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Utility of perinatal pathology for the obstetrician and neonatologist
Drucilla J. Roberts, MD [email protected]
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Disclosures
• I have the following disclosure: – Author for UpToDate
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Utility of perinatal pathology
• Explains a “bad” outcome • Determine cause of death • Predicts recurrence • Provides risk assessment for immediate
and eventual outcome • Nearly always helpful in defense of medical
malpractice claims
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Case
• 28 y/o G1P0 with obesity presents at term with LGA fetus and delivers with shoulder dystocia. APGARS 2,4,7.
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Placenta
• 850g, >99th percentile • Slightly immature villi • Chorangiosis • Multiple intervillous thrombi
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Longstanding descriptions of placentas associated with DM
• Heavy placentas • Villous immaturity • Chorangiosis • Villous fibrinoid necrosis • Decreased intervillous space • Syncytiotrophoblastic necrosis • Cytotrophoblastic hyperplasia • Thickening of the villous trophoblastic basement
membrane All might be modulated by the timing of the glucose intolerance, quality of the glucose control, and the complication of hypertension.
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Hypothesis
• GDM results in increased trophoblastic apoptosis which results in placental pathology
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Longstanding descriptions of GDM exposed placentas
• Heavy placentas • Villous immaturity • Chorangiosis • Villous fibrinoid necrosis • Decreased intervillous space • Syncytiotrophoblastic necrosis • Cytotrophoblastic hyperplasia • Thickening of the villous trophoblastic basement
membrane All might be modulated by the timing of the glucose intolerance, quality of the glucose control, and the complication of hypertension.
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Non-diabetic GDM0.0
2.5
5.0
7.5
10.0
12.5 *
TUN
EL
Pos
itive
cel
ls, %
of t
otal
Trophoblast from Human Placentas
Unpublished data
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Another example of trophoblastic necrosis/apoptosis
Intervillous Thrombi
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Intervillous thrombi
• Relatively common findings (~5% of all placentas) – Laminated fibrin and red blood cells in intervillous
space – Limited “collateral damage” of surrounding villi
• Thought to be due to fetal hemorrhage into the maternal space and maternal “clotting” of the hemorrhage (controversial) – Presence of HgbF
• Associated with male gender**Becroft DM, Thompson JM, Mitchell EA. Placental infarcts, intervillous fibrin plaques, and intervillous thrombi: incidences, co-occurrences, and epidemiological associations Pediatr Dev Pathol. 2004 Jan-Feb;7(1):26-34. .
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Study design • Database of well characterized DM in pregnancy
with placental pathology available. • 206 cases of DM including:
– T1DM: 39 – T2DM: 37 – GDM: 130
• Histology and pathology reports reviewed • GA matched controls from cohort of placentas
examined ONLY for indication of GBS carrier – Euglycemia confirmed by EMR review
• Collected cases of IVT
Work done with K. Basnet
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IVT are significantly increased in GDM
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Source of IVT
• Subset of IVTs from DM (9) and controls (5) were sent to Nationwide Children’s Hospital in Columbus, Ohio for HgbF IHC
• All controls and 6 of 9 cases showed at least focal +IHC for HgbF in the thrombi
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Placentas in DM
• Pathological diagnosis should suggest findings consistent with maternal glucose intolerance, for example: – Heavy immature or slightly immature placenta – Chorangiosis – Intervillous thrombi – Increased villous fibrinoid necrosis
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Example
• 41 y/o G4P0-1 with FVL homozygosity and h/o DVT/PE
• 39 week spontaneous labor with sudden fetal bradycardia
• STAT c/s APGARS 0,0,0
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Dilatation of chorionic plate vessels
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Vascular thrombosis
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Fetal Vascular Malperfusion
• Etiology – Obstruction: cord knots, membranous vessels – Slow flow: heart failure, high red cell mass – Coagulopathy: sepsis, inherited*, malignancy – Vascular injury: inflammation, meconium,
pressure necrosis
* Second “hit” usually required
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Cord obstruction
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Case
• 36 week infant to a 16 y/o primigravida • NSVD • APGARS 8,9 • Goes home but returns on DOL 4 with
seizures
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CMV
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CMV PLACENTITIS histopathologic findings
• Lymphoplasmacytic villitis• Sclerosis of the villous capillaries• Chorionic vessel thromboses• Necrotizing villitis• Hemosiderin deposition in the villous stroma• Normoblastemia• Viral inclusions observed in 10% of cases
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CMV with IUFD
• Rare • High viral load • Consider evaluation for HIV
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Case
• 38 week with NRFHT and maternal fever • C/S delivery • APGARS 2,3,5 • Cord pH 6.97 base deficit 13 • Hypoxic-ischemic encephalopathy • NICU admission for cooling
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Chorioamnionitis Placental Pathology
• Acute chorioamnionitis: – Maternal and fetal stage (anatomic location) and
grade (intensity) – Mycoplasma, E. Coli, GBS, GAS, Fusobacteria,
Candida – Non-infectious
• Acute villitis: Listeria, GBS, E.coli • Intervillositis: malaria
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Chorioamnionitis• Clinical chorioamnionitis defined by
maternal fever • Histologic chorioamnionitis not always
correlated with maternal symptoms – Common in preterm deliveries – Preterm chorioamnionitis usually infectious. – Term chorioamnionitis can be non-infectious – Fetal response predictive of neurological
outcome
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Importance of fetal side inflammation in acute chorioamnionitis
• Higher association with neonatal morbidity – Sepsis – Pneumonia – RDS/BPD – Necrotizing enterocolitis – Intraventricular hemorrhage – ?Stroke and HIE
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Hypoxic Ischemic Encephalopathy
• Fetal inflammatory response • Fetal vascular malperfusion • Acute insult findings:
– Acute villous edema – Meconium
• Maternal vascular malperfusion
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Preterm pre-eclampsia with severe features – maternal vascular malperfusion
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Chronic Abruption
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Why are the placental findings of maternal vascular malperfusion important?
• Confers a risk for the development of neurocompromise – Especially preterm PET – Especially with decidual arteriopathy and
atherosis
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Placenta critical
• Essential part of any perinatal autopsy • Should be performed even if no autopsy
consent granted. • All placentas from NICU admissions should
be examined • Any unexpected (or expected) “bad”
outcomes should have the placenta examined • Any abnormal placenta at delivery should be
examined
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Placenta “recruitment”
• Different strategies for placenta submission for pathologic exam – Obstetric indications – Pediatric indications – Maternal indications – Litigious indications – “funny looking placenta”
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Communication
• If something does not make sense • Findings of immediate clinical utility
– Specific infection – Malignancy – Storage disorders
• Findings worrisome for neurocompromise
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In conclusion• Placental pathology is an essential part of the perinatal
autopsy and can be helpful when autopsy consent is declined
• Placental pathology can help in the treatment of the newborn and in predicting neurological outcome of the infant
• Pathologists are an important part of the OB/GYN and Pediatric team.
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Case
• 35 week delivery • C/S delivery for IUGR at <3rd %ile • Mild hydrops fetalis • NICU admission for respiratory
complications
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Inborn errors of metabolism
• Most “storage” diseases could be diagnosed at birth by placental pathology
• Early diagnosis = early treatment • Family counselling