Skip to main content Accessibility help
×
Hostname: page-component-848d4c4894-sjtt6 Total loading time: 0 Render date: 2024-06-14T07:01:33.710Z Has data issue: false hasContentIssue false

Chapter 20 - Placental Pathology and the Etiology of Fetal and Neonatal Brain Injury

from Section 3 - Diagnosis of the Infant with Brain Injury

Published online by Cambridge University Press:  13 December 2017

David K. Stevenson
Affiliation:
Stanford University, California
William E. Benitz
Affiliation:
Stanford University, California
Philip Sunshine
Affiliation:
Stanford University, California
Susan R. Hintz
Affiliation:
Stanford University, California
Maurice L. Druzin
Affiliation:
Stanford University, California
Get access

Summary

Image of the first page of this content. For PDF version, please use the ‘Save PDF’ preceeding this image.'
Type
Chapter
Information
Publisher: Cambridge University Press
Print publication year: 2017

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Lakshmanan, J, Ross, MG. Mechanism(s) of in utero meconium passage. J Perinatol 2008; 28(Suppl 3): S813.CrossRefGoogle ScholarPubMed
Miller, PW, Coen, RW, Benirschke, K. Dating the time interval from meconium passage to birth. Obstet Gynecol 1985; 66: 459–62.Google Scholar
Incerti, M, Locatelli, A, Consonni, S, et al. Can placental histology establish the timing of meconium passage during labor? Acta Obstet Gynecol Scand 2011; 90: 863–8.CrossRefGoogle ScholarPubMed
Sepulveda, WH, Gonzalez, C, Cruz, MA, et al. Vasoconstrictive effect of bile acids on isolated human placental chorionic veins. Eur J Obstet Gynecol 1995; 173: 1075–8.Google Scholar
Holcberg, G, Huleihel, M, Katz, M, et al. Vasoconstrictive activity of meconium stained amniotic fluid in the human placental vasculature. Eur J Obstet Gynecol Reprod Biol 1999; 87: 147–50.CrossRefGoogle ScholarPubMed
King, EL, Redline, RW, Smith, SD, et al. Myocytes of chorionic vessels from placentas with meconium-associated vascular necrosis exhibit apoptotic markers. Hum Pathol 2004; 35: 412–17.Google Scholar
Holcberg, G, Sapir, O, Huleihel, M, et al. Vasoconstrictive activity of oxytocin in meconium impregnated human placentas. Eur J Obstet Gynecol Reprod Biol 2002; 101: 139–42.Google Scholar
Cimic, A, Baergen, R. Meconium-associated umbilical vascular myonecrosis: correlations with adverse outcome. Pediatr Dev Pathol 2016; 19(4): 315–9.Google Scholar
Altshuler, G, Hyde, S. Meconium-induced vasocontraction: a potential cause of cerebral and other fetal hypoperfusion and of poor pregnancy outcome. J Child Neurol 1989; 4: 137–42.Google Scholar
Altshuler, G, Arizawa, M, Molnar-Nadasy, G. Meconium-induced umbilical cord vascular necrosis and ulceration: a potential link between the placenta and poor outcome. Obstet Gynecol 1992; 79: 760–6.Google Scholar
Locatelli, A, Regalia, AL, Patregnani, C, et al. Prognostic value of change in amniotic fluid color curing labor. Fetal Diagn Ther 2005; 20: 59.Google Scholar
Sheiner, E, Hadar, A, Shoham-Vardi, I. The effect of meconium on perinatal outcome: a prospective analysis. J Matern Fetal Neonat Med 2002; 11: 54–9.CrossRefGoogle ScholarPubMed
De Beaufort, AJ, Pelikan, DMV, Elferink, JGR, et al. Effect of interleukin 8 in meconium on in vitro neutrophil chemotaxis. Lancet 1998; 352: 102–5.Google Scholar
Burgess, AM, Hutchins, GM. Inflammation of the lungs, umbilical cord and placenta associated with meconium passage in utero. Pathol Res Pract 1996; 192: 1121–8.Google Scholar
Yamada, T, Minakami, H, Matsubara, S, et al. Meconium-stained amniotic fluid exhibits chemotactic activity for polymorphonuclear leukocytes in vitro. J Reprod Immunol 2000; 46: 2130.Google Scholar
Ferber, A, Minior, VK, Bornstein, E, et al. Fetal “nonreassuring status” is associated with elevation of nucleated red blood cell counts and interleukin-6. Am J Obstet Gynecol 2005; 192: 1427–9.Google Scholar
Dulay, AT, Buhimschi, IA, Zhao, G, et al. Nucleated red blood cells are a direct response to mediators of inflammation in newborns with early-onset neonatal sepsis. Am J Obstet Gynecol 2008; 198: 426.Google Scholar
Ferber, A, Minior, VK, Bornstein, E, et al. Fetal “nonreassuring status” is associated with elevation of nucleated red blood cell counts and interleukin-6. J Obstet Gynecol 2005; 192: 1427–9.CrossRefGoogle ScholarPubMed
Ferber, A, Fridel, Z, Weissmann-Brenner, A, et al. Are elevated nucleated red blood cell counts an indirect reflection of enhanced erythropoietin activity? Am J Obstet Gynecol 2004; 190: 1473–5.Google Scholar
Maier, RF, Gunther, A, Vogel, M, et al. Umbilical venous erythropoietin and umbilical arterial pH in relation to morphologic placental abnormalities. Obstet Gynecol 1994; 84: 81–7.Google Scholar
Hermansen, MC. Nucleated red blood cells in the fetus and newborn. Arch Dis Child Fetal Neonatal Ed 2001; 84: F211–15.Google Scholar
Silva, AM, Smith, RN, Lehmann, CU, et al. Neonatal nucleated red blood cells and the prediction of cerebral white matter injury in preterm infants. Obstet Gynecol 2006; 107: 550–6.CrossRefGoogle ScholarPubMed
Phelan, JP, Korst, LM, Ahn, MO, et al. Neonatal nucleated red blood cell and lymphocyte counts in fetal brain injury. Obstet Gynecol 1998; 91: 485–9.Google Scholar
Korst, LM, Phelan, JP, Ahn, MO, et al. Nucleated red blood cells: an update in the marker for fetal asphyxia. Am J Obstet Gynecol 1996; 175: 843–6.Google Scholar
Phelan, JP, Ahn, MO, Korst, LM, et al. Nucleated red blood cells: a marker for fetal asphyxia? Am J Obstet Gynecol 1995; 173: 1380–4.Google Scholar
Axt-Fliedner, R, Hendrik, HJ, Schmidt, W. Nucleated red blood cell counts in growth-restricted neonates with absent or reversed-end-diastolic umbilical artery velocity. Clin Exp Obstet Gynecol 2002; 29: 242–6.Google ScholarPubMed
McCarthy, JM, Capullari, T, Thompson, Z, et al. Umbilical nucleated red blood cell counts: normal values and the effect of labor. J Perinatol 2006; 26: 8992.Google Scholar
Redline, RW, O’Riordan, A. Placental lesions associated with cerebral palsy and neurologic impairment following term birth. Arch Pathol Lab Med 2000; 124: 1785–91.CrossRefGoogle ScholarPubMed
Manegold, G, Meyer-Monard, S, Tichelli, A, et al. Cesarean section due to fetal distress increases the number of stem cells in umbilical cord blood. Transfusion 2008; 48: 871–6.CrossRefGoogle ScholarPubMed
Baschat, AA, Gungor, S, Kush, ML, et al. Nucleated red blood cell counts in the first week of life: a critical appraisal of relationships with perinatal outcome in preterm growth-restricted neonates. Am J Obstet Gynecol 2007; 197(286): e18.Google Scholar
Buonocore, G, Perrone, S, Gioia, D, et al. Nucleated red blood cell count at birth as an index of perinatal brain damage. Am J Obstet Gynecol 1999; 181: 1500–5.Google Scholar
Ghosh, B, Mittal, S, Kumar, S, et al. Prediction of perinatal asphyxia with nucleated red blood cells in cord blood of newborns. Int J Gynaecol Obstet 2003; 81: 267–71.Google Scholar
Hanion-Lundberg, KM, Kirby, RS, Gandhi, S, et al. Nucleated red blood cells in cord blood of singleton term neonates. Am J Obstet Gynecol 1997; 176: 1149–54.Google Scholar
Hebbar, S, Misha, M, Rai, L. Significance of maternal and cord blood nucleated red blood cell count in pregnancies complicated by preeclampsia. J Pregnancy 2014; 496416.Google Scholar
Hamrick, SE, Miller, SP, Newton, NR, et al. Neonatal red blood cell counts: not associated with brain injury or outcome. Pediatr Neurol 2003; 29: 278–83.Google Scholar
Li, J, Kobata, K, Kamei, Y, et al. Nucleated red blood cell counts: an early predictor of brain injury and 2-year outcome in neonates with hypoxic-ischemic encephalopathy in the era of cooling-based treatment. Brain Dev 2014; 36: 472–8.Google Scholar
Walsh, BH, Boylan, GB, Murray, DM. Nucleated red blood cells and early EEG: predicting Sarnat stage and two year outcome. Early Hum Dev 2011; 87: 335–9.CrossRefGoogle ScholarPubMed
Christensen, RD, Henry, E, Andres, RL, et al. Reference ranges for blood concentrations of nucleated red blood cells in neonates. Neonatology 2011; 99: 289–94.Google Scholar
Phelan, JP, Ahn, MO, Korst, L, et al. Intrapartum asphyxial brain injury with absent multiorgan system dysfunction. J Matern Fetal Med 1998; 7: 1922.Google Scholar
Benirschke, K. The use of the placenta in the understanding of perinatal injury. In Donn, SM, Fisher, CW, eds., Risk Management Techniques in Perinatal and Neonatal Practice. Armonk, NY: Futura, 1996: 325–45.Google Scholar
Grafe, MR. The correlation of prenatal brain damage with placental pathology. J Neuropathol Exp Neurol 1994; 53: 407–15.Google Scholar
Baergen, RN. Manual of Benirschke and Kaufmann’s Pathology of the Human Placenta. New York: Springer, 2005.Google Scholar
Benirschke, K, Kaufmann, P, Baergen, RN. Pathology of the Human Placenta, 32nd edn. New York: Springer, 2006.Google Scholar
Miller, ME, Higginbottom, M, Smith, DA. Short umbilical cord: its origin and relevance. Pediatrics 1981; 67: 618–21.Google Scholar
Kumazaki, K, Nakayama, M, Sumida, Y, et al. Placental features in preterm infants with periventricular leukomalacia. Pediatrics 2002; 109: 650–5.Google Scholar
Chasen, ST, Baergen, RN. Necrotizing funisitis with intrapartum umbilical cord rupture. J Perinatol 1999; 19: 325–6.Google Scholar
Altshuler, G, Arizawa, M, Molnar-Nadasdy, G. Meconium induced umbilical cord vascular necrosis and ulceration: a potential link between the placenta and poor pregnancy outcome. Obstet Gynecol 1992; 79: 760–6.Google ScholarPubMed
Santamaria, M, Benirschke, K, Carpenter, PM, et al. Transplacental hemorrhage associated with placental neoplasms. Pediatr Pathol 1987; 7: 601–15.Google Scholar
Karsidag, ATK, Kars, B, Dansuk, R, et al. Brain damage to the survivor within 30 minutes of co-twin demise in monochorionic twins. Fetal Diagn Ther 2005; 20: 91–5.Google Scholar
Spellancy, WN, Gravem, H, Fisch, RO. The umbilical cord complications of true knots, nuchal coils and cords around the body: a report from the collaborative study of cerebral palsy. Am J Obstet Gynecol 1966; 94: 1136–42.Google Scholar
Baergen, RN, Malicki, D, Behling, C, et al. Morbidity, mortality, and placental pathology in excessively long umbilical cords: retrospective study. Pediatr Dev Pathol 2001; 4: 144–53.CrossRefGoogle ScholarPubMed
Spinillo, A, Cesari, S, Bariselli, S, et al. Placental lesions associated with oligohydramnios in fetal growth restricted (FGR) pregnancies. Placenta 2015; 36: 538–44.Google Scholar
Machin, GA, Ackerman, J, Gilbert-Barness, E. Abnormal umbilical cord coiling is associated with adverse perinatal outcomes. Pediatr Dev Pathol 2000; 3: 462–71.CrossRefGoogle ScholarPubMed
Redline, RW. Clinical and pathological umbilical cord abnormalities in fetal thrombotic vasculopathy. Hum Pathol 2004; 35: 1494–8.CrossRefGoogle ScholarPubMed
Peng, HQ, Levitin-Smith, M, Rochelson, B, et al. Umbilical cord stricture and overcoiling are common causes of fetal demise. Pediatr Dev Pathol 2006; 9: 1419.CrossRefGoogle ScholarPubMed
Murphy, DJ, MacKenzie, IZ. The mortality and morbidity associated with umbilical cord prolapse. Br J Obstet Gynaecol 1995; 102: 826–30.Google Scholar
Ikeda, T, Murata, Y, Quilligan, EJ, et al. Physiologic and histologic changes in near-term fetal lambs exposed to asphyxia by partial umbilical cord occlusion. Am J Obstet Gynecol 1998; 178: 2432.Google Scholar
Kraus, FT, Acheen, VI. Fetal thrombotic vasculopathy in the placenta: cerebral thrombi and infarcts, coagulopathies and cerebral palsy. Hum Pathol 1999; 30: 759–69.Google Scholar
Heifetz, SA. Thrombosis of the umbilical cord: analysis of 52 cases and literature review. Pediatr Pathol 1988; 8: 3754.CrossRefGoogle ScholarPubMed
Kalish, RB, Hunter, T, Sharma, G, et al. Clinical significance of the umbilical cord twist. Am J Obstet Gynecol 2003; 189: 736–9.Google Scholar
Strong, TH, Elliott, JP, Radin, TR. Non-coiled umbilical blood vessels: a new marker for the fetus at risk. Obstet Gynecol 1993; 81: 409–11.Google Scholar
Benirschke, K. Obstetrically important lesions of the umbilical cord. J Reprod Med 1994; 39: 6272.Google Scholar
de Laat, MWM, van Alderen, ED, Franx, A, et al. The umbilical coiling index in complicated pregnancy. Eur J Obstet Gynecol Reprod Biol 2007; 130: 6672.Google Scholar
Heifetz, SA. The umbilical cord: obstetrically important lesions. Clin Obstet Gynecol 1996; 39: 7187.Google Scholar
Hersh, J, Buchino, JJ. Umbilical cord torsion/constriction sequence. In Saul, RA, ed., Proceedings of the Greenwood Genetics Conference, vol. 7. Clinton, SC: Jacobs Press, 1988: 181–2.Google Scholar
Gardiner, JP. The umbilical cord: normal length; length in cord complications; etiology and frequency of coiling. Surg Gynecol Obstet 1922; 34: 252–6.Google Scholar
Snider, W. Placental pathology casebook. J Perinatol 1997; 17: 327–9.Google Scholar
Naeye, RL, Tafari, N. Noninfectious disorders of the placenta, fetal membranes and umbilical cord. In Naeye, RL, Tafari, N, eds., Risk Factors in Pregnancy and Disease of the Fetus and Newborn. Baltimore: Williams & Wilkins, 1983: 145–72.Google Scholar
Moessinger, AC, Blanc, WA, Marone, PA, et al. Umbilical cord length as an index of fetal activity: experimental study and clinical implications. Pediatr Res 1982; 16: 109–12.Google Scholar
Boué, DR, Stanley, C, Baergen, RN. Placental pathology casebook. J Perinatol 1995; 15: 429–31.Google Scholar
Faye-Petersen, O, Baergen, RN. Long umbilical cords and pre-viable fetal death. Pediatr Dev Pathol 2001; 4: 414.Google Scholar
Gilbert-Barness, E, Drut, RM, Drut, R, et al. Developmental abnormalities resulting in short umbilical cord. Birth Defects Original Article Series 1993; 29: 113–40.Google Scholar
Collins, JC. Umbilical cord accidents: human studies. Semin Perinatol 2002; 26: 7982.Google Scholar
Soernes, T. Umbilical cord encirclements and fetal growth restriction. Obstet Gynecol 1995; 86: 725–8.Google Scholar
Vanhaesebrouck, P, Vanneste, K, de Praeter, C, et al. Tight nuchal cord and neonatal hypovolemic shock. Arch Dis Child 1987; 62: 1276–7.Google Scholar
Nelson, KB, Grether, JK. Potentially asphyxiating conditions and spastic cerebral palsy in infants of normal birth weight. Am J Obstet Gynecol 1998; 179: 507–13.Google Scholar
Lin, MG. Umbilical cord prolapse. Obstet Gynecol Surv 2006; 61: 269–77.Google Scholar
Torrey, WE. Vasa previa. Am J Obstet Gynecol 1952; 63: 146–52.Google Scholar
Heinonen, S, Ryynänen, M, Kirkinen, P, et al. Perinatal diagnostic evaluation of velamentous umbilical cord insertion: clinical, Doppler, and ultrasonic findings. Obstet Gynecol 1996; 87: 112–17.Google Scholar
Cordero, DR, Helfgott, AW, Landy, HJ, et al. A non-hemorrhagic manifestation of vasa previa: a clinicopathologic case report. Obstet Gynecol 1993; 82: 698700.Google Scholar
Redline, RW, Ariel, I, Baergen, RN, et al. Fetal vascular obstructive lesions: nosology and reproducibility of placental reaction patterns. Pediatr Dev Pathol 2004; 7: 443–52.Google Scholar
Sander, CM, Gilliland, D, Akers, C, et al. Livebirths with placental hemorrhagic endovasculitis: interlesional relationships and perinatal outcomes. Arch Pathol Lab Med 2002; 126: 157–64.Google Scholar
Redline, RW. Severe fetal placental vascular lesions in term infants with neurologic impairment. Am J Obstet Gynecol 2005; 192: 452–7.Google Scholar
Bejar, RF, Wozniak, P, Allard, M, et al. Antenatal origin of neurologic damage in newborn infants. I. Preterm infants. Am J Obstet Gynecol 1988; 159: 357–63.Google Scholar
Redline, RW, Wilson-Costello, D, Borawski, E, et al. The relationship between placental and other perinatal risk factors for neurologic impairment in very low birth weight children. Pediatr Res 2000; 47: 721–6.Google Scholar
Redline, RW, Boyd, T, Campbell, V, et al. Maternal vascular malperfusion: nosology and reproducibility of placental reaction patterns. Pediatr Dev Pathol 2004; 7: 237–49.Google Scholar
Burke, CJ, Tannenberg, AE, Payton, DJ. Ischaemic cerebral injury, intrauterine growth retardation, and placental infarction. Dev Med Child Neurol 1997; 39: 726–30.Google Scholar
Redline, RW, Wilson-Costello, D, Borawski, E, et al. Placental lesions associated with neurologic impairment and cerebral palsy in very low-birth-weight infants. Arch Pathol Lab Med 1998; 122: 1091–8.Google Scholar
Parra-Saavedra, M, Simeone, S, Triunfo, S, et al. Correlation between histological signs of placental underperfusion and perinatal morbidity in late-onset small-for-gestational-age fetuses. Ultrasound Obstet Gynecol 2015; 45: 149–55.Google Scholar
Ananth, CV, Friedman, AM. Ischemic placental disease and risks of perinatal mortality and morbidity and neurodevelopmental outcomes. Semin Perinatol 2014; 38: 151–8.Google Scholar
Redline, RW. Villitis of unknown etiology: noninfectious chronic villitis in the placenta. Hum Pathol 2007; 38: 1439–46.Google Scholar
Bendon, RW, Hommel, AB. Maternal floor infarction in autoimmune disease: two cases. Pediatr Pathol Lab Med 1996; 16: 293–7.CrossRefGoogle ScholarPubMed
Sebire, NJ, Backos, M, Goldin, RD, et al. Placental massive perivillous fibrin deposition associated with antiphospholipid syndrome. BJOG 2002; 109: 570–3.Google Scholar
Katzman, PJ, Genest, DR. Maternal floor infarction and massive previllous fibrin deposition: histological definitions, association with intrauterine fetal growth restriction, and risk of recurrence. Pediatr Dev Pathol 2002; 5: 159–64.Google Scholar
Chang, P, Miller, D, Tsang, P, et al. Intravenous immunoglobulin in antiphospholipid syndrome and maternal floor infarction when standard treatment fails: a case report. Am J Perinatol 2006; 23: 125–9.Google Scholar
Makino, A, Suzuki, Y, Yamamoto, T, et al. Use of aspirin and low-molecular-weight heparin to prevent recurrence of maternal floor infarction in women without evidence of antiphospholipid antibody syndrome. Fetal Diagn Ther 2004; 19: 261–5.Google Scholar
Chang, P, Millar, D, Tsang, P, et al. Intravenous immunoglobulin in antiphospholipid syndrome and maternal floor infarction when standard treatment fails. Am J Perinatol 2006; 23: 125–9.Google Scholar
Kim, CJ, Romero, R, Chaemsaithong, P, et al. Chronic inflammation of the placenta: definition, classification, pathogenesis, and clinical significance. Am J Obstet Gynecol 2015; 213(4 Suppl): S5369.CrossRefGoogle ScholarPubMed
Rudzinski, E, Gilroy, M, Newbill, C, et al. Positive C4d immunostaining of placental villous syncytiotrophoblasts supports host-versus-graft rejection in villitis of unknown etiology. Pediatr Dev Pathol 2013; 16: 713.Google Scholar
Redline, RW, O’Riordan, MA. Placental lesions associated with cerebral palsy and neurologic impairment following term birth. Arch Pathol Lab Med 2000; 124: 1785–91.Google Scholar
Scher, MS, Trucco, GS, Beggarly, ME, et al. Neonates with electrically confirmed seizures and possible placental associations. Pediatr Neurol 1998; 19: 3741.Google Scholar
Mir, IN, Johnson-Welch, SF, Nelson, DB, et al. Placental pathology is associated with severity of neonatal encephalopathy and adverse developmental outcomes following hypothermia. Am J Obstet Gynecol 2015; 213:849.e17.Google Scholar
Lee, J, Romero, R, Chaiworapongsa, T, et al. Characterization of the fetal blood transcriptome and proteome in maternal anti-fetal rejection: evidence of a distinct and novel type of human fetal systemic inflammatory response. Am J Reprod Immunol 2013 Oct; 70: 265–84.Google Scholar
Adams-Chapman, I, Vaucher, YE, Bejar, RF, et al. Maternal floor infarction of the placenta: association with central nervous system injury and adverse neurodevelopmental outcome. J Perinatol 2002; 22: 236–41.Google Scholar
Andres, RL, Kuyper, W, Resnik, R, et al. The association of maternal floor infarction of the placenta with adverse perinatal outcome. Am J Obstet Gynecol 1990; 163: 935–8.Google Scholar
Heller, D, Tellier, R, Pabbaraju, K, et al. Placental massive perivillous fibrinoid deposition associated with coxsackievirus A16: report of a case and review of the literature. Pediatr Dev Pathol 2016; 19(5): 421–3.Google Scholar
Romero, R, Whitten, A, Korzeniewski, SJ, et al. Maternal floor infarction/massive perivillous fibrin deposition: a manifestation of maternal antifetal rejection? Am J Reprod Immunol 2013; 70: 285–98.Google Scholar
Linn, RL, Kiley, J, Minturn, L, et al. Recurrent massive perivillous fibrin deposition in the placenta associated with fetal renal tubular dysgenesis: case report and literature review. Pediatr Dev Pathol 2013; 16: 378–86.Google Scholar
Al-Adnani, M, Kiho, L, Scheimberg, I, et al. Recurrent placental massive perivillous fibrin deposition associated with polymyositis: a case report and review of the literature. Pediatr Dev Pathol 2008; 11: 226–9.CrossRefGoogle ScholarPubMed
Griffin, AC, Strauss, AW, Bennett, MJ, et al. Mutations in long-chain 3-hydroxyacyl coenzyme a dehydrogenase are associated with placental maternal floor infarction/massive perivillous fibrin deposition. Pediatr Dev Pathol 2012; 15: 368–74.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×