INTRODUCTION

• The placenta plays a crucial role throughout pregnancy, and its

importance may be overlooked during routine antenatal imaging
evaluation.
• Detailed systematic assessment of the placenta at ultrasonography
(US), the standard imaging examination during pregnancy is
important
 Early Placenta Formation
• The blastocyst adheres to the endometrium, and
the outer trophoectoderm layer differentiates into
syncytiotrophoblasts and cytotrophoblasts
• Syncytiotrophoblasts - establishing lacunar
networks, which are the primordia of the
intervillous spaces of the placenta
• Cytotrophoblasts - form a stem cell column for
villous development
• As the chorionic sac grows, the villi associated with
the decidua basalis rapidly increase in number,
developing a brushy area called the villous chorion
(chorion frondosum), which later evolves and forms
the placenta.
IMAGING OF NORMAL PLACENTA
Ultrasonography
• The placenta is visible by 10 weeks gestation,
where it is seen as a thickened echogenic rim
of tissue surrounding the gestational sac.
• By 15 weeks gestation, the placenta is well
formed and the retroplacental (subplacental)
hypoechoic zone is visualized referred to as
the retroplacental clear space (1–2 cm thick).
• The fetal side of the placenta is called the
chorionic plate, and the maternal side is Normal placenta :US image shows a homogeneous
called the basal plate. placenta (P) with central placental cord insertion (CI)
and the hypoechoic retroplacental complex (arrows)
behind the placenta.
• Normal placenta is discoid with uniform echogenicity and rounded margins
• It may show a few focal sonographic lucencies with slow flow, which are called
venous lakes.
• The umbilical cord typically inserts centrally

Color-flow Doppler image shows

scattered sonolucencies (arrows) within
the substance of the placenta with little or
no flow
MR Imaging
• usually reserved as a complementary technique/ if additional
information is required.
• the normal placenta between 19 and 23 weeks gestation has relatively
homogeneous high T2 signal intensity and low T1 signal intensity.
• Between 24 and 31 weeks gestation, the placenta becomes slightly
lobulated and forms multiple septa between the lobules leading to
increased heterogeneity.
• Delineation between the placenta and uterine wall is possible on T2-
weighted images, where the placenta appears hyperintense relative to
the myometrium.
 Normal placenta at 19 weeks gestation. Axial
T2- weighted MR image shows a
homogeneous hyperintense placenta (P). The
The green trace outlines the placenta. The blue bracketed area appears slightly myometrium is slightly hypointense (arrows)
blurry, and one might think of placental invasion... however, this does not hold
up on other images. relative to the placenta
The red arrows point to the inner and outer myometrial layer. The yellow arrow
points at the inner T2 hyperintense layer.
 VARIATIONS IN PLACENTAL
MORPHOLOGY
Succenturiate Placenta:
• Placenta with an accessory lobe is called a succenturiate
placenta.
• USG:
• The accessory lobe is usually smaller than the main
placenta
• however, occasionally the accessory lobe is equal in size
to the main lobe, which is termed as bilobed placenta
• there is no placental tissue bridging the two placental
components. They are connected by intramembranous
blood vessels, with the umbilical cord originating from color Doppler image of a placenta at 24 weeks gestation shows
two separate placental lobes, with the placental cord insertion
the main placenta (CI) at the margin of the main lobe (P), near the membranes
connecting the lobes. The blood vessels (arrow) are seen
traveling from the main lobe and crossing posteriorly toward the
succenturiate lobe
 Circumvallate Placenta
• In this, Chorionic membranes do not insert at
the edge of the placenta but at some distance
inward from the margins, resulting in a rolled
up and thickened placental edge and a central
depression
• US: the raised edge of the placenta is depicted
as a linear band or shelf-like structure
isoechoic to the placental tissue.

Longitudinal gray-scale US image at 21 weeks

gestation shows the raised edge of the placenta
(P) as a linear band of tissue or shelf-like
structure (arrow)
Placenta Membranacea or Diffusa
• placenta is a thin membranous
structure circumferentially
occupying the entire periphery of
the chorion
 Placental Thickness
• Increases linearly with gestational age (a) Normal placental
throughout a normal pregnancy, with the thickness
thickness in millimeters usually correlating
with the gestational age in weeks.
• Normal placenta ranges from 2 to 4 cm
• Anterior placentas are approximately 0.7
cm thinner than posterior or fundal
placentas.
• An anterior placenta of greater than 3.3 cm (b)Thin placenta
and a posterior placenta of greater than 4
cm should be considered thickened
 Placental Location
• determined according to the main placental body position from the uterine equator
• low-lying placenta is used when the placental edge is located in the lower uterine
segment within 2 cm or less of the internal cervical os;
• placenta previa is used when the placental edge covers the internal cervical os

(a) Complete placenta previa.

Longitudinal gray-scale US
image shows the placenta
(P) completely covering the
internal os (x).
(b) Partial placenta previa.
Longitudinal gray-scale US
image of shows a low-lying
placenta (P) extending to,
but not covering, the
internal os (x).
Placental Cord
Insertion
• Marginal Cord Insertion: defined as placental cord insertion within 2 cm of
the placental edge
Velamentous Cord Insertion:
• cord inserts into and traverses through the membranes (between the amnion
and chorion) before entering the placental tissue
• Vasa Previa:
• diagnosed when the umbilical vessels run
through the fetal membranes not
supported by the placental tissue or
Wharton jelly and are close to the internal
cervical os and below the presenting part
of the fetus.
• US:appears as linear echolucent structures
crossing the cervix. Color Doppler US
shows vascular structures overlying the
internal cervical os with a fixed position
during maternal repositioning.
• Spectral waveforms obtained with
Doppler US demonstrate fetal-type flow (a) US image shows fetal blood vessels (arrow) overlying the
internal cervical os (arrowhead).
(with a fetal heart rate) (b) Spectral Doppler image shows arterial flow with a fetal heart
rate in these vessels, confirming vasa previa
Placental Cysts
• also called chorionic plate cysts
• are anechoic thin-walled structures
usually seen along the fetal surface
of the placenta, typically near the
cord insertion
• demonstrate no internal vascularity
at Doppler imaging

Chorionic plate cyst. color Doppler image shows a well-

defined anechoic avascular structure (arrow) along the fetal
surface of the placenta (P)
Placental Abruption and Associated Hematomas
• Placental Abruption: defined as premature
placental separation from the implantation site.
• US is insensitive for detection of placental
abruption
• This is because acute and subacute hematomas are
frequently isoechoic to placental tissue.
• In the setting of trauma to the pregnant patient,
the most common injury after solid organ injury
is placental abruption.
Crescent of avascular, low echogenicity between
the placenta and uterine wall consistent with
placental abruption.
• Placental hematomas are categorized as periplacental—including
subchorionic (preplacental) hematomas and retroplacental hematomas.
• Subchorionic hematomas are the most common type and are usually due to
rupture of the uteroplacental veins near the placental margin.
• Retroplacental hematoma is thought to be due to rupture of small decidual
arteries and extends between the placenta and uterine wall
 Morbidly Adherent Placenta
• abnormal placental invasion into the uterine wall, leading to failure of placental
separation at delivery.
• MAP is classified according to the depth of placental invasion into the uterine
wall
• Placenta accreta - the placenta is in direct contact with the myometrium
• Placenta increta - the placenta invades into the myometrium
• Placenta percreta - the placental invasion extends beyond the uterine serosa and
into surrounding structures
• US: an irregular or absent retroplacental clear space and multiple irregular
placental lacunae (Swiss-cheese appearance), with turbulent high-velocity flow
deep in the placenta separate from the fetal surface of the placenta.
(a) Myometrial thinning. color
Doppler image shows loss of the
normal hypoechoic
retroplacental space and
reduced thickness of the
myometrium (arrows).
(b) Placental lacunae. US image
shows multiple hypoechoic
areas (arrowheads) representing
placenta lacunae.
(c) Increased vascularity.
Longitudinal color Doppler
image of placenta increta shows
increased intraplacental and
retroplacental vascularity
(arrows).
(d) (e) images shows bulging
(arrows in d) of the placenta (P)
and bladder, with increased
chaotic vascularity along the
interface (arrowheads in e)
• MR imaging
• Dark intraplacental bands on T2-weighted images,
• disorganized intraplacental vascularity, abnormal uterine bulge,
• thinning or loss of the retroplacental dark zone on T2-weighted
images,
• myometrial thinning or focal disruption of the myometrium,
• invasion of adjacent organs (particularly the bladder), and tenting
of the bladder.
(a) Placenta increta. Coronal T2-weighted image shows placenta previa with a
focal bulge (arrows) at the lower aspect of the uterus, with discontinuity of
the myometrium without bladder-serosa interruption.
(b) Placenta percreta. Sagittal (b) and axial (c) T2-weighted images show a
Sagittal T2 SSFSE shows complete placenta previa with loss of low-signal intensity
focal placental bulge (white arrows in c) at the right anterolateral aspect of
at interface between bladder and uterus (thin arrow). There is marked myometrial
the uterus, with discontinuity (black arrows) of the myometrium thinning, with increased vascularity or neovascularization along anterior lower
(arrowheads in b) uterine segment and superior aspect of bladder (arrowheads), which is in contrast
to normal appearance of posterior aspect of myometrium (thick arrow).
Gestational Trophoblastic Disease/molar
pregnancy
• Complete hydatidiform mole is the most common type of GTD.
• US: the endometrial cavity is expanded by hyperechoic or
isoechoic tissue with multiple variable-sized cysts, giving the classic
“snowstorm” or “clusters of grapes” appearance.
Complete molar pregnancy. (a) US image shows expansion of the endometrial cavity by a multicystic
mass (arrows) (snowstorm appearance). No fetal parts can be identified.
(b) Coronal gadolinium enhanced T1-weighted MR image shows expansion of the endometrial cavity
(arrows) with lattice-like enhancement of the contents.
(c) Photograph of the gross specimen shows multiple small cysts (arrowheads) within the mass,
representing a complete molar pregnancy.
• Partial hydatidiform mole is the second most common type of GTD.
• US: shows focal cystic changes of the placenta, and a gestational sac
may be seen. When fetal tissue is identified, it is usually abnormal
Twin pregnancy with a normal fetus and a
complete mole, proven at pathologic
examination, at 12 weeks gestation in a
patient with a history of in vitro
fertilization. Longitudinal gray-scale US
image shows a normal fetus (F) and normal
placenta (P) in one gestational sac and an
abnormally thick placenta (TP) with
multiple cysts (arrows) in the other
gestational sac; the latter represents a
complete molar pregnancy. No normal fetal
parts are seen in this gestational sac.
PERSISTENT TROPHOBLASTIC NEOPLASIA
(PTN)
• invasive mole - (most common)
• US - cystic foci or nodules in the myometrium. Hypervascularity
and high-velocity, low-impedance arterial flow may be seen at color
Doppler imaging
• MR: usually has heterogeneous signal intensity on T2-weighted
images
• and an indistinct boundary between the endometrium and
myometrium, with either focal or diffuse disruption of the zonal
architecture
Placental Nontrophoblastic Tumors
• Chorioangioma is the most common -
benign vascular tumor supplied by the
fetal circulation.
• US-seen as a well-circumscribed tumor
with mixed echogenicity different from
the adjacent placental tissue
• Chorioangioma has abundant internal
vascularity with low-resistance arterial
flow Chorioangioma (a) color Doppler image shows a well-
circumscribed hypoechoic mass (black arrows) arising from the
fetal surface of the placenta (P) adjacent to the cord insertion
(CI). It demonstrates internal vascularity and a large feeding
vessel (white arrow).
(b) Cut section of the delivered placenta from another patient
with chorioangioma. Note the reddish mass (arrow) in the
placenta (P)
SUMMARY
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