Placental Tissue Destruction and Insufficiency from COVID-19 Causes Stillbirth and Neonatal Death from Hypoxic-Ischemic Injury: A Study of 68 Cases with SARS-CoV-2 Placentitis from 12 Countries

CONTEXT.—

Perinatal death is an increasingly important problem as the COVID-19 pandemic continues, but the mechanism of death has been unclear.

OBJECTIVE.—

To evaluate the role of the placenta in causing stillbirth and neonatal death following maternal infection with COVID-19 and confirmed placental positivity for SARS-CoV-2.

DESIGN.—

Case-based retrospective clinico-pathological analysis by a multinational group of 44 perinatal specialists from 12 countries of placental and autopsy pathology findings from 64 stillborns and 4 neonatal deaths having placentas testing positive for SARS-CoV-2 following delivery to mothers with COVID-19.

RESULTS.—

All 68 placentas had increased fibrin deposition and villous trophoblast necrosis and 66 had chronic histiocytic intervillositis, the three findings constituting SARS-CoV-2 placentitis. Sixty-three placentas had massive perivillous fibrin deposition. Severe destructive placental disease from SARS-CoV-2 placentitis averaged 77.7% tissue involvement. Other findings included multiple intervillous thrombi (37%; 25/68) and chronic villitis (32%; 22/68). The majority (19, 63%) of the 30 autopsies revealed no significant fetal abnormalities except for intrauterine hypoxia and asphyxia. Among all 68 cases, SARS-CoV-2 was detected from a body specimen in 16 of 28 cases tested, most frequently from nasopharyngeal swabs. Four autopsied stillborns had SARS-CoV-2 identified in internal organs.

CONCLUSIONS.—

The pathology abnormalities composing SARS-CoV-2 placentitis cause widespread and severe placental destruction resulting in placental malperfusion and insufficiency. In these cases, intrauterine and perinatal death likely results directly from placental insufficiency and fetal hypoxic-ischemic injury. There was no evidence that SARS-CoV-2 involvement of the fetus had a role in causing these deaths.

Fetal deaths in Ireland due to SARS-CoV-2 placentitis caused by SARS-CoV-2 Alpha

CONTEXT

- A severe third wave of COVID-19 disease affected Ireland in the first 3 months of 2021. In this wave, 1 second trimester miscarriage and 6 stillbirths were observed in the Irish population due to placental insufficiency as a result of SARS-CoV-2 placentitis. This observation was at odds with the country's previous experience with COVID-19 disease in pregnant mothers.

OBJECTIVE

- To describe the clinical and pathological features of these pregnancy losses.

DESIGN

- Retrospective review of clinical and pathological data of cases of second trimester miscarriage, stillbirth or neonatal death identified by perinatal pathologists as being due to SARS-CoV-2 placentitis during the third wave of COVID-19 in Ireland.

RESULTS

- Clinical and pathological data was available for review in 6 pregnancies. Sequencing or genotyping of the virus identified SARS-CoV-2 Alpha (B.1.1.7) in all cases. Three of the 6 cases had maternal thrombocytopenia, while fetal growth restriction was not prominent suggesting a rapidly progressive placental disease.

CONCLUSIONS

- The identification of SARS-CoV-2 Alpha in all these cases suggests that the emergence of the variant was associated with an increased risk of fetal death due to SARSCoV-2 placentitis when compared to the original virus. Maternal thrombocytopenia, may have potential as a clinical marker of placentitis but other inflammatory markers need investigation. Three of the 6 women had been assessed for reduced fetal movements in hospital some days before the fetal deaths actually occurred; this could suggest that there may be a window for intervention in some cases.

Vertical Transmission of Trypanosoma Cruzi in a Non-Endemic Country: Histology of the Infected Placenta

Chagas disease, once confined to rural Latin America is an increasing public health concern in non-endemic countries due to population movements. Here we present an unexpected finding of a placenta infected with T. cruzi from a Brazilian woman residing in Ireland. Histology of the placenta showed a lymphocytic chorioamnionitis with multinucleated giant cells (MNGCs) as well as cord vasculitis and funisitis. Amastigotes of trypanosomiasis were found in both cord and membranes. The placenta parenchyma, however, had no villitis or amastigotes and maturation was appropriate for gestation. To date, there have been few reported cases of vertical transmission in non-endemic countries. We discuss the histological findings and review the literature on potential modes of transmission from mother to fetus.