disciplines bringing together obstetrics and pathology for the common goal of gross placental examination. It is written for physicians, nurse midwives physician-extenders and nurses - for everyone who grossly examines the placenta. The chapters are succinctly written and quick to read, making it the perfect reference for the busy delivery room and gross room.About the Author:
Doris Schuler-Maloney received her Master's of Science Degree from the University of Maryland at Baltimore and works at Mercy Hospital Medical Center in Des Moines, Iowa as a Pathologists' Assistant. Dr. Steve Lee completed his Pathology Residency at Beth Israel Hospital in Boston, Massachusetts and participated in the Pathology Fellowship program at Boston Hospital for Women. He works as a pathologist specializing in Surgical Pathology and Electron Microscopy at Mercy Hospital Medical Center In Des Moines, Iowa. Together they have examined thousands of placentas at the Surgical Pathology gross bench and at autopsy. Marty Boesenberg trained as a Cytotechnologist at Mercy Hospital Medical Center and currently is the Program Director for the Mercy Hospital School of Cytotechnology.
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