Case study:
28-year-old woman, gravida 2, para 1, presented for her routine 20-week ultrasound. The ultrasound examination was performed transabdominally with a high-frequency transducer. The placenta was located in the anterior uterine wall and appeared to be normal in size and shape. However, a 4-cm hypoechoic mass was noted on the fetal surface of the placenta. The mass was well-circumscribed and had few vessels seen entering it. There was no evidence of fluid around the mass or any other abnormalities in the fetus.
Ultrasound scan showed these images:
Chorioangioma
Subchorionic hematoma
Placental teratoma
Placental mesenchymal hamartoma
A. Chorioangioma: This is the most likely diagnosis in this case, given the presence of few vessels entering the mass. Chorioangiomas are benign vascular tumors of the placenta and are the most common primary tumor of the placenta. They are typically asymptomatic and are often found incidentally on ultrasound. However, large chorioangiomas can be associated with complications such as preterm labor, fetal growth restriction, and non-immune hydrops fetalis.
B. Subchorionic hematoma: This is a collection of blood between the placenta and the uterine wall. It is a common finding in pregnancy, and most subchorionic hematomas resolve without any complications. However, large subchorionic hematomas can be associated with an increased risk of preterm labor and fetal growth restriction.
C. Placental teratoma: This is a rare tumor of the placenta that is made up of a variety of tissues, such as hair, teeth, and bone. Placental teratomas are typically benign, but they can sometimes be associated with complications such as preterm labor and fetal growth restriction.
D. Placental mesenchymal hamartoma: This is a benign tumor of the placenta that is made up of connective tissue. Placental mesenchymal hamartomas are typically asymptomatic and are often found incidentally on ultrasound. However, large placental mesenchymal hamartomas can be associated with complications such as preterm labor and fetal growth restriction.
The differential diagnosis for a placental hypoechoic mass can be further narrowed down by using ultrasound imaging features. For example, chorioangiomas typically have a "bubbly" appearance on ultrasound, due to the presence of multiple blood vessels within the tumor. Subchorionic hematomas typically have a more solid appearance on ultrasound and are between the placenta and uterine surface. Placental teratomas and placental mesenchymal hamartomas can have a variety of appearances on ultrasound, and it may be difficult to distinguish them from chorioangiomas without further testing.
Further testing:
In some cases, it may be necessary to perform additional imaging tests, such as magnetic resonance imaging (MRI), to help confirm the diagnosis of a placental hypoechoic mass. MRI can provide more detailed information about the size, shape, and location of the mass, as well as the presence of any other abnormalities in the placenta or fetus.
Management:
The management of a placental chorioangioma depends on the size and location of the mass, as well as the presence of any complications. Small chorioangiomas that are asymptomatic may be managed expectantly with close ultrasound monitoring. Larger chorioangiomas or those that are associated with complications may require more aggressive management, such as delivery at an earlier gestational age or laser ablation of the tumor.
In this case, the patient was advised to have follow-up ultrasound scans every 4 weeks to monitor the size of the mass. She was also given the option to deliver her baby at an earlier gestational age if the mass grew significantly or if she developed any complications. The patient ultimately chose to continue her pregnancy.
The prognosis: for a pregnancy with a placental hypoechoic mass is generally good. However, the risk of complications does increase with the size of the mass. Women with large chorioangiomas or those who develop complications during pregnancy should be closely monitored by their healthcare providers.
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