Perinatal outcome of pregnancies complicated by placental chorioangioma: systematic review and meta-analysis

A singleton pregnancy with placental chorioangioma and hydrops fetalis complicated with mirror syndrome and ritodrine-induced side effects: a case report

BACKGROUND

Ritodrine hydrochloride is a widely used beta-adrenergic agonist used to stop preterm labor in Taiwan. Many side effects causing maternal morbidity and mortality have been reported. We report a case complicated with ritodrine-induced side effects and mirror syndrome that was associated with placental chorioangioma.

CASE PRESENTATION

A 36-year-old singleton pregnant woman at 25 6/7 weeks of gestation, with an undiagnosed placental chorioangioma, underwent tocolysis due to preterm uterine contractions. Her clinical condition deteriorated, attributed to mirror syndrome and adverse events induced by ritodrine. An emergency cesarean section was performed at 27 1/7 weeks of gestation, delivering an infant with generalized subcutaneous edema. A placental tumor measuring 8.5 cm was discovered during the operation, and pathology confirmed chorioangioma. Gradual improvement in her symptoms and laboratory data was observed during the postpartum period. Identifying mirror syndrome and ritodrine-induced side effects poses challenges. Therefore, this case is educational and warrants discussion.

CONCLUSION

Our case demonstrates mirror syndrome induced by chorioangioma, which is rare, and ritodrine-induced side effects. The cessation of intravenous ritodrine and delivery are the best methods to treat maternal critical status due to fluid overload.

Management of large placental chorioangioma: two-port laser approach for fetal intervention

OBJECTIVES

There is a paucity of literature providing evidence-based guidelines for the management of large placental chorioangioma (≥ 4 cm in diameter). The objectives of this study were to compare outcomes between patients managed expectantly and those undergoing in-utero intervention and to describe the different in-utero techniques used for cessation of blood flow to the tumor and the associated outcome.

METHODS

This was a retrospective cohort study of 34 patients referred for the management of large placental chorioangioma in a single center between January 2011 and December 2022, who were managed expectantly or underwent in-utero intervention. In-utero intervention was performed when the fetus developed any signs of impending compromise, including high combined cardiac output (CCO), worsening polyhydramnios or abnormal fetal Doppler velocimetry findings. Interventions included radiofrequency ablation (RFA), interstitial laser ablation (ILA) and single-port or two-port fetoscopic laser photocoagulation (FLP). Treatment selection was dependent on the proximity of the tumor to the umbilical cord insertion (UCI) and placental location. The two-port technique was performed in patients with a chorioangioma with large feeding vessels (≥ 3 mm) located in the posterior placenta, in which one port was used for occlusion using bipolar forceps and the other port was used for laser photocoagulation of the feeding vessels downstream. The single-port technique was used for chorioangioma with small feeding vessels (< 3 mm) located in the posterior placenta. ILA or RFA was performed in cases with an anterior placenta. Supportive treatments, including amnioreduction and intrauterine transfusion (IUT), were performed for worsening polyhydramnios and suspected fetal anemia based on middle cerebral artery Doppler flow studies, respectively. Comparative statistical analysis between cases undergoing expectant management vs in-utero intervention was performed. Descriptive details were provided for patients who underwent in-utero intervention.

RESULTS

Thirty-four cases of large chorioangioma were evaluated, of which 25 (73.5%) were managed expectantly and nine (26.5%) underwent intervention. The frequency of polyhydramnios was significantly higher in the intervention group compared with the expectant-management group (66.7% vs 8.0%, P < 0.001). The live-birth rate among expectantly managed cases with large chorioangioma was significantly higher compared with that in cases that underwent in-utero intervention (96.0% vs 62.5%, P = 0.01). In the intervention group, preoperative CCO was elevated in all cases with available information and preoperative hydrops was present in 33.3% (3/9) of cases. One patient experienced fetal demise following IUT prior to planned FLP. Among the remaining eight patients, four underwent two-port FLP, two underwent single-port FLP, one underwent ILA and one underwent both ILA and RFA. All three cases in which hydrops was present at the time of intervention resulted in fetal demise.

CONCLUSIONS

In-utero interventions aimed at cessation of blood flow in the feeding vessels are a therapeutic option for the management of cases with large chorioangioma. The two-port percutaneous technique appears to improve the efficiency of FLP when a large chorioangioma with large feeding vessels is located in the posterior placenta. We propose that in-utero interventions for large chorioangioma should be initiated prior to the development of fetal hydrops. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Giant Chorioangioma of the Placenta as a Cause of Maternal, Foetal, and Neonatal Complications

Chorioangioma is a benign placental neoplasm seen in about one percent of all pregnancies. The larger neoplasms generally cause severe foeto-maternal complications. We are reporting a case of a 33-year-old gravida three para two female who was incidentally diagnosed with chorioangioma at her routine 28-week antenatal follow-up. She delivered a preterm small-for-gestational-age female baby at 34 weeks with complications. Therefore, an early diagnosis warrants a close follow-up and timely intervention for a better outcome of the pregnancy.

Placental chorioangioma and pregnancy outcome: a ten-year retrospective study in a tertiary referral centre

BACKGROUND

Placental chorioangioma is a rare disorder in pregnancy. We retrospectively reviewed the perinatal complications and long-term outcomes in pregnancies with placental chorioangioma and evaluated the factors affecting disease prognosis.

METHODS

We reviewed pregnant women who delivered at our hospital in the past decade and whose diagnosis of placental chorioangioma was confirmed by pathological diagnosis. Information on maternal demographics, prenatal sonographic findings and perinatal outcomes was obtained by reviewing the medical records. In the latter part of the study, follow-up of children was conducted by phone interview.

RESULTS

In the 10 years from August 2008 to December 2018, 175 cases(0.17%) were identified as placental chorioangioma histologically and 44(0.04%) of them were large chorioangiomas. Nearly one-third of cases with large chorioangiomas were associated with severe maternal and fetal complications or required prenatal intervention. Although one-fifth of fetuses/newborns complicated with large chorioangiomas were lost perinatally, the long-term prognosis for surviving fetuses was generally good. Further statistical analysis revealed that tumor size and location affect prognosis.

CONCLUSION

Placental chorioangioma may cause an unfavorable perinatal outcome. Regular ultrasound monitoring can provide the tumor characteristics which can be referred to for predicting the tendency of those complications and indicate when intervention may be necessary. It is not clear which factors lead to complications with fetal damage as the main manifestation or polyhydramnios as the main manifestation.

Placental chorioangioma separation in third trimester after fetoscopic laser therapy: Report of a rare case

A primigravida received fetoscopic laser photocoagulation treatment at 25⁺¹ weeks gestation as a chorioangioma enlarged to 61 × 46 × 52 mm. However, a cesarean section was performed due to the chorioangioma separated from the placenta at 32⁺² weeks gestation. As the chorioangioma's blood supply were blocked, it was possible to provide expectant treatment.

Giant Placental Chorangioma and Severe Ductal Arch Constriction: A Case Report With a Favorable Outcome

Giant chorangiomas are uncommon yet frequently associated with adverse pregnancy outcomes. A 37-year-old female was referred due to findings of a placental mass during a second-trimester ultrasound. A fetal survey at 26 weeks revealed a 69×97×75 mm heterogenous placental tumor with two prominent feeding vessels. Her prenatal course was complicated by worsening polyhydramnios requiring amnioreduction, gestational diabetes, and transient severe ductal arch (DA) constriction. Placental pathology confirmed the diagnosis of giant chorioangioma following delivery at 36 weeks. To our knowledge, this represents the first case of DA constriction in the setting of a giant chorangioma.

Fetal and placental metastases associated with maternal cancers

PURPOSE

Review the effects of fetal and placental metastases in the setting of maternal cancer.

METHOD

Data reported in the peer-reviewed literature were combined with guidelines to evaluate the incidence, type and prognosis for fetal and placental metastasis in the setting of maternal cancer.

RESULTS

Limited literature available. Fetal and placental metastasis are rare. Fetal metastasis generally occurs on the background of concurrent placental metastasis thus it is important to thoroughly examine the placenta in cases of known gestational cancers. Tumor molecular testing is used to confirm maternal to offspring transmission. Maternal to offspring transmission may have a long timeline between birth to clinical presentation. Prognosis in offspring may be better than in the mother who may have a more aggressive phenotype.

CONCLUSION

Fetal and placental metastasis associated with maternal cancers are rare and limited peer-reviewed literature is available. The occurrence may be confirmed by detailed histological placental evaluation and molecular testing in the offspring.

Radio frequency ablation for the intrauterine treatment of giant placental chorioangioma associated with fetal compromise: A case report

Giant placental chorioangiomas associated with fetal hyperdynamic circulation complications are rare to see. Here, we summarized a case of giant placental chorioangioma associated with fetal anemia and heart failure treated by radiofrequency ablation (RFA) combined with cordocentesis and intrauterine transfusion. The sonographic appearance of the placental chorioangioma was atypical which was isoechoic with unclear boundary. RFA was performed successfully at 27 weeks of gestation, when the chorioangioma has increased to 17.0 × 10.6 × 12.3 cm³ . Unfortunately, intrauterine fetal demise was found on the first day after operation. After induction of labor, it was pathologically confirmed as placental chorioangioma.

Placental and Umbilical Cord Anomalies Diagnosed by Two- and Three-Dimensional Ultrasound

The aim of this review is to present a wide spectrum of placental and umbilical cord pathologies affecting the pregnancy. Placental and umbilical cord anomalies are highly associated with high-risk pregnancies and may jeopardize fetal well-being in utero as well as causing a predisposition towards poor perinatal outcome with increased fetal and neonatal mortality and morbidity. The permanent, computerized perinatology databases of different international centers have been searched and investigated to fulfil the aim of this manuscript. An extended gallery of prenatal imaging with autopsy correlation in specific cases will help to provide readers with a useful iconographic tool and will assist with the understanding and definition of this critical obstetrical and perinatological issue.

Placenta segmentation in ultrasound imaging: Addressing sources of uncertainty and limited field-of-view

Automatic segmentation of the placenta in fetal ultrasound (US) is challenging due to the (i) high diversity of placenta appearance, (ii) the restricted quality in US resulting in highly variable reference annotations, and (iii) the limited field-of-view of US prohibiting whole placenta assessment at late gestation. In this work, we address these three challenges with a multi-task learning approach that combines the classification of placental location (e.g., anterior, posterior) and semantic placenta segmentation in a single convolutional neural network. Through the classification task the model can learn from larger and more diverse datasets while improving the accuracy of the segmentation task in particular in limited training set conditions. With this approach we investigate the variability in annotations from multiple raters and show that our automatic segmentations (Dice of 0.86 for anterior and 0.83 for posterior placentas) achieve human-level performance as compared to intra- and inter-observer variability. Lastly, our approach can deliver whole placenta segmentation using a multi-view US acquisition pipeline consisting of three stages: multi-probe image acquisition, image fusion and image segmentation. This results in high quality segmentation of larger structures such as the placenta in US with reduced image artifacts which are beyond the field-of-view of single probes.

Intrauterine transfusion of a hydropic fetus with anemia due to a giant chorioangioma: A case report

Giant chorioangiomas are a potentially life-threatening condition that may require intrauterine therapy. We describe a case of a large chorioangioma (>4cm) diagnosed at 30 weeks of gestation causing severe fetal anemia and hydrops. An intrauterine blood transfusion was performed at 31 weeks with reversal of the anemia and hydrops. The neonate was born at 37 weeks showing respiratory distress syndrome that required neonatal intensive care unit admission but was discharged at 30 days of life. Further evaluation at two months of age showed no signs of abnormal neurodevelopment. When timely indicated, intrauterine transfusion of a hydropic fetus with anemia due to a giant chorioangioma is a potentially life-saving therapy that shows good neurodevelopment of the surviving fetus.

A case of placental multiple giant chorangioma leading to neonatal death from fetal hydrops

Objectives

Although placental chorangiomas are often asymptomatic, larger tumors (>4–5 cm) can cause various perinatal complications, including polyhydramnios, preterm birth, fetal anemia, fetal hydrops, and intrauterine fetal death. Symptomatic placental chorangiomas are often diagnosed prenatally on ultrasonography as a mass on the fetal side of the placenta.

Case presentation

A 37-year-old pregnant woman underwent emergency cesarean delivery at 34 weeks’ gestation due to rapidly progressive fetal hydrops leading to fetal dysfunction, resulting in neonatal death. Placental pathology indicated multiple placental giant chorangiomas that occupied 40% of the placenta. Because of the disk shape of the placenta, prenatal diagnosis by ultrasonography was difficult.

Conclusions

Some placental chorangiomas are difficult to diagnose and lead to fetal hydrops and poor prognosis, even if ultrasonography does not show an obvious mass in the placenta.

Safety of vaginal delivery in women with placental chorioangiomas diagnosed by prenatal ultrasound: A retrospective cohort study

This study aimed to examine the maternal and neonatal outcomes in different mode of delivery in pregnant women with placental chorioangiomas, in order to determine the safety of vaginal delivery. We conducted a retrospective study of 54 women with placental chorioangioma diagnosed by prenatal ultrasound and subsequently proven histologically, excluding those who underwent cesarean section for obstetric indications. The mode of delivery was divided into a vaginal delivery group (23 women) and a cesarean section group (31 women). The indication of cesarean section group was only for placental chorioangioma, no other obstetric indications. The maternal characteristics, pregnancy outcomes and the color doppler imaging characteristics of placental chorioangioma of the 2 groups were compared, and the clinical characteristics of women in the vaginal delivery group were described in detail. The incidence of placental chorioangioma was nearly 0.43‰ in our study. There was no significant difference in the maternal characteristics and pregnancy outcomes between the 2 groups. 82.6% (19/23) of the women successfully delivered vaginally and 4 failed who turned to cesarean section in the vaginal delivery group; among them, 17 women had giant chorioangiomas (>4 cm in diameter). The direct cause of vaginal delivery failure was fetal distress, persistent occiput posterior fetal position and cephalopelvic disproportion. Pregnant women with placental chorioangiomas and no other obstetric indications for cesarean section may attempt a vaginal delivery, even with giant chorioangiomas. If there are risk factors of vaginal delivery failure, the progress of labor needs to be closely monitored.

Interstitial Laser Ablation of Feeding Vessels to a Large Placental Chorioangioma

BACKGROUND

Chorioangioma is a vascular neoplasm of the placenta with the potential to cause heart failure, hydrops, and even death.

CASE

A 30-year-old patient was referred owing to a large placental chorioangioma and fetal hydrops at 28 weeks of gestation. The patient underwent ultrasound-guided interstitial laser ablation. Ten days later, fetal blood transfusion was performed and at 31 weeks of gestation, and the patient delivered a female infant by cesarean section. The newborn was discharged from the neonatal intensive care unit without any complication.

CONCLUSION

According to our case, large placental chorioangioma may have a favorable outcome with interstitial laser ablation and fetal transfusion.

Risk Factors for Short Stature in Children Born Small for Gestational Age at Full-Term

OBJECTIVE

This study aims to identify the risk factors associated with short stature in children born small for gestational age (SGA) at full-term.

METHODS

This was a retrospective study. The subjects were full-term SGA infants who were followed up until the age of 2 years. The risk factors for short stature were identified with univariate and multivariate analyses.

RESULTS

Of 456 full-term SGA children enrolled in this study, 28 cases had short stature at 2 years of age. A significant decrease in placental perfusion was found in the short children group with intravoxel incoherent motion (IVIM) technology, which was an advanced bi-exponential diffusion-weighted imaging (DWI) model of magnetic resonance imaging (MRI) (p = 0.012). Compared to non-short children born SGA at full-term, the short children group underwent an incomplete catch-up growth. Mothers who suffered from systemic lupus erythematosus were more likely to have a short child born SGA (p = 0.023). The morbidity of giant placental chorioangioma was higher in the short children group. The pulsatility index (PI), resistivity index (RI), and systolic-diastolic (S/D) ratio of umbilical artery were higher in the short children group than in the non-short control group (p = 0.042, 0.041, and 0.043). Multivariate analysis demonstrated that decrease of perfusion fraction (f _p) in IVIM of placental MRI, chromosomal abnormalities, short parental height, and absence of catch-up growth were associated with a higher risk of short stature in children born SGA at full-term.

CONCLUSION

Risk factors for short stature in full-term SGA children at 2 years of age included a decrease of perfusion fraction f _p in IVIM of placental MRI, chromosomal abnormalities, and short parental height.

Successful expectant management of a giant chorioangioma

Giant chorioangiomas are benign placental tumours, which can have potential severe fetal consequences. Complications in pregnancy include polyhydramnios, fetal hydrops and growth restriction. Such pregnancies can carry a significant risk of poor perinatal outcome and require close monitoring. Therapeutic options include fetoscopic or interstitial vessel ablation, chemosclerosis and embolisation. Where there is no evidence of fetal compromise, such pregnancies can successfully be managed conservatively.