Placental chorioangioma: prenatal diagnosis and clinical significance

Ablative effect of the interstitial laser setting in the human placental model

AIM

To assess the impact of laser power and time on interstitial ablation generated by neodymium-doped yttrium aluminium garnet (Nd:YAG) and diode laser in the human placental model.

METHODS

The experiment was carried out in a simulation model of interstitial laser ablation on ex-vivo placental tissue. One-hundred and forty-four pieces of fresh placentae were interstitially ablated with Nd:YAG or diode laser at various power (15, 20, 25, 30 W)-time (5, 10, 15 s) combinations. The ablation tissues were evaluated using both sonographic and histopathologic measurements.

RESULTS

Laser generator, power, and time significantly affected the ablation size (p < 0.001). The coagulation zone continuously increased with extending time at the power of 15, 20, and 25 W. When adjusting to the power of 30 W, increased time from 10 to 15 s did not induce the larger coagulation diameter. The maximal diameter was obtained at the laser power of 20 W for 15 s. The ablation from the diode laser was greater than that from Nd:YAG laser. The sonographic evaluation overestimated the ablation size by an average of 24%.

CONCLUSION

Diode laser destroys greater tissue than Nd:YAG laser. Different power settings of interstitial laser ablation produce diverse patterns of correlation between laser time and coagulation size.

A rare case of intra-uterine blood transfusion for fetal anemia caused by a giant placental chorioangioma

Objectives

Chorioangiomas (CAs) are the most frequent tumor-like-lesions of the placenta. Giant CAs (more than 4–5 cm in diameter) is rare and may result in severe maternal fetal complications.

Case presentation

A 38-year-old multigravida presented at 31 weeks’ gestation with contractions. Upon evaluation, contractions were spontaneously ceased, and the cervix was closed. Ultrasound examination revealed a single viable fetus, polyhydramnios and a 75 x 48 x 82 mm vascular lesion located on the placental surface near the cord insertion. Doppler assessment was suggestive of fetal anemia with middle cerebral artery-peak systolic velocity (MCA-PSV) 1.8 MoM’s. Fetal heart rate monitoring and biophysical scores were reassuring. Following betamethasone fetal cord sampling that revealed fetal hemoglobin level of 8.8 g/dL, 57 cc of blood was transfused resulting in final hemoglobin level of 14.3 g/dL measured prior to needle extraction. MCA-PSV was normalized immediately after the procedure, however aggravated at the following day with MCA-PSV 65 cm/s (1.46 MoM’s). No other intervention was taken and MCA-PSV continued to fluctuate from slight to severe anemia spontaneously over a period of two weeks. At 34 gestational weeks, the women delivered a healthy baby. Fetal hemoglobin level at delivery was 21 g/dL.

Conclusions

Fetal blood transfusion is a reasonable treatment for fetal anemia in cases of giant chorioangiomas. Following transfusion, MCA-PSV may act unexpectedly reflecting various mechanisms affecting the flow.

Diffuse Chorangiomatosis as a Cause of Cardiomegaly, Microangiopathic Hemolytic Anemia and Thrombocytopenia in a Newborn

INTRODUCTION

The hallmark of diffuse chorangiomatosis is capillary dysvasculogenesis, diffusely involving the placenta. It can cause massive placental enlargement and may have adverse fetal effects.

CASE REPORT

A 32 weeks gestation male infant was born via cesarean section and had a placenta weighing 900 g. There was diffuse vascular proliferation involving the stem villi and intermediate villi. Short Nucleotide Polymorphism (SNP) microarray analysis of the placenta showed no biparental mosaicism or loss of heterozygosity, ruling out placental mesenchymal dysplasia. The infant also had cardiomegaly, microangiopathic hemolytic anemia and thrombocytopenia which spontaneously improved over time.

CONCLUSION

Diffuse chorangiomatosis can be associated with hemolysis, thrombocytopenia and cardiomegaly in the newborn. However, once delivered, these findings can spontaneously resolve over time.

Large multiple chorangiomas of the placenta causing acute neonatal respiratory failure

Chorangioma is the most common benign tumor of the placenta. Tumors larger than 5 cm can cause adverse fetal outcomes. We describe the case of a term infant presenting with acute respiratory failure due to fetal heart insufficiency. In this particular case, the presence of a multifocal chorangiomatosis causing fetal heart failure was not diagnosed prenatally by ultrasound but first by the histopathological report of the placenta.

Giant chorioangioma treated in utero via laser of feeding vessels with subsequent development of multifocal infantile hemangiomas

We report a case of a giant placental chorioangioma (15.6 cm diameter) complicated by polyhydramnios and severe fetal heart failure. Fetoscopic laser occlusion of a dominant feeding vessel was performed at 29 weeks' gestation and partial devascularization was achieved. In the 33rd week of the pregnancy, the decision was made to preemptively deliver the fetus due to persistent signs of fetal cardiac failure. After birth, the infant developed multifocal infantile hemangiomas with extracutaneous involvement. We posit that the development of infantile hemangiomas may be linked to the presence of the large chorioangioma. Further study is required to ascertain if fetal treatment of the chorioangioma may have been an exacerbating factor.

Giant placental chorioangioma: natural history and pregnancy outcome

OBJECTIVES

Giant placental chorioangiomas are associated with a high prevalence of pregnancy complications and a poor perinatal outcome. The aim of the study was to evaluate the natural history, intrauterine treatment and outcome of pregnancies complicated by giant placental chorioangioma.

METHODS

This was a retrospective study of 19 cases of giant placental chorioangioma, in which the natural history, intrauterine treatment and outcome of pregnancy were evaluated.

RESULTS

Eighteen of the 19 cases were associated with a wide variety of fetal complications, including polyhydramnios, growth restriction, hyperdynamic circulation, cardiomegaly, anemia and non-immune hydrops. Two-thirds of the cases developed complications that required either elective delivery for fetal growth restriction (n = 6) or intervention for cardiovascular effects (n = 7). Fetal therapy, when required, was tailored to the particular complication and resulted in a successful pregnancy in all cases.

CONCLUSIONS

The presence of large placental chorioangioma is associated with the development of fetal growth restriction and hyperdynamic state in a significant number of cases. This series elucidates some of the putative underlying mechanisms for these complications, and reports on a safe and effective treatment modality, percutaneous ultrasound-guided interstitial laser therapy.

Chorangioma and related vascular lesions of the placenta--a review

Chorangioma has been referred to as a hamartoma-like, or a hyperplastic capillary lesion, rather than a true neoplasm. Its incidence is 1 in 100 placentas. In chorangiomas larger than 4 cm, there can be significant effects on the hemodynamic and circulatory processes of the fetus, leading to grave clinical consequences, such as polyhydramnios and fetal heart failure. Chorangiomas can show various histopathologic pictures, ranging from vascular to cellular, and can undergo degenerative changes. They can be diagnosed prenatally by ultrasound, color Doppler imaging, and magnetic resonance imaging (MRI). Chorangioma must be differentiated from other villous capillary lesions, namely, chorangiomatosis and chorangiosis. They have overlapping similarities with chorangioma, and have clinical implications. Chorangiomatosis has been associated with negative fetal outcomes such as intrauterine growth retardation (IUGR) and preeclampsia. Chorangiosis is associated with maternal diabetes mellitus. Another rarer differential is chorangioma with trophoblast proliferation ("chorangiocarcinoma," a probable misnomer), a rare proliferation of trophoblastic tissue seen in the vicinity of otherwise benign chorangioma. Treatment modalities of chorangioma include endoscopic devascularization, alcoholic ablation, and interstitial laser coagulation. In this article, we will review the clinical and pathologic picture of chorangioma as well as treatment, and discuss its main differentials.

Fetal cardiovascular response to large placental chorioangiomas

A large placental chorioangioma is a relatively rare condition, which in 50% of all cases will lead to maternal and fetal complications. Since chorioangiomas are often associated with significant arterio-venous shunting within the placenta, several fetal hemodynamic compensatory mechanisms are initiated. Ultrasound and color Doppler flow mapping are important for the prenatal diagnosis of chorioangiomas, as an early prenatal diagnosis is crucial to minimize the risks for fetal well-being. Close surveillance of pregnancy and pregnancy termination by cesarean section at the earliest signs of fetal cardiac decompensation are indicated to reduce fetal and neonatal complications. Novel intrauterine treatment options include intravascular transfusion, fetoscopic devascularization, microcoil embolization, and intravascular injection of absolute alcohol.

Chorioangioma and its severe infantile sequelae: case report

OBJECTIVE

This case report describes a rare clinical presentation of chorioangioma diagnosed prenatally because of raised-maternal serum (MS) alpha-fetoprotein.

METHODS

A thirty-year-old woman gravida 2, para 1 was referred to the ultrasound unit at 18 weeks of gestation because of abnormal MS triple-test results. This included AFP level of 14.9 MoM; hCG of 3.42 MoM and uE3 of 1.01 MoM. A detailed anomaly scan revealed a singleton fetus with no sonographically detectable malformations and normal amniotic fluid. The placenta was posterior. A well-circumscribed, rounded, predominantly hypoechoic lesion near the chorionic surface measuring 5 x 5 cm and protruding into the amniotic cavity was detected. Color Doppler sonogram showed no blood flow within the mass, but clear fetal waveforms in its periphery were demonstrated, and the diagnosis of chorioangioma was made. The pregnancy was followed uneventfully until 35 weeks of gestation when polyhydramnios and severe fetal cardiomegaly developed. Labor was therefore induced.

RESULTS

A euploid female, who had multiple diffuse cutaneous and liver angiomatosis was born. She died at the age of one month because of cardiac failure and infection.

CONCLUSIONS

The present case alerts to the interrelationship between placental and fetal angiomas. This may lead to severe infantile sequelae because of similar lesions.

Role of color Doppler imaging in diagnosing and managing pregnancies complicated by placental chorioangioma

PURPOSE

The purpose of this study was to evaluate the role of color Doppler imaging in the diagnosis and management of placental chorioangioma.

METHODS

The medical records, sonographic reports, and sonograms of all pregnant women who had placental masses diagnosed in our sonography unit during the years 1992 through 2000 and had been evaluated using both gray-scale and color Doppler sonography were included in this study. Subjective evaluation of the amount and distribution of intralesional vascularity by color Doppler imaging was made in all cases. Cases of chorioangioma of the placenta were compared with cases of placental hemorrhage or subchorionic hematoma. The outcomes of the pregnancies were also recorded.

RESULTS

Fifteen cases of placental masses were evaluated; 8 of them were identified as placental hemorrhage or subchorionic hematoma on the basis of the sonographic findings. The other 7 cases were identified prenatally as placental chorioangioma, at a mean menstrual age of 23 weeks and a mean maternal age of 29 years. The mean size of the tumor was 6.5 cm (range, 4-13 cm). All cases of chorioangioma showed either substantial internal vascularity or a large feeding vessel within the tumor. Three infants were delivered at term with favorable outcome; 2 of them demonstrated reduction of the intratumoral blood flow during follow-up. The other 4 cases were delivered at or before 32 weeks' menstrual age (1 intrauterine fetal death, 2 terminated pregnancies, and 1 normal infant). No case of placental hematoma demonstrated blood flow within the lesion or was associated with complications of the pregnancy.

CONCLUSIONS

Color Doppler imaging helps differentiate placental chorioangioma from other placental lesions and may be useful in the prenatal follow-up of chorioangioma.

Alcoholization: the choice of intrauterine treatment for chorioangioma

Chorioangioma is a vascular tumor of the placenta. Most are small and asymptomatic, whereas the large tumors are clinically significant and often associated with polyhydramnios and fetal heart failure. To prevent fetal loss from these complications, many interventions have been proposed, including intrauterine transfusion in anemic cases and fetoscopic surgery to ablate the feeding vessels. The case presented herein had large chorioangiomas, 8 and 4cm in diameter, associated with polyhydramnios and early signs of hydrops fetalis, diagnosed at 27 weeks gestation. After extensive counseling, we performed alcohol ablation of the feeding vessel of the larger tumor. Signs of fetal heart failure and hydrops fetalis disappeared dramatically. The pregnancy was extended for 2 weeks, followed by premature rupture of the membranes and spontaneous labor at 32 weeks gestation and a surviving female baby, weighing 1360g, was delivered uneventfully. This preliminary experience suggests that alcoholization may be one of the best choices for this condition due to its high efficacy, simplicity, safety and very low cost. To our knowledge, this is the first report using alcoholization for the treatment of hydrops fetalis secondary to chorioangioma.

Premature infant with severe periventricular leukomalacia associated with a large placental chorioangioma: a case report

We present the first reported case of severe periventricular leukomalacia associated with a large placental chorioangioma. We believe that the large chorioangioma near the point of umbilical cord insertion was not only disrupting fetoplacental circulation but may also have led to the periventricular leukomalacia lesions.

Increased incidence of placental chorioangioma in high-altitude pregnancies: hypobaric hypoxia as a possible etiologic factor

OBJECTIVES

Our purpose was to determine the effects of pregnancy at high altitude on the human placental structure.

STUDY DESIGN

Histologic material from 22 term placentas delivered at altitudes above 3600 m was examined and compared with control material from 760 m.

RESULTS

Intraplacental chorioangiomas were identified in 5 of the 22 high-altitude placentas but in none of the 59 controls. The lesions were not visible on the external surface of the placentas and were not encapsulated. The state of differentiation varied; some contained numerous capillaries that showed sinusoidal dilations, whereas in others at the opposite extreme mesenchymal cells predominated. The presence of chorioangiomas was frequently associated with threatened premature delivery, a circumvallate placenta, and multiple infarction. The lesions represented only a small percentage of the overall placental volume (<10%).

CONCLUSIONS

The increased incidence of placental chorioangioma observed at high altitude (above 3600 m) may be due to the prevailing hypobaric hypoxia. Overexpression of angiogenic cytokines such as vascular endothelial growth factor, which is known to be up-regulated by this factor in vitro, may mediate this effect.