A placental chorioangioma is a benign vascular tumour of placental origin. It is the most common tumour of the placenta, and is usually found incidentally.
The estimated incidence is at ~1% of all pregnancies 3.
In most cases chorioangiomas are asymptomatic, and merely incidental findings. Occasionally, when they are large or multiple, they can result in poor outcomes for both the fetus and the mother.
A chorioangioma is generally thought to arise as a malformation of the primitive angioblastic tissue of the placenta. The angiomas are perfused by the fetal circulation and thus, when they are large, may represent a significant impediment to fetal cardiac activity. They may also sequester platelets and can in turn give a fetal thrombocytopenia.
There is some debate as to the exact nature of chorioangiomas. Most authors consider them as a benign neoplasm while others however, categorise them as hamartomas, given their composition of mostly native placental tissue and their inability to metastasise.
There can be significant variation in size. Most lesions tend to small and lesions >4 cm are generally rare 8. Large tumours can however produce degenerative phenomenona like, necrosis, calcification, hyalinisation, or myxomatous degeneration.
Three histological types are recognised:
- angiomatoid: characterised by numerous blood vessels
- cellular: with poor vascularisation
Most cases tend to be sporadic.
They tend to occur on the fetal side of the placenta (close to cord insertion).
Recognised associations include
- Beckwith-Wiedemann syndrome
- single umbilical artery
- fetal anaemia
- fetal congestive cardiac failure
- hydrops fetalis: also listed under complications
- polyhydramnios: also listed under complications
Typically a chorioangioma is located near the insertion of the cord, and protrudes into the amniotic cavity.
- often seen as a hypoechoic, rounded mass, located near the chorionic plate +/- umbilical cord insertion site.
- It usually contains anechoic 'cystic' areas, and can be seen as distinctly separate to normal surrounding placental tissue
- some heterogeneous areas caused by degenerative processes/ internal haemorrhage can be seen.
- chorioangiomas can also rarely appear pedunculated
- Doppler: often demonstrates low resistance pulsatile flow within the anechoic 'cystic' areas, which actually represent enlarged vascular channels.
Large chorioangiomas may undergo spontaneous infarction with decreased echogenicity, decreased tumour volume, and decreased blood flow on colour Doppler images 6.
MRI usually demonstrates a heterogeneous mass. Signal characteristics include:
- T1: isointense to placenta if uncomplicated can be hyperintense if there has been a haemorrhage
- T2: high signal intensity; can be heterogeneous, an appearance similar to that of a haemangioma 6.
Vascular shunting may cause fetal high-output cardiac failure and hydrops fetalis.
Other complications include:
- premature labour
- fetal thrombocytopaenia
- intrauterine growth restriction (IUGR)
- placental abruption
Treatment and prognosis
Chorioangiomas are usually treated with expectant management, as the majority of tumours are asymptomatic. Small tumours are often monitored with ultrasound ~every 6-8 weeks, whereas large tumours require serial ultrasound examinations more frequently ~every 1-2 weeks. Some tumours may even regress spontaneously during pregnancy 12.
The overall prognosis is somewhat dependent on the presence and/or development of hydrops fetalis. In general lesions, larger than 4 cm are considered to produce haemodynamic effects on the fetus 3. Therapeutic amnio-drainage is an option if there is excessive polyhydramios.
History and etymology
They were thought to have been first described by Clarke in 1798 13 .
For ultrasound appearances consider:
- subamniotic haematoma
- partial hydatidiform mole
- submucosal uterine fibroid: sub-mucosal leiomyoma of the uterus
- placental teratoma
- atypical placental venous lake: on greyscale imaging
- 1. Fournet P, Eloit S, Allessandri JL et-al. [Chorioangioma of the placenta. Echographic, radiologic and anatomo-pathologic correlations] J Gynecol Obstet Biol Reprod (Paris). 1989;18 (7): 913-8. - Pubmed citation
- 2. Hadi HA, Finley J, Strickland D. Placental chorioangioma: prenatal diagnosis and clinical significance. Am J Perinatol. 1993;10 (2): 146-9. doi:10.1055/s-2007-994648 - Pubmed citation
- 3. Amer HZ, Heller DS. Chorangioma and related vascular lesions of the placenta--a review. Fetal Pediatr Pathol. 2010;29 (4): 199-206. doi:10.3109/15513815.2010.487009 - Pubmed citation
- 4. Sepulveda W, Alcalde JL, Schnapp C et-al. Perinatal outcome after prenatal diagnosis of placental chorioangioma. Obstet Gynecol. 2003;102 (5 Pt 1): 1028-33. - Pubmed citation
- 5. Zanardini C, Papageorghiou A, Bhide A et-al. Giant placental chorioangioma: natural history and pregnancy outcome. Ultrasound Obstet Gynecol. 2010;35 (3): 332-6. doi:10.1002/uog.7451 - Pubmed citation
- 6. Kirkpatrick AD, Podberesky DJ, Gray AE et-al. Best cases from the AFIP: Placental chorioangioma. Radiographics. 27 (4): 1187-90. doi:10.1148/rg.274065207 - Pubmed citation
- 7. Shih JC, Ko TL, Lin MC et-al. Quantitative three-dimensional power Doppler ultrasound predicts the outcome of placental chorioangioma. Ultrasound Obstet Gynecol. 2004;24 (2): 202-6. doi:10.1002/uog.1081 - Pubmed citation
- 8. Taori K, Patil P, Attarde V et-al. Chorioangioma of placenta: sonographic features. J Clin Ultrasound. 2008;36 (2): 113-5. doi:10.1002/jcu.20366 - Pubmed citation
- 9. O'malley BP, Toi A, Desa DJ et-al. Ultrasound appearances of placental chorioangioma. Radiology. 1981;138 (1): 159-60. Radiology (abstract) - Pubmed citation
- 10. Lopez HB, Kristoffersen SE. Chorioangioma of the placenta. Gynecol. Obstet. Invest. 1989;28 (2): 108-10. - Pubmed citation
- 11. Zalel Y, Weisz B, Gamzu R et-al. Chorioangiomas of the placenta: sonographic and Doppler flow characteristics. J Ultrasound Med. 2002;21 (8): 909-13. J Ultrasound Med (full text) - Pubmed citation
- 12. Entezami M, Albig M, Knoll U et-al. Ultrasound Diagnosis of Fetal Anomalies. Thieme. (2003) ISBN:1588902129. Read it at Google Books - Find it at Amazon
- 13. Jaffe R, Siegal A, Rat L et-al. Placental chorioangiomatosis--a high risk pregnancy. Postgrad Med J. 1985;61 (715): 453-5. doi:10.1136/pgmj.61.715.453 - Free text at pubmed - Pubmed citation