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Chapter 44 ■ Sonographic Evaluation of the Placenta 1517
A
C
B
FIGURE 44-28. Umbilical cord cysts. A, Transvaginal
sonogram early in the first trimester demonstrates the yolk sac (long
arrow), which is extra-amniotic, and umbilical cord cyst (short
arrow). B, Transvaginal sonogram of a first-trimester fetus with an
umbilical cord cyst (calipers), which is near the abdominal umbilical cord insertion site. C, Color Doppler sonogram with flow in
the umbilical cord around the cyst.
FIGURE 44-29.
gram of a third-trimester fetus shows an edematous area (arrow)
of cord near the abdominal umbilical cord insertion.
Edematous cord. Transabdominal sono-
1518 PART IV ■ Obstetric Sonography
A
C
The normal umbilical cord has three vessels; one vein
carries oxygenated blood to the fetus, and two arteries
carry deoxygenated blood from the fetus. In 1% to 2%
of pregnancies, however, there is only a single umbilical
artery (Fig. 44-30). The diagnosis is made either by
examining a free loop of cord in the amniotic fluid or
by assessing the umbilical arteries around the fetal
bladder. Although associated with aneuploidy as well as
renal and cardiac abnormalities, in isolation a single
umbilical artery has no functional importance.
Insertion into the Placenta
The normal umbilical cord inserts into the central
portion of the placenta. Identifying the placental umbilical cord insertion is important to recognize abnormalities
of the umbilical cord vessels, as with gray-scale imaging
and color or power Doppler sonography (Fig. 44-31).
B
FIGURE 44-30. Single umbilical artery. A and B, Gray-
scale and color Doppler sonograms show a single artery and a single
vein. C, Color Doppler ultrasound adjacent to the fetal bladder shows
a single umbilical artery.
Velamentous and Marginal
Cord Insertions
A velamentous umbilical cord insertion refers to the
situation where the umbilical cord inserts into the
membranes and not the placental disc (Fig. 44-32). A
marginal cord insertion, also known as a battledore
placenta, occurs when the umbilical cord inserts into the
very margin of the placenta (Fig. 44-33). Velamentous
umbilical cord insertions occur in approximately 1% of
singleton pregnancies; marginal cord insertions occur in
approximately 7% of singletons. Both these cord insertions are more common in multiple gestations and are
also associated with single umbilical arteries.
24
Velamentous umbilical cord insertions are sonographically identified throughout the second and third
trimesters of pregnancy with great reliability. Sepulveda
144
identified the placental cord insertion in more
et al.
than 99% of pregnancies, correctly identifying all
Chapter 44 ■ Sonographic Evaluation of the Placenta 1519
FIGURE 44-31. Normal cord insertion into pla-
centa. Power Doppler sonogram shows central cord insertion
(arrow) in a posterior placenta.
A
C
velamentous cord insertions using both gray-scale and
color Doppler sonography.
tion has been identified as early as 10 weeks’ gestation
and can be routinely identified on the 11 to 14–week
first-trimester scan.
146
144
A velamentous cord inser-
145
Velamentous cord insertions are
B
FIGURE 44-32. Velamentous cord insertion. A, Transab-
dominal sonogram of a second-trimester placenta with cord insertion
entering the membranes and not the placental disc. B, Color Doppler
transvaginal sonogram of a second-trimester velamentous cord insertion shows the umbilical vessels inserting away from the placenta. The
internal cervical os is indicated by the arrow. C, Examination of the
placenta after delivery shows umbilical cord (arrow) with fetal vessels
coursing through the membranes into the placental disc.
associated with IUGR, preterm delivery, congenital
anomalies, low Apgar scores, neonatal death, and retained
placenta after delivery.
insertions are not associated with IUGR or preterm
delivery
148
but are associated with vasa previa.
144,147
Marginal umbilical cord
1520 PART IV ■ Obstetric Sonography
FIGURE 44-33. Marginal cord insertion. Color
Doppler sonogram shows the umbilical cord inserting into the
edge of the placenta (arrow).
The insertion of the umbilical cord into the membranes leads to the unsupported coursing of the umbilical vessels to the placental disc and many complications.
Wharton’s jelly supports and protects the umbilical
vessels in the umbilical cord. With the vessels in the
membranes, no Wharton’s jelly is present, leading to
increased risk of compression or even rupture of these
vessels. Intrapartum fetal heart rate patterns show more
variable decelerations and no accelerations with velamentous cord insertions during the first and second
stages of labor compared to controls.
147
Increasing length
of the unsupported membrane vessels is associated with
increasing rates of abnormal heart rate patterns, as is the
umbilical cord insertion being in the lower portion
rather than the middle or upper portion of the uterus.
147
Nonreassuring fetal heart rate patterns and emergency
cesarean deliveries are more frequent with velamentous
cord insertions in the lower third than in the middle or
upper third of the uterus.
147
Because velamentous cord insertions are typically
located low in the uterus, transvaginal sonography can
be critical to making this diagnosis.
Vasa Previa
Vasa previa is the situation where the umbilical cord
vessels overlie the internal cervical os (Fig. 44-34; Video
44-6). Because these are fetal vessels, even a small amount
of blood loss can lead to fetal death. High-risk situations
that require specific exclusion of vasa previa include velamentous umbilical cord insertions in which the membranous fetal umbilical vessels can traverse the internal
cervical os somewhere along their length. Marginal
umbilical cord insertions, especially those with aberrant
vessels within the membranes, also are associated with
vasa previa.
more common succenturiate lobes
149
Presence of bilobed placentas
151
requires that a
150
or the
vasa previa be excluded, given the potential for a poor
neonatal outcome. Prior low placenta, placenta previa,
multiple gestations, and pregnancies resulting from in
vitro fertilization are all associated with vasa previa.
Once a vasa previa is diagnosed, obstetric management is critical to optimize outcome. Delivery at 35 to
36 weeks’ gestation is recommended to obviate the risks
of vessel rupture that can occur with labor or rupture of
the membranes. If the patient has preterm labor, ruptured membranes, or bleeding before 35 weeks, delivery
at the earlier gestational age should be considered.
Vasa previa is diagnosed when a fetal vessel is identified overlying the internal cervical os. Although grayscale ultrasound can identify the vessel, color or power
Doppler sonography can assist with visualizing the vessel.
Pulsed wave Doppler ultrasound should confirm a fetal
artery, by demonstrating the heart rate of the fetus rather
than that of the pregnant woman. Three-dimensional
sonography may assist with making the diagnosis of a
vasa previa,
149,154
especially using 3-D power Doppler
sonography to map out the aberrant vessels.
cian must be careful, however, especially when using
color or power Doppler ultrasound, not to equate identification of the umbilical cord in the lower uterine
segment or overlying the cervix with a vasa previa. The
cord could be free floating in this area, termed a funic
presentation, and not a vasa previa (Fig. 44-35). Careful
attention to detail, using movement of the probe or
follow-up sonography, may be necessary to reach the
correct diagnosis.
156
PLACENTA DURING LABOR
AND POSTPARTUM
Third Stage of Labor
Ultrasound may have some role during the third stage
of labor, the time from delivery of the neonate to delivery
149,151,152
155
The clini-
152,153
Chapter 44 ■ Sonographic Evaluation of the Placenta 1521
A B
C D
FIGURE 44-34. Vasa previa. A, Transvaginal sonogram of a vasa previa using color and pulsed wave Doppler ultrasound. The gate
is at the level of the internal cervical os. A fetal arterial pulse wave is shown. B, In another patient, transvaginal color Doppler sonogram
shows the umbilical cord inserting into the membranes, consistent with a velamentous cord insertion. Long arrow shows the cord insertion at the level of the internal cervical os; short arrow indicates placenta. C, In a different patient, transvaginal power Doppler sonogram
shows vessels between two lobes of a bilobed placenta; arrow indicates internal cervical os. D, Transabdominal color and pulsed Doppler
sonogram shows a low placenta with a fetal artery traversing the internal cervical os.
of the placenta. A prolonged third stage, with the placenta retained, has various etiologies. If the placenta does
not separate, a placenta accreta could be present.
54
A
and the placenta.
separates varies, based on prior cesarean delivery and a
prolonged second stage of labor.
159
The manner in which the placenta
160
prolonged third stage may also be caused by retention of
a detached placenta from poor contractility or atony of
the uterus, sometimes from infection. These abnormalities are treated differently, and ultrasound may help differentiate the various causes of a prolonged third stage
of labor and lead to improved patient care.
The mechanism of placental separation has been
reported using gray-scale sonography.
157
158
Color Doppler
ultrasound provides information on the phases of placental separation during the third stage of labor by specifically assessing blood flow between the myometrium
Retained Products of Conception
Women with suspected retained products of conception
(RPOC) typically present with abnormal bleeding.
RPOC are most common after second-trimester spontaneous abortion, extreme preterm birth, medical termination of pregnancy, and unsuspected placenta accreta.
RPOC are suggested when an echogenic endometrial
mass is visualized within the uterine cavity (Fig. 44-36).
This mass may extend into the myometrium
161
and can
1522 PART IV ■ Obstetric Sonography
FIGURE 44-35. Funic presentation. Transvaginal ultra-
sound of a single loop of normal umbilical cord, free floating and
overlying the internal cervical os. The cervix is indicated by the
calipers. The three vessels of the umbilical cord are seen in cross
section.
A
C
B
FIGURE 44-36. Retained products of conception.
A, Transabdominal sonogram shows a heterogeneous area of echogenic tissue in the endometrial cavity. B, Transvaginal color
Doppler sonogram in a different patient shows vascularization of
an endometrial mass. C, Transvaginal sonogram in another patient
shows a calcified endometrial mass. In each case, the mass has
retained products of conception.
Chapter 44 ■ Sonographic Evaluation of the Placenta 1523
be differentiated from blood clot when flow is demonstrated. However, lack of flow does not exclude RPOC.
Care should be taken not to mistake vascularized RPOC
for a uterine arteriovenous malformation, because prominent flow can be seen in RPOC.
161
Calcifications in the
endometrial mass are highly suggestive of RPOC. These
calcifications present normal placental maturation that
occurred during pregnancy.
CONCLUSION
Multiple abnormalities associated with placental development and function can be identified by prenatal
sonography. Sonographers and sonologists need to
understand the basic anatomy and physiology of the
placenta so that abnormal findings on prenatal sonography can be acknowledged, to achieve the best possible
outcome for mother and neonate.
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1524 PART IV ■ Obstetric Sonography
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Chapter 44 ■ Sonographic Evaluation of the Placenta 1525
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1526 PART IV ■ Obstetric Sonography
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