Fibrinoid necrosis of placental villi

Placental morphometrical and histopathology changes in the different clinical presentations of Hypertensive Syndromes in Pregnancy

OBJECTIVE

Even though there are clinical studies emphasizing the diagnosis and the perinatal intercurrent diseases of the Hypertensive Syndromes in Pregnancy, few of these studies establish the clinical forms of the specific hypertensive syndromes with the associated morphological placental alterations. The lack of studies on placental morphology and the etiopathogenesis of the different clinical standards for HSP, together with the need to objectively characterize these morphological placental lesions justify this study.

STUDY DESIGN

A retrospective study was carried out with 91 placentas examined throughout the period from 2000 to 2003. All placentas from patients presenting HSP in this period were included in the study. These were classified according to features well established by the literature such as laboratory and clinical criteria into: gestational hypertension (GH), chronic hypertension (CH), pre-eclampsia (PE) and pre-eclampsia superimposed on chronic hypertension (PSCH).

RESULTS

The number of knots presented a positive correlation with the length of time and severity of the hypertension during gestation (Spearman correlation: 0.253; P = 0.0158). The fibrin deposit was greater in all HSP groups but the pattern of distribution changes in the most severe cases from perivillous to intravillous as in the PSCH group (P = 0.002). There was no statistically significant difference in the area of the stem vessel walls among the groups. The cases with PE and CH presented a larger number of terminal villi vessels (P < 0.001).

CONCLUSION

This report suggests, that although they could be different types of hypertension or an evaluation of the same disease, the final pathway that leads to microscopic lesions in the placenta is the same, with only different intensity due to the severity of the disease.

Hypobaric hypoxia and villous trophoblast: evidence that human pregnancy at high altitude (3600 m) perturbs epithelial turnover and coagulation-fibrinolysis in the intervillous space

Spatial relationships between fibrin-type fibrinoid and regions of villous trophoblast were examined in order to address two main questions: [1] is high-altitude pregnancy accompanied by changes in the sizes of trophoblast compartments (cytotrophoblast, syncytiotrophoblast, denudation sites)?, and [2] do highland placentae differ in the amounts and distribution patterns of perivillous fibrin-type fibrinoid? Placentae were collected from two ethnic groups completing term pregnancies at low (400 m above sea level; n=25) and high (3600 m; n=45) altitude in Bolivia. Masson trichrome-stained sections were sampled randomly and analysed stereologically to estimate compartment volumes and surfaces. Comparisons were drawn using variance, Chi-squared and contingency table analyses. At high altitude, birthweights were 265 g lower and placentas had a larger intervillous space (270 cf 181 cm(3)), less fibrin-type fibrinoid (4.1 cf 8.4 cm(3) by volume; 2570 cf 4430 cm(2) by surface area), less villous trophoblast (50 cf 73 cm(3)) and a smaller villous surface (5.6 cf 7.0 m(2)). Volumes were reduced in all syncytiotrophoblast compartments (with and without nuclear aggregations). Cytotrophoblast was maintained and its relative volume increased significantly (from 2.7 to 3.6 per cent of trophoblast volume). Decreases in villous surface area affected primarily thinner (nuclear aggregate-free) regions of syncytium. Regardless of altitude, fibrin-type fibrinoid was deposited non-randomly: it was preferentially located at sites of trophoblast denudation. Although no altitudinal differences in fibrin-type fibrinoid patterns were detected, absolute surfaces were diminished on denuded and thinner regions of trophoblast but not on syncytial knots or bridges. Ethnic differences at low altitude (relatively greater deposits on denudations in Amerindians) were minimized at high altitude. We conclude that pregnancy at high altitude alters the epithelial steady state (towards cytotrophoblast and away from syncytiotrophoblast) and the coagulation-fibrinolysis steady state in the intervillous space (to favour fibrinolysis over coagulation). Thinner regions of syncytiotrophoblast may be the main sites of greater fibrinolytic or anticoagulatory activity. The findings are partly consistent with results from in vitro studies which indicate that hypoxia stimulates proliferation of cytotrophoblast but impairs fusion into syncytium.

A stereological method for testing whether or not there is random deposition of perivillous fibrin-type fibrinoid at the villous surface: description and pilot applications to term placentae

We present a stereological method for testing whether or not there is random deposition of fibrin-type fibrinoid (FTF) at the villous surface of human placenta. The method requires random sampling of tissue with test lattice lines superimposed on microscopic fields at random positions and orientations. Test lines are used to generate chance intersections with specified sub-domains of the villous surface. At least three sub-domains are distinguishable: non-syncytial knots (nonSK), syncytial knots (SK) and areas of trophoblast de-epithelialization (DEP). Other sub-domains may be included to suit individual circumstances and project aims. The relative numbers of intersections with sub-domains provide the basis for an 'expected' distribution. Subsequently, this is compared with an 'observed' distribution which can be calculated from empirical estimates of the numbers of intersections with sub-domains associated with perivillous FTF (e.g. nonSK+FTF, SK+FTF and DEP+FTF). Expected and observed distributions can be compared by a chi-squared analysis. If the null hypothesis (no difference) is rejected, chi-squared values for individual sub-domains can be analysed in order to localize and interpret sites of preferential deposition. Comparisons may be drawn for individual placentae as well as a group of placentae, thereby permitting assessment of inter-placental variability. Finally, between-group comparisons may be drawn in order to test whether or not FTF deposition patterns differ in control and other pregnancies. Worked examples of the statistical procedures are provided. Preliminary results of applications to placentae from normal and complicated (hypobaric hypoxia) pregnancies are presented. They show that FTF deposition is non-random and preferentially located at sites of de-epithelialization. De-epithelialization may be a consequence of syncytial degeneration but also, at least in part, of continuous trophoblast turnover in which syncytial fragments rich in (pre-) apoptotic nuclei detach from the epithelium and are deported from the maternal intervillous space. The nascent detachment site is immediately covered by FTF prior to repair by re-epithelialization.

Ontogenetic and phylogenetic evaluation of the presence of fibrin-type fibrinoid in the villous haemochorial placenta

The hypothesis that fibrin type fibrinoid deposition on villi is unique to the term human placenta was tested. Bright-field microscopy was used to examine sections of first and second trimester human placental villi and tissues from three animal species that have villous haemochorial placentae similar to the human: the armadillo, the baboon and the rhesus. Sections stained with haematoxylin and eosin showed fibrin type fibrinoid deposits were hypocellular, eosinophilic masses attached to the surface of villi examined from both the human and the animal species. The deposits were located at discontinuities in the syncytiotrophoblast layer, and the fibrinoid provided a matrix for trophoblast re-epithelization of the villous surface. It is concluded that fibrin-type fibrinoid is not unique to the term human placenta. The presence of the syncytiotrophoblast discontinuities associated with the fibrinoid deposition must be considered in models of maternal-fetal exchange in the villous haemochorial placenta.

The fibrinoids of the human placenta: origin, composition and functional relevance

Placental fibrinoids are extracellularly deposited materials which are histologically glossy and acid staining, and can be found in every normal and pathological placenta at all stages of pregnancy. The amount of fibrinoid is, in general, independent of pregnancy outcome and fetal wellbeing. According to new findings, the classical histological term "fibrinoid" covers two distinctive extracellular matrices which differ as regards structure, composition and function. Fibrin-type fibrinoid is mostly composed of fibrin together with other molecules derived from blood clotting or degenerative processes. It is mainly a maternal blood-clot product which is used (a) to adapt the intervillous space to optimized flow conditions and (b) to control growth of the villous trees by encasing new villous branches which caused intervillous stasis or turbulence of maternal blood. Moreover, fibrin-type fibrinoid replaces degenerative syncytiotrophoblast at the maternofetal exchange surfaces, thus acting as a kind of substitute barrier. Matrix-type fibrinoid is a secretory product of invasive extravillous trophoblast cells. It shares some similarities with basement membranes, however, it is secreted in an apolar fashion, embedding the secreting cells. Like basement membranes, it contains laminins, collagen IV, and heparan sulfate. In addition, oncofetal fibronectins, vitronectin, and i-glycosylated molecules but no collagens I, III, and VII can be found. Matrix-type fibrinoid is thought to regulate trophoblast invasion by specific interactions with cell surface integrins. As a kind of "glue", it anchors the placenta to the uterine wall and seems to play an important role in materno-fetal immune interactions at this particular site. Both types of fibrinoid are usually co-localized, thus indicating close morphogenetic and functional interrelations.

Significance of placental damage in vertical transmission of human immunodeficiency virus

The significance of physical breaches of the trophoblastic layer of the placenta in transmission of HIV from mother to infant was evaluated in 17 HIV-infected pregnant women. Samples of peripheral blood were obtained from the women during pregnancy and at delivery, at which time a small piece of placental tissue was obtained from a random site and immediately placed into fixative. Blood samples were obtained from infants at or shortly after birth and thereafter at approximately 3-month intervals, until the age of 18 months, in order to determine their HIV infection status. HIV RNA and p24 antigen were quantified in maternal plasma and CD4 cells enumerated. Paediatric diagnosis was conducted using polymerase chain reaction, virus isolation, detection of p24 antigen, and measurement of class-specific antibodies. Placental damage was quantified and evaluated using transmission electron microscopy. Maternal viral load was low, with a mean RNA copy number of 8,237 per millilitre of plasma (range 230-37,233 copies/ml). Only two women were p24-antigenaemic, and CD4 numbers ranged from 0.09 to 2.8 x 10(9)/l. There was evidence of breaks in the trophoblastic surface to the depth of the basement membrane in all 17 placentas, and perivillous fibrinoid deposits were also observed to a varying degree in all samples. However, none of the 13 infants available for follow-up had evidence of infection with HIV. Superficial damage to the trophoblastic surface of the placenta, with exposure of the basement membrane and potential exposure of CD4-expressing cells, does not appear to be a significant factor in the transmission of HIV from mother to infant during pregnancy.

Mechanisms of alphafetoprotein transfer in the perfused human placental cotyledon from uncomplicated pregnancy

We investigated the mechanisms of alphafetoprotein (AFP) transfer across the human placenta by correlating measurements of AFP transfer with cytochemical localization of AFP. Placental cotyledons were dually perfused in vitro with either the fetal or maternal perfusate containing umbilical cord plasma as a source of AFP. Steady state AFP clearance, corrected for release of endogenous AFP, was 0.973 +/- 0.292 microliter/min per gram in the fetal to maternal direction (n = 10), significantly higher (P < 0.02) than that in the maternal to fetal direction (n = 5; 0.022 +/- 0.013 microliter/min per gram). Clearance of a similarly sized protein, horseradish peroxidase was also asymmetric but clearance of the small tracer creatinine was not. Using a monoclonal antibody, we localized AFP to fibrinoid deposits in regions of villi with discontinuities of the syncytiotrophoblast, to cytotrophoblast cells in these deposits, to syncytiotrophoblast on some villi, and to trophoblast cells in the decidua. We conclude that AFP transfer in the placenta is asymmetric and that there are two available pathways for AFP transfer: (a) from the fetal circulation into the villous core and across fibrinoid deposits at discontinuities in the villous syncytiotrophoblast to enter the maternal circulation; and (b) AFP present in the decidua could enter vessels that traverse the basal plate.

Immunohistochemical localization of extracellular matrix in perivillous fibrinoid of normal human term placenta

The extracellular matrix of perivillous fibrinoid in normal human term placenta was investigated by means of the indirect immunofluorescent technique. Polyclonal antibodies to collagen types I, III, IV, V, fibronectin, fibrinogen, laminin, entactin and heparan sulphate proteoglycan and monoclonal antibodies BC-1, IST-9 and IST-4 to human fibronectin were used. The antigens can be grouped according to their presence in fibrinoid as abundant (fibrinogen, fibronectin, heparan sulphate proteoglycan, basement membrane collagen types IV and V), absent (laminin) and variable between fibrinoids (interstitial collagen types I and III, entactin). Our results also demonstrate that fibronectin in fibrinoid originates from placental cells (presumably cytotrophoblast). Monoclonal antibodies BC-1 and IST-9 specific to tissue fibronectin do not stain neighbouring placental extracellular matrix but do bind to fibrinoids on the same sections. Work by other authors has presented evidence that fibrin actually originates from maternal blood and even makes an attempt to substitute the term "fibrinoid" for "fibrin deposition". Our data on the composition of perivillous fibrinoids and the abundance of extracellular matrix components do not support this view and suggest that fibrinoid is a more relevant term for this interesting phenomenon, which deserves further investigation.

Factor VIII procoagulant: a marker of fibrinoid necrosis in normal term human placentae

Factor VIII procoagulant (FVIIIPC) is a plasma glycoprotein cofactor for activated factor IX that activates factor X in prothrombin convertase and results in fibrin deposition. We have studied 50 normal term placentae for the presence of FVIIIPC, and found it in granular deposits almost exclusively in areas of fibrinoid necrosis. This observation was made in all fibrinoid areas. These deposits were associated with specific factors of the coagulation, anticoagulation and fibrinolytic pathways. These findings suggest coagulation and fibrinolysis are activated in areas of fibrinoid necrosis and indicate FVIIIPC is a marker of these areas.

Thrombin receptor on the placental syncytiotrophoblastic plasma membrane

Purified placental syncytiotrophoblastic membrane has been used in a radioreceptor assay to study the binding of tritium radiolabeled human thrombin. Binding was found to be saturable at higher membrane concentrations when using a fixed amount of ligand and showed a hyperbola analogous to enzyme-substrate binding. A Scatchard plot was linear and revealed homogeneous binding sites with a high-affinity constant Ka = 3 X 10(10) M-1 and capacity of 3.05 X 10(11) sites/mg of membrane protein. This high-affinity compares well with chick and embryo cell thrombin receptor which has homogeneous sites and high-affinity in contrast to platelet thrombin receptor which exhibits multiple binding sites and cooperative effects as previously noted. A thrombin receptor on the placenta might serve to mobilize thrombin into placental tissue leading to conversion of fibrinogen into fibrin, fibrinoid necrosis being so common in certain placentae. A receptor-mediated transplacental passage of thrombin into the fetal circulation is also proposed.

Fetal microcirculation of abnormal human placenta. I. Scanning electron microscopy of placental vascular casts from small for gestational age fetus

The latex injection-corrosion cast technique coupled with scanning electron microscopy was applied to the study of small for gestational age placentas. The main ultrastructural changes observed in the fetal vasculature of small for gestational age placentas were less branching of arteries and veins, capillaries with variable diameters, and many capillary bud projections; also numerous "H"-shaped anastomoses were present in the capillary network. The corrosion/cast technique approach enabled us to visualize the three-dimensional distribution of arteries, veins, and capillary network as well as the ultrastructural alterations among the various-sized vessels in the abnormal placenta. Light microscopic examination of these placentas revealed numerous syncytial knots and fibrinoid deposits pressing on arteriolar and capillary vessels at different locations. We suggest that the numerous capillary buds and anastomoses are characteristics of neovascularization and may be a compensatory phenomenon of the capillary network. This information could shed new light on alterations of physiologic functions of the pathologic placenta.

Monoclonal antibodies to human amnion

Mouse hybridoma cell lines secreting monoclonal antibodies to human amnion were established. The reactivities of eight of these monoclonal antibodies (GB1, GB3, GB4, GB5, GB6, GB9, GB10 and GB11) on human skin and term extra-embryonic tissues, which included reflected amniochorions, basal plates, placentae, chorionic plates and umbilical cords, are reported. GB1, GB4, GB5, GB6, GB9 and GB11 showed various reactivity patterns on the epithelial cells of amnion, chorion and skin at different stages of differentiation. In addition, GB9 and GB11 showed extracellular reactivities; GB9 detected chorionic villi which were usually surrounded by fibrinoid and GB11 reacted with fibrinoid structures in the placentae and chorion laeve. GB10 recognized connective tissues in fetal mesenchyme and adult dermis. This study demonstrates the expression of many shared antigens between tissues derived from the extra-embryonic ectoderm and adult skin. These monoclonal antibodies will provide useful tools for further investigations of epithelial differentiation and transformation.

Maternal serum sialomucins during pregnancy and postpartum in patients with pre-eclampsia

The seromucoid fraction of maternal serum glycoproteins is increased in pre-eclampsia and the rise, which is proportional to the severity of the disease, may reflect progressive placental deterioration with increasing trophoblast fragmentation and deportation. The pulmonary lysis of deported trophoblast effects the local release of fetal antigens and thromboplastin in the lungs. The former, which are immunologically inert because they are complexed with maternal serum seromucoid, are released into the peripheral circulation, while the local coagulation hazard presented by the latter is countered by intensified fibrinolytic activity, the products of which are also released into the peripheral circulation. In severe pre-eclampsia the peripheral circulation contains a considerable excess of physically similar proteins derived from the seromucoid fraction and fibrin degradation products, and the conditions which then obtain in the renal glomerulus favour the physical process of coacervation. In that event the mechanism of the origin and development of the renal lesion can be described in purely physical terms.

Immunohistological and elution studies of the human placenta

An immunohistological survey of 28 full-term human placentas has demonstrated deposits of IgG, beta1C, beta1E, and fibrinogen/fibrin in areas of fibrinoid necrosis and on the trophoblast basement membrane in approximately 35% of placental villi. Traces of IgM were detected at similar sites in 18 of 28 full-term placentas. In 11 specimens of immature placentas (10-18 wk gestation) traces of IgG and beta1C and deposits of fibrinogen/fibrin were also present, but IgM was not detected in this material. IgG was recovered in acidic eluates from an homogenized placenta which behaved as an antibody reactive with unidentified material present in fibrinoid deposits and on the thickened trophoblast basement membrane of some villi. It could not be determined whether this IgG was derived from the maternal or fetal circulation.