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Chan ES, de Koning L, Yu W, Chadha R. C4d Staining Is Present in Normal Placentas From Pregnancies Prior to Pregnancy Loss Associated With Chronic Histiocytic Intervillositis and Is Reduced by Immunomodulatory Therapy in Subsequent Pregnancies. Pediatr Dev Pathol 2023; 26:374-387. [PMID: 37232363 PMCID: PMC10559644 DOI: 10.1177/10935266231176682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Chronic histiocytic intervillositis (CHI) is associated with adverse pregnancy outcomes and high recurrence risk. Recent studies suggest that CHI may represent a host-vs-graft rejection, and that C4d immunostain can be used as a marker for complement activation and antibody-mediated rejection in the CHI. MATERIALS AND METHODS This retrospective cohort study focused on 5 fetal autopsy cases associated with CHI (5 index cases) from 5 women. We analyzed placentas from the index cases (fetal autopsy cases associated with CHI) and placentas from the women's previous and subsequent pregnancies. We assessed the presence and extent of CHI and C4d immunostaining in these placentas. We evaluated each available placenta and graded the severity of CHI as either <50% or ≥50%. Additionally, we conducted C4d immunostaining on one representative section from each placenta and graded the staining levels as follows: 0+ for staining <5%; 1+ for staining between 5% and <25%; 2+ for staining between 25% and <75%; and 3+ for staining ≥75%. RESULTS Three of the 5 women had pregnancies prior to their index cases (fetal autopsy cases associated with CHI). Despite the absence of CHI in their initial pregnancies, the placentas displayed positive C4d staining with grades of 1+, 3+, and 3+, respectively. These results suggest the presence of complement activation and antibody-mediated rejection in placentas from their prior pregnancies without CHI. Three of the 5 women received immunomodulatory therapy after experiencing pregnancy losses associated with CHI. After treatment, 2 of these women had live births at 35 and 37 gestational weeks, respectively, while the third had a stillbirth at 25 gestational weeks. The severity of CHI and the degree of C4d staining in the placentas decreased in all 3 cases following immunomodulatory therapies. Specifically, the level of C4d staining decreased from 3+ to 2+, 2+ to 0+, and 3+ to 1+ in these 3 cases, respectively. DISCUSSION In women with a history of recurrent pregnancy loss associated with CHI, C4d immunostaining was present in the placentas from their previous non-CHI pregnancies, suggesting activation of the classical complement pathway and antibody-mediated reaction in their prior non-CHI pregnancies before the development of CHI in subsequent pregnancies. Immunomodulatory therapy may improve pregnancy outcomes by reducing complement activation, as shown by the reduction of C4d immunopositivity in the placentas after immunomodulatory treatment. Although we believe that the study provides valuable insights, we acknowledge that there are limitations to the findings. Therefore, to further elucidate the pathogenesis of CHI, additional research efforts with a collaborative and multidisciplinary approach are necessary.
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Affiliation(s)
- Elaine S. Chan
- Department of Pathology and Laboratory Medicine, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Alberta Children’s Hospital, Calgary, AB, Canada
- Alberta Precision Laboratories, Calgary, AB, Canada
| | - Lawrence de Koning
- Department of Pathology and Laboratory Medicine, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Alberta Children’s Hospital, Calgary, AB, Canada
- Alberta Precision Laboratories, Calgary, AB, Canada
| | - Weiming Yu
- Department of Pathology and Laboratory Medicine, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Alberta Children’s Hospital, Calgary, AB, Canada
- Alberta Precision Laboratories, Calgary, AB, Canada
| | - Rati Chadha
- Department of Obstetrics and Gynaecology, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
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Redline RW, Roberts DJ, Parast MM, Ernst LM, Morgan TK, Greene MF, Gyamfi-Bannerman C, Louis JM, Maltepe E, Mestan KK, Romero R, Stone J. Placental pathology is necessary to understand common pregnancy complications and achieve an improved taxonomy of obstetrical disease. Am J Obstet Gynecol 2023; 228:187-202. [PMID: 35973475 PMCID: PMC10337668 DOI: 10.1016/j.ajog.2022.08.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/08/2022] [Accepted: 08/08/2022] [Indexed: 01/28/2023]
Abstract
The importance of a fully functioning placenta for a good pregnancy outcome is unquestioned. Loss of function can lead to pregnancy complications and is often detected by a thorough placental pathologic examination. Placental pathology has advanced the science and practice of obstetrics and neonatal-perinatal medicine by classifying diseases according to underlying biology and specific patterns of injury. Many past obstacles have limited the incorporation of placental findings into both clinical studies and day-to-day practice. Limitations have included variability in the nomenclature used to describe placental lesions, a shortage of perinatal pathologists fully competent to analyze placental specimens, and a troubling lack of understanding of placental diagnoses by clinicians. However, the potential use of placental pathology for phenotypic classification, improved understanding of the biology of adverse pregnancy outcomes, the development of treatment and prevention, and patient counseling has never been greater. This review, written partly in response to a recent critique published in a major obstetrics-gynecology journal, reexamines the role of placental pathology by reviewing current concepts of biology; explaining the most recent terminology; emphasizing the usefulness of specific diagnoses for obstetrician-gynecologists, neonatologists, and patients; previewing upcoming changes in recommendations for placental submission; and suggesting future improvements. These improvements should include further consideration of overall healthcare costs, cost-effectiveness, the clinical value added of placental assessment, improvements in placental pathology education and practice, and leveraging of placental pathology to identify new biomarkers of disease and evaluate novel therapies tailored to specific clinicopathologic phenotypes of both women and infants.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology and Reproductive Biology, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center and Cleveland, OH.
| | - Drucilla J Roberts
- Department of Pathology, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - Mana M Parast
- Department of Pathology, Sanford Consortium for Regenerative Medicine, University of California San Diego, La Jolla, CA
| | - Linda M Ernst
- Department of Pathology and Laboratory Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Terry K Morgan
- Department of Pathology and Obstetrics and Gynecology, Center for Developmental Health, Oregon Health Sciences University, Portland, OR
| | - Michael F Greene
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, La Jolla, CA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University South Florida, Tampa, FL
| | - Emin Maltepe
- Department of Pediatrics, University California, San Francisco, San Francisco, CA
| | - Karen K Mestan
- Department of Pediatrics and Neonatology, University of California, San Diego, School of Medicine and Rady Children's Hospital, San Diego, CA
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, Maryland, Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Detroit Medical Center, Detroit, MI
| | - Joanne Stone
- Raquel and Jaime Gilinski Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
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Bullock HA, Fuchs E, Martines RB, Lush M, Bollweg B, Rutan A, Nelson A, Brisso M, Owusu-Ansah A, Sitzman C, Ketterl L, Timmons T, Lopez P, Mitchell E, McCutchen E, Figliomeni J, Iwen P, Uyeki TM, Reagan-Steiner S, Donahue M. Probable vertical transmission of Alpha variant of concern (B.1.1.7) with evidence of SARS-CoV-2 infection in the syncytiotrophoblast, a case report. Front Med (Lausanne) 2023; 9:1099408. [PMID: 36687432 PMCID: PMC9853166 DOI: 10.3389/fmed.2022.1099408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/13/2022] [Indexed: 01/09/2023] Open
Abstract
Introduction Definitive vertical transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection has been rarely reported. We present a case of a third trimester pregnancy with fetal distress necessitating cesarean section that demonstrated maternal, placental, and infant infection with the SARS-CoV-2 Alpha variant/B.1.1.7. Methods CDC's Influenza SARS-CoV-2 Multiplex RT-PCR Assay was used to test for SARS-CoV-2 in a maternal NP swab, maternal plasma, infant NP swab, and formalin-fixed paraffin-embedded (FFPE) placental tissue specimens. Whole genome sequencing (WGS) was performed on maternal plasma, infant, and placental specimens to determine the SARS-CoV-2 genotype. Histopathological evaluation, SARS-CoV-2 immunohistochemistry testing (IHC), and electron microscopy (EM) analysis were performed on placenta, umbilical cord, and membrane FFPE blocks. Results All specimens tested positive for SARS-CoV-2 by RT-PCR. WGS further revealed identical SARS-CoV-2 sequences from clade 20I/501Y.V1 (lineage Alpha/B.1.1.7) in maternal plasma, infant, and placental specimens. Histopathologic evaluation of the placenta showed histiocytic and neutrophilic intervillositis with fibrin deposition and trophoblast necrosis with positive SARS-CoV-2 immunostaining in the syncytiotrophoblast and electron microscopy evidence of coronavirus. Discussion These findings suggest vertical transmission of SARS-CoV-2, supported by clinical course timing, identical SARS-CoV-2 genotypes from maternal, placental, and infant samples, and IHC and EM evidence of placental infection. However, determination of the timing or distinction between prepartum and peripartum SARS-CoV-2 transmission remains unclear.
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Affiliation(s)
- Hannah A. Bullock
- Centers for Disease Control and Prevention, Atlanta, GA, United States,*Correspondence: Hannah A. Bullock ✉
| | - Erika Fuchs
- Centers for Disease Control and Prevention, Atlanta, GA, United States,Nebraska Department of Health and Human Services, Lincoln, NE, United States
| | | | - Mamie Lush
- Nebraska Department of Health and Human Services, Lincoln, NE, United States
| | - Brigid Bollweg
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Amy Nelson
- Bryan Health, Lincoln, NE, United States
| | | | | | | | | | - Tim Timmons
- Lincoln-Lancaster County Health Department, Lincoln, NE, United States
| | - Patricia Lopez
- Lincoln-Lancaster County Health Department, Lincoln, NE, United States
| | - Elizabeth Mitchell
- Nebraska Public Health Laboratory, Omaha, NE, United States,University of Nebraska Medical Center, Omaha, NE, United States
| | - Emily McCutchen
- Nebraska Public Health Laboratory, Omaha, NE, United States,University of Nebraska Medical Center, Omaha, NE, United States
| | - Jonathan Figliomeni
- Nebraska Department of Health and Human Services, Lincoln, NE, United States
| | - Peter Iwen
- Nebraska Public Health Laboratory, Omaha, NE, United States,University of Nebraska Medical Center, Omaha, NE, United States
| | - Timothy M. Uyeki
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Matthew Donahue
- Nebraska Department of Health and Human Services, Lincoln, NE, United States
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Bos M, Koenders MJM, Dijkstra KL, van der Meeren LE, Nikkels PGJ, Bloemenkamp KWM, Eikmans M, Baelde HJ, van der Hoorn MLP. The severity of chronic histiocytic intervillositis is associated with gestational age and fetal weight. Placenta 2023; 131:28-35. [PMID: 36473391 DOI: 10.1016/j.placenta.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 10/20/2022] [Accepted: 11/25/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Chronic histiocytic intervillositis (CHI) is a rare histopathological lesion in the placenta that is associated with poor reproductive outcomes. The intervillous infiltrate consists mostly of maternal mononuclear cells and fibrin depositions, which are both indicators for the severity of the intervillous infiltrate. The severity of the intervillous infiltrate as well as the clinical outcomes of pregnancy differ between cases. Our objective is to determine the relation between the severity of the intervillous infiltrate and the clinical outcomes of CHI. METHODS Cases of CHI were semi-quantitatively graded based on histopathological severity scores. Hereto, CD68 positive mononuclear cells were quantified, fibrin depositions visualized by both a PTAH stain and an immuohistochemical staining, and placental dysfunction was assessed via thrombomodulin staining. RESULTS This study included 36 women with CHI. A higher CD68 score was significantly associated with a lower birthweight. Loss of placental thrombomodulin was associated with lower gestational age, lower birthweight, and a lower placenta weight. The combined severity score based on CD68 and PTAH was significantly associated with fetal growth restriction, and the joint score of CD68 and fibrin was associated with birthweight and placental weight. DISCUSSION More severe intervillous infiltrates in CHI placentas is associated with a lower birth weight and placental weight. Furthermore, this study proposes thrombomodulin as a possible new severity marker of placental damage. More research is needed to better understand the pathophysiology of CHI.
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Affiliation(s)
- M Bos
- Department of Pathology, Leiden University Medical Center, the Netherlands; Department of Obstetrics and Gynaecology, Leiden University Medical Center, the Netherlands
| | - M J M Koenders
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, the Netherlands
| | - K L Dijkstra
- Department of Pathology, Leiden University Medical Center, the Netherlands
| | - L E van der Meeren
- Department of Pathology, Leiden University Medical Center, the Netherlands; Department of Pathology, University Medical Center Utrecht, the Netherlands
| | - P G J Nikkels
- Department of Pathology, University Medical Center Utrecht, the Netherlands
| | - K W M Bloemenkamp
- Department of Obstetrics, Birth Center Wilhelmina's Children Hospital, Division Woman and Baby, University Medical Center Utrecht, the Netherlands
| | - M Eikmans
- Department of Immunology, Leiden University Medical Center, the Netherlands
| | - H J Baelde
- Department of Pathology, Leiden University Medical Center, the Netherlands
| | - M L P van der Hoorn
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, the Netherlands.
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Cornish EF, McDonnell T, Williams DJ. Chronic Inflammatory Placental Disorders Associated With Recurrent Adverse Pregnancy Outcome. Front Immunol 2022; 13:825075. [PMID: 35529853 PMCID: PMC9072631 DOI: 10.3389/fimmu.2022.825075] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/29/2022] [Indexed: 12/11/2022] Open
Abstract
Chronic inflammatory placental disorders are a group of rare but devastating gestational syndromes associated with adverse pregnancy outcome. This review focuses on three related conditions: villitis of unknown etiology (VUE), chronic histiocytic intervillositis (CHI) and massive perivillous fibrin deposition (MPFD). The hallmark of these disorders is infiltration of the placental architecture by maternal immune cells and disruption of the intervillous space, where gas exchange between the mother and fetus occurs. Currently, they can only be detected through histopathological examination of the placenta after a pregnancy has ended. All three are associated with a significant risk of recurrence in subsequent pregnancies. Villitis of unknown etiology is characterised by a destructive infiltrate of maternal CD8+ T lymphocytes invading into the chorionic villi, combined with activation of fetal villous macrophages. The diagnosis can only be made when an infectious aetiology has been excluded. VUE becomes more common as pregnancy progresses and is frequently seen with normal pregnancy outcome. However, severe early-onset villitis is usually associated with fetal growth restriction and recurrent pregnancy loss. Chronic histiocytic intervillositis is characterised by excessive accumulation of maternal CD68+ histiocytes in the intervillous space. It is associated with a wide spectrum of adverse pregnancy outcomes including high rates of first-trimester miscarriage, severe fetal growth restriction and late intrauterine fetal death. Intervillous histiocytes can also accumulate due to infection, including SARS-CoV-2, although this infection-induced intervillositis does not appear to recur. As with VUE, the diagnosis of CHI requires exclusion of an infectious cause. Women with recurrent CHI and their families are predisposed to autoimmune diseases, suggesting CHI may have an alloimmune pathology. This observation has driven attempts to prevent CHI with a wide range of maternal immunosuppression. Massive perivillous fibrin deposition is diagnosed when >25% of the intervillous space is occupied by fibrin, and is associated with fetal growth restriction and late intrauterine fetal death. Although not an inflammatory disorder per se, MPFD is frequently seen in association with both VUE and CHI. This review summarises current understanding of the prevalence, diagnostic features, clinical consequences, immune pathology and potential prophylaxis against recurrence in these three chronic inflammatory placental syndromes.
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Affiliation(s)
- Emily F. Cornish
- Elizabeth Garrett Anderson Institute for Women’s Health, Department of Maternal and Fetal Medicine, University College London, London, United Kingdom,*Correspondence: Emily F. Cornish,
| | - Thomas McDonnell
- Faculty of Engineering Science, Department of Biochemical Engineering, University College London, London, United Kingdom
| | - David J. Williams
- Elizabeth Garrett Anderson Institute for Women’s Health, Department of Maternal and Fetal Medicine, University College London, London, United Kingdom
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Placental SARS-CoV-2 distribution correlates with level of tissue oxygenation in COVID-19-associated necrotizing histiocytic intervillositis/perivillous fibrin deposition. Placenta 2022; 117:187-193. [PMID: 34929459 PMCID: PMC8638245 DOI: 10.1016/j.placenta.2021.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/12/2021] [Accepted: 12/01/2021] [Indexed: 12/20/2022]
Abstract
Introduction Recent evidence supports the – rare – occurrence of vertical transplacental SARS-CoV-2 transmission. We previously determined that placental expression of angiotensin-converting enzyme 2 (ACE2), the SARS-CoV-2 receptor, and associated viral cell entry regulators is upregulated by hypoxia. In the present study, we utilized a clinically relevant model of SARS-CoV-2-associated chronic histiocytic intervillositis/massive perivillous fibrin deposition (CHIV/MPFVD) to test the hypothesis that placental hypoxia may facilitate placental SARS-CoV-2 infection. Methods We performed a comparative immunohistochemical and/or RNAscope in-situ hybridization analysis of carbonic anhydrase IX (CAIX, hypoxia marker), ACE2 and SARS-CoV-2 expression in free-floating versus fibrin-encased chorionic villi in a 20-weeks’ gestation placenta with SARS-CoV-2-associated CHIV/MPVFD. Results The levels of CAIX and ACE2 immunoreactivity were significantly higher in trophoblastic cells of fibrin-encased villi than in those of free-floating villi, consistent with hypoxia-induced ACE2 upregulation. SARS-CoV-2 showed a similar preferential localization to trophoblastic cells of fibrin-encased villi. Discussion The localization of SARS-CoV-2 to hypoxic, fibrin-encased villi in this placenta with CHIV/MPVFD suggests placental infection and, therefore, transplacental SARS-CoV-2 transmission may be promoted by hypoxic conditions, mediated by ACE2 and similar hypoxia-sensitive viral cell entry mechanisms. Understanding of a causative link between placental hypoxia and SARS-CoV-2 transmittability may potentially lead to the development of alternative strategies for prevention of intrauterine COVID-19 transmission.
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Bouachba A, Allias F, Nadaud B, Massardier J, Mekki Y, Bouscambert Duchamp M, Fourniere BDLA, Huissoud C, Trecourt A, Collardeau-Frachon S. Placental lesions and SARS-Cov-2 infection: Diffuse placenta damage associated to poor fetal outcome. Placenta 2021; 112:97-104. [PMID: 34329973 PMCID: PMC8280612 DOI: 10.1016/j.placenta.2021.07.288] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/29/2021] [Accepted: 07/14/2021] [Indexed: 12/15/2022]
Abstract
Introduction Pregnant women with covid-19 are more likely to experience preterm birth. The virus seems to be associated with a wide range of placental lesions, none of them specific. Method We collected cases of Covid-19 maternal infection during pregnancy associated with poor pregnancy outcomes, for which we received the placenta. We studied clinical data and described pathological findings of placenta and post-mortem examination of fetuses. We performed an immunohistochemical study and RT-PCR of SARS-Cov-2 on placenta samples. Results We report 5 cases of poor fetal outcome, 3 fetal deaths and 2 extreme premature neonates, one with growth restriction, without clinical and biological sign of SARS-Cov-2 infection. All placenta presented massive perivillous fibrin deposition and large intervillous thrombi associated with strong SARS-Cov-2 expression in trophoblast and SARS-CoV-2 PCR positivity in amniotic fluid or on placenta samples. Chronic histiocytic intervillositis was present in 4/5 cases. Placental ultrasound was abnormal and the sFLT1-PIGF ratio was increased in one case. Timing between mothers’ infection and the poor fetal outcome was ≤10 days in 4 cases. The massive placental damage are directly induced by the virus whose receptors are expressed on trophoblast, leading to trophoblast necrosis and massive inflammation in villous chamber, in a similar way it occurs in diffuse alveolar damage in adults infected by SARS-Cov-2. Discussion SARS-Cov-2 can be associated to a rare set of placental lesions which can lead to fetal demise, preterm birth, or growth restriction. Stronger surveillance of mothers infected by SARS-Cov-2 is required.
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Affiliation(s)
- Amine Bouachba
- Institut de Pathologie Multisite des Hospices Civils de Lyon, 69677, Bron Cedex, Lyon, France; SOFFOET-Société Française de Fœtopathologie, 75014, Paris, France.
| | - Fabienne Allias
- SOFFOET-Société Française de Fœtopathologie, 75014, Paris, France; Institut de Pathologie, Centre hospitalier Lyon Sud, Hospices Civils de Lyon, 69495, Pierre Bénite, Lyon, France
| | - Beatrice Nadaud
- Institut de Pathologie Multisite des Hospices Civils de Lyon, 69677, Bron Cedex, Lyon, France; SOFFOET-Société Française de Fœtopathologie, 75014, Paris, France
| | - Jerome Massardier
- SOFFOET-Société Française de Fœtopathologie, 75014, Paris, France; Service de gynécologie-obstétrique de l'Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, 69677, Bron Cedex, Lyon, France
| | - Yahia Mekki
- Institut des Agents Infectieux des Hospices Civils de Lyon, Service de Virologie, 69004, Lyon, France
| | - Maude Bouscambert Duchamp
- Institut des Agents Infectieux des Hospices Civils de Lyon, Service de Virologie, 69004, Lyon, France
| | - Benoit De LA Fourniere
- Service de Gynécologie-obstétrique de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France
| | - Cyril Huissoud
- Service de Gynécologie-obstétrique de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France; Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est, 69008, France
| | - Alexis Trecourt
- Institut de Pathologie Multisite des Hospices Civils de Lyon, 69677, Bron Cedex, Lyon, France
| | - Sophie Collardeau-Frachon
- Institut de Pathologie Multisite des Hospices Civils de Lyon, 69677, Bron Cedex, Lyon, France; SOFFOET-Société Française de Fœtopathologie, 75014, Paris, France; Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est, 69008, France
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Debelenko L, Katsyv I, Chong AM, Peruyero L, Szabolcs M, Uhlemann AC. Trophoblast damage with acute and chronic intervillositis: disruption of the placental barrier by severe acute respiratory syndrome coronavirus 2. Hum Pathol 2020; 109:69-79. [PMID: 33321162 PMCID: PMC7733682 DOI: 10.1016/j.humpath.2020.12.004] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/18/2020] [Accepted: 12/09/2020] [Indexed: 10/28/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was demonstrated in the placenta; however, the data on the prevalence of placental infection and associated histopathology are limited. To identify the frequency and features of SARS-CoV-2 involvement, we performed a clinicopathologic analysis of 75 placental cases from women infected at the time of delivery and 75 uninfected controls. Placental samples were studied with anti-SARS-CoV-2 immunohistochemistry and/or in situ hybridization. Positive results were confirmed by electron microscopy and quantitative reverse-transcription polymerase chain reaction (qRT-PCR). During delivery, only one woman had symptoms of coronavirus disease 2019, six women reported previous symptoms, and 68 women were asymptomatic. All neonates tested negative for SARS-CoV-2 as per nasopharyngeal swab PCR results. Obstetric histories were unremarkable in 29 of 75 SARS-CoV-2-positive and 8 of 75 SARS-CoV-2-negative women. Placental examination was normal in 12 of 75 infected and 3 of 75 uninfected subjects, respectively. In the remaining cases, placental pathology correlated with obstetric comorbidities without significant differences between SARS-CoV-2-positive and SARS-CoV-2-negative women. SARS-CoV-2 was identified in one placenta of an infected, but asymptomatic, parturient. Viral staining was predominantly localized to the syncytiotrophoblast (STB) which demonstrated marked damage accompanied by perivillous fibrin deposition and mixed intervillositis. A significant decrease of viral titers was detected in the attached umbilical cord compared with the villous parenchyma as per qRT-PCR. SARS-CoV-2 is seldom identified in placentas of infected women. Placental involvement by the virus is characterized by STB damage disrupting the placental barrier and can be seen in asymptomatic mothers without evidence of vertical transmission.
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Affiliation(s)
- Larisa Debelenko
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, 10032, USA.
| | - Igor Katsyv
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Alexander M Chong
- Department of Medicine, Division of Infectious Diseases, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Leonore Peruyero
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Matthias Szabolcs
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Anne-Catrin Uhlemann
- Department of Medicine, Division of Infectious Diseases, Columbia University Irving Medical Center, New York, NY, 10032, USA
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Goldstein JA, Gallagher K, Beck C, Kumar R, Gernand AD. Maternal-Fetal Inflammation in the Placenta and the Developmental Origins of Health and Disease. Front Immunol 2020; 11:531543. [PMID: 33281808 PMCID: PMC7691234 DOI: 10.3389/fimmu.2020.531543] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 10/06/2020] [Indexed: 12/17/2022] Open
Abstract
Events in fetal life impact long-term health outcomes. The placenta is the first organ to form and is the site of juxtaposition between the maternal and fetal circulations. Most diseases of pregnancy are caused by, impact, or are reflected in the placenta. The purpose of this review is to describe the main inflammatory processes in the placenta, discuss their immunology, and relate their short- and long-term disease associations. Acute placental inflammation (API), including maternal and fetal inflammatory responses corresponds to the clinical diagnosis of chorioamnionitis and is associated with respiratory and neurodevelopmental diseases. The chronic placental inflammatory pathologies (CPI), include chronic villitis of unknown etiology, chronic deciduitis, chronic chorionitis, eosinophilic T-cell vasculitis, and chronic histiocytic intervillositis. These diseases are less-well studied, but have complex immunology and show mechanistic impacts on the fetal immune system. Overall, much work remains to be done in describing the long-term impacts of placental inflammation on offspring health.
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Affiliation(s)
- Jeffery A. Goldstein
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Kelly Gallagher
- Department of Nutritional Sciences, College of Health and Human Development, Penn State University, University Park, PA, United States
| | - Celeste Beck
- Department of Nutritional Sciences, College of Health and Human Development, Penn State University, University Park, PA, United States
| | - Rajesh Kumar
- Section of Allergy and Immunology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital and Northwestern University, Chicago, IL, United States
| | - Alison D. Gernand
- Department of Nutritional Sciences, College of Health and Human Development, Penn State University, University Park, PA, United States
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Mattuizzi A, Sauvestre F, André G, Poingt M, Camberlein C, Carles D, Pelluard F, Blanco P, Sentilhes L, Lazaro E. Adverse perinatal outcomes of chronic intervillositis of unknown etiology: an observational retrospective study of 122 cases. Sci Rep 2020; 10:12611. [PMID: 32724097 PMCID: PMC7387519 DOI: 10.1038/s41598-020-69191-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 07/03/2020] [Indexed: 01/03/2023] Open
Abstract
Our study aimed to assess perinatal outcomes and recurrence rate of Chronic Intervillositis of Unknown Etiology (CIUE). We conducted an observational retrospective study in a tertiary care university hospital in France from January 1, 1997 to July 31, 2018. 122 pregnancies (102 women) with CIUE were included. Cases of the Department of Histopathology placenta database were re-analysed independently by three pathologists specializing in fetal pathology. Diagnosis of CIUE was confirmed according to: (1) the presence of cellular infiltrate in the intervillous space, (2) ~ 80% of the mononuclear cells in the intervillous space positive for CD68, (3) infiltration occupying at least 5% of the intervillous space, and (4) no clinical or histopathological sign of infection. Outcomes of pregnancies with CIUE (miscarriages, stillbirths, terminations of pregnancy, live birth with or without prematurity or fetal growth restriction) and proportion of CIUE recurrence were analysed. The lost pregnancies comprised 17 (13.9%) miscarriages, 17 (13.9%) stillbirths, and 18 (14.8%) terminations of pregnancy. Of the 70 (57.4%) pregnancies that led to a live birth, 38 (54.3%) new-borns were premature and 50 (72.5%) exhibited fetal growth restriction. Among the 102 women, 23 subsequently became pregnant, half of whom (n = 11) developed recurrent CIUE. CIUE was associated with high rates of adverse perinatal outcomes, including pregnancy loss, fetal growth restriction, and preterm birth with a risk of recurrence nearly 50%.
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Affiliation(s)
- Aurélien Mattuizzi
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Place Amélie Rabat Léon, 33000, Bordeaux, France. .,CNRS-UMR 5164, ImmunoConcEpT, Bordeaux University, Bordeaux, France.
| | - Fanny Sauvestre
- Department of Pathology, Bordeaux University Hospital, Bordeaux, France.,CNRS-UMR 5164, ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Gwenaëlle André
- Department of Pathology, Bordeaux University Hospital, Bordeaux, France
| | - Marion Poingt
- Department of Obstetrics and Gynaecology, Bordeaux Nord Polyclinic, Bordeaux, France
| | - Camille Camberlein
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Place Amélie Rabat Léon, 33000, Bordeaux, France
| | - Dominique Carles
- Department of Pathology, Bordeaux University Hospital, Bordeaux, France
| | - Fanny Pelluard
- Department of Pathology, Bordeaux University Hospital, Bordeaux, France
| | - Patrick Blanco
- Department of Immunology, Bordeaux University Hospital, Bordeaux, France.,CNRS-UMR 5164, ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Place Amélie Rabat Léon, 33000, Bordeaux, France
| | - Estibaliz Lazaro
- Department of Internal Medicine, Bordeaux University Hospital, Bordeaux, France.,CNRS-UMR 5164, ImmunoConcEpT, Bordeaux University, Bordeaux, France
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11
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Bos M, Harris-Mostert ETMS, van der Meeren LE, Baelde JJ, Williams DJ, Nikkels PGJ, Bloemenkamp KWM, van der Hoorn MLP. Clinical outcomes in chronic intervillositis of unknown etiology. Placenta 2020; 91:19-23. [PMID: 32174302 DOI: 10.1016/j.placenta.2020.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/29/2019] [Accepted: 01/03/2020] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Chronic intervillositis of unknown etiology (CIUE) is a histopathological lesion of the placenta that is frequently accompanied by unfavourable pregnancy outcomes, e.g. miscarriage, fetal growth restriction (FGR) and intrauterine fetal death. Earlier described case series and cohorts have been based on diverse diagnostic criteria of CIUE. To improve our understanding of clinical outcomes associated with CIUE, we report the obstetric and perinatal outcomes in a cohort based on the recently described diagnostic criteria. METHODS CIUE is defined as an infiltrate occupying 5% or more of the intervillous space with approximately 80% of mononuclear cells positive for CD68 in the absence of an infection. Thirty-eight cases were included. Also previous and subsequent pregnancies were described. RESULTS Pregnancies accompanied by CIUE frequently resulted in FGR (51.6%) and pre-term birth (55.3%). Twenty-nine out of 38 pregnancies (76.3%) with CIUE resulted in a living baby. Women with CIUE frequently have had a miscarriage (16/38; 42%). Four-teen subsequent pregnancies in 8 women resulted in 2 miscarriages, 2 terminations of pregnancy for FGR, 1 early neonatal death and 9 living babies (9/14; 64.3%). Histopathologically confirmed CIUE recurred in 5 out of 10 subsequent pregnancies. Two pregnancies with recurrent CIUE were terminated, one pregnancy ended in a late miscarriage and another resulted in term birth complicated by FGR. Recurrent CIUE can also be accompanied by an uncomplicated pregnancy (1/5; 20%). CONCLUSION This study provides additional insight into the clinical phenotype of CIUE and emphasises the need for further research to understand the pathophysiology behind different pregnancy outcomes in CIUE.
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Affiliation(s)
- M Bos
- Department of Pathology, Leiden University Medical Center, the Netherlands; Department of Obstetrics and Gynaecology, Leiden University Medical Center, the Netherlands.
| | | | - L E van der Meeren
- Department of Pathology, University Medical Center Utrecht, the Netherlands
| | - J J Baelde
- Department of Pathology, Leiden University Medical Center, the Netherlands
| | - D J Williams
- Institute for Women's Health, University College London Hospitals, United Kingdom
| | - P G J Nikkels
- Department of Pathology, University Medical Center Utrecht, the Netherlands
| | - K W M Bloemenkamp
- Department of Obstetrics, Birth Center Wilhelmina's Children Hospital, Division Woman and Baby, University Medical Center Utrecht, the Netherlands
| | - M L P van der Hoorn
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, the Netherlands
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12
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Intervillites chroniques histiocytaires : bilan et prise en charge. Rev Med Interne 2018; 39:117-121. [DOI: 10.1016/j.revmed.2017.10.422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 12/29/2022]
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13
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Chen A, Roberts DJ. Placental pathologic lesions with a significant recurrence risk - what not to miss! APMIS 2017; 126:589-601. [PMID: 29271494 DOI: 10.1111/apm.12796] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 10/25/2017] [Indexed: 01/08/2023]
Abstract
Here, we review three important placental pathologies with significant clinical implications and recurrence risks. They are, in order of most to least frequently seen, villitis of unknown etiology, chronic histiocytic intervillositis, and massive perivillous fibrin deposition (also known as maternal floor infarction). These entities occur in both preterm and term gestations and are observed more frequently with maternal and obstetric disorders including prior pregnancy loss, hypertension/preeclampsia, and autoimmune disease. They are associated with, and probably the cause of, significant perinatal morbidity and mortality including intrauterine growth restriction, fetal and neonatal demise, and fetal/neonatal neurocompromise (seizures and cerebral palsy). All three entities have high recurrence risks, with recurrence rates ranging from 34 to 100%. The histologic features of villitis of unknown etiology, chronic histiocytic intervillositis, and massive perivillous fibrin deposition are described herein. We discuss the clinical associations and suggest the subsequent clinical and pathological evaluation. Hypotheses as to the biology of these lesions are reviewed.
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Affiliation(s)
- Athena Chen
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Drucilla J Roberts
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
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14
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Bos M, Nikkels PGJ, Cohen D, Schoones JW, Bloemenkamp KWM, Bruijn JA, Baelde HJ, van der Hoorn MLP, Turner RJ. Towards standardized criteria for diagnosing chronic intervillositis of unknown etiology: A systematic review. Placenta 2017; 61:80-88. [PMID: 29277275 DOI: 10.1016/j.placenta.2017.11.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/05/2017] [Accepted: 11/20/2017] [Indexed: 12/25/2022]
Abstract
Chronic intervillositis of unknown etiology (CIUE) is a poorly understood, relatively rare condition characterized histologically by the intervillous infiltration of mononuclear cells in the placenta. Clinically, CIUE is associated with poor pregnancy outcome (e.g., impaired fetal growth, preterm birth, fetal death) and high risk of recurrence in subsequent pregnancies. Because CIUE is not defined consistently, it is essential to clearly define this condition. We therefore review the published definitions of CIUE. In addition, we provide an overview of the reviewed histopathological and maternal characteristics, obstetric features, and pregnancy outcomes. Medical publication databases were searched for articles published through February 2017. Eighteen studies were included in our systematic review. The sole inclusion criterion used in all studies was the presence of intervillous infiltrates. Overall, CIUE was characterized by adverse pregnancy outcome. Miscarriage occurred in 24% of cases, with approximately half of these miscarriages defined as late. Impaired growth was commonly observed, 32.4% of pregnancies reached term, and the live birth rate was 54.9%. The high recurrence rate (25.1%) of the intervillous infiltrates in subsequent pregnancies underscores the clinical relevance of CIUE, the need for increased awareness among pathologists and clinicians, and the need for further research. Criteria for the diagnosis of CIUE are proposed and a Delphi study could be used to resolve any controversy regarding these criteria. Future studies should be designed to characterize the full clinical spectrum of CIUE.
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Affiliation(s)
- M Bos
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands.
| | - P G J Nikkels
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - D Cohen
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - J W Schoones
- Walaeus Medical Library, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - K W M Bloemenkamp
- Department of Obstetrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Birth Centre, Lundlaan 6, 3584 EA Utrecht, The Netherlands
| | - J A Bruijn
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - H J Baelde
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - M L P van der Hoorn
- Department of Obstetrics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - R J Turner
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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Labarrere CA, Hardin JW, Haas DM, Kassab GS. Chronic villitis of unknown etiology and massive chronic intervillositis have similar immune cell composition. Placenta 2015; 36:681-6. [PMID: 25911290 DOI: 10.1016/j.placenta.2015.03.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 03/18/2015] [Accepted: 03/21/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Chronic villitis of unknown etiology (CVUE) and massive chronic intervillositis (MCI) are placental lesions associated with infiltration of mononuclear cells in the chorionic villi and the intervillous spaces, respectively. It is not well known whether immune cells in CVUE and MCI have similar phenotypic characteristics. METHODS A cross-sectional study of third trimester placentas was conducted to identify immune cell subpopulations in CVUE and MCI (n = 17/group). CVUE was diagnosed with H&E staining and antibody to CD3 in serial sections; and MCI, by the presence of massive infiltration of mononuclear cells in the intervillous spaces. Immune cells, ICAM-1 expression and nuclear factor κB (NF-κB) activation were determined immunohistochemically. RESULTS CVUE and MCI showed similar infiltrates, mainly CD68+ and CD3+ cells. Most cells (>80%) were CD45RB+, and one third were CD45RO+ in both lesions. There were slightly more CD8+ than CD4+ cells in both CVUE and MCI. More than 90% of cells in CVUE and MCI were ICAM-1+ with NFκB nuclear localization. Syncytiotrophoblast ICAM-1 expression was significantly (p < 0.001) higher in MCI (mean of 81.0; range of 71.6-86.0) than in CVUE (52.4; 36.4-59.4) or normal placentas (0.2; 0.0-0.6). Both, failure of physiologic transformation of spiral arteries and placental atherosclerosis-like lesions of atherosis were significantly more frequent in MCI than in CVUE or normal placentas (p = 0.044 and p = 0.007, respectively). DISCUSSION These finding suggest that MCI and CVUE have very similar infiltration of immune cells although MCI has more severe placental lesions.
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Affiliation(s)
- C A Labarrere
- CBL Partners for Life, Indianapolis, IN, USA; California Medical Innovations Institute, San Diego, CA, USA.
| | - J W Hardin
- Epidemiology and Biostatistics, Columbia, SC, USA
| | - D M Haas
- Obstetrics and Gynecology, Indiana University School of Medicine Wishard-Eskenazi Hospital, Indianapolis, IN, USA
| | - G S Kassab
- California Medical Innovations Institute, San Diego, CA, USA
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16
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Abstract
Villitis of unknown etiology (VUE) is a common lesion affecting from 6.6% to 33.8% of third-trimester placentas. VUE needs to be distinguished from villitis of infectious etiology, most commonly cytomegalovirus and syphilis. Clinically, this lesion is associated with intrauterine growth retardation, intrauterine fetal demise, fetal neural impairment, maternal alloimmune and autoimmune disease, and maternal hypertension. It has a tendency to recur in subsequent pregnancies. Massive chronic intervillositis (MCI), also known as chronic histiocytic intervillositis, is a rare lesion that has an unclear relationship with VUE. MCI is associated with recurrent abortions.
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Affiliation(s)
- Joanna S Y Chan
- Department of Pathology, Anatomy, and Cell Biology; Thomas Jefferson University Hospital; 132 South 10th Street, Main Building; Philadelphia, PA 19123.
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