Bilobed Placenta with Velamentous Umbilical Cord Insert

Courtney Mashburn
DMS 497
Fall 2015

CERTIFICATE OF AUTHORSHIP: I certify that I am the author of this research paper. I have
cited all of the sources from which I used data, ideas, or words (quoted or paraphrased). I also
certify that this paper was prepared by me specifically for this course.
Signature ______Courtney Mashburn___________

Date: _________11/30/2015___________

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Abstract
A bilobed placenta consists of two similarly sized placental lobes separated by intervening
membranes. There is a high association between bilobed placentas, placenta previa and
velamentous umbilical cord insertions. Bilobed placentas are a rare occurrence seen in only 4%
of pregnancies with velamentous umbilical cord insertions seen in only 1% of pregnancies.
These abnormalities can have an association with IUGR (intrauterine growth restriction), preterm
delivery, congenital anomalies, low APGAR scores, neonatal death, and retained placenta after
delivery. Bleeding in the second and third trimester can be seen with a bilobed placenta and can
increase the mothers risk for hemorrhage. Since the use of transvaginal and transabdominal
sonography with color and spectral Doppler, the incidence of maternal and fetal morbidity and
mortality has significantly declined based on these early findings.

Keywords: placenta, bilobed, velamentous, umbilical cord, sonograph

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A bilobed placenta is a variation in placental morphology and refers to a placenta separated into
two near equal lobes. The estimated incidence is at up to 4% of pregnancies. It is thought to
result from localized atrophy as a result of poor vascularization of a part of the uterus.

Case Report
The patient was a 21 year old Caucasian female who was receiving daily biophysical profile
sonograms and biweekly fetal measurements for complete placenta previa, a bilobed placenta
with velamentous cord insertion involving the anterior placental lobe. She was gravida two,
parity one. She has no history of gestational hypertension or diabetes and her fasting glucose was
normal at 96 mg/dL. The patient started receiving weekly biophysical profiles at 29 weeks
gestation and continued them until delivery via cesarean section at 35 weeks 3 days gestation
when she started passing large clots. The patient had no labs drawn at the facility to screen for
fetal abnormalities or open neural defects such as alpha-fetoprotein (AFP). Throughout the
exams the fetus consistently received a score of 8/8 for gross body movement, tone, breathing,
and amniotic fluid index. The cord Doppler demonstrated a low resistive waveform with the
systolic/diastolic ratio measuring 2.9 cm/s. The amniotic fluid index measured 8.2 centimeters
with the largest pocket measuring 3 centimeters. The fetal heart rate was consistently in the 120s.
Sonographic Findings
The placenta begins as a diffusely thick echogenic ring surrounding the early gestational sac,
changes to a bright focal area known as the chorionic frondosum, which eventually becomes the
placenta. The attachment site, or base of the placenta, should be clearly delineated from the
underlying myometrium. The placenta appears slightly more echogenic then the surrounding
myometrium and can range from homogeneous to heterogeneous with multiple anechoic areas

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representing the umbilical cord insertion and the retroplacental and intraplacental arteries.
Ultrasound identification of the umbilical cord insertion into the placenta is important for
assessment of fetal circulation. Placental mean thickness closely approximates in millimeters the
gestational age in weeks in the first half of pregnancy. The placental thickness should not
exceed 4 centimeters and should not be thinner than 1.5 centimeters
A bilobed placenta will be seen sonographically as two separate placental discs of near equal
size. The umbilical cord usually attaches to a thin connecting rim of chorionic tissue which
bridges the two lobes.
Vasa previa will be seen best sonographically utilizing color Doppler to demonstrate flow within
vessels which are seen overlying the internal cervical os.
Discussion
The placenta is the most vital support organ for the developing fetus. It is the transfer site of
maternal and fetal oxygen, carbon dioxide, and nutrition. The placenta develops from the
trophoblastic cells that make up the chorion which is then covered by the villi that are the
functional units of the placenta around 4 to 5 weeks gestation. One-third of this tissue will
continue to develop as the placenta (chorion frondosum). By 12 weeks gestation the placenta is
established and contains approximately 50 villous trees known as placentomas. The placenta acts
as a barrier to prevent most pathogens, microorganisms, and viruses from entering fetal
circulation. The placenta location can vary within the uterus and can be found anterior, posterior,
lateral left, lateral right, or fundal.
The term placenta previa refers to a placenta that is previous to the fetus in the birth canal. The
incidence at delivery is approximately 0.5% of all pregnancies. Bleeding in the second and
third trimesters is the hallmark of placenta previa. This bleeding can be life threatening to the

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mother and fetus but with expectant management and cesarean delivery, both maternal and
perinatal mortality have decreased over the past 40 years. Placenta previa can be classified as
complete placenta previa, partial placenta previa, incomplete placenta previa, marginal placenta
previa, low-lying placenta, and placenta distant from the internal cervical os. These
classifications directly apply to the placental position relative to the cervix. Complete placenta
previa describes the situation in which the internal cervical os is totally covered by the placenta.
Bilobed placentas consist of two similarly sized placental lobes separated by intervening
membranes. There must be some vascular connection between the lobes, and the umbilical cord
may insert between the lobes in the membrane. Bilobed placentas may have more unprotected
vessels.
Succenturiate lobes, or accessory lobes, of the placenta can be a single lobe or multiple lobes in
addition to the main placental lobe. One concern with succenturiate lobes involves retained
placental accessory lobes after delivery. Succenturiate lobes can also lie over the cervix as a
variant of placenta previa. Even more important is the concern over the location of the vascular
connection between the main placenta and the succenturiate lobe. If the vessels lie in proximity
to the cervix, a vasa previa may be present. Vasa previa is a condition which arises when fetal
blood vessels implant into the placenta in a way that covers the internal os of the uterus.
A velamentous umbilical cord insertion refers to the situation where the umbilical cord inserts
into the membranes and not the placental disc. Velamentous umbilical cord insertions occur in
approximately 1% of singleton pregnancies. A velamentous cord insertion can be identified
with ultrasound as early as 11 to 14 weeks gestation. Velamentous cord insertions are associated
with IUGR, preterm delivery, congenital anomalies, low APGAR scores, neonatal death, and
retained placenta after delivery. The insertion of the umbilical cord into the membranes leads to

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unsupported coursing of the umbilical vessels to the placental disc which means that the
protective jelly, Whartons jelly, is not present. This can lead to increased risk of compression,
thrombus, or even rupture of the vessels. Increasing length of the unsupported membrane
vessels is associated with increasing rates of abnormal heart rate patterns. Nonreassuring fetal
heart tones and emergency cesarean deliveries are more frequent with velamentous cord
insertions.
Conclusion
In conclusion, the patient was a 21 year old Caucasian female who was being assessed daily for
her diagnosis of a bilobed placenta with a velamentous umbilical cord insertion. Besides being
two separate lobes, the placenta had the typical sonographic appearance, homogeneous, mediumlevels gray demonstrating internal vascularity of the placental arteries. Bilobed placentas are a
rare occurrence seen in only 4% of pregnancies and velamentous umbilical cord insertions are
seen in only 1%. Having a bilobed placenta and a velamentous cord insertion puts mother and
fetus at risk during pregnancy and during birth. Velamentous cords are not protected by
Whartons jelly so they are more susceptible to compression, thrombus, and rupture.
Velamentous cord insertions are associated with IUGR, preterm delivery, congenital anomalies,
low APGAR scores, and neonatal death. Bilobed placentas are highly associated with placenta
previa which is where all or part of the placenta is covering the internal cervical os, which puts
the mother at risk for hemorrhage during birth. Both bilobed placentas and velamentous cord
insertions are at risk for retained placental products after delivery but the incidence of this has
drastically decreased due to the use of sonograms in determining placenta previa and also
cesarean deliveries. This patient started daily biophysical profiles at 29 weeks gestation and

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continued them until cesarean delivery at 35 weeks 3 days gestation where the baby received a
10/10 APGAR score.

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