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Stanek J. CD34 immunostain increases the sensitivity of placental examination for distal fetal vascular malperfusion in liveborn infants. Placenta 2023; 140:117-124. [PMID: 37573725 DOI: 10.1016/j.placenta.2023.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Placental fetal vascular malperfusion (FVM) is associated with increased perinatal morbidity and mortality. This retrospective observational analysis was performed to compare the impact of large proximal vessel (global) FVM, established/remote distal villous FVM, and recent (acute) FVM diagnosed by clustered endothelial fragmentation by CD34 immunostaining, on clinical and other placental phenotypes. METHODS Clinical and placental phenotypes of 581 consecutive high-risk pregnancies with a live birth divided in five groups based on presence and type of FVM were analyzed. CD34 immunostaining was performed on all cases to refine the diagnosis of FVM. The statistical analysis was by ANOVA and Chi square. RESULTS FVM was present in 88% of placentas from pregnancies dominated by congenital anomalies. 43% of those had global FVM (partial, large proximal vessel) without distal villous changes, either acute (endothelial fragmentation) or established (avascular villi). Acute distal villous FVM without avascular villi did not link with significant perinatal morbidity/mortality, likely because of its short duration. Established distal villous FVM with active endothelial fragmentation, labelled as FVM with temporal heterogeneity, is associated with preterm births, preeclampsia, abnormal Dopplers, fetal growth restriction, highest cesarean section rate, and high grade FVM, particularly the latter. DISCUSSION Lesions of global FVM are common, featuring relatively low sensitivity for perinatal complications. Caution is indicated in assigning significance to isolated lesions such as fetal vascular ectasia, intramural fibrin deposition and stem vessel obliteration. Established and on-going FVM diagnosed by using CD34 immunostain, is much more significant and portends the most complicated perinatal outcomes.
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Affiliation(s)
- Jerzy Stanek
- Division of Pathology, Cincinnati Children's Hospital Medical Center, 3333 Burnett Avenue, Cincinnati, OH, 45229, USA.
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2
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Sekiguchi M, Mukai T, Shitara Y, Kashima K, Seyama T, Kumasawa K, Takahashi N. Case report: A case of fetal umbilical vein varix presenting disseminated intravascular coagulation, polycythemia, and neonatal hepatitis in an extremely low birth weight infant. Front Pediatr 2023; 11:1154820. [PMID: 37063663 PMCID: PMC10098078 DOI: 10.3389/fped.2023.1154820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/14/2023] [Indexed: 04/18/2023] Open
Abstract
Reports on the clinical course of fetal umbilical vein varix in premature infants are limited. We report a case of an extremely low body weight infant with intra-abdominal umbilical vein varix who developed disseminated intravascular coagulation, polycythemia, and hyperbilirubinemia after birth; late-onset neonatal hepatitis; and fetal thrombotic vasculopathy confirmed by placental histopathology. Ultrasonography after birth showed a dilated portion of the umbilical vein at the hepatic hilum with thrombi inside. We speculate that the umbilical vein varix caused the fetal thrombotic vasculopathy, and the presence of umbilical vein varix and fetal thrombotic vasculopathy in combination with prematurity caused coagulopathy, polycythemia, hyperbilirubinemia, and hepatitis. Despite the favorable outcomes reported in the literature, premature infants with umbilical vein varix may require careful observation and management for coagulopathy and late-onset hepatitis. Furthermore, placental histopathology could aid in the understanding of various clinical outcomes in infants with umbilical vein varices.
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Affiliation(s)
- Mariko Sekiguchi
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Takeo Mukai
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
- Correspondence: Takeo Mukai
| | - Yoshihiko Shitara
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Kohei Kashima
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Takahiro Seyama
- Department of Obstetrics and Gynecology, The University of Tokyo Hospital, Tokyo, Japan
| | - Keiichi Kumasawa
- Department of Obstetrics and Gynecology, The University of Tokyo Hospital, Tokyo, Japan
| | - Naoto Takahashi
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
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3
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Tieu P, Paes B, Ahmed A, Matino D, Chan A, Bhatt M. Inferior vena cava syndrome in neonates: An evidence-based systematic review of the literature. Pediatr Blood Cancer 2020; 67:e28114. [PMID: 31876366 DOI: 10.1002/pbc.28114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 11/08/2019] [Accepted: 11/12/2019] [Indexed: 11/11/2022]
Abstract
Neonatal inferior vena cava syndrome (IVCS), though uncommon, is associated with significant morbidity and mortality. Information on risk factors, diagnosis, treatment, and outcomes is limited. This review comprised 61 neonates across 33 reports. Thrombosis occurred in 98% and 42% involved a central venous catheter. Diagnosis was mainly established by ultrasound in 82%. Therapeutically, heparin was employed in 36% and thrombolysis in 18% of the cases. The overall mortality was 23%. An algorithm of clinical signs, investigation, and management is presented. Well-designed prospective studies are needed to establish a concrete investigational approach to neonatal IVCS and institute safe, evidence-based treatment.
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Affiliation(s)
- Paul Tieu
- Bachelor of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Bosco Paes
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Afrah Ahmed
- Department of Clinical Studies, University of Guelph, Guelph, Ontario, Canada
| | - Davide Matino
- Division of Pediatric Hematology/Oncology, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Anthony Chan
- Division of Pediatric Hematology/Oncology, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada and the Thrombosis and Hemostasis in Newborns (THiN) Group
| | - Mihir Bhatt
- Division of Pediatric Hematology/Oncology, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
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Mittal N, Byard RW, Dahlstrom JE. A practical guide to placental examination for forensic pathologists. Forensic Sci Med Pathol 2019; 16:295-312. [PMID: 31873913 PMCID: PMC8585837 DOI: 10.1007/s12024-019-00214-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2019] [Indexed: 02/04/2023]
Abstract
The placenta is a complex interface organ that may hold clues to the reasons for fetal, neonatal or maternal demise. For this reason, placental examination should be a mandatory part of all perinatal or maternal autopsies. While published protocols for the examination of the placenta exist, they are often not adopted. The following review provides practical guidelines for placental examination, with discussion of specific medical conditions that can negatively impact upon the fetus, neonate or mother involving placental pathology to cause death. The review aims to discuss concepts, with illustrations, that forensic pathologists may not routinely focus on in death investigations that may either contribute or mask the cause of a fetal or neonatal death, or are associated with a recurrence risk. While it is recognized that many forensic facilities do not have formal guidelines for placental examination, involvement of local perinatal pathology services in cases is one way of obtaining additional specialist expertise.
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Affiliation(s)
- Namita Mittal
- Anatomical Pathology, ACT Pathology, The Canberra Hospital, Canberra Health Services PO Box 11, Woden, ACT, 2606, Australia
| | - Roger W Byard
- Faculty of Medicine, University of Adelaide, Frome Rd., Adelaide, 5005, Australia.,Forensic Science SA, GPO Box 2790, Adelaide, 5001, Australia
| | - Jane E Dahlstrom
- Anatomical Pathology, ACT Pathology, The Canberra Hospital, Canberra Health Services PO Box 11, Woden, ACT, 2606, Australia. .,College of Health and Medicine, Australian National University Medical School, Canberra, ACT, 2601, Australia.
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5
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Stanek J, Abdaljaleel M. CD34 immunostain increases the sensitivity of placental diagnosis of fetal vascular malperfusion in stillbirth. Placenta 2019; 77:30-38. [PMID: 30827353 DOI: 10.1016/j.placenta.2019.02.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/17/2018] [Accepted: 02/01/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Postmortem regressive placental changes of stillbirth may obscure the pre-existing placental histomorphology. The objective is to find out whether the use of CD34 immunostain can increase the sensitivity of placental examination in the diagnosis of fetal vascular malperfusion (FVM). METHODS Twenty six independent clinical and 46 placental variables of 46 placentas from stillbirths were statistically compared to those of 92 placentas from livebirths. One histologically most unremarkable section per case was stained using double E-cadherin/CD34 immunostain (ECCD34). Clusters of avascular/hypovascular chorionic villi on hematoxylin and eosin (H&E) staining system and/or CD34 immunostaining, the latter also including endothelial CD34 positive debris in the villous stroma, were regarded as evidence of FVM. RESULTS The gestational age and cesarean section rate were statistically significantly lower and the induction of labor and mild erythroblastosis of fetal blood was higher, but the frequencies of clinical and placental features of umbilical cord compromise were not statistically significant between stillbirths and livebirths, respectively. By using H&E stain, 9 (19.6%) of stillbirths and 30 (32.6%) of livebirths showed clusters of avascular villi on H&E. By CD34, the rates of FVM increased to 23 (50%) and 34 (40%), respectively. The increase was statistically significant for stillbirths only (Chi square = 9.4, p = 0.002). By CD34, new clusters of hypovascular chorionic villi or villi with endothelial fragmentation were found in 23 stillbirth cases (50%) as opposed to livebirths (29 cases, 31.5%)(Chi square = 9.4, p = 0.002). DISCUSSION When compared with H&E stain, the CD34 increases sensitivity and/or upgrades FVM in placental examination in stillbirths but not in livebirths.
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Affiliation(s)
- Jerzy Stanek
- Division of Pathology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
| | - Maram Abdaljaleel
- Division of Pathology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
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Nakamura M, Umehara N, Ishii K, Sasahara J, Kiyoshi K, Ozawa K, Tanaka K, Tanemoto T, Ichizuka K, Hasegawa J, Ishikawa H, Murakoshi T, Sago H. A poor long-term neurological prognosis is associated with abnormal cord insertion in severe growth-restricted fetuses. J Perinat Med 2018; 46:1040-1047. [PMID: 29267174 DOI: 10.1515/jpm-2017-0240] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 11/07/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To clarify and compare if the neurological outcomes of fetal growth restriction (FGR) cases with abnormal cord insertion (CI) are associated with a higher risk of a poor neurological outcome in subjects aged 3 years or less versus those with normal CI. METHODS A multicenter retrospective cohort study was conducted among patients with a birth weight lower than the 3rd percentile, based on the standard reference values for Japanese subjects after 22 weeks' gestation, who were treated at a consortium of nine perinatal centers in Japan between June 2005 and March 2011. Patients whose birth weights were less than the 3rd percentile and whose neurological outcomes from birth to 3 years of age could be checked from their medical records were analyzed. The relationship between abnormal CI and neurological outcomes was analyzed. Univariate and multivariate models of multivariate logistic regression were employed to estimate the raw and odds ratio (OR) with 95% confidence intervals comparing marginal (MCI) and velamentous cord insertion (VCI) to normal CI. RESULTS Among 365 neonates, 63 cases of MCI and 14 cases of VCI were observed. After excluding 24 cases with neonatal or infant death from the total FGR population, the assessment of the outcomes of the infants aged 3 years or younger showed the following rates of neurological complications: 7.3% (n=25) for cerebral palsy, 8.8% (n=30) for developmental disorders, 16.7% (n=57) for small-for-gestational-age short stature (SGA), 0.6% (n=2) for impaired hearing, 0.9% (n=3) for epilepsy, 1.2% (n=4). The ORs (95% confidence intervals) based on multivariate analysis were as follows: cerebral palsy=10.1 (2.4-41.5) in the VCI group and 4.3 (1.6-11.9) in the MCI group, developmental disorders=6.7 (1.7-26) in the VCI group and 3.9 (1.1-14.2) in the single umbilical artery (SUA) group, 5.1 (1.4-18.7) for birth weight <1000 g and 2.8 (1.2-6.7) for placental weight <200 g. CONCLUSIONS The present results indicate that growth-restricted fetuses diagnosed with a birth weight below the 3rd percentile exhibiting abnormal umbilical CI are at a high risk for poor neurological outcomes, including cerebral palsy and/or developmental disorders.
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Affiliation(s)
- Masamitsu Nakamura
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Nagayoshi Umehara
- Department of Obstetrics and Gynecology, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Jun Sasahara
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Kenji Kiyoshi
- Department of Obstetrics and Gynecology, Hyogo Children's Hospital, Hyogo, Japan
| | - Katsusuke Ozawa
- Department of Maternal and Fetal Medicine, Miyagi Children's Hospital, Miyagi, Japan
| | - Kei Tanaka
- Department of Obstetrics and Gynecology, Kyorin University Hospital, Tokyo, Japan
| | - Tomohiro Tanemoto
- Department of Obstetrics and Gynecology, Jikei University Hospital, Tokyo, Japan
| | - Kiyotake Ichizuka
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Junichi Hasegawa
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Hiroshi Ishikawa
- Department of Obstetrics and Gynecology, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Takeshi Murakoshi
- Department of Obstetrics and Gynecology, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Haruhiko Sago
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
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7
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Redline RW, Ravishankar S. Fetal vascular malperfusion, an update. APMIS 2018; 126:561-569. [PMID: 30129125 DOI: 10.1111/apm.12849] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 05/03/2018] [Indexed: 01/08/2023]
Abstract
Fetal vascular malperfusion is the most recent term applied to a group of placental lesions indicating reduced or absent perfusion of the villous parenchyma by the fetus. The most common etiology of malperfusion is umbilical cord obstruction leading to stasis, ischemia, and in some cases thrombosis. Other contributing factors may include maternal diabetes, fetal cardiac insufficiency or hyperviscosity, and inherited or acquired thrombophilias. Severe or high grade fetal vascular malperfusion is an important risk factor for adverse pregnancy outcomes including fetal growth restriction, fetal CNS injury, and stillbirth. Overall recurrence risk for subsequent pregnancies is low.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sanjita Ravishankar
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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8
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Cerebellar hemorrhage in utero associated with ‘massive’ fetal thrombotic vasculopathy. ASIAN BIOMED 2018. [DOI: 10.2478/abm-2010-0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Abstract
Background: Cerebellar hemorrhage is a rare but serious perinatal condition with various etiologies leading to fetal and neonatal death and adverse neurological complications. Complete autopsy and placental examination are essential for identification of a cause of the bleeding. Objective: Present a case of cerebellar hemorrhage in utero associated with ‘massive’ fetal thrombotic vasculopathy (FTV). Method: Autopsy of a stillborn female fetus, 26 weeks gestation, with intrauterine growth restriction, delivered by a 37-year-old woman. Results: The fetus showed multiple recent peticheal hemorrhages along the cerebellar cortex. The placenta revealed a large thrombosed chorionic blood vessel. Microscopic findings showed multiple vascular thrombosis and massive FTV throughout the placental villi. These were recognized as two histologic patterns, ‘early’ stromal karryorhxis, and ‘late’ villous stromal involution. Conclusion: Massive FTV was a leading cause of fetal stress due to increased resistant of downstream placental villi. This longstanding stressful environment induced auto-regulation impairment of fetal cerebral blood flow resulting in cerebellar parenchymal bleeding. Careful placental examination is beneficial for understating the mode and mechanism of fetal death.
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Abstract
CONTEXT - Fetal vascular malperfusion, also known as fetal thrombotic vasculopathy, remains an underrecognized pathologic finding and should be noted during placental evaluation. OBJECTIVE - To review histologic findings, gain familiarity with the updated terminology, and to recognize important clinical associations with this entity. DATA SOURCES - University of Michigan cases, PubMed search, multiple review articles including recent placental workshop group consensus statement, and selected book chapters. CONCLUSIONS - Multiple histologic patterns of fetal vascular malperfusion have been described including thrombosis, avascular villi, villous stromal-vascular karyorrhexis, intramural fibrin thrombi, and stem villous vascular obliteration. Various underlying etiologies can be involved in fetal vascular malperfusion. Cord lesions including abnormal insertion, length, and coiling are important causes. Maternal vascular malperfusion such as preeclampsia, hypercoagulable states, lupus anticoagulant, and sometimes diabetes have been associated with this condition. Fetal cardiac dysfunction/malformations and severe fetal inflammatory response in the setting of ascending intrauterine infection have also been attributed to this important finding. Fetal vascular malperfusion has been implicated in several significant and sometimes devastating clinical associations; these include intrauterine growth restriction, poor perinatal outcome, fetal demise, and neurodevelopmental sequelae. A diagnostic challenge may be encountered in cases with prior intrauterine fetal death, since degenerative changes post demise result in a similar histomorphologic picture. The diffuse versus the focal nature of the lesions may help in the distinction.
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Affiliation(s)
- Amer Heider
- From the Department of Pathology Michigan Medicine, University of Michigan, Ann Arbor
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10
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Idiopathic perinatal hepatic infarct as a cause of liver mass. ANNALS OF PEDIATRIC SURGERY 2016. [DOI: 10.1097/01.xps.0000491015.13170.fb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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12
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Abstract
The clinical utility of placental pathology is both overestimated and underestimated, and the overall quality of placental pathology reporting, even at major medical centers, is highly variable. Clear benefits of examining placentas include the immediate diagnosis of treatable conditions in both the mother and the infant, clarification of the underlying etiology of adverse pregnancy outcomes, estimation of recurrence risk, and guidance for the management of future pregnancies. In order to realize these benefits and get the most out of their pathology departments, it is critical for clinicians to understand the range and implications of placental lesions. This article will review the nomenclature, diagnostic criteria and pitfalls, and clinical significance of seven common placental disease processes and a handful of other lesions.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106.
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13
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Downey LC, O'Shea TM, Allred EN, Kuban K, McElrath TF, Warner DD, Ware J, Hecht JL, Onderdonk A, Leviton A. Antenatal and early postnatal antecedents of parent-reported attention problems at 2 years of age. J Pediatr 2015; 166:20-5. [PMID: 25241173 DOI: 10.1016/j.jpeds.2014.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 07/03/2014] [Accepted: 08/06/2014] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To assess antenatal and early postnatal antecedents of attention problems identified by the Child Behavior Checklist in extremely preterm children. STUDY DESIGN In a cohort of 826 children born between 23 and 27 weeks' gestation, we collected demographic, birth, and postnatal information. We then identified behavior problems by using parent ratings from the Child Behavior Checklist at 2 years' adjusted age. We created time-oriented logistic regression risk models to identify significant risk factors for attention problems and Diagnostic and Statistical Manual of Mental Disorders-compatible attention deficit/hyperactivity problems (ADHP(DSM)). RESULTS Children were at increased risk of both attention problems if they were born to a woman who had no formal education beyond high school and/or a woman who was exposed to secondhand smoke. Recovery of a single organism from the placenta was associated with increased risk of an attention problem, and fetal stem vessel thrombosis and recovery of Mycoplasma species were associated with increased risk of ADHP(DSM). Infants of multifetal gestations were at reduced risk of both attention problems. The only postnatal risk factor for an attention problem was recovery of bacteria from a tracheal aspirate. CONCLUSION Among extremely preterm infants, several potentially modifiable antenatal and perinatal antecedents are associated with increased risk for attention problems and ADHP(DSM) at 2 years adjusted age.
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Affiliation(s)
- L Corbin Downey
- Division of Neonatology, Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
| | - T Michael O'Shea
- Division of Neonatology, Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
| | - Elizabeth N Allred
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Karl Kuban
- Division of Pediatric Neurology, Department of Pediatrics, Boston University, Boston, MA
| | - Thomas F McElrath
- Division of Maternal-Fetal Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Diane D Warner
- Division of Neonatology, Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Janice Ware
- Division of Developmental Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Jonathan L Hecht
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Andrew Onderdonk
- Department of Pathology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Alan Leviton
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
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14
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Abstract
Formal examination of the placenta may provide valuable information to the clinicians, family, and court of law in cases of adverse pregnancy outcome when litigation is initiated. Placental examination contributes towards the identification of specific intrinsic or secondary placental lesions, and understanding the nature of the intrauterine environment. This article provides an update of important placental pathologies that may contribute towards neurologic injury of the newborn child, and describes the role of placental findings in the adjudication of cases of adverse neonatal outcome.
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Affiliation(s)
- Kenneth Tou-En Chang
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore.
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15
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Lepais L, Gaillot-Durand L, Boutitie F, Lebreton F, Buffin R, Huissoud C, Massardier J, Guibaud L, Devouassoux-Shisheboran M, Allias F. Fetal thrombotic vasculopathy is associated with thromboembolic events and adverse perinatal outcome but not with neurologic complications: a retrospective cohort study of 54 cases with a 3-year follow-up of children. Placenta 2014; 35:611-7. [PMID: 24862569 DOI: 10.1016/j.placenta.2014.04.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 04/15/2014] [Accepted: 04/22/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE to test the hypothesis that placental fetal thrombotic vasculopathy (FTV) is associated with obstetric complications and predisposes the child to unfavorable outcomes. METHODS 54 placentas with FTV lesions and 100 placentas without FTV lesions were collected over a 5-year period at the Croix-Rousse Pathology Department. Clinical findings including maternal, fetal, neonatal condition and pediatric outcome up to three years were collected for each case and control observation. The statistical analyses were assessed with Wald's chi-square derived from conditional logistic regression modeling. RESULTS FTV was associated with a significantly higher frequency of obstetric complications: (pregnancy-induced hypertension (OR 3.620, CI 1.563-8.385), preeclampsia (OR 3.674, CI 1.500-8.998), emergency delivery procedures (OR 3.727, CI 1.477-9.403), cesarean sections (OR 2.684, CI 1.016-7.088)), poor fetal condition (intrauterine growth restriction (IUGR) (OR 5.440, CI 2.007-14.748), nonreassuring fetal heart tracing (OR 6.062, CI 2.280-16.115), difficulties in immediate ex utero adaptation (OR 3.416, CI 1.087-10.732)) and perinatal or early childhood demise (OR 3.043, CI 1.327-6.978). On pathological examination, FTV was associated with marginal cord insertion (OR 3.492, CI 1.350-9.035), cord stricture and hypercoiled cord (OR 3.936, CI 1.209-12.813). Thromboembolic events were significantly more frequent in cases with FTV (OR 2.154, CI 1.032-5.622). Neurological complications within the first 3 years of life were also more frequent in the FTV group compared to the control group, but this association was not statistically significant. CONCLUSIONS FTV is associated with maternal complications, pathological findings in the placenta, especially gross cord abnormalities, IUGR, and poor perinatal or early childhood outcome. It may also predispose children to somatic thromboembolic events.
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Affiliation(s)
- L Lepais
- Centre de Pathologique Nord, Hôpital de la Croix-Rousse, 103 Grande Rue de la Croix-Rousse, 69317 Lyon Cedex 04, France
| | - L Gaillot-Durand
- Centre de Pathologique Nord, Hôpital de la Croix-Rousse, 103 Grande Rue de la Croix-Rousse, 69317 Lyon Cedex 04, France
| | - F Boutitie
- Service de Biostatistique, Hospices Civils de Lyon, F-69003 Lyon, France; CNRS, UMR5558, F-69100 Villeurbanne, France
| | - F Lebreton
- Centre de Pathologique Nord, Hôpital de la Croix-Rousse, 103 Grande Rue de la Croix-Rousse, 69317 Lyon Cedex 04, France
| | - R Buffin
- Service de Réanimation Néonatale, Hôpital de la Croix-Rousse, 103 Grande Rue de la Croix-Rousse, 69317 Lyon Cedex 04, France
| | - C Huissoud
- Service d'Obstétrique, Hôpital de la Croix-Rousse, 103 Grande Rue de la Croix-Rousse, 69317 Lyon Cedex 04, France
| | - J Massardier
- Service d'Obstétrique, Hôpital Femme-Mère-Enfant, 59 Boulevard Pinel, 69677 Bron Cedex, France
| | - L Guibaud
- Service d'Imagerie Pédiatrique et Fœtale, Hôpital Femme-Mère-Enfant, 59 Boulevard Pinel, 69677 Bron Cedex, France
| | - M Devouassoux-Shisheboran
- Centre de Pathologique Nord, Hôpital de la Croix-Rousse, 103 Grande Rue de la Croix-Rousse, 69317 Lyon Cedex 04, France
| | - F Allias
- Centre de Pathologique Nord, Hôpital de la Croix-Rousse, 103 Grande Rue de la Croix-Rousse, 69317 Lyon Cedex 04, France.
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Lee S, Ananth P, Boyd T, Esrick E, Kim HB. Successful surgical thrombectomy for neonatal IVC and bilateral renal vein thrombosis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2014. [DOI: 10.1016/j.epsc.2014.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Lian DWQ, Lam JCM, Aung ACL, Li FX, Chang KTE. Intestinal atresia occurring in association with placental fetal thrombotic vasculopathy: a case report with literature review. Pediatr Dev Pathol 2013; 16:28-31. [PMID: 22989172 DOI: 10.2350/12-08-1242-cr.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Fetal thrombotic vasculopathy (FTV) is a thrombo-occlusive disorder of the placenta that has been reported in association with perinatal conditions such as cardiac abnormalities, neurological injury, and perinatal liver disease. These complications are related to fetal circulation vascular compromise. We herein report a previously undocumented association of congenital intestinal atresia and placental FTV. Vascular occlusion of the fetal mesenteric vessels has been hypothesized to result in congenital intestinal atresia. Our report provides support for this vascular hypothesis and illustrates the value of formal pathological examination of the placenta in explaining this occurrence of congenital intestinal atresia.
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Affiliation(s)
- Derrick W Q Lian
- Department of Pathology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
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Lo AA, Faye-Petersen OM, Ernst LM. Intrauterine fetal death of a monochorionic twin with peripheral pulmonary infarcts: potential thromboembolic events following death of co-twin. Pediatr Dev Pathol 2012; 15:142-5. [PMID: 22070756 DOI: 10.2350/11-07-1056-cr.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In utero fetal lung infarction has rarely been reported. We present a case of intrauterine lung infarction in a 28-3/7 weeks' gestation monochorionic twin following intrauterine fetal demise of the co-twin at 20 weeks. This case highlights the potential for thromboembolic events (TBEs) associated with monochorionic gestations to include pulmonary TBE and infarction among the risks for fetal morbidity and mortality.
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Affiliation(s)
- Amy A Lo
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
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Helderman JB, O'Shea TM, Kuban KCK, Allred EN, Hecht JL, Dammann O, Paneth N, McElrath TF, Onderdonk A, Leviton A. Antenatal antecedents of cognitive impairment at 24 months in extremely low gestational age newborns. Pediatrics 2012; 129:494-502. [PMID: 22331342 PMCID: PMC3289523 DOI: 10.1542/peds.2011-1796] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2011] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Extremely low gestational age neonates are more likely than term infants to develop cognitive impairment. Few studies have addressed antenatal risk factors of this condition. We identified antenatal antecedents of cognitive impairment determined by the Mental Development Index (MDI) portion of the Bayley Scales of Infant Development, Second Edition (BSID-II), at 24 months corrected age. METHODS We studied a multicenter cohort of 921 infants born before 28 weeks of gestation during 2002 to 2004 and assessed their placentas for histologic characteristics and microorganisms. The mother was interviewed and her medical record was reviewed. At 24 months adjusted age, children were assessed with BSID-II. Multinomial logistic models were used to estimate odds ratios. RESULTS A total of 103 infants (11%) had an MDI <55, and 99 infants (11%) had an MDI between 55 and 69. No associations were identified between organisms recovered from the placenta and developmental delay. Factors most strongly associated with MDI <55 were thrombosis of fetal vessels (OR 3.1; 95% confidence interval [CI] 1.2, 7.7), maternal BMI >30 (OR 2.0; 95% CI 1.1, 3.5), maternal education ≤12 years (OR 3.4; 95% CI 1.9, 6.2), nonwhite race (OR 2.2; 95% CI 1.3, 3.8), birth weight z score < -2 (OR 2.8; 95% CI 1.1, 6.9), and male gender (OR 2.7; 95% CI 1.6, 4.5). CONCLUSIONS Antenatal factors, including thrombosis of fetal vessels in the placenta, severe fetal growth restriction, and maternal obesity, convey information about the risk of cognitive impairment among extremely premature newborns.
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Affiliation(s)
- Jennifer B Helderman
- Department of Pediatrics (Neonatology), Wake Forest University Health Sciences, Medical Center Blvd, Winston-Salem, NC 27157, USA.
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Wintermark P, Boyd T, Gregas MC, Labrecque M, Hansen A. Placental pathology in asphyxiated newborns meeting the criteria for therapeutic hypothermia. Am J Obstet Gynecol 2010; 203:579.e1-9. [PMID: 20851370 DOI: 10.1016/j.ajog.2010.08.024] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Revised: 07/17/2010] [Accepted: 08/09/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE We sought to describe placental findings in asphyxiated term newborns meeting therapeutic hypothermia criteria and to assess whether histopathologic correlation exists between these placental lesions and the severity of later brain injury. STUDY DESIGN We conducted a prospective cohort study of the placentas of asphyxiated newborns, in whom later brain injury was defined by magnetic resonance imaging. RESULTS A total of 23 newborns were enrolled. Eighty-seven percent of their placentas had an abnormality on the fetal side of the placenta, including umbilical cord lesions (39%), chorioamnionitis (35%) with fetal vasculitis (22%), chorionic plate meconium (30%), and fetal thrombotic vasculopathy (26%). A total of 48% displayed placental growth restriction. Chorioamnionitis with fetal vasculitis and chorionic plate meconium were significantly associated with brain injury (P = .03). Placental growth restriction appears to significantly offer protection against the development of these injuries (P = .03). CONCLUSION Therapeutic hypothermia may not be effective in asphyxiated newborns whose placentas show evidence of chorioamnionitis with fetal vasculitis and chorionic plate meconium.
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Incidence and clinicopathologic correlation of fetal vessel thrombosis in mono- and dichorionic twin placentas. J Perinatol 2010; 30:660-4. [PMID: 20200539 DOI: 10.1038/jp.2010.19] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine the incidence of fetal vessel thrombosis in monochorionic-diamniotic and dichorionic-diamniotic twin placentas, and its association with intrauterine growth retardation (IUGR), hypertensive disorders of pregnancy, twin-twin transfusion syndrome (TTTS), fetal vascular anastomoses, chorangiosis, and chorioamnionitis. STUDY DESIGN Histologic slides from 80 pairs of monochorionic and 80 pairs of dichorionic twin placentas were reviewed for evidence of fetal vessel thrombosis (≥5 adjacent avascular terminal villi with upstream intravascular fibrin thrombi). Associations with clinical and other pathologic variables were analyzed by χ(2) tests. RESULT Thrombosis occurred in 7.5% of monochorionic and 3.1% of dichorionic twin placentas (P=0.090). It was associated with IUGR among the monochorionic twins (P=<0.0001) and with hypertensive disorders of pregnancy among the dichorionic twins (P=0.018). Vascular anastomoses, TTTS, chorangiosis, and chorioamnionitis were not associated with fetal vessel thrombosis. CONCLUSION Fetal vessel thrombosis was identified more frequently in monochorionic twins, but this difference was not statistically significant. It is associated with IUGR in monochorionic twins, but not with TTTS or fetal vascular anastomoses at the chorionic surface.
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Taweevisit M, Thorner PS. Massive fetal thrombotic vasculopathy associated with excessively long umbilical cord and fetal demise: case report and literature review. Pediatr Dev Pathol 2010; 13:112-5. [PMID: 19888870 DOI: 10.2350/09-07-0680-cr.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Both excessively long umbilical cord (ELUC) and fetal thrombotic vasculopathy (FTV) have been associated with adverse perinatal outcomes, in particular, fetal loss and long-term neurological complications. The etiologies of these conditions are unclear and are likely multifactorial. Excessively long umbilical cord has been associated with FTV and fetal demise, with cases generally showing other cord abnormalities and only localized FTV. We report a 37-week male stillborn fetus whose placenta had a 113-cm-long umbilical cord with no other cord abnormalities associated with "massive" FTV (ie, >25% of the placental mass). This case illustrates the unusual occurrence of FTV of such severe extent in association with ELUC leading to fetal demise. This case illustrates that ELUC alone may be enough to predispose the placenta to massive FTV.
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Affiliation(s)
- Mana Taweevisit
- Department of Pathology, Faculty of Medicine, Chulalongkorn University, 1873 King Rama IV Street, Pathumwan, Bangkok, 10330 Thailand.
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Wintermark P, Boyd T, Parast MM, Van Marter LJ, Warfield SK, Robertson RL, Ringer SA. Fetal placental thrombosis and neonatal implications. Am J Perinatol 2010; 27:251-6. [PMID: 19806531 PMCID: PMC3694425 DOI: 10.1055/s-0029-1239486] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We present the neonatal complications of two premature newborn infants whose placentas demonstrated placental thrombosis in the fetal circulation. Both mothers presented with a 3-day history of decreased fetal movements before delivery. The first infant presented with thrombocytopenia and disseminated intravascular coagulation. The second infant had extended bilateral extended hemorrhagic venous infarctions. Severe fetal placental vascular lesions seem to be a predisposing factor for some adverse neonatal outcomes. We present these two cases with a brief review of the literature.
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Affiliation(s)
- Pia Wintermark
- Division of Newborn Medicine, Children's Hospital Boston, Boston, Massachusetts 02115, USA.
| | - Theonia Boyd
- Department of Pathology, Newborn Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Mana M. Parast
- Children’s Hospital Boston, Boston, Massachusetts, Newborn Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Linda J. Van Marter
- Division of Newborn Medicine, Newborn Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Simon K. Warfield
- Department of Radiology, Newborn Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Richard L. Robertson
- Department of Radiology, Newborn Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Steven A. Ringer
- Anatomic and Clinical Pathology, Newborn Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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de Chadarévian JP, Bouie SM, Peddinghaus ME, Luck LR, Schwartz MZ, Prasad R, Faerber EN. Terminal ileal atresia, total colonic aganglionosis, and thrombophilia. Pediatr Dev Pathol 2009; 12:394-7. [PMID: 19226190 DOI: 10.2350/08-09-0534.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Inherited thrombophilia, a predisposition for a hypercoagulable state, has been associated with cases of intestinal atresia. In this communication, we report a case of terminal ileal atresia and total colonic aganglionosis (Hirschsprung's disease), a rarely documented association, in a neonate who seemed to have a hypercoagulable state. The case stresses the need for recognition of this sequence of events in order to achieve optimal management.
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Affiliation(s)
- Jean-Pierre de Chadarévian
- Department of Pathology and Laboratory Medicine, Drexel University College of Medicine and St. Christopher's Hospital for Children, Philadelphia, PA, USA.
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Abstract
Disorders of the placental circulation, including the release of deleterious mediators to the fetus, are important risk factors for central nervous system complications. These disorders result in discrete patterns of placental injury detectable by a thorough placental pathologic examination. Consideration of the location, severity, multiplicity, and timing of these lesions is critical to a full understanding of their significance. Less than 10% of placentas from term infants that later develop cerebral palsy lack any evidence of placental abnormalities potentially related to adverse outcome.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, Case Western Reserve University School of Medicine, OH 44106, USA.
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Ernst LM, Chou D, Parry S. Fetal thrombotic vasculopathy in twin placentas with complete hydatidiform mole. Pediatr Dev Pathol 2009; 12:63-7. [PMID: 18702565 DOI: 10.2350/08-04-0446.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Accepted: 08/07/2008] [Indexed: 11/20/2022]
Abstract
Complete hydatidiform mole with a coexistent normal twin is rare, but the mortality rate for the coexistent twin is high, usually attributed to preeclampsia or vaginal bleeding. Placental examination of 3 twin pregnancies complicated by complete hydatidiform mole revealed significant abnormalities in the fetal vasculature. In 1 case, an intrauterine demise at 27 weeks, the placenta showed chorionic plate vessels with mural fibrin thrombi. The placenta from a second case, delivered at 30 weeks for preterm labor, showed similar thrombi in chorionic plate vessels, accompanied by calcification. A third case delivered at 35 weeks produced a liveborn infant, and the placenta showed villous stromal-vascular karyorrhexis, avascular villi, and stem villous thrombosis. Fetal placental thrombotic lesions seen in the coexistent twin circulation, associated with a complete hydatidiform mole, may play a heretofore unrecognized role in the morbidity and mortality of the fetus.
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Affiliation(s)
- Linda M Ernst
- The Children's Hospital of Philadelphia, Department of Pathology and Laboratory Medicine, University of Pennsylvania School of Medicine, PA, USA.
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27
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Placental histologic criteria for umbilical blood flow restriction in unexplained stillbirth. Hum Pathol 2008; 39:948-53. [DOI: 10.1016/j.humpath.2007.10.032] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Revised: 10/10/2007] [Accepted: 10/26/2007] [Indexed: 11/21/2022]
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Ernst LM, Grossman AB, Ruchelli ED. Familial perinatal liver disease and fetal thrombotic vasculopathy. Pediatr Dev Pathol 2008; 11:160-3. [PMID: 17990937 DOI: 10.2350/07-06-0301.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2007] [Accepted: 06/29/2007] [Indexed: 11/20/2022]
Abstract
The association between placental fetal thrombotic vasculopathy (FTV) and perinatal liver disease was not recognized until 2002, when Dahms and colleagues reported a series of 3 patients in whom severe liver disease developed in the first 2 days of life. All had abnormal liver histology and showed a variety of abnormalities, including Budd-Chiari syndrome, changes mimicking extrahepatic obstruction, lobular fibrosis, cholestasis, and hepatocyte giant cell transformation. We report recurrent significant perinatal liver disease in a family, associated with proven FTV in at least 1 pregnancy. A 30-year-old gravida 4 female with a history of heterozygous methylenetetrahydrofolate A1298C mutation had a normal 1st pregnancy and then experienced an intrauterine fetal demise at 38 weeks of gestation. Placental examination revealed extensive occlusive and mural thrombi of chorionic vessels associated with a large focus of avascular villi. Histologic examination of the liver showed extensive giant cell transformation and hepatocyte dropout. No excess hemosiderin pigment was present in the liver, pancreas, or heart. A 3rd pregnancy produced a live-born term infant with transient neonatal cholestasis. The 4th pregnancy also produced a term neonate who presented with acute hepatic failure of unknown cause, ultimately requiring liver transplantation. Fetal thrombotic vasculopathy is an underrecognized association with perinatal liver disease that may be associated with abnormal liver perfusion and that may recur in families, especially when a genetic thrombophilia is present.
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Affiliation(s)
- Linda M Ernst
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Raspollini MR, Oliva E, Roberts DJ. Placental histopathologic features in patients with thrombophilic mutations. J Matern Fetal Neonatal Med 2007; 20:113-23. [PMID: 17437209 DOI: 10.1080/14767050601178345] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The purpose of this article is to review the histopathologic findings in the placenta of women with a known thrombophilic mutation. The findings range from normal to severe pathologic features including decidual vasculopathy, placental infarctions, syncytial knotting, maternal floor infarction, fetal thrombotic vasculopathy, vasculitis, and chronic villitis. They are, however, not pathognomonic of thrombophilic states, nor are necessarily markers of perinatal damage. The prospective evaluation of cases with known thrombophilic mutations and the application of tissue microarray examination of the placenta may allow identification of major histopathologic features and molecular parameters associated with maternal and/or fetal thrombophilic states. This may assist clinicians in their consultation with patients and optimize management in future pregnancies.
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Affiliation(s)
- Maria Rosaria Raspollini
- Department of Human Pathology and Oncology, University of Florence School of Medicine, Florence, Italy
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Shimojima N, Shibata R, Hoshino K, Kawachi S, Tanabe M, Wakabayashi G, Shimazu M, Sakamoto M, Morikawa Y, Kitajima M. Cryptogenic fulminant hepatic failure in infancy: report of 2 cases with unique vascular obstructive changes in native livers. Liver Transpl 2006; 12:1418-22. [PMID: 16933237 DOI: 10.1002/lt.20850] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Although the causes of fulminant hepatic failure (FHF) remain cryptogenic in many cases, a few reports have reviewed the pathological findings of native livers to evaluate the etiology. We report 2 cases of infantile cryptogenic FHF with unique vascular obstructive changes in the native livers. Clinically, it was notable that these 2 patients developed FHF very early in life, at 2 months and 5 months of age, respectively. One patient died from chronic rejection associated with hepatic veno-occlusive disease 4 months after transplantation. Histologically, hepatocytes in the native livers were completely destroyed in both patients, and vascular findings revealed obstruction of central veins in 1 patient and obstruction of portal veins in the other patient. Although the pathogenesis of vascular obstructions is not yet understood, this study suggests that an obstructive vascular event may be a contributing etiologic factor of FHF in infancy.
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Affiliation(s)
- Naoki Shimojima
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Whitington PF, Kelly S, Ekong UD. Neonatal hemochromatosis: fetal liver disease leading to liver failure in the fetus and newborn. Pediatr Transplant 2005; 9:640-5. [PMID: 16176424 DOI: 10.1111/j.1399-3046.2005.00357.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Acute liver failure in the newborn is relatively rare but often fatal. The broadest definition of acute liver failure is failure of the vital functions of the liver occurring within weeks or a few months of the onset of clinical liver disease. Therefore, by definition, any liver failure in the newborn can be construed to be acute liver failure. A second component of the general definition of acute liver failure is the lack of known preexisting liver disease. In the case of neonatal acute liver failure, preexisting disease would by definition be liver disease that affects the fetus. Almost nothing is known about fetal onset liver failure, and there is no literature addressing the subject. This review will address fetal liver disease that leads to liver failure in the fetus or newborn.
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Affiliation(s)
- Peter F Whitington
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Children's Memorial Hospital, The Siragusa Transplantation Center, Chicago, IL 60614, USA.
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Redline RW. Severe fetal placental vascular lesions in term infants with neurologic impairment. Am J Obstet Gynecol 2005; 192:452-7. [PMID: 15695986 DOI: 10.1016/j.ajog.2004.07.030] [Citation(s) in RCA: 202] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study tests the hypothesis that placental disease can identify antepartum processes that either progress into the intrapartum period or predispose to intrapartum brain injury. STUDY DESIGN Lesions that affect large fetal vessels were compared in the placentas of 125 neurologically impaired term infants who were the focus of clinical negligence litigation and 250 consecutive singleton deliveries of >/=36 weeks of gestation. RESULTS One or more of 4 severe placental fetal vascular lesions (fetal thrombotic vasculopathy, chronic villitis with obliterative fetal vasculopathy, chorioamnionitis with severe fetal vasculitis, and meconium-associated fetal vascular necrosis) were found in 51% of index cases versus 10% of the comparison group ( P <.0001). Prevalence of these lesions in the 64 infants with cerebral palsy was 52% ( P <.0001). CONCLUSION Severe fetal placental vascular lesions are correlated highly with neurologic impairment and cerebral palsy. Their nature, duration, and anatomic location make them strong candidates for the antepartum processes that place fetuses at risk for brain injury during the intrapartum period.
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Affiliation(s)
- Raymond W Redline
- Departments of Pathology and Reproductive Biology, Case School of Medicine and University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio, USA
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Abstract
Although inherited fetal coagulation disorders may lead to fetal thrombotic vasculopathy (FTV) in occasional cases, several studies have failed to show a significant association between these 2 entities. This study tests the hypothesis that vascular stasis related to chronic umbilical cord obstruction might be a contributing factor. The study population consisted of 125 neurologically impaired term infants who were the focus of clinical negligence litigation. FTV, as defined by an average of >15 villi per slide exhibiting either a complete lack of blood vessels or villous stromal karyorrhexis, was found in the placentas of 23 cases. Clinical umbilical cord entanglement (ie, true knots or cord loops around the neck or body parts at delivery) was significantly more common in cases with FTV (61% vs 24% in cases without FTV; P = 0.0009). Potentially obstructive pathological abnormalities of the umbilical cord (marginal/ membranous insertion, decreased Wharton's jelly, maximum cord diameter <8 mm, or hypercoiling) were also more frequent in this group (30% vs 9% without FTV; P = 0.0055). Overall, 16 of 23 placentas with FTV had either clinical or pathological cord abnormalities. This study, with careful documentation of cord status at delivery and on the delivered placenta, is the first to report that clinical cord entanglement and pathological cord abnormalities are significantly increased in placentas with FTV.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, Case School of Medicine and University Hospitals of Cleveland, Cleveland, OH, USA
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Redline RW, Ariel I, Baergen RN, Desa DJ, Kraus FT, Roberts DJ, Sander CM. Fetal vascular obstructive lesions: nosology and reproducibility of placental reaction patterns. Pediatr Dev Pathol 2004; 7:443-52. [PMID: 15547768 DOI: 10.1007/s10024-004-2020-x] [Citation(s) in RCA: 230] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2004] [Accepted: 04/16/2004] [Indexed: 11/24/2022]
Abstract
The purpose of this study was to assemble and test the reliability of a complete set of the placental reaction patterns seen with chronic fetal vascular obstruction in the hope that this might provide a standardized diagnostic framework useful for practicing pathologists. Study cases (14 with fetal vascular obstructive lesions, 6 controls) were reviewed blindly by seven pathologists after agreement on a standard set of diagnostic criteria. Majority vote served as the gold standard and 80% of the 180 diagnoses rendered (9 diagnoses each for 20 cases) were agreed upon by at least six of the seven scores. The sensitivity of individual diagnosis relative to the group consensus averaged 83% (range, 69-100%) and specificity averaged 91% (range, 86-100%). Reproducibility was measured by unweighted kappa-values and interpreted as follows: < 0.2, poor; 0.2-0.6, fair/moderate; > 0.6, substantial. Kappa values for lesions of distal villi were generally superior to those for lesions involving large fetal vessels: avascular villi (0.49), villous stromal-vascular karyorrhexis (0.58), and villitis of unknown etiology (VUE) with stem villitis and avascular villi (0.65) versus large vessel thrombi (any vessel, 0.34; chorionic plate vessel, 0.40) and intimal fibrin cushions (recent, 0.47; remote, 0.78). Reproducibility for a global impression of any villous change consistent with chronic fetal vascular obstruction was substantial (0.63), while that for a more severe subgroup was moderate (0.44). Three points are worthy of emphasis. Our system separately recognizes, but later combines, uniformly avascular villi and villous stromal-vascular karyorrhexis as manifestations of the same underlying process. We propose that this combined group of villous lesions be dichotomized with the terms fetal thrombotic vasculopathy or extensive avascular villi (and/or villous stromal-vascular karyorrhexis) being reserved for the group with 15 or more affected terminal villi per section. Scattered foci of avascular villi (and/or villous stromal-vascular karyorrhexis) could be used to describe less severe cases. Finally, we distinguish VUE with stem villitis and avascular villi (obliterative fetal vasculopathy) as a distinct process with substantial perinatal morbidity.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, University Hospitals of Cleveland and Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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