Placental Chorioangioma

Diagnosis and Management of an Enlarging Placental Immature Teratoma: A Case Report

The clinical imaging and pathology of a rare case of immature teratoma of the placenta is presented with a discussion of controversies related to classification and clinical suggestions for therapy and follow-up.

Clinicopathological characteristics of placental chorioangioma: A clinicopathological study of 30 cases

OBJECTIVE

The objective is to explore clinicopathological characteristics, diagnosis, differential diagnoses, treatment, and prognoses of placental chorioangioma (PCA).

MATERIALS AND METHODS

The pathological data of 30 cases of PCA were collected; the color Doppler ultrasound, Down's screening, fetal survival, and pathological characteristics were observed; and the literature was reviewed.

RESULTS

Of the 30 patients, the ages ranged from 20 to 38 years, with an average of 29.6 years. Pregnancy comorbidity occurred in 14 patients; intrauterine fetal death occurred in 4; the gross appearance of the tumor: a reddish-brown nodule, slightly round, 0.5-8 cm in diameter, can be seen on the cut surface of the placenta Pregnancy comorbidity occurred in 14 patients and intrauterine fetal death in 4. On sectioning the placenta, tumors grossly appeared as reddish-brown nodules, slightly round and ranging in diameter from 0.5 to 8 cm. Microscopically, the tumor has small, densely packed capillaries with fibrous connective tissue in the stroma. There were 10 cases with high risk of Down's syndrome screening, and the immunophenotype CD34 (+) and Ki-67 proliferation index were less than 10%.

CONCLUSIONS

PCA is rare and may be misdiagnosed as malignant tumor, which may be related to pregnancy comorbidity and high risk of Down's screening, so improving the understanding of PCA can provide the basis for clinical diagnosis and intervention. PCA is a rare tumor which may be misdiagnosed as a malignancy. It may be related to pregnancy comorbidity and high risk of Down's screening. Improving the understanding of PCA could provide the basis for clinical diagnosis and intervention.

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.

Large Chorioangioma in Triplets: An Uncommon Occurrence

A 25-year-old primigravida presented at 26 weeks of gestation by dates, the first time for the routine antenatal checkup. No histories were suggestive of pregnancy-induced hypertension (PIH) and edema. On physical examination, pallor was present with microcytic hypochromic anemia. Raised beta-human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) levels were present. Ultrasonography revealed triples with two thin echogenic intertwining membranes. Anomaly scan did not reveal any abnormality in fetuses. The placenta showed a large oval hypoechoic mass arising from its edge and bulge into the amniotic fluid. A central feeding vessel with a branching pattern and pulsatile color flow like that of the umbilical artery is noted on the color Doppler. She was spontaneously preterm delivered vaginally at 28 weeks of gestation. All three fetuses were stillborn. Histopathological diagnosis of angiomatous chorioangioma was confirmed. This case classically represents a grave complication of the large chorioangioma.

Degenerative type of placental chorioangioma requiring fetal blood transfusion

We experienced a case with fetal hydrops, polyhydramnios, and a well-defined oval anechoic lesion of approximately 9 cm in size, without blood flow at 26 weeks' gestation. As increased middle cerebral artery peak systolic velocity, the fetal hydrops was caused by a placental tumor such as a chorioangioma; however, the tumor was atypical. Fetal blood hemoglobin was 8.3 g/dl on percutaneous umbilical cord blood sampling. After erythrocytes transfusion to the fetus, the mother normally delivered at 38 weeks' gestation. The placental tumor was histologically diagnosed as a necrotic chorioangioma. Obstetricians should note such atypical chorioangiomas when differential diagnosis of placental tumors.

Imaging findings in association with altered maternal alpha-fetoprotein levels during pregnancy

Maternal serum alpha-fetoprotein is a valuable laboratory test used in pregnant women as an indicator to detect certain clinical abnormalities. These can be grouped into four main categories: fetal factors, pregnancy complications, placental abnormalities, and maternal factors. Imaging is an invaluable tool to investigate the various etiologies leading to altered maternal serum alpha-fetoprotein. By reading this article, the radiologist, sonologist, or other health care practitioner should be able to define the probable pathology leading to the laboratory detected abnormal maternal serum levels, thus helping the clinician to appropriately manage the pregnancy and counsel the patient.

A mystery mass on the placenta

Chorioangioma or chorangioma is a benign placental tumour which occurs in 1% of the pregnancies. Large lesions of more than 4-5 cm in size, also known as giant chorangiomas, are rare with the incidence of 1:3500 and 1:9000 birth. Unlike small tumours, the giant chorangiomas are highly associated with pregnancy complications. We report a case of multiple large chorangiomas resulting in an extremely preterm delivery. A 24-year-old primigravida presented at 25 weeks of gestation for threatened preterm labour. Transabdominal ultrasound revealed an echogenic mass on the placenta measuring 8.7 × 4.4 cm. Following a successful tocolysis and administration of a course of antenatal corticosteroids, she was discharged home. At 27 weeks of gestation, she developed a second episode of preterm contractions. Besides, the foetus was found to be small for gestational age. In the second episode of preterm contractions, intravenous magnesium sulfate infusion was commenced for foetal neuroprotection. Tocolysis was commenced for severe prematurity. She went into spontaneous preterm labour. Placenta examination revealed multiple solid masses with fleshy and congested dark red surface. A histopathological examination of the placenta confirmed the diagnosis of chorangiomas. The baby was discharged in good condition at 5 months of age. Placental chorangiomas, notably when they are multiple and large in size, are associated with adverse pregnancy outcomes. Therefore, close antenatal surveillance is necessary to allow timely recognition and intervention of pregnancy complications. Our case portrays an unexpected favourable neonatal outcome associated with a giant chorangiomas.

Can ultrasound be helpful in selecting optimal management methods for pregnancies complicated by placental non-trophpblastic tumors?

Placental chorioangioma is the most common subtype of non-trophoblastic placental tumors. Other subtypes are very rare and usually associated with an uneventful course of pregnancy. Most chorioangiomas are small and of no clinical significance. Giant chorioangiomas may be associated with serious fetal and maternal complications. So far, no established ultrasound guidelines are available for the management of placental non-trophoblastic tumors. This may be attributed to the rarity of the disease entity and its different clinical features and complications. In this article, the role of ultrasound findings such as the tumor’s size, vascularity, feeding vessels, amniotic fluid and location of the placenta in the diagnosis, treatment and follow up of these tumors is presented relying on up-todate literature review. Conservative management with serial ultrasound examinations can be an adequate method for monitoring small uncomplicated tumors. Ultrasound-guided procedures such as amnioreduction and cordocentesis can be used for amelioration of complications. Chorioangioma-specific treatment is reserved for complicated cases in the second trimester of pregnancy when prematurity is a matter of concern. Endoscopic laser ablation is indicated when the feeding vessel is superficial and small. Interstitial laser ablation is helpful when the placenta is located in the anterior uterine wall. Ligation of the feeding vessels is preferred when they are large. Alcohol injection should be performed away from the vasculature to prevent toxicity. Microcoils should be inserted as near as possible to the tumor to prevent collateral formation. Ultrasound is also a method of choice for monitoring the effectiveness of these procedures.

A rare giant placental chorioangioma with favorable outcome: A case report and review of the literature

We describe a rare giant placental chorioangioma in a patient who had a favorable outcome with close prenatal surveillance in a 28-year-old primigravida who was referred to our clinic for ultrasound evaluation of a suspected placental mass at 23 weeks' gestation. A detailed ultrasound scan revealed a well-circumscribed, echogenic lesion measuring 11.0 × 10.3 × 7.3 cm and protruding into the amniotic cavity. A diagnosis of placental chorioangioma was made and intensive prenatal surveillance was scheduled. A small-for-gestational age (2,325 g) but normal female neonate was delivered at 37 weeks by cesarean section and discharged from hospital on the second day of the delivery. A giant chorioangioma may not cause any adverse effect to the fetus and may not require any medication or invasive intervention. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 43:254-256, 2015.

Placental tumor (chorioangioma) as a cause of polyhydramnios: a case report

Placental chorioangioma is the most common type of placental tumor. It is usually symptomless and may be associated with serious maternal and fetal complication when it reaches a large size. We presented a case of an angiomatous type of placental hemangioma diagnosed in the second trimester of pregnancy in a patient with polyhydramnios. A normal volume of amniotic fluid was successfully achieved by three amnioreductions with conservative management. The size of the placental tumor remained the same from the time of diagnosis to the end of pregnancy. A term labor was uncomplicated and a healthy newborn was delivered. Macroscopic and microscopic examination of the placenta confirmed the diagnosis. Despite the rarity of placental tumors, they should be considered as differential diagnosis in cases of polyhydramnios.

Successful Outcome of a Pregnancy Complicated by a Voluminous Placental Chorangioma: Case report with Review of the Literature

Placental chorangioma is a rare, benign, placental neoplasm associated with a myriad foetomaternal and neonatal complications. Voluminous chorangiomas have frequent complications and adverse outcomes. The successful outcome of a pregnancy complicated by a voluminous chorangioma is reported herein, with the literature review. Chorangiomas mostly occur in primiparous women over 30years of age, complicated by polyhydramnios, placenta praevia, ante-partum haemorrahage, premature separation of membranes, premature labour, toxaemia of pregnancy, hydrops foetalis and midterm intrauterine death. The neonatal period may be complicated by effects of low birth weight, cardiomegaly, cardiac failure, anaemia, thrombocytopenia and unsuspected congenital anomalies. This case had an unusually uneventful antenatal period for 36weeks, culminating in a medically unassisted, spontaneous, vaginal, breech delivery with a successful pregnancy outcome, in spite of having a voluminous chorangioma.

An epidemiological study investigating the relationship between chorangioma and infantile hemangioma

OBJECTIVES

This study aimed to verify whether the infantile hemangioma (IH) incidence in children whose placentas showed a chorangioma is higher than in the general population, thus addressing the hypothesized relationship between chorangioma and IH.

METHODS

All chorangioma diagnoses by the 1st Service of Pathology, University of Padova in 2004-2010, based on the analysis of placentas sent by the Department of Gynecological Sciences and Human Reproduction (University of Padova), were identified. Demographic, anamnestic and clinical data were collected from the mothers and newborns; mothers and pediatricians were interviewed by telephone within 1 year after birth to verify if any IH appeared. The incidence rates of IH and other adverse events (IUGR, preterm delivery, cesarean section, stillbirth) were compared with national and regional data, when available, or with estimates from the scientific literature.

RESULTS

Thirty-eight chorangioma diagnoses were found. Of 33 infants born with a placenta affected by chorangioma, 18 infants had IH. The IH incidence recorded in our series (55%) was significantly higher than that recorded in national and regional surveys and in the scientific literature. Similar findings have been observed for the incidence of stillbirth, preterm birth and low birth weight incidence.

CONCLUSIONS

The IH incidence observed in our series appears to be significantly higher than that recorded among the general population, suggesting that an association between placental chorangioma and IH could exist which should be further verified in prospective studies.

Prenatal Diagnosis and Fetomaternal Outcomes of Two Cases with Placental Chorioangioma

Placental chorioangiomas greater than 4 cm in diameter are rare placental tumors. They have adverse fetomaternal outcomes. We present our experience with two cases having a giant angioma and review the relevant literature.