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Brady CA, Ford LB, Moss C, Zou Z, Crocker IP, Heazell AEP. Virtual crossmatching reveals upregulation of placental HLA-Class II in chronic histiocytic intervillositis. Sci Rep 2024; 14:18714. [PMID: 39134702 PMCID: PMC11319473 DOI: 10.1038/s41598-024-69315-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/02/2024] [Indexed: 08/15/2024] Open
Abstract
Chronic histiocytic intervillositis (CHI) is a recurrent placental lesion where maternal macrophages infiltrate the intervillous space. Its cause is unknown, though due to similarities to rejected allografts one hypothesis is that CHI represents maternal-fetal rejection. Here, virtual crossmatching was applied to healthy pregnancies and those with a history of CHI. Anti-HLA antibodies, measured by Luminex, were present in slightly more controls than CHI (8/17 (47.1%) vs 5/14 (35.7%)), but there was no significant difference in levels of sensitisation or fetal specific antibodies. Quantification of immunohistochemical staining for HLA-Class II was increased in syncytiotrophoblast of placentas with CHI (Grade 0.44 [IQR 0.1-0.7]) compared to healthy controls (0.06 [IQR 0-0.2]) and subsequent pregnancies (0.13 [IQR 0-0.3]) (P = 0.0004). HLA-Class II expression was positively related both to the severity of CHI (r = 0.67) and C4d deposition (r = 0.48). There was no difference in overall C4d and HLA-Class I immunostaining. Though increased anti-HLA antibodies were not evident in CHI, increased expression of HLA-Class II at the maternal-fetal interface suggests that they may be relevant in its pathogenesis. Further investigation of antibodies immediately after diagnosis is warranted in a larger cohort of CHI cases to better understand the role of HLA in its pathophysiology.
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Affiliation(s)
- Chloe A Brady
- Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, UK.
| | - Laura B Ford
- Transplantation Laboratory, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Chloe Moss
- Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, UK
| | - Zhiyong Zou
- Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, UK
| | - Ian P Crocker
- Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, UK
| | - Alexander E P Heazell
- Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, UK
- Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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Simula N, McRae K, Habte R, Fayek B, Won E, Liu YD, Albert A, AbdelHafez FF, Terry J, Bedaiwy MA. Reproductive and treatment outcomes in chronic intervillositis of unknown etiology: A systematic review and meta-analysis. J Reprod Immunol 2024; 164:104285. [PMID: 38941926 DOI: 10.1016/j.jri.2024.104285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 06/07/2024] [Accepted: 06/17/2024] [Indexed: 06/30/2024]
Abstract
Chronic Intervillositis of Unknown Etiology (CIUE) is a rare idiopathic inflammatory disorder of the placenta. The evidence suggests an increased risk for poor obstetrical outcomes and a risk of recurrence as high as 100 %. This meta-analysis examined CIUE prevalence, recurrence, association with autoimmune disorders, reproductive outcomes, pregnancy complications, and the benefits of medical treatments. A systematic review, following PRISMA guidelines, involved a thorough search across multiple databases including Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Evidence Based Medical Reviews, and Scopus. Out of 590 initially identified studies, 19 studies were included for both qualitative synthesis and meta-analysis after full-text review. Risk of bias was assessed using appropriate tools: The Risk Of Bias In Non-randomized Studies of Interventions tool was applied to twelve studies, while the Joanna Briggs Institute case series critical appraisal tool was used for seven studies. Our findings confirm that CIUE is a rare condition (0.7 %). CIUE is associated with decreased live birth rates (53 %), increased recurrent pregnancy loss (23 %), fetal loss beyond 22 weeks gestation (25 %), a higher prevalence of autoimmune diseases (14 %), and a recurrence rate of 30 % in subsequent pregnancies. Moreover, individuals with CIUE had higher rates of pregnancy complications, including gestational hypertension (19 %), intrauterine growth restriction (45 %), and preterm births (43 %). No significant improvement in live birth rate was observed among treated CIUE patients; however, caution is warranted when interpreting these findings due to the limited sample size. Future research in CIUE is crucial given its rarity and complexity.
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Affiliation(s)
- Natasha Simula
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Kathryn McRae
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Ruth Habte
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Women's Health Research Institute, Vancouver, BC, Canada
| | - Bahi Fayek
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Division of Reproductive Endocrinology & Infertility, Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Erica Won
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Division of Reproductive Endocrinology & Infertility, Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Yang Doris Liu
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Division of Reproductive Endocrinology & Infertility, Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Arianne Albert
- Women's Health Research Institute, Vancouver, BC, Canada
| | - Faten F AbdelHafez
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Division of Reproductive Endocrinology & Infertility, Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Jefferson Terry
- Division of Anatomical Pathology, Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mohamed A Bedaiwy
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Women's Health Research Institute, Vancouver, BC, Canada; Division of Reproductive Endocrinology & Infertility, Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada.
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Brady CA, Riley T, Batra G, Crocker I, Heazell AEP. Characterizing Histopathologic Features in Pregnancies With Chronic Histiocytic Intervillositis Using Computerized Image Analysis. Arch Pathol Lab Med 2024; 148:430-442. [PMID: 37490411 DOI: 10.5858/arpa.2022-0494-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2023] [Indexed: 07/27/2023]
Abstract
CONTEXT.— Chronic histiocytic intervillositis (CHI) is a rare condition characterized by maternal immune cell infiltration into the human placenta. CHI is strongly associated with fetal growth restriction, miscarriage, and stillbirth, and knowledge of its etiology, and consequently effective treatment, is limited. Currently, diagnosis is largely subjective and varies between centers, making comparison between studies challenging. OBJECTIVE.— To objectively quantify and interrelate inflammatory cells and fibrin in placentas with CHI compared with controls and determine how pathology may be altered in subsequent pregnancies following diagnosis. Macrophage phenotype was also investigated in untreated cases of CHI. DESIGN.— Computerized analysis was applied to immunohistochemically stained untreated (index) cases of CHI, subsequent pregnancies, and controls. Index placentas were additionally stained by immunofluorescence for M1 (CD80 and CD86) and M2 macrophage markers (CD163 and CD206). RESULTS.— Quantification revealed a median 32-fold increase in macrophage infiltration in index cases versus controls, with CHI recurring in 2 of 11 (18.2%) subsequent pregnancies. A total of 4 of 14 placentas (28.6%) with a diagnosis of CHI did not exhibit infiltration above controls. Macrophages in index pregnancies strongly expressed CD163. There was no significant difference in fibrin deposition between index cases and controls, although subsequent pregnancies displayed a 2-fold decrease compared with index pregnancies. CD3+ T cells were significantly elevated in index pregnancies; however, they returned to normal levels in subsequent pregnancies. CONCLUSIONS.— In CHI, intervillous macrophages expressed CD163, possibly representing an attempt to resolve inflammation. Computerized analysis of inflammation in CHI may be useful in determining how treatment affects recurrence, and alongside pathologist expertise in grading lesion severity.
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Affiliation(s)
- Chloe A Brady
- From Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, United Kingdom (Brady, Riley, Crocker, Heazell)
| | - Tihesia Riley
- From Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, United Kingdom (Brady, Riley, Crocker, Heazell)
- the Royal Bolton Hospital, Bolton NHS Foundation Trust, Bolton, United Kingdom (Riley)
| | - Gauri Batra
- the Department of Paediatric and Perinatal Pathology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom (Batra)
| | - Ian Crocker
- From Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, United Kingdom (Brady, Riley, Crocker, Heazell)
| | - Alexander E P Heazell
- From Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, United Kingdom (Brady, Riley, Crocker, Heazell)
- Saint Mary's Hospital Managed Clinical Maternity Service, Manchester Academic Health Science Centre, Manchester, United Kingdom (Heazell)
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Merriel A, Fitzgerald B, O'Donoghue K. SARS-CoV-2-Placental effects and association with stillbirth. BJOG 2024; 131:385-400. [PMID: 37984971 DOI: 10.1111/1471-0528.17698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 10/02/2023] [Accepted: 10/14/2023] [Indexed: 11/22/2023]
Abstract
SARS-CoV-2 has had a significant impact on pregnancy outcomes due to the effects of the virus and the altered healthcare environment. Stillbirth has been relatively hidden during the COVID-19 pandemic, but a clear link between SARS-CoV-2 and poor fetal outcome emerged in the Alpha and Delta waves. A small minority of women/birthing people who contracted COVID-19 developed SARS-CoV-2 placentitis. In many reported cases this was linked to intrauterine fetal death, although there are cases of delivery just before imminent fetal demise and we shall discuss how some cases are sub-clinical. What is surprising, is that SARS-CoV-2 placentitis is often not associated with severe maternal COVID-19 infection and this makes it difficult to predict. The worst outcomes seem to be with diffuse placental disease which occurs within 21 days of COVID-19 diagnosis. Poor outcomes are often pre-dated by reduced fetal movements but are not associated with ultrasound changes. In some cases, there has also been maternal thrombocytopenia, or coagulation abnormalities, which may provide a clue as to which pregnancies are at risk of fetal demise if a further variant of concern is to emerge. In future, multidisciplinary collaboration and cross-boundary working must be prioritised, to identify quickly such a phenomenon and provide clinicians with clear guidance for reducing fetal death and associated poor outcomes. While we wait to see if COVID-19 brings a future variant of concern, we must focus on appropriate future management of women who have had SARS-CoV-2 placentitis. As a placental condition with an infectious aetiology, SARS-CoV-placentitis is unlikely to recur in a subsequent pregnancy and thus a measured approach to subsequent pregnancy management is needed.
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Affiliation(s)
- Abi Merriel
- Centre for Women's Health Research, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- Liverpool Women's Hospital, Liverpool, UK
| | | | - Keelin O'Donoghue
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
- Cork University Maternity Hospital, Cork, Ireland
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Lopuhaä B, Voorham QJM, van Kemenade FJ, von der Thüsen JH. COVID-19 in the Netherlands: lessons from a nationwide query of dutch autopsy, histology, and cytology pathological reports. Virchows Arch 2024; 484:429-439. [PMID: 38413389 PMCID: PMC11021292 DOI: 10.1007/s00428-024-03771-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/08/2024] [Accepted: 02/20/2024] [Indexed: 02/29/2024]
Abstract
Since the onset of the COVID-19 pandemic, autopsies have played a valuable role in understanding the pathophysiology of COVID-19. In this study, we have analyzed COVID-19-related pathology reports from autopsies, histology, and cytology on a nationwide level. Pathology reports from all 43 pathology laboratories in the Netherlands stating "COVID," "Corona," and/or "SARS" were queried from the Dutch Nationwide Pathology Database (Palga). Consecutive reports of the included patients were also retrieved. Out of 5065 entries, a total of 1833 eligible COVID-19-related pathology reports between January 2020 and June 2021 were included in this collection of reports. Lung histopathology reports reflected differences in the severity of abnormalities (acute diffuse alveolar damage, alveolar histiocytes, and thrombi during the first three pandemic waves (Wuhan variant) versus the fourth wave (alpha variant)). Autopsy reports from 2020 state significantly shorter disease duration and younger age of death compared to autopsy reports from 2021. All reports together reflected a more granular pathology with comorbidities such as chronic histiocytic intervillositis, perniosis, and thrombi found in a variety of organs (lungs, kidneys, and small and large intestines). This nationwide overview of pathology reports provides data related to deaths as well as comorbidities in a clinical setting of COVID-19. Certain findings reported in SARS-CoV-infected lungs and placentas were also reported in post-COVID-19 tissue of the same kind. Consecutive reports after the earliest reports with COVID-19 allowed for follow-up reports. These follow-up reports can help with post-viral studies regarding long-term effects of COVID-19 as well as identifying the effects of different SARS-CoV-2 variants.
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Affiliation(s)
- Boaz Lopuhaä
- Department of Pathology and Clinical Bioinformatics, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - Q J M Voorham
- Dutch Nationwide Pathology Databank (Palga), Houten, the Netherlands
| | - Folkert J van Kemenade
- Department of Pathology and Clinical Bioinformatics, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Jan H von der Thüsen
- Department of Pathology and Clinical Bioinformatics, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
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Chan ES, de Koning L, Yu W, Chadha R. C4d Staining Is Present in Normal Placentas From Pregnancies Prior to Pregnancy Loss Associated With Chronic Histiocytic Intervillositis and Is Reduced by Immunomodulatory Therapy in Subsequent Pregnancies. Pediatr Dev Pathol 2023; 26:374-387. [PMID: 37232363 PMCID: PMC10559644 DOI: 10.1177/10935266231176682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Chronic histiocytic intervillositis (CHI) is associated with adverse pregnancy outcomes and high recurrence risk. Recent studies suggest that CHI may represent a host-vs-graft rejection, and that C4d immunostain can be used as a marker for complement activation and antibody-mediated rejection in the CHI. MATERIALS AND METHODS This retrospective cohort study focused on 5 fetal autopsy cases associated with CHI (5 index cases) from 5 women. We analyzed placentas from the index cases (fetal autopsy cases associated with CHI) and placentas from the women's previous and subsequent pregnancies. We assessed the presence and extent of CHI and C4d immunostaining in these placentas. We evaluated each available placenta and graded the severity of CHI as either <50% or ≥50%. Additionally, we conducted C4d immunostaining on one representative section from each placenta and graded the staining levels as follows: 0+ for staining <5%; 1+ for staining between 5% and <25%; 2+ for staining between 25% and <75%; and 3+ for staining ≥75%. RESULTS Three of the 5 women had pregnancies prior to their index cases (fetal autopsy cases associated with CHI). Despite the absence of CHI in their initial pregnancies, the placentas displayed positive C4d staining with grades of 1+, 3+, and 3+, respectively. These results suggest the presence of complement activation and antibody-mediated rejection in placentas from their prior pregnancies without CHI. Three of the 5 women received immunomodulatory therapy after experiencing pregnancy losses associated with CHI. After treatment, 2 of these women had live births at 35 and 37 gestational weeks, respectively, while the third had a stillbirth at 25 gestational weeks. The severity of CHI and the degree of C4d staining in the placentas decreased in all 3 cases following immunomodulatory therapies. Specifically, the level of C4d staining decreased from 3+ to 2+, 2+ to 0+, and 3+ to 1+ in these 3 cases, respectively. DISCUSSION In women with a history of recurrent pregnancy loss associated with CHI, C4d immunostaining was present in the placentas from their previous non-CHI pregnancies, suggesting activation of the classical complement pathway and antibody-mediated reaction in their prior non-CHI pregnancies before the development of CHI in subsequent pregnancies. Immunomodulatory therapy may improve pregnancy outcomes by reducing complement activation, as shown by the reduction of C4d immunopositivity in the placentas after immunomodulatory treatment. Although we believe that the study provides valuable insights, we acknowledge that there are limitations to the findings. Therefore, to further elucidate the pathogenesis of CHI, additional research efforts with a collaborative and multidisciplinary approach are necessary.
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Affiliation(s)
- Elaine S. Chan
- Department of Pathology and Laboratory Medicine, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Alberta Children’s Hospital, Calgary, AB, Canada
- Alberta Precision Laboratories, Calgary, AB, Canada
| | - Lawrence de Koning
- Department of Pathology and Laboratory Medicine, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Alberta Children’s Hospital, Calgary, AB, Canada
- Alberta Precision Laboratories, Calgary, AB, Canada
| | - Weiming Yu
- Department of Pathology and Laboratory Medicine, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Alberta Children’s Hospital, Calgary, AB, Canada
- Alberta Precision Laboratories, Calgary, AB, Canada
| | - Rati Chadha
- Department of Obstetrics and Gynaecology, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
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De Luca D, Vauloup-Fellous C, Benachi A, Vivanti A. Transmission of SARS-CoV-2 from mother to fetus or neonate: What to know and what to do? Semin Fetal Neonatal Med 2023; 28:101429. [PMID: 36935314 PMCID: PMC10010052 DOI: 10.1016/j.siny.2023.101429] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
SARS-CoV-2 can be vertically transmitted from the mother to the fetus and the neonate. This transmission route is rare compared to the environmental or horizontal spread and therefore, the risk can be deemed inconsequential by some medical providers. However, severe, although just as rare, feto-neonatal consequences are possible: fetal demise, severe/critical neonatal COVID-19 and multi-inflammatory syndrome (MIS-N) have been described. Therefore, it is important for the clinicians to know the mechanism of vertical transmission, how to recognize this, and how to deal with neonatal COVID-19 and MIS-N. Our knowledge about this field has significantly increased in the last three years. This is a summary of the pathophysiology, diagnostics, and therapeutics of vertical SARS-CoV-2 transmission that clinicians apply in their clinical practice.
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Affiliation(s)
- Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "Antoine Béclère" Hospital, Paris Saclay University Hospitals, APHP, Clamart, France.
| | - Christelle Vauloup-Fellous
- Division of Virology, "Paul Brousse" Hospital, Paris Saclay University Hospitals, APHP, Villejuif, France
| | - Alexandra Benachi
- Division of Obstetrics and Gynecology, "Antoine Béclère" Hospital, Paris Saclay University Hospitals, APHP, Clamart, France
| | - Alexandre Vivanti
- Division of Obstetrics and Gynecology, "Antoine Béclère" Hospital, Paris Saclay University Hospitals, APHP, Clamart, France
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Redline RW, Roberts DJ, Parast MM, Ernst LM, Morgan TK, Greene MF, Gyamfi-Bannerman C, Louis JM, Maltepe E, Mestan KK, Romero R, Stone J. Placental pathology is necessary to understand common pregnancy complications and achieve an improved taxonomy of obstetrical disease. Am J Obstet Gynecol 2023; 228:187-202. [PMID: 35973475 PMCID: PMC10337668 DOI: 10.1016/j.ajog.2022.08.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/08/2022] [Accepted: 08/08/2022] [Indexed: 01/28/2023]
Abstract
The importance of a fully functioning placenta for a good pregnancy outcome is unquestioned. Loss of function can lead to pregnancy complications and is often detected by a thorough placental pathologic examination. Placental pathology has advanced the science and practice of obstetrics and neonatal-perinatal medicine by classifying diseases according to underlying biology and specific patterns of injury. Many past obstacles have limited the incorporation of placental findings into both clinical studies and day-to-day practice. Limitations have included variability in the nomenclature used to describe placental lesions, a shortage of perinatal pathologists fully competent to analyze placental specimens, and a troubling lack of understanding of placental diagnoses by clinicians. However, the potential use of placental pathology for phenotypic classification, improved understanding of the biology of adverse pregnancy outcomes, the development of treatment and prevention, and patient counseling has never been greater. This review, written partly in response to a recent critique published in a major obstetrics-gynecology journal, reexamines the role of placental pathology by reviewing current concepts of biology; explaining the most recent terminology; emphasizing the usefulness of specific diagnoses for obstetrician-gynecologists, neonatologists, and patients; previewing upcoming changes in recommendations for placental submission; and suggesting future improvements. These improvements should include further consideration of overall healthcare costs, cost-effectiveness, the clinical value added of placental assessment, improvements in placental pathology education and practice, and leveraging of placental pathology to identify new biomarkers of disease and evaluate novel therapies tailored to specific clinicopathologic phenotypes of both women and infants.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology and Reproductive Biology, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center and Cleveland, OH.
| | - Drucilla J Roberts
- Department of Pathology, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - Mana M Parast
- Department of Pathology, Sanford Consortium for Regenerative Medicine, University of California San Diego, La Jolla, CA
| | - Linda M Ernst
- Department of Pathology and Laboratory Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Terry K Morgan
- Department of Pathology and Obstetrics and Gynecology, Center for Developmental Health, Oregon Health Sciences University, Portland, OR
| | - Michael F Greene
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, La Jolla, CA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University South Florida, Tampa, FL
| | - Emin Maltepe
- Department of Pediatrics, University California, San Francisco, San Francisco, CA
| | - Karen K Mestan
- Department of Pediatrics and Neonatology, University of California, San Diego, School of Medicine and Rady Children's Hospital, San Diego, CA
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, Maryland, Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Detroit Medical Center, Detroit, MI
| | - Joanne Stone
- Raquel and Jaime Gilinski Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
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Dall'Asta A, Melito C, Morganelli G, Lees C, Ghi T. Determinants of placental insufficiency in fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:152-157. [PMID: 36349884 DOI: 10.1002/uog.26111] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/14/2022] [Accepted: 10/18/2022] [Indexed: 05/27/2023]
Affiliation(s)
- A Dall'Asta
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
- Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, London, UK
| | - C Melito
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
- Department of Obstetrics and Gynaecology, IRCCS Fondazione Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - G Morganelli
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
| | - C Lees
- Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, London, UK
- Centre for Fetal Care, Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - T Ghi
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
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Terry J, Bedaiwy MA. Placental interferon signaling is involved in chronic intervillositis of unknown etiology. Placenta 2022; 124:5-11. [DOI: 10.1016/j.placenta.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/02/2022] [Accepted: 05/10/2022] [Indexed: 11/29/2022]
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11
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Cornish EF, McDonnell T, Williams DJ. Chronic Inflammatory Placental Disorders Associated With Recurrent Adverse Pregnancy Outcome. Front Immunol 2022; 13:825075. [PMID: 35529853 PMCID: PMC9072631 DOI: 10.3389/fimmu.2022.825075] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/29/2022] [Indexed: 12/11/2022] Open
Abstract
Chronic inflammatory placental disorders are a group of rare but devastating gestational syndromes associated with adverse pregnancy outcome. This review focuses on three related conditions: villitis of unknown etiology (VUE), chronic histiocytic intervillositis (CHI) and massive perivillous fibrin deposition (MPFD). The hallmark of these disorders is infiltration of the placental architecture by maternal immune cells and disruption of the intervillous space, where gas exchange between the mother and fetus occurs. Currently, they can only be detected through histopathological examination of the placenta after a pregnancy has ended. All three are associated with a significant risk of recurrence in subsequent pregnancies. Villitis of unknown etiology is characterised by a destructive infiltrate of maternal CD8+ T lymphocytes invading into the chorionic villi, combined with activation of fetal villous macrophages. The diagnosis can only be made when an infectious aetiology has been excluded. VUE becomes more common as pregnancy progresses and is frequently seen with normal pregnancy outcome. However, severe early-onset villitis is usually associated with fetal growth restriction and recurrent pregnancy loss. Chronic histiocytic intervillositis is characterised by excessive accumulation of maternal CD68+ histiocytes in the intervillous space. It is associated with a wide spectrum of adverse pregnancy outcomes including high rates of first-trimester miscarriage, severe fetal growth restriction and late intrauterine fetal death. Intervillous histiocytes can also accumulate due to infection, including SARS-CoV-2, although this infection-induced intervillositis does not appear to recur. As with VUE, the diagnosis of CHI requires exclusion of an infectious cause. Women with recurrent CHI and their families are predisposed to autoimmune diseases, suggesting CHI may have an alloimmune pathology. This observation has driven attempts to prevent CHI with a wide range of maternal immunosuppression. Massive perivillous fibrin deposition is diagnosed when >25% of the intervillous space is occupied by fibrin, and is associated with fetal growth restriction and late intrauterine fetal death. Although not an inflammatory disorder per se, MPFD is frequently seen in association with both VUE and CHI. This review summarises current understanding of the prevalence, diagnostic features, clinical consequences, immune pathology and potential prophylaxis against recurrence in these three chronic inflammatory placental syndromes.
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Affiliation(s)
- Emily F. Cornish
- Elizabeth Garrett Anderson Institute for Women’s Health, Department of Maternal and Fetal Medicine, University College London, London, United Kingdom,*Correspondence: Emily F. Cornish,
| | - Thomas McDonnell
- Faculty of Engineering Science, Department of Biochemical Engineering, University College London, London, United Kingdom
| | - David J. Williams
- Elizabeth Garrett Anderson Institute for Women’s Health, Department of Maternal and Fetal Medicine, University College London, London, United Kingdom
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12
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Bouariu A, Gică N, Ciobanu AM, Scutelnicu AM, Popescu MR, Panaitescu AM. The Potential Benefit of Hydroxychloroquine in Chronic Placental Inflammation of Unknown Etiology Associated with Adverse Pregnancy Outcomes. Healthcare (Basel) 2022; 10:168. [PMID: 35052331 PMCID: PMC8775717 DOI: 10.3390/healthcare10010168] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/27/2021] [Accepted: 01/14/2022] [Indexed: 11/17/2022] Open
Abstract
The placenta is the site of connection between maternal and fetal circulation, and the liaison is established early in pregnancy. A large variety of pregnancy complications such as preterm birth, fetal growth restriction, or pregnancy loss have placental expression and can be accompanied in some cases of acute or chronic identifiable placental inflamatory lesions. Chronic placental inflammatory (CPI) lesions include chronic villitis of unknow etiology (CVUE), chronic intervillositis of unknown etiology, CIUE (also described as chronic histiocytic intervillositis, CHI), and chronic deciduits. Hydroxychloroquine (HCQ) has been prescribed with good results during pregnancy to prevent adverse perinatal outcomes in maternal autoimmune conditions. Its success has paved the way to its use in CPI as CIUE/CHI; however, to date, there are no prospective, informatively designed, controlled studies on its value in these setting. This review aims to explore the potential role of HCQ in CPI of unknown etiology. Ideally, properly designed, probably multicentric studies should be undertaken to fully understand HCQ's role for prevention of adverse pregnancy outcomes after a chronic placental inflammation.
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Affiliation(s)
- Alexandra Bouariu
- Department of Obstetrics and Gynecology Filantropia, Clinical Hospital Bucharest, 011171 Bucharest, Romania; (A.B.); (N.G.); (A.M.C.); (A.M.S.)
| | - Nicolae Gică
- Department of Obstetrics and Gynecology Filantropia, Clinical Hospital Bucharest, 011171 Bucharest, Romania; (A.B.); (N.G.); (A.M.C.); (A.M.S.)
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Anca Marina Ciobanu
- Department of Obstetrics and Gynecology Filantropia, Clinical Hospital Bucharest, 011171 Bucharest, Romania; (A.B.); (N.G.); (A.M.C.); (A.M.S.)
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Ana Maria Scutelnicu
- Department of Obstetrics and Gynecology Filantropia, Clinical Hospital Bucharest, 011171 Bucharest, Romania; (A.B.); (N.G.); (A.M.C.); (A.M.S.)
| | - Mihaela Roxana Popescu
- Department of Obstetrics and Gynecology Filantropia, Clinical Hospital Bucharest, 011171 Bucharest, Romania; (A.B.); (N.G.); (A.M.C.); (A.M.S.)
- Department of Cardiology, Elias University Hospital Bucharest, 011461 Bucharest, Romania
| | - Anca Maria Panaitescu
- Department of Obstetrics and Gynecology Filantropia, Clinical Hospital Bucharest, 011171 Bucharest, Romania; (A.B.); (N.G.); (A.M.C.); (A.M.S.)
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
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13
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Moar L, Simela C, Nanda S, Marnerides A, Al-Adnani M, Nelson-Piercy C, Nicolaides KH, Shangaris P. Chronic histiocytic intervillositis (CHI): current treatments and perinatal outcomes, a systematic review and a meta-analysis. Front Endocrinol (Lausanne) 2022; 13:945543. [PMID: 35937841 PMCID: PMC9355722 DOI: 10.3389/fendo.2022.945543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/29/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Chronic histiocytic intervillositis (CHI) is a rare placental lesion with a high recurrence rate and poor perinatal outcomes. There are currently limited guidelines regarding the diagnosis of this condition in the index pregnancy and treatment where recurrence is suspected. OBJECTIVE The primary objective of this systematic review and meta-analysis was to determine the perinatal outcomes of pregnancies affected by chronic histiocytic intervillositis and to what extent they can be improved with treatment. The secondary objective was to assess the relationship between CHI lesion severity and pregnancy loss. METHODS A systematic search of Ovid Embase, Web of Science, Science Direct, PubMed, Ovid Medline, Google Scholar and CINAHL was carried out. Case reports, cohort, case-control and randomised controlled trials (RCT) detailing the perinatal outcomes of CHI pregnancies, both treated and untreated, were included. RESULTS No RCTs were identified. However, in a review population of 659 pregnancies, with additional 7 in case reports, CHI treatments included aspirin, prednisone, prednisolone, low molecular weight heparin (LMWH), hydroxychloroquine and adalimumab. A descriptive synthesis of data found mixed results for treatments in relation to live birth, miscarriage and fetal growth restriction outcomes. Furthermore, quantitative synthesis of 38 pregnancies revealed a non-significant improvement in live birth rate with CHI targeted treatment (OR 1.79 [95% CI 0.33-9.61] (p=0.50), while meta-analysis of CHI severity in line with pregnancy loss, in a sample of 231 pregnancies, revealed lower odds of pregnancy loss with less severe lesions (OR: 0.17 [0.03-0.80], p=0.03). CONCLUSIONS This systematic review and meta-analysis reinforce notions surrounding the insufficient evidence for CHI treatment. It also strengthens previous hypotheses detailing the positive association between CHI lesion severity and odds of pregnancy loss. Aspirin, LMWH, prednisolone, hydroxychloroquine and adalimumab are candidates with varying levels of weak to moderate evidence supporting their use. Further prospective research is required to obtain robust evidence pertaining to treatment safety and efficacy and optimal drug regimes. SYSTEMATIC REVIEW REGISTRATION [website], identifier CRD42021237604.
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Affiliation(s)
- Laurel Moar
- School of Life Course and Population Sciences, King’s College London, London, United Kingdom
| | - Chloe Simela
- School of Life Course and Population Sciences, King’s College London, London, United Kingdom
| | - Surabhi Nanda
- School of Life Course and Population Sciences, King’s College London, London, United Kingdom
- Department of Women and Children, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Andreas Marnerides
- Department of Histopathology, St. Thomas Hospital, Westminster Bridge Road, London, United Kingdom
| | - Mudher Al-Adnani
- Department of Histopathology, St. Thomas Hospital, Westminster Bridge Road, London, United Kingdom
| | - Catherine Nelson-Piercy
- School of Life Course and Population Sciences, King’s College London, London, United Kingdom
- Department of Women and Children, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Kypros H. Nicolaides
- School of Life Course and Population Sciences, King’s College London, London, United Kingdom
- Harris Birthright Research Centre for Fetal Medicine, King’s College London, London, United Kingdom
| | - Panicos Shangaris
- School of Life Course and Population Sciences, King’s College London, London, United Kingdom
- Department of Women and Children, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- *Correspondence: Panicos Shangaris,
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14
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Moresi S, Dell'Aquila M, Salvi S, Rullo R, Fruci S, Stollagli F, Arena V, Lanzone A. SARS-CoV-2 Infection in Pregnancy: Clinical Signs, Placental Pathology, and Neonatal Outcome-Implications for Clinical Care. Front Med (Lausanne) 2021; 8:676870. [PMID: 34820390 PMCID: PMC8606406 DOI: 10.3389/fmed.2021.676870] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 10/04/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction: The current COVID-19 pandemic has been associated with high rates of mortality and significant morbidity. Both the risk of infection for pregnant women and the risk of vertical transmission have been evaluated, and the presence of the SARS-CoV-2 virus has been demonstrated both in the placenta and in the amniochorionic membranes. However, the actual effects of this pathogen on pregnancy and on placental morphology are still unclear. Objective: To describe histopathologic findings in the placentas of women with SARS-CoV-2 infection during pregnancy and their correlation with clinical signs and perinatal outcome. Methods: Placental tissues from pregnant women with SARS-CoV-2 infection delivering between March 2020 and February 2021 were analyzed. Results: One hundred six placentas from women with SARS-CoV-2 infection during pregnancy who delivered in Fondazione Policlinico A. Gemelli were examined. Most of them were asymptomatic. All neonates had available test results for SARS-CoV-2 and only one resulted positive. Placental tissues mainly showed signs of maternal vascular malperfusion and of placenta injury in terms of syncytial node increase (96.2%), villar agglutination (77.3%), neointimal hyperplasia (76.4%), excessive fibrin deposition (43.3%), and chorangiosis (35.8%). No significant differences in the frequency of the histopathological lesions were observed according to maternal symptoms. Conclusion: Looking to placental tissues from SARS-CoV-2 positive women at the screening performed close to delivery, placental injuries could be detected without any correlation with fetal and neonatal outcomes. We hypothesize that short latency between SARS-CoV-2 infection and delivery is the main reason for these observations.
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Affiliation(s)
- Sascia Moresi
- UOC di Ostetricia e Patologia Ostetrica, Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Marco Dell'Aquila
- UO Gineco-patologia e Patologia Mammaria, Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Silvia Salvi
- UOC di Ostetricia e Patologia Ostetrica, Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Roberta Rullo
- UOC di Ostetricia e Patologia Ostetrica, Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Stefano Fruci
- UOC di Ostetricia e Patologia Ostetrica, Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesca Stollagli
- UOC di Ostetricia e Patologia Ostetrica, Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Vincenzo Arena
- UO Gineco-patologia e Patologia Mammaria, Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Antonio Lanzone
- UOC di Ostetricia e Patologia Ostetrica, Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
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15
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Brady CA, Williams C, Batra G, Church E, Tower CL, Crocker IP, Heazell AEP. Immunomodulatory Therapy Reduces the Severity of Placental Lesions in Chronic Histiocytic Intervillositis. Front Med (Lausanne) 2021; 8:753220. [PMID: 34733868 PMCID: PMC8558526 DOI: 10.3389/fmed.2021.753220] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/23/2021] [Indexed: 11/25/2022] Open
Abstract
Chronic histiocytic intervillositis (CHI) is a rare, but highly recurrent inflammatory placental lesion wherein maternal macrophages infiltrate the intervillous space. Pregnancies with CHI are at high risk of fetal growth restriction, miscarriage or stillbirth. Presently, the diagnosis can only be made after histopathological examination of the placenta. Given its proposed immunological etiology, current treatments include aspirin, heparin, and immunomodulatory agents. However, the rationale for these medications is largely based upon small case series and reports as there is a lack of larger studies investigating treatment efficacy. Therefore, this study sought to determine whether inclusion of immunomodulatory medications was effective at reducing the severity of lesions and improving pregnancy outcomes in subsequent pregnancies. Thirty-three women with a history of CHI in at least one pregnancy (index case) were identified retrospectively through medical records. Twenty-eight participants presented with a first subsequent pregnancy and a further 11 with a second subsequent pregnancy at a specialist clinic for pregnancy after loss. Data on maternal demographics, medical history, medication, pregnancy outcome, and placental pathology was collected and compared between pregnancies. Twenty-seven (69%) subsequent pregnancies were treated with at least one or both of prednisolone and hydroxychloroquine. Inclusion of at least one immunomodulatory agent in treatment regimen resulted in an almost 25% increase in overall livebirth rate (61.5 vs. 86.2%). In women treated with immunomodulatory medication a greater proportion of placentas had reduced severity of lesions compared to those treated without (86.7 vs. 33.3%, respectively). A reduction in CHI severity was associated with a 62.3% improvement in livebirth rate compared to those where severity remained unchanged in relation to the index case. These data provide preliminary evidence that the use of immunomodulatory medication in the management of CHI improves histopathological lesions and the chance of livebirth in subsequent pregnancies. Due to CHI's rarity and ethical and feasibility issues, randomized controlled trials in affected women are challenging to conduct. As a result, collaboration between centers is required in future to increase study sample sizes and elucidate the mechanisms of hydroxychloroquine and prednisolone in reducing pathology.
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Affiliation(s)
- Chloe A Brady
- Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, United Kingdom
| | - Charlotte Williams
- Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, United Kingdom.,Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Gauri Batra
- Pediatric Histopathology, Central Manchester University Hospitals National Health Service Foundation Trust, Manchester, United Kingdom
| | - Elaine Church
- Saint Mary's Hospital Managed Clinical Maternity Service, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Clare L Tower
- Saint Mary's Hospital Managed Clinical Maternity Service, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Ian P Crocker
- Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, United Kingdom
| | - Alexander E P Heazell
- Tommy's Maternal and Fetal Health Research Centre, St Mary's Hospital, The University of Manchester, Manchester, United Kingdom.,Saint Mary's Hospital Managed Clinical Maternity Service, Manchester Academic Health Science Centre, Manchester, United Kingdom
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16
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Schoenmakers S, Snijder P, Verdijk RM, Kuiken T, Kamphuis SSM, Koopman LP, Krasemann TB, Rousian M, Broekhuizen M, Steegers EAP, Koopmans MPG, Fraaij PLA, Reiss IKM. Severe Acute Respiratory Syndrome Coronavirus 2 Placental Infection and Inflammation Leading to Fetal Distress and Neonatal Multi-Organ Failure in an Asymptomatic Woman. J Pediatric Infect Dis Soc 2021; 10:556-561. [PMID: 33367801 PMCID: PMC7798999 DOI: 10.1093/jpids/piaa153] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/23/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND In general, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy is not considered to be an increased risk for severe maternal outcomes but has been associated with an increased risk for fetal distress. Maternal-fetal transmission of SARS-CoV-2 was initially deemed uncertain; however, recently a few cases of vertical transmission have been reported. The intrauterine mechanisms, besides direct vertical transmission, leading to the perinatal adverse outcomes are not well understood. METHODS Multiple maternal, placental, and neonatal swabs were collected for the detection of SARS-CoV-2 using real-time quantitative polymerase chain reaction (RT-qPCR). Serology of immunoglobulins against SARS-CoV-2 was tested in maternal, umbilical cord, and neonatal blood. Placental examination included immunohistochemical investigation against SARS-CoV-2 antigen expression, with SARS-CoV-2 ribonucleic acid (RNA) in situ hybridization and transmission electron microscopy. RESULTS RT-qPCRs of the oropharynx, maternal blood, vagina, placenta, and urine were all positive over a period of 6 days, while breast milk, feces, and all neonatal samples tested negative. Placental findings showed the presence of SARS-CoV-2 particles with generalized inflammation characterized by histiocytic intervillositis with diffuse perivillous fibrin depositions with damage to the syncytiotrophoblasts. CONCLUSIONS Placental infection by SARS-CoV-2 leads to fibrin depositions hampering fetal-maternal gas exchange with resulting fetal distress necessitating a premature emergency cesarean section. Postpartum, the neonate showed a fetal or pediatric inflammatory multisystem-like syndrome with coronary artery ectasia temporarily associated with SARS-CoV-2 for which admittance and care on the neonatal intensive care unit (NICU) were required, despite being negative for SARS-CoV-2. This highlights the need for awareness of adverse fetal and neonatal outcomes during the current coronavirus disease 2019 pandemic, especially considering that the majority of pregnant women appear asymptomatic.
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Affiliation(s)
- Sam Schoenmakers
- Department of Obstetrics and Gynaecology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Pauline Snijder
- Department of Neonatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Robert M Verdijk
- Department of Pathology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Thijs Kuiken
- Department of Viroscience, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sylvia S M Kamphuis
- Department of Pediatric Infectiology, Immunology and Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Laurens P Koopman
- Department of Pediatric Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Thomas B Krasemann
- Department of Pediatric Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Melek Rousian
- Department of Obstetrics and Gynaecology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Michelle Broekhuizen
- Department of Neonatology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Pharmacology and Vascular Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eric A P Steegers
- Department of Obstetrics and Gynaecology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marion P G Koopmans
- Department of Viroscience, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Pieter L A Fraaij
- Department of Viroscience, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Pediatric Infectiology, Immunology and Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Department of Neonatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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17
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One-Sided Chronic Intervillositis of Unknown Etiology in Dizygotic Twins: A Description of 3 Cases. Int J Mol Sci 2021; 22:ijms22094786. [PMID: 33946432 PMCID: PMC8125367 DOI: 10.3390/ijms22094786] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 04/23/2021] [Accepted: 04/27/2021] [Indexed: 11/16/2022] Open
Abstract
Chronic intervillositis of unknown etiology (CIUE) is a rare, poorly understood, histopathological diagnosis of the placenta that is frequently accompanied by adverse pregnancy outcomes including miscarriage, fetal growth restriction, and intrauterine fetal death. CIUE is thought to have an immunologically driven pathophysiology and may be related to human leukocyte antigen mismatches between the mother and the fetus. Dizygotic twins with one-sided CIUE provide an interesting context to study the influence of immunogenetic differences in such cases. The main immune-cell subsets were investigated using immunohistochemistry. We identified three dizygotic twin pregnancies in which CIUE was present in only one of the two placentas. Two of the pregnancies ended in term delivery and one ended in preterm delivery. Presence of CIUE was correlated with lower placental weight and lower birthweight. Relative number of CD68, CD56, CD20, and CD3 positive cells were comparable between co-twins. The presence of one-sided CIUE in dizygotic twin pregnancy was associated with selective growth restriction in the affected twin. This suggests a unique fetal immunogenetic contribution to the pathogenesis of CIUE. Further study of dizygotic and monozygotic placentas affected by CIUE could identify new insights into its pathophysiology and into the field of reproductive immunology.
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18
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Melamed N, Baschat A, Yinon Y, Athanasiadis A, Mecacci F, Figueras F, Berghella V, Nazareth A, Tahlak M, McIntyre HD, Da Silva Costa F, Kihara AB, Hadar E, McAuliffe F, Hanson M, Ma RC, Gooden R, Sheiner E, Kapur A, Divakar H, Ayres‐de‐Campos D, Hiersch L, Poon LC, Kingdom J, Romero R, Hod M. FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction. Int J Gynaecol Obstet 2021; 152 Suppl 1:3-57. [PMID: 33740264 PMCID: PMC8252743 DOI: 10.1002/ijgo.13522] [Citation(s) in RCA: 187] [Impact Index Per Article: 62.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Fetal growth restriction (FGR) is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction. Worldwide, FGR is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Ongoing advances in clinical care, especially in definitions, diagnosis, and management of FGR, require efforts to effectively translate these changes to the wide range of obstetric care providers. This article highlights agreements based on current research in the diagnosis and management of FGR, and the areas that need more research to provide further clarification of recommendations. The purpose of this article is to provide a comprehensive summary of available evidence along with practical recommendations concerning the care of pregnancies at risk of or complicated by FGR, with the overall goal to decrease the risk of stillbirth and neonatal mortality and morbidity associated with this condition. To achieve these goals, FIGO (the International Federation of Gynecology and Obstetrics) brought together international experts to review and summarize current knowledge of FGR. This summary is directed at multiple stakeholders, including healthcare providers, healthcare delivery organizations and providers, FIGO member societies, and professional organizations. Recognizing the variation in the resources and expertise available for the management of FGR in different countries or regions, this article attempts to take into consideration the unique aspects of antenatal care in low-resource settings (labelled “LRS” in the recommendations). This was achieved by collaboration with authors and FIGO member societies from low-resource settings such as India, Sub-Saharan Africa, the Middle East, and Latin America.
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Affiliation(s)
- Nir Melamed
- Division of Maternal Fetal MedicineDepartment of Obstetrics and GynecologySunnybrook Health Sciences CentreUniversity of TorontoTorontoONCanada
| | - Ahmet Baschat
- Center for Fetal TherapyDepartment of Gynecology and ObstetricsJohns Hopkins UniversityBaltimoreMDUSA
| | - Yoav Yinon
- Fetal Medicine UnitDepartment of Obstetrics and GynecologySheba Medical CenterTel‐HashomerSackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
| | - Apostolos Athanasiadis
- Third Department of Obstetrics and GynecologyAristotle University of ThessalonikiThessalonikiGreece
| | - Federico Mecacci
- Maternal Fetal Medicine UnitDivision of Obstetrics and GynecologyDepartment of Biomedical, Experimental and Clinical SciencesUniversity of FlorenceFlorenceItaly
| | - Francesc Figueras
- Maternal‐Fetal Medicine DepartmentBarcelona Clinic HospitalUniversity of BarcelonaBarcelonaSpain
| | - Vincenzo Berghella
- Division of Maternal‐Fetal MedicineDepartment of Obstetrics and GynecologyThomas Jefferson UniversityPhiladelphiaPAUSA
| | - Amala Nazareth
- Jumeira Prime Healthcare GroupEmirates Medical AssociationDubaiUnited Arab Emirates
| | - Muna Tahlak
- Latifa Hospital for Women and ChildrenDubai Health AuthorityEmirates Medical AssociationMohammad Bin Rashid University for Medical Sciences, Dubai, United Arab Emirates
| | | | - Fabrício Da Silva Costa
- Department of Gynecology and ObstetricsRibeirão Preto Medical SchoolUniversity of São PauloRibeirão PretoSão PauloBrazil
| | - Anne B. Kihara
- African Federation of Obstetricians and GynaecologistsKhartoumSudan
| | - Eran Hadar
- Helen Schneider Hospital for WomenRabin Medical CenterPetach TikvaIsrael
- Sackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
| | - Fionnuala McAuliffe
- UCD Perinatal Research CentreSchool of MedicineNational Maternity HospitalUniversity College DublinDublinIreland
| | - Mark Hanson
- Institute of Developmental SciencesUniversity Hospital SouthamptonSouthamptonUK
- NIHR Southampton Biomedical Research CentreUniversity of SouthamptonSouthamptonUK
| | - Ronald C. Ma
- Department of Medicine and TherapeuticsThe Chinese University of Hong KongHong Kong SARChina
- Hong Kong Institute of Diabetes and ObesityThe Chinese University of Hong KongHong Kong SARChina
| | - Rachel Gooden
- FIGO (International Federation of Gynecology and Obstetrics)LondonUK
| | - Eyal Sheiner
- Soroka University Medical CenterBen‐Gurion University of the NegevBe’er‐ShevaIsrael
| | - Anil Kapur
- World Diabetes FoundationBagsværdDenmark
| | | | | | - Liran Hiersch
- Sourasky Medical Center and Sackler Faculty of MedicineLis Maternity HospitalTel Aviv UniversityTel AvivIsrael
| | - Liona C. Poon
- Department of Obstetrics and GynecologyPrince of Wales HospitalThe Chinese University of Hong KongShatinHong Kong SAR, China
| | - John Kingdom
- Division of Maternal Fetal MedicineDepartment of Obstetrics and GynecologyMount Sinai HospitalUniversity of TorontoTorontoONCanada
| | - Roberto Romero
- Perinatology Research BranchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMDUSA
| | - Moshe Hod
- Helen Schneider Hospital for WomenRabin Medical CenterPetach TikvaIsrael
- Sackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
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19
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Brady CA, Williams C, Sharps MC, Shelleh A, Batra G, Heazell AEP, Crocker IP. Chronic histiocytic intervillositis: A breakdown in immune tolerance comparable to allograft rejection? Am J Reprod Immunol 2021; 85:e13373. [PMID: 33155353 PMCID: PMC7988544 DOI: 10.1111/aji.13373] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/14/2020] [Accepted: 11/03/2020] [Indexed: 12/15/2022] Open
Abstract
Chronic histiocytic intervillositis (CHI) is a pregnancy disorder characterized by infiltration of maternal macrophages into the intervillous space of the human placenta, often with accompanying perivillous fibrin deposition. CHI is associated strongly with foetal growth restriction and increased risk of miscarriage and stillbirth. Although rare, affecting 6 in every 10 000 pregnancies beyond 12 weeks' gestation, the rate of recurrence is high at 25%-100%. To date, diagnosis of CHI can only be made post-delivery upon examination of the placenta due to a lack of diagnostic biomarkers, and criteria vary across publications. No treatment options have shown proven efficacy, and CHI remains a serious obstetric conundrum. Although its underlying aetiology is unclear, due to the presence of maternal macrophages and the reported increased incidence in women with autoimmune disease, CHI is hypothesized to be an inappropriate immune response to the semi-allogeneic foetus. Given this lack of understanding, treatment approaches remain experimental with limited rationale. However, there is recent evidence that immunosuppression and antithrombotic therapies may be effective in preventing recurrence of associated adverse pregnancy outcomes. With similarities noted between the pathological features of CHI and acute rejection of solid organ transplants, further investigation of this hypothesis may provide a basis for tackling CHI and other immune-related placental conditions. This review will explore parallels between CHI and allograft rejection and identify areas requiring further confirmation and exploitation of this comparison.
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Affiliation(s)
- Chloe A. Brady
- Tommy's Maternal and Fetal Health Research CentreSt. Mary’s HospitalThe University of ManchesterManchesterUK
| | - Charlotte Williams
- Tommy's Maternal and Fetal Health Research CentreSt. Mary’s HospitalThe University of ManchesterManchesterUK
- University of ExeterExeterUK
| | - Megan C. Sharps
- Tommy's Maternal and Fetal Health Research CentreSt. Mary’s HospitalThe University of ManchesterManchesterUK
| | - Amena Shelleh
- St Mary’s HospitalManchester University NHS Foundation TrustManchesterUK
| | - Gauri Batra
- Paediatric HistopathologyCentral Manchester University Hospitals NHS Foundation TrustManchesterUK
| | - Alexander E. P. Heazell
- Tommy's Maternal and Fetal Health Research CentreSt. Mary’s HospitalThe University of ManchesterManchesterUK
- St Mary’s HospitalManchester University NHS Foundation TrustManchesterUK
| | - Ian P. Crocker
- Tommy's Maternal and Fetal Health Research CentreSt. Mary’s HospitalThe University of ManchesterManchesterUK
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20
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Chronic Intervillositis of Unknown Etiology: Development of a Grading and Scoring System That Is Strongly Associated With Poor Perinatal Outcomes. Am J Surg Pathol 2020; 44:1367-1373. [PMID: 32773529 DOI: 10.1097/pas.0000000000001549] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Chronic intervillositis of unknown etiology (CIUE) is a rare placental disease characterized by intervillous infiltration of maternal macrophages and associated with poor pregnancy outcomes and a high risk of recurrence in subsequent pregnancies. Its pathophysiology remains unclear and prognostic factors have not yet been established. In addition, clear relationships between the histologic extent of lesions and the severity of perinatal outcomes have not been demonstrated. Our objectives were to validate a CIUE classification system based on the gradation of macrophagic infiltration of the intervillous space, and to attempt to correlate these results with perinatal outcomes. For this multicenter retrospective study, 3 pathologists reviewed all cases diagnosed with "intervillositis" between 1997 and 2018. Confirmed CIUE cases were semiquantitatively graded based on the percentage of macrophagic infiltrate in the intervillous space: grade 1 (5% to 10%), grade 2 (10% to 50%), and grade 3 (>50%). Multiple pregnancies and pregnancies with medical follow-up completed outside of the study centers were excluded. In total, 122 cases of CIUE in 102 patients were included in the study. Microscopic classification based on one criterion was easy to perform, and interobserver correlation was good. Grade 3 infiltration was strongly associated with poor perinatal outcomes and fetal growth restriction (P<0.0001). After delivery, only 16.1% of newborns from the grade 3 CIUE group were alive, compared with 59% from the grade 2 and 86.5% from the grade 1 group (P=0.0002). Recurrence risk was associated with CIUE gradation of the index case (P=0.004), with 95% of recurrent CIUE cases being from patients with grades 2 and 3 CIUE. In this study, conducted with the largest CIUE cohort to date, a classification based only on the degree of macrophagic infiltration of the intervillous space was validated, and this classification was shown to be strongly associated with poor perinatal outcomes and risk of recurrence.
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21
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de Moreuil C, Hannigsberg J, Chauvet J, Remoue A, Tremouilhac C, Merviel P, Bellot C, Pan Petesch B, Le Moigne E, Lacut K, Marcorelles P. Factors associated with poor fetal outcome in placental abruption. Pregnancy Hypertens 2020; 23:59-65. [PMID: 33264704 DOI: 10.1016/j.preghy.2020.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/20/2020] [Accepted: 11/19/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES We aimed at describing placental abruption in our county and at evaluating factors associated with poor fetal outcome. STUDY DESIGN In this case-control study, women with placental abruption were identified from two databases of Brest University Hospital between January 2013 and December 2018. MAIN OUTCOME MEASURES Placental histological findings, course of pregnancies, maternal and fetal characteristics were described and compared between cases (placental abruption with stillbirth or neonatal death) and controls. RESULTS We identified 135 placental abruption, of whom 24.4% were complicated with stillbirth and 6.5% with neonatal death. Forty percent of women were smokers and 14.1% had a history of vasculoplacental disorder. Pregnancies were complicated with 42.2% of pre-eclampsia and 43% of intrauterine growth restriction. Cases were associated with more autoimmune diseases in mother (20.0% versus 3.2%, P = 0.003), more aspirin or heparin use during pregnancy (20.0% versus 6.3%, P = 0.03), less pre-eclampsia (25.0% versus 49.5%, P = 0.01) and more deliveries ≤ 34 weeks of gestation (80.0% versus 43.2%, P = 0.0001) than controls. Placentas from cases showed more placental indentation ≥ 30% (42.5% versus 5.3%, P < 0.0001) and less histological chronic inflammation, especially less chronic chorioamniotitis (2.5% versus 24.2%, P = 0.002) than controls. In multivariate analysis, factors negatively associated with poor fetal outcome were placental histological chronic inflammation (P = 0.01) and macroscopic infarcts (P = 0.01). CONCLUSIONS Poor fetal outcome is negatively associated with certain placental histological chronic lesions, but not with pre-eclampsia, what suggests various pathophysiological processes among placental abruption.
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Affiliation(s)
- Claire de Moreuil
- Département de Médecine Vasculaire, Médecine Interne et Pneumologie, CHU de Brest, Hôpital La Cavale Blanche, 29609 Brest Cedex, France; EA 3878, GETBO, Université Bretagne Loire, 29200 Brest, France.
| | - Jacob Hannigsberg
- EA 3878, GETBO, Université Bretagne Loire, 29200 Brest, France; Service de Gynécologie et d'Obstétrique, CHU de Brest, Hôpital Morvan, 29200 Brest, France
| | - Juliette Chauvet
- Département de Biochimie, CHU de Brest, Hôpital La Cavale Blanche, 29609 Brest Cedex, France
| | - Annabelle Remoue
- Service d'Anatomopathologie, CHU de Brest, Hôpital Morvan, 29200 Brest, France
| | - Christophe Tremouilhac
- EA 3878, GETBO, Université Bretagne Loire, 29200 Brest, France; Service de Gynécologie et d'Obstétrique, CHU de Brest, Hôpital Morvan, 29200 Brest, France
| | - Philippe Merviel
- EA 3878, GETBO, Université Bretagne Loire, 29200 Brest, France; Service de Gynécologie et d'Obstétrique, CHU de Brest, Hôpital Morvan, 29200 Brest, France
| | - Charles Bellot
- Service de Gynécologie et d'Obstétrique, CHIC de Quimper, 29000 Quimper, France
| | - Brigitte Pan Petesch
- EA 3878, GETBO, Université Bretagne Loire, 29200 Brest, France; Fédération de Cancérologie et d'Hématologie, CHU de Brest, Hôpital Morvan, 29200 Brest, France
| | - Emmanuelle Le Moigne
- Département de Médecine Vasculaire, Médecine Interne et Pneumologie, CHU de Brest, Hôpital La Cavale Blanche, 29609 Brest Cedex, France; EA 3878, GETBO, Université Bretagne Loire, 29200 Brest, France
| | - Karine Lacut
- Département de Médecine Vasculaire, Médecine Interne et Pneumologie, CHU de Brest, Hôpital La Cavale Blanche, 29609 Brest Cedex, France; EA 3878, GETBO, Université Bretagne Loire, 29200 Brest, France
| | - Pascale Marcorelles
- Service d'Anatomopathologie, CHU de Brest, Hôpital Morvan, 29200 Brest, France; EA 4685 LIEN, Université Bretagne Loire, 29200 Brest, France
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22
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Amabebe E, Anumba DO. The transmembrane G protein-coupled CXCR3 receptor-ligand system and maternal foetal allograft rejection. Placenta 2020; 104:81-88. [PMID: 33296735 DOI: 10.1016/j.placenta.2020.11.003] [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: 10/24/2020] [Accepted: 11/11/2020] [Indexed: 01/14/2023]
Abstract
Chronic placental inflammatory lesions lead to poor obstetric outcomes. These lesions often proceed undetected until examination of placental tissues after delivery and are mediated by CXCR3, a seven-transmembrane G protein-coupled receptor, and its chemokine ligands - CXCL9, CXCL10 and CXCL11. CXCR3-chemokine ligand interaction disrupts feto-maternal immune tolerance and activate obnoxious immunological responses similar to transplant rejection and graft-versus-host disease. The resultant chronic inflammatory responses manifest in different parts of the placenta characterised by the presence of incompatible immunocompetent cells from the feto-maternal unit i.e. maternal CD8+ T cells in the chorionic membrane or plate (chronic chorioamnionitis); foetal Hofbauer cells and maternal CD8+ T cells in the chorionic villous tree (villitis of unknown aetiology); maternal CD8+ T and plasma cells in the basal plate (chronic deciduitis); and maternal CD8+ T cells, histiocytes and T regulatory cells in the intervillous space (chronic intervillositis). This review critically examines how the CXCR3-chemokine ligand interaction disrupts feto-maternal immune tolerance, initiates a series of chronic placental inflammatory lesions, and consequently activates the pathways to intrauterine growth restriction, stillbirth, spontaneous abortion, preterm prelabour rupture of membranes, preterm labour and birth. The possibility of interrupting these signalling pathways through the use of CXCR3 chemokine inhibitors to prevent adverse reproductive sequelae as well as the potential clinical utility of CXCR3 chemokines as non-invasive predictive clinical biomarkers are also highlighted.
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Affiliation(s)
- Emmanuel Amabebe
- Department of Oncology and Metabolism, University of Sheffield, UK
| | - Dilly O Anumba
- Department of Oncology and Metabolism, University of Sheffield, UK.
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23
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Goldstein JA, Gallagher K, Beck C, Kumar R, Gernand AD. Maternal-Fetal Inflammation in the Placenta and the Developmental Origins of Health and Disease. Front Immunol 2020; 11:531543. [PMID: 33281808 PMCID: PMC7691234 DOI: 10.3389/fimmu.2020.531543] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 10/06/2020] [Indexed: 12/17/2022] Open
Abstract
Events in fetal life impact long-term health outcomes. The placenta is the first organ to form and is the site of juxtaposition between the maternal and fetal circulations. Most diseases of pregnancy are caused by, impact, or are reflected in the placenta. The purpose of this review is to describe the main inflammatory processes in the placenta, discuss their immunology, and relate their short- and long-term disease associations. Acute placental inflammation (API), including maternal and fetal inflammatory responses corresponds to the clinical diagnosis of chorioamnionitis and is associated with respiratory and neurodevelopmental diseases. The chronic placental inflammatory pathologies (CPI), include chronic villitis of unknown etiology, chronic deciduitis, chronic chorionitis, eosinophilic T-cell vasculitis, and chronic histiocytic intervillositis. These diseases are less-well studied, but have complex immunology and show mechanistic impacts on the fetal immune system. Overall, much work remains to be done in describing the long-term impacts of placental inflammation on offspring health.
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Affiliation(s)
- Jeffery A. Goldstein
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Kelly Gallagher
- Department of Nutritional Sciences, College of Health and Human Development, Penn State University, University Park, PA, United States
| | - Celeste Beck
- Department of Nutritional Sciences, College of Health and Human Development, Penn State University, University Park, PA, United States
| | - Rajesh Kumar
- Section of Allergy and Immunology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital and Northwestern University, Chicago, IL, United States
| | - Alison D. Gernand
- Department of Nutritional Sciences, College of Health and Human Development, Penn State University, University Park, PA, United States
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24
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Abstract
Two primary patterns of placental calcification have been described, each with distinctive pathophysiology and clinical relevance. We report a novel pattern of diffuse subamniotic calcification. It occurred in a 25-week placenta involved by recurrent chronic histiocytic intervillositis (CHI) associated with severe intrauterine growth restriction (IUGR) and intrauterine fetal demise (IUFD). This was the mother's third stillbirth related to CHI, despite treatment with intravenous immunoglobulin (IVIG), prednisone, low-molecular-weight heparin, and acetylsalicylic acid (ASA). On placental examination, the majority of the fetal surface was calcified. This variably formed a continuous band or dispersed calcium microparticles. Electron microscopy demonstrated associated electron dense deposits highly suggestive of immune complex deposition. CHI explains recurrent IUGR and stillbirth, but has not been associated with calcification or immune complex deposition. We hypothesize IVIG therapy may have caused immune complex deposition and subsequent dystrophic calcification, supported by its rare association with immune complex deposition disorders in the kidney. Identification of additional cases with this pattern of calcification, with additional studies on fresh tissue including immunofluorescence, electron microscopy and mass spectrometry, may aid in elucidating the underlying pathophysiology and clinical significance of this unusual lesion.
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Affiliation(s)
- Erik W Nohr
- Department of Pathology & Laboratory Medicine, Alberta Precision Laboratories, University of Calgary, Calgary, Alberta, Canada
| | - James R Wright
- Department of Pathology & Laboratory Medicine, Alberta Precision Laboratories, University of Calgary, Calgary, Alberta, Canada
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25
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Alonso-Espías M, Martínez-Sánchez N, Robles-Marhuenda A, Martín-Boado ME, Regojo-Zapata RM, Bartha JL. Diagnosis of amyopathic dermatomyositis after two intrauterine fetal deaths. Obstet Med 2020; 14:109-112. [PMID: 34394721 DOI: 10.1177/1753495x20929507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 04/29/2020] [Indexed: 11/16/2022] Open
Abstract
Chronic histiocytic intervillositis (CHIV) is an uncommon condition, characterized by an infiltrate of mononuclear cells of maternal origin in the intervillous space that has been related to placenta insufficiency and poor perinatal outcomes. The aetiology is unclear, although maternal immunological aggression toward fetal tissues has been proposed. Dermatomyositis (DM) is a multisystem autoimmune inflammatory myopathy. Different autoantibodies have been associated with particular clinical phenotypes; presence of anti-melanoma differentiation-associated gen 5 (MDA5) antibody has been associated with rapidly progressive interstitial lung disease and severe skin lesions, none of which the woman had. Described here is a case of a woman diagnosed with amyopathic DM with positive anti-MDA5 antibodies after two intrauterine fetal deaths. Pathological examination of the placenta in both pregnancies showed CHIV. The presence of a potential relationship between both processes is discussed.
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Affiliation(s)
- M Alonso-Espías
- Department of Obstetrics & Gynaecology, Hospital Universitario La Paz, Madrid, Spain
| | - N Martínez-Sánchez
- Department of Obstetrics & Gynaecology, Hospital Universitario La Paz, Madrid, Spain
| | - A Robles-Marhuenda
- Department of Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
| | - M E Martín-Boado
- Department of Obstetrics & Gynaecology, Hospital Universitario La Paz, Madrid, Spain
| | - R M Regojo-Zapata
- Department of Pathology, Hospital Universitario La Paz, Madrid, Spain
| | - J L Bartha
- Department of Obstetrics & Gynaecology, Hospital Universitario La Paz, Madrid, Spain
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26
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Simula NK, Terry J, Kent NE, Robertson J, Purkiss S, Bloomenthal D, Williams C, Bedaiwy MA. Chronic Intervillositis of Unknown Etiology (CIUE): Prevalence, patterns and reproductive outcomes at a tertiary referral institution. Placenta 2020; 100:60-65. [PMID: 32841927 DOI: 10.1016/j.placenta.2020.07.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/21/2020] [Accepted: 07/31/2020] [Indexed: 01/09/2023]
Abstract
INTRODUCTION the objective of this study was to evaluate the incidence of Chronic Intervillositis of Unknown Etiology (CIUE) at our institution and to report on the pregnancy outcomes based on severity of lesions. METHODS retrospective cohort study including 29 889 perinatal specimens from 27 968 patients. The pathology database at our institution was queried for the keywords "intervillositis" and "CIUE" between February 2006 and April 2019. Histology was re-examined using a standardized diagnostic criterion to confirm diagnosis. Cases in which diagnosis was confirmed were categorized as low grade (5-49% intervillous space involvement) or high grade (≥50% involvement). Interventions and pregnancy outcomes were recorded. RESULTS The overall prevalence of CIUE is 0.17% (47 of 27 968 patients), with significantly higher prevalence in 1st trimester products of conception compared with 2nd and 3rd trimester specimens (0.38% vs 0.09%; p < 0.0001). A total of 97 specimens were initially diagnosed with chronic intervillositis. 56 out of 97 (57.7%) specimens met our diagnostic criteria for CIUE on review. Pregnancies with confirmed CIUE had significantly higher rates of pregnancy loss compared with pregnancies with chronic intervillositis not meeting our study criteria for CIUE (94% vs 71%; p = 0.003). Pregnancy loss between low grade (42.9%; 24 out of 56 cases of CIUE) and high grade (57.1%; 32 out of 56 cases) CIUE were not significantly different. DISCUSSION CIUE prevalence is low at 0.17%, but it is associated with pregnancy loss, particularly in the first trimester. High grade disease may be associated with worse pregnancy outcomes than low grade disease.
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Affiliation(s)
- Natasha K Simula
- University of British Columbia, Department of Obstetrics and Gynaecology, Vancouver, BC, V6Z 2K8, Canada
| | - Jefferson Terry
- University of British Columbia, Department of Pathology and Laboratory Medicine, Vancouver, BC, V6T 2B5, Canada
| | - Nancy E Kent
- University of British Columbia, Department of Obstetrics and Gynaecology, Vancouver, BC, V6Z 2K8, Canada
| | - Julie Robertson
- University of British Columbia, Department of Obstetrics and Gynaecology, Vancouver, BC, V6Z 2K8, Canada
| | - Susan Purkiss
- University of British Columbia, Department of Medicine, Vancouver, BC, V6Z 1Y6, Canada
| | - Dena Bloomenthal
- University of British Columbia, Department of Obstetrics and Gynaecology, Vancouver, BC, V6Z 2K8, Canada
| | - Christina Williams
- University of British Columbia, Department of Obstetrics and Gynaecology, Vancouver, BC, V6Z 2K8, Canada
| | - Mohamed A Bedaiwy
- University of British Columbia, Department of Obstetrics and Gynaecology, Vancouver, BC, V6Z 2K8, Canada.
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27
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Mattuizzi A, Sauvestre F, André G, Poingt M, Camberlein C, Carles D, Pelluard F, Blanco P, Sentilhes L, Lazaro E. Adverse perinatal outcomes of chronic intervillositis of unknown etiology: an observational retrospective study of 122 cases. Sci Rep 2020; 10:12611. [PMID: 32724097 PMCID: PMC7387519 DOI: 10.1038/s41598-020-69191-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 07/03/2020] [Indexed: 01/03/2023] Open
Abstract
Our study aimed to assess perinatal outcomes and recurrence rate of Chronic Intervillositis of Unknown Etiology (CIUE). We conducted an observational retrospective study in a tertiary care university hospital in France from January 1, 1997 to July 31, 2018. 122 pregnancies (102 women) with CIUE were included. Cases of the Department of Histopathology placenta database were re-analysed independently by three pathologists specializing in fetal pathology. Diagnosis of CIUE was confirmed according to: (1) the presence of cellular infiltrate in the intervillous space, (2) ~ 80% of the mononuclear cells in the intervillous space positive for CD68, (3) infiltration occupying at least 5% of the intervillous space, and (4) no clinical or histopathological sign of infection. Outcomes of pregnancies with CIUE (miscarriages, stillbirths, terminations of pregnancy, live birth with or without prematurity or fetal growth restriction) and proportion of CIUE recurrence were analysed. The lost pregnancies comprised 17 (13.9%) miscarriages, 17 (13.9%) stillbirths, and 18 (14.8%) terminations of pregnancy. Of the 70 (57.4%) pregnancies that led to a live birth, 38 (54.3%) new-borns were premature and 50 (72.5%) exhibited fetal growth restriction. Among the 102 women, 23 subsequently became pregnant, half of whom (n = 11) developed recurrent CIUE. CIUE was associated with high rates of adverse perinatal outcomes, including pregnancy loss, fetal growth restriction, and preterm birth with a risk of recurrence nearly 50%.
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Affiliation(s)
- Aurélien Mattuizzi
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Place Amélie Rabat Léon, 33000, Bordeaux, France. .,CNRS-UMR 5164, ImmunoConcEpT, Bordeaux University, Bordeaux, France.
| | - Fanny Sauvestre
- Department of Pathology, Bordeaux University Hospital, Bordeaux, France.,CNRS-UMR 5164, ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Gwenaëlle André
- Department of Pathology, Bordeaux University Hospital, Bordeaux, France
| | - Marion Poingt
- Department of Obstetrics and Gynaecology, Bordeaux Nord Polyclinic, Bordeaux, France
| | - Camille Camberlein
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Place Amélie Rabat Léon, 33000, Bordeaux, France
| | - Dominique Carles
- Department of Pathology, Bordeaux University Hospital, Bordeaux, France
| | - Fanny Pelluard
- Department of Pathology, Bordeaux University Hospital, Bordeaux, France
| | - Patrick Blanco
- Department of Immunology, Bordeaux University Hospital, Bordeaux, France.,CNRS-UMR 5164, ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Place Amélie Rabat Léon, 33000, Bordeaux, France
| | - Estibaliz Lazaro
- Department of Internal Medicine, Bordeaux University Hospital, Bordeaux, France.,CNRS-UMR 5164, ImmunoConcEpT, Bordeaux University, Bordeaux, France
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28
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Kreis NN, Ritter A, Louwen F, Yuan J. A Message from the Human Placenta: Structural and Immunomodulatory Defense against SARS-CoV-2. Cells 2020; 9:E1777. [PMID: 32722449 PMCID: PMC7465902 DOI: 10.3390/cells9081777] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 07/20/2020] [Accepted: 07/24/2020] [Indexed: 12/31/2022] Open
Abstract
The outbreak of the coronavirus disease 2019 (COVID-19) pandemic has caused a global public health crisis. Viral infections may predispose pregnant women to a higher rate of pregnancy complications, including preterm births, miscarriage, and stillbirth. Despite reports of neonatal COVID-19, definitive proof of vertical transmission is still lacking. In this review, we summarize studies regarding the potential evidence for transplacental transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), characterize the expression of its receptors and proteases, describe the placental pathology and analyze virus-host interactions at the maternal-fetal interface. We focus on the syncytium, the barrier between mother and fetus, and describe in detail its physical and structural defense against viral infections. We further discuss the potential molecular mechanisms, whereby the placenta serves as a defense front against pathogens by regulating the interferon type III signaling, microRNA-triggered autophagy and the nuclear factor-κB pathway. Based on these data, we conclude that vertical transmission may occur but rare, ascribed to the potent physical barrier, the fine-regulated placental immune defense and modulation strategies. Particularly, immunomodulatory mechanisms employed by the placenta may mitigate violent immune response, maybe soften cytokine storm tightly associated with severely ill COVID-19 patients, possibly minimizing cell and tissue damages, and potentially reducing SARS-CoV-2 transmission.
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Affiliation(s)
- Nina-Naomi Kreis
- Division of Obstetrics and Prenatal Medicine, Department of Gynecology and Obstetrics, University Hospital Frankfurt, J. W. Goethe-University, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany; (A.R.); (F.L.)
| | | | | | - Juping Yuan
- Division of Obstetrics and Prenatal Medicine, Department of Gynecology and Obstetrics, University Hospital Frankfurt, J. W. Goethe-University, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany; (A.R.); (F.L.)
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29
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Abstract
Chronic intervillositis of unknown etiology (CIUE) is a rare placental inflammatory process associated with pregnancy loss and recurrence. We conducted a quality assurance study to assess the diagnostic accuracy and reproducibility of CIUE grading at our institution. Hematoxylin and eosin-stained slides from 20 CIUE cases (31 slides) were reviewed by 7 perinatal pathologists in 2 sequential rounds. Reviewers were instructed to use the diagnostic criteria they were presently following for CIUE and to grade each slide according to the Rota scheme. In the first round, 20 slides were assessed. The diagnostic accuracy was 94%, the average percent agreement of Rota grade was 79%, and the Fleiss' kappa value for interobserver variability was 0.54. The results were reviewed by all pathologists with diagnostic and grading criteria agreed upon prior to the second round. In round 2, the remaining 11 slides were assessed. Diagnostic accuracy was 83%, the average percent agreement on Rota grade was 70%, and the Fleiss' kappa value for interobserver variability was 0.36. Overall, diagnostic accuracy was high and agreement on Rota grade was moderate. Group review did not appear to improve accuracy. Simplifying CIUE grading to a low-grade/high-grade scheme (<50% or ≥50%) might improve grading reproducibility.
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Affiliation(s)
- Deidre Ongaro
- Department of Pathology and Laboratory Medicine, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Jefferson Terry
- Department of Pathology and Laboratory Medicine, BC Children's Hospital, Vancouver, British Columbia, Canada
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30
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Is chronic histiocytic intervillositis a severe placental disease? A case-control study. Placenta 2019; 91:31-36. [PMID: 32174304 DOI: 10.1016/j.placenta.2019.12.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 12/27/2019] [Accepted: 12/28/2019] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Chronic histiocytic intervillositis (CHI) is a placental disease that has been associated with unfavorable obstetric outcomes in small, noncomparative series. The objective was to measure the excess risk of adverse obstetric outcomes associated with the discovery of CHI after birth. METHODS Retrospective single-center case-control study from 2000 through 2016. The case patients had a CHI diagnosis after a pathology analysis of the placenta. Two types of controls were defined for each case: low-risk control women were those who gave birth in our hospital immediately before each case patient, and the high-risk controls were the next women after each case for whom microscopic examination of the placenta was indicated. RESULTS We observed 111 cases of CHI during the study period. Compared with the 111 low-risk controls, the cases had a significantly higher frequency of late miscarriages (5.4 vs 0.0%, p < .03), small for gestational age (SGA) babies <3rd centile (70.4 vs 0.9%, p < .001, OR 140, 95% CI, 19.9-2800), and in utero deaths (35.1 vs 0.9%, p < .001, OR 59.6, 95% CI 8.5-1192), with significantly fewer children surviving to discharge (54.9 vs 99.1%, p < .001, OR 0.01, 95% CI, 0.00-0.08). All of these factors also differed significantly compared with the high-risk women (severe SGA: OR 3.7, 95% CI 1.9-7.0; in utero death: OR 4.1, 95% CI 1.9-8.7; children surviving to discharge: OR 0.27, 95% CI, 0.14-0.52). DISCUSSION Even compared with high-risk pregnancies, CHI is a severe placental disease associated with a substantial excess rate of late miscarriages, severe SGA and in utero death.
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Graham N, Heazell AEP. When the Fetus Goes Still and the Birth Is Tragic: The Role of the Placenta in Stillbirths. Obstet Gynecol Clin North Am 2019; 47:183-196. [PMID: 32008668 DOI: 10.1016/j.ogc.2019.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Because of the critical role that placental structure and function plays during pregnancy, abnormal placental structure and function is closely related to stillbirth: when an infant dies before birth. However, understanding the role of the placental and specific lesions is incomplete, in part because of the variation in definitions of lesions and in classifying causes of stillbirths. Nevertheless, placental abnormalities are seen more frequently in stillbirths than live births, with placental abruption, chorioamnionitis, and maternal vascular malperfusion most commonly reported. Critically, some placental lesions affect the management of subsequent pregnancies. Histopathological examination of the placenta is recommended following stillbirth.
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Affiliation(s)
- Nicole Graham
- Faculty of Biological, Medical and Human Sciences, Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, 5th Floor (Research), Oxford Road, Manchester M13 9WL, UK
| | - Alexander E P Heazell
- Faculty of Biological, Medical and Human Sciences, Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, 5th Floor (Research), Oxford Road, Manchester M13 9WL, UK.
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Abstract
Placental dysfunction is a major contributing factor to fetal growth restriction. Placenta-mediated fetal growth restriction occurs through chronic fetal hypoxia owing to poor placental perfusion through a variety of mechanisms. Maternal vascular malperfusion is the most common placental disease contributing to fetal growth restriction; however, the role of rare placental diseases should not be overlooked. Although the features of maternal vascular malperfusion are identifiable on placental pathology, antepartum diagnostic methods are evolving. Placental imaging and uterine artery Doppler, used in conjunction with angiogenic growth factors (specifically placenta growth factor and soluble fms-like tyrosine kinase-1), play an increasingly important role.
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de Moreuil C, Moineau MP, Padelli M, Lede F, Remoue A, Tremouilhac C, Merviel P, Pan Petesch B, Le Moigne E, Lacut K, Marcorelles P. First trimester serum biomarkers in pregnancies complicated with placental chronic inflammation. Eur J Obstet Gynecol Reprod Biol 2019; 241:119-125. [PMID: 31505304 DOI: 10.1016/j.ejogrb.2019.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 08/02/2019] [Accepted: 08/22/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study aimed at determining if first trimester serum biomarkers could predict adverse pregnancy outcomes associated with villitis (VUE) and chronic intervillositis of unknown etiology (CIUE). STUDY DESIGN Between January 2013 and June 2018, we selected from pathology department files placentas with VUE or CIUE associated with VUE and control placentas with available first trimester Down syndrome screening results. First trimester PAPP-A and βhCG levels were recorded. Placental growth factor (PlGF) levels were measured in patients with an available first trimester serum sample. Histological findings in placentas, course of pregnancies and newborns' characteristics were compared between cases and controls. RESULTS 78 cases and 75 controls were included. In cases, there were 21,8% intrauterine growth restriction (IUGR), 30,8% small for gestational age (SGA). Compared to controls, placentas from cases were smaller (425 g [IQR 370-480] vs 460 g [IQR 390-523], p = 0,03), showed more maternal vascular malperfusion features (79,5% vs 22,7%, p < 0,0001) and more fetal vascular malperfusion features (33,3% vs 12%, p = 0,002). Cases had lower PlGF (29,74 pg/ml [IQR 19,74-36,17] vs 36,37 pg/ml [IQR 27,36-49,13], p = 0,007) and βhCG levels (0,74 MoM [IQR 0,53-1,12] vs 1,00 MoM [IQR 0,72-1,53], p = 0,002) than controls. These differences resulted from lower PlGF levels in VUE patients compared to CIUE associated with VUE patients and controls (28,35 vs 34,05 and 36,37 pg/ml, p = 0,01) and from lower βhCG levels in CIUE associated with VUE patients compared to VUE patients and controls (0,65 vs 0,86 and 1, p = 0,005). CONCLUSION Low first trimester PlGF levels in cases, especially in VUE patients, suggest that reduced angiogenesis is involved in adverse pregnancy outcomes related to VUE.
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Affiliation(s)
- Claire de Moreuil
- Département de médecine interne et pneumologie, CHU de Brest, Hôpital La Cavale Blanche, Brest Cedex, France; EA 3878, GETBO, Université Bretagne Loire, Brest Cedex, France.
| | - Marie-Pierre Moineau
- Département de biochimie, CHU de Brest, Hôpital La Cavale Blanche, Brest Cedex, France
| | - Maël Padelli
- Département de biochimie, CHU de Brest, Hôpital La Cavale Blanche, Brest Cedex, France
| | - Françoise Lede
- Service d'anatomopathologie, CHU de Brest, Hôpital Morvan, Brest Cedex, France
| | - Annabelle Remoue
- Service d'anatomopathologie, CHU de Brest, Hôpital Morvan, Brest Cedex, France
| | - Christophe Tremouilhac
- EA 3878, GETBO, Université Bretagne Loire, Brest Cedex, France; Service de gynécologie et d'obstétrique, CHU de Brest, Hôpital Morvan, Brest Cedex, France
| | - Philippe Merviel
- EA 3878, GETBO, Université Bretagne Loire, Brest Cedex, France; Service de gynécologie et d'obstétrique, CHU de Brest, Hôpital Morvan, Brest Cedex, France
| | - Brigitte Pan Petesch
- EA 3878, GETBO, Université Bretagne Loire, Brest Cedex, France; Fédération de cancérologie et d'hématologie, CHU de Brest, Hôpital Morvan, Brest Cedex, France
| | - Emmanuelle Le Moigne
- Département de médecine interne et pneumologie, CHU de Brest, Hôpital La Cavale Blanche, Brest Cedex, France; EA 3878, GETBO, Université Bretagne Loire, Brest Cedex, France
| | - Karine Lacut
- Département de médecine interne et pneumologie, CHU de Brest, Hôpital La Cavale Blanche, Brest Cedex, France; EA 3878, GETBO, Université Bretagne Loire, Brest Cedex, France
| | - Pascale Marcorelles
- Service d'anatomopathologie, CHU de Brest, Hôpital Morvan, Brest Cedex, France; EA 4685 LIEN, Université Bretagne Loire, Brest Cedex, France
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CD39 downregulation in chronic intervillositis of unknown etiology. Virchows Arch 2019; 475:357-364. [PMID: 31218404 DOI: 10.1007/s00428-019-02598-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/08/2019] [Accepted: 06/03/2019] [Indexed: 10/26/2022]
Abstract
Chronic intervillositis of unknown etiology (CIUE) is a rare placental lesion associated with infiltration of mononuclear inflammatory cells into the intervillous space, poor perinatal outcomes (intrauterine fetal demise or fetal growth restriction), and high rates of recurrence. CD39 is the ectonucleotidase that protects tissues from inflammatory stress and cell injury, which is localized on the surface of villi in normal placentas; however, its expression and role in CIUE are unknown. The aims of this retrospective study were to determine the expression of CD39 in CIUE and its significance in pregnancy outcomes. We compared the number of CD68- and CD3-positive cells, CD39 expression, and complement 4d (C4d) and fibrin deposition in placental tissues from patients with CIUE (n = 22) and gestational age-matched controls (n = 20), and between CIUE pregnancies with poor and good outcomes. The numbers of CD68- or CD3-positive cells were significantly higher (P < 0.0001), whereas CD39 expression on the surface of villi and endothelial cells of the stem villi was significantly lower in the CIUE group than that in controls (45% vs. 95%, P < 0.0001 and 77% vs. 96%, P < 0.001, respectively). C4d and fibrin deposition were also significantly increased in CIUE compared with those of controls. Furthermore, CD39 downregulation and the number of CD68 cells were strongly associated with poor pregnancy outcomes (P < 0.01 and P < 0.05, respectively), but other histological parameters (CD3, C4d, and fibrin) did not show this association. Our study suggests that CD39 downregulation is a useful marker of CIUE and is associated with poor pregnancy outcomes in patients with CIUE.
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Orefice R, Kent A, Sethna F, Dahlstrom JE. Of pregnancies complicated by small for gestational age babies at term, what proportions have placental findings with implications for future pregnancies or neonatal outcomes? J Matern Fetal Neonatal Med 2019; 33:2990-2995. [PMID: 30646781 DOI: 10.1080/14767058.2019.1566899] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Small for gestational age (SGA) is a term to define any baby born with birth weight <10th centile. SGA can be associated with a number of placental pathology findings, which may influence maternal outcomes, neonatal neurodevelopment, and future pregnancies.Aims: To identify the proportion of term pregnancies complicated by SGA with placental findings that may have implications for future pregnancies or neonatal outcomes.Method: A retrospective review between 2011 and 2015 of babies and placentas born at term with SGA histopathological findings were categorized as to whether they had a high recurrence rate and where the long-term neurodevelopmental outcome may affect the neonate.Results: Six hundred and ninety-eight babies were identified as SGA. Only 335 (47.8%) placentas were sent for histopathological assessment. Of these, 60 (17.9%) had histopathological findings associated with high recurrence rates and 68 (20.2%) had findings associated with potential adverse neonatal outcomes.Conclusions: Of those placentas sent for examination between 17.9% and 20.2% had findings associated with either high recurrence rates or findings that may benefit from neonatal follow-up. Under 50% of pregnancies complicated by SGA at term had a placental examination, resulting in a significant number of potential important clinical consequences being missed.
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Affiliation(s)
| | - Alison Kent
- Department of Neonatology, Canberra Hospital, Canberra, Australia
| | - Farah Sethna
- Fetal Medicine Unit, Canberra Hospital, Canberra, Australia
| | - Jane E Dahlstrom
- Department of Anatomical Pathology, Canberra Hospital, Canberra, Australia
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Ladhani NNN, Fockler ME, Stephens L, Barrett JF, Heazell AE. No 369 - Prise en charge de la grossesse aprés une mortinaissance. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:1684-1700. [DOI: 10.1016/j.jogc.2018.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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No. 369-Management of Pregnancy Subsequent to Stillbirth. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:1669-1683. [DOI: 10.1016/j.jogc.2018.07.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Hannaford P, Mittal N, Sethna F, Dahlstrom JE. Recurrent Chronic Intervillositis: The Diagnostic Challenge - A Case Report and Review of the Literature. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 41:344-347. [PMID: 30414807 DOI: 10.1016/j.jogc.2018.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/26/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Chronic intervillositis (CI) is a rare placental condition involving diffuse infiltration of intervillous spaces by CD68- or CD45-positive maternal mononuclear inflammatory cells. Because no validated clinical or biochemical markers are specific to CI, the diagnosis is purely histopathological and is made postpartum. CASE This report describes a case of recurrent CI associated with adverse complications in two successive pregnancies. Both pregnancies were complicated by intrauterine growth restriction. Coexistent massive perivillous fibrin deposition was present in the first placenta. This case highlights the importance of CI in explaining and predicting adverse perinatal outcomes. CONCLUSION CI is associated with adverse pregnancy outcomes and a high risk of recurrence, and it can coexist with massive perivillous fibrin deposition. Pathologists must ensure that the significance of these diagnoses is adequately conveyed to clinicians, to optimize management of subsequent pregnancies.
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Affiliation(s)
| | - Namita Mittal
- ACT Pathology, The Canberra Hospital, Woden, Australia
| | - Farah Sethna
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Division of Women, Youth and Children, The Canberra Hospital, Woden, Australia
| | - Jane E Dahlstrom
- ACT Pathology, The Canberra Hospital, Woden, Australia; Australian National University Medical School, Canberra, Australia
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Koby L, Keating S, Malinowski AK, D'Souza R. Chronic histiocytic intervillositis – Clinical, biochemical and radiological findings: An observational study. Placenta 2018; 64:1-6. [DOI: 10.1016/j.placenta.2018.02.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 01/28/2018] [Accepted: 02/05/2018] [Indexed: 01/12/2023]
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Intervillites chroniques histiocytaires : bilan et prise en charge. Rev Med Interne 2018; 39:117-121. [DOI: 10.1016/j.revmed.2017.10.422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 12/29/2022]
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Kingdom JC, Audette MC, Hobson SR, Windrim RC, Morgen E. A placenta clinic approach to the diagnosis and management of fetal growth restriction. Am J Obstet Gynecol 2018; 218:S803-S817. [PMID: 29254754 DOI: 10.1016/j.ajog.2017.11.575] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 11/10/2017] [Accepted: 11/10/2017] [Indexed: 12/13/2022]
Abstract
Effective detection and management of fetal growth restriction is relevant to all obstetric care providers. Models of best practice to care for these patients and their families continue to evolve. Since much of the disease burden in fetal growth restriction originates in the placenta, the concept of a multidisciplinary placenta clinic program, managed primarily within a maternal-fetal medicine division, has gained popularity. In this context, fetal growth restriction is merely one of many placenta-related disorders that can benefit from an interdisciplinary approach, incorporating expertise from specialist perinatal ultrasound and magnetic resonance imaging, reproductive genetics, neonatal pediatrics, internal medicine subspecialties, perinatal pathology, and nursing. The accurate diagnosis and prognosis for women with fetal growth restriction is established by comprehensive clinical review and detailed sonographic evaluation of the fetus, combined with uterine artery Doppler and morphologic assessment of the placenta. Diagnostic accuracy for placenta-mediated fetal growth restriction may be enhanced by quantification of maternal serum biomarkers including placenta growth factor alone or combined with soluble fms-like tyrosine kinase-1. Uterine artery Doppler is typically abnormal in most instances of early-onset fetal growth restriction and is associated with coexistent preeclampsia and underlying maternal vascular malperfusion pathology of the placenta. By contrast, rare but potentially more serious underlying placental diagnoses, such as massive perivillous fibrinoid deposition, chronic histiocytic intervillositis, or fetal thrombotic vasculopathy, may be associated with normal uterine artery Doppler waveforms. Despite minor variations in placental size, shape, and cord insertion, placental function remains, largely normal in the general population. Consequently, morphologic assessment of the placenta is not currently incorporated into current screening programs for placental complications. However, placental ultrasound can be diagnostic in the context of fetal growth restriction, for example in Breus' mole and triploidy, which in turn may enhance diagnosis and management. Several examples are illustrated in our figures and supplementary videos. Recent advances in the ability of multiparameter screening and intervention programs to reduce the risk of severe preeclampsia will likely increase efforts to deliver similar improvements for women at risk of fetal growth restriction. Placental pathology is important because the underlying pathologies associated with fetal growth restriction have a wide range of recurrence risks. Rare conditions such as massive perivillous fibrinoid deposition or chronic histolytic intervillositis may recur in >50% of subsequent pregnancies. Postpartum care in a placenta-focused program can provide effective counseling for modifiable maternal risk factors, and can assist in planning future pregnancy care based on the pathologic basis of fetal growth restriction.
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Chen A, Roberts DJ. Placental pathologic lesions with a significant recurrence risk - what not to miss! APMIS 2017; 126:589-601. [PMID: 29271494 DOI: 10.1111/apm.12796] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 10/25/2017] [Indexed: 01/08/2023]
Abstract
Here, we review three important placental pathologies with significant clinical implications and recurrence risks. They are, in order of most to least frequently seen, villitis of unknown etiology, chronic histiocytic intervillositis, and massive perivillous fibrin deposition (also known as maternal floor infarction). These entities occur in both preterm and term gestations and are observed more frequently with maternal and obstetric disorders including prior pregnancy loss, hypertension/preeclampsia, and autoimmune disease. They are associated with, and probably the cause of, significant perinatal morbidity and mortality including intrauterine growth restriction, fetal and neonatal demise, and fetal/neonatal neurocompromise (seizures and cerebral palsy). All three entities have high recurrence risks, with recurrence rates ranging from 34 to 100%. The histologic features of villitis of unknown etiology, chronic histiocytic intervillositis, and massive perivillous fibrin deposition are described herein. We discuss the clinical associations and suggest the subsequent clinical and pathological evaluation. Hypotheses as to the biology of these lesions are reviewed.
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Affiliation(s)
- Athena Chen
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Drucilla J Roberts
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
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Bos M, Nikkels PGJ, Cohen D, Schoones JW, Bloemenkamp KWM, Bruijn JA, Baelde HJ, van der Hoorn MLP, Turner RJ. Towards standardized criteria for diagnosing chronic intervillositis of unknown etiology: A systematic review. Placenta 2017; 61:80-88. [PMID: 29277275 DOI: 10.1016/j.placenta.2017.11.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/05/2017] [Accepted: 11/20/2017] [Indexed: 12/25/2022]
Abstract
Chronic intervillositis of unknown etiology (CIUE) is a poorly understood, relatively rare condition characterized histologically by the intervillous infiltration of mononuclear cells in the placenta. Clinically, CIUE is associated with poor pregnancy outcome (e.g., impaired fetal growth, preterm birth, fetal death) and high risk of recurrence in subsequent pregnancies. Because CIUE is not defined consistently, it is essential to clearly define this condition. We therefore review the published definitions of CIUE. In addition, we provide an overview of the reviewed histopathological and maternal characteristics, obstetric features, and pregnancy outcomes. Medical publication databases were searched for articles published through February 2017. Eighteen studies were included in our systematic review. The sole inclusion criterion used in all studies was the presence of intervillous infiltrates. Overall, CIUE was characterized by adverse pregnancy outcome. Miscarriage occurred in 24% of cases, with approximately half of these miscarriages defined as late. Impaired growth was commonly observed, 32.4% of pregnancies reached term, and the live birth rate was 54.9%. The high recurrence rate (25.1%) of the intervillous infiltrates in subsequent pregnancies underscores the clinical relevance of CIUE, the need for increased awareness among pathologists and clinicians, and the need for further research. Criteria for the diagnosis of CIUE are proposed and a Delphi study could be used to resolve any controversy regarding these criteria. Future studies should be designed to characterize the full clinical spectrum of CIUE.
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Affiliation(s)
- M Bos
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands.
| | - P G J Nikkels
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - D Cohen
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - J W Schoones
- Walaeus Medical Library, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - K W M Bloemenkamp
- Department of Obstetrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Birth Centre, Lundlaan 6, 3584 EA Utrecht, The Netherlands
| | - J A Bruijn
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - H J Baelde
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - M L P van der Hoorn
- Department of Obstetrics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - R J Turner
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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Recurrent Massive Perivillous Fibrin Deposition and Chronic Intervillositis Treated With Heparin and Intravenous Immunoglobulin: A Case Report. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:676-681. [DOI: 10.1016/j.jogc.2017.03.089] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/04/2017] [Accepted: 03/06/2017] [Indexed: 11/20/2022]
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Ozawa N, Yamaguchi K, Shibata M, Sugibayashi R, Yagi H, Sago H, Matsuoka K. Chronic histiocytic intervillositis in three consecutive pregnancies in a single patient: Differing clinical results and pathology according to treatment used. J Obstet Gynaecol Res 2017; 43:1504-1508. [PMID: 28691359 DOI: 10.1111/jog.13404] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/13/2017] [Accepted: 05/01/2017] [Indexed: 11/29/2022]
Abstract
Chronic histiocytic intervillositis (CHI) is an extremely rare pathological condition but is strongly associated with severe obstetric complications and has a high recurrence rate. The management of this condition has not yet been established. We describe herein the occurrence of CHI in the late second-third trimester in each of three consecutive pregnancies in a single patient with four previous consecutive early miscarriages. In this patient, each of the three complicated pregnancies was managed with one of the following, respectively: low-dose aspirin; heparin plus low-dose aspirin; and prednisolone plus low-dose aspirin. CHI was histologically confirmed in all three pregnancies, but the clinical results and pathology (e.g. extent of histiocytic infiltration) in each pregnancy clearly differed with treatment. Both combination treatments eventuated in a live birth. Immunosuppressive therapy seemed to produce better clinical results by restricting the extent of the affected areas. The elevated alkaline phosphatase associated with the CHI was assumed to have no clinical prognostic value.
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Affiliation(s)
- Nobuaki Ozawa
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Koushi Yamaguchi
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Megumi Shibata
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Rika Sugibayashi
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroya Yagi
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Haruhiko Sago
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kentaro Matsuoka
- Department of Pathology, Dokkyo Medical University, Koshigaya Hospital, Saitama, Japan
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Abstract
Pregnancy after stillbirth presents unique challenges for families and healthcare providers. Medical surveillance and interventions must be optimized to improve outcomes and provide individualized support for families. A key component of acceptable care is psychosocial support that is delivered in a timely and sensitive manner by care providers with knowledge about the pervasive impact of stillbirth. With the lack of existing evidence to guide care, there is an urgent need for global leadership and research to address knowledge gaps.
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Vardi L, Paterson H, Hung NA. Successful pregnancy following treatment of recurrent chronic histiocytic intervillositis. BMJ Case Rep 2017; 2017:bcr-2016-217886. [PMID: 28073874 DOI: 10.1136/bcr-2016-217886] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Chronic histiocytic intervillositis (CHI) is a rare placental lesion associated with adverse obstetric outcomes and high recurrence rate. We report a case of six consecutive pregnancies in one woman, where CHI was detected following an intrauterine death in the fifth pregnancy, after being missed in four earlier losses. The successful sixth pregnancy was treated with a combination of immunosuppressive and antithrombotic agents. While low-molecular-weight heparin (LMWH) and aspirin had been shown to improve pregnancy outcome in recurrent pregnancy loss, there was limited evidence of improved outcome in CHI. It has been suggested that CHI may result from a maternal immunological process and there have been a few reports of the use of corticosteroids because of this possibility, though without convincing evidence of efficacy. We too tried a corticosteroid, in combination with LMWH and aspirin. Comparative histopathological analysis of the placentae supported post-treatment effectiveness of our intervention strategy.
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Affiliation(s)
- Leehe Vardi
- Department of Women's Health, Dunedin Public Hospital, Dunedin, New Zealand.,Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand
| | - Helen Paterson
- Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand
| | - Noelyn Anne Hung
- Department of Pathology, University of Otago, Dunedin School of Medicine, Dunedin, New Zealand
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48
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Man J, Hutchinson JC, Heazell AE, Ashworth M, Jeffrey I, Sebire NJ. Stillbirth and intrauterine fetal death: role of routine histopathological placental findings to determine cause of death. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:579-584. [PMID: 27781319 DOI: 10.1002/uog.16019] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 07/05/2016] [Accepted: 07/06/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Placental abnormalities are a common cause of death in stillbirth, ranking second only to unexplained deaths, though there is wide variation in the proportion attributed to placental disease. In clinical practice, interpretation of the significance of placental findings is difficult, since many placental features in stillbirths overlap with those in live births. Our aim was to examine objectively classified placental findings from a series of > 1000 autopsies following intrauterine death in order to evaluate the role of placental histological examination in determining the cause of death. METHODS As part of a larger study evaluating several aspects of autopsy findings in intrauterine death, a dedicated database was used to collate antenatal and postmortem examination details for all cases examined between 2005 and 2013 at two tertiary specialist centers in London, UK. Histological findings for placentas were evaluated in relation to the final cause of death. RESULTS Among 1064 intrauterine deaths, 946 (89%) cases had the placenta submitted for examination as part of the autopsy. Of these, 307 (32%) cases had the cause of death assigned to abnormalities of the placenta, cord or membranes. Around one third of stillbirths (≥ 24 weeks) had some isolated placental histological abnormality identified, many of uncertain significance, a significantly greater proportion than in cases of second-trimester intrauterine fetal demise (P < 0.0001). The cause of death was ascending infection in 176/946 (19%) cases, peaking at 22 weeks' gestation, with significantly more black mothers having ascending infection compared with other ethnicities (P < 0.0001). Maternal vascular malperfusion was the largest category of placental abnormalities in stillbirth, with peak prevalence in the early third trimester. There were 18 (2%) cases with specific histological abnormalities, including chronic histiocytic intervillositis and massive perivillous fibrin deposition. CONCLUSIONS Placental pathologies represent the largest category of cause of intrauterine death. Placental histological examination is the single most useful component of the autopsy process in this clinical setting. A minority of cases are associated with specific placental pathologies, often with high recurrence rates, that can be diagnosed only on microscopic examination of the placenta. Many deaths remain unexplained, although placental histological lesions may be present which are of uncertain significance. A rigorous, systematic approach to placental pathology research and classification may yield better understanding of the significance of placental findings and reduce the rate of unexplained intrauterine deaths. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J Man
- Department of Histopathology, Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK
- University College London, Institute of Child Health, London, UK
| | - J C Hutchinson
- Department of Histopathology, Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK
- University College London, Institute of Child Health, London, UK
| | - A E Heazell
- Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester, UK
| | - M Ashworth
- Department of Histopathology, Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK
| | - I Jeffrey
- Department of Histopathology, St George's Hospital, London, UK
| | - N J Sebire
- Department of Histopathology, Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK
- University College London, Institute of Child Health, London, UK
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49
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Crawford A, Moore L, Bennett G, Savarirayan R, Manton N, Khong Y, Barnett CP, Haan E. Recurrent chronic histiocytic intervillositis with intrauterine growth restriction, osteopenia, and fractures. Am J Med Genet A 2016; 170:2960-2964. [DOI: 10.1002/ajmg.a.37856] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 07/07/2016] [Indexed: 12/24/2022]
Affiliation(s)
- April Crawford
- Department of Surgical Pathology; SA Pathology (at Women's and Children's Hospital); Adelaide South Australia Australia
| | - Lynette Moore
- Department of Surgical Pathology; SA Pathology (at Women's and Children's Hospital); Adelaide South Australia Australia
- School of Medicine; University of Adelaide; Adelaide South Australia Australia
| | - Gregory Bennett
- Australian Red Cross Blood Service; National Transplant Services; Adelaide South Australia Australia
| | - Ravi Savarirayan
- Victorian Clinical Genetics Services; Murdoch Children's Research Institute; Melbourne Victoria Australia
- Department of Paediatrics; University of Melbourne; Melbourne Victoria Australia
| | - Nicholas Manton
- Department of Surgical Pathology; SA Pathology (at Women's and Children's Hospital); Adelaide South Australia Australia
- School of Medicine; University of Adelaide; Adelaide South Australia Australia
| | - Yee Khong
- Department of Surgical Pathology; SA Pathology (at Women's and Children's Hospital); Adelaide South Australia Australia
- School of Medicine; University of Adelaide; Adelaide South Australia Australia
| | - Christopher P. Barnett
- Paediatric & Reproductive Genetics; South Australian Clinical Genetics Service; SA Pathology (at Women's and Children's Hospital); Adelaide South Australia Australia
- School of Medicine; University of Adelaide; Adelaide South Australia Australia
| | - Eric Haan
- Paediatric & Reproductive Genetics; South Australian Clinical Genetics Service; SA Pathology (at Women's and Children's Hospital); Adelaide South Australia Australia
- School of Medicine; University of Adelaide; Adelaide South Australia Australia
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50
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Khong TY, Mooney EE, Ariel I, Balmus NCM, Boyd TK, Brundler MA, Derricott H, Evans MJ, Faye-Petersen OM, Gillan JE, Heazell AEP, Heller DS, Jacques SM, Keating S, Kelehan P, Maes A, McKay EM, Morgan TK, Nikkels PGJ, Parks WT, Redline RW, Scheimberg I, Schoots MH, Sebire NJ, Timmer A, Turowski G, van der Voorn JP, van Lijnschoten I, Gordijn SJ. Sampling and Definitions of Placental Lesions: Amsterdam Placental Workshop Group Consensus Statement. Arch Pathol Lab Med 2016; 140:698-713. [PMID: 27223167 DOI: 10.5858/arpa.2015-0225-cc] [Citation(s) in RCA: 981] [Impact Index Per Article: 122.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT -The value of placental examination in investigations of adverse pregnancy outcomes may be compromised by sampling and definition differences between laboratories. OBJECTIVE -To establish an agreed-upon protocol for sampling the placenta, and for diagnostic criteria for placental lesions. Recommendations would cover reporting placentas in tertiary centers as well as in community hospitals and district general hospitals, and are also relevant to the scientific research community. DATA SOURCES -Areas of controversy or uncertainty were explored prior to a 1-day meeting where placental and perinatal pathologists, and maternal-fetal medicine specialists discussed available evidence and subsequently reached consensus where possible. CONCLUSIONS -The group agreed on sets of uniform sampling criteria, placental gross descriptors, pathologic terminologies, and diagnostic criteria. The terminology and microscopic descriptions for maternal vascular malperfusion, fetal vascular malperfusion, delayed villous maturation, patterns of ascending intrauterine infection, and villitis of unknown etiology were agreed upon. Topics requiring further discussion were highlighted. Ongoing developments in our understanding of the pathology of the placenta, scientific bases of the maternofetoplacental triad, and evolution of the clinical significance of defined lesions may necessitate further refinements of these consensus guidelines. The proposed structure will assist in international comparability of clinicopathologic and scientific studies and assist in refining the significance of lesions associated with adverse pregnancy and later health outcomes.
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Affiliation(s)
- T Yee Khong
- From SA Pathology, Women's and Children's Hospital, University of Adelaide, North Adelaide, Australia (Dr Khong); the Department of Pathology, National Maternity Hospital, Dublin, Ireland (Drs Mooney and Kelehan); the Department of Pathology, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem, Israel (Dr Ariel); the Department of Pathology, Kennemer Gasthuis, Haarlem, the Netherlands (Dr Balmus); the Department of Pathology, Boston Children's Hospital, and the Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Dr Boyd); the Departments of Pathology and Laboratory Medicine, and Pediatrics, University of Calgary, Calgary, Alberta, Canada (Dr Brundler); the Maternal & Fetal Health Research Centre, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom (Ms Derricott); the Department of Pathology, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (Dr Evans); the Department of Pathology, University of Alabama at Birmingham, (Dr Faye-Petersen); the Department of Pathology, Rotunda Hospital, Dublin, Ireland (Dr Gillan); the Institute of Human Development, Faculty of Medical and Human Sciences
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