Ultrasound Obstet Gynecol 2011; 37: 328–334

Published online 28 January 2011 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.7733

Exploring the relationship between preterm placental

calcification and adverse maternal and fetal outcome
K. H. CHEN*†‡, L. R. CHEN§¶ and Y. H. LEE*
*Department of Obstetrics and Gynecology, Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei, Taiwan; †School of Medicine, Tzu Chi University,
Hualien, Taiwan; ‡Graduate Institute of Health Care Organization Administration, College of Public Health, National Taiwan University, Taipei,
Taiwan; §Mackay Memorial Hospital, Taipei, Taiwan; ¶School of Biomedical Science and Engineering, National Yang Ming University, Taipei, Taiwan

K E Y W O R D S: birth weight; fetal outcome; maternal outcome; preterm placental calcification

ABSTRACT Group 3. In contrast, there were no significant differences in

Objectives To explore the relationship between preterm
placental calcification and adverse pregnancy outcome,
including maternal and fetal outcomes.
Methods In this prospective cohort study, monthly
ultrasonography was performed starting at 28 weeks’
gestation to establish the diagnosis of Grade III placental
calcification. Women were classified into three groups: Group
1, the early preterm group, with placental calcification found
prior to 32 weeks (n = 63); Group 2, the late preterm group,
with placental calcification found between 32 and 36 weeks (n
= 192); and Group 3, the control group, without placental
calcification noted between 28 and 36 weeks (n = 521).
Women who smoked cigarettes or drank alcohol during
pregnancy, or who had hypertension, diabetes, significant
antenatal anemia or placenta previa were all excluded.
Logistic regression analysis was used to estimate the risks of
adverse pregnancy outcome in Groups 1 and 2 by calculating
odds ratios (OR) with 95% CIs, adjusted by maternal age,
body mass index, economic status, marital status, type of
delivery and parity.
Results Risks for adverse maternal outcome includ-ing
postpartum hemorrhage (OR, 3.43; 95% CI, 1.251 – 9.388),
placental abruption (OR, 6.52; 95% CI,
1.356 – 31.382) and maternal transfer to the intensive care
unit (OR, 9.76; 95% CI, 1.826 – 52.195) and for adverse fetal
outcomes including preterm birth (OR, 4.20; 95% CI, 1.775 –
9.940), low birth weight (OR, 4.58; 95% CI, 2.201 – 9.522),
low Apgar score (OR, 6.53; 95% CI, 2.116 – 20.142) and
neonatal death (OR, 9.04; 95% CI,
1.722 – 47.411) were much higher in Group 1 than in
adverse pregnancy outcome between Groups 2 and 3.
Conclusions Early preterm placental calcification is asso-
ciated with a higher incidence of adverse pregnancy outcome,
and may serve as an indicator of adverse mater-nal and fetal
outcomes when noted on ultrasonography. Conversely, women
with late preterm placental calcifica-tion are not at greater
risk for adverse pregnancy outcome. Copyright 2011 ISUOG.
Published by John Wiley & Sons, Ltd.
INTRODUCTION
Placental calcification, often noted on ultrasound exami-nation
during pregnancy, is characterized by widespread deposition
of calcium on the placenta, resulting in echogenic foci 1,2.
When the process has advanced to the deposition of calcium
on the basal plate and septa, calcification may appear to be
linear or even circular3,4. Under the Grannum classification
for ultrasound grad-ing, placental calcification of this degree
is designated Grade III, with significant formation of
indentations or ring-like structures within the placenta (Figure
1)5. Pla-cental calcification commonly increases with
gestational age, and becomes apparent after 36 weeks’
gestation. When it becomes notable prior to 36 weeks’
gestation, it is considered to be preterm placental
calcification5. The prevalence of preterm placental
calcification has been reported as 3.8% (measured only at 36
weeks)6; 9% (before 28 weeks)7; 15% (at 34 – 36 weeks)8;
and 23.7% (at 31 – 34 weeks)9. Miller et al.10 reported that
Grade III placental calcification was found in 39.4% of
pregnant women at term.

Correspondence to: Dr K. H. Chen, Department of Obstetrics and Gynecology, Buddhist Tzu Chi General Hospital, Taipei Branch, No.
289, Jianguo Road, Xindian City, Taipei County, Taiwan (e-mail: alexgfctw@yahoo.com.tw)
Accepted: 14 June 2010

Copyright 2011 ISUOG. Published by John Wiley & Sons, Ltd. ORIGINALPAPER
Preterm placental calcification and pregnancy outcome
Figure 1 Ultrasound images of Grade III placental calcification
according to the Grannum classification, showing: (a) diffuse
echogenic lines along the basal plate representing prominent
calcification and (b) indentations of the chorionic plate, central
hypoechoic areas and irregular marginal echodensities with acoustic
shadowing.
Placental calcification is usually thought to represent a
physiological aging process3 – 5. Nevertheless, it can be a
pathological change resulting from the effects of
environmental factors on the placenta. Possible mechanisms
of tissue calcification involve physiological (similar to that of
bone), dystrophic (ischemia-related) or metastatic processes
(mineralization in a supersaturated environment)11. Previous
studies have shown that factors predisposing to placental
calcification include smoking5 ,6,8,12 – 14, low parity4,6,8,15
and young maternal age6,8,13, despite some disagreement
regarding the role of smoking in placental calcification16.
Alcohol consumption is not associated with placental
calcification6.
With regard to adverse pregnancy outcome, smoking is a
major risk factor for preterm delivery and low birth
weight17,18. Studies have also revealed that alcohol
consumption17 and young maternal age19 are risk factors for
poor birth outcome; however, the clinical significance of
placental calcification for pregnancy outcome remains
controversial. Many textbooks3 – 5 state that placental
calcification is believed to be of no clinical significance.
Copyright 2011 ISUOG. Published by John Wiley & Sons, Ltd.
329
Some studies, however, have observed that preterm placental
calcification has significant effects on fetal outcome.
There are discordant conclusions regarding the rela-tionship
between placental calcification and adverse preg-nancy
outcome. Some studies have reported that preterm placental
calcification is associated with a greater inci-dence of
–
intrauterine growth restriction6,9,20 22
, low birth
6,8,9,21 – 23 8 9
weight , low Apgar score , fetal distress , and
pregnancy-induced hypertension6,20,22,24, while other
studies have reported that preterm placental calcification is not
associated with a greater incidence of intrauter-ine growth
restriction10,16, low birth weight25, low Apgar score25 or
fetal distress26, and is of little value in predicting high-risk
pregnancy7. Conflicting conclusions drawn from these studies
using different instruments and different research designs are
confusing. However, the major prob-lem with previous studies
– except for that of McKenna et al.6 in 2005 – is that most of
them were carried out many years ago with ultrasound
equipment of poorer resolution than is currently available and
they involved relatively few participants, rendering their
conclusions questionable. Furthermore, the mediating effects
of poten-tial confounders such as cigarette smoking, diabetes
and hypertension were not considered in some studies, thus
some conclusions might be incorrect or misleading. More-
over, there is a paucity of research evaluating the effect of
preterm placental calcification on maternal outcome. We felt,
therefore, that it was important to clarify the relationship
between preterm placental calcification and pregnancy
outcome, including both maternal and fetal outcomes, by
including more participants and using newer instruments of
better resolution, with stricter selection criteria.
METHODS
Study design and participants
This prospective cohort study was conducted in a tertiary
hospital with an average of 200 or more deliveries per month.
The hospital provides routine obstetric clinics for the general
population of pregnant women and special obstetric clinics
(where a referral is needed) for high-risk pregnancies.
Pregnant women who are found to have antenatal
complications in the routine clinic, and those who are referred
from other hospitals because of antenatal complications, are
transferred to the special obstetric clinic for evaluation and
management of high-risk pregnancy. Between July 2007 and
June 2009, pregnant women without significant antenatal
complications were invited to participate in the study, and the
volunteers were screened with ultrasound for placental
calcification. Monthly ultrasound scans were performed
starting at 28 weeks’ gestation to establish the diagnosis of
preterm placental calcification. The first ultrasound
examination for the volunteers was done at between 28 and 32
weeks’ gestation and subsequent ultrasound examinations
were arranged once a month. All ultrasound examinations
were
Ultrasound Obstet Gynecol 2011; 37: 328–334.
330 Chen et al.

Women who underwent

antenatal examination in the
clinic, 2007–2009 (n  1049)

Women willing to
participate in the study
(n  862) 86 women excluded because of:
smoking; use of alcohol during
pregnancy; antenatal
complications e.g.
hypertension, diabetes,
significant anemia
Women who met
inclusion criteria: enrolled
participants (n  776)

Group 1: women with Group 2: women with Group 3: control group

early preterm placental late preterm placental (women without
calcification (noted at calcification (noted at placental calcification
28–32 weeks’ gestation) 32–36 weeks’ gestation) at 28–36 weeks’ gestation)
(n = 63) (n = 192) (n  521)

Figure 2 Flow chart for selection and grouping of the women in the study groups with placental calcification noted at different stages of pregnancy.

performed using a Voluson 730 machine (GE Medical
Systems, Zipf, Austria) equipped with a 2.8 – 10-MHz
transabdominal transducer, by one qualified obstetrician to
avoid interobserver bias, and all images were further reviewed
by another experienced obstetrician to ensure the accuracy of
the diagnosis.
Women were classified into one of three groups according
to the time when placental calcification was initially
confirmed: an early preterm placental calcification group
(Group 1, n = 63), in whom placental calcification was found
prior to 32 weeks’ gestation; a late preterm placental
calcification group (Group 2, n = 192), in whom placental
calcification was found at between 32 and 36 weeks’
gestation; and a control group (Group 3, n = 521), in whom
placental calcification was not seen between 28 and 36 weeks’
gestation (Figure 2).
Maternal outcomes evaluated included: postpartum
hemorrhage (a total of 500 mL or more of blood loss during
delivery), placental abruption and maternal transfer to the
intensive care unit. Fetal outcomes evaluated include: preterm
delivery (delivery before 37 weeks’ gestation), low birth
weight (< 2500 g), low Apgar score (< 7 at 5 min) and
neonatal death.
As mentioned above, smoking and alcohol consumption are
two important confounding factors in placental calcification
and pregnancy outcome, therefore women who smoked or
drank alcohol were excluded from the study. Also excluded
were women who had complications noted on prenatal
examination, such as chronic or pregnancy-induced
hypertension (including pre-eclampsia), severe anemia
(hemoglobin < 8 g/dL),
confirmed maternal thalassemia, placenta previa or diabetes
(either overt or gestational). In addition, multiple gestation is a
risk factor for preterm delivery or postpartum hemorrhage,
and any fetus with major congenital anomalies is at increased
risk of preterm delivery, low birth weight and poor neonatal
outcome. Therefore, pregnancies complicated by multiple
gestation or major congenital anomalies found on antenatal
examination were excluded from this study. Except for the
high-risk patients mentioned above, all pregnant women in the
routine obstetric clinic were asked to volunteer for the study if
they met the inclusion criteria. Participants were recruited by
means of survey rather than obstetrician’s preference (highly
selected samples) so as to avoid selection bias.
Basic information on the participants, including age, body
mass index, economic status, marital status, parity and past
medical history was obtained at the first antenatal visit.
Determination of gestational age was principally based on the
last menstrual period and validation of true gestational age
was confirmed by ultrasound measurement of fetal
development in early pregnancy. If there was a significant
discrepancy (> 1 week) between them, a further ultrasound
scan was arranged to determine the true gestational age. With
regard to economic status, ‘poor’ was defined as having a per
capita income of < 50% of the median according to the
definition of the European Union27. Ascertainment of
smoking or alcohol consumption during pregnancy,
identification of major congenital anomalies or placenta previa
by ultrasound and the diagnosis

Copyright 2011 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2011; 37: 328–334.
Preterm placental calcification and pregnancy outcome 331

of pregnancy-induced hypertension, pre-eclampsia and
gestational diabetes were made on subsequent visits at 12 – 28
weeks’ gestation. We recorded the condition of participants
and newborns at delivery, and followed the infants for 3
months after delivery. The study was approved by the ethics
committee of Tzu-Chi General Hospital, Taipei, Taiwan.
Data analysis
Data were collected and analyzed using SPSS 12.0 (SPSS
Inc., Chicago, IL, USA). The statistics used in this study
included descriptive statistics, chi-square test, loglinear
analysis (for expected numbers < 5) and ANOVA to compare
the differences in personal characteristics and the differences
in pregnancy outcome between the three groups. We
performed logistic regression analysis to estimate the risks of
adverse pregnancy outcomes associated with early and with
late preterm placental calcification in comparison with the
control group. The odds ratios (OR) with the 95% CIs for each
group were calculated and presented after adjusting for the
effects of maternal age, body mass index, economic status,
marital status, parity and type of delivery, on maternal and
fetal outcomes.
above – 63 women in Group 1, 192 in Group 2 and 521 in
Group 3. The demographic characteristics of the women are
shown in Table 1. The total numbers of divorced and widowed
women were both less than 10, and both were included in the
married category. There were no significant differences in
maternal age, body mass index, economic status, marital
status, parity and type of delivery among the three groups. In
all three groups, the majority of women were married and
nulliparous at presentation, had a vaginal delivery and, with
regard to economic status, were classified as ‘nonpoor’. In all
three groups the average maternal age was around 26 years
and the average body mass index was around 21 kg/m2.
There were notable differences in the distribution of Apgar
score at delivery (P < 0.01), gestational age at delivery (P <
0.001) and neonatal birth weight (P < 0.01) among the three
groups. The mean gestational age at delivery was 37.2, 38.6
and 38.6 weeks in Groups 1, 2 and 3, respectively, and the
mean birth weight was 3019.4, 3218.1 and 3198.6 g,
respectively. Posthoc examination of one-way analysis of
variance showed that fetuses of women in Group 1 had a
lower gestational age at delivery and a lower birth weight than
those in Groups 2 and 3.

RESULTS
Characteristics of participants
Seven hundred and seventy-six participants were enrolled in
the study, divided into the three groups mentioned
Outcome
Pregnancy outcomes in the three groups are listed in Table 2.
Maternal and fetal outcomes were compared by chi-square test
and loglinear analysis. Among these three groups, significant
differences were noted in

Table 1 Characteristics of the women in the three study groups

Group 1 Group 2 Group 3

Characteristic (n = 63) (n = 192) (n = 521) P

Economic status 0.233

Poor 12 (19.0) 32 (16.7) 67 (12.9)
Non-poor 51 (81.0) 160 (83.3) 454 (87.1)
Marital status 0.602
Unmarried 6 (9.5) 16 (8.3) 35 (6.7)
Married† 57 (90.5) 176 (91.7) 486 (93.3)
Parity 0.955
0 35 (55.6) 105 (54.7) 283 (54.3)
1 21 (33.3) 62 (32.3) 163 (31.3)
≥2 7 (11.1) 25 (13.0) 75 (14.4)
Type of delivery 0.657
Vaginal 41 (65.1) 127 (66.1) 360 (69.1)
Cesarean section 22 (34.9) 65 (33.9) 161 (30.9)
Apgar score at 5 min 0.001*
7 –10 57 (90.5) 189 (98.4) 513 (98.5)
4 –6 4 (6.3) 2 (1.0) 6 (1.2)
0 –3 2 (3.2) 1 (0.5) 2 (0.4)
Maternal age (years) 2 26.24 ± 2.23 26.78 ± 2.04 26.89 ± 2.03 0.060
Body mass index (kg/m ) 21.89 ± 1.54 21.58 ± 1.19 21.53 ± 1.09 0.063
Gestational age at delivery (weeks) 37.23 ± 1.93 38.57 ± 1.21 38.56 ± 1.19 < 0.001**
Birth weight (g) 3019.36 ± 577.39 3218.08 ± 418.45 3198.61 ± 431.08 0.006*
Data presented as n (%) or mean ± SD. Group 1, women with early preterm placental calcification (noted at 28–32 weeks’ gestation); Group 2, women
with late preterm placental calcification (noted at 32–36 weeks’ gestation); Group 3, controls, i.e. women with no placental calcification noted on
ultrasound at 28–36 weeks’ gestation. *P < 0.01, **P < 0.001: chi-square test for categorical factors of expected numbers > 5, loglinear analysis for
categorical factors of expected numbers < 5 and one-way analysis of variance for continuous factors. †Including divorced and widowed.

Copyright 2011 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2011; 37: 328–334.
332 Chen et al.

maternal outcomes including postpartum hemorrhage (P <
0.05), placental abruption (P < 0.01) and maternal transfer to
the intensive care unit (ICU) (P < 0.01). Significant
differences were also noted in fetal outcomes including
preterm birth (P < 0.01), low birth weight (P < 0.001), low
Apgar score (P < 0.01) and neonatal death (P < 0.05).
Further analysis was performed by logistic regression to
compare the differences in pregnancy outcomes among the
three groups, adjusted by maternal age, body mass index,
economic status, marital status, type of delivery and
parity (Table 3). The risks of adverse maternal outcome were
much greater in Group 1 than in Group 3. These adverse
outcomes included postpartum hemorrhage (OR, 3.43; 95%
CI, 1.251 – 9.388), placental abruption (OR,
6.52; 95% CI, 1.356 – 31.382) and maternal transfer to the
ICU (OR, 9.76; 95% CI, 1.826 – 52.195). Similarly, the risks
of adverse fetal outcome, including preterm birth (OR, 4.20;
95% CI, 1.775 – 9.940), low birth weight (OR, 4.58; 95% CI,
2.201 – 9.522), low Apgar score (OR, 6.53; 95% CI, 2.116 –
20.142) and neonatal death (OR, 9.04; 95% CI, 1.722 –
47.411) were also greater in Group 1. In

Table 2 Pregnancy outcomes of the women in the three study groups

Outcome Group 1 Group 2 Group 3 P

Maternal outcome
Postpartum hemorrhage 0.047*
Yes 6 (9.5) 5 (2.6) 15 (2.9)
No 57 (90.5) 187 (97.4) 506 (97.1)
Placental abruption 0.007**
Yes 4 (6.3) 1 (0.5) 3 (0.6)
No 59 (93.7) 191 (99.5) 518 (99.4)
Maternal transfer to ICU 0.004**
Yes 4 (6.3) 1 (0.5) 2 (0.4)
No 59 (93.7) 191 (99.5) 519 (99.6)
Fetal outcome
Preterm birth 0.007**
Yes 9 (14.3) 7 (3.6) 20 (3.8)
No 54 (85.7) 185 (96.4) 501 (96.2)
Low birth weight < 0.001***
Yes 14 (22.2) 9 (4.7) 30 (5.8)
No 49 (77.8) 183 (95.3) 491 (94.2)
Low Apgar score† 0.006**
Yes 6 (9.5) 3 (1.6) 8 (1.5)
No 57 (90.5) 189 (98.4) 513 (98.5)
Neonatal death 0.024*
Yes 3 (4.8) 1 (0.5) 2 (0.4)
No 60 (95.2) 191 (99.5) 519 (99.6)

Data presented as n (%). Group 1, women with early preterm placental calcification (noted at 28–32 weeks’ gestation); Group 2, women with late
preterm placental calcification (noted at 32–36 weeks’ gestation); Group 3, controls, i.e. women with no placental calcification noted on ultrasound at
28–36 weeks’ gestation. *P < 0.05, **P < 0.01, ***P < 0.001: chi-square test for categorical factors of expected numbers > 5, loglinear analysis for
categorical factors of expected numbers < 5. †Score < 7 at 5 min. ICU, intensive care unit.

Table 3 Odds ratios for comparison of adverse pregnancy outcome in the study groups

Odds ratio (95% CI)

Outcome Group 1 Group 2

Maternal outcome
Postpartum hemorrhage 3.43 (1.251–9.388)* 0.90 (0.322 –2.514)
Placental abruption 6.52 (1.356–31.382)** 0.72 (0.078 –6.511)
Maternal transfer to ICU 9.76 (1.826–52.195)** 0.96 (0.098 –9.341)
Fetal outcome
Preterm birth 4.20 (1.775–9.940)** 0.95 (0.392 –2.290)
Low birth weight 4.58 (2.201–9.522)*** 0.80 (0.371 –1.735)
Low Apgar score† 6.53 (2.116–20.142)** 1.02 (0.200 –3.915)
Neonatal death 9.04 (1.722–47.411)** 1.87 (0.308 –11.396)

Group 1, women with early preterm placental calcification (noted at 28–32 weeks’ gestation); Group 2, women with late preterm placental calcification
(noted at 32–36 weeks’ gestation). Odds ratios compared to control group (women with no placental calcification noted on ultrasound at 28–36 weeks’
gestation), calculated by logistic regression analysis and adjusted by maternal age, body mass index, economic status, marital status, type of delivery and
parity. *P < 0.05, **P < 0.01, ***P < 0.001. †Score < 7 at 5 min. ICU, intensive care unit.

Copyright 2011 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2011; 37: 328–334.
Preterm placental calcification and pregnancy outcome
contrast, there were no statistically significant differences in
adverse maternal or fetal outcomes between Groups 2 and 3.
DISCUSSION
The results of this study reveal that pregnant women with
early preterm placental calcification (noted before 32 weeks’
gestation) had a higher incidence of adverse maternal outcome
including postpartum hemorrhage, placental abruption and
maternal transfer to the ICU, and a higher incidence of
adverse fetal outcome including preterm birth, low birth
weight, low Apgar score and neonatal death. In contrast, the
incidence of adverse maternal and fetal outcomes was no
greater in the group with late preterm placental calcification
(noted between 32 and 36 weeks’ gestation) than in the
control group. In other words, isolated early preterm placental
calcification noted on ultrasound is a risk factor for adverse
pregnancy outcome, even in the absence of other risk factors
such as cigarette smoking, alcohol consumption, diabetes or
hypertension. Conversely, women with late preterm placental
calcification are not at greater risk for adverse maternal and
fetal outcomes. These findings may help to identify the at-risk
pregnancy and to provide information for counseling.
Pregnant women with early preterm placental calcification
may be warned about the greater risk to both mother and fetus,
and may require closer surveillance for fetal wellbeing.
Vintzileos and Tsapanos28 proposed adding placental
grading as a component of the biophysical profile for the
evaluation of fetal wellbeing. In their scoring system, a
finding of Grade III placenta would have the lowest score (0).
This is equivocal since many researchers regard placental
calcification as an aging process rather than a pathological
change. Our results also indicate that only ‘isolated early
preterm placental calcification’ may play a role in adverse
pregnancy outcome. Late preterm placental calcification is not
associated with adverse pregnancy outcome. We favor not
including placental grading as a part of the biophysical profile
at present unless there is a distinct description of the different
stages of placental calcification in the profile.
As mentioned above, cigarette smoking can be a causative
factor for both significant placental calcification and adverse
fetal outcome such as low birth weight. Nevertheless, our
study suggests that early preterm placental calcification
without a history of smoking is a predictor of adverse
pregnancy outcome. This implies that there may exist some
unknown factor(s) predisposing to early preterm placental
calcification and subsequent adverse outcome. Although some
researchers have proposed that occult nanobacterial infection
of the placenta might be responsible for preterm placental
calcification29, the true mechanism remains unclear. The
serial changes are supposed to be gradual occlusion of vessels
by deposition of calcium and fibrin (notable on ultrasound),
which impairs placental function and eventually results in
poorer pregnancy outcomes30. The
Copyright 2011 ISUOG. Published by John Wiley & Sons, Ltd.
333
action appears to be time-dependent because late preterm
placental calcification is not related to adverse pregnancy
outcome. Hence, placental calcification is not only an aging
progress, but is also a reflection of underlying placental
dysfunction when it is noted in earlier stages of pregnancy.
More attention should be paid to women with early preterm
placental calcification even if the pregnancy is regarded as
normal, in the absence of risk factors such as smoking, alcohol
consumption, hypertension or diabetes. In these women with
early preterm placental calcification, closer antepartum
surveillance may be considered for the evaluation of fetal
wellbeing. In addition, these women should be closely
monitored and well prepared during delivery because of their
increased risk for maternal complications.
Our study has some limitations. First, we recruited
participants who received care in a large hospital. Applying
the conclusions to small hospitals or local clinics is not
necessarily valid because of questionable external validity.
Second, some characteristics of the pregnant women,
including race and educational status, were not considered in
our study. These factors may affect the results. Finally,
because this was a longitudinal study, we could not
completely control for changes in medical policies and some
factors that vary with time. A longer follow-up investigation
may overcome this problem and provide more reliable results.
ACKNOWLEDGMENTS
We are particularly grateful to the postpartum women who
participated in the study. This research was supported by a
grant from Buddhist Tzu Chi General Hospital, Taipei Branch,
Taiwan (TCRD-TPE-96-35).
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