Large placental chorioangioma as a cause of sudden intrauterine fetal death. A case report

Giant Placental Chorangioma and Severe Ductal Arch Constriction: A Case Report With a Favorable Outcome

Giant chorangiomas are uncommon yet frequently associated with adverse pregnancy outcomes. A 37-year-old female was referred due to findings of a placental mass during a second-trimester ultrasound. A fetal survey at 26 weeks revealed a 69×97×75 mm heterogenous placental tumor with two prominent feeding vessels. Her prenatal course was complicated by worsening polyhydramnios requiring amnioreduction, gestational diabetes, and transient severe ductal arch (DA) constriction. Placental pathology confirmed the diagnosis of giant chorioangioma following delivery at 36 weeks. To our knowledge, this represents the first case of DA constriction in the setting of a giant chorangioma.

Consecutive chorioangiomas in the same pregnancy: A clinical case and review of literature

Background and Aims

Aetiopathogenesis of chorioangioma is already unknown. Among the risk factors, hypoxia, environmental and genetic factors are believed to induce the overexpression of angiogenic cytokines promoting vascular proliferation. We reported a case of prenatally diagnosed 67 mm‐wide placental chorioangioma, which occurred at 32 weeks of gestational age, infarcted, and followed by the onset of a second infarcted chorioangioma at 35 weeks of gestational age. Besides, we discussed the hypothesis of chorioangioma aetiopathogenesis and behavior through a literature summary.

Methods

We carried out a literature search of chorioangioma cases without a time interval. Therefore, we carried out a literature summary on chorioangioma risk factors and etiology, by selecting articles within a time interval from 1995 to 2021.

Results

This is the first case of two consecutive chorioangiomas in the same pregnancy published in the literature. We found a possible genetic predisposition in women developing chorioangioma while infarction may be related to the abnormal structure of tumor vessels. The onset of a second lesion could reflect hypoxic stimuli following infarction and involves hypoxia‐induced factor‐1alpha, vascular endothelial growth factor, transforming growth factor‐beta, and soluble Fms‐like tyrosine kinase‐1 pathways. Chorangiosis can be coexistent and may reflect a mutual etiology in susceptible individuals.

Conclusion

In a predisposed placenta, that previously generated a chorioangioma, infarction of the chorioangioma should not represent a sign for pregnancy termination, but a marker for closer monitoring to early detect the possible onset of a second chorioangioma and a higher risk of umbilical cord thrombosis.

Multiple Chorangioma Following Long-Term Secondary Infertility: A Rare Case Report and Review of Pathologic Differential Diagnosis

Chorangioma (placental hemangioma) is a benign non-trophoblastic neoplasm of the placenta. Small chorangiomas are usually asymptomatic, but the giant and multiple ones rarely have a favorable outcome. We report a case of 29 weeks of gestational age (after long-term secondary infertility) with premature labor pain and undiagnosed multiple chorangioma leading to hydrops fetalis and neonatal death. Here we report the clinicopathological features of our case and chorangioma in general, along with comparison of different vascular lesions of placenta in terms of incidence, risk factors, complications, histologic origin, macroscopic and light and electron microscopic features.

Unusual complications of placental chorioangioma: consumption coagulopathy and hypertension in a preterm newborn

We report a case of a preterm neonate born to a mother with giant placental chorioangioma. The baby had microangiopathic haemolytic anaemia, thrombocytopenia and cardiac failure at birth. In addition, she had a disseminated intravascular coagulation-like picture and had bleeding from multiple sites, which was treated with transfusion of multiple blood products. She also developed transient hypertension and required antihypertensive drugs for 3 weeks. The baby was successfully managed and discharged home, though with signs of neurosensory impairment.

Placental chorioangioma: literature review

Placental chorioangioma is the most common benign non-trophoblastic tumor of the placenta. It is derived from primitive chorionic mesenchyme and is typically vascular. Placenta chorioangiomas occur in approximately 1% of pregnancies. Most placental chorioangiomas are small and are not clinically important. However, those measuring more than 4-5 cm in diameter may be associated with maternal and fetal complications. Early diagnosis, close prenatal surveillance and appropriate intervention may prevent severe complications and perinatal mortality caused by chorioangioma. Here we review the incidence, prenatal diagnosis, complications, the pathophysiological mechanisms of maternal and fetal complications, and the therapeutic possibilities in pregnancies complicated by placental chorioangiomas.

Antenatal embolization of a large placental chorioangioma: a case report

Introduction

A chorioangioma is the most common benign tumor of the placenta. The majority of pregnancies with chorioangiomas are asymptomatic. Pregnancies with large chorioangiomas are associated with maternal and fetal complications, such as growth restriction, cardiomegaly, congestive heart failure, fetal anemia, thrombocytopenia, nonimmune hydrops and intrauterine fetal death. There are several modalities of treatment published to date with various results. Our case was the third such case report published on the successful treatment with antenatal embolization of the feeding vessel of the chorioangioma. To the best of our knowledge, there have been no published cases about antenatal treatment of placental chorioangiomas in Saudi Arabia, or any other Gulf state.

Case presentation

We describe the case of a 28-year-old Arab woman diagnosed at 22 weeks of gestation with a chorioangioma. A glue material - enbucrilate (Histoacryl) - was used for embolization of the feeding vessel. Intrauterine fetal blood transfusions were performed twice, as a treatment for fetal anemia. The fetus developed heart failure at 30 weeks of gestation. A Cesarean section was performed and the outcome was a live baby with right ventricular hypertrophy. The baby was admitted to our neonatal intensive care unit and discharged at 42 days following birth in a stable condition,with follow-up with our cardiology team.

Conclusion

In this case, we found that intrauterine embolization of the feeding vessel of a chorioangioma with Histoacryl was a valid treatment option that carried a small risk considering the good pregnancy outcome.

Giant placental chorioangioma: a rare cause of fetal hydrops

Giant choriangiomas are rare placental tumours, associated with a high prevalence of pregnancy complications and a poor perinatal outcome. Neonatal consequences include severe microangiopathic haemolytic anaemia, thrombocytopaenia and hydrops. The associated high perinatal death rate (30-40%) has led to a number of prenatal therapeutic interventions with limited success in most cases. The authors present a case of non-immune fetal hydrops caused by a giant chorioangioma, diagnosed at 27 weeks of gestational age. Despite tocolytic therapy, the baby was born prematurely (28 weeks of gestational age) and required transfusion of blood derivatives, intensive phototherapy and exchange transfusion. She had an uncomplicated recovery and was discharged home in the second month of life. The authors emphasise the need to consider chorioangioma as a cause of non-immune fetal hydrops and microangiopathic haemolytic anaemia.

Chorangioma and related vascular lesions of the placenta--a review

Chorangioma has been referred to as a hamartoma-like, or a hyperplastic capillary lesion, rather than a true neoplasm. Its incidence is 1 in 100 placentas. In chorangiomas larger than 4 cm, there can be significant effects on the hemodynamic and circulatory processes of the fetus, leading to grave clinical consequences, such as polyhydramnios and fetal heart failure. Chorangiomas can show various histopathologic pictures, ranging from vascular to cellular, and can undergo degenerative changes. They can be diagnosed prenatally by ultrasound, color Doppler imaging, and magnetic resonance imaging (MRI). Chorangioma must be differentiated from other villous capillary lesions, namely, chorangiomatosis and chorangiosis. They have overlapping similarities with chorangioma, and have clinical implications. Chorangiomatosis has been associated with negative fetal outcomes such as intrauterine growth retardation (IUGR) and preeclampsia. Chorangiosis is associated with maternal diabetes mellitus. Another rarer differential is chorangioma with trophoblast proliferation ("chorangiocarcinoma," a probable misnomer), a rare proliferation of trophoblastic tissue seen in the vicinity of otherwise benign chorangioma. Treatment modalities of chorangioma include endoscopic devascularization, alcoholic ablation, and interstitial laser coagulation. In this article, we will review the clinical and pathologic picture of chorangioma as well as treatment, and discuss its main differentials.

Ultrasound of the placenta: a systematic approach. Part I: Imaging

Diagnostic ultrasound has been in use in clinical obstetrics for close to half-a-century. However, in the literature, examination of the placenta appears to be treated with less attention than the fetus or the pregnant uterus. This is somewhat unexpected, given the obvious major functions this organ performs during the entire pregnancy. Examination of the placenta plays a foremost role in the assessment of normal and abnormal pregnancies. A methodical sonographic evaluation of the placenta should include: location, visual estimation of the size (and, if appearing abnormal, measurement of thickness and/or volume), implantation, morphology, anatomy, as well as a search for anomalies, such as additional lobes and tumors. Additional assessment for multiple gestations consists of examining the intervening membranes (if present). The current review considers the various placental characteristics, as they can be evaluated by ultrasound, and the clinical significance of abnormalities of these features. Numerous and varied pathologies of the placenta can be detected by routine ultrasound. It is incumbent on the clinician performing obstetrical ultrasound to examine the placenta in details and in a methodical fashion because of the far reaching clinical significance and potentially avoidable severe consequences of many of these abnormalities.

Chorioangioma of placenta: sonographic features

Chorioangioma is a benign vascular tumor of the placenta arising from primitive chorionic mesenchyme. Large (>4 cm) chorioangiomas are much rarer and are often associated with maternal and/or fetal complications. We describe the sonographic features of a large placental chorioangioma with normal outcome.

Quantitative three-dimensional power Doppler ultrasound predicts the outcome of placental chorioangioma

The relationship of large and vascularized chorioangiomas to adverse pregnancy outcome is well recognized. We present a patient with a large placental tumor and signs of impending fetal cardiac failure. The angioarchitecture of the tumor depicted by three-dimensional (3D) power Doppler ultrasound enabled us to accurately diagnose a placental chorioangioma. During the follow-up period, quantitative flow data obtained using 3D power Doppler indicated altered hemodynamics in the tumor and concomitant improvement in the condition of the fetus, enabling us to manage the mother conservatively. Spontaneous delivery occurred at 38 weeks without any complications. This report demonstrates the potential value of 3D power Doppler in prenatal diagnosis and monitoring of pregnancies complicated by large, vascularized chorioangioma.

Case of large placental chorioangioma associated with diffuse neonatal hemangiomatosis

Chorioangioma is the most frequent nontrophoblastic tumor of the placenta with a incidence ranging from 0.01 to 1.3%. Vascular anomalies of the placenta coincidental with infantile hemangioendothelioma (IH) of the liver are rarely described. Here we report a case of a large chorioangioma of the placenta associated with cutaneous hemangiomatosis and IH of the liver. The relationship between hemangiomas and placental chorioangioma is discussed.

Récurrence de chorio-angiomes multiples : à propos d’un cas

Diffuse chorioangiomatosis is a rare placental pathology characterized by multiple chorioangiomas, inducing a high risk of fetal complications, especially cardiovascular, with a risk of fetal death. The physiopathology is not clearly established but seems to be related with an over-expression of vascular growth factors related to hypobaric-hypoxia. Here, we describe a case of recurrent chorioangiomatosis with fetal demise. No risk factors were identified (high altitude, genetic disease like Beckwith-Wiedemann, diabetes). Intra-amniotic, plasmatic values of alphafetoprotein and plasmatic beta gonadotrophin chorionic hormone remained low. Ultrasonographic assessment of placental thickness was in the normal range, at 22 and 32 weeks of gestation. In case of previous chorioangiomatosis, we recommend a weekly sonographic monitoring to diagnose fetal complications associated with an early inpatient hospitalization for daily surveillance at the age of previous accidents. Labor will be induced in case of fetal intolerance or systematically after 37-38 weeks of gestation.