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Soni S, Stevens A, Batra G, Heazell AEP. Characterising delayed villous maturation: A narrative literature review. Placenta 2024; 158:48-56. [PMID: 39368233 DOI: 10.1016/j.placenta.2024.09.020] [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] [Received: 08/12/2024] [Revised: 09/25/2024] [Accepted: 09/30/2024] [Indexed: 10/07/2024]
Abstract
The normal development of the placenta is vital for fetal growth and a healthy pregnancy outcome. Delayed villous maturation (DVM) is a placental lesion that has been implicated in stillbirth. In DVM, villi do not maturate adequately for their gestational age. DVM is characterised by larger and fewer terminal placental villi, low numbers of syncytial knots, and thicker and fewer vasculosyncytial membranes. DVM is most commonly reported in conjunction with maternal diabetes; however, the occurrence of idiopathic DVM suggests that there may be multiple mechanistic pathways that contribute to DVM. DVM can only be diagnosed through histopathological examination after birth, and there is significant interobserver variability in diagnosis. Establishing objective criteria to distinguish between DVM and healthy placentas is key to increasing the understanding of DVM. Vasculosyncytial membrane count, numbers of syncytial knots and CD15, among others, have been presented as potential diagnostic criteria in the literature. This review aims to compile information on DVM, including the pathophysiology, conditions that have reported associations with DVM and potential markers that could be used as criteria to differentiate between DVM and healthy placentas.
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Affiliation(s)
- Sharanam Soni
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Adam Stevens
- Division of Developmental Biology & Medicine, Faculty of Biology, Medicine, and Health, School of Biological Sciences, The University of Manchester, Manchester, UK
| | - Gauri Batra
- Department of Paediatric Histopathology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Alexander E P Heazell
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Department of Obstetrics, Manchester University NHS Foundation Trust, Manchester, UK
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Ortega MA, Pekarek T, De Leon-Oliva D, Boaru DL, Fraile-Martinez O, García-Montero C, Bujan J, Pekarek L, Barrena-Blázquez S, Gragera R, Rodríguez-Benitez P, Hernández-Fernández M, López-González L, Díaz-Pedrero R, Asúnsolo Á, Álvarez-Mon M, García-Honduvilla N, Saez MA, De León-Luis JA, Bravo C. Placental Tissue Calcification and Its Molecular Pathways in Female Patients with Late-Onset Preeclampsia. Biomolecules 2024; 14:1237. [PMID: 39456171 PMCID: PMC11506500 DOI: 10.3390/biom14101237] [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: 07/07/2024] [Revised: 08/20/2024] [Accepted: 09/27/2024] [Indexed: 10/28/2024] Open
Abstract
Preeclampsia (PE) is a complex multisystem disease characterized by hypertension of sudden onset (>20 weeks' gestation) coupled with the presence of at least one additional complication, such as proteinuria, maternal organ dysfunction, or uteroplacental dysfunction. Hypertensive states during pregnancy carry life-threatening risks for both mother and baby. The pathogenesis of PE develops due to a dysfunctional placenta with aberrant architecture that releases factors contributing to endothelial dysfunction, an antiangiogenic state, increased oxidative stress, and maternal inflammatory responses. Previous studies have shown a correlation between grade 3 placental calcifications and an elevated risk of developing PE at term. However, little is known about the molecular pathways leading to placental calcification. In this work, we studied the gene and protein expression of c-Jun N-terminal kinase (JNK), Runt-related transcription factor 2 (RUNX2), osteocalcin (OSC), osteopontin (OSP), pigment epithelium-derived factor (PEDF), MSX-2/HOX8, SOX-9, WNT-1, and β-catenin in placental tissue from women with late-onset PE (LO-PE). In addition, we employed von Kossa staining to detect mineral deposits in placental tissues. Our results show a significant increase of all these components in placentas from women with LO-PE. Therefore, our study suggests that LO-PE may be associated with the activation of molecular pathways of placental calcification. These results could be the starting point for future research to describe the molecular mechanisms that promote placental calcification in PE and the development of therapeutic strategies directed against it.
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Affiliation(s)
- Miguel A. Ortega
- Department of Medicine and Medical Specialities, (CIBEREHD), Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (T.P.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (J.B.); (L.P.); (R.G.); (M.Á.-M.); (N.G.-H.); (M.A.S.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (S.B.-B.); (L.L.-G.); (R.D.-P.); (Á.A.)
| | - Tatiana Pekarek
- Department of Medicine and Medical Specialities, (CIBEREHD), Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (T.P.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (J.B.); (L.P.); (R.G.); (M.Á.-M.); (N.G.-H.); (M.A.S.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (S.B.-B.); (L.L.-G.); (R.D.-P.); (Á.A.)
| | - Diego De Leon-Oliva
- Department of Medicine and Medical Specialities, (CIBEREHD), Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (T.P.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (J.B.); (L.P.); (R.G.); (M.Á.-M.); (N.G.-H.); (M.A.S.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (S.B.-B.); (L.L.-G.); (R.D.-P.); (Á.A.)
| | - Diego Liviu Boaru
- Department of Medicine and Medical Specialities, (CIBEREHD), Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (T.P.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (J.B.); (L.P.); (R.G.); (M.Á.-M.); (N.G.-H.); (M.A.S.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (S.B.-B.); (L.L.-G.); (R.D.-P.); (Á.A.)
| | - Oscar Fraile-Martinez
- Department of Medicine and Medical Specialities, (CIBEREHD), Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (T.P.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (J.B.); (L.P.); (R.G.); (M.Á.-M.); (N.G.-H.); (M.A.S.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (S.B.-B.); (L.L.-G.); (R.D.-P.); (Á.A.)
| | - Cielo García-Montero
- Department of Medicine and Medical Specialities, (CIBEREHD), Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (T.P.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (J.B.); (L.P.); (R.G.); (M.Á.-M.); (N.G.-H.); (M.A.S.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (S.B.-B.); (L.L.-G.); (R.D.-P.); (Á.A.)
| | - Julia Bujan
- Department of Medicine and Medical Specialities, (CIBEREHD), Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (T.P.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (J.B.); (L.P.); (R.G.); (M.Á.-M.); (N.G.-H.); (M.A.S.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (S.B.-B.); (L.L.-G.); (R.D.-P.); (Á.A.)
| | - Leonel Pekarek
- Department of Medicine and Medical Specialities, (CIBEREHD), Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (T.P.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (J.B.); (L.P.); (R.G.); (M.Á.-M.); (N.G.-H.); (M.A.S.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (S.B.-B.); (L.L.-G.); (R.D.-P.); (Á.A.)
| | - Silvestra Barrena-Blázquez
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (S.B.-B.); (L.L.-G.); (R.D.-P.); (Á.A.)
- Department of Nursing and Physiotherapy, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain
| | - Raquel Gragera
- Department of Medicine and Medical Specialities, (CIBEREHD), Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (T.P.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (J.B.); (L.P.); (R.G.); (M.Á.-M.); (N.G.-H.); (M.A.S.)
| | - Patrocinio Rodríguez-Benitez
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (P.R.-B.); (J.A.D.L.-L.); (C.B.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
- Department of Nephrology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
| | - Mauricio Hernández-Fernández
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain;
| | - Laura López-González
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (S.B.-B.); (L.L.-G.); (R.D.-P.); (Á.A.)
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain;
| | - Raul Díaz-Pedrero
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (S.B.-B.); (L.L.-G.); (R.D.-P.); (Á.A.)
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain;
| | - Ángel Asúnsolo
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (S.B.-B.); (L.L.-G.); (R.D.-P.); (Á.A.)
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain;
| | - Melchor Álvarez-Mon
- Department of Medicine and Medical Specialities, (CIBEREHD), Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (T.P.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (J.B.); (L.P.); (R.G.); (M.Á.-M.); (N.G.-H.); (M.A.S.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (S.B.-B.); (L.L.-G.); (R.D.-P.); (Á.A.)
- Immune System Diseases-Rheumatology and Internal Medicine Service, University Hospital Prince of Asturias, Networking Research Center on for Liver and Digestive Diseases (CIBEREHD), 28806 Alcala de Henares, Spain
| | - Natalio García-Honduvilla
- Department of Medicine and Medical Specialities, (CIBEREHD), Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (T.P.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (J.B.); (L.P.); (R.G.); (M.Á.-M.); (N.G.-H.); (M.A.S.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (S.B.-B.); (L.L.-G.); (R.D.-P.); (Á.A.)
| | - Miguel A. Saez
- Department of Medicine and Medical Specialities, (CIBEREHD), Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (T.P.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (J.B.); (L.P.); (R.G.); (M.Á.-M.); (N.G.-H.); (M.A.S.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (S.B.-B.); (L.L.-G.); (R.D.-P.); (Á.A.)
- Pathological Anatomy Service, University Hospital Gómez-Ulla, 28806 Alcala de Henares, Spain
| | - Juan A. De León-Luis
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (P.R.-B.); (J.A.D.L.-L.); (C.B.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Coral Bravo
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (P.R.-B.); (J.A.D.L.-L.); (C.B.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
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Farias Arcos Júnior G, Pulcineli Vieira Francisco R, Kill B, Verzinhasse Peres S, B C Gibelli MA, Ibidi SM, Brunow de Carvalho W, Braz Simões A, Brizot MDL, Schultz R, Azevedo Carvalho M. Severe COVID-19 in pregnant women: Analysis of placental features and perinatal outcomes. Am J Clin Pathol 2024:aqae072. [PMID: 38895930 DOI: 10.1093/ajcp/aqae072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 05/17/2024] [Indexed: 06/21/2024] Open
Abstract
OBJECTIVES Changes in placental features, such as maternal and fetal vascular malperfusion, are associated with SARS-CoV-2 infection. The anatomopathologic study of the placenta is crucial for understanding pregnancy and fetal complications. To that end, this study aimed to describe placental features and analyze the association between placental findings and perinatal outcomes in a cohort of pregnant women with severe COVID-19. METHODS This nested study within a prospective cohort study consisted of 121 singleton pregnant women with a diagnosis of severe COVID-19. Placental pathologic findings were described, and the associations between severe COVID-19 and clinical parameters and perinatal outcomes were assessed. RESULTS The prevalence of maternal vascular malperfusion was 52.1%, followed by fetal vascular malperfusion at 21.5%, ascending intrauterine infections at 11.6%, and inflammatory lesions at 11.6%. Other lesions were observed in 39.7% of the placentas examined. Inflammatory lesions were an independent factor (P = .042) in 5-minute Apgar scores below 7. Ascending infection was associated with fetal death (P = .027). CONCLUSIONS Maternal vascular malperfusion was the most prevalent placental feature in patients with severe COVID-19. Chorangiosis is associated with poor perinatal outcomes.
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Affiliation(s)
- Gelson Farias Arcos Júnior
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Rossana Pulcineli Vieira Francisco
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Beatriz Kill
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Stela Verzinhasse Peres
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Maria Augusta B C Gibelli
- Divisao de Neonatologia, Instituto da Crianca do Hospital das Clinicas HCFMUSP, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Silvia Maria Ibidi
- Divisao de Neonatologia, Instituto da Crianca do Hospital das Clinicas HCFMUSP, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Werther Brunow de Carvalho
- Divisao de Neonatologia, Instituto da Crianca do Hospital das Clinicas HCFMUSP, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Angélica Braz Simões
- Servico de Anatomia Patologica do Hospital Universitario da USP, Sao Paulo, Brazil
| | - Maria de Lourdes Brizot
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Regina Schultz
- Divisao de Anatomia Patologica, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Mariana Azevedo Carvalho
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
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Lai YM, Tan GC, Shah SA, Abd Rahman R, Mohd Saleh MF, Mansor S, Khong TY, Wong YP. Non-hypertensive gestational diabetes mellitus: Placental histomorphology and its association with perinatal outcomes. Placenta 2024; 147:21-27. [PMID: 38278001 DOI: 10.1016/j.placenta.2024.01.012] [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] [Received: 10/09/2023] [Revised: 12/12/2023] [Accepted: 01/22/2024] [Indexed: 01/28/2024]
Abstract
INTRODUCTION Gestational diabetes mellitus (GDM) exerts a great impact on the placenta and reflects changes on placentas both morphological and functionally. The aims of this study are to evaluate the prevalence of placental histopathological lesions in pregnancies complicated by GDM compared to gestational age-matched controls, and their association with maternal and fetal complications. METHODS Fifty-four singleton GDM-complicated pregnancies were recruited and compared to 33 consecutive normal pregnancies. Two pathologists, blinded to all clinical data, reviewed and evaluated all histological samples of the placentas in accordance with Amsterdam criteria. Relevant demographic, clinical data and primary birth outcomes were recorded. RESULTS A myriad of histomorphological abnormalities, including chronic inflammation (n = 9/54, p = 0.031), histological chorioamnionitis (n = 23/54, p < 0.001), umbilical/chorionic vasculitis (n = 9/54, p = 0.031), changes related to maternal vascular malperfusion (n = 22/54, p = 0.003), chorangiosis (n = 10/54, p = 0.046) and villous dysmaturity (n = 9/54, p = 0.012) were observed more frequently in the GDM placentas compared to the controls. Additionally, GDM significantly increased the risk of fetal complications, including macrosomia/fetal growth restriction (n = 13/54, p = 0.004). DISCUSSION Histoarchitectural abnormalities were observed more frequently in placentas of GDM pregnancies compared to the controls. Our findings support the hypothesis that diabetic-induced damage in the placental function may be associated with the increased in fetal growth disorders in GDM-complicated pregnancies.
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Affiliation(s)
- Yip Meng Lai
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, 56000, Kuala Lumpur, Malaysia
| | - Geok Chin Tan
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, 56000, Kuala Lumpur, Malaysia
| | - Shamsul Azhar Shah
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, 56000, Kuala Lumpur, Malaysia
| | - Rahana Abd Rahman
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, 56000, Kuala Lumpur, Malaysia
| | - Muhamad Fakhri Mohd Saleh
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, 56000, Kuala Lumpur, Malaysia
| | - Suhada Mansor
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, 56000, Kuala Lumpur, Malaysia
| | - Teck Yee Khong
- Department of Pathology, Women's and Children's Hospital, Adelaide, SA 5006, Australia
| | - Yin Ping Wong
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, 56000, Kuala Lumpur, Malaysia.
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Rakha S, Mohamed AA, Yussif SM. Placental Histopathologic Findings in the Setting of Prenatally Diagnosed Major Congenital Heart Disease. Fetal Pediatr Pathol 2023; 42:922-935. [PMID: 37817745 DOI: 10.1080/15513815.2023.2266489] [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] [Received: 03/03/2023] [Accepted: 09/26/2023] [Indexed: 10/12/2023]
Abstract
Objectives: Studies suggest an association between placenta and congenital heart disease (CHD). We evaluated placental pathologies associated with major CHD. Methods: A prospective study included fetuses with major CHD, identified by fetal echocardiography. Fetal Doppler of umbilical artery (UA), middle cerebral artery (MCA), and placental histopathology were assessed. Outcome was measured by mortality at one month of age. Results: 21 cases were analyzed. Hypoplastic left heart syndrome was the commonest lesion (23.8%). Significant differences were detected among categories regarding MCA systolic/diastolic (S/D) ratio & pulsatility index (p = 0.023; 0.036), respectively. Placental histopathologies were demonstrated in 18(85.7%), predominately involved fetal malperfusion lesions 16/21(76.2%), especially chorangiosis (33.3%). No significant association was detected between placental histopathological abnormalities and Doppler parameter, diagnostic category, or mortality. Conclusion: The high prevalence of abnormal placental histopathological findings in major fetal CHD provides additional evidence of placental-cardiac interlinkage. No association was detected between abnormal placental histopathology and fetal Doppler measurements or neonatal outcome of CHD.
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Affiliation(s)
- Shaimaa Rakha
- Pediatric Cardiology Unit, Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Alhussein Ahmed Mohamed
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Shaimaa M Yussif
- Department of Pathology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Dankó I, Kelemen E, Tankó A, Cserni G. Correlations of Placental Histopathology, Neonatal Outcome, and Cardiotocogram Baseline Variability and Acceleration Patterns in the Growth Restricted Preterm Population. Pediatr Dev Pathol 2023; 26:447-457. [PMID: 37334626 DOI: 10.1177/10935266231178615] [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: 06/20/2023]
Abstract
OBJECTIVE To evaluate the possible connections of cardiotocography (CTG) signs with neonatal outcome and placental histopathology between growth restricted preterms. MATERIALS AND METHODS Placental slides, baseline variability, and acceleration patterns of cardiotocograms, and neonatal parameters were studied retrospectively. Placental histopathological changes were diagnosed according to the Amsterdam criteria; percentage of intact terminal villi and capillarization of villi were also studied. 50 cases were analyzed: 24 were early-onset fetal growth restriction (FGR), 26 were late-onset FGR. RESULTS Reduced baseline variability was related to poor neonatal outcome; lack of accelerations similarly had associations with poor outcomes. Maternal vascular malperfusion, avascular villi, VUE, and chorangiosis were more common in the background of reduced baseline variability and absence of accelerations. Lower percentage of intact terminal villi was significantly associated with lower umbilical artery pH, higher lactate levels, and reduced baseline variability on CTG; absence of accelerations was correlated with decreased capillarization of terminal villi. CONCLUSIONS Baseline variability and absence of accelerations seem to be useful and reliable markers in predicting poor neonatal outcome. Maternal and fetal vascular malperfusion signs, decreased capillarization, and lower percentage of intact villi in placenta could contribute to pathologic CTG signs and poor prognosis.
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Affiliation(s)
- István Dankó
- Bács-Kiskun County Teaching Hospital, Department of Obstetrics and Gynecology, Kecskemét, Hungary
| | - Edit Kelemen
- Bács-Kiskun County Teaching Hospital, Perinatal Intensive Centre, Kecskemét, Hungary
| | - András Tankó
- Bács-Kiskun County Teaching Hospital, Department of Obstetrics and Gynecology, Kecskemét, Hungary
| | - Gábor Cserni
- Bács-Kiskun County Teaching Hospital, Department of Pathology, Kecskemét, Hungary
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7
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Mehreen A, Suresh S, Freedman AA, Ernst LM. Histopathologic Findings in Large for Gestational Age Placentas and Correlation With CD15 Immunohistochemistry. Pediatr Dev Pathol 2023; 26:458-465. [PMID: 37599445 DOI: 10.1177/10935266231191965] [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: 08/22/2023]
Abstract
BACKGROUND The histopathology and CD15 expression in large for gestational age (LGA) placentas is not well-documented. METHODS To analyze this, we utilized 2 separate cohorts of placentas from singleton term deliveries. LGA and appropriate for gestational age (AGA) placentas were compared for major histopathologies including acute and chronic inflammation, maternal and fetal vascular malperfusion, delayed villous maturation (DVM), and villous hypervascularity/chorangiosis. We also examined CD15 immunohistochemistry in LGA and AGA placentas. Stained slides were reviewed blinded to the placental weight. Five random 20× fields were scored semi-quantitatively for CD15 staining of villous capillaries on a scale of 0 to 5 (0 = 0%, 1 = 1%-5%, 2 = 5%-25%, 3 = 25%-50%, 4 = 50%-75%, and 5 = >75%). RESULTS In 1 cohort, 1238 LGA and 7908 AGA placentas were identified. Patients with LGA placentas were significantly more likely to have higher birthweight babies, obesity, hypertensive disorders, pre-gestational, and gestational diabetes. Also, LGA placentas had a higher prevalence of fetal vascular malperfusion, DVM, and villous chorangiosis. In other cohort of 75 LGA placentas and 73 AGA controls, the average score of CD15 staining in villous capillaries was significantly higher amongst LGA placentas. CONCLUSION We conclude that LGA placentas have increased expression of CD15 in villous capillary endothelium and higher prevalence of FVM, DVM, and villous chorangiosis than AGA placentas.
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Affiliation(s)
- Ansa Mehreen
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
- Department of Pathology and Laboratory Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Sunitha Suresh
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, IL, USA
| | - Alexa A Freedman
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, IL, USA
| | - Linda M Ernst
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
- Department of Pathology and Laboratory Medicine, NorthShore University HealthSystem, Evanston, IL, USA
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8
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Faghir-Ganji M, Amanollahi A, Nikbina M, Ansari-Moghaddam A, Abdolmohammadi N. Prevalence and risk factors of anemia in first, second and third trimesters of pregnancy in Iran: A systematic review and meta-analysis. Heliyon 2023; 9:e14197. [PMID: 36938395 PMCID: PMC10018475 DOI: 10.1016/j.heliyon.2023.e14197] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 03/06/2023] Open
Abstract
Anemia is a common health problem during pregnancy worldwide that has many short-term and long-term effects on women. This study examined the Prevalence and Risk factors of anemia in first, second and third trimesters of pregnancy in Iran between 2000 and 2021. PubMed, Medline, Scopus, Google Scholar, and national databases of Magiran and SID were searched for articles, which were then subjected to PRISMA-compliant screening. A systematic review and meta-analysis (using a random-effects model in STATA version 17) were conducted on the 18 eligible cross-sectional studies (published between July 23, 2000 and September 1, 2021) that revealed significant data on the prevalence of anemia in pregnant women. This study included 18 reports with a total of 25,831 individuals in which 15% of study subjects had anemia (95% CI: 12-19%). The pooled prevalence of anemia was 13% in people older than 26 years old (95% CI: 9-17%) compared to 22% in people younger than 26 years old (95% CI: 15-29). It was 18% (95% CI: 11-27%) for pregnant women having their second child in comparison to 20% (95% CI: 11-32%) for women who have had three or more children. Anemia was thought to affect 11% of housewives (95% CI: 2-26%) and 10% of working women (95% CI: 6-16%). Anemia frequency was 22%, 17% and 13% amongst first (22%), second (17%), and third (13%) trimesters, respectively. Nevertheless, it happened much less often after the second trimester. Moreover, poor education, a history of low birth weight in children, and a low socioeconomic level within women were associated with the prevalence of anemia. The pooled prevalence of anemia in pregnant women is marginally lower than in earlier report. However, it seems to be a health problem in developing countries including Iran currently. Therefore, the study suggest that health system should design comprehensive preventive and control measurements such as more effective treatments to minimize anemia in vulnerable segments of society, particularly mothers, and improve their health through increasing access to services for mothers.
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Affiliation(s)
- Monireh Faghir-Ganji
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
- Student Research Committee, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Amanollahi
- Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Nikbina
- Department of Midwifery, Shoushtar Faculty of Medical Sciences, Shoushtar, Iran
| | | | - Narjes Abdolmohammadi
- Department of Epidemiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author.
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9
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Tekeli Taşkömür A, Özen FZ, Erten Ö. Evaluation of the relationship between reduced fetal movement and obstetric-neonatal outcomes and placental pathologies. Minerva Obstet Gynecol 2022; 74:401-409. [PMID: 36239529 DOI: 10.23736/s2724-606x.22.04955-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Fetal movements are one of the simple methods that show the baby's well-being. Conditions associated with decreased fetal movements have not been determined, so it is important to analyze their different aspects. This study aimed to evaluate the relationship between reduced fetal movement and obstetric-neonatal outcomes, and placental pathologies. METHODS In this prospective controlled study, laboratory results (blood glucose, hemoglobin, thyroid-stimulating hormone [TSH]), a non-stress test (NST), biophysical profile results, obstetric and neonatal outcomes, and placental pathological results of 74 pregnant women at 35 or more gestational weeks (to exclude the effect of prematurity on obstetric and neonatal outcomes) attending the obstetrics clinic between December 26, 2017 and January 30, 2019 with complaints of reduced fetal movement, were compared with 74 healthy pregnant women. Since prematurity and post-maturity may adversely affect obstetric-neonatal and placental pathology results, term pregnancies between 370/7-406/7 weeks were evaluated separately. RESULTS In the group with reduced fetal movement, the biophysical profile was lower than the controls (P=0.013). Among placental pathologies, chorangiosis and hypercoiled cord were significantly higher in the group with reduced fetal movement than controls (P<0.05). Small for gestational age (SGA) and fetal growth restriction (FGR) in this group had these pathologies. Results of women at 370/7-406/7 weeks were similar except for the additional finding of chorioamnionitis. CONCLUSIONS Reduced fetal movement may be associated with the low biophysical profile. In cases where fetal movement decreases, placental chorangiosis and hypercoiled cord seem to be associated with fetal growth restriction.
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Affiliation(s)
- Aysun Tekeli Taşkömür
- Department of Gynecology and Obstetrics, Faculty of Medicine, Amasya University, Amasya, Turkey -
| | - Fatma Z Özen
- Department of Pathology, Faculty of Medicine, Amasya University, Amasya, Turkey
| | - Özlem Erten
- Department of Gynecology and Obstetrics, Faculty of Medicine, Kütahya Health Sciences University, Kütahya, Turkey
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10
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Association of Maternal Serum Ischemia Modified Albumin (IMA) with Placental Histopathological Changes and Fetomaternal Outcome: A Prospective Case Control Study in Normotensive and Pre-eclamptic Women. J Obstet Gynaecol India 2022; 72:166-173. [PMID: 35928062 PMCID: PMC9343519 DOI: 10.1007/s13224-021-01614-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022] Open
Abstract
Introduction Ischemia and oxidative stress leads to generation of hydroxyl free radicals and modification of 'N-terminus' of human serum albumin. This modified albumin molecule, known as Ischemia Modified Albumin (IMA), is elevated in early stages of ischemia. It has recently been approved by US Food and Drug Administration (US FDA) for its clinical use, as early marker of myocardial ischemia in cardiology. IMA is a novel marker of ischemia and is elevated in other clinical conditions associated with ischemia like pulmonary embolism, uncontrolled type II diabetes mellitus, acute decompensated heart failure, preeclampsia, recurrent pregnancy losses and IUGR. Role of IMA in birth asphyxia in perinatology is of current interest and needs further research. Methodology A prospective case control study was conducted in a tertiary center in North India for one year. Total 80 pregnant women between 34 and 40 weeks were recruited and allocated in two groups. Case group comprised of 40 pre-eclamptic pregnant women and control group comprised of 40 normotensive pregnant women. Comparison and association of maternal serum IMA levels with fetomaternal outcome and number and types of placental histopathological changes was done in two groups. Results In preeclampsia group mean serum IMA (115.23 ± 49.51) was significantly higher as compared to the normotensive group (79.21 ± 14.35). The optimum cut off value of IMA to detect a case was 94.5 IU/ml (sensitivity 65%, specificity 87.5%, PPV 83.9%, NPV 71.4% and diagnostic accuracy of 76.3). Pre-eclamptic women, had significantly higher incidence of PTVD, lower fetal birth weight and placental histopathological changes as compared to normotensive group. 83.8% of the women with raised IMA levels were pre-eclamptic. Raised IMA levels were significantly associated with higher incidence of PTVD, birth weight ≤ 2 kg and hypoxic histopathological lesions of chorangiosis, intervillous fibrin and hyalinization. Conclusion Determination of maternal serum IMA levels early in pregnancy can predict preeclampsia and avoid future severe preeclampsia related complications. It might be useful to optimize both maternal and fetal/neonatal outcomes.
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Aljhdali HM, Abdullah LS, Alhazmi DA, Almosallam AM, Bondagji NS. Practice of Placenta Submission for Histopathological Examination, Experience of a Teaching/Tertiary Care Hospital in Saudi Arabia. Cureus 2021; 13:e17364. [PMID: 34567903 PMCID: PMC8454601 DOI: 10.7759/cureus.17364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 11/30/2022] Open
Abstract
Objectives The aim of this study is to determine the appropriateness of histopathologic examination of the placenta at King Abdulaziz University Hospital (KAUH), Jeddah, based on the guidelines of the College of American Pathologists (CAP). Methods It is a retrospective review of obstetric and pathologic records for all deliveries at KAUH, between January 1, 2017, and April 30, 2019. The placentae were assessed for eligibility to undergo pathologic examination. Furthermore, examined and non-examined placentae meeting the CAP criteria were compared based on their actual indications. Results There were 8,929 deliveries, of which 1,444 (16.2%) placentae met the CAP guidelines. A total of 583/1,444 placentae (40.4%; 95% confidence interval [CI] = 37.8-43) were sent for pathologic examination. Of the 7,485 placentae that did not require submission for pathological examination, as determined by the pathologist, 7,456 (99.6%; 95% CI = 99.4-99.7) were not submitted appropriately. The labor and delivery staff were more likely to submit placentae with fetal/neonatal indications rather than those with maternal indications for examination, which was statistically significant (odds ratio = 6.5; 95% CI = 5.08-8.30). Conclusion While most of the examined placentae at KAUH met the CAP guidelines, there was a substantial under-submission of eligible placentae. Further studies are advised to reveal the reasons behind this underestimation so that correctional measures may be adopted, as placenta examination is a valuable tool to understand the risk factors and pathogenesis of deleterious maternal, neonatal, and fetal events.
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Affiliation(s)
- Hessa M Aljhdali
- Anatomic Pathology, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | - Layla S Abdullah
- Anatomic Pathology, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | - Dalia A Alhazmi
- Anatomic Pathology, King Abdulaziz University Hospital, Jeddah, SAU
| | - Ahmed M Almosallam
- Anatomic Pathology, King Faisal Specialist Hospital and Research Centre, Jeddah, SAU
| | - Nabeel S Bondagji
- Obstetrics and Gynecology, Fetomaternal Medicine, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
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12
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Abstract
Ein besonderes Augenmerk bei der durch das Severe-acute-respiratory-syndrome-Coronavirus‑2 (SARS-CoV-2) hervorgerufenen Coronaviruskrankheit 2019 (COVID-19) wurde von Beginn an auf die Gruppe der Schwangeren gelegt. Nach einer Einführung zur Immunabwehr der Plazenta und viralen plazentaren Infektionen, beschreiben wir die morphologischen Veränderungen der Plazenta bei SARS-CoV-2-Infektion der Mutter, ziehen Vergleiche zur SARS-Epidemie und diskutieren die Frage der vertikalen Transmission von SARS-CoV‑2 von der Mutter auf das Neugeborene. Die häufigsten pathologischen Befunde der Plazenta bestehen in Zeichen der maternalen und auch fetalen Malperfusion sowie immunologisch bzw. thromboinflammatorisch vermittelten Veränderungen. Es finden sich Infarkte, deziduale Vaskulopathie sowie Thromben im fetalen Kreislauf und Vermehrung avaskulärer Villi. Daneben zeigen sich in einigen Fällen Entzündungsreaktionen mit Villitis und Intervillositis sowie eine Vaskulitis fetaler Gefäße. Zudem konnte der Nachweis erbracht werden, dass SARS-CoV‑2 die Plazenta direkt infizieren kann. Somit ist auch eine vertikale Transmission möglich. Ein COVID-19-spezifisches Schädigungsmuster der Plazenta liegt bislang nicht vor, obwohl der Nachweis von fetaler Thrombovaskulitis, Villitis und Intervillositis sowie einer fetalen und maternalen Malperfusion in Analogie zu der bereits bekannten allgemeinen Pathophysiologie von COVID-19 (Entzündungsreaktion und Mikrozirkulationsstörung) interpretiert werden könnte. Der Nachweis viraler RNA in den fetalen Kompartimenten der Plazenta/der Nabelschnur zeugt von der vertikalen SARS-CoV‑2 Transmission.
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吴 琳, 林 新, 郑 直, 何 泽. [Influence of placental pathological chorangiosis on neonates: an analysis of 450 cases]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:494-498. [PMID: 34020740 PMCID: PMC8140339 DOI: 10.7499/j.issn.1008-8830.2102055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/18/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To study the influence of placental pathological chorangiosis in the mother on the mortality of neonates and the incidence rate of complications. METHODS A retrospective analysis was performed for the neonates who were hospitalized within 3 days after birth in the Department of Neonatology, Xiamen Maternal and Child Health Hospital, from July 2016 to February 2020. According to whether the placental pathology showed chorangiosis, the neonates were divided into an observation group and a control group (n=450 each). The two groups were analyzed in terms of general status, maternal comorbidities during pregnancy, neonatal mortality, and incidence rate of complications in neonates. RESULTS Compared with the control group, the observation group had a significantly higher cesarean section rate (P < 0.05) and a significantly higher incidence rate of maternal gestational hypertension (P < 0.05). The observation group had significantly higher incidence rates of congenital malformation, small-for-gestational-age birth, and low Apgar score than the control group (P < 0.05). The observation group also had significantly higher mortality rate and incidence rates of brain injury, retinopathy of prematurity, and extrauterine growth retardation (P < 0.05). CONCLUSIONS Neonates born to mothers with placental pathological chorangiosis tend to have a higher morbidity rate and incidence rate of complications. It is important to improve the understanding of chorangiosis and provide intervention as soon as possible, in order to reduce complications and improve prognosis.
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Affiliation(s)
- 琳琳 吴
- 厦门大学附属妇女儿童医院/厦门市妇幼保健院新生儿科, 厦门市围产-新生儿感染重点实验室, 福建厦门 361001Department of Neonatology, Women and Children's Hospital, School of Medicine, Xiamen Key Laboratory of Perinatal Infection, Xiamen, Fujian 361001, China
| | - 新祝 林
- 厦门大学附属妇女儿童医院/厦门市妇幼保健院新生儿科, 厦门市围产-新生儿感染重点实验室, 福建厦门 361001Department of Neonatology, Women and Children's Hospital, School of Medicine, Xiamen Key Laboratory of Perinatal Infection, Xiamen, Fujian 361001, China
| | - 直 郑
- 厦门大学附属妇女儿童医院/厦门市妇幼保健院新生儿科, 厦门市围产-新生儿感染重点实验室, 福建厦门 361001Department of Neonatology, Women and Children's Hospital, School of Medicine, Xiamen Key Laboratory of Perinatal Infection, Xiamen, Fujian 361001, China
| | - 泽生 何
- 厦门大学附属妇女儿童医院/厦门市妇幼保健院病理科, 福建厦门 361001
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14
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Vafaei H, Karimi Z, Akbarzadeh-Jahromi M, Asadian F. Association of placental chorangiosis with pregnancy complication and prenatal outcome: a case-control study. BMC Pregnancy Childbirth 2021; 21:99. [PMID: 33516193 PMCID: PMC7847032 DOI: 10.1186/s12884-021-03576-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 01/20/2021] [Indexed: 11/22/2022] Open
Abstract
Background Chorangiosis is a vascular change involving the terminal chorionic villi in the placenta. It results from longstanding, low-grade hypoxia in the placental tissue, and is associated with such conditions as intrauterine growth restriction (IUGR), diabetes, and gestational hypertension in pregnancy. Chorangiosis rarely occurs in normal pregnancies. However, its prevalence is 5–7% of all placentas from infants admitted to newborn intensive care units. The present study was aimed at determining the association of chorangiosis with pregnancy complications and perinatal outcomes. Methods In this case-control study, 308 chorangiosis cases were compared with 308 controls (with other diagnoses in pathology) in terms of maternal, placental, prenatal, and neonatal characteristics derived from the medical records of participants retrospectively. R and SPSS version 22 software tools were used, and the statistical significance level was considered 0.05 for all the tests. Results Preeclampsia, diabetes mellitus, maternal hemoglobin, maternal hematocrit, C/S, oligohydramnios, fetal anomaly, dead neonates, NICU admissions were significantly higher in the chorangiosis group OR = 1.6, 3.98, 1.68, 1.92, 2.1, 4.47, 4.22, 2.9, 2.46, respectively (p-value< 0.05 for all). Amniotic fluid index, birth weight, cord PH amount, 1st, and 5th Apgar score was lower in the chorangiosis group OR = 0.31, 1, 0.097, 0.83, 0.85, respectively (p-value< 0.05 for all). Moreover, fundal placenta, retro placental hemorrhage, perivillous fibrin deposition, calcification, and acute chorioamnionitis were higher in the chorangiosis group OR = 2.1, 11.8, 19.96, 4.05, and 6.38 respectively, (p-value< 0.05). There was a high agreement between the two pathologists, and the power of the study was estimated at 99%. Conclusion Although chorangiosis is an uncommon condition, it is associated with a higher incidence of perinatal and neonatal morbidity and mortality. Therefore, it should be considered an important clinical sign of adverse pregnancy outcomes and should be reported in the pathology evaluation.
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Affiliation(s)
- Homeira Vafaei
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Obstetrics & Gynecology department, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zinat Karimi
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Obstetrics & Gynecology department, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mojgan Akbarzadeh-Jahromi
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. .,Pathology Department, School of Medicine, Shiraz University of Medical Sciences, Postal code/ P.O. Box: 34786-71946, Shiraz, Iran.
| | - Fatemeh Asadian
- Department of Medical Laboratory Sciences, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
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