The intrauterine growth-restricted fetus and placenta evaluation

Does placental VEGF-A protein expression predict early neurological outcome of neonates from FGR complicated pregnancies?

OBJECTIVES

Fetal hypoxia due to placental dysfunction is the hallmark of fetal growth restriction (FGR). Preferential perfusion of the brain (brain-sparing effect), as a part of physiological placental cardiovascular compensatory mechanisms to hypoxia, in FGR was reported. Therefore, the correlation between vascular endothelial growth factor A (VEGF-A) protein expression in the FGR placentas and newborns' early neurological outcome was examined.

METHODS

This study included 50 women with FGR complicated pregnancies and 30 uneventful pregnancies. Fetal hemodynamic parameters, neonatal acid-base status after delivery, placental pathohistology and VEGF-A expression were followed. Early neonatal morphological brain evaluation by ultrasound and functional evaluation of neurological status by Amiel - Tison Neurological Assessment at Term (ATNAT) were performed.

RESULTS

VEGF-A protein expression level was significantly higher in the FGR placentas than normal term placentas (Fisher-Freeman-Halton's test, p≤0.001). No statistically significant correlation between placental VEGF-A expression and different prenatal and postnatal parameters was noticed. Whereas the alteration of an early neurological status assessed by ATNAT was found in 58 % of FGR newborns, morphological brain changes evaluated by UZV was noticed in 48 % of cases. No association between the level of placental VEGF-A expression and the early neurological deficits was found.

CONCLUSIONS

As far as we know this is the first study of a possible connection between VEGF-A protein expression in the FGR placentas and neonates' early neurological outcomes. The lack of correlation between the FGR placental VEGF-A expression and neonates' neurological outcome could indicate that optimal early neurodevelopment may take place due to compensatory mechanism not related to placental VEGF-A expression.

Influence of chest/head circumference ratio at birth on obstetric and neonatal outcomes: The Japan environment and children's study

OBJECTIVES

Some newborns that are not small-for-gestational-age (non-SGA, birthweight ≥10th percentile for a given gestational age) may have pathologic growth restrictions. This study examined the association of adverse obstetric and neonatal outcomes with chest/head circumference ratio at birth in non-SGA and SGA newborns.

METHODS

This study was a cross-sectional evaluation of data from a nationwide prospective birth cohort study, the Japan Environment and Children's Study. We analyzed 93 690 non-anomalous singletons born at 34-41 gestational weeks. We defined low, normal, and high chest/head circumference ratio as <10th percentile, 10th-90th percentile, and >90th percentile, respectively, according to the internally constructed chest/head circumference percentile chart. Modified Poisson regression was used to estimate adjusted prevalence ratios (aPR) for the outcomes studied.

RESULTS

Compared with non-SGA newborns with a normal ratio, those with a low ratio had an increased occurrence of low birthweight (1.75, 1.58-1.94 [aPR, 95% confidence interval]), cesarean delivery (1.34, 1.29-1.38), Apgar score <7 at 5 min (1.57, 1.14-2.17), respiratory complications (1.20, 1.04-1.39), and prolonged hospitalization (1.36, 1.30-1.42). In contrast, the high-ratio group had a lower rate of low birthweight (0.71, 0.59-0.86), cesarean delivery (0.82, 0.77-0.87), and prolonged hospitalization (0.83, 0.78-0.89). In SGA newborns, a low ratio was associated with increased aPRs for low birthweight, cesarean delivery, hypoglycemia, and prolonged hospitalization, whereas a high ratio showed no such association.

CONCLUSIONS

Findings indicate that the chest/head circumference ratio at birth influence obstetric and neonatal outcomes regardless of the birthweight status.

Acute Histological Chorioamnionitis and Birth Weight in Pregnancies With Preterm Prelabor Rupture of Membranes: A Retrospective Cohort Study

Aim: To assess the association between the birth weight of newborns from pregnancies with preterm prelabor rupture of membranes (PPROM) and the presence of acute histological chorioamnionitis (HCA) with respect to the: i) fetal and maternal inflammatory responses and ii) acute inflammation of the amnion.

Material and Methods: This retrospective cohort study included 818 women with PPROM. A histopathological examination of the placenta was performed. Fetal inflammatory response was defined as the presence of any neutrophils in umbilical cord (histological grades 1–4) and/or chorionic vasculitis (histological grade 4 for the chorionic plate). Maternal inflammatory response was defined as the presence of histological grade 3–4 for the chorion-decidua and/or grade 3 for the chorionic plate and/or grade 1–4 for the amnion. Acute inflammation of the amnion was defined as the presence of any neutrophils in the amnion (histological grade 1–4 for the amnion). Birth weights of newborns were expressed as percentiles derived from INTERGROWTH-21st standards for the i) estimated fetal weight and ii) newborn birth weight.

Results: No difference in percentiles of birth weights of newborns was found among the women with the women with HCA with fetal inflammatory response, with HCA with maternal inflammatory response and those without HCA. Women with HCA with acute inflammation of the amnion had lower percentiles of birth weights of newborns, derived from the estimated fetal weight standards, than women with HCA without acute inflammation of the amnion and those with the absence of HCA in the crude (with acute inflammation: median 46, without acute inflammation: median 52, the absence of HCA: median 55; p = 0.004) and adjusted (p = 0.02) analyses. The same subset of pregnancies exhibited the highest rate of newborns with a birth weight of ≤25 percentile. When percentiles were derived from the newborn weight standards, no differences in birth weights were observed among the subgroups.

Conclusion: Acute inflammation of the amnion was associated with a lower birth weight in PPROM pregnancies, expressed as percentiles derived from the estimated fetal weight standards.

Intra-amniotic inflammation and birth weight in pregnancies with preterm labor with intact membranes: A retrospective cohort study

OBJECTIVE

To assess the association between newborn birth weight and the presence of intra-amniotic infection, presence of sterile intra-amniotic inflammation, and absence of intra-amniotic inflammation in pregnancies with preterm labor with intact membranes.

METHODS

A total of 69 pregnancies with preterm labor with intact membranes between gestational ages 22 + 0 and 34 + 6 weeks who delivered within seven days of admission were included in this retrospective cohort study. Transabdominal amniocentesis to determine the presence of microorganisms and/or their nucleic acids in amniotic fluid (through culturing and molecular biology methods) and intra-amniotic inflammation (according to amniotic fluid interleukin-6 concentrations) were performed as part of standard clinical management. The participants were further divided into three subgroups: intra-amniotic infection (presence of microorganisms and/or nucleic acids along with intra-amniotic inflammation), sterile intra-amniotic inflammation (intra-amniotic inflammation alone), and without intra-amniotic inflammation. Birth weights of newborns were expressed as percentiles derived from the INTERGROWTH-21st standards for (i) estimated fetal weight and (ii) newborn birth weight.

RESULTS

No difference in birth weights, expressed as percentiles derived from the standard for estimated fetal weight, was found among the women with intra-amniotic infection, with sterile intra-amniotic inflammation, and without intra-amniotic inflammation (with infection, median 29; with sterile inflammation, median 54; without inflammation, median 53; p = 0.06). Differences among the subgroups were identified in the birth weight rates, expressed as percentiles derived from the standard for estimated fetal weight, which were less than the 10th percentile (with infection: 20%, with inflammation: 13%, without inflammation: 0%; p = 0.04) and 25th percentile (with infection: 47%, with inflammation: 31%, without inflammation: 9%; p = 0.01). No differences among the subgroups were observed when percentiles of birth weight were derived from the birth weight standard.

CONCLUSIONS

The presence of intra-amniotic inflammatory complications in pregnancies with preterm labor with intact membranes prior to the gestational age of 35 weeks was associated with a higher rate of newborns with birth weight less than the 10th and 25th percentile, when percentiles of birth weight were derived from the standard for estimated fetal weight.

Passively inhaled tobacco smoke - pregnancy and neonatal outcomes in correlation with placental histopathology

INTRODUCTION

We aimed to investigate the effect of maternal passive smoking (MPS) during pregnancy-on placental pathology and pregnancy outcomes.

METHODS

A prospective case-control study. We recruited low-risk laboring women at 37+0-41 + 0 weeks between 9/2019-7/2020. MPS was defined as exposure to in-house spouse tobacco smoking of >20 cigarettes/day in the absence of maternal active-smoking. In attempt to "purify" the effect of MPS on placental pathology-we excluded cases with preeclampsia, diabetes, suspected fetal growth restriction (FGR), preterm labor, and illicit drug use. Maternal characteristics, pregnancy outcomes, and placental pathology were compared between the MPS group and a control group matched for gestational age, maternal age, and delivery date. Placental lesions were classified according to the "Amsterdam" criteria. The study was powered to detect a 33% difference in placental malperfusion lesions. Multivariable regression was performed to identify independent associations with placental malperfusion lesions.

RESULTS

In labor, the MPS group (n = 115) had higher rates of meconium stained amniotic fluid (MSAF, p < 0.001) and non-reassuring fetal heart-rate (NRFHR,p = 0.006), compared to controls (n = 115). Neonates in the MPS group had higher rates of undiagnosed FGR (p = 0.01) and NICU admissions (p = 0.004). The MPS group had higher rates of placental-hypoplasia (p = 0.02) and fetal vascular malperfusion (FVM) lesions (p = 0.04). In regression analysis MPS was associated with FVM lesions independent of background confounders (aOR = 1.24 95% CI 1.10-2.65).

DISCUSSION

In otherwise low-risk pregnancies, MPS was associated with higher rates of MSAF, NRFHR, undiagnosed FGR, and NICU admissions, probably mediated via placental FVM. These worrisome findings mandate patient counseling and further investigation in larger population-based studies.

The effect of concomitant histologic chorioamnionitis in pregnancies complicated by fetal growth restriction

INTRODUCTION

We aimed to investigate the effect of placental histologic chorioamnionitis (HC) on neonatal outcomes in pregnancies complicated by fetal growth restriction (FGR).

METHODS

- The computerized medical files of all pregnancies diagnosed with FGR (birthweight <10th percentile) at 24-42 weeks of gestation between 2008 and 2019 were reviewed. Maternal and neonatal outcomes were compared between FGR with and without evidence of placental HC. Placental lesions were classified according to "Amsterdam" criteria. Composite adverse neonatal outcome-included any of the following complications: neurological morbidity, neonatal respiratory assistance, RDS, NEC, sepsis, blood transfusion, phototherapy, hypoglycemia, or neonatal death. Composite severe adverse neonatal outcome included any of the following complications - neurological morbidity, blood transfusion, NEC, sepsis, RDS, neonatal death.

RESULTS

- Compared to FGR without HC (n = 446), FGR with HC (n = 57) was characterized by more advanced gestational age at delivery 39.2 (38.3-39.9) vs. 38.2 (36.9-39.2), weeks respectively, p < 0.001), higher rate of nulliparity (73.7% vs. 45.1%, p < 0.001), less vascular lesions of MVM (1.8% vs.11.2%, p = 0.02), higher rate of Apgar scores at 5 min <7 (10.5% vs. 2%, p = 0.004), increased neonatal death (7.0% vs. 0.9%, p = 0.007), higher rates of both composite adverse neonatal outcome (31.1% vs. 17.3% p = 0.02), and composite severe adverse neonatal outcome (16.3% vs. 8.2% p = 0.04). By multivariate regression analysis HC was found to be independently associated with composite adverse neonatal outcome (aOR = 1.21, 95% CI 1.08-2.38) and with severe composite adverse neonatal outcome (aOR = 1.39, 95% CI 1.16-3.76).

CONCLUSIONS

Pregnancies complicated by FGR with concomitant HC were associated with higher rates of adverse neonatal outcomes.

Does macroscopic estimation of the extent of placental abruption correlate with pregnancy outcomes?

INTRODUCTION

We aimed to study the correlation between the extent of placental abruption (PA), as grossly estimated immediately after delivery, and pregnancy outcomes, in correlation with placental histopathology.

MATERIALS AND METHODS

Pregnancy and placental reports of all pregnancies complicated by PA (clinically diagnosed) between 11/2008-12/2018 were reviewed. We compared maternal background, pregnancy outcomes, and placental histopathology between cases of PA divided into three groups according to the extent of abruption: Group 1-<30 %, Group 2-30-49 %, and Group 3->50 % of placental surface. Placental lesions were classified according to the current "Amsterdam" criteria. The primary outcome was defined as a composite of severe neonatal morbidity and included ≥ 1 of the following complications: seizures, intraventricular hemorrhage, hypoxic-ischemic encephalopathy, periventricular leukomalacia, blood transfusion, necrotizing enterocolitis, intrauterine fetal demise, or neonatal death.

RESULTS

A total of 260 PA cases were included: 111 (42.7 %) in Group 1, 94 (36.2 %) in Group 2, and 55 (21.1 %) in Group 3. The rate of the primary outcome (7.2 % vs. 11.7 % vs. 27.3 %, p = 0.02) was associated with the degree of PA as well as maternal heavy smoking (p = 0.04), DIC (p = 0.03), umbilical artery Ph <7.1 (p = 0.02), 5-minute Apgar scores <7 (p = 0.03), NICU admissions, placental maternal vascular malperfusion lesions (p = 0.04), and neonatal weights <5th percentile (0.04). In multivariable analysis severe adverse neonatal outcome was independently associated with the percentage of PA (aOR = 1.4, 95 % CI = 1.3-3.9).

CONCLUSION

The extent of placental abruption, as estimated by the examiner, correlated with DIC and severe neonatal outcomes and may serve as an early alarming sign in deliveries complicated by PA.

Maternal use of selective serotonin reuptake inhibitors (SSRI) during pregnancy-neonatal outcomes in correlation with placental histopathology

OBJECTIVE

We investigated the association between prenatal selective serotonin reuptake inhibitors (SSRI) exposure and pregnancy-outcomes with correlation to placental-histopathology.

STUDY DESIGN

Included were pregnancies with maternal SSRI use throughout pregnancy (SSRI-group) and the control group was matched with pregnancies unexposed to SSRI. Placental lesions were classified according to the "Amsterdam" criteria. Adverse neonatal outcome was defined as ≥1 early neonatal-complications.

RESULTS

SSRI group had lower birthweights (p < 0.001), higher rates of meconium (p = 0.009), NICU admissions (p < 0.001), and adverse neonatal-outcome (p < 0.001). SSRI placentas had lower birthweight-to-placental-weight ratio (p = 0.02) and higher rates of fetal vascular malperfusion (FVM) lesions (p = 0.03). Using multivariable analyses: GA < 37 weeks (aOR = 2.1, 95%CI 1.7-4.6) and SSRI (aOR = 1.7, 95%CI 1.3-3.9) were independently associated with adverse neonatal outcome while GA < 37 weeks (aOR = 1.6, 95%CI 1.2-3.4), SSRI (aOR = 1.3, 95%CI 1.1-2.6), and smoking (aOR = 1.2, 95%CI 1.1-4.0) were independently associated with FVM lesions.

CONCLUSION

SSRI use during pregnancy was independently associated with adverse neonatal outcome and placental FVM.

Placental pathology in pregnancies complicated by fetal growth restriction: recurrence vs. new onset

OBJECTIVE

In an attempt to shed new light on the pathogenesis of fetal growth restriction (FGR), we aimed to study pregnancy characteristics, neonatal outcomes, and placental histopathological lesions of FGR pregnancies in two different subgroups: when developed after appropriate for gestational age (AGA) pregnancy and when developed after previous pregnancy with FGR.

STUDY DESIGN

Pregnancy and placental reports of all singleton pregnancies complicated by FGR (defined as actual birthweight below the 10th percentile according to local birthweight nomograms) between 2008 and 2018 were reviewed. Included were only cases with previous delivery. Maternal background, neonatal outcomes, and placental histopathology were compared between FGR that occurred after FGR (recurrent FGR group) and FGR that occurred after an AGA pregnancy (FGR after AGA group). Placental lesions were classified according to the current "Amsterdam" criteria. Continuous variables were compared using the Student's t test or the Mann-Whitney test as appropriate. Categorical variables were compared using Chi-square or Fisher's exact test as appropriate.

RESULTS

A total of 334 FGR cases with a previous delivery were included in the study. Of them, 111 cases constituted the recurrent FGR group and 223 constituted the FGR after AGA group. The recurrent FGR group was characterized by higher rates of maternal diabetes during pregnancy and hypertensive diseases (9% versus 2.7%, p = 0.01 and 19.8% versus 11.6%, p = 0.04). The FGR after AGA group was characterized by a higher rate of fetal vascular malperfusion (FVM) lesions (29.6% versus 18.0%, p = 0.02), and by lower mean birthweight (1842 ± 424.9 versus 1977.4 ± 412.2, p = 0.005), as compared to the recurrent FGR group.

CONCLUSION

Recurrent FGR was associated with maternal background morbidities during pregnancy which represents a chronic repeated insult, while "new" FGR cases (those followed an AGA pregnancy) were characterized by a higher rate of FVM lesions and lower birthweight which probably represent an "accident" in placentation. These findings may suggest that different mechanisms of placental dysfunction exist in the two subgroups of FGR.

Pregnancy outcomes in correlation with placental histopathology in subsequent pregnancies complicated by fetal growth restriction

OBJECTIVE

In attempt to shed new light on the etiopathogenesis of fetal growth restriction (FGR) we aimed to compare pregnancy outcomes and placental histopathology in cases of first vs. subsequent FGR occurrence.

STUDY DESIGN

Pregnancy and placental reports of FGR pregnancies (defined by birth weight <10th percentile), born between 2008 and 2018 were reviewed. Included only cases with recurrent FGR, in two consecutive pregnancies, thus each subject served as her own control in two FGRs consecutive pregnancies. Neonatal outcome and placental histopathology were compared between the first FGR delivery (first FGR group) and the subsequent FGR delivery (subsequent FGR group). Composite adverse neonatal outcome was defined as one or more early neonatal complications.

RESULTS

Included in the study a total of 96 cases with recurrence of FGR pregnancies. Placentas from the first FGR group were characterized by higher rate of maternal vascular malperfusion (MVM) lesions as compared with the subsequent FGR group (71.8% versus 55.2%, respectively, p = 0 .02). Adverse neonatal outcome was more prevalent in the first FGR group as compared to the recurrent FGR group (41.6% versus 25%, respectively, p = 0.02). After controlling for confounders, using multivariate regression analysis, placental MVM lesions (aOR = 1.36, 95% CI = 1.12-1.45) and composite adverse neonatal outcome (aOR = 1.18 95% CI = 1.09-1.55) were found to be independently associated with the first FGR group.

CONCLUSION

First event of FGR is associated with a higher rate of placental MVM lesions and adverse neonatal outcome as compared to FGR in subsequent pregnancies.

Placental and Clinical Characteristics of Term Small-for-Gestational-Age Neonates: A Case-Control Study

Numerous conditions, including placental vascular compromise, can lead to small-for-gestational-age (SGA) infants. As few studies have investigated primarily term placentas from SGA infants, we compared placentas from 67 SGA infants to placentas from 67 infants with appropriate weights for gestational age (AGA) in this population, matched for gestational age and gender. Placental histology was reviewed and electronic records were queried for maternal and fetal birth data, infant morbidities, and infant follow-up weights. Comparison of these 2 cohorts showed that placentas from SGA infants were more likely to have smaller weights and thinner umbilical cords than those from AGA infants. SGA placentas had a significant increase in another uteroplacental malperfusion feature: single and multiple infarctions. Rates of preeclampsia, infant cardiac anomalies, and infant genetic abnormalities were not statistically different between groups. Fetal and maternal inflammatory responses, nongestational diabetes, and gestational hypertension were more common in the controls, but these are common indications for placental examination. No statistical differences were present for decidual vasculopathy, chronic villitis, intervillous thrombi, or meconium. More SGA neonates had hypoglycemia compared to their AGA counterparts. SGA infants tended to have decreased weights up to 7 months of age; however, the low number of infants with follow-up limited the statistical significance. This study confirms that small placental size and select features of uteroplacental malperfusion are more common in SGA versus AGA term placentas. The lack of other significant differences may be due to the inclusion of only term infants, with more severe pathology leading to preterm delivery.

Pathological examination of the placenta in small for gestational age (SGA) children with or without postnatal catch-up growth

BACKGROUND/OBJECTIVE

Approximately 10% of small for gestational age (SGA) infants fail to catch up. The relationship between postnatal growth and placental pathology in SGA infants remains unclear. Our aim was to assess the involvement of placental pathology in postnatal growth of SGA infants.

METHODS

We retrospectively evaluated placental pathology and postnatal growth in single-pregnancy infants born after 37 gestational weeks in our institution, with both birth weight and length below -2 standard deviation scores (SDS) of the normal weight and length. "Catch-up" was defined as height reaching -2 SDS before the second birthday. Pathology of the placenta was classified into: abnormality due to maternal factors or fatal factors, villitis of unknown etiology (VUE), other abnormalities and no abnormality.

RESULTS

Of the 33 084 infants, 142 met our criteria and 49 of them had analyzable data. The overall catch-up rate was 84%. Catch-up growth took place in all infants with no placental abnormality and only 57% of infants with abnormality due to fatal factors. There was no significant relationship between catch-up rate and other factors.

CONCLUSION

Placental pathology is associated with postnatal growth in SGA children born at term. Placental abnormality due to fetal factors is related to poor catch-up rate.

Placental findings in late-onset SGA births without Doppler signs of placental insufficiency

OBJECTIVES

To describe placental pathological findings in late-onset small-for-gestational age (SGA) births for which Doppler signs of placental insufficiency are lacking.

METHODS

A series of placentas were evaluated from singleton pregnancies of SGA births (birth weight below the 10th percentile) delivered after 34 weeks with normal umbilical artery Doppler (pulsatility index below the 95th percentile), that were matched by gestational age with adequate-for-gestational age (AGA) controls. Using a hierarchical and standardized system, placental lesions were classified histologically as consequence of maternal underperfusion, fetal underperfusion or inflammation.

RESULTS

A total of 284 placentas were evaluated (142 SGA and 142 AGA). In the SGA group, 54.2% (77/142) of the placentas had weights below the 3rd percentile for GA while it was a 9.9% (14/142) in the AGA group (p < 0.001). Only 21.8% (31/142) of SGA placentas were free of histological abnormalities, while it was 74.6% (106/142) in the AGA group (p < 0.001). In the abnormal SGA placentas (111/142) there were a total of 161 lesions, attributable to MUP in 64% (103/161), FUP in 15.5% (25/161), and inflammation in 20.5% (33/161).

DISCUSSION

In most placentas of term SGA neonates with normal UA Doppler histological abnormalities secondary to maternal underperfusion prevail, reflecting latent insufficiency in uteroplacental blood supply. This is consistent with the higher risk of adverse perinatal outcome reported in this population and underscores a need for new markers of placental disease.

CONCLUSIONS

A significant proportion of late-onset SGA births with normal umbilical artery Doppler may still be explained by placental insufficiency.

Syncytin-1 modulates placental trophoblast cell proliferation by promoting G1/S transition

Placental syncytiotrophoblasts formed by the fusion of cytotrophoblasts constitute the interface between maternal and fetal circulations. The syncytium, composed of a continuous layer of syncytiotrophoblasts, assumes the fetal-maternal nutrient exchange, placental barrier, and endocrine functions important for the maintenance of normal pregnancy. Syncytin-1, an endogenous retroviral gene product, mediates the fusion of cytotrophoblasts. While the fusogenic function of syncytin-1 has been well established, little is known regarding its nonfusogenic activities. This study investigates the role of syncytin-1 in trophoblast proliferation. We found that syncytin-1 knockdown significantly inhibited BeWo cell growth and DNA synthesis. Moreover, time course studies on key cell cycle regulators demonstrated an upregulation of p15 and downregulation of CDK4, E2F1, PCNA, and c-Myc, which consequently led to a reduced level of CDK1. These results, together with those from flow cytometry analysis, indicated that syncytin-1 knockdown blocked the G1/S transition phase of the cell cycle. Moreover, syncytin-1 overexpression promoted CHO cell proliferation and led to changes opposite to those observed in syncytin-1 knockdown experiments, confirming the critical role of syncytin-1 for G1/S transition. Thus, syncytin-1, through both nonfusogenic and fusogenic, functions, may co-regulate the input (proliferation) and output (fusion) of the cytotrophoblast "pool". Such co-regulation could be an efficient way to achieve the balance between these two opposing processes, which is required for syncytium homeostasis. Since decreased syncytin-1 expression has been shown to be associated with preeclamptic and hypoxic condition, insufficient replenishing of the cytotrophoblast "pool" may contribute to syncytium deficiency, a critical pathological change frequently found in preeclamptic placentas.

Placental histologic criteria for diagnosis of cord accident: sensitivity and specificity

"Cord accident" (compromised umbilical blood flow) as a cause of stillbirth is underreported, mainly due to a lack of diagnostic criteria. Based on fetal vascular pathology in the placenta, we have previously established histologic criteria for the diagnosis of cord accident. In the current study, we set out to test the sensitivity and specificity of these criteria by reviewing an independent set of stillbirth cases. Placental slides from 26 cases (in which cord accident was deemed the cause of death) and 62 controls (in which the cause of death was anything other than cord accident) were reviewed. The following histologic changes were noted: (1) dilated fetal vessels, (2) thrombosis in fetal vessels, and (3) avascular or near-avascular chorionic villi. "Minimal" criteria were defined as the presence of dilated and thrombosed fetal vessels, while the additional presence of focal or regional avascular or near-avascular villi satisfied the complete criteria. Of the 62 stillbirth controls with cause of death other than cord accident, 13 (21%) met the minimal criteria (specificity 79%) and only 4 (6%) met the complete criteria for cord accident (specificity 94%). In contrast, of the 26 cases with a cause of death related to cord accident, 16 met the minimal criteria (sensitivity 62%) and 12 met the complete criteria (sensitivity 46%). These histologic criteria identify cases of cord accident as a cause of stillbirth with very high specificity. This study confirms the utility of these criteria for diagnosis of cord accident and further stresses placental examination in evaluation of stillbirths.

The M2 haplotype in the ANXA5 gene is an independent risk factor for idiopathic small-for-gestational age newborns

Hereditary thrombophilias can impair vascular placental functions and predispose to the birth of small-for-gestational age (SGA) babies. The placental anticoagulant protein annexin A5 (ANXA5) may contribute to this process. A functional haplotype (M2) within the ANXA5 gene is associated with fetal loss and venous thrombosis. This study investigated the prevalence of the M2 haplotype in a group of women with idiopathic SGA newborn babies. Seventy-eight women with at least one previous unexplained SGA birth and 195 controls all from Southern Italy were investigated. Hereditary thrombophilia was found in 13 (16.5%) cases and 21 (11%) controls (P < 0.05.). The M2 haplotype was found in 29% of cases (n = 23) and 15% of controls [n = 30; P = 0.001; OR = 2.3, 95% CI (1.17-4.48)]. Within the case group, 82.5% of the M2 haplotype carriers gave birth to babies with a birthweight below the 3rd percentile [P = 0.01; OR = 2.4, 95% CI (1.26-4.73)]. A logistic regression, corrected for age, parity and gravity showed that the M2 haplotype was independently associated with the delivery of an SGA new born [P = 0.029; OR = 2.6, 95% CI (1.1-6.0)]. In conclusion, the M2 haplotype of the ANXA5 gene confers a risk of delivering SGA babies.

Obstetric and perinatal complications in placentas with fetal thrombotic vasculopathy

Fetal thrombotic vasculopathy (FTV) is a placental lesion characterized by regionally distributed avascular villi and is often accompanied by upstream thrombosis in placental fetal vessels. Previous studies, using preselected populations, have shown associations of this lesion with adverse neurodevelopmental outcomes and potentially obstructive lesions of the umbilical cord. We investigated the prevalence of obstetric complications, perinatal disease, and placental abnormalities in cases with FTV. One hundred thirteen cases of placentas with FTV were identified in our pathology database over an 18-year period. Two hundred sixteen placentas without the diagnosis of FTV, frequency matched on year of birth, were selected as controls. Electronic medical records and pathology reports were used to extract maternal and gestational age, method of delivery, neonatal outcome, lesions of the umbilical cord, obstetric complications, and fetal abnormalities. Placentas with FTV were associated with a 9-fold increase in rate of stillbirth and a 2-fold increase in intrauterine growth restriction. The increase in pregnancy-induced hypertension/preeclampsia was not significant when adjusted for maternal and gestational age. Although the rate of potentially obstructive cord lesions was similar in both groups, there was an almost 6-fold increase in the presence of oligohydramnios in FTV placentas, compared with controls. Finally, FTV was associated with a 6-fold increase in fetal cardiac abnormalities. Fetal thrombotic vasculopathy is associated with a significantly higher rate of obstetric and perinatal complications. This study points to abnormal fetal circulation, either in the form of congenital heart disease or oligohydramnios predisposing to cord compression, as a risk factor for FTV.

Placenta: chronicle of intrauterine growth restriction

The foundation for adult health is laid in utero and requires a healthy placenta. A common manifestation of abnormal placental development is impaired fetal growth. While placental pathology is the final common denominator in many cases of fetal growth restriction, a variety of discreet lesions have been described involving both the maternal and fetal circulations at their confluence in the placenta. Detailed examination of the placenta provides a means of elucidating the pathophysiology of poor fetal growth. This is an essential step in developing effective strategies for the prediction, prevention, and possible treatment of the growth restricted fetus.

Placental vascular lesion differences in pregnancy-induced hypertension and normotensive fetal growth restriction

OBJECTIVE

Pregnancy-induced hypertension/preeclampsia (PIH) and fetal growth restriction (FGR) share a common placental origin. The pathologic classification that divides placental lesions to maternal or fetal origin was compared between these disorders.

STUDY DESIGN

Placentas from pregnancies that were complicated by PIH, normotensive FGR, or by both (combined) were analyzed, and lesions were classified as those consistent with maternal under-perfusion and with fetal thromboocclusive disease.

RESULTS

Maternal vascular lesions were more common in the PIH group and combined group (61% and 59%, respectively), compared with the FGR group (16.2%; P < .001), and villous lesions were more common in the combined group, compared with the FGR and PIH groups (79.5%, 53.5%, and 46.9%, respectively; P = .004). Fetal villous changes were observed in 16.2% in the FGR group, compared with 3.1% in the PIH group (P = .03), and chronic villitis was 15.2% in the FGR group vs 1.6% in the PIH group (P = .004).

CONCLUSION

Placental lesions correspond with different clinical presentations.

Placental aetiologies of foetal growth restriction: clinical and pathological differences

BACKGROUND

Placental morphology and pregnancy outcome differ between normal pregnancies and those with foetal growth restriction (FGR). Most reports do not differentiate among different placental injury patterns related to foetal growth restriction.

AIMS

To evaluate placental and perinatal findings in growth restricted pregnancies based on three placental injury patterns: maternal and foetal blood supply abnormalities, and villitis of unknown aetiology, compared to those of preeclampsia (PE) and normal pregnancies.

STUDY DESIGN

Retrospective review.

SUBJECTS

65 growth restricted newborns and their placentas.

OUTCOME MEASURES

Comparison of the clinical perinatal characteristics and outcomes, placental pathology and the number of syncytiocapillary membranes in the terminal villi, of the 65 FGR cases with 13 pregnancies complicated with preeclampsia (PE), and 25 uncomplicated pregnancies as controls, at 34-40weeks gestation.

RESULTS

The most common injury patterns of FGR placentas were maternal underperfusion (66%) (group 1), foetal blood supply abnormality (17%) (group 2), and villitis of unknown aetiology (17%) (group 3). The rate of induced labours was the highest in group 1 but the rate of operative deliveries due to suspected foetal asphyxia was the highest in group 2 (p<0.05). In the FGR cases, inverse relationship was found between birth weight and the number of syncytiocapillary membranes (r=-0.31, p<.05) in the maternal underperfusion FGR cases (group 1) only.

CONCLUSIONS

The different injury patterns in placentas of FGR patients may be correlated to different clinical outcomes. Placental examination in FGR pregnancies can provide a specific pathophysiologic explanation that may recur in subsequent pregnancies and lead to changes in follow-up and management.

The diagnostic significance of hCG and hPL via immunohistochemistry of placental tissues in pregnancies diagnosed with IUGR and IUD

Placentas of patients diagnosed with intrauterine growth restriction (IUGR) and intrauterine death (IUD) were examined by immunohistochemistry for alpha-beta subunits of human chorionic gonadotropin (hCG) and human placental lactogen (hPL) antibodies, and compared with placentas from women with healthy pregnancies. In total, 114 subjects were evaluated. The patient group comprised 27 cases of IUGR and 57 of IUD, and the control group consisted of 30 women with normal pregnancies. Placental specimens were examined for primary antibodies using immunohistochemical techniques. Placentas from 22 cases of IUGR were stained positively for alpha-hCG. All 27 specimens obtained from this group were stained positively for beta-hCG and hPL. Among the cases of IUD, 44 placentas were stained positively for alpha-hCG, and all 57 specimens were stained positively for beta-hCG and hPL.