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Placental insufficiency Information | Mount Sinai

Placental dysfunction; Uteroplacental vascular insufficiency; Oligohydramnios

The placenta is the link between you and your baby. When the placenta does not work as well as it should, your baby can get less oxygen and nutrients from you. As a result, your baby may:

• Not grow well
• Show signs of fetal stress (this means the baby's heart does not work normally)
• Have a harder time during labor

The placenta provides the fetus with oxygen and nutrients and takes away waste such as carbon dioxide via the umbilical cord.

In the placenta, nutrients, wastes, and gases are exchanged between the mothers blood and the babys blood.

Causes

The placenta may not work well, either due to pregnancy problems or social habits. These may include: 

• Diabetes
• Going past your due date
• High blood pressure during pregnancy (called preeclampsia)
• Medical conditions that increase the mother's chances of blood clots
• Smoking
• Taking cocaine or other drugs
• Anemia

Certain medicines can also increase the risk for placental insufficiency.

In some cases, the placenta:

• May have an abnormal shape
• May not grow big enough (more likely if you are carrying twins or other multiples)
• Does not attach correctly to the surface of the womb
• Breaks away from the surface of the womb or bleeds prematurely

Symptoms

A woman with placental insufficiency usually does not have any symptoms. However, certain diseases, such as preeclampsia, which can be symptomatic, can cause placental insufficiency.

Exams and Tests

Your health care provider will measure the size of your growing womb (uterus) at each visit, starting about halfway through your pregnancy.

If your uterus is not growing as expected, a pregnancy ultrasound will be done. This test will measure your baby's size and growth, and assess the size and placement of the placenta.

Other times, problems with the placenta or your baby's growth may be found on a routine ultrasound that is done during your pregnancy.

Either way, your provider will order tests to check how your baby is doing. The tests may show that your baby is active and healthy, and the amount of amniotic fluid is normal. Or, these tests can show that the baby is having problems.

You may be asked to keep a daily record of how often your baby moves or kicks.

Treatment

The next steps your provider will take depend on:

• The results of tests
• Your due date
• Other problems that may be present, such as high blood pressure or diabetes

If your pregnancy is less than 37 weeks and the tests show that your baby is not under too much stress, your provider may decide to wait longer. Sometimes you may need to get more rest. You will have tests often to make sure your baby is doing well. Treating high blood pressure or diabetes may also help improve the baby's growth.

If your pregnancy is over 37 weeks or tests show your baby is not doing well, your provider may want to deliver your baby. Labor may be induced (you will be given medicine to make labor start), or you may need a cesarean delivery (C-section).

Outlook (Prognosis)

Problems with the placenta can affect the developing baby's growth. The baby cannot grow and develop normally in the womb if it does not get enough oxygen and nutrients.

Possible Complications

Complications associated with placental insufficiency may include:

• Preeclampsia
• Preterm labor
• Intrauterine growth restriction (IUGR)
• Placental abruption or premature separation of the placenta
• Decreased oxygen delivery to the baby at birth
• Increased risk for fetal loss

Prevention

Getting prenatal care early in pregnancy will help make sure that the mother is as healthy as possible during the pregnancy.

Smoking, alcohol, and other recreational drugs can interfere with the baby's growth. Avoiding these substances may help prevent placental insufficiency and other pregnancy complications.

Benson AE, Branch DW. Collagen vascular diseases in pregnancy. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Philadelphia, PA: Elsevier; 2021:chap 51.

Lausman A, Kingdom J; Maternal Fetal Medicine Committee, et al. Intrauterine growth restriction: screening, diagnosis, and management. J Obstet Gynaecol Can. 2013;35(8):741-748. PMID: 24007710 pubmed.ncbi.nlm.nih.gov/24007710/.

Rampersad R, Macones GA. Late- and postterm pregnancy. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Philadelphia, PA: Elsevier; 2021:chap 29.

Resnik R. Intrauterine growth restriction. In: Resnik R, Lockwood CJ, Moore TR, Greene MF, Copel JA, Silver RM, eds. Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice. 8th ed. Philadelphia, PA: Elsevier; 2019:chap 47.

Last reviewed on: 12/2/2020

Reviewed by: LaQuita Martinez, MD, Department of Obstetrics and Gynecology, Emory Johns Creek Hospital, Alpharetta, GA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Placental insufficiency - what is it and how to treat it

1. Types and causes of placental insufficiency
2. Diagnosis of placental insufficiency
3. Treatment of placental insufficiency

Most women know that the placenta connects mother and baby during pregnancy and provides nutrients and oxygen to the baby.

Are there situations when the placenta ceases to perform its function correctly and fully? Is it possible to somehow prevent this?

What is the function of the placenta

So, the placenta is an important organ that is formed only during pregnancy. The placenta is formed from the chorion - the embryonic membranes of the fetus. At the very beginning of pregnancy, chorionic villi - outgrowths of the membrane - evenly cover the entire surface of the fetal egg, starting from the second month of pregnancy, on one side of the fetal egg, the villi begin to lengthen, increase in size and form the placenta.

Inside the villi flows the blood of the baby, and outside they are bathed in the blood of the mother. Between the blood flow of mother and baby there is only one layer of cells, which plays the role of a barrier between the body of mother and child. Thanks to this membrane, the blood of the mother and fetus does not mix.

However, in recent years it has become known that fetal blood cells still penetrate the placental barrier into the mother's bloodstream, and thanks to this, it has become possible to conduct genetic analyzes and determine chromosomal abnormalities, Rh factor and fetal sex from the blood of a pregnant woman (non-invasive prenatal test) .

In the placenta, there is a constant exchange of substances between mother and child. Oxygen and nutrients are supplied from the mother's blood to the fetus, carbon dioxide and metabolic products from the fetus back to the mother, to be removed from the body.

The placental barrier performs an immunological function, as it allows some protective antibodies - blood cells that fight infectious agents, in addition, it is impervious to certain harmful substances, viruses and bacteria. Unfortunately, the placental barrier is easily overcome by drugs, alcohol, nicotine, components of many drugs and some viruses.

An important function of the placenta is the production of hormones and biologically active substances. First of all, these are hormones that are important for successful pregnancy, for example, chorionic gonadotropin, placental lactogen, estrogens, etc.

Unfortunately, things don't always go well. Due to a variety of reasons, deviations in the development and functioning of the placenta may occur at different stages of pregnancy. These changes never go unnoticed for mom and baby, and often have dire consequences.

If the placenta ceases to perform its functions to the fullest, the so-called placental insufficiency develops. In fact, it consists in the deterioration of blood circulation in the mother-placenta-fetus system.

Types and causes of placental insufficiency

Doctors distinguish between acute and chronic placental insufficiency:

Acute placental insufficiency

This is a condition that requires urgent medical attention. It is characterized by a rapid deterioration in placental blood flow. Acute placental insufficiency occurs mainly as a result of placental abruption or the death of certain areas of placental tissue, for example, during the formation of blood clots in the vessels. Abdominal trauma, antiphospholipid syndrome can serve as the cause of detachment.

Phospholipids are complex fats that are part of the membranes of all body cells. In some cases, the body's immune system produces a large number of antibodies to some of its own phospholipids and proteins that bind these lipids. They are called antiphospholipid antibodies and, when interacting with the cells of the body, cause cell damage and activation of the blood coagulation system, which leads to thrombosis.

Antiphospholipid syndrome is the most common cause of thrombotic complications in pregnancy, including placental abruption and acute placental insufficiency.
A severe course of gestosis, a formidable complication of the second half of pregnancy, manifested by edema, increased pressure and the appearance of protein in the urine, can also cause placental abruption.

Acute placental insufficiency develops when more than 2/3 of the placental surface is detached.

In case of acute placental insufficiency, it is necessary to perform a caesarean section as soon as possible to save the life of the baby and mother.

Chronic placental insufficiency

Chronic placental insufficiency is much more common in pregnant women. In this case, there is a violation of the formation and maturation of the placenta, the uteroplacental and fetal-placental blood flow decreases, gas exchange and metabolism in the placenta are limited, and the synthesis of placental hormones decreases. All these changes determine the insufficient supply of oxygen and nutrients to the baby, cause a delay in the growth and development of the fetus.

The most common causes of placental insufficiency are previous abortions, especially surgical abortion during the first pregnancy, smoking, while the number and strength of cigarettes smoked do not matter, since tobacco smoke, not nicotine, has a negative effect on the formation of defective placental vessels.

The risk group for the development of placental insufficiency also includes women with chronic diseases such as arterial hypertension, iron deficiency anemia, pyelonephritis, diabetes, thyroid disease.
In recent years, there has been a significant increase in placental insufficiency caused by bacteria, viruses, fungi. The reason for this can be both an acute infection suffered by the expectant mother during pregnancy, and the activation of a chronic infectious process in the body of a pregnant woman.

Of no small importance in the formation of chronic placental insufficiency is the pathology of the uterus: endometriosis, malformations of the uterus (saddle-shaped, bicornuate). Doctors also consider uterine fibroids to be a risk factor. Of course, a number of drugs have an adverse effect on the formation of the placenta and the development of the fetus. Currently, a list of drugs that are not approved for use during pregnancy has been defined.

Also of great importance in the development of placental insufficiency is thrombophilia - an increased tendency of the body to form blood clots - blood clots in the vessels.

In some cases, placental insufficiency may be due to the presence of chromosomal abnormalities in the fetus, in particular in Down syndrome (the presence of an additional chromosome 21 in the fetus) or Edwards syndrome (an additional chromosome 18 in the fetus), placental dysfunction is diagnosed already in the early stages of pregnancy.

It should be noted that among the complications of pregnancy, most often leading to the development of chronic placental insufficiency, a significant factor is preeclampsia (or late preeclampsia) - a complication of the second half of pregnancy, manifested by edema, increased pressure and the appearance of protein in the urine.
Regardless of the factors contributing to the development of placental insufficiency, it is based on circulatory disorders in the uterine-placental complex, leading to disruption of all functions of the placenta. Consequently, the symptoms of chronic placental insufficiency will be due to a lack of oxygen and nutrients to the fetus.

This is, first of all, intrauterine fetal growth retardation - a lag in the size of the fetus and a slowdown in its growth. Often there is a change in the motor activity of the fetus. At first there may be some increase in movements, and then a decrease. Violation of the protective function of the placenta leads to intrauterine infection of the fetus under the action of pathogenic (pathogenic) microorganisms penetrating the placenta. The fetus, the development of which occurs in conditions of placental insufficiency, is much more at risk of trauma during childbirth, they have a violation of adaptation to extrauterine life, increased morbidity in the first year of life.

According to the time of occurrence, doctors divide placental insufficiency into early and late.

Early (or primary) placental insufficiency

Develops before 16 weeks of gestation. It occurs already at the stage of placenta formation and is associated with diseases of a pregnant woman that are present before pregnancy, for example, with uterine pathology, chronic arterial hypertension, and endocrinological diseases. In this case, the formation of defective vessels in the placenta occurs.

Late (or secondary) placental insufficiency

Occurs after 16 weeks of pregnancy and is most often associated with diseases that have already occurred during pregnancy. Most often, these are iron deficiency anemia (that is, a decrease in the concentration of hemoglobin and iron in the blood), gestational diabetes mellitus (that is, a violation of the absorption of glucose by the body that occurred during pregnancy), past viral and bacterial infections.

It is important to subdivide placental insufficiency into compensated and decompensated forms.

Compensated placental insufficiency

It develops, for example, with the threat of abortion and mild forms of late preeclampsia, if these complications are successfully amenable to medical correction.

Decompensated placental insufficiency

Causes the development of fetal growth retardation, chronic intrauterine hypoxia, up to fetal death.

Learn more about services:

• Ultrasound for pregnant women
• Ultrasound of the 1st trimester of pregnancy
• Ultrasound of vessels during pregnancy
• Consultation with a gynecologist

Diagnosis of placental insufficiency

It is almost impossible to treat an already developed placental insufficiency, so doctors actively seek to identify pregnant women who are at risk of developing placental dysfunction. If placental insufficiency is detected in the 3rd trimester of pregnancy, there is no effective treatment, unfortunately. Therefore, all methods of identifying in the early stages of pregnancy those women whose formation of the placenta has been disturbed are being very actively used.

First of all, when registering for pregnancy, the most significant risk factors are identified - smoking, abortions, aggravated heredity (low birth weight, tendency to thrombosis), the presence of chronic diseases of the heart, blood vessels, diabetes mellitus.

Preventive measures against the development of placental insufficiency are especially relevant and necessary until 16-17 weeks of pregnancy, when the formation of placental structures occurs.

Significant assistance in assessing the risk of developing placental insufficiency is provided by prenatal screening, which is carried out at 11-14 weeks of pregnancy. It is carried out to detect Down syndrome, Edwards syndrome and other chromosomal diseases in the fetus. Currently, the most relevant is to conduct a comprehensive early screening of a pregnant woman to predict the risk of developing placental insufficiency, preeclampsia and intrauterine growth retardation. Since this type of diagnostics is one of the most modern and advanced, unfortunately, it is not yet included in the list of services provided in the antenatal clinic within the framework of compulsory medical insurance, but is available to everyone in prenatal diagnostic centers.

Determination of proteins produced by the placenta

First of all, the PAPP-A protein is determined, it is also a marker of chromosomal abnormalities of the fetus. A decrease in the concentration of PAPP-A in the blood at 11-14 weeks of gestation occurs in pregnant women who have a high risk of placental insufficiency and fetal growth retardation.

The second placental hormone that helps in assessing the risk of placental insufficiency is PIGF (placental growth factor). Its concentration in the blood decreases long before the first manifestations of placental insufficiency. Its definition is not as widely used as PAPP-A, but many laboratories have already included this protein in 1st trimester prenatal screening. It is extremely important when screening the 1st trimester to measure blood flow in the vessels of the uterus. It has been unambiguously proven that the narrowing of the vessels of the uterus, determined during the study, indicates the inferiority of the formation of the placenta, which will worsen with increasing gestational age and lead to a decrease in the nutrition of the baby and the supply of oxygen, that is, to the development of placental insufficiency and fetal growth retardation. With normal sizes of uterine vessels at 11-14 weeks of gestation, the risk of severe placental insufficiency is negligible.

The next mandatory screening ultrasound is at 20-21 weeks of gestation. In this case, measurements of the fetus must be carried out in order to assess whether there is a lag in growth. After all, with oxygen starvation, the growth rate of the fetus slows down and its size begins to lag behind the norm for each period of pregnancy. In addition, the doctor must evaluate the condition and maturity of the placenta. During ultrasound, dopplerometry of the uterine vessels is also performed to detect early changes that precede the clinical manifestations of placental insufficiency.

In patients belonging to the high-risk group, in addition to ultrasound and dopplerometry, daily monitoring of blood pressure fluctuations is also carried out, the amount of protein in the urine sample collected per day is determined, and the indicators of the blood coagulation system are evaluated.

The third ultrasound is performed for all expectant mothers at 30-34 weeks of pregnancy. The doctor measures the circumference of the head and abdomen of the crumbs, the length of the bones of his arms and legs, and calculates the estimated weight of the fetus. These measurements allow the doctor to make sure that the baby is developing normally. The structure of the placenta is also important, the presence of signs of aging in it, as a result of which it usually ceases to fully supply the baby with blood, which means that it ceases to have enough oxygen and nutrients and the development of the child is disturbed. During ultrasound, the amount and type of amniotic fluid is assessed, which can also change with intrauterine fetal suffering.

Doppler

Doppler of the placental and umbilical cord vessels (method of studying blood flow velocities in these vessels) also allows you to assess the well-being of the baby. The doctor examines the blood flow in the arteries of the uterus, umbilical cord, heart and brain of the child. This study allows you to determine whether the placenta is working well, whether there are signs of a lack of oxygen in the baby, or the development of preeclampsia in the mother. With a decrease in the speed of blood flow in any vessel, one can speak of fetal malnutrition of varying severity.

A well-timed examination makes it possible to identify the initial stages of blood supply deficiency. In such cases, treatment can prevent formidable complications, such as hypoxia and intrauterine growth retardation of the baby. Dopperometry is carried out at 20-21 weeks and at 30-32 weeks of pregnancy, if there are changes, control is carried out at least every two weeks.

Cardiotocography

This is an important method for assessing the condition of the fetus. CTG is performed at a gestational age of 33 weeks or more, since only at this stage of the intrauterine development of the baby is a complete regulation of the activity of the cardiovascular system of the fetus established by the centers of the spinal cord and brain. Recording of fetal heartbeats is carried out for 20-40 minutes, and if necessary, the study can be extended up to 1.5 hours.

The device registers and records the baby's heart rate. The obstetrician-gynecologist evaluates the heartbeat recording curve, episodes of slowing down and a sharp increase in the fetal heart rate, and based on these data, makes a conclusion about how comfortable the baby feels in the mother's stomach. For example, with a decrease in the concentration of oxygen in the blood of the fetus, its supply to the cells of the nervous system also decreases, which in turn affects the heart rate. In the normal course of pregnancy, CTG is performed after 33 weeks 1 time in 10-14 days, sometimes more often. Some clinics currently offer the service of continuous CTG monitoring, which becomes relevant in the presence of signs of placental insufficiency. A pregnant woman is given a monitor that records changes in the baby's heart activity and these data are transmitted via the Internet to the attending physician.

Treatment of placental insufficiency

There are currently no specific treatments for placental insufficiency because there are no drugs that selectively improve uteroplacental blood flow. That is why all measures to combat placental insufficiency are aimed at prevention. If the patient is at high risk for the development of placental insufficiency, from early pregnancy she is prescribed drugs whose effectiveness is well proven and which prevent the early development of severe placental dysfunction.

If during the additional methods of assessing the condition of the fetus, initial disturbances in the supply of oxygen to the baby are detected, drug treatment is carried out aimed at increasing the flow of blood and oxygen through the placenta and mandatory control examinations against the background of ongoing therapy. If the changes are serious and the baby experiences a pronounced deficiency of oxygen and nutrients, his condition suffers, then in such cases an emergency delivery is performed.

10 amazing facts about the placenta

Home "News" 10 amazing facts about the placenta

10.10.2020

Liat Ben -Senior, MBA MSC