Placental chorioangioma with hydrops foetalis: a case report

Field: Medicine (Health Sciences)

Placental chorioangioma is a rare tumor and occurs in 1% of pregnancies (1). Large and vascular chorioangiomas are notorious for causing fetal anemia, fetal hydrops and fetal death. Diagnosis is suspected antenatally by ultrasound and Doppler studies and is confirmed by histopathology post delivery. Here we report a pregnancy complicated by a large placental chorioangioma resulting in preterm delivery of a plethoric stillborn fetus. A 23-year-old second gravida was referred to Nehru Hospital, attached to the Postgraduate Institute of Medical Education and Research, at 26 weeks' gestation with a diagnosis of polyhydramnios, hydrops foetalis and placental tumor. Her previous pregnancy was uneventful, resulting in normal delivery of a healthy baby. In the present pregnancy, she had early confirmation and had no complaint until 22 weeks' gestation. Ultrasound carried out at this time suggested a normal fetus corresponding to the period of gestation with an increased amount of liquor. The placenta was in the upper segment, grade one, with a well-defined growth arising from the fetal surface of the placenta, predominantly hypoechoic with multiple cystic areas measuring 11 × 8 × 6 cm, suggestive of placental tumor. Subsequent ultrasound examination after an interval of 2 weeks revealed fetal cardiomegaly, pericardial effusion, and ascites. The portal vein was dilated (8 mm) and the hepatic vein was 4–5 mm wide. These findings suggested hyperdynamic fetal congestive failure. Duplex Doppler evaluation of the mass showed an arterial flow pattern. This finding suggested chorioangioma. The patient had abdominal discomfort, for which she was admitted. Her hematocrit and blood biochemistry, i.e. renal function and glucose tolerance tests, were within normal limits. Her blood group was A negative and an indirect Coomb's test was negative. During the hospital stay, she remained comfortable. At 27 weeks' gestation she went into spontaneous labor. The patient had an assisted breech delivery after 5 h of short labor. The baby was fresh stillborn and weighed 1100 g, with ascites and generalized edema. The placenta weighed 1100 g and was soft and friable, with an 11 × 8-cm lobulated mass on the fetal surface extending into the placental substance (Fig. 1). Histopathological examination of the placenta showed a lesion comprising of numerous small vascular channels supported by inconspicuous loose stroma. A diagnosis of chorioangioma was confirmed. Specimen of placenta showing chorioangioma. The patient had an uneventful post partum period. Chorioangioma is the commonest nontrophoblastic tumor of the placenta. Incidence is approximately 1% (1). It is most likely the hamartoma of primitive chorionic messenchyme. Small tumors are asymptomatic but large tumors may be associated with fetal anemia, hydrops, polyhydramnios or antepartum hemorrhage (2). The present case also showed hydrops, polyhydramnios and a large placental chorioangioma. Neonatal morbidity and mortality rates are high because of prematurity and metabolic changes resulting from vascular growth of the placenta (2). The index case also had a preterm delivery, resulting in a stillborn fetus. Antenatal diagnosis is not difficult. Greyscale ultrasound examination followed by color Doppler imaging confirms the diagnosis. Jauniaux et al. (3) used color Doppler imaging for confirmation of diagnosis of placental tumors in nine cases. He concluded that vascularization of the tumor is a pivotal determining factor of pregnancy outcome. The more vascular the tumor, the worse the perinatal outcome. The tumor in this case was also very vascular and thus had a bad outcome. Ogino and Redline (4) have further classified villous capillary lesions of the placenta into chorioangioma, chorioangiomatosis and chorioangiosis depending upon the size and number. In the present case the histopathology was confirmatory of chorioangioma. Management of such cases includes a serial ultrasound examination accompanied by hospitalization and bed rest. Hydramnios can be treated with amniocentesis, and fetal anemia with intrauterine transfusion. In spite of hospitalization and bed rest, our patient went into preterm labor just after a short 4-day stay. Immediate hospitalization and therapeutic amniocentesis may have helped the patient if she had presented at an earlier stage.