LETTER TO THE EDITOR

Placenta membranacea

Samadh F. Ravangard • Kimberly Henderson •

Kisti Fuller

Received: 25 October 2012 / Accepted: 21 February 2013 / Published online: 7 March 2013

� Springer-Verlag Berlin Heidelberg 2013

Abstract Placenta membranacea is a rare placental dis-

order characterized by the presence of fetal membranes

(complete or partially) covered by chorionic villi. A

35-year-old woman, gravida 1, was admitted for preterm

labor at 24 weeks and 5 days. She subsequently developed

heavy vaginal bleeding and underwent a classical cesarean

delivery for suspected abruption. Postpartum inspection of

the placenta demonstrated a small placenta with tan colored

membranes, and diffusely scattered placental cotyledons.

Histologic examination revealed chorionic villi directly

attached to the fetal membranes on the periphery,consistent

with the diagnosis of a partial placenta membranacea.

Placenta membranacea should be considered in the etiol-

ogy of painless vaginal bleeding in the second and third

trimester. This condition can be associated with other

placental abnormalities, such as placenta previa or accreta.

Perinatal outcome may include stillbirth, preterm delivery,

or neonatal death.

Introduction

First described in 1853 by Dr. Seneca Sargent, placenta

membranacea is a rare placental anomaly that has been

reported to complicate 1:20,000–40,000 births [1, 2]. To

date, there have been 41 previously reported cases in the

literature. This unusual condition is believed to result from

the failure of the trophoblastic shell to differentiate into the

chorion frondosum and chorion laeve at 8–10 weeks of

gestation. This results in membranes that are either com-

pletely or partially covered by chorionic villi [2–6]. The

majority of cases are diagnosed postpartum, however, these

women commonly present with painless vaginal bleeding

and preterm labor in the second or third trimester [2, 3].

Placenta membranacea is a clinically significant and

potentially under-recognized condition that may be asso-

ciated with hemorrhage in the antepartum or postpartum

period, abnormal placental adherence, and pregnancy loss

[2]. Here we present a case of placenta membranacea with

a review of the literature.

Case

A 35-year-old woman, gravida 1, para 0 at 24 weeks and

5 days initially presented with the complaint of uterine

cramping every 4 min, which was associated with vaginal

spotting. Her antenatal course had been otherwise

uncomplicated prior to her admission.

On presentation she was found to be contracting every

5 min, and her cervix was 1 cm dilated and 100 % effaced.

She initially received magnesium sulfate for tocolysis and

betamethasone for fetal lung maturity. However, the

patient continued to contract and was additionally stabi-

lized with indomethacin. Trans-abdominal ultrasound per-

formed on admission, demonstrated a normal appearing

anterior placenta with the fetus in breech position and

estimated weight of 633 g (12 %).

On the morning of hospital day 2, the patient had a

single episode vaginal bleeding with approximately 75 cc

and her cervix was found to have progressed to 3 cm

dilated with bulging membranes. Shortly after, she devel-

oped steady vaginal bleeding. Her bleeding was attributed

S. F. Ravangard (&) � K. Henderson � K. Fuller

Department of Obstetrics and Gynecology, University

of Connecticut Health Center, 263 Farmington Avenue,

Farmington, CT 06030-2947, USA

e-mail: sravangard@resident.uchc.edu

123

Arch Gynecol Obstet (2013) 288:709–712

DOI 10.1007/s00404-013-2778-z

to a placental abruption. As a result of persistent, heavy

vaginal bleeding, the decision was made to proceed with a

primary classical cesarean section. Fetal heart tracing was

reassuring throughout the hospital course. The patient

delivered a viable male infant, weighing 700 g (24 %) with

the APGAR scores of 1, 4, and 7 at 1, 5, and 10 min.

Post operatively, the placenta was inspected and noted

to have irregularly thickened tan colored membranes with

sparse, disorganized placental cotyledons (Fig. 1). The

placenta weighted 153 g and had a marginally inserted

3-vessel cord. Histologically, chorionic villi were seen to

attach directly to fetal membranes on samples taken from

the periphery of the gross specimen, indicating a partial

placenta membranacea (Fig. 2). The villi also appeared to

have mild multifocal maturation.

The neonate expired on the second day of life due to

complications of prematurity. The maternal postpartum

course was otherwise uncomplicated and she was dis-

charged on post-operative day 3.

Discussion

Placenta membranacea is a rarely encountered anomaly of

the placenta where fetal membranes are completely or

partially covered by chorionic villi. Previous accounts have

described placenta membranacea as tan colored mem-

branes with diffusely scattered placental cotyledons of

varying thickness. Descriptions have also commonly noted

a marginal cord insertion with a distinct placental disk at

the insertion site [2–9].

This condition is believed to result from the failure of

the trophoblastic shell to differentiate during 8–10 weeks,

into the chroion frondosum and chorion laeve [2–6]. The

etiology is not entirely clear. It has been theorized that this

disorder may result from a previous endometritis, poorly

developed blood supply in the decidua basalis or exces-

sive blood supply to the decidua capsularis allowing for

the persistence of villi on the chorion laeve, a failure in

the dysgenesis of the trophoblasts resulting the develop-

ment of a primitive form of placenta, deep implantation of

the ovum, and atrophy or hypoplasia of the endometrium

[2, 7].

The majority of patients present in the second or early

third trimester with painless vaginal bleeding and/or

symptoms of preterm labor. In a review of the literature, 31

out of 41 cases (75.6 %) were associated with a preterm

delivery and 6 cases (14 %) occurred at less than 23 weeks

gestation. In addition, 33 out of 40 cases (82.5 %) preceded

delivery with an antepartum hemorrhage (Table 1). Simi-

larly to our case, the clinical picture of placenta mem-

branacea very closely resembles an abruption and should

be included in the differential of vaginal bleeding in the

second or third trimester.

Among the method of delivery in prior reports, 15 of 39

cases (38.5 %) were delivered by cesarean section of which

8 had hysterectomies at the time of delivery. This largely

reflects the association of placenta membranacea with

abnormal placental adherence and postpartum hemorrhage.

14 out of 39 cases (35.9 %) were complicated by abnormal

adherence including encounters of placenta previa and

accreta. In addition, postpartum hemorrhage was seen in 13

of 40 cases (32.5 %).

Perinatal outcome ranges from still birth to preterm or

term delivery [2, 3]. 22 out of 38 cases (57.9 %) resulted in

a live birth, with 5 neonatal deaths after delivery. It has

been previously suggested, that placenta membranacea

may be associated with intrauterine growth restriction [10].

However, only one neonate was born with a birth weight

\10 %. As seen in our case, we speculate that the

Fig. 1 Gross appearance of placenta postpartum

Fig. 2 Histologic appearance of chorionic villi directly attached to

fetal membranes

710 Arch Gynecol Obstet (2013) 288:709–712

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Table 1 Case reports of placenta membranacea

Author(s) (year) Case Gestational ageat delivery

Antepartumhemorrhage

Postpartumhemorrhage

Placentaladherence

Deliverymethod

Livebirth

Birthweight

Percentile Fetal outcome

Sargent [1] 1 6 months ? - - Vag - 909 g 80 %

von Weiss [12] 2 23 weeks ? ? ? Vag ? NA NA Death at 30 min of life

Braun and vonWeiss [13]

3 5–6 months ? ? NA Vag ? NA NA Death described assoon after birth

Reinprecht [14] 4 23 weeks ? ? ? Vag - 370 g 15 %

DeLee [15] 5 Preterm - ? ? Vag ? 2,018 g NA

Viana [16] 6 7 months ? - - Vag - 750 g 15 %

Routh [17] 7 5 months ? - - Vag - NA NA

Kapferer [18] 8 7 months ? ? - Vag - NA NA

Finn [8] 9 27 weeks ? ? - Ces ? 1,446 g 90 % Death at 72 h of life

10 24 weeks ? - - Ces ? 879 g 80 % Death at 1 h of life

Rodriguez-Soriano[19]

11 43 weeks ? ? - Ces ? 4,000 g 95 %

Aguero [20] 12 Term - - - Vag ? NA NA

13 Preterm ? ? ? Vag NA NA NA

14 40 weeks ? NA NA NA NA NA NA

Shanklin [21] 15 30 weeks NA NA NA NA NA NA NA

Janovski andGranowitz [7]

16 20 weeks ? - - Ces* - 120 g NA

Bukovsky et al. [22] 17 42 weeks ? - ? Ces* ? 4,250 g NA

Culp [11] 19 32 weeks ? - - Vag ? 1,700 g 40 %

Pryse-Davies [23] 18 20 weeks ? - - Vag - 378 g NA

Benirschke andDriscoll [24]

20 NA NA ? ? NA* NA NA NA

Wladimiroff et al.[9]

21 26 weeks ? - - Vag - 560 g 10 %

Las Heras et al. [5] 22 40 weeks ? - - Ces ? 3,630 g 75 %

Molloy et al. [10] 23 30 weeks ? - - Ces ? 1,109 g 15 %

Lindner [25] 24 40 weeks ? - ? Ces* ? 2,900 g Na

Hurley andBeischer [6]

25 36 weeks - - - Ces ? 2,630 g 45 %

26 37 weeks ? ? - Vag ? 3,520 g 90 %

27 35 weeks ? ? ? Vag ? 2,235 g 30 %

Greenburg et al. [2] 28 32 weeks - ? ? Ces* ? 1,690 g 25 %

Wilkins et al. [26] 29 24 weeks ? - - Vag - NA NA

30 19 weeks ? - ? Vag - NA NA

31 18 weeks ? - - Vag - NA NA

32 22 weeks ? - - Vag - NA NA

33 17 weeks ? - -- Vag - NA NA

34 17 weeks ? ? ? Vag - NA NA

35 30 weeks ? - - Ces ? NA NA

Dinh [4] 36 37 weeks ? - ? Ces* ? 2945 g NA

Ekoukou et al. [27] 37 38 weeks ? - ? Ces* ? NA NA

Ahmed [3] 38 17 weeks - - - Vag - NA NA

39 37 weeks - - - Vag ? NA NA

40 12 weeks - - - Vag - NA NA

Sparic et al. [28] 41 31 weeks ? - ? Ces* ? 1,800 g NA

Ravangard et al.(present case)

42 24 wk ? - - Ces ? 700 g 25 % Death at 48 h of life

NA not available, Vag vaginal, Ces cesarean

* Hysterectomy at time of delivery

Arch Gynecol Obstet (2013) 288:709–712 711

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accelerated maturation of villi may allow an abnormal

placenta to compensate and sustain an appropriately grown

fetus for some degree of time.

Antenatal diagnosis of placenta membranacea remains a

clinical challenge. The majority of cases have been diag-

nosed during postpartum examination of the placenta.

However, there have been two reports of antenatal diag-

nosis using ultrasonography [9, 10]. Angiography has also

been reported in the successful diagnosis of one case ret-

rospectively [11]. The ability to detect the distinguishing

placental cotyledons or the placental disk at cord insertion

site with thinning placental tissue distally on ultrasonog-

raphy may raise suspicion of this rare diagnosis [9, 10]. In

our case, we were unable to retrospectively identify any

distinguishing characteristics of placenta membranacea on

ultrasonography.

Placenta membranacea is an unusual placental disorder

that is potentially unrecognized. These patients typically

present with vaginal bleeding in the second or third tri-

mester. The majority of pregnancies result in an appro-

priately grown preterm neonate, but outcome can range

from stillbirth to a viable term delivery. Placenta mem-

branacea may be further complicated by postpartum hem-

orrhage and/or abnormal placental adherence. Previous

cases of placenta membranacea have almost entirely been

diagnosed during postpartum placental examination, how-

ever, advances in diagnostic imaging may allow for future

antenatal diagnosis.

Conflict of interest None.

References

1. Sargent S (1854) Case of a foetus within the placenta. Boston

Med Surg J 49:163–164

2. Greenberg JA, Sorem KA, Shifren JL, Riley LE (1991) Placenta

membranacea with placenta increta: a case report and literature

review. Obstet Gynecol 78:512–514

3. Ahmed A (2003) Placenta membranacea: a developmental

anomaly with diverse clinical presentation. Pediatr Dev Path

6:201–202

4. Dinh TV, Bedi DG, Salinas J (1992) Placenta membranacea,

previa and accrete a case report. J Reprod Med 37:97–99

5. Las Heras J, Harding PG, Haust MD (1982) Recurrent bleeding

associated with placenta membranacea partialis: report of a case.

Am J Obtet Gynecol 144:480–482

6. Hurley VA, Beischer NA (1987) Placenta membranacea. Case

reports. Br J Obstet Gynaecol 94:798–802

7. Janovski NA, Granowitz ET (1961) Placenta membranacea.

Obstet Gynecol 18:206–212

8. Finn JL (1954) Placenta membranacea. Obstet Gynecol 3:438–

440

9. Wladimiroff JW, Wallenburg HCS, Putten PVD, Drogendijk AC

(1976) Ultrasonic diagnosis of placenta membranacea. Arch

Gynaekol 221:167–174

10. Molloy CE, McDowell W, Armour T, Crawford W, Berstine R

(1983) Ultrasonic diagnosis of placenta membranacea in utero.

J Ultrasound Med 2:377–379

11. Culp WC, Bryan RN, Morettin LB (1973) Placenta membrana-

cea. Radiology 108:309–310

12. Von Weiss O (1893) Uber placenta membranacea and ihre be-

ziehungen zur placenta praevia. Wien Klin Wochenschr 6:915

13. Braun R, von Weiss O (1894) Berichte aus gynaklog. Gesells-

chaften und krankenhausern. Zentralbl Gynaekol 18:76–79

14. Reinprecht L (1902) Placenta membranacea. Zentralbl Gynaekol

26:73

15. DeLee JB (1902) Placenta membranacea. Am J Obstet 46:530–

531

16. Torpin R (1969) The human placenta: it’s shape, form, origin, and

development. Charles C. Thomas, Springfield, Illinois, pp 88–92

17. Routh A (1908) Placenta diffusa. Proc R Soc Med 1:127–128

18. Kapferer R (1921) Ein fall von placenta difusa. Zentralbl Gy-

naekol 45:661

19. Rodriguez-Soriano JA (1956) Contribucion al studio de la pla-

centa difusa total. An Med (Lima) 42:53–58

20. Aguero O (1957) Anomalias morfologicas de la placenta y su

significado clinic. Caracas, Venezuela, Artegrafia, pp 97–99

21. Shanklin DR (1958) The human placenta: a clinicopathologic

study. Obstet Gynecol 11:129–138

22. Bukovsky I, Hirsch H (1971) Placenta praevia accreta mem-

branacea. Intern Surg 56:422

23. Pryse-Davies J, Dewhurst CJ, Campbell S (1973) Placenta

membranacea. J Obstet Gynaecol Br Commonw 80:1106–1110

24. Benirschke K, Driscoll SG (1974) The pathology of the human

placenta. Springer, New York, pp 109–111

25. Linder E, Zacharlas L, Elkojok M, Kerzabi K (1986) Exceptional

observation of a placenta praevia centralis accrete, increta, percreta,

and membranacea. Acta Univ Palack Olomuc Fac Med 114:225

26. Wilkins BS, Batcup G, Vinall PS (1991) Partial placenta mem-

branacea. Br J Obstet Gynaecol 98:675–679

27. Ekoukou D, Ng Wing Tin L, Nere MB, Bourdet O, Elalaoui Y,

Bazin C (1995) Placenta membranacea. Review of the literature,

a case report. J Gynecol Obstet Biol Reprod (Paris) 24:189–193

28. Sparic R, Kadija S, Tadic J, Dokic M, Milenkovic V (2007)

Intrapartal resection of the bicornuete uterus for placenta mem-

branacea percreta. Srp Arh Celok Lek 135:85–87

712 Arch Gynecol Obstet (2013) 288:709–712

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