International Journal of Clinical Medicine, 2011, 2, 310-312
doi:10.4236/ijcm.2011.23053 Published Online July 2011 (http://www.SciRP.org/journal/ijcm)
Abnormal Placental Findings Associated with
Non-reassuring Fetal Monitoring and Excellent
Neonatal Outcomes
Gary Ventolini1, Shanthi Ramesh1, Sheela Barhan1, Ran Neiger2
1Wright State Physicians Boonshoft School of Medicine Department of Obstetrics and Gynecology, Dayton Ohio, USA; 2Perinatal
Partners, Miami Valley Hospital Berry Building, Maternal Fetal Medicine, Dayton Ohio, USA.
Received February 29th, 2011; revised April 27th, 2011; accepted May 12th, 2011.
ABSTRACT
Objective: Obstetricians, Neonatologists, and Pathologists have studied gross histological analysis of human placentas
in search of specific alterations in placental functions that can be correlated with neonatal outcomes. Our study as-
sessed the prevalence of abnormal placental findings associated with non-reassuring fetal monitoring in labor requir-
ing emergent instrumental or cesarean delivery, followed by an excellent neonatal outcome. Study Design: One hun-
dred consecutive emergency deliveries, instrumental or cesarean, performed due to non-reassuring fetal monitoring
while in labor were retrospectively evaluated. All patien ts were low-risk for obstetric complications, and had a single-
ton, term pregnancy. They had a normal antenatal routine testing and a normal anatomy ultrasound scan at 20 to 22
weeks gestation. Results: There were 35 placentas (35%) with gross placental anomalies at the delivery triage. Addi-
tionally 7 placentas (7%) were reported to be abnormal at the patholog y examination. Conclusions: The prevalence of
abnormal placental findings in our studied popula tion was 42%.
Keywords: Abnormal Placental Findings, Excellent Neonatal Outcomes, Non-Reassuring Fetal Monitoring
1. Introduction
Obstetricians, Neonatologists, and Pathologists have
studied gross and histological analysis of human pla-
centas in search of specific alterations in placental func-
tion that can be correlated with neonatal outcomes. The
placenta provides a third party perspective regarding the
pregnancy and many maternal and fetal conditions are
evidenced by placental abnormalities [1]. Specific pla-
cental pathology is found in pregnancy loss associated
with thrombophilia, in many stillbirths and neonatal
deaths, and in cases of non-immune hydrops fetalis [2].
Many grossly and histopathological abnormal placentas
are, however, not associated with adverse neonatal out-
comes. Further attention to placental analysis including
more rigorous guidelines for pathologic diagnosis is
needed to delineate which abnormal findings are associ-
ated with adverse neonatal outcomes.
Per The College of American Pathologists (CAP)
guidelines, all human placentas should be inspected and
triaged at the delivery room and the abnormal ones
should be sent to pathology for a complete examination
using specific examination criteria as established by the
CAP. As previously determined by Ventolini et al., in a
cohort of 88 uneventful deliveries, 42% of placentas had
abnormal findings during pathological evaluation. Thir-
teen of the abnormal placentas (35.1%) showed pathol-
ogy unassociated with fetal compromise. Twenty-four of
the placentas (27.3% of the total cohort and 64.9% of the
abnormal placentas) showed findings associated with
fetal compromoise, all with APGAR scores at birth of
greater than or equal to 7 at 1 and 5 minutes. The most
common pathologies were marginal cord insertion, cho-
rioamnionitis, and abruption [3].
The purpose of our study was to assess the prevalence
of abnormal placental findings associated with non-re-
assuring fetal monitoring in labor requiring emergent
instrumental or cesarean delivery, followed by an excel-
lent neonatal outcome.
2. Materials and Methods
One hundred consecutive emergency deliveries, instru-
mental or cesarean, performed due to non-reassuring
fetal monitoring while in labor were retrospectively

Abnormal Placental Findings Associated with Non-reassuring Fetal Monitoring and Excellent Neonatal Outcomes 311
evaluated. The study was approved by the Institutional
Review Board and took place at a large tertiary hospital
between January 2003 and December 2008. All patients
were low-risk for obstetric complications, and had a
singleton, term pregnancy. In addition they had a normal
antenatal routine testing and a normal anatomy ultra-
sound scan at 20 to 22 weeks gestation.
The patients were admitted to the hospital in active
labor. Their fetal monitoring tracings on admission were
all reactive as well as the admission routine prenatal
laboratory parameters were within normal limits. Fur-
thermore, on admission history, they recollected having
no changes in fetal behavior the 48 hours prior to admis-
sion. They were all non-smokers and their urinary drug
toxicology screen was negative on admission.
As labor progressed, the patient’s fetuses manifested
intolerance to labor, characterized by repeat prolonged
decelerations and/or repeat late decelerations that required
emergent instrumental delivery and/or cesarean delivery.
Their fetal intolerance was not preceded by uterine hyper-
stimulation or by regional anesthesia placement and not
fully resolved by fetal intrauterine resuscitation.
All the neonates were delivered with APGAR scores
of equal or more than 7 at 5 minutes of birth, normal
arterial and venous umbilical blood cord gases and un-
eventful nursery stay. All the placentas were triaged at
the delivery room, the ones revealing any anomaly at
gross assessment, were sent to pathology for examina-
tion. Statistical analysis was performed with GraphPad
Software (GraphPad Software, San Diego, CA)
3. Results
Twenty eight patients (28%) had an instrumental deliv-
ery: 12 deliveries (12%) were vacuum assisted and 16
deliveries (16%) were forceps assisted. Seventy two
patients (72%) had a cesarean delivery (see Table 1).
There were 35 placentas (35%) with gross placental
anomalies at the delivery triage. The placental findings
were: 7 (7%) had opaque amniotic membranes, 6 (6%)
with velamentous cord insertion, 6 (6%) had a long um-
bilical cord (105 cm), 6 (6%) presented with foul smell-
ing amniotic membranes, 4 (4%) had a short umbilical
cord, 4 (4%) with retro placental hemorrhage and 2 (2%)
with acute abruption. Additionally 7 placentas (7%)
were reported to be abnormal at the pathology examina-
tion as follow: chorioamnionitis, funisitis, and true knots
(see Table 2).
4. Discussion
The placenta serves as vital resource in evaluating neo-
natal and maternal outcomes following delivery for non
reassuring fetal heart monitoring. The placenta contains
nine months of data available that could be gathered
through careful pathologic evaluation regarding etiolo
Table 1. Mode of delivery.
Instrumental Patients
Abnormal
Placentas Normal P Value
Vaccum Assisted 12 4 8 0.48
Forceps Assisted 16 5 11 0.35
Cesarean 72 33 39 0.66
Total 100 42 58
Table 2. Placental findings.
#
Placentas Triage Macroscopy Path Microscopy Path
6 Velamentos
cord insertion Agreed 6 2 Fibrin deposits
1 Small infarct
7
Opaque
amniotic
membranes
Agreed 7
1 Funisitis
2 Micro calcifications
2 Meconium stain
6
Long
umbilical
cord
Agreed 6
Mean length
112 cm (103 - 120)
1 Funisitis
1 Vasculopathy
6
Foul smelling
amniotic
membranes
Agreed 5 5 Chorioamniotis
1 Meconium stain
4 Short
umbilical cord
Agreed 2
(clots not seen at
examination)
1 Old infarct
1 Micro calcifications
2 Fibrin deposits
4
Retro
placental
hemorrhage
Agreed 4 None
2 Acute
abruption Agreed 2 1 Recent infarct
7 Normal Agreed 7
2 Chorioamniontis
1 Mecomium stain
3 Fibrin deposits
1 Funisitis
gies of immediate insults requiring delivery, as well as a
timeline of chronic events leading to fetal intolerance to
labor. In placental pathology, few diagnoses are immedi-
ately apparent: generally only those, which are hemato-
genously disseminated, like infectious organisms or some
specific inborn errors of metabolism. However, on closer
examination, histopathological evidence of choriamnion-
tiis including one specific finding of umbilical cord in-
flammation (funisitis) is associated with fetal sepsis.
According to Rhone et al., in review of 100 sequential
placentas, 75% were submitted to pathology for review
by CAP protocol with 50% having findings consistent
with inflammation [4]. Fetal clinical indicators of infec-
tion were associated with placental findings of chorioam-
nionitis, while maternal clinical indicators were not, em-
phasizing the utility of placental examination in identi-
fying unknown material infection.
Also of interest are pathological findings of endothe-
lial damage to fetal vessels secondary to infection or
vascular insults in the placenta resulting in fetal side
infarctions that can be a hallmark of neonatal embolic

Abnormal Placental Findings Associated with Non-reassuring Fetal Monitoring and Excellent Neonatal Outcomes
312
disease. Roberts et al. [5] reported that “fetal thrombotic
vasculopathy,” referring to inflammatory damages to
vessels secondary to infection or vascular insult and
related placental findings is often cited in a legal context
[6-8], however, further research is need to determine
prognostically how these findings affect long-term neo-
natal outcome.
Our study found 35% of placentas with gross abnor-
malities associated with potential for adverse fetal con-
sequences including opaque or foul smelling amniotic
membranes; velamentous cord insertion, long umbilical
cord, and short umbilical cord, acute abruption, and retro
placental hemorrhage. Additionally 7 placentas (7%)
were reported to be abnormal at the pathology examina-
tion as follow: chorioamnionitis, funisitis, and true knots.
Such abnormalities were associated with reassuring
neonatal outcomes as measured by APGAR scores of
more than 7 at 5 minutes of birth, normal arterial and
venous umbilical blood cord gases and uneventful nurs-
ery stay. What is unknown is the degree to which these
placental anomalies, while not associated with abnormal
fetal development, effect placental perfusion, leading to
fetal intolerance of labor.
A recent classification system of cerebral palsy calls
for an assessment of the timing and etiology of brain
injury [9]. The placental examination is an underused
resource for addressing these important questions. An
expert assessment of the placental pathology can provide
temporally and mechanistically specific data not avail-
able from any other source. An analysis of 125 placentas
from term infants with cerebral palsy, neonatal encepha-
lopathy, and other neurodisabilities compared with 200
term placentas from healthy infants, found four lesions:
fetal thrombotic vasculopathy, chronic villitis with oblit-
erative vasculopathy, chorioamnionitis with intense cho-
rionic vasculitis, and meconium associated vascular ne-
crosis to be statistically significantly increased in af-
fected infants when controlled for confounding factors.
Further analysis demonstrated that the lesions were
equally common in affected infants with normal or ab-
normal umbilical blood gases and 5 min APGAR scores
[10]. While this data is limited, it does demonstrate a
placental abnormality as seen on histological examina-
tion as correlated with neonatal outcome.
5. Comments
The prevalence of abnormal placental findings in our
studied population was 42%. Placental anomalies could
contribute to non-reassuring tracings that require emer-
gent delivery. Further delineation of specific placental
abnormalities in relationship to adverse neonatal out-
comes requires increased collaboration between Obste-
tricians, Pathologists, and Neonatologists with diligent
analysis of placentas both grossly and histologically.
6. Key Points
 All human placentas should be inspected and triaged
at the delivery room and the abnormal ones should be
sent to pathology for a complete examination
 The placenta provides a third party perspective re-
garding the pregnancy and many maternal and fetal
conditions are evidenced by placental abnormalities.
 Placental anomalies could contribute to non-reas-
suring tracings that require emergent delivery.
 The prevalence of abnormal placental findings in our
studied population was 42%
 The most common pathologies were marginal core
insertion, chorioamnionitis and abruption
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