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Relationship of placental grade to gestational age
tesis in a term infant. Lucy’ briefly mentioned injury to “fetal heart, brain, or lung” during intrauterine fetal blood transfusion for Rh disease, but no further details of brain injury were given. Creasman’ reported that injection of amniography dye into the brain of a 2% week fetus resulted in subdural hemorrhage and stillbirth. It seems likely that the relative infrequency of fetal brain trauma compared to trauma of the fetal chest, abdomen, extremity, and umbilical cord is due to both the protective effect of the cranial vault and the relative ease of manual identification of the head during amniocentesis. The present case represents an unusual picture for perinatal intracranial hemorrhage. Of the four major types of neonatal intracranial hemorrhage-periventricular, primary subarachnoid, subdural, and intracerebellar-the clinical presentation of this case most closely resembles a massive subdural hemorrhage. Predisposing factors include precipitate or prolonged delivery, severe cephalopelvic disproportion, irregular presentation, as in breech, face, or brow, and unusually rigid pelvic structures occurring in very young primiparous or elderly multiparous mothers. These factors were not present in this case since the infant was delivered via elective cesarean section with minimal trauma. Because no needle tract was found through the bone, it is possible that the needle did not directly lacerate the dura but distorted the cranial vault sufficiently to produce a hemorrhage. The unfortunate outcome of this case provides important lessons. Obtaining blood from an amniocentesis attempt and/or development of a fetal heart rate abnormality should alert the obstetrician to the possibility of fetal distress. Blood can be rapidly determined to be of fetal origin by the Kleihauer-Betke technique. Either fetal tachycardia or fetal blood obtained at amniocentesis in a term infant may justify immediate abdominal delivery. Even in a premature fetus likely to have immature lungs, the presence of both fetal blood obtained at amniocentesis and fetal heart rate abnormalities after amniocentesis would probably provide adequate evidence for emergency delivery and resuscitation.:’ Perhaps the most important issue concerns the routine use of amniocentesis to determine fetal pulmonary maturity prior to elective cesarean section. In this case, where ultrasonography confirmed dates at 23 weeks and the risk of iatrogenic prematurity with respiratory distress syndrome was extremely low, amniocentesis probably could have been safely avoided.* We thank preparation
Susan Seidler and Judy of the manuscript.
Carbone
for
help
with
REFERENCES
1. Creasman, W. T.: Fetal JAMA 264:949, 1968. 2. Lucy, J. F.: Intrauterine
complications transfusion
of amniocentesis, and erythroblastosis
fetalis, Report of Fifty-third Ross Conference on Pediatric Research, Columbus, Ohio, 1967. Ross Laboratories, pp. 14-15. 3. Gassner, C. B., and Paul, R. H.: Laceration of umbilical cord vessels secondary to amniocentesis, Obstet. Gynecol. 48:627, 1976.
4. Frigoletto,
F. D.: Avoiding
elective repeat cesarean of amniocentesis, AM.
iatrogenic
section J.
prematurity
with
the routine
use
without
OBSTET.
GYNECOL.
137:521,
1980.
Relationship of placental to gestational age RUTH
A.
LAWRENCE
PETRUCHA,
grade M.D.
D. PLATT,
M.D
Department of Obstetrics and Gynecology, Southern Calz~ornia School of Medicine, Hospital, Los Angels County/University Califoornia Medical Center, Los Angeles,
University of and Women’s of Southern California
HISTOLOGIC and morphologic features of the placenta show characteristic changes that can be correlated with advancing gestational age. Previous studies showing correlation between placental calcification and gestational age required x-ray techniques and, thus, were unsatisfactory for routine in vivo placental study.’ Diagnostic ultrasound allows evaluation of the calcification and other features of the placenta without radiation exposure. Several author?, 3 have noted characteristic changes in the ultrasound examination of the placenta as pregnancy advances. A placental grading system based on these changes has been proposed by Grannum and associates3 The grading system used the compound B-scan for imaging the placenta. We have recently shown that real-time ultrasound yields comparable results. In addition, it has the advantage of being a rapid and easily used method.4 In both Grannum’s study and our previous study, observations on placental grade were made after 34 weeks’ gestation. The purpose of this paper is to extend these previous observations by assessing placental grade incidence from 10 weeks’ gestation onward. From January to August of 1981, 964 nondiabetic patients drawn from the outpatient antepartum clinics and inpatient antepartum ward of Los Angeles County/ University of Southern California Medical Center, Women’s Hospital, were examined by real-time ultrasound in the antepartum assessment unit. Patients were both high and low risk and were referred for real-time ultrasound examination for various reasons, including
Reprint requests: Lawrence D. Platt, M.D., Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Women’s Hospital, Room 5K22, 1240 North Mission Road, Los Angeles, California 90033. 0002-9378/82/220733+03$00.30/O
0
1982
The C. V. Mosbv
Co.
Table I. Distribution of 964 patients age and placental grade
by gestational
No. Weeks’ gestation
10 11 12 13 14 15
Fig. 1. Composite of real-time ultrasound Grades 0 through III.
scans of placental
pregnancy dating, genetic amniocentesis, suspected intrauterine abnormality, placenta location, amniocentesis for pulmonary maturity, suspected twins, and abnormal lie. Specifically, patients with diabetes and Rh sensitization were excluded from this study. This was not a random selection from our patient population as a whole; however, most examinations were performed on uncomplicated pregnancies. Seventy-four patients were examined more than once (from two to six times) during gestation. All patients were examined with a real-time linear array ultrasound 3.5 mHz transducer. Each fetus was examined for biparietal diameter and placental grade. The biparietal diameter was the greatest diameter measured at the level of the thalamus showing a strong midline echo. The gestational age was determined by the last menstrual period as confirmed by the biparietal diameter. The placenta was graded according to the system described by Grannum and associates.3 They graded the placenta from 0 to III based on changes in the: (1) chorionic plate, (2) placental substance, and (3) basal layer. In a Grade 0 placenta, the chorionic plate is
Graa’e I
Grade II
10
-
-
-
10
7 3 4 12
-
-
-
7 3 4 13
Grade
0
I
16
10
1
;:
17 18
24
19
18
5 5 4 3 3 2 4 3 5 23
20
16
21
13
22 23 24 Ei
12 9 12 i
27 28 29 30 31 32 33 34 35 36 37 38
10
6
6
10 12
10
39
6 9 7 6 6 8 5 3 2 2
40+
1
18 20 23 25 34 28 41 43 39 21 2i
-
Grade III
-
Total
-
11
-
33 28 28 21
19 15 16 12 17 118
-
1
2 2 3 5 6 7 15 23 17 32 48 28 30
2 -
1 1 1 5 13 20 16 21
16 18 24 29 34 36
39 56 48 68
91 109 67 73
smooth, the placental substance is homogeneous, and the basal layer is not calcified. In a Grade I placenta, the chorionic plate contains subtle undulations, and the placental substance contains small, echogenic areas, while the basal layer remains uncalcified. The chorionic plate of a Grade II placenta develops marked indentations that do not reach the basal layer, the placental substance is divided by comma-like densities continuous with the chorionic plate, and the basal layer shows a linear arrangement of small echogenic areas. A Grade III placenta consists of a chorionic plate that has indentations extending to the basal layer, a placental substance divided into compartments with echo-free areas, and a basal layer containing dense, almost confluent, echogenic areas (Fig. 1). Frequency of any given placental grade was calculated as a percentage of the whole in each gestational age group. No attempt was made to correlate disease state to placental grade. Table I shows the distribution of the 964 nondiabetic, non-Rh-sensitized patients by gestational age and placental grade. Fig. 2 shows, in graphic representation, the incidence of the various placental grades as gestation advances. Progressive changes in ultrasonic placental architec-
Volume Number
Communications
144 6
100
Grade Grade Grade Grade
OQ\
90
0 1 2 3
in brief
735
o Cl A 0
“\ o-o,o.o
; Y
a0 \
0.
Cl
111 7o z” lu
60
5
50
g
40
0 4
q
*MU \
00
/
\ PI-A A/\
A
30
~-US&
20
q / uvl
\o
./
/4
Ax
10
cl/ IO
12
14
16
18
20
22
GESTATIONAL
24
A-A.,
O-0 */ .-.Aoao
26
30
AGE
20
32
34
/’ 36
38
40
Fig. 2. Graph of placental grades versus progressing gestational age.
ture are a function of increasing gestational age. This relates to recent speculation that the Grade III placenta may be a marker for fetal pulmonary maturity. Ninety-five percent of Grade III placentas appear beyond 35 weeks’ gestation. This corresponds quite closely to the gestational age at which the abrupt rise in mature lecithin/sphingomyelin (L/S) ratios occurs.s An association between the ultrasonically mature placenta and a mature L/S ratio can be expected if only because they develop in the same gestational age period. The studies to date comparing placental grade to L/S ratios indeed suggest a relationship but are of small sample size.3, 4 More work must be done in this area before reliance is placed on the placental grade as a predictor of lung maturity. Since only 15% of placentas are destined to reach Grade III, this potential marker of pulmonary maturity has an inherent limitation of applicability. The cases of Grade III placentas in pregnancies less than 35 weeks’ gestation deserve comment. The earliest gestational age associated with a Grade III placenta was 30 weeks. In each of four cases where a Grade III placenta occurred before 35 weeks, intrauterine growth retardation was found in the fetus. Amniocentesis was
performed in two of the four cases; a mature pulmonary profile was found in both instances. The present report summarizes the incidence of placental Grades 0 through III at gestational ages 10 through 40 weeks. The study suggests that placental grade is a function of gestational age. No conclusions can be reached concerning the relation of the Grade III placenta to pulmonary maturity. REFERENCES
1. Tindall, V. R., and Scott, J. 8: Placental calcification: A study of 3,025 singleton and multiple pregnancies, J. Obstet. Gynaecol. Br. Commonw. 72:365, 1965. 2. Fischer, C. C., Garrett, W., and Kossoff, G.: Placental aging monitored by gray-scale echography, AM. J. OBSTET. GYNECOL. 124:483, 1976. 3. Grannum, P. A. T., Berkowitz, R. L., and Hobbins, J. D.: The ultrasonic changes in the maturing placenta and their relation to fetal pulmonic maturity, AM. J. OBSTET. GYNECOL.
133:915,
1979.
4. Petrucha, R. A., Golde, S. H., and Platt, L. D.: Real-time ultrasound of the placenta in assessment of fetal pulmonic maturity, AM. J. OBSTET. GYNECOL. 142:463, 1982. 5. Gluck, L., and Kulovich, M. V.: Lecithin/sphingomyelin ratios in amniotic fluid in normal and abnormal pregnancy, AM. J. OBSTET. GYNECOL. 115:539, 1973.
Susan Seidler and Judy of the manuscript.
Carbone
for
help
with
REFERENCES
1. Creasman, W. T.: Fetal JAMA 264:949, 1968. 2. Lucy, J. F.: Intrauterine
complications transfusion
of amniocentesis, and erythroblastosis
fetalis, Report of Fifty-third Ross Conference on Pediatric Research, Columbus, Ohio, 1967. Ross Laboratories, pp. 14-15. 3. Gassner, C. B., and Paul, R. H.: Laceration of umbilical cord vessels secondary to amniocentesis, Obstet. Gynecol. 48:627, 1976.
4. Frigoletto,
F. D.: Avoiding
elective repeat cesarean of amniocentesis, AM.
iatrogenic
section J.
prematurity
with
the routine
use
without
OBSTET.
GYNECOL.
137:521,
1980.
Relationship of placental to gestational age RUTH
A.
LAWRENCE
PETRUCHA,
grade M.D.
D. PLATT,
M.D
Department of Obstetrics and Gynecology, Southern Calz~ornia School of Medicine, Hospital, Los Angels County/University Califoornia Medical Center, Los Angeles,
University of and Women’s of Southern California
HISTOLOGIC and morphologic features of the placenta show characteristic changes that can be correlated with advancing gestational age. Previous studies showing correlation between placental calcification and gestational age required x-ray techniques and, thus, were unsatisfactory for routine in vivo placental study.’ Diagnostic ultrasound allows evaluation of the calcification and other features of the placenta without radiation exposure. Several author?, 3 have noted characteristic changes in the ultrasound examination of the placenta as pregnancy advances. A placental grading system based on these changes has been proposed by Grannum and associates3 The grading system used the compound B-scan for imaging the placenta. We have recently shown that real-time ultrasound yields comparable results. In addition, it has the advantage of being a rapid and easily used method.4 In both Grannum’s study and our previous study, observations on placental grade were made after 34 weeks’ gestation. The purpose of this paper is to extend these previous observations by assessing placental grade incidence from 10 weeks’ gestation onward. From January to August of 1981, 964 nondiabetic patients drawn from the outpatient antepartum clinics and inpatient antepartum ward of Los Angeles County/ University of Southern California Medical Center, Women’s Hospital, were examined by real-time ultrasound in the antepartum assessment unit. Patients were both high and low risk and were referred for real-time ultrasound examination for various reasons, including
Reprint requests: Lawrence D. Platt, M.D., Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Women’s Hospital, Room 5K22, 1240 North Mission Road, Los Angeles, California 90033. 0002-9378/82/220733+03$00.30/O
0
1982
The C. V. Mosbv
Co.
Table I. Distribution of 964 patients age and placental grade
by gestational
No. Weeks’ gestation
10 11 12 13 14 15
Fig. 1. Composite of real-time ultrasound Grades 0 through III.
scans of placental
pregnancy dating, genetic amniocentesis, suspected intrauterine abnormality, placenta location, amniocentesis for pulmonary maturity, suspected twins, and abnormal lie. Specifically, patients with diabetes and Rh sensitization were excluded from this study. This was not a random selection from our patient population as a whole; however, most examinations were performed on uncomplicated pregnancies. Seventy-four patients were examined more than once (from two to six times) during gestation. All patients were examined with a real-time linear array ultrasound 3.5 mHz transducer. Each fetus was examined for biparietal diameter and placental grade. The biparietal diameter was the greatest diameter measured at the level of the thalamus showing a strong midline echo. The gestational age was determined by the last menstrual period as confirmed by the biparietal diameter. The placenta was graded according to the system described by Grannum and associates.3 They graded the placenta from 0 to III based on changes in the: (1) chorionic plate, (2) placental substance, and (3) basal layer. In a Grade 0 placenta, the chorionic plate is
Graa’e I
Grade II
10
-
-
-
10
7 3 4 12
-
-
-
7 3 4 13
Grade
0
I
16
10
1
;:
17 18
24
19
18
5 5 4 3 3 2 4 3 5 23
20
16
21
13
22 23 24 Ei
12 9 12 i
27 28 29 30 31 32 33 34 35 36 37 38
10
6
6
10 12
10
39
6 9 7 6 6 8 5 3 2 2
40+
1
18 20 23 25 34 28 41 43 39 21 2i
-
Grade III
-
Total
-
11
-
33 28 28 21
19 15 16 12 17 118
-
1
2 2 3 5 6 7 15 23 17 32 48 28 30
2 -
1 1 1 5 13 20 16 21
16 18 24 29 34 36
39 56 48 68
91 109 67 73
smooth, the placental substance is homogeneous, and the basal layer is not calcified. In a Grade I placenta, the chorionic plate contains subtle undulations, and the placental substance contains small, echogenic areas, while the basal layer remains uncalcified. The chorionic plate of a Grade II placenta develops marked indentations that do not reach the basal layer, the placental substance is divided by comma-like densities continuous with the chorionic plate, and the basal layer shows a linear arrangement of small echogenic areas. A Grade III placenta consists of a chorionic plate that has indentations extending to the basal layer, a placental substance divided into compartments with echo-free areas, and a basal layer containing dense, almost confluent, echogenic areas (Fig. 1). Frequency of any given placental grade was calculated as a percentage of the whole in each gestational age group. No attempt was made to correlate disease state to placental grade. Table I shows the distribution of the 964 nondiabetic, non-Rh-sensitized patients by gestational age and placental grade. Fig. 2 shows, in graphic representation, the incidence of the various placental grades as gestation advances. Progressive changes in ultrasonic placental architec-
Volume Number
Communications
144 6
100
Grade Grade Grade Grade
OQ\
90
0 1 2 3
in brief
735
o Cl A 0
“\ o-o,o.o
; Y
a0 \
0.
Cl
111 7o z” lu
60
5
50
g
40
0 4
q
*MU \
00
/
\ PI-A A/\
A
30
~-US&
20
q / uvl
\o
./
/4
Ax
10
cl/ IO
12
14
16
18
20
22
GESTATIONAL
24
A-A.,
O-0 */ .-.Aoao
26
30
AGE
20
32
34
/’ 36
38
40
Fig. 2. Graph of placental grades versus progressing gestational age.
ture are a function of increasing gestational age. This relates to recent speculation that the Grade III placenta may be a marker for fetal pulmonary maturity. Ninety-five percent of Grade III placentas appear beyond 35 weeks’ gestation. This corresponds quite closely to the gestational age at which the abrupt rise in mature lecithin/sphingomyelin (L/S) ratios occurs.s An association between the ultrasonically mature placenta and a mature L/S ratio can be expected if only because they develop in the same gestational age period. The studies to date comparing placental grade to L/S ratios indeed suggest a relationship but are of small sample size.3, 4 More work must be done in this area before reliance is placed on the placental grade as a predictor of lung maturity. Since only 15% of placentas are destined to reach Grade III, this potential marker of pulmonary maturity has an inherent limitation of applicability. The cases of Grade III placentas in pregnancies less than 35 weeks’ gestation deserve comment. The earliest gestational age associated with a Grade III placenta was 30 weeks. In each of four cases where a Grade III placenta occurred before 35 weeks, intrauterine growth retardation was found in the fetus. Amniocentesis was
performed in two of the four cases; a mature pulmonary profile was found in both instances. The present report summarizes the incidence of placental Grades 0 through III at gestational ages 10 through 40 weeks. The study suggests that placental grade is a function of gestational age. No conclusions can be reached concerning the relation of the Grade III placenta to pulmonary maturity. REFERENCES
1. Tindall, V. R., and Scott, J. 8: Placental calcification: A study of 3,025 singleton and multiple pregnancies, J. Obstet. Gynaecol. Br. Commonw. 72:365, 1965. 2. Fischer, C. C., Garrett, W., and Kossoff, G.: Placental aging monitored by gray-scale echography, AM. J. OBSTET. GYNECOL. 124:483, 1976. 3. Grannum, P. A. T., Berkowitz, R. L., and Hobbins, J. D.: The ultrasonic changes in the maturing placenta and their relation to fetal pulmonic maturity, AM. J. OBSTET. GYNECOL.
133:915,
1979.
4. Petrucha, R. A., Golde, S. H., and Platt, L. D.: Real-time ultrasound of the placenta in assessment of fetal pulmonic maturity, AM. J. OBSTET. GYNECOL. 142:463, 1982. 5. Gluck, L., and Kulovich, M. V.: Lecithin/sphingomyelin ratios in amniotic fluid in normal and abnormal pregnancy, AM. J. OBSTET. GYNECOL. 115:539, 1973.