Shared developmental pathways of the placenta and fetal heart

Congenital heart defects (CHD) remain the most common class of birth defect worldwide, affecting 1 in every 110 live births. A host of clinical and morphological indicators of placental dysfunction are observed in pregnancies complicated by fetal CHD and, with the recent emergence of single-cell sequencing capabilities, the molecular and physiological associations between the embryonic heart and developing placenta are increasingly evident. In CHD pregnancies, a hostile intrauterine environment may negatively influence and alter fetal development. Placental maldevelopment and dysfunction creates this hostile in-utero environment and may manifest in the development of various subtypes of CHD, with downstream perfusion and flow-related alterations leading to yet further disruption in placental structure and function. The adverse in-utero environment of CHD-complicated pregnancies is well studied, however the specific etiological role that the placenta plays in CHD development remains unclear. Many mouse and rat models have been used to characterize the relationship between CHD and placental dysfunction, but these paradigms present substantial limitations in the assessment of both the heart and placenta. Improvements in non-invasive placental assessment can mitigate these limitations and drive human-specific investigation in relation to fetal and placental development. Here, we review the clinical, structural, and molecular relationships between CHD and placental dysfunction, the CHD subtype-dependence of these changes, and the future of Placenta-Heart axis modeling and investigation.

Histopathologic Findings in Large for Gestational Age Placentas and Correlation With CD15 Immunohistochemistry

BACKGROUND

The histopathology and CD15 expression in large for gestational age (LGA) placentas is not well-documented.

METHODS

To analyze this, we utilized 2 separate cohorts of placentas from singleton term deliveries. LGA and appropriate for gestational age (AGA) placentas were compared for major histopathologies including acute and chronic inflammation, maternal and fetal vascular malperfusion, delayed villous maturation (DVM), and villous hypervascularity/chorangiosis. We also examined CD15 immunohistochemistry in LGA and AGA placentas. Stained slides were reviewed blinded to the placental weight. Five random 20× fields were scored semi-quantitatively for CD15 staining of villous capillaries on a scale of 0 to 5 (0 = 0%, 1 = 1%-5%, 2 = 5%-25%, 3 = 25%-50%, 4 = 50%-75%, and 5 = >75%).

RESULTS

In 1 cohort, 1238 LGA and 7908 AGA placentas were identified. Patients with LGA placentas were significantly more likely to have higher birthweight babies, obesity, hypertensive disorders, pre-gestational, and gestational diabetes. Also, LGA placentas had a higher prevalence of fetal vascular malperfusion, DVM, and villous chorangiosis. In other cohort of 75 LGA placentas and 73 AGA controls, the average score of CD15 staining in villous capillaries was significantly higher amongst LGA placentas.

CONCLUSION

We conclude that LGA placentas have increased expression of CD15 in villous capillary endothelium and higher prevalence of FVM, DVM, and villous chorangiosis than AGA placentas.

Placental pathology findings in perinatal deaths from 28 weeks gestation in Aotearoa New Zealand

INTRODUCTION

Women of South Asian ethnicity are overrepresented in adverse pregnancy outcome across high-income countries, including those related to placental dysfunction. It has been hypothesised that placental aging occurs at earlier gestation in South Asian pregnancies. We aimed to identify differences in placental pathology among perinatal deaths ≥28 weeks gestation, between South Asian, Māori and New Zealand (NZ) European women in Aotearoa NZ, with a focus on women of South Asian ethnicity.

METHODS

Placental pathology reports and clinical data from perinatal deaths between 2008 and 2017 were provided by the NZ Perinatal and Maternal Mortality Review Committee, blinded, and analysed by an experienced perinatal pathologist using the Amsterdam Placental Workshop Group Consensus Statement criteria.

RESULTS

790 of 1161 placental pathology reports, 346 preterm (28⁺⁰ to 36⁺⁶ weeks) and 444 term (≥37⁺⁰ weeks) deaths, met the inclusion criteria. Among preterm deaths, South Asian women had higher rates of maternal vascular malperfusion compared with Māori (aOR 4.16, 95%CI 1.55-11.15) and NZ European (aOR 2.60, 95%CI 1.10-6.16). Among term deaths, South Asian women had higher rates of abnormal villous morphology compared with Māori (aOR 2.19, 95%CI 1.04-4.62) and NZ European (aOR 2.12, 95%CI 1.14-3.94), mostly due to increased rates of chorangiosis (36.7%, compared to 23.3% and 21.7%, respectively).

DISCUSSION

Differences in placental pathology by ethnicity were observed among preterm and term perinatal deaths. While we suspect differing underlying causal pathways, these deaths may be associated with maternal diabetic and red blood cell disorders among South Asian women, leading to a hypoxic state in-utero.

Ultrasound-based nomogram for postpartum hemorrhage prediction in pernicious placenta previa

Background: Pernicious placenta previa (PPP) is one of the most dangerous complications in pregnancy after cesarean section, with high perinatal mortality. This study aimed to develop a nomogram to predict postpartum hemorrhage in patients with PPP.

Methods: A total of 246 patients with confirmed PPP at Shengjing Hospital of China Medical University from January 2018 to December 2021 were included. Patients were divided into to two cohorts depending on a postpartum blood loss of > 1000 ml (n = 146) or ≤ 1000 ml (n = 100). Lasso regression analysis was performed on the risk factors screened by univariate analysis to screen out the final risk factors affecting postpartum hemorrhage. Based on the final risk factors, a Nomogram prediction model with excellent performance was constructed using Logistic regression. A nomogram was constructed with further screening of the selected risk factors of postpartum hemorrhage in PPP. A second nomogram based only on the total ultrasonic risk score was constructed. Decision curve analysis (DCA) was used to evaluate the clinical efficacy of the nomograms.

Results: Older age, larger gestational age, larger neonatal birth weight, presence of gestational diabetes mellitus, larger amniotic fluid index, absence of gestational bleeding, and higher ultrasonic risk single score were selected to establish a nomogram for postpartum hemorrhage in PPP. The area under the curve of the nomogram constructed by Lasso regression analysis was higher than that of the ultrasonic total score alone (0.887 vs. 0.833). Additionally, DCA indicated better clinical efficacy in the former nomogram than in the later nomogram. Furthermore, internal verification of the nomogram constructed by Lasso regression analysis showed good agreement between predicted and actual values.

Conclusion: A nomogram for postpartum hemorrhage in PPP was developed and validated to assist clinicians in evaluating postpartum hemorrhage. This nomogram was more accurate than using the ultrasonic score alone.

Hypertensive Disorders of Pregnancy and Fetal Growth Restriction: Clinical Characteristics and Placental Lesions and Possible Preventive Nutritional Targets

Background: The purpose of this study was to describe the placental lesions in pregnancies complicated by hypertensive disorders (HDP) and/or fetal growth restriction (FGR) and in uneventful control pregnancies. Methods: This is a case control study that included singleton pregnancies with HDP and normally grown fetus (HDP-AGA fetus), with HDP and FGR, early FGR, late FGR, and uneventful pregnancies. Feto-placental Doppler velocimetry and sFlt-1/PlGF ratio were performed. Placental histology was evaluated blinded according to the Amsterdam Consensus criteria. Results: Placental lesions with maternal vascular malperfusion (MVM) were significantly more frequent in HDP-FGR and early FGR (92% and 83%). MVM were significantly associated with abnormal feto-placental Doppler parameters, especially in early FGR. Delayed villous maturation (DVM) was associated with late FGR (83%). HDP-AGA fetus cases presented a heterogeneous pattern of placental lesions, including 60% of cases with MVM, but were not associated with abnormal Doppler feto-placental velocimetry. Conclusions: We found a prevalence of placental maternal vascular malperfusion in HDP-FGR and early FGR groups. These lesions were also associated with abnormal, anti-, and angiogenic markers. Conversely HDP-AGA fetus and late FGR presented more heterogeneous placental lesions not severe enough to cause feto-placental Doppler anomalies. These conditions are likely associated with different etiologies, such as maternal pre-pregnancy risk factors for metabolic syndrome. These findings suggest a possible preventive nutritional approach in addition to low-dose aspirin in pregnant women with predisposing factors for HDP-AGA fetuses and late FGR.

Accuracy of Prenatal Ultrasound in Evaluating Placental Pathology Using Superb Microvascular Imaging: A Prospective Observation Study

Superb microvascular imaging (SMI) is a new Doppler method that enables the visualization of low-velocity blood flow. The aim of the study described here was to clarify whether SMI can detect prenatal pathological findings in pathologic placentas. In this prospective diagnostic observational study, pregnant women who were admitted to our center for perinatal management were enrolled. Ultrasound examinations to identify placental pathologies using SMI were performed before delivery. After delivery, the placental tissue was clipped for microscopic examination at locations determined under ultrasound guidance. The accuracy of prenatal ultrasound detection of placental pathologies was compared between women who were admitted because of fetal growth restriction (FGR), pre-eclampsia and other indications. The highest accuracy was observed with placental infarction in FGR (positive predictive value = 100%, sensitivity = 89%, area under the curve = 0.945). As a result, it became clear that SMI can accurately detect placental pathologic findings, such as placental infarction and avascular villi. This modality may improve perinatal management in cases of placental dysfunction.

Placental pathology: Pathways leading to or associated with perinatal brain injury in experimental neurology, special issue: Placental mediated mechanisms of perinatal brain injury

Perinatal brain injury is a multifactorial process. In utero placental physiology plays a major role in neuroprotection and the normal development of the fetal central nervous system. Advances in placental pathology have clarified several specific mechanisms of injury and the histologic lesions most strongly associated with them. This review provides an updated summary of the relevant placental anatomy and physiology, the specific placental pathways leading to brain injury, the revised Amsterdam classification system for placental pathology, and the known associations of specific placental lesions with subtypes of adverse neurologic outcomes.

[Influence of placental pathological chorangiosis on neonates: an analysis of 450 cases]

OBJECTIVE

To study the influence of placental pathological chorangiosis in the mother on the mortality of neonates and the incidence rate of complications.

METHODS

A retrospective analysis was performed for the neonates who were hospitalized within 3 days after birth in the Department of Neonatology, Xiamen Maternal and Child Health Hospital, from July 2016 to February 2020. According to whether the placental pathology showed chorangiosis, the neonates were divided into an observation group and a control group (n=450 each). The two groups were analyzed in terms of general status, maternal comorbidities during pregnancy, neonatal mortality, and incidence rate of complications in neonates.

RESULTS

Compared with the control group, the observation group had a significantly higher cesarean section rate (P < 0.05) and a significantly higher incidence rate of maternal gestational hypertension (P < 0.05). The observation group had significantly higher incidence rates of congenital malformation, small-for-gestational-age birth, and low Apgar score than the control group (P < 0.05). The observation group also had significantly higher mortality rate and incidence rates of brain injury, retinopathy of prematurity, and extrauterine growth retardation (P < 0.05).

CONCLUSIONS

Neonates born to mothers with placental pathological chorangiosis tend to have a higher morbidity rate and incidence rate of complications. It is important to improve the understanding of chorangiosis and provide intervention as soon as possible, in order to reduce complications and improve prognosis.

Association of placental chorangiosis with pregnancy complication and prenatal outcome: a case-control study

Background

Chorangiosis is a vascular change involving the terminal chorionic villi in the placenta. It results from longstanding, low-grade hypoxia in the placental tissue, and is associated with such conditions as intrauterine growth restriction (IUGR), diabetes, and gestational hypertension in pregnancy. Chorangiosis rarely occurs in normal pregnancies. However, its prevalence is 5–7% of all placentas from infants admitted to newborn intensive care units. The present study was aimed at determining the association of chorangiosis with pregnancy complications and perinatal outcomes.

Methods

In this case-control study, 308 chorangiosis cases were compared with 308 controls (with other diagnoses in pathology) in terms of maternal, placental, prenatal, and neonatal characteristics derived from the medical records of participants retrospectively. R and SPSS version 22 software tools were used, and the statistical significance level was considered 0.05 for all the tests.

Results

Preeclampsia, diabetes mellitus, maternal hemoglobin, maternal hematocrit, C/S, oligohydramnios, fetal anomaly, dead neonates, NICU admissions were significantly higher in the chorangiosis group OR = 1.6, 3.98, 1.68, 1.92, 2.1, 4.47, 4.22, 2.9, 2.46, respectively (p-value< 0.05 for all). Amniotic fluid index, birth weight, cord PH amount, 1st, and 5th Apgar score was lower in the chorangiosis group OR = 0.31, 1, 0.097, 0.83, 0.85, respectively (p-value< 0.05 for all). Moreover, fundal placenta, retro placental hemorrhage, perivillous fibrin deposition, calcification, and acute chorioamnionitis were higher in the chorangiosis group OR = 2.1, 11.8, 19.96, 4.05, and 6.38 respectively, (p-value< 0.05). There was a high agreement between the two pathologists, and the power of the study was estimated at 99%.

Conclusion

Although chorangiosis is an uncommon condition, it is associated with a higher incidence of perinatal and neonatal morbidity and mortality. Therefore, it should be considered an important clinical sign of adverse pregnancy outcomes and should be reported in the pathology evaluation.

Clinical Characteristics of Mother-Infant Dyad and Placental Pathology in COVID-19 Cases in Predominantly African American Population

Objective  In this currently evolving coronavirus disease 2019 (COVID-19) pandemic, the evidence is scarce about the impact of COVID-19 infection on women in labor and neonates in an inner city African-Americans (AA) population. The objective of this study was to evaluate the clinical outcomes and placental pathology in mother-infant dyads in COVID-19 cases. Study Design  Retrospective chart review was conducted on 34 COVID-19 positive mother-infant dyads to study their baseline characteristics and outcomes. Placental pathology was reviewed by two perinatal pathologists. Results  COVID-19 was noted in 3% of pregnant women who delivered in our institution. The majority (82%) of them were asymptomatic. Out of the four mothers who were symptomatic, only three (9%) required supplemental oxygen. None of them required invasive ventilation. All the neonates tested negative for COVID-19 at 24 hours of age. There were no gross or microscopic pathological abnormalities detected that could be definitely associated with any COVID-19 related complications during pregnancy in any of the 34 placentas. Conclusion  COVID-19 does not appear to increase morbidity and mortality among pregnant women and their neonates in a predominantly AA population. Our study did not find any evidence of vertical transmission of COVID-19 infection nor any specific findings on placental pathology. Key Points Majority of women infected by coronavirus disease 2019 (COVID-19) during labor were asymptomatic.None of the newborns tested positive for COVID-19 at 24 hours of age.Placental pathology findings were nonspecific in COVID-19 mothers.

Fetal Growth Restriction in Hypertensive vs. Heavy Smoking Women-Placental Pathology, Ultrasound Findings, and Pregnancy Outcomes

We compared placental pathology, ultrasonographic findings, and obstetric outcomes, in gestations complicated by fetal growth restriction (FGR) with either a background of hypertensive disorder or heavy tobacco cigarette smoking. The medical records and placental pathology reports of pregnancies complicated with FGR (birthweight < 10th percentile) between December 2008 and May 2018 from a single tertiary center were reviewed. Placental pathology, ultrasound findings, and pregnancy outcomes were compared between hypertensive patients (HTN) and heavy smokers (SMO). We included 213 pregnancies: 129 (60.6%) in the SMO group and 84 (39.4%) in the HTN group. The HTN group was characterized by a higher BMI (p = 0.01), higher rates of Cesarean deliveries (p = 0.006), and a lower gestational age at delivery (35.6 ± 3.8 vs. 37.5 ± 2.9 weeks, p < 0.001). The HTN group had higher rates of placental weights < 10th percentile (p = 0.04) and maternal vascular malperfusion lesions (p < 0.001), while the SMO group had higher rates of inflammatory lesions (p = 0.04). On ultrasound, the HTN group had a higher head/abdomen circumference ratio (p < 0.001) and more abnormal Doppler studies (< 0.001). Neonates in the HTN group had lower birthweights (p < 0.001) and higher rates of NICU admissions (p = 0.002) and adverse neonatal outcome (p = 0.006). On multivariable analysis, gestational age at delivery (aOR = 0.65, 95%CI 0.55-0.87), hypertensive disorders (aOR = 1.8, 95%CI = 1.21-4.81), placental MVM lesions (aOR = 1.23, 95%CI = 1.08-5.02), and the combination of HTN+MVM (aOR = 2.63, 95%CI 1.78-7.30) were independently associated with adverse neonatal outcome. Hypertension and smoking may lead to FGR in different pathways as the two groups significantly differed in maternal characteristics, placental pathology, ultrasound findings, and neonatal outcomes. A hypertensive disorder probably represents a more hostile maternal environment than smoking and these pregnancies would probably benefit from closes monitoring.

Placentas From Women of Advanced Maternal Age

CONTEXT.—

The percentage of pregnant women with advanced maternal age (AMA) has increased during the past several decades due to various socioeconomic factors and advances in assisted reproduction. These pregnancies are associated with adverse maternal and fetal outcomes. However, the underlying placental pathology has not been well described.

OBJECTIVE.—

To investigate the placental histopathology associated with AMA pregnancies.

DESIGN.—

Placental pathology from 168 AMA women 35 years or older at delivery was reviewed. The cases were subdivided into 2 age subgroups, ages 35 to 39 and 40 or older, as well as a "pure AMA" subgroup where the only indication for placental examination was AMA. A group of 60 consecutive non-AMA placentas was also identified and used as comparison. The spectrum of histologic features in each case was catalogued.

RESULTS.—

Of the overall AMA cases, meconium deposition was seen in 55% (93 of 168), chorangiosis in 40% (68 of 168), and acute chorioamnionitis in 36% (60 of 168). Fetal vascular malperfusion was also seen with high frequency (30%; 50 of 168). Two histologic alterations found to be significantly different between the 35 to 39 and greater than 40 age subgroups were fetal vascular malperfusion (11% [7 of 65] versus 42% [43 of 103]; P = .001) and delayed villous maturation (1.5% [1 of 65] versus 13% [13 of 103]; P = .02). The pure AMA subgroup showed no statistically significant differences compared with the overall AMA group. Chronic deciduitis was the only statistically significant difference between the overall AMA group and the non-AMA comparison group (14% [23 of 168] versus 30% [18 of 60]; P = .02).

CONCLUSIONS.—

Our findings, particularly the high frequency of fetal vascular malperfusion, suggest that AMA should be an independent indication for placental pathologic examination.

Effect of embryo stage at transfer on placental histopathology features in singleton live births resulting from fresh embryo transfers

OBJECTIVE

To evaluate the effect of embryo stage at transfer on placental histopathology and perinatal outcome in singleton live births resulting from fresh embryo transfers (ETs).

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

The study population included all live births after fresh ETs during the period from 2009 to 2017.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Primary outcomes included anatomic, inflammatory, vascular malperfusion, and villous maturation placental features. Secondary outcomes included fetal, maternal, and perinatal complications.

RESULT(S)

A total of 677 live births were included in the final analysis and were allocated to the cleavage-stage (n = 252) and blastocyst (n = 425) ET groups. After the adjustment for confounding factors, the blastocyst group was found to be associated with a higher incidence of circummarginate membranes insertion (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.2-3.4), delayed villous maturation (OR 8.5, 95% CI 1.2-69.3), chorangiosis (OR 2.0, 95% CI 1.2-3.8), parenchymal calcifications (OR 10.6, 95% CI 1.4-80.2), and intrapartum nonreassuring fetal heart rate tracing (OR 2.4, 95% CI 1.3-4.5). Compared with cleavage-stage ETs, live births resulting from the blastocysts were associated with a lower incidence of velamentous cord insertion (OR 0.5, 95% CI 0.3-0.9), retroplacental hematoma (OR 0.3, 95% CI 0.1-0.8), subchorionic thrombi (OR 0.3, 95% CI 0.1-0.8), and avascular villi (OR 0.2, 95% CI 0.03-0.7).

CONCLUSION(S)

Live births resulting from fresh cleavage-stage and blastocyst ETs have different placental histopathology features, with a higher rate of intrapartum nonreassuring fetal heart rate tracing in the blastocyst group.

The effect of mother's β-thalassemia minor on placental histology and neonatal outcomes

Objective: β-thalassemia is a prevalent disease in Iran. The adverse effects of anemia on placental and neonatal outcomes have previously been shown. Women require additional iron during pregnancy and the anemia of women with β-thalassemia may adversely affect the neonatal outcome and increase placental abnormalities. In this study, we compared the placental histology and neonatal outcomes among pregnant women with and without β-thalassemia.Material and methods: In this population-based cross-sectional study, 144 pregnant women with β-thalassemia minor (case group) were compared to 142 women without β-thalassemia (control group). Women with singleton pregnancies over 20 weeks of gestation without pregnancy complications, anemia, collagen vascular diseases, or other hemoglobinopathies, all referred to hospitals affiliated to Shiraz University of Medical Sciences from March 2014 to February 2016, were included and maternal and neonatal data were extracted from medical records. After child birth, the placenta was evaluated for macroscopic and microscopic changes.Results: The frequency of LBW was significantly higher in the case group than that in the control group (19.7 vs. 9.7%, respectively) (p = .019). Six in the case group had gross abnormalities of placenta, while none in the control group (p = .03) and the case group had a higher frequency of chorangiosis, calcification, syncytial knot, and umbilical cord position (p < .05).Conclusion: As β-thalassemia increases the chance of placental abnormalities, it is recommended to pay more attention to patients with β-thalassemia, especially during pregnancy, to prevent placental and neonatal adverse outcomes.

The influence of gestational diabetes mellitus (GDM) and gestational hypertension (GH) on placental morphological changes

Gestational diabetes mellitus (GDM) and gestational hypertension (GH) are some of the most common medical conditions associated with pregnancy. These can be correlated with placental morphopathological changes and implicitly can influence good fetal development. The age and weight of the mother can be correlated directly proportionally with those of the fetus but also with histoarchitecture and placental vascularization. The placental appearance associated with GDM and GH reveals macroscopic features, such as calcifications, fibrin deposits and placental infarcts, but the most relevant pathological features are the microscopic ones, highlighted by the classical staining techniques: Hematoxylin-Eosin (HE), Periodic Acid-Schiff (PAS)-Hematoxylin and Masson's trichrome (MT), but also by immunohistochemical technique with the help of the anti-cluster of differentiation 34 (CD34) antibody that labeled the capital endothelium in the structure of the placental terminal villi and thus we were able to quantify the vascular density according to the associated medical pathology. The microscopic changes identified were represented by intravillous and extravillous fibrin depositions, massive placental infarctions caused by vascular suppression due to various causes, such as thrombosis, but also placental calcifications. All these macroscopic and microscopic morphopathological changes, together with the clinical data of the mother and the newborn, we have demonstrated that they are interconnected and that they can vary depending on the pathology, GH or GDM.

Distinctive patterns of placental lesions in pre-eclampsia vs small-for-gestational age and their association with fetoplacental Doppler

OBJECTIVES

To describe placental histopathological findings in a large cohort of pregnancies complicated by pre-eclampsia (PE) and/or small-for-gestational age (SGA), and to investigate their association with fetoplacental Doppler parameters.

METHODS

This was a prospective observational study of normotensive pregnancies with SGA (defined as birth weight < 10^th centile) (n = 184), PE pregnancies with a normally grown fetus (n = 102), pregnancies with both PE and SGA (n = 120) and uncomplicated pregnancies (n = 202). Uterine (UtA), umbilical (UA) and fetal middle cerebral (MCA) artery pulsatility indices (PI) were assessed. The cerebroplacental ratio (CPR) was calculated by dividing MCA-PI by UA-PI. Doppler parameters were considered abnormal when UtA-PI or UA-PI was > 95^th centile or MCA-PI or CPR was < 5^th centile. Placental lesions were categorized as vascular (maternal or fetal side), immunoinflammatory or other, according to the 2014 Amsterdam Placental Workshop Group Consensus Statement. Comparison between the study groups was performed using univariate and multiple regression analysis, and logistic regression was used to determine the relationship between abnormal Doppler parameters and placental lesions.

RESULTS

Maternal-side vascular lesions were significantly more common in PE pregnancies with SGA than in the other groups (PE + SGA, 73% vs PE, 46% vs SGA, 38% vs controls, 31%; P = 0.01) and included mainly two types of lesion: developmental (PE + SGA, 13% vs PE, 5% vs SGA, 3% vs controls, 1.5%; P < 0.001) and malperfusion (PE + SGA, 70% vs PE, 39% vs SGA, 32% vs controls, 25%; P = 0.001). In contrast, the incidence of fetal-side developmental lesions was significantly higher in normotensive SGA pregnancies than in controls and PE pregnancies (PE + SGA, 0% vs PE, 3% vs SGA, 8% vs controls, 2%; P = 0.001). All cases displayed a lower prevalence of infectious lesions than did controls, with the highest prevalence of immune lesions observed in pregnancies with both PE and SGA (PE + SGA, 18% vs PE, 8% vs SGA, 10% vs controls, 9%; P = 0.001). All fetoplacental Doppler parameters evaluated were associated with maternal-side vascular lesions, mainly malperfusion (mean UtA-PI: odds ratio (OR), 2.45 (95% CI, 1.51-3.97); UA-PI: OR, 2.05 (95% CI, 1.02-4.47); MCA-PI: OR, 2.75 (95% CI, 1.40-5.42); CPR: OR, 1.75 (95% CI, 1.04-2.95)). This association was evident mainly in the normotensive SGA group, being non-significant in controls or PE pregnancies without SGA. No significant associations were observed between fetoplacental Doppler parameters and other placental lesions in any of the study groups.

CONCLUSIONS

PE and SGA are associated with different patterns of placental histopathological lesions in accordance with the clinical manifestation of the placental disorder (maternal vs fetal). Fetoplacental Doppler findings show an association with placental malperfusion lesions on the maternal side, supporting the use of abnormal Doppler as a surrogate for placental insufficiency. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Focal Chorangiosis: Does It Have Clinical and Pathologic Significance?

INTRODUCTION

Chorangiosis is a proliferation of capillaries in terminal chorionic villi and is considered to be a marker for hypoxia and poor clinical outcome. Not all cases with hypervascular villi meet the generally accepted diagnostic criteria as reported by Altshuler. Our aim was to evaluate cases with villous hypervascularity that do not meet the diagnosis of chorangiosis, in which increased vascularity was present in a significant portion of the villous tissue but was not a diffuse process, which we call focal chorangiosis, to ascertain whether there were clinical or pathologic associations.

MATERIALS AND METHODS

A total of 175 placentas with the finding of focal chorangiosis and 176 maternal age- and gestational age-matched controls were evaluated retrospectively. We defined focal chorangiosis as villous hypervascularity that did not meet criteria for a diagnosis of chorangiosis, but in which there was involvement of at least 50% of villi on at least 2 of 3 slides of placental tissue or involvement of all the villi on 1 slide. In these focal areas, the criteria of 10 capillaries in each of 10 villi in ten 10× microscopic fields were required.

RESULTS

We found that focal chorangiosis is associated with a decrease in Apgar scores, increased placental weight, fetal vascular thrombosis (fetal vascular malperfusion), umbilical cord abnormalities, increased fetal nucleated red blood cells, villous dysmaturity, and increased rate of vaginal delivery.

DISCUSSION

Many of these associations are shared with chorangiosis as traditionally defined, suggesting that focal chorangiosis is a significant finding that should be reported.

Histological Features of Shallow Placental Implantation Unify Early-Onset and Late-Onset Preeclampsia

Preeclampsia is distinguishable from other hypertensive conditions of pregnancy by its high rates of decidual arteriopathy, the uterine type of chronic hypoxic placental injury, the occurrence of villous infarctions, and clusters of multinucleate trophoblasts in the maternal floor. To retrospectively study the clinical and placental phenotypes of 230 women with early-onset preeclampsia, 261 women with late-onset preeclampsia, and 5059 women without hypertension in pregnancy (comparative group), 24 clinical and 46 placental phenotypes were statistically compared (analysis of variance, χ² with Bonferroni correction). The frequency of decidual arteriopathy (both hypertrophic and atherosis), patterns of chronic hypoxic placental injury, villous infarction, membrane laminar necrosis, membrane microscopic chorionic pseudocysts, clusters of maternal floor multinucleated trophoblasts, excessive number of extravillous trophoblasts, and intervillous thrombi was strikingly higher in both late-onset preeclampsia and early-onset preeclampsia than in the comparative group without hypertension in pregnancy. All 3 patterns of chronic hypoxic placental injury were 2- to 3-fold more common in preeclampsia. Although the preuterine pattern was as common in early-onset preeclampsia as it was in late-onset preeclampsia, the postuterine pattern was 2-fold more common in early-onset preeclampsia, and chronic villitis of unknown etiology was more common in late-onset preeclampsia than in the other 2 groups. Features of shallow placental implantation occurred at the same frequency in early-onset preeclampsia as in late-onset preeclampsia, which reflects an underlying common pathological mechanism in both subgroups of preeclampsia, while hypoxic lesions and patterns of placental injury were more common in early-onset preeclampsia than in late-onset preeclampsia, which correlates with more severe clinical outcomes of the former.

Chorangiosis placenta with 5-vessel umbilical cord with omphalomesenteric duct remnant: An unusual association

Placenta is an organ that is responsible for nourishing and protecting the fetus during pregnancy. Histologic examination of the placenta can yield significant information about pre-uterine and uterine conditions affecting fetal growth. Chorangiosis is defined as the presence of ≥10 terminal villi, each containing ≥10 capillaries per terminal villus in ≥10 low power (×10) fields in at least 3 or more random, non-infarcted cotyledons of the placenta. Chorangiosis is an adaptive response to in-utero hypoxia and its presence signifies better pregnancy outcomes. Abnormalities that lead to multiple cord vessels are rare with the majority of reported cases highlighting four vessels due to a persistent right umbilical vein. We report here a case of chorangiosis of placenta associated with a rare 5-vessel umbilical cord and omphalomesenteric duct remnant. To the best of our knowledge, this is the first case report to document such an association.

Histological Analysis of Term Placentas from Hyperimmune Globulin-Treated and Untreated Mothers with Primary Cytomegalovirus Infection

BACKGROUND

The Congenital Human Cytomegalovirus Infection Prevention (CHIP) study, a randomized, blinded, placebo-controlled trial, demonstrated that the efficacy of hyperimmune globulin (HIG) was not different from that of placebo regarding transmission of cytomegalovirus (CMV) from mothers to newborns. Our aim was to analyze histologically HIG effects on placentas collected for the CHIP study.

MATERIALS AND METHODS

Virological and histological analyses were performed on 40 placentas from transmitter and nontransmitter HIG-treated and untreated mothers by assessing the number of CMV-positive cells, tissue viral load, tissue damage, and compensatory mechanisms.

RESULTS

The HIG and placebo groups showed no significant differences in the number of CMV-positive cells (median number in 10 fields at 10 high-power fields: 2.5 vs. 2, p = 0.969) and viral load (median load: 5 copies/5 ng vs. 10.5 copies/5 ng, p = 0.874). Regarding histological examination, the scores of parameters related to tissue damage and hypoxic parenchymal compensation were higher in transmitters except for chorangiosis, with statistically significant differences observed for chronic villitis (p = 0.007), calcification (p = 0.011), and the total score of tissue damage (p < 0.001). The HIG and placebo groups showed no significant differences for all tissue damage and compensation parameters and overall scores.

DISCUSSION

HIGs are not able to reduce placental viral load and histological damage, which was significantly associated only with infection.

Oxidative stress in placental pathology

The most important function of the placenta is the exchange of nutrients and oxygen between a mother and her fetus. To establish a healthy functioning placenta, placentation needs to occur with adequate remodelling of spiral arteries by extravillous trophoblasts. When this process is impaired, the resulting suboptimal and inadequate placenta function results in the manifestation of pregnancy complications. Impaired placenta function can cause preeclampsia and leads to fetal growth restriction due to hypoxia. Presence of hypoxia leads to oxidative stress due to an imbalance between reactive oxygen species and antioxidants, thereby causing damage to proteins, lipids and DNA. In the placenta, signs of morphological adaptation in response to hypoxia can be found. Different placental lesions like maternal or fetal vascular malperfusion or chronic villitis lead to a decreased exchange of oxygen between the mother and the fetus. Clinically, several biomarkers indicative for oxidative stress, e.g. malondialdehyde and reduced levels of free thiols are found. This review aims to give an overview of the causes and (potential) role of placental oxidative stress in the development of placental parenchymal pathology and its clinical consequences. Also, therapeutic options aiming at prevention or treatment of hypoxia of the placenta and fetus are described.

The placental component and neonatal outcome in singleton vs. twin pregnancies complicated by gestational diabetes mellitus

OBJECTIVE

We aimed to compare placental histopathological lesions and neonatal outcome in singleton vs. twin pregnancies complicated by gestational diabetes mellitus (GDM).

METHODS

Maternal characteristics, neonatal outcomes, and placental histopathology reports of pregnancies complicated by GDM, between 1/2008-10/2016, were reviewed. Results were compared between singletons (singleton group) and dichorionic-diamniotic twins (twin group). Placental lesions were classified as placental weight abnormalities, maternal and fetal vascular malperfusion lesions (MVM, FVM), inflammatory lesions, and lesions associated with chronic villitis. LGA was defined as birth-weight ≥90th percentile. Composite adverse neonatal outcome was defined as one or more early neonatal complications.

RESULTS

Compared with the twin group (n = 57), the singleton group (n = 228) was characterized by higher gestational-age (38.6 ± 0.9 vs. 35.1 ± 1.8 weeks, p < 0.001) and a higher rate of insulin treatment (32.9% vs. 17.5%, p = 0.023). Placentas from the singleton group were characterized by higher rates of MVM lesions (54.4% vs. 30.7%, p < 0.001), villitis of unknown etiology (VUE, 5.7% vs. 0.9%, p = 0.040), villous immaturity (10.1% vs. 0.9%, p = 0.001), and placental weight <10th percentile (16.7% vs. 8.8%, respectively, p = 0.049). Using multivariable regression analysis, MVM (aOR = 2.2, 95% CI = 1.6-4.1), VUE (aOR = 1.2, 95% CI = 1.1-2.1), villous immaturity (aOR = 2.3, 95% CI 1.8-7.6), and placental weight <10th percentile (aOR = 1.1, 95% CI = 1.02-1.6), were the only lesions associated with singleton pregnancies. Composite adverse neonatal outcome was more common in the twin group (54.3% vs. 14.0%, p < 0.001) and it was associated only with lower GA (aOR = 3.7, 95% CI 2.1-7.3).

CONCLUSION

Higher rate of placental weight <10th percentile, MVM lesions, villous immaturity, and VUE characterize GDM singleton pregnancy as compared to twins GDM gestation, suggesting different placental alterations in the diabetic environment.

Decidual arteriolopathy with or without associated hypertension modifies the underlying histomorphology in placentas from diabetic mothers

AIM

The aim of this study was to retrospectively document the impact of hypertensive conditions in pregnancy and decidual arteriolopathy on the patterns of placental injury in maternal diabetes mellitus (MDM).

METHODS

Among all 5248 > 20 weeks' placentas, the frequencies of 19 selected clinical and 24 placental phenotypes were compared between 287 MDM placentas and 4961 remaining placentas (control group [CG]) before and after further exclusion of 85 and 611 patients with hypertensive conditions (gestational hypertension, pre-eclampsia, chronic hypertension).

RESULTS

Cesarean section rate, heavy placentas, decidual arteriolopathy, microscopic chorionic pseudocysts, and chorangiosis were more common in MDM than in the CG both before and after exclusion of hypertensive conditions. The frequencies of preuterine patterns of chronic hypoxic placental injury and plasma cell deciduitis became statistically significant only after exclusion of hypertensive conditions.

CONCLUSION

Hypertensive conditions of pregnancy may obscure the underlying preuterine placental hypoxic pattern in MDM placentas. Even in normotensive patients, decidual arteriolopathy, and shallow placental implantation significantly impact placental histomorphology in MDM.