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Nardi E, Seidita I, Abati I, Donati C, Bernacchioni C, Castiglione F, Serena C, Mecacci F, Bloise E, Petraglia F. The placenta in fetal death: molecular evidence of dysregulation of inflammatory, proliferative, and fetal protective pathways. Am J Obstet Gynecol 2024:S0002-9378(24)00679-3. [PMID: 38908653 DOI: 10.1016/j.ajog.2024.06.011] [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: 07/12/2023] [Revised: 06/13/2024] [Accepted: 06/14/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND It is estimated that over 2 million cases of fetal death occur worldwide every year, but, despite the high incidence, several basic and clinical characteristics of this disorder are still unclear. Placenta is suggested to play a central role in fetal death. Placenta produces hormones, cytokines and growth factors that modulate functions of the placental-maternal unit. Fetal death has been correlated with impaired secretion of some of these regulatory factors. OBJECTIVE The aim of the present study was to evaluate, in placentas collected from fetal death, the gene expression of inflammatory, proliferative and protective factors. STUDY DESIGN Cases of fetal death in singleton pregnancy were retrospectively selected, excluding pregnancies complicated by fetal anomalies, gestational diabetes, intrauterine growth restriction and moderate to severe maternal diseases. A group of placentas collected from healthy singleton term pregnancies were used as controls. Groups were compared regarding maternal and gestational age, fetal sex and birthweight. Placental messenger RNA expression of inflammatory (interleukin 6), proliferative (activin A, transforming growth factor β1) and regulatory (vascular endothelial growth factor, vascular endothelial growth factor receptor 2, ATP-binding cassette transporters (ABC) ABCB1 and ABCG2, sphingosine 1-phosphate signaling pathway) markers was conducted using real-time polymerase chain reaction. Statistical analysis and graphical representation of the data were performed using the GraphPad Prism 5 software. For the statistical analysis, Student's t test was used, and P values<.05 were considered significant. RESULTS Placental mRNA expression of interleukin 6 and vascular endothelial growth factor receptor 2 resulted significantly higher in the fetal death group compared to controls (P<.01), while activin A, ABCB1, and ABCG2 expression resulted significantly lower (P<.01). A significant alteration in the sphingosine 1-phosphate signaling pathway was found in the fetal death group, with an increased expression of the specific receptor isoforms sphingosine 1-phosphate receptor 1, 3, and 4 (sphingosine 1-phosphate1, sphingosine 1-phosphate3, sphingosine 1-phosphate4) and of sphingosine kinase 2, 1 of the enzyme isoforms responsible for sphingosine 1-phosphate synthesis (P<.01). CONCLUSION The present study confirmed a significantly increased expression of placental interleukin 6 and vascular endothelial growth factor receptor 2 mRNA, and for the first time showed an increased expression of sphingosine 1-phosphate receptors and sphingosine kinase 2 as well as a decreased expression of activin A and of selected ATP-binding cassette transporters, suggesting that multiple inflammatory and protective factors are deranged in placenta of fetal death.
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Affiliation(s)
- Eleonora Nardi
- Pathology, Department of Health Science, University of Florence, Florence, Italy
| | - Isabelle Seidita
- Lipid Cell Signaling and Biology Lab, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Isabella Abati
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Chiara Donati
- Lipid Cell Signaling and Biology Lab, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Caterina Bernacchioni
- Lipid Cell Signaling and Biology Lab, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | | | - Caterina Serena
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Federico Mecacci
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Enrrico Bloise
- Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil; Department of Physiology, University of Toronto, Toronto, ON, Canada
| | - Felice Petraglia
- Obstetrics and Gynecology, Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy.
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Sundar PM, Gurusamy U, Natarajan L. Maternal COVID-19 infection and intrauterine fetal death: Impact on the placenta and fetus. Pathol Res Pract 2024; 254:155139. [PMID: 38301365 DOI: 10.1016/j.prp.2024.155139] [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: 12/10/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Placental damage due to viral infections increases risk of adverse perinatal outcomes. Histopathologic examination of placenta can provide information regarding association between infection and outcome. There is paucity of data describing placental pathology with respect to intrauterine fetal death (IUFD) in pregnant mothers affected with COVID-19. METHODS 4 fetuses and 10 placentas, including one twin placenta from 9 women with history of IUFD and SARS-CoV-2 infection underwent evaluation. These findings were contrasted with 3 fetuses and 21 gestational age matched placentas from non-infected women with history of IUFD. RESULTS Extensive gross placental lesions, mixture of histologic features (maternal/ fetal vascular malperfusion) and isolated cases of massive perivillous fibrin depositon and chronic intervillositis were observed in COVID-IUFD group. There were no distinguishing histologic findings when compared to control. Three fetuses showed signs of intraventricular/intraparenchymal hemorrhage in autopsy. CONCLUSION These findings demonstrate that IUFD does not correspond with maternal symptoms and lacks distinctive lesion. However, there was significant placental damage which developed rapidly. These results show that SARS-CoV-2 infection results in rapid placental deterioration and fetal death. This information can be used to educate infected mothers and remind medical professionals, value of monitoring placental function especially following diagnosis of infection.
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Affiliation(s)
| | - Umamaheswari Gurusamy
- Department of Pathology, PSG Institute of Medical Sciences and Research, Coimbatore, India
| | - Lalitha Natarajan
- Department of Obstetrics and Gynaecology, PSG Institute of Medical Sciences and Research, Coimbatore, India.
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Cersonsky TEK, Cersonsky RK, Silver RM, Dudley DJ, Pinar H. Placental Lesions Associated With Stillbirth by Gestational Age, as Related to Cause of Death: Follow-Up Results From the Stillbirth Collaborative Research Network. Pediatr Dev Pathol 2024; 27:39-44. [PMID: 37749052 DOI: 10.1177/10935266231197349] [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: 09/27/2023]
Abstract
BACKGROUND We previously identified placental lesions associated with stillbirths of varying gestational ages (GA) using advanced feature analysis. We further investigated the relationships between placental lesions and cause of death in stillbirths within these GA ranges. METHODS Using data from the Stillbirth Collaborative Research Network, we derived a sample of stillbirths who underwent placental examination and Initial Causes of Fetal Death (INCODE) evaluation for determining cause of death. We then compared the rates of causes of death within and among GA ranges (extreme preterm stillbirth [PTSB] [<28 weeks], early PTSB [28-336/7 weeks], late PTSB [34-366/7 weeks], term stillbirth [≥37 weeks]) according to the presence of these lesions. RESULTS We evaluated 352 stillbirths. In extreme PTSB, obstetric complications and infections were associated with acute funisitis. In early PTSB, uteroplacental insufficiency was associated with parenchymal infarcts. In term stillbirth (vs early PTSB), increased syncytial knots were associated with umbilical cord causes and infection. CONCLUSIONS Placental lesions of high importance in distinguishing stillbirths at different GAs are associated with specific causes of death. This information is important in relating the presence of placental lesions and fetal death and in helping to understand etiologies of stillbirths at different GAs.
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Affiliation(s)
| | - Rose K Cersonsky
- Department of Chemical and Biological Engineering, University of Wisconsin, Madison, WI, USA
| | - Robert M Silver
- Department of Obstetrics & Gynecology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Donald J Dudley
- Department of Obstetrics & Gynecology, University of Virginia, Charlottesville, VA, USA
| | - Halit Pinar
- Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Pathology, Women and Infants Hospital of Rhode Island, Providence, RI, USA
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4
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Goldenberg RL, Hwang K, Saleem S, Tikmani SS, Yogeshkumar S, Kulkani V, Ghanchi N, Harakuni S, Ahmed I, Uddin Z, Goudar SS, Guruprasad G, Dhaded S, Goco N, Silver RM, McClure EM. Data usefulness in determining cause of stillbirth in South Asia. BJOG 2023; 130 Suppl 3:61-67. [PMID: 37470078 DOI: 10.1111/1471-0528.17592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/11/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE To evaluate the usefulness of data to determine cause of stillbirth in India and Pakistan. DESIGN Prospective, observational study. SETTINGS Study hospitals in India and Pakistan. POPULATION 200 fetal deaths with placental evaluation and minimally invasive tissue sampling (MITS) of internal organs and polymerase chain reaction (PCR) test for 75 pathogens. MAIN OUTCOME MEASURES Data defined as useful to determine stillbirth causes. RESULTS Placental pathology was the most useful to determine cause of stillbirth. Comparing placental and fetal weight with standard weights was useful in 44.5% and 48.5%, respectively. Lung histology was useful in 42.5%. Most of the other findings of internal organ histology were only occasionally useful. Signs of abruption, by maternal history or placental evaluation, were always deemed useful. Placenta, brain and cord blood PCR were also useful, but less often than histology. CONCLUSION Based on this analysis, maternal clinical history, placental histology and fetal examination were most informative. Comparing the placental and fetal weights with recognised standards was useful in nearly half the cases. Fetal tissue histology and PCR were also informative. Of all the potential tests of MITS-obtained specimens, we would first recommend histological evaluation of the lungs, and using a multiplex PCR platform would determine pathogens in blood and brain/CSF. We recognise that this approach will not identify some causes, including some genetic and internal organ anomalies, but will confirm most common causes of stillbirth and most of the preventable causes of stillbirth in low- and middle-income countries.
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Affiliation(s)
| | - Kay Hwang
- RTI International, Durham, North Carolina, USA
| | | | | | - S Yogeshkumar
- KLE Academy of Higher Education's JN Medical College, Belagavi, India
| | | | | | - Sheetal Harakuni
- KLE Academy of Higher Education's JN Medical College, Belagavi, India
| | - Imran Ahmed
- RTI International, Durham, North Carolina, USA
| | | | | | | | - Sangappa Dhaded
- KLE Academy of Higher Education's JN Medical College, Belagavi, India
| | - Norman Goco
- RTI International, Durham, North Carolina, USA
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Suhren JT, Hussein K, Kreipe H, Schaumann N. Comparison of Prenatal and Postmortem Diagnoses from 251 Fetal Autopsies: High Rate of Placenta Pathologies, Low Rate of Discrepancies. Fetal Pediatr Pathol 2023; 42:630-641. [PMID: 37129914 DOI: 10.1080/15513815.2023.2201623] [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: 07/01/2022] [Revised: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 05/03/2023]
Abstract
Background: In cases of intrauterine fetal death (IUFD), autopsy and placenta pathology can provide additional information to sonographic findings. We assessed the frequency of prenatally missed relevant diagnoses. Materials and methods: A retrospective evaluation of fetal autopsies from 2006 to 2021 was performed and were classified as: i) agreement, ii) cases where autopsy revealed additional findings, or iii) postmortem findings which changed the diagnosis. Results: A total of 199/251 spontaneous IUFD and 52/251 induced abortions were included. In spontaneous IUFD, placenta pathologies were the leading cause of death (89%). Full agreement was found in most cases (91% and 87% in spontaneous IUFD and induced abortion, respectively), while additional findings (7% and 12%) and major discrepancies (each 2%) were detected less frequently. Conclusion: In some cases where major findings were missed, autopsy could establish a diagnosis.
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Affiliation(s)
- Jan-Theile Suhren
- Institute of Pathology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Kais Hussein
- MVZ Pathologie Hildesheim Hannover-Zentrum GmbH, Senator-Braun-Allee 35, 31135, Hildesheim
| | - Hans Kreipe
- Institute of Pathology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Nora Schaumann
- Institute of Pathology, Medizinische Hochschule Hannover, Hannover, Germany
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6
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Schwartz DA, Avvad-Portari E, Babál P, Baldewijns M, Blomberg M, Bouachba A, Camacho J, Collardeau-Frachon S, Colson A, Dehaene I, Ferreres JC, Fitzgerald B, Garrido-Pontnou M, Gerges H, Hargitai B, Helguera-Repetto AC, Holmström S, Irles CL, Leijonhfvud Å, Libbrecht S, Marton T, McEntagart N, Molina JT, Morotti R, Nadal A, Navarro A, Nelander M, Oviedo A, Oyamada Otani AR, Papadogiannakis N, Petersen AC, Roberts DJ, Saad AG, Sand A, Schoenmakers S, Sehn JK, Simpson PR, Thomas K, Valdespino-Vázquez MY, van der Meeren LE, Van Dorpe J, Verdijk RM, Watkins JC, Zaigham M. Placental Tissue Destruction and Insufficiency from COVID-19 Causes Stillbirth and Neonatal Death from Hypoxic-Ischemic Injury: A Study of 68 Cases with SARS-CoV-2 Placentitis from 12 Countries. Arch Pathol Lab Med 2022; 146:660-676. [PMID: 35142798 DOI: 10.5858/arpa.2022-0029-sa] [Citation(s) in RCA: 113] [Impact Index Per Article: 56.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2022] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Perinatal death is an increasingly important problem as the COVID-19 pandemic continues, but the mechanism of death has been unclear. OBJECTIVE.— To evaluate the role of the placenta in causing stillbirth and neonatal death following maternal infection with COVID-19 and confirmed placental positivity for SARS-CoV-2. DESIGN.— Case-based retrospective clinico-pathological analysis by a multinational group of 44 perinatal specialists from 12 countries of placental and autopsy pathology findings from 64 stillborns and 4 neonatal deaths having placentas testing positive for SARS-CoV-2 following delivery to mothers with COVID-19. RESULTS.— All 68 placentas had increased fibrin deposition and villous trophoblast necrosis and 66 had chronic histiocytic intervillositis, the three findings constituting SARS-CoV-2 placentitis. Sixty-three placentas had massive perivillous fibrin deposition. Severe destructive placental disease from SARS-CoV-2 placentitis averaged 77.7% tissue involvement. Other findings included multiple intervillous thrombi (37%; 25/68) and chronic villitis (32%; 22/68). The majority (19, 63%) of the 30 autopsies revealed no significant fetal abnormalities except for intrauterine hypoxia and asphyxia. Among all 68 cases, SARS-CoV-2 was detected from a body specimen in 16 of 28 cases tested, most frequently from nasopharyngeal swabs. Four autopsied stillborns had SARS-CoV-2 identified in internal organs. CONCLUSIONS.— The pathology abnormalities composing SARS-CoV-2 placentitis cause widespread and severe placental destruction resulting in placental malperfusion and insufficiency. In these cases, intrauterine and perinatal death likely results directly from placental insufficiency and fetal hypoxic-ischemic injury. There was no evidence that SARS-CoV-2 involvement of the fetus had a role in causing these deaths.
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Affiliation(s)
| | - Elyzabeth Avvad-Portari
- Department of Pathology, Fernandes Figueira Institute, FIOCRUZ - Rio de Janeiro, Brazil (Avvad-Portari)
| | - Pavel Babál
- Department of Pathology, Faculty of Medicine, Comenius University, Bratislava, Slovakia (Babál)
| | - Marcella Baldewijns
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium (Baldewijns)
| | - Marie Blomberg
- Department of Obstetrics and Gynecology and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden (Blomberg)
| | - Amine Bouachba
- Institut de Pathologie Multisite des Hospices Civils de Lyon, Lyon, France; SOFFOET-Société Française de Foetopathologie, Paris, France (Bouachba)
| | - Jessica Camacho
- Pathology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain (Camacho)
| | - Sophie Collardeau-Frachon
- Department of Pathology, Hopital Femme-Mère Enfant, Hospices Civils de Lyon, Université Claude Bernard Lyon 1 and SOFFOET-Société Française de Foetopathologie, Paris France (Collardeau-Frachon)
| | - Arthur Colson
- Department of Obstetrics, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium (Colson)
| | - Isabelle Dehaene
- Department of Obstetrics and Gynaecology, Ghent University Hospital, Ghent, Belgium (Dehaene)
| | - Joan Carles Ferreres
- Pathology Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Barcelona, Spain (Ferreres)
| | - Brendan Fitzgerald
- Department of Pathology, Cork University Hospital, Wilton, Cork, Republic of Ireland (Fitzgerald)
| | - Marta Garrido-Pontnou
- Pathology Department, Hospital Universitari Vall d'Hebron, Department of Morphological Sciences, School of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain (Garrido-Pontnou)
| | - Hazem Gerges
- Department of Obstetrics and Gynaecology, Doncaster and Bassetlaw NHS Teaching Hospitals, Women's Hospital, Doncaster, United Kingdom (Gerges)
| | - Beata Hargitai
- Division of Perinatal Pathology, Department of Cellular Pathology, Birmingham Women's and Children's Hospital, NHS Foundation Trust, Birmingham, United Kingdom (Hargitai)
| | - A Cecilia Helguera-Repetto
- Immunobiochemistry Department, National Institute of Perinatology, Mexico City, Mexico (Helguera-Repetto)
| | - Sandra Holmström
- Department of Obstetrics and Gynaecology, Halland Hospital, Varberg, Sweden (Holmström)
| | - Claudine Liliane Irles
- Department of Physiology and Cellular Development, National Institute of Perinatology "Isidro Espinosa de los Reyes", Mexico City, Mexico (Irles)
| | - Åsa Leijonhfvud
- Department of Obstetrics and Gynaecology, Helsingborg Hospital, Department of Clinical Science Helsingborg, Lund University, Lund, Sweden (Leijonhfvud)
| | - Sasha Libbrecht
- Department of Pathological Anatomy, Antwerp University Hospital, Edegem, Belgium (Libbrecht)
| | - Tamás Marton
- Cellular Pathology Department, Birmingham Women's Hospital, Birmingham, United Kingdom (Marton)
| | - Noel McEntagart
- Histopathology, Rotunda Hospital, Dublin, Republic of Ireland (McEntagart)
| | - James T Molina
- Pathology and Laboratory Medicine, CHRISTUS Hospital St. Elizabeth, 2830 Calder St, Beaumont, Texas (Molina)
| | - Raffaella Morotti
- Department of Pathology and Pediatrics, Autopsy Service, Yale University School of Medicine, New Haven, Connecticut (Morotti)
| | - Alfons Nadal
- Pathology Department, Hospital Clínic, Barcelona, Spain (Nadal).,Department of Basic Clinical Practice, School of Medicine, Universitat de Barcelona, and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (Nadal)
| | - Alexandra Navarro
- Pathology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain (Navarro)
| | - Maria Nelander
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden (Nelander)
| | - Angelica Oviedo
- Department of Pathology and Laboratory Medicine, Burrell College of Osteopathic Medicine, Las Cruces, New Mexico (Oviedo)
| | | | - Nikos Papadogiannakis
- Department of Laboratory Medicine, Division of Pathology, Karolinska Institute and Department of Pathology, Karolinska University Hospital, Stockholm, Sweden (Papadogiannakis)
| | - Astrid C Petersen
- Department of Pathology, Aalborg University Hospital, Aalborg, Denmark (Petersen)
| | - Drucilla J Roberts
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Roberts)
| | - Ali G Saad
- Pediatric Pathology and Neuropathology, Department of Pathology, University of Miami Miller School of Medicine/Jackson Health System/Holtz Children's Hospital, Miami, Florida (Saad)
| | - Anna Sand
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden; Department of Obstetrics and Gynaecology, Karolinska University Hospital, Solna, Stockholm, Sweden (Sand)
| | - Sam Schoenmakers
- Department of Obstetrics and Gynaecology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands (Schoenmakers)
| | - Jennifer K Sehn
- Department of Pathology, St. Louis University School of Medicine, St. Louis, Missouri (Sehn)
| | - Preston R Simpson
- Department of Pathology, CHRISTUS Hospital St. Elizabeth, 2830 Calder St., Beaumont, Texas (Simpson)
| | - Kristen Thomas
- Department of Pathology, NYU Langone Health - Main Campus & Bellevue Hospital Center, New York University School of Medicine, New York, New York (Thomas)
| | | | - Lotte E van der Meeren
- Department of Pathology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands (van der Meeren).,Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands (van der Meeren)
| | - Jo Van Dorpe
- Department of Pathology, Ghent University Hospital, Ghent, Belgium (Van Dorpe)
| | - Robert M Verdijk
- Department of Pathology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands (Verdijk)
| | - Jaclyn C Watkins
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Watkins)
| | - Mehreen Zaigham
- Obstetrics & Gynecology, Institution of Clinical Sciences Lund, Lund University, Sweden (Zaigham).,Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö and Lund, Sweden (Zaigham)
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Taweevisit M, Thorner PS. Placental Findings Contributing to Perinatal Death: A 15-Year Retrospective Review from a Teaching Hospital in Thailand. Fetal Pediatr Pathol 2022; 41:18-28. [PMID: 32238079 DOI: 10.1080/15513815.2020.1747121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: The placenta is infrequently examined in developing countries. This study examined the role of placental pathology in perinatal deaths at Chulalongkorn University Hospital, Bangkok. Methods: Included were singleton intrauterine deaths after gestational week 20 and live-born infants up to 1 week old, over a 15-year period. Placental lesions were classified as: inflammatory-immune, maternal stromal-vascular, fetal stromal-vascular, umbilical cord complications and other. Results: 208 such cases had the placenta available. A placental cause of death was found in 96 (46%), non-placental causes in 28% and the cause of death was unknown in 26%. Of those 96 placentas, 44% were categorized as inflammatory-immune, 30% maternal stromal-vascular, 13% fetal stromal-vascular, 7% umbilical cord complications and 6% other. Conclusions: Placental causes of death were less common than in many Western studies, but inflammatory-immune processes more common. These differences may relate to how cases were accrued, and/or local socioeconomic factors, and warrant further study.
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Affiliation(s)
- Mana Taweevisit
- Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Paul Scott Thorner
- Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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8
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Stanek J, Drach A. Placental
CD34
immunohistochemistry in fetal vascular malperfusion in stillbirth. J Obstet Gynaecol Res 2022; 48:719-728. [DOI: 10.1111/jog.15169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/14/2021] [Accepted: 01/19/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Jerzy Stanek
- Division of Pathology Cincinnati Children's Hospital Medical Center Cincinnati Ohio USA
| | - Alex Drach
- Division of Pathology Cincinnati Children's Hospital Medical Center Cincinnati Ohio USA
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9
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Kulkarni VG, Sunilkumar KB, Nagaraj T, Uddin Z, Ahmed I, Hwang K, Goudar SS, Guruprasad G, Saleem S, Tikmani SS, Dhaded SM, Yogeshkumar S, Somannavar MS, McClure EM, Goldenberg RL. Maternal and fetal vascular lesions of malperfusion in the placentas associated with fetal and neonatal death: results of a prospective observational study. Am J Obstet Gynecol 2021; 225:660.e1-660.e12. [PMID: 34111407 DOI: 10.1016/j.ajog.2021.06.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 05/30/2021] [Accepted: 06/02/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Fetal death is one of the major adverse pregnancy outcomes and is common in low- and middle-income countries. Placental lesions may play an important role in the etiology of fetal and neonatal deaths. Previous research relating placental lesions to fetal death causation was hindered by a lack of agreement on a placental classification scheme. The Amsterdam consensus statement that was published in 2016 focused its attention on malperfusions in the maternal and fetal placental circulations. OBJECTIVE This study aimed to investigate the relationships of placental maternal and fetal vascular malperfusions in fetal and neonatal deaths, focusing on the most important maternal clinical conditions in the pathway to fetal and neonatal deaths, such as maternal hypertension, antepartum hemorrhage, and decreased fetal growth. STUDY DESIGN This was a prospective, observational cohort study conducted at 2 Asian sites. The data collected included clinical history, gross and histologic evaluations of the placenta, and several other investigations and were used to determine the cause of death. The placenta was evaluated at both sites using the Amsterdam consensus framework. We estimated the risk of placental maternal and fetal vascular malperfusions in fetal and neonatal deaths. RESULTS Between July 2018 and January 2020 in India and Pakistan, 1633 women with placentas available for the study provided consent. Of these women, 814 had fetal deaths, 618 had preterm live births and subsequent neonatal deaths, and 201 had term live births. The prevalence of maternal vascular malperfusion was higher in the placentas associated with fetal deaths (58.4%) and preterm neonatal deaths (31.1%) than in the placentas associated with term live births (15.4%). Adjusting for site, maternal vascular malperfusion had a relative risk of 3.88 (95% confidence interval, 2.70-5.59) in fetal deaths vs term live births and a relative risk of 2.07 (95% confidence interval, 1.41-3.02) in preterm neonatal deaths vs term live births. Infarcts and distal villous hypoplasia were the most common histologic components of maternal vascular malperfusion. Compared with maternal vascular malperfusion (58.4%), fetal vascular malperfusion was less common in the placentas associated with fetal deaths (19.0%). However, there were higher frequencies of fetal vascular malperfusion in the placentas associated with fetal deaths (19.0%) than in placentas associated with neonatal deaths (8.3%) or term live birth (5.0%). Adjusting for site, fetal vascular malperfusion had a relative risk of 4.09 (95% confidence interval, 2.15-7.75) in fetal deaths vs term live births and a relative risk of 1.77 (95% confidence interval, 0.90-3.49) in preterm neonatal deaths vs term live births. Furthermore, there was a higher incidence of maternal vascular malperfusion in cases of maternal hypertension (71.4%), small for gestational age (69.9%), and antepartum hemorrhage (59.1%) than in cases of fetal deaths with none of these conditions (43.3%). There was no significant difference in the occurrence of fetal vascular malperfusion in the 4 clinical categories. CONCLUSION Histologic examination of the placenta, especially for malperfusion disorders, is crucial in elucidating pathways to fetal and neonatal deaths in preterm infants. In particular, focusing on placental maternal and fetal vascular malperfusions during pregnancy is a means to identify fetuses at risk of fetal death and is an important strategy to reduce the risk of fetal death early delivery. We hope that the increased risk of fetal and neonatal deaths in these pregnancies can be reduced by the development of an intervention that reduces the likelihood of developing maternal and fetal vascular malperfusion.
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Lieschke A, Dahlstrom JE, Kent AL, Sethna F. Uncertainty over implications of placental histopathological findings: A survey of Australian and New Zealand neonatologists. J Paediatr Child Health 2020; 56:259-264. [PMID: 31576644 DOI: 10.1111/jpc.14576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 06/10/2019] [Accepted: 07/06/2019] [Indexed: 01/15/2023]
Abstract
AIM Placental examination is known to provide useful information following an adverse pregnancy outcome. Despite existing literature and guidelines for placental examination; current workplace practices, attitudes towards the value of placental examination and the knowledge of perinatal clinicians regarding placental lesions of significance are unknown. The aim of the study is to explore the current knowledge of neonatologists and maternal fetal medicine specialists on placental histopathological findings and clinical management based on placental pathology. METHODS A total of 280 specialists working in perinatal centres across Australia and New Zealand were invited to complete a 20-question online multiple-choice-based survey addressing work-place placental examination practices, and participant beliefs regarding the utility of histopathological findings and follow-up practices. RESULTS A total of 74 neonatologists participated in the survey (28.2% response rate). Maternal fetal medicine specialists were excluded due to low response rate (2%). A total of 100% of respondents believed placental examination provided useful information regarding recent pregnancy and neonatal outcomes. They reported being aware of the presence of protocols for macroscopic examination of, and indications for histopathological examination of the placenta (55.4 and 54.1%, respectively). Nine neonatologists reported a system for actioning abnormal placental reports. There was no consensus amongst neonatologists as to which specific placental lesions held implications for future pregnancy or neonatal outcomes, and how these findings should be followed. CONCLUSIONS Our findings show placental examination is valued amongst neonatologists in Australia and New Zealand, but highlights the need for better education regarding the significance and utility of the results and what would be best practice for following up reports.
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Affiliation(s)
- Anna Lieschke
- College of Health and Medicine, Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - Jane E Dahlstrom
- College of Health and Medicine, Australian National University Medical School, Canberra, Australian Capital Territory, Australia.,Department of Anatomical Pathology, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Alison L Kent
- College of Health and Medicine, Australian National University Medical School, Canberra, Australian Capital Territory, Australia.,Division of Neonatology, University of Rochester, Golisano Children's Hospital at URMC, Rochester, New York, United States
| | - Farah Sethna
- College of Health and Medicine, Australian National University Medical School, Canberra, Australian Capital Territory, Australia.,Department of Obstetrics and Gynaecology, Centenary Hospital for Women and Children, Canberra Hospital, Canberra, Australian Capital Territory, Australia
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11
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Pacora P, Romero R, Jaiman S, Erez O, Bhatti G, Panaitescu B, Benshalom-Tirosh N, Jung Jung E, Hsu CD, Hassan SS, Yeo L, Kadar N. Mechanisms of death in structurally normal stillbirths. J Perinat Med 2019; 47:222-240. [PMID: 30231013 PMCID: PMC6349478 DOI: 10.1515/jpm-2018-0216] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 07/20/2018] [Indexed: 01/05/2023]
Abstract
Objectives To investigate mechanisms of in utero death in normally formed fetuses by measuring amniotic fluid (AF) biomarkers for hypoxia (erythropoietin [EPO]), myocardial damage (cardiac troponin I [cTnI]) and brain injury (glial fibrillary acidic protein [GFAP]), correlated with risk factors for fetal death and placental histopathology. Methods This retrospective, observational cohort study included intrauterine deaths with transabdominal amniocentesis prior to induction of labor. Women with a normal pregnancy and an indicated amniocentesis at term were randomly selected as controls. AF was assayed for EPO, cTnI and GFAP using commercial immunoassays. Placental histopathology was reviewed, and CD15-immunohistochemistry was used. Analyte concentrations >90th centile for controls were considered "raised". Raised AF EPO, AF cTnI and AF GFAP concentrations were considered evidence of hypoxia, myocardial and brain injury, respectively. Results There were 60 cases and 60 controls. Hypoxia was present in 88% (53/60), myocardial damage in 70% (42/60) and brain injury in 45% (27/60) of fetal deaths. Hypoxic fetuses had evidence of myocardial injury, brain injury or both in 77% (41/53), 49% (26/53) and 13% (7/53) of cases, respectively. Histopathological evidence for placental dysfunction was found in 74% (43/58) of these cases. Conclusion Hypoxia, secondary to placental dysfunction, was found to be the mechanism of death in the majority of fetal deaths among structurally normal fetuses. Ninety-one percent of hypoxic fetal deaths sustained brain, myocardial or both brain and myocardial injuries in utero. Hypoxic myocardial injury was an attributable mechanism of death in 70% of the cases. Non-hypoxic cases may be caused by cardiac arrhythmia secondary to a cardiac conduction defect.
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Affiliation(s)
- Percy Pacora
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan,Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan,Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan
| | - Sunil Jaiman
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Offer Erez
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan,Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Gaurav Bhatti
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Bogdan Panaitescu
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Neta Benshalom-Tirosh
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan,Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Eun Jung Jung
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Chaur-Dong Hsu
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Sonia S. Hassan
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan,Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan
| | - Lami Yeo
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Nicholas Kadar
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
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12
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Benton SJ, Lafreniere AJ, Grynspan D, Bainbridge SA. A synoptic framework and future directions for placental pathology reporting. Placenta 2019; 77:46-57. [DOI: 10.1016/j.placenta.2019.01.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 01/06/2019] [Accepted: 01/08/2019] [Indexed: 12/17/2022]
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13
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Ykema JMA, D'Haens EJ, Havenith M, van Eyck J, van Lingen RA, Hemels MAC. Pilot study demonstrates that placental histology can provide an additional tool for diagnosing early-onset neonatal sepsis. Acta Paediatr 2018; 107:2086-2091. [PMID: 29786145 DOI: 10.1111/apa.14410] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/20/2018] [Accepted: 05/16/2018] [Indexed: 12/29/2022]
Abstract
AIM We explored whether placental histology could help to diagnose early-onset neonatal sepsis (EONS), guide clinical decision-making 48 hours after birth and reduce antibiotic use. METHODS This study comprised 109 infants born at less than 32 weeks of gestation, who were admitted to the neonatal intensive care unit of Isala, Zwolle, The Netherlands, between January 2013 and December 2013. EONS was defined as clinical symptoms plus raised serial C-reactive protein (CRP) >10 mg/L and a positive (proven EONS) or a negative (suspected EONS) blood culture. Placentas were studied for a histological inflammatory response and scored according to Redline's criteria. RESULTS A histological inflammatory response was seen in 15/88 (17%) placentas and this occurred significantly more often in infants with a high suspicion of EONS (p < 0.05). No histological inflammatory response was seen if maternal risk factors for EONS were absent, despite a raised CRP level. Based on placental histology, the duration of antibiotic therapy was reduced from more than five days to 48 hours in 20/27 infants (74%). CONCLUSION Histological examination of the placenta helped to diagnose EONS and guide clinical decision-making 48 hours after birth and led to a clinically relevant reduction in antibiotic use.
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Affiliation(s)
- J M A Ykema
- Princess Amalia Children's Centre; Department of Neonatology; Isala Women and Children's Hospital Zwolle; AB Zwolle The Netherlands
| | - E J D'Haens
- Princess Amalia Children's Centre; Department of Neonatology; Isala Women and Children's Hospital Zwolle; AB Zwolle The Netherlands
| | - M Havenith
- Department of Pathology; Isala Women and Children's Hospital Zwolle; AB Zwolle The Netherlands
| | - J van Eyck
- Department of Obstetrics and Gynaecology; Isala Woman and Children's Hospital Zwolle; AB Zwolle The Netherlands
| | - R A van Lingen
- Princess Amalia Children's Centre; Department of Neonatology; Isala Women and Children's Hospital Zwolle; AB Zwolle The Netherlands
| | - M A C Hemels
- Princess Amalia Children's Centre; Department of Neonatology; Isala Women and Children's Hospital Zwolle; AB Zwolle The Netherlands
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14
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Chaiworapongsa T, Romero R, Erez O, Tarca AL, Conde-Agudelo A, Chaemsaithong P, Kim CJ, Kim YM, Kim JS, Yoon BH, Hassan SS, Yeo L, Korzeniewski SJ. The prediction of fetal death with a simple maternal blood test at 20-24 weeks: a role for angiogenic index-1 (PlGF/sVEGFR-1 ratio). Am J Obstet Gynecol 2017; 217:682.e1-682.e13. [PMID: 29037482 PMCID: PMC5951183 DOI: 10.1016/j.ajog.2017.10.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/29/2017] [Accepted: 10/01/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Fetal death is an obstetrical syndrome that annually affects 2.4 to 3 million pregnancies worldwide, including more than 20,000 in the United States each year. Currently, there is no test available to identify patients at risk for this pregnancy complication. OBJECTIVE We sought to determine if maternal plasma concentrations of angiogenic and antiangiogenic factors measured at 24-28 weeks of gestation can predict subsequent fetal death. STUDY DESIGN A case-cohort study was designed to include 1000 randomly selected subjects and all remaining fetal deaths (cases) from a cohort of 4006 women with a singleton pregnancy, enrolled at 6-22 weeks of gestation, in a pregnancy biomarker cohort study. The placentas of all fetal deaths were histologically examined by pathologists who used a standardized protocol and were blinded to patient outcomes. Placental growth factor, soluble endoglin, and soluble vascular endothelial growth factor receptor-1 concentrations were measured by enzyme-linked immunosorbent assays. Quantiles of the analyte concentrations (or concentration ratios) were estimated as a function of gestational age among women who delivered a live neonate but did not develop preeclampsia or deliver a small-for-gestational-age newborn. A positive test was defined as analyte concentrations (or ratios) <2.5th and 10th centiles (placental growth factor, placental growth factor/soluble vascular endothelial growth factor receptor-1 [angiogenic index-1] and placental growth factor/soluble endoglin) or >90th and 97.5th centiles (soluble vascular endothelial growth factor receptor-1 and soluble endoglin). Inverse probability weighting was used to reflect the parent cohort when estimating the relative risk. RESULTS There were 11 fetal deaths and 829 controls with samples available for analysis between 24-28 weeks of gestation. Three fetal deaths occurred <28 weeks and 8 occurred ≥28 weeks of gestation. The rate of placental lesions consistent with maternal vascular underperfusion was 33.3% (1/3) among those who had a fetal death <28 weeks and 87.5% (7/8) of those who had this complication ≥28 weeks of gestation. The maternal plasma angiogenic index-1 value was <10th centile in 63.6% (7/11) of the fetal death group and in 11.1% (92/829) of the controls. The angiogenic index-1 value was <2.5th centile in 54.5% (6/11) of the fetal death group and in 3.7% (31/829) of the controls. An angiogenic index-1 value <2.5th centile had the largest positive likelihood ratio for predicting fetal death >24 weeks (14.6; 95% confidence interval, 7.7-27.7) and a relative risk of 29.1 (95% confidence interval, 8.8-97.1), followed by soluble endoglin >97.5th centile and placental growth factor/soluble endoglin <2.5th, both with a positive likelihood ratio of 13.7 (95% confidence interval, 7.3-25.8) and a relative risk of 27.4 (95% confidence interval, 8.2-91.2). Among women without a fetal death whose plasma angiogenic index-1 concentration ratio was <2.5th centile, 61% (19/31) developed preeclampsia or delivered a small-for-gestational-age neonate; when the 10th centile was used as the cut-off, 37% (34/92) of women had these adverse outcomes. CONCLUSION (1) A maternal plasma angiogenic index-1 value <2.5th centile (0.126) at 24-28 weeks of gestation carries a 29-fold increase in the risk of subsequent fetal death and identifies 55% of subsequent fetal deaths with a false-positive rate of 3.5%; and (2) 61% of women who have a false-positive test result will subsequently experience adverse pregnancy outcomes.
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Affiliation(s)
- Tinnakorn Chaiworapongsa
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Roberto Romero
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI.
| | - Offer Erez
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Adi L Tarca
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Agustin Conde-Agudelo
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI
| | - Piya Chaemsaithong
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Chong Jai Kim
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeon Mee Kim
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Pathology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Jung-Sun Kim
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Bo Hyun Yoon
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sonia S Hassan
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Lami Yeo
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Steven J Korzeniewski
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI
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Lannaman K, Romero R, Chaiworapongsa T, Kim YM, Korzeniewski SJ, Maymon E, Gomez-Lopez N, Panaitescu B, Hassan SS, Yeo L, Yoon BH, Kim CJ, Erez O. Fetal death: an extreme manifestation of maternal anti-fetal rejection. J Perinat Med 2017; 45:851-868. [PMID: 28862989 PMCID: PMC5848503 DOI: 10.1515/jpm-2017-0073] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 03/08/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this study was to determine the association between chronic placental inflammation and amniotic fluid (AF) markers of maternal anti-fetal rejection as well as the presence of microorganisms in the AF fluid of patients with fetal death. STUDY DESIGN This cohort study included 40 patients with fetal death whose placentas were examined for chronic inflammatory lesions and whose AF chemokine ligand (CXCL)10 and interleukin (IL)-6 concentrations were determined by immunoassays. AF was processed for bacteria, mycoplasmas and viruses using cultivation and molecular microbiologic techniques (i.e. PCR-ESI/MS). RESULTS (1) The most prevalent placental findings were maternal vascular underperfusion (63.2%, 24/38), followed by chronic inflammatory lesions (57.9%, 22/38); (2) chronic chorioamnionitis (18/38) was three times more frequent than villitis of unknown etiology (6/38); (3) an elevated AF CXCL10 concentration (above the 95th centile) was present in 60% of the cases, and a receiver operating characteristics (ROC)-derived cut-off of 2.9 ng/mL had a sensitivity of 73% and a specificity of 75% in the identification of chronic placental inflammatory lesions; (4) only five cases had microbial invasion of the amniotic cavity, and the presence of microorganisms did not correlate with chronic placental inflammation. CONCLUSION In women with unexplained fetal death, there is an association between elevated AF CXCL10 and chronic placental inflammatory lesions. Therefore, we conclude that a subset of patients with fetal death may have endured a breakdown of maternal-fetal tolerance, which cannot be attributed to microorganisms in the amniotic cavity.
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Affiliation(s)
- Kia Lannaman
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yeon Mee Kim
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Pathology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Steven J. Korzeniewski
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
| | - Eli Maymon
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Nardhy Gomez-Lopez
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Immunology and Microbiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Bogdan Panaitescu
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Sonia S. Hassan
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Lami Yeo
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Bo Hyun Yoon
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chong Jai Kim
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Offer Erez
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
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Nijkamp J, Sebire N, Bouman K, Korteweg F, Erwich J, Gordijn S. Perinatal death investigations: What is current practice? Semin Fetal Neonatal Med 2017; 22:167-175. [PMID: 28325580 PMCID: PMC7118457 DOI: 10.1016/j.siny.2017.02.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Perinatal death (PD) is a devastating obstetric complication. Determination of cause of death helps in understanding why and how it occurs, and it is an indispensable aid to parents wanting to understand why their baby died and to determine the recurrence risk and management in subsequent pregnancy. Consequently, a perinatal death requires adequate diagnostic investigation. An important first step in the analysis of PD is to identify the case circumstances, including relevant details regarding maternal history, obstetric history and current pregnancy (complications are evaluated and recorded). In the next step, placental examination is suggested in all cases, together with molecular cytogenetic evaluation and fetal autopsy. Investigation for fetal-maternal hemorrhage by Kleihauer is also recommended as standard. In cases where parents do not consent to autopsy, alternative approaches such as minimally invasive postmortem examination, postmortem magnetic resonance imaging, and fetal photographs are good alternatives. After all investigations have been performed it is important to combine findings from the clinical review and investigations together, to identify the most probable cause of death and counsel the parents regarding their loss.
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Affiliation(s)
- J.W. Nijkamp
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands,Corresponding author. Department of Obstetrics and Gynecology, University Medical Centre Groningen, CB 21, P.O. box 30001, 9700 RB Groningen, The Netherlands.
| | - N.J. Sebire
- Department of Pediatric Pathology, Clinical Molecular Genetics, Great Ormond Street Hospital for Children and UCL Institute of Child Health, London, UK
| | - K. Bouman
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - F.J. Korteweg
- Department of Obstetrics and Gynecology, Martini Hospital, Groningen, The Netherlands
| | - J.J.H.M. Erwich
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - S.J. Gordijn
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Page JM, Christiansen-Lindquist L, Thorsten V, Parker CB, Reddy UM, Dudley DJ, Saade GR, Coustan D, Rowland Hogue CJ, Conway D, Bukowski R, Pinar H, Heuser CC, Gibbins KJ, Goldenberg RL, Silver RM. Diagnostic Tests for Evaluation of Stillbirth. Obstet Gynecol 2017; 129:699-706. [DOI: 10.1097/aog.0000000000001937] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hirst JE, Villar J, Victora CG, Papageorghiou AT, Finkton D, Barros FC, Gravett MG, Giuliani F, Purwar M, Frederick IO, Pang R, Cheikh Ismail L, Lambert A, Stones W, Jaffer YA, Altman DG, Noble JA, Ohuma EO, Kennedy SH, Bhutta ZA. The antepartum stillbirth syndrome: risk factors and pregnancy conditions identified from the INTERGROWTH-21 st Project. BJOG 2016; 125:1145-1153. [PMID: 28029221 PMCID: PMC6055673 DOI: 10.1111/1471-0528.14463] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To identify risk factors for antepartum stillbirth, including fetal growth restriction, among women with well-dated pregnancies and access to antenatal care. DESIGN Population-based, prospective, observational study. SETTING Eight international urban populations. POPULATION Pregnant women and their babies enrolled in the Newborn Cross-Sectional Study of the INTERGROWTH-21st Project. METHODS Cox proportional hazard models were used to compare risks among antepartum stillborn and liveborn babies. MAIN OUTCOME MEASURES Antepartum stillbirth was defined as any fetal death after 16 weeks' gestation before the onset of labour. RESULTS Of 60 121 babies, 553 were stillborn (9.2 per 1000 births), of which 445 were antepartum deaths (7.4 per 1000 births). After adjustment for site, risk factors were low socio-economic status, hazard ratio (HR): 1.6 (95% CI, 1.2-2.1); single marital status, HR 2.0 (95% CI, 1.4-2.8); age ≥40 years, HR 2.2 (95% CI, 1.4-3.7); essential hypertension, HR 4.0 (95% CI, 2.7-5.9); HIV/AIDS, HR 4.3 (95% CI, 2.0-9.1); pre-eclampsia, HR 1.6 (95% CI, 1.1-3.8); multiple pregnancy, HR 3.3 (95% CI, 2.0-5.6); and antepartum haemorrhage, HR 3.3 (95% CI, 2.5-4.5). Birth weight <3rd centile was associated with antepartum stillbirth [HR, 4.6 (95% CI, 3.4-6.2)]. The greatest risk was seen in babies not suspected to have been growth restricted antenatally, with an HR of 5.0 (95% CI, 3.6-7.0). The population-attributable risk of antepartum death associated with small-for-gestational-age neonates diagnosed at birth was 11%. CONCLUSIONS Antepartum stillbirth is a complex syndrome associated with several risk factors. Although small babies are at higher risk, current growth restriction detection strategies only modestly reduced the rate of stillbirth. TWEETABLE ABSTRACT International stillbirth study finds individual risks poor predictors of death but combinations promising.
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Affiliation(s)
- J E Hirst
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - J Villar
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - C G Victora
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal de Pelotas, Pelotas, Brazil
| | - A T Papageorghiou
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - D Finkton
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - F C Barros
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal de Pelotas, Pelotas, Brazil.,Programa de Pós-Graduação em Saúde e Comportamento, Universidade Católica de Pelotas, Pelotas, RS, Brazil
| | - M G Gravett
- Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), Seattle, WA, USA
| | - F Giuliani
- Dipartimento di Scienze della Sanità Pubblica e Pediatriche, Università degli Studi di Torino, Torino, Italy
| | - M Purwar
- Nagpur INTERGROWTH-21st Research Centre, Ketkar Hospital, Nagpur, India
| | - I O Frederick
- Center for Perinatal Studies, Swedish Medical Center, Seattle, WA, USA
| | - R Pang
- School of Public Health, Peking University, Beijing, China
| | - L Cheikh Ismail
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - A Lambert
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - W Stones
- Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya
| | - Y A Jaffer
- Department of Family & Community Health, Ministry of Health, Muscat, Oman
| | - D G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - J A Noble
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - E O Ohuma
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK.,Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - S H Kennedy
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Z A Bhutta
- Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan.,Center for Global Health for Sick Children, Toronto, ON, Canada
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Yang MS, Zhou M. Relationship between intestinal flora microenvironment and colorectal cancer. Shijie Huaren Xiaohua Zazhi 2016; 24:4759-4765. [DOI: 10.11569/wcjd.v24.i36.4759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Intestinal flora is a hot research topic. Studies suggest that intestinal flora is associated with the development of metabolic diseases, autoimmune diseases, neurological disorders, cognitive and behavioral disorders, cancer and so on. In this paper, we retrieved and analyzed the literature published in the past ten years which studied the relationship between microbiota microenvironment and colorectal cancer. We discuss the definitions of intestinal flora, microbiota microenvironment and colorectal cancer, the composition of intestinal flora, imbalance of intestinal flora, correlation between microbiota microenvironment and colorectal cancer, and the pathophysiology of colorectal cancer associated with microbiota microenvironment, with an aim to reveal the role of intestinal flora microenvironment in the pathogenesis of colorectal cancer, and to provide ideas and clues for the development of new intestinal flora-targeted approaches for prevention and treatment of colorectal cancer.
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Mecacci F, Serena C, Avagliano L, Cozzolino M, Baroni E, Rambaldi MP, Simeone S, Castiglione F, Taddei GL, Bulfamante G. Stillbirths at Term: Case Control Study of Risk Factors, Growth Status and Placental Histology. PLoS One 2016; 11:e0166514. [PMID: 27936018 PMCID: PMC5147826 DOI: 10.1371/journal.pone.0166514] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 10/31/2016] [Indexed: 02/07/2023] Open
Abstract
Objective To investigate the proportion of stillbirths at term associated with abnormal growth using customized birth weight percentiles and to compare histological placental findings both in underweight stillborn fetuses and in live births. Methods A retrospective case-control study of 150 singleton term stillbirths. The livebirth control groups included 586 cases of low-risk pregnancies and 153 late fetal growth restriction fetuses. Stillbirths and livebirths from low-risk pregnancies were classified using customized standards for fetal weight at birth, as adequate for gestational age (AGA; 10-90th percentile), small (SGA; <10th percentile) or large for gestational age (LGA; >90th percentile). Placental characteristics in stillbirth were compared with those from livebirths using four categories: inflammation, disruptive, obstructive and adaptive lesions. Results There was a higher rate of SGA (26% vs 6%, p<0.001) and LGA fetuses (10.6% vs 5.6%, p<0.05) in the stillbirth group. Among stillbirth fetuses, almost half of the SGA were very low birthweight (≤3°percentile) (12% vs 0.3%, p<0.001). The disruptive (7.3% vs 0.17%;p<0.001), obstructive (54.6% vs 7.5%;p<0.001) and adaptive (46.6% vs 35.8%;p<0.001) findings were significantly more common in than in livebirth-low risk. Placental characteristics of AGA and SGA stillbirth were compared with those of AGA and FGR livebirth. In stillbirths-SGA we found a higher number of disruptive (12.8% vs 0%; p<0.001), obstructive (58.9% vs 23.5%;p<0.001) and adaptive lesions (56.4% vs 49%; p 0.47) than in livebirth-FGR. Conclusion The assessment of fetal weight with customized curves can identify fetuses which have not reached their genetically determined growth potential and are therefore at risk for adverse outcomes. Placental evaluation in stillbirths can reveal chronic histological signs that might be useful to clinical assessment, especially in underweight fetuses.
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Affiliation(s)
- Federico Mecacci
- Department of Sciences for the Health of Women and Children, Careggi Hospital, Florence, Italy
| | - Caterina Serena
- Department of Sciences for the Health of Women and Children, Careggi Hospital, Florence, Italy
- * E-mail:
| | - Laura Avagliano
- Department of Health Sciences, San Paolo Hospital Medical School University of Milan, Milan, Italy
| | - Mauro Cozzolino
- Department of Biomedical, Experimental and Clinical Sciences-Division of Obstetrics and Gynaecology, University of Florence, Florence, Italy
| | - Eleonora Baroni
- Department of Sciences for the Health of Women and Children, Careggi Hospital, Florence, Italy
| | - Marianna Pina Rambaldi
- Department of Sciences for the Health of Women and Children, Careggi Hospital, Florence, Italy
| | - Serena Simeone
- Department of Sciences for the Health of Women and Children, Careggi Hospital, Florence, Italy
| | | | | | - Gaetano Bulfamante
- Department of Health Sciences, San Paolo Hospital Medical School University of Milan, Milan, Italy
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21
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Man J, Hutchinson JC, Heazell AE, Ashworth M, Jeffrey I, Sebire NJ. Stillbirth and intrauterine fetal death: role of routine histopathological placental findings to determine cause of death. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:579-584. [PMID: 27781319 DOI: 10.1002/uog.16019] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 07/05/2016] [Accepted: 07/06/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Placental abnormalities are a common cause of death in stillbirth, ranking second only to unexplained deaths, though there is wide variation in the proportion attributed to placental disease. In clinical practice, interpretation of the significance of placental findings is difficult, since many placental features in stillbirths overlap with those in live births. Our aim was to examine objectively classified placental findings from a series of > 1000 autopsies following intrauterine death in order to evaluate the role of placental histological examination in determining the cause of death. METHODS As part of a larger study evaluating several aspects of autopsy findings in intrauterine death, a dedicated database was used to collate antenatal and postmortem examination details for all cases examined between 2005 and 2013 at two tertiary specialist centers in London, UK. Histological findings for placentas were evaluated in relation to the final cause of death. RESULTS Among 1064 intrauterine deaths, 946 (89%) cases had the placenta submitted for examination as part of the autopsy. Of these, 307 (32%) cases had the cause of death assigned to abnormalities of the placenta, cord or membranes. Around one third of stillbirths (≥ 24 weeks) had some isolated placental histological abnormality identified, many of uncertain significance, a significantly greater proportion than in cases of second-trimester intrauterine fetal demise (P < 0.0001). The cause of death was ascending infection in 176/946 (19%) cases, peaking at 22 weeks' gestation, with significantly more black mothers having ascending infection compared with other ethnicities (P < 0.0001). Maternal vascular malperfusion was the largest category of placental abnormalities in stillbirth, with peak prevalence in the early third trimester. There were 18 (2%) cases with specific histological abnormalities, including chronic histiocytic intervillositis and massive perivillous fibrin deposition. CONCLUSIONS Placental pathologies represent the largest category of cause of intrauterine death. Placental histological examination is the single most useful component of the autopsy process in this clinical setting. A minority of cases are associated with specific placental pathologies, often with high recurrence rates, that can be diagnosed only on microscopic examination of the placenta. Many deaths remain unexplained, although placental histological lesions may be present which are of uncertain significance. A rigorous, systematic approach to placental pathology research and classification may yield better understanding of the significance of placental findings and reduce the rate of unexplained intrauterine deaths. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J Man
- Department of Histopathology, Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK
- University College London, Institute of Child Health, London, UK
| | - J C Hutchinson
- Department of Histopathology, Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK
- University College London, Institute of Child Health, London, UK
| | - A E Heazell
- Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester, UK
| | - M Ashworth
- Department of Histopathology, Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK
| | - I Jeffrey
- Department of Histopathology, St George's Hospital, London, UK
| | - N J Sebire
- Department of Histopathology, Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK
- University College London, Institute of Child Health, London, UK
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Man J, Hutchinson JC, Ashworth M, Judge-Kronis L, Levine S, Sebire NJ. Stillbirth and intrauterine fetal death: role of routine histological organ sampling to determine cause of death. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:596-601. [PMID: 27781316 DOI: 10.1002/uog.16020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 07/05/2016] [Accepted: 07/06/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Guidelines for the investigation of intrauterine death and sudden unexpected death in infancy (SUDI) recommend, based on expert opinion, autopsy procedures and tissue sampling strategies for histological analysis. Although stillbirth is much more common than SUDI, there have been no large-scale studies published which evaluate the usefulness of histological evaluation of specific organs in stillbirth for determining cause of death. Our aim was to evaluate the use of macroscopic and microscopic assessment of internal organs to determine cause of intrauterine death. METHODS As part of a larger study evaluating several aspects of autopsy findings in intrauterine death, a dedicated database was used to collate antenatal and postmortem examination details for cases of intrauterine death examined between 2005 and 2013 at two tertiary specialist centers in London, UK. Histological findings for all organs were examined in relation to the final cause of death, as determined by objective criteria. RESULTS Among 1064 intrauterine deaths, the majority (> 80%) of cases had internal organs that were normal on both macroscopic and microscopic examination. There was no case in which histological cardiac examination provided the cause of death when the macroscopic appearance of the heart was normal. Microscopic examination of lung tissue revealed 13 (1%) cases with histological abnormalities that provided the cause of death when the macroscopic appearance was normal, but there was only one (0.1%) case in which the diagnosis would not have been apparent on placental examination: a case of congenital cytomegalovirus infection. There was no case in which microscopic examination of macroscopically normal liver, kidneys, adrenals, spleen, thymus, intestines, pancreas, brain or thyroid provided the cause of death. CONCLUSION In this large series of autopsies in cases of intrauterine death, only around 1% of cases demonstrated histological abnormalities which provided the cause of death when the internal organs appeared normal macroscopically. There was no case in which routine histological examination of most tissues provided diagnostically useful information that was not apparent from other examinations, such as placental pathology. There is little benefit, purely in terms of determining cause of death, in obtaining tissue from most macroscopically normal organs for routine histological examination. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J Man
- Department of Histopathology, Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK
- University College London, Institute of Child Health, London, UK
| | - J C Hutchinson
- Department of Histopathology, Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK
- University College London, Institute of Child Health, London, UK
| | - M Ashworth
- Department of Histopathology, Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK
| | - L Judge-Kronis
- Department of Histopathology, Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK
| | - S Levine
- Department of Histopathology, St George's Hospital, London, UK
| | - N J Sebire
- Department of Histopathology, Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK
- University College London, Institute of Child Health, London, UK
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Puri RD, Kotecha U, Lall M, Dash P, Bijarnia-Mahay S, Verma IC. Is the diagnostic yield influenced by the indication for fetal autopsy? Am J Med Genet A 2016; 170:2119-26. [PMID: 27197608 DOI: 10.1002/ajmg.a.37743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 05/02/2016] [Indexed: 01/10/2023]
Abstract
The utility of fetal autopsy to corroborate antenatal ultrasound findings and to aid genetic counseling is well known. However, the ability to identify an underlying cause for the common indications for which it is performed is not well studied. This study aimed to determine if the diagnostic yield of fetal autopsy in identifying the underlying cause is determined by the indication of the autopsy. Five groups of fetuses were defined based on the indication for the autopsy performed in 903 cases: (i) malformations, (ii) intrauterine death (IUD), (iii) cystic hygroma and hydrops fetalis, (iv) isolated abnormalities of amniotic fluid, and (v) intrauterine growth restriction (IUGR). The highest diagnostic yield was in fetuses with isolated abnormalities of amniotic fluid (77%), followed by those with IUGR (75%), with IUD (69.6%), those in group five (55.2%) and lowest (45%) in fetuses with malformations (P < 0.001). A cause was identified in 77.8% fetuses with multiple malformations compared to 37.5% with isolated malformations (P < 0.001), with chromosomal abnormalities in 31.8% versus 9.9% respectively (P < 0.001) and malformation syndromes in 42.5% versus 26.3% (P < 0.001). Placental examination provided the highest yield in IUD, IUGR, and oligohydramnios (43.1%; P < 0.003) whereas chromosomal analysis was most useful in cystic hygroma/NIHF (28.9%; P < 0.001). This information on the diagnostic yield in fetal autopsy related its common indications, can be utilized to counsel families of the utility of autopsy to establish cause and recurrence risks and thereby assist then to make an informed decision to consent for the procedure. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ratna Dua Puri
- Center of Medical Genetics, Ganga Ram Institute of Postgraduate Medical Education and Research, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India
| | - Udhaya Kotecha
- Center of Medical Genetics, Ganga Ram Institute of Postgraduate Medical Education and Research, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India
| | - Meena Lall
- Center of Medical Genetics, Ganga Ram Institute of Postgraduate Medical Education and Research, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India
| | - Pratima Dash
- Center of Medical Genetics, Ganga Ram Institute of Postgraduate Medical Education and Research, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India
| | - Sunita Bijarnia-Mahay
- Center of Medical Genetics, Ganga Ram Institute of Postgraduate Medical Education and Research, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India
| | - Ishwar Chander Verma
- Center of Medical Genetics, Ganga Ram Institute of Postgraduate Medical Education and Research, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India
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Korzeniewski SJ, Romero R, Chaiworapongsa T, Chaemsaithong P, Kim CJ, Kim YM, Kim JS, Yoon BH, Hassan SS, Yeo L. Maternal plasma angiogenic index-1 (placental growth factor/soluble vascular endothelial growth factor receptor-1) is a biomarker for the burden of placental lesions consistent with uteroplacental underperfusion: a longitudinal case-cohort study. Am J Obstet Gynecol 2016; 214:629.e1-629.e17. [PMID: 26688491 DOI: 10.1016/j.ajog.2015.11.015] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 09/21/2015] [Accepted: 11/18/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Placental lesions consistent with maternal vascular underperfusion (MVU) are thought to be pathogenically linked to preeclampsia, small-for-gestational-age newborns, fetal death, and spontaneous preterm labor and delivery; yet, these lesions cannot be diagnosed antenatally. We previously reported that patients with such conditions and lesions have an abnormal profile of the angiogenic placental growth factor (PlGF) and antiangiogenic factors (eg, soluble vascular endothelial growth factor receptor [sVEGFR]-1). OBJECTIVE The objectives of this study were to: (1) examine the relationship between the maternal plasma PlGF/sVEGFR-1 concentration ratio (referred to herein as angiogenic index-1) and the burden of histologic placental features consistent with MVU; and (2) test the hypothesis that angiogenic index-1 can identify patients in the midtrimester who are destined to deliver before 34 weeks of gestation with multiple (ie, ≥3) histologic placental features consistent with MVU. STUDY DESIGN A 2-stage case-cohort sampling strategy was used to select participants from among 4006 women with singleton gestations enrolled from 2006 through 2010 in a longitudinal study. Maternal plasma angiogenic index-1 ratios were determined using enzyme-linked immunosorbent assays. Placentas underwent histologic examination according to standardized protocols by experienced pediatric pathologists who were blinded to clinical diagnoses and pregnancy outcomes. The diagnosis of lesions consistent with MVU was made using criteria proposed by the Perinatal Section of the Society for Pediatric Pathology. Weighted analyses were performed to reflect the parent cohort; "n*" is used to reflect weighted frequencies. RESULTS (1) Angiogenic index-1 (PlGF/sVEGFR-1) concentration ratios were determined in 7560 plasma samples collected from 1499 study participants; (2) the prevalence of lesions consistent with MVU was 21% (n* = 833.9/3904) and 27% (n* = 11.4/42.7) of women with ≥3 MVU lesions delivered before 34 weeks of gestation; (3) a low angiogenic index-1 (<2.5th quantile for gestational age) in maternal plasma samples obtained within 48 hours of delivery had a sensitivity of 73% (n* = 8.3/11.4; 95% confidence interval [CI], 47-98%), a specificity of 94% (n* = 3130.9/3316.2; 95% CI, 94-95%), a positive likelihood ratio of 12.2, and a negative likelihood ratio of 0.29 in the identification of patients who delivered placentas with ≥3 MVU lesions at <34 weeks; (4) prospectively, at 20-23 weeks of gestation, a maternal plasma concentration of angiogenic index-1 <2.5th quantile identified 70% (n* = 7.2/10.3; 95% CI, 42-98%) of patients who delivered placentas with ≥3 MVU lesions before 34 weeks (specificity, 97% [n* = 2831.3/2918; 95% CI, 96-98%]; positive likelihood ratio, 23; negative likelihood ratio, 0.31); and (5) among women without obstetrical complications who delivered at term, angiogenic index-1 was lower in women with than without placental lesions consistent with MVU (P < .05). CONCLUSION Maternal plasma angiogenic index-1 (PlGF/sVEGFR-1) is the first biomarker for the burden of placental lesions consistent with MVU. We propose that an accumulation of these lesions in placentas delivered before 34 weeks is a histologic counterpart of an antiangiogenic profile.
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Weida JN, Schubert FP, Pastrick MA, Patil AS. Comprehensive Review of the Stillborn Placenta. J Midwifery Womens Health 2015; 60:380-9. [DOI: 10.1111/jmwh.12338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
The perinatal autopsy is an important tool in the investigation of fetal and neonatal death, and a complete understanding of its risks and benefits is necessary for providers of perinatal care. This review, from the perspective of a perinatal pathologist, reports the details of the autopsy procedure, its goals, its value to individual patients and the health care system in general, and its alternatives. Even with new emerging technologies, the conventional perinatal autopsy remains the gold standard for determining the cause of death and the final summary of all pathologic findings. Therefore, the information provided in this review can help providers properly convey information about perinatal autopsy to bereaved families.
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Affiliation(s)
- Linda M Ernst
- Department of Pathology, Northwestern University Feinberg School of Medicine, Olson Pavilion 2-461, 710 N. Fairbanks Court, Chicago, IL 60611.
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27
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Ptacek I, Sebire N, Man J, Brownbill P, Heazell A. Systematic review of placental pathology reported in association with stillbirth. Placenta 2014; 35:552-62. [DOI: 10.1016/j.placenta.2014.05.011] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Revised: 05/25/2014] [Accepted: 05/27/2014] [Indexed: 11/30/2022]
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Roescher AM, Timmer A, Erwich JJHM, Bos AF. Placental pathology, perinatal death, neonatal outcome, and neurological development: a systematic review. PLoS One 2014; 9:e89419. [PMID: 24586764 PMCID: PMC3934891 DOI: 10.1371/journal.pone.0089419] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 01/21/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The placenta plays a crucial role during pregnancy for growth and development of the fetus. Less than optimal placental performance may result in morbidity or even mortality of both mother and fetus. Awareness among pediatricians, however, of the benefit of placental findings for neonatal care, is limited. OBJECTIVES To provide a systematic overview of the relation between placental lesions and neonatal outcome. DATA SOURCES Pubmed database, reference lists of selected publications and important research groups in the field. STUDY APPRAISAL AND SYNTHESIS METHODS We systematically searched the Pubmed database for literature on the relation between placental lesions and fetal and neonatal mortality, neonatal morbidity and neurological outcome. We conducted three separate searches starting with a search for placental pathology and fetal and neonatal mortality, followed by placental pathology and neonatal morbidity, and finally placental pathology and neurological development. We limited our search to full-text articles published in English from January 1995 to October 2013. We refined our search results by selecting the appropriate articles from the ones found during the initial searches. The first selection was based on the title, the second on the abstract, and the third on the full article. The quality of the selected articles was determined by using the Newcastle-Ottawa Quality Assessment Scale. RESULTS Placental lesions are one of the main causes of fetal death, where placental lesions consistent with maternal vascular underperfusion are most important. Several neonatal problems are also associated with placental lesions, whereby ascending intrauterine infection (with a fetal component) and fetal thrombotic vasculopathy constitute the greatest problem. CONCLUSIONS The placenta plays a key role in fetal and neonatal mortality, morbidity, and outcome. Pediatricians should make an effort to obtain the results of placental examinations.
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Affiliation(s)
- Annemiek M. Roescher
- Division of Neonatology, Beatrix Children's Hospital, University of Groningen, University Medical Center, Groningen, the Netherlands
| | - Albert Timmer
- Department of Pathology and Medical Biology, University of Groningen, University Medical Center, Groningen, the Netherlands
| | - Jan Jaap H. M. Erwich
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center, Groningen, the Netherlands
| | - Arend F. Bos
- Division of Neonatology, Beatrix Children's Hospital, University of Groningen, University Medical Center, Groningen, the Netherlands
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[Evaluation of intrauterine death: importance of examination of fetal, placental and maternal factors]. DER PATHOLOGE 2013; 35:77-82. [PMID: 24036943 DOI: 10.1007/s00292-013-1858-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
AIMS Intrauterine death is a multifactorial major complication during pregnancy. In this retrospective analysis the pathological anatomical findings of fetuses and placentas as well as maternal factors were evaluated. MATERIAL AND METHODS A retrospective screening of post-mortem examinations, corresponding placental examinations and clinical data on maternal status (1998-2008) was carried out. A classification of all findings was made with the ReCoDe system and induced abortions and cases with incomplete data were excluded from the study. RESULTS A total of 84 pregnancies involving 87 fetuses (9 siblings) were evaluated. The median gestation age was 20 weeks (range 12-41). The evaluation based on the ReCoDe system revealed that intrauterine death was mainly associated with placental diseases (n = 63) and to a lesser extent with fetal malformations (n = 15) or maternal diseases (n = 4). Idiopathic cases were rare (n = 2). CONCLUSIONS Placental examination is important for explaining intrauterine death because in most cases an association with placental diseases can be found but fetal malformation and maternal diseases must be taken into account.
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Ernst LM, Gawron L, Fritsch MK. Pathologic Examination of Fetal and Placental Tissue Obtained by Dilation and Evacuation. Arch Pathol Lab Med 2013; 137:326-37. [DOI: 10.5858/arpa.2012-0090-ra] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—Dilation and evacuation (D&E) is an alternative method to induction of labor for pregnancy termination and intrauterine fetal demise, and it is the most common mode of second-trimester uterine evacuation in the United States. Many D&E specimens are examined in surgical pathology, and there is little information available in surgical pathology textbooks or the literature to assist pathologists in these examinations.
Objective.—To provide an overview of the D&E procedure, discuss related legal issues, provide guidelines for routine pathologic examination of D&E specimens, and demonstrate the importance of careful pathologic examination of D&E specimens.
Data Sources.—Case-derived material and literature review.
Conclusions.—Pathologic examination of D&E specimens has been understudied. However, the available literature and our experience support the fact that careful pathologic examination of D&E specimens can identify significant fetal and placental changes that can confirm clinical diagnoses or provide definitive diagnosis, assist in explaining the cause of intrauterine fetal demise, and identify unexpected anomalies that may provide further clues to a diagnostic syndrome or mechanism of anomaly formation.
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Affiliation(s)
- Linda M. Ernst
- From the Departments of Pathology (Drs Ernst and Fritsch) and Obstetrics and Gynecology (Dr Gawron), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lori Gawron
- From the Departments of Pathology (Drs Ernst and Fritsch) and Obstetrics and Gynecology (Dr Gawron), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael K. Fritsch
- From the Departments of Pathology (Drs Ernst and Fritsch) and Obstetrics and Gynecology (Dr Gawron), Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Jacques SM, Kupsky WJ, Giorgadze T, Qureshi F. Fetal central nervous system injury in third trimester stillbirth: a clinicopathologic study of 63 cases. Pediatr Dev Pathol 2012; 15:375-84. [PMID: 22849388 DOI: 10.2350/12-01-1137-oa.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report the neuropathologic findings and clinicopathologic associations in 63 3rd trimester singleton stillborn fetuses. All were ≥ 28 weeks estimated gestational age (EGA) with complete autopsies, including placental examination. Fetuses with chromosomal abnormalities, major congenital anomalies, and intrapartum demise were excluded. The cases were divided into those with abruption (n = 12) and those with unexplained fetal demise (n = 51). The latter group was then subdivided by gestational age with 3 subgroups (preterm 28 to < 32 weeks EGA (n = 16), preterm 32 to <37 weeks EGA (n = 13), and term 37-41 weeks EGA (n = 22). Each group was further subdivided as appropriate-for-gestational age/large-for-gestational age (AGA/LGA) or small-for-gestational age (SGA). Placental lesions were also evaluated and correlated with brain lesions. Established or recent injury involving gray or white matter was seen in 88% of the fetuses with unexplained demise versus 42% with abruption (P = 0.001). The most common form of brain injury was established gray matter damage, seen in 65% of the fetuses with unexplained demise versus 25% with abruption (P = 0.021), the most common pattern being established pontosubicular neuronal necrosis plus established neuronal necrosis in other sites. There was no significant difference in the frequency of brain injury between the SGA fetuses and AGA/LGA fetuses or between the unexplained stillbirth preterm and term subgroups, and there was no unequivocal correlation between placental lesions and brain lesions. Brain injury, most frequently established gray matter damage, is seen in the majority of stillborn infants with unexplained demise, indicating that the brain injury predates the period immediately before death.
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Affiliation(s)
- Suzanne M Jacques
- Department of Pathology, Detroit Medical Center and Wayne State University School of Medicine, Hutzel Women's Hospital, 3990 John R, Detroit, MI 48201, USA.
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