Placental Ultrasound NORMAL ANATOMY AND POSITION Maternal surface - Termed basal plate - Lie congruous with the

deciduas basalis - Irregular Fetal Surface - Termed chorionic plate - Smooth - Covered by amniotic membrane Placental Circulation - Intervillous spaces located within placental lobules - Oxygenated maternal blood enters the intervillous spaces via spiral arteries - From intervillous spaces, blood flows around and over surface of villi. This process permits exchange of oxygen and nutrients with fetal blood flowing in villous capillaries Placental Size - Placental thickness usually does not exceed 5cm Ap dimension - Large placenta may be associated with 1. maternal diabetes 2. Rh sensitization 3. congenital neoplasm 4. Non-immune hydrops - Small placenta may be associated with 1. IUGR 2. Placental insufficiency Placental Position - Placenta position in uterus can be categorized as: 1. posterior 2. anterior 3. RT lateral or LT lateral 4. fundal 5. combination Placental Migration - It is the impression of placental ascension from the cervical os during the last trimester of pregnancy, due to differential growth of lower uterine segment. Placental Number - Singleton - Dizygotic twin 2 placentas (may be fused)

- Monozygotic twin 1. Dichoriotic / Diamniotic 2 placentas (may be fused) 2. Monochoriotic / Diamniotic 1 placenta 3. Monochoriotic / Monoamniotic 1 placenta

SONOGRAPHIC APPEARANCE OF PLACENTA 1. In 8 weeks, the early placenta is visible sonographically as a generalized thickening around the gestational sac. 2. 10-12 weeks, diffuse granular texture of the placenta is clearly apparent sonographically. 3. Chorionic plate is usually seen as an echogenic line in the fetal surface of placenta. Basal plate cannot be identified sonographically unless it becomes calcified near term. 4. The incidence of placental calcification increases exponentially with increasing gestational age, beginning at about 29 weeks. More than 50% of the placentas show some idegrees of calcification after 33 weeks.

PLACENTAL GRADING NORMAL PLACENTAL GRADES Grade 0 - Smooth chorionic plate, homogenous echotexture of substance of placenta. Most common in 1st trimester and early 2nd trimester (8-20weeks). Grade I - Small intraplacental calcification randomly dispersed within the substance of a placenta. May appear as early as 14 weeks, and is most common until 34 weeks. Grade II - Calcification iof basal plate. Does not usually appear until after 30 weeks. Grade III - Calcified indentation of placenta extending from the basal plate to the chorionic plate ( placental cotyledons ). Usually not seen until 35 weeks. Found in 30% of term placentas. ABNORMAL PLACENTAL GRADES

- Delayed placental calcification may be associated with 1. maternal DM 2. Rh sensitization - Accerated placental calcification may be associated with 1. hypertension 2. IUGR 3. cigarette smoking PLACENTA PREVIA - 93% of women with placenta previa experience significant vaginal bleeding. The clinical hallmark of placenta previa is painless vaginal bleeding, which usually occurs in the third trimester but can occur as early as 20 weeks. - Overly distended urinary bladder and focal uterine contractions are the two most common technical factors responsible for a false positive diagnosis by ultraound. - When any type of previa is visualized, it should be reevaluated pprior to term to confirm or deny persistence of a previa. - Low-lying placenta - implants low in uterus with lower segment approaching but not encroaching on the internal cervical os. Types of Previa 1. Marginal Previa - small edge or segment of placenta extends to the margin of internal cervical os 2. Partial Previa - internal os partially covered by placenta (also called incomplete previa) 3. Complete Previa - placenta covers entire area of internal os ( also called total previa)

ABRUPTION - Premature placental detachment - Two types: retroplacental and marginal - Clinical symptoms: vaginal bleeding, a tense or painful uterus, and possible shock. - A significant retroplacental or marginal haematoma will appear as a hypoechoic or complex mass beneath the elevated placental membranes on sonography. - Prognosis: associated with premature labour and delivery, and fetal demise.

MASS AND LESIONS - Chorioangioma vascular malformation, sonographically appear a swellcircumscribed intraplacental mass lesions with complex echo pattern - Teratoma and metastatic neoplasm exceedingly rare - Hydatidiform mole multiple diffuse iintraplacental sonolucent lesions (vesicular pattern). - Complete mole hydatidiform swelling of all villi and absence of an embryo, or a viable fetus may coexist with a true mole in case of twin pregnancy with on twin surviving - Partial mole showing areas of molar changes alternating with normal villi. A fetus may be present and is often triploid (69 chromosomes) clinically present early onset or pre-eclampsia in second trimester.

UMBILICAL CORD Structure and function of umbilical cord - Umbilical cord is covered by amnion and contains a single umbilical vein, and two umbilical arteries supported in Wharton jelly. - Amnion covers the umbilical cord except near the fetal insertion, where an epithelial covering is substituted. The arteries wind around the umbilical vein in a spiral fashion and, because the vessels are longer the cord itself, there are a number of foldings or tortuorties producing protusions or false knots on the cord surface. - The Wharton jelly protects the vessels from undue torsion and compression. Sonographic anatomy of umbilical cord - The umbilical stalk may occasionally be seen in the late first trimester, adjacent to the anterior abdominal wall of the fetus. In the second and third trimesters, the cord is much more readily visualized. - In the longitudinal section, a portion of cord will be seen as as series of parallel lines and sometimes the spiral

course of umbilical arteries can be demonstrated. In the transverse section, the arteries and veins will be seen as three separately circular lucencies. - By scanning near the center of placenta, the insertion site of the cord may be demonstrated as sonolucent area adjacent to the chorionic plate. At the insertion of the cord into the anterior abdominal wall of the fetus, the origin of umbilical vein and hypogastric arteries may be seen. Cord Position - Normally loops of umbilical cord lie anterior to the fetal abdominal wall and adjacent to the limbs. In a number of instances, there may be loopings of cord around fetal neck or limbs or alternatively, loops of cord may lie between the fetal presentation part and the lower uterine segment (funic presentation). - The most important umbilical cord malpositions include prolapses, knots, and neck, body, and shoulder loopins. - Funic presentation is more common with malpresentations such as breech or transverse lie. Single Umbilical Artery (SUA) - A single umbilical artery may be seen in approximately 1% of all singleton births, 5% of twins, and 2.5% of abortuses. - On sonography, it is diagnosed by demonstrating a complete parallel course of umbilical artery and vein in longitudinal section, and by demonstrating only two circular lucencies in the transverse section. Umbilical Cord Masses - False knots - True knots - Haematoma - Allantoic duct cyst - Neoplasm - Umbilical hernia - Omphalocele and gastroschisis

http://www.droid.cuhk.edu.hk/service/ultrasound/exam_protocol/us_exam_obs_2.htm

Vascularity o Very vascular has 2 blood supplies Blood from fetus through 2 (sometimes 1) umbilical arteries through umbilical cord from fetal hypogastric arteries to placenta 1 umbilical vein carries blood back to fetal left portal vein Blood from mom through branches of uterine arteries through the myometrium (arcuate arteries) through the basilar plate (spiral arteries) into the placenta The two circulations intertwine in the placenta but do not mix o Exchange of oxygen and nutrients occurs over the large vascular surface area o Maternal venous channels in the placenta are hypoechoic or anechoic spaces called venous lakes (usually small, but can be large) Anatomy on US o Inner border of placenta against the uterine wall has the combined hypoechoic myometrium and interposed basilar layer = hypoechoic band called the decidua basalis (contains maternal blood vessels) o Outer surface abutting the amniotic fluid = chorionic plate (chorioamniotic membrane) = bright specular reflector Placental thickness judged subjectively o But if measure at midposition or cord insertion 2-4 cm = normal

Grade 0 Late 1st trimesterearly 2nd trimester Uniform moderate echogenicity Smooth chorionic plate without indentations

Grade 1 Mid 2nd trimester early 3rd trimester (~18-29 wks) Subtle indentations of chorionic plate Small, diffuse calcifications (hyperechoic) randomly dispersed in placenta

Grade 2 Late 3rd trimester (~30 wks to delivery) Larger indentations along chorionic plate Larger calcifications in a dot-dash configuration along the basilar plate

Grade 3 39 wks post dates Complete indentations of chorionic plate through to the basilar plate creating cotyledons (portions of placenta separated by the indentations) More irregular calcifications with significant shadowing May signify placental dysmaturity which can cause IUGR Associated with smoking, chronic hypertension, SLE, diabetes

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