Clinical Imaging xxx (2014) xxx–xxx Contents lists available at ScienceDirect Clinical Imaging journal homepage: http://www.clinicalimaging.org Case Report Succenturiate lobe of placenta with vessel anomaly: a case report of prenatal diagnosis and literature review Anna Franca Cavaliere ⁎, Paolo Rosati, Paola Ciliberti, Silvia Buongiorno, Lorenzo Guariglia, Giovanni Scambia, Mauro Tintoni Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy a r t i c l e i n f o Article history: Received 1 November 2013 Received in revised form 22 January 2014 Accepted 22 January 2014 Available online xxxx Keywords: Succenturiate placenta Placental anomalies Fetal vascular anomalies Doppler ultrasonography Placenta a b s t r a c t We report the case of a 33-year-old woman with antenatal ultrasound diagnosis of succenturiate placental lobe at 33 weeks confirmed by B-flow rendering, describing the advantages of the application of color Doppler to diagnosis and management of placental anomalies. We searched studies about antenatal diagnosis of succenturiate placental lobe, including only cases in which color Doppler was used. This case underlines the importance of color Doppler in increasing the accuracy of diagnosis and achieving an improved differential diagnosis. © 2014 Elsevier Inc. All rights reserved. 1. Introduction Perinatal death is most frequent in pregnant women with abnormalities of placenta, umbilical cord, and fetal membranes. Despite advances in perinatal medicine, approximately 2% of lowrisk pregnant women still require an emergency cesarean section after the onset of labor [1,2]. The succenturiate placenta is a clinically relevant diagnosis in which one or more small accessory lobes develop in the membranes apart from the main placental body to which they are usually connected by vessels of fetal origin [3]. Although Callen [4] and Benirschke [5] reported an incidence of succenturiate lobes of placenta of 5%–6%, Cunningham [6] and Suzuki [7] encountered them very infrequently. Advanced maternal age and in vitro fertilization, both increasing, are considered risk factors for succenturiate lobe, probably because of the underlying progressive vascular damage that involves placenta in both conditions [7,8]. The diagnosis of this placental anomaly often occurs at birth, and only very few cases of prenatal diagnosis with ultrasound are reported. The antenatal diagnosis of succenturiate lobe involves strictly differential diagnosis among other conditions because the presence of vessels running between the two parts can appear similar to amniotic band or uterine septum at ultrasound examination [9,10]. Moreover, this placental anomaly should be differentiated from the conditions described below: firstly, the bipartite or bilobed ⁎ Corresponding author. Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy. Tel.: + 39 06 30156014; fax: + 39 06 30156332. E-mail address: afcavaliere@hotmail.com (A.F. Cavaliere). placenta that is described as two placentas of equal or near-equal size separated by a membrane [11], and secondly, the chorionicity in multiple pregnancies that could be identified during the first trimester by the visualization of two separated placentas in the case of dichorionicity. In cases with a single or fused placenta, evaluation of the intervening membrane can help distinguish between dichorionic and monochorionic placentation. Separate membrane thickness, number of layers, and the presence of either the lambda or T-sign at the base of the membrane, evaluated by ultrasound, can be useful to the diagnosis [12]. Some studies also suggest that the succenturiate lobes are the effective cause of sudden fetal death, particularly when vessels cross the cervical os as vasa previa [13–16]. Moreover, considering that its presence can alert the obstetrician to wait for delivery of both portions of the placenta during the final stage of labor, antenatal detection allows to avoid the morbidity (postpartum hemorrhages and infections) associated with unsuspected retained products of conception [17]. The accuracy of prenatal diagnosis could be very important in improving the management and the outcome of these pregnancies, and color Doppler imaging represents a useful instrument for a correct diagnosis of succenturiate lobe and related vascular anomalies. 2. Case report A 33-year-old woman, gravid 2 with a previous cesarean section, was admitted to our third-level center because of a diagnosis of vascular placental anomaly at 33 weeks. The suspicion was a freefloating vessel in the amniotic cavity or vasa previa. A previous firstlevel ultrasound scan at 21weeks of gestation reported the placenta as 0899-7071/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clinimag.2014.01.018 Please cite this article as: Cavaliere AF, et al, Succenturiate lobe of placenta with vessel anomaly: a case report of prenatal diagnosis and literature review, Clin Imaging (2014), http://dx.doi.org/10.1016/j.clinimag.2014.01.018 2 A.F. Cavaliere et al. / Clinical Imaging xxx (2014) xxx–xxx both placental lobes (Fig. 3). The application of a 3-dimensional rendering B-flow allowed us to confirm that the vessel was not free in the amniotic fluid as suspected before. B-flow technology digitally enhances signals from weak blood reflectors from vessels and, at the same time, suppresses strong signals from surrounding tissues [18]. The method does not rely on Doppler ultrasonography to display blood flow; it is not angle-dependent and allows relatively high frame rates with excellent spatial resolution. In our case, the vessels did not cross the cervical os as vasa previa. At 37 weeks of gestation, the patient was hospitalized for the onset of contractile activity. The cardiotocography (CTG) revealed tachycardia and reduction of variability. In relation to gestational age and to the nonreassuring fetal CTG, as an American Congress of Obstetricians and Gynecologists Committee Opinion (2004) states [19], a decision for emergency cesarean delivery was taken. The surgical intervention was performed without complications. Placenta appeared inserted on anterior uterine wall with a succenturiate posterior lobe and two vessels connecting them, lying over the membranes (Fig. 4); no vessels free in the amniotic fluid were detected. A female baby was born, birth weight was 2740 g, and Apgar score was 8 at 1 min and 9 at 5 min. No neonatal complications were recorded. 3. Discussion Fig. 1. Transabdominal grayscale ultrasound shows the main anterior placenta (□) and the succenturiate posterior lobe (*) completely apart from the placenta. located on the anterior wall with no fetal or placental abnormalities. At 33 gestational weeks, we performed a transabdominal ultrasound scan that evidenced a succenturiate lobe located on the posterior wall and completely apart from the anterior placenta (Fig. 1). Color Doppler technology revealed a vessel running from the anterior placenta to the posterior lobe and compatible with a venous type (Fig. 2). Moreover, it permitted the study of the vascularization of The presence of a succenturiate lobe is usually diagnosed after delivery. The use of ultrasonographic scan could determine misdiagnosis because the vessels between the two parts of placenta can be considered as an amniotic band [13,14]. Before the introduction of the use of color Doppler in the differential diagnosis of the placental anomalies, the grayscale ultrasonographic imaging was the only method used for the diagnosis of placental anomalies [20–22]. Color Doppler imaging, revealing fetal blood flow, is helpful in excluding the suspicion of amniotic band. Furthermore, it is useful in detection of vasa previa that can complicate some cases of succenturiate lobe [23]. A prenatal diagnosis of succenturiate placental lobe could permit the highlighting of the anomaly to the clinician in order to manage in a Fig. 2. Transabdominal color Doppler imaging of the floating vessel inside the amniotic cavity, running between the anterior placenta and posterior lobe and compatible with a venous type as it is confirmed by its spectral waveform. Please cite this article as: Cavaliere AF, et al, Succenturiate lobe of placenta with vessel anomaly: a case report of prenatal diagnosis and literature review, Clin Imaging (2014), http://dx.doi.org/10.1016/j.clinimag.2014.01.018 A.F. Cavaliere et al. / Clinical Imaging xxx (2014) xxx–xxx Fig. 3. Placental vascularization at transabdominal color Doppler imaging showing the vessels supplying the main anterior placental (□) and the succenturiate lobe (*). better way pregnancy and delivery. There are very few publications of antenatal diagnosis of succenturiate placental lobe and only two regarding the additional use of the color Doppler. Meizner et al. [24] in 1998 diagnosed a succenturiate lobe at 21 weeks of gestation using both ultrasonographic and color Doppler imaging. They found an isolated placental lobe connected to the main placental body by a band at the ultrasonographic scan. Because of the suspected presence of vessels in the band seen, a color Doppler examination was performed, and an arterial flow waveform was demonstrated, confirming the diagnosis of a succenturiate lobe. No data about the outcome of pregnancy were reported. Chihara et al. [25] also diagnosed a succenturiate lobe in 2000. With an ultrasonographic scan performed at 16 weeks of gestation, an amniotic band-like structure was detected. In particular, this structure extended from the edge of the anterior placenta to the right side of the uterus, and it followed fetal breathing and body movements. The use of color Doppler imaging revealed fetal blood flow within the band with a pulsatility index higher than that in umbilical artery. The patient Fig. 4. Postpartum placenta appearance: succenturiate posterior lobe and anterior placenta with two vessels lying over the membranes between them. 3 delivered at 41 weeks of gestation, and a baby of 3950 g with an Apgar score of 9 at 1 min and 10 at 5 min was born. The succenturiate lobe was confirmed at the postpartum control of the placenta. The mode of delivery was not reported. Because of the lack of experiences, it is difficult to determine an “evidence-based” management of these placental anomalies even when prenatally diagnosed with ultrasound. Considering the progress in prenatal ultrasound capability, the diagnosis of succenturiate lobe is improving. The possibility to perform a differential diagnosis using color Doppler technology will give to the obstetricians an important role in the management of these pregnancies to reduce fetal and maternal complications [26]. At the moment, no strong indications to perform an elective cesarean section are suggested unless diagnosis of vasa previa is associated with succenturiate lobe. In our case, the fetal CTG anomaly led to perform an emergency cesarean section. Since succenturiate placenta may lead to both fetal and maternal morbidity, an antenatal ultrasound diagnosis may be helpful in prenatal care. Even if transabdominal scan is a worthwhile method for prenatal diagnosis of this anomaly, the evidence of a posterior succenturiate lobe could often be difficult because of the interposition of the fetal body [22,27]. Color Doppler imaging has a central role in the definition of correct diagnosis supported, sometimes, by other recent technologies like B-flow. 4. Conclusion Our case report demonstrates the importance of the antenatal diagnosis of placental anomalies, giving to ultrasonographic evaluation an important role and adding the use of color Doppler imaging that, revealing fetal blood flow, is helpful in excluding other conditions. A prenatal diagnosis of succenturiate placental lobe could permit the clinician to manage in a better way pregnancy and delivery. Further studies are needed to establish indications concerning the antenatal diagnosis and the management of succenturiate placental lobes. References [1] Rocha J, Carvalho J, Costa F, Meireles I, do Carmo O. Velamentous cord insertion in a singleton pregnancy: an obscure cause of emergency cesarean-a case report. Case Rep Obstet Gynecol 2012;2012:4. [2] Hasegawa J, Matsuoka R, Ichizuka K, Sekizawa A, Okai T. Velamentous cord insertion: significance of prenatal detection to predict perinatal complications. Taiwan J Obstet Gynecol 2006;45:21–5. 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