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OJHAS Vol. 9, Issue 4:
Oct-Dec, 2010) |
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Multiple Choriangiomas of Placenta |
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Vijay Shankar
S, Associate
Professor,
Swarna
Shivakumar,, Professor and Head,
Nalini
Krishnan, Associate
Professor,
Thejaswini
MU, Assistant
Professor,
Abhishek
MG, Assistant
Professor,
Department of Pathology, Adichunchangiri Institute
of Medical Sciences, BG Nagara, Nagamangala taluk, Mandya district,
Karnataka, India
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Address For Correspondence |
No 45, Ananda
shylam,
3rd cross, 1st
main ,
KN extension, Yeswanthpur,
Bangalore - 560022,
Karnataka, India.
E-mail:
vijayshankarpatho@gmail.com |
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Vijay Shankar S, Shivakumar S, Thejaswini MU, Abhishek MG.
Multiple Choriangiomas of Placenta. Online J Health Allied Scs.
2010;9(4):27 |
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Submitted: Dec 6,
2010; Accepted: Dec 28, 2010; Published: Jan 20, 2011 |
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| Abstract: |
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Placental
chorangiomas, not an uncommon condition is often small and hence
usually goes unnoticed . However the incidence of complications is high
when the chorangioma is large. We hereby present an unusual case of
large and multiple choriangiomas with secondary changes and associated
congenital anomalies with hydrops fetalis.
Key Words: Chorangiomas; Hydrops; Degenerative changes
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Chorangioma
of the palcenta was originally described by Clarke in 1798.1 It is the most common benign vascular tumor ranging widely
in size and approximately 1% of all pregnancies.2
It is most likely a hamartoma of primitive chorionic mesenchyme
composed of capillary sized and cavernous vascular spaces embedded in
a fibrotic /myxoid stroma.2
It most often
goes unnoticed. However it is accompanied by maternal and fetal complications.
A 25-year-old
female with 7 months of amenorrhea presented for a regular antenatal
check up. Her marriage was consanginuous and had a 2-year-old
healthy female child which was delivered by full-term normal delivery.
There was no history of spontaneous or induced abortions in the past.
During this pregnancy, she had an uneventful first and second trimester.
Ultrasound examination revealed multiple congenital anomalies with features
of hydrops and hence labour was induced to terminate the pregnancy.
Patient delivered
an anomalous male baby weighing 1.25 kg, with low set ears, web neck
along with features of hydrops. Along with the placenta, multiple large
grey brown soft tissue masses were also delivered. Placenta along with
the soft tissue masses were sent for histopathological examination.
Pathological
Examination:
Gross examination
of the placenta showed a fleshy area on the fetal surface . Along with
this, multiple grey brown soft , well circumscribed, irregular masses
were present; largest measuring 8x5x4 cm. Placenta weighed 900g and
the masses weighed 450 gms. Cut section of all the masses were soft, hemorrhagic,
with focal grey white areas (Figure 1).
Microscopic
examination of the masses showed a well delineated tumor, predominantly
composed of capillary sized blood vessels lined by plump endothelial
cells, along with few cavernous spaces filled with blood (Figure 2).
The vascular spaces are separated by fibrous stroma. The stroma also
showed extensive areas of ischemic necrosis and myxoid degeneration.
These features were diagnostic of chorangioma of placenta with
secondary degenerative changes and infarction.
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| Figure 1: Cut section of
the masses revealing hemorrhagic and grey white areas. |
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Figure 2: Tumor composed
of capillary and cavernous sized blood vessels (100x) |
Choriangiomas
of the placenta are benign, primary, non-trophoblastic placental vascular
tumors. The incidence is approximately 1% of all the placentas and are
analogous to hemangiomas at other sites.1 It is found that
chorangiomas are more frequent in first or twin pregnancies and also
when the fetus is female.3 In our case the chorangioma
is found in second pregnancy and the fetus is male. These are expansile
nodular lesions composed entirely of vascular channels with intervening
stroma and surrounded by trophoblastic tissue.
Chorangiomas can be intraplacental or extraplacental where it is attached as a bulging
mass on the fetal surface of the placenta. In one of the study it is
found that chorangiomas are most frequently found in areas
where it is poorly perfused as in marginal and subchorionic regions. They are least frequently found in areas of best perfusion like in centrobasal
region of the placenta.4 Most cases of chorangiomas are
diagnosed following delivery. The macroscopic size of the chorangioma
varies from few millimetres to several centimetres. Chorangiomas are
considered as large when the size is more than 4 centimeters. They are
fleshy, dark and often congested.1 In our case
the chorangioma was extraplacental large and multiple which
were soft and hemorrhagic with focal grey white areas. It was diagnosed
following the termination of pregnancy.
Microscopically
various patterns have been described. They are capillary, cavernous,
endotheliomatous, fibrosing and fibromatous forms.2 Alternatively
they are also classified as angiomatous (capillary), cellular and
degenerative.2 some authors believe that, such precision
is unwarranted as the clinical outcome is always the same , and
it depends on the size of the mass(es) than the composition of the tumor(s).1 The
angiomatous pattern, is the most common among these and is composed
of numerous small endothelial lined capillaries, with blood vessels
and surrounded by trophoblastic tissue. The intervening perivascular
stroma is composed of fibroblasts, macrophages and collagen. These tumors
often have degenerative changes, calcification, infarcts and thrombosis
which may leave hemosiderin behind.1
In our case the tumor was capillary and cavernous type
with extensive areas of necrosis and myxoid degeneration.
A vast majority
of the chorangiomas are small and have no clinical significance.
Complications are usually seen when the chorangiomas are multiple and
are large.5 The complications affect the mother as well
as the fetus. The maternal complications include hydramnios, prematurity,
abruption of placenta and post partum hemorrhage.
Fetal complications
include non-immune hydrops fetalis, cardiomegaly, congestive cardiac
failure, anemia, prematuruity and sudden death. Few cases of thrombocytopenic
purpura is also noted. Hydrops fetalis in chorangioma of the placenta
may be due to the compression of the umbilical vessels by the tumor
, increased secretion of fetal metabolites through the tumor or may
be due to transudation of the fluid from the tumor.5
It is intriguing
to note that, inspite of large and multiple choriagiomas, this patient
did not have any maternal complications. However the fetus had
congenital anomalies with features of hydrops.
- Bashiri
A, Maymon E, Wiznitzer A, Maor E, Mazor M. Chorangioma of the placenta
in association with early severe polyhydramnios and elevated maternal
serum HCG: a case report. Eur J Obstet Gynecol Reprod Biol 1998;79:103–105.
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Flores GJ, Malagon VG,
Malagon VJ. Giant chorioangioma of the placenta. Intl
J Gynecol Obstet 2005;89:280-281.
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Ogino
S, Redline RW. Villous capillary lesions of the placenta: Distinction
between chorangioma, chorangiomatosis, and chorangiosis. Human Pathology
2000;31:945–954.
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Beirschke
K, Kaufmann P, Baergen R. Benign tumors and chorangiosis. In: Beirschke
K, Kaufmann P, Baergen R, editors. Pathology of human placenta. 5th
edn. New York: Springer; 2006. p. 863-76.
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Jashnani
DK, Doshi BJ, Rege DJ. Placental Chorangioma – A Cause Of Hydrops
Fetalis And Intrauterine Fetal Death. Bombay Hosp Journal. April 2000;42(2)411. Available
http://www.bhj.org/journal/2000_4202_apr00/case_411.htm
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