Significant association between circumvallate placenta, placental abruption and acute chorioamnionitis in preterm birth: A 23-year retrospective cohort study

AIM

circumvallate placenta, placental abruption and acute chorioamnionitis separately are associated with unfavourable clinical outcomes. We aimed to determine the prevalence and define whether an association exists between the three abnormalities.

METHODS

16,042 placenta pathology reports between 1997 and 2020 from a tertiary care centre in the Netherlands were retrospectively analysed. For the statistical analysis, the chi-square test and bootstrapping were used to evaluate an association.

RESULTS

In our cohort the prevalence of circumvallate placenta is 2.2 %, placental abruption cases 4.0 % and acute chorioamnionitis 20.6 %. We observed a statistically significant association between all three placental abnormalities: circumvallate placenta, placental abruption and acute chorioamnionitis. In addition, there was also an association between circumvallate placenta and acute chorioamnionitis.

CONCLUSION

Our results show that combined presence of circumvallate placenta, placental abruption and acute chorioamnionitis are associated in preterm birth (p = 0.001). A remarkable finding is that the combination of all three abnormalities (circumvallate placenta, placental abruption and acute chorioamnionitis) was not observed in term pregnancies >37 weeks.

Predictors of singleton preterm birth using multinomial regression models accounting for missing data: A birth registry-based cohort study in northern Tanzania

BACKGROUND

Preterm birth is a significant contributor of under-five and newborn deaths globally. Recent estimates indicated that, Tanzania ranks the tenth country with the highest preterm birth rates in the world, and shares 2.2% of the global proportion of all preterm births. Previous studies applied binary regression models to determine predictors of preterm birth by collapsing gestational age at birth to <37 weeks. For targeted interventions, this study aimed to determine predictors of preterm birth using multinomial regression models accounting for missing data.

METHODS

We carried out a secondary analysis of cohort data from the KCMC zonal referral hospital Medical Birth Registry for 44,117 women who gave birth to singletons between 2000-2015. KCMC is located in the Moshi Municipality, Kilimanjaro region, northern Tanzania. Data analysis was performed using Stata version 15.1. Assuming a nonmonotone pattern of missingness, data were imputed using a fully conditional specification (FCS) technique under the missing at random (MAR) assumption. Multinomial regression models with robust standard errors were used to determine predictors of moderately to late ([32,37) weeks of gestation) and very/extreme (<32 weeks of gestation) preterm birth.

RESULTS

The overall proportion of preterm births among singleton births was 11.7%. The trends of preterm birth were significantly rising between the years 2000-2015 by 22.2% (95%CI 12.2%, 32.1%, p<0.001) for moderately to late preterm and 4.6% (95%CI 2.2%, 7.0%, p = 0.001) for very/extremely preterm birth category. After imputation of missing values, higher odds of moderately to late preterm delivery were among adolescent mothers (OR = 1.23, 95%CI 1.09, 1.39), with primary education level (OR = 1.28, 95%CI 1.18, 1.39), referred for delivery (OR = 1.19, 95%CI 1.09, 1.29), with pre-eclampsia/eclampsia (OR = 1.77, 95%CI 1.54, 2.02), inadequate (<4) antenatal care (ANC) visits (OR = 2.55, 95%CI 2.37, 2.74), PROM (OR = 1.80, 95%CI 1.50, 2.17), abruption placenta (OR = 2.05, 95%CI 1.32, 3.18), placenta previa (OR = 4.35, 95%CI 2.58, 7.33), delivery through CS (OR = 1.16, 95%CI 1.08, 1.25), delivered LBW baby (OR = 8.08, 95%CI 7.46, 8.76), experienced perinatal death (OR = 2.09, 95%CI 1.83, 2.40), and delivered male children (OR = 1.11, 95%CI 1.04, 1.20). Maternal age, education level, abruption placenta, and CS delivery showed no statistically significant association with very/extremely preterm birth. The effect of (<4) ANC visits, placenta previa, LBW, and perinatal death were more pronounced on the very/extremely preterm compared to the moderately to late preterm birth. Notably, extremely higher odds of very/extreme preterm birth were among the LBW babies (OR = 38.34, 95%CI 31.87, 46.11).

CONCLUSIONS

The trends of preterm birth have increased over time in northern Tanzania. Policy decisions should intensify efforts to improve maternal and child care throughout the course of pregnancy and childbirth towards preterm birth prevention. For a positive pregnancy outcome, interventions to increase uptake and quality of ANC services should also be strengthened in Tanzania at all levels of care, where several interventions can easily be delivered to pregnant women, especially those at high-risk of experiencing adverse pregnancy outcomes.

The endothelial protein C receptor plays an essential role in the maintenance of pregnancy

Placenta-mediated pregnancy complications are a major challenge in the management of maternal-fetal health. Maternal thrombophilia is a suspected risk factor, but the role of thrombotic processes in these complications has remained unclear. Endothelial protein C receptor (EPCR) is an anticoagulant protein highly expressed in the placenta. EPCR autoantibodies and gene variants are associated with poor pregnancy outcomes. In mice, fetal EPCR deficiency results in placental failure and in utero death. We show that inhibition of molecules involved in thrombin generation or in the activation of maternal platelets allows placental development and embryonic survival. Nonetheless, placentae exhibit venous thrombosis in uteroplacental circulation associated with neonatal death. In contrast, maternal EPCR deficiency results in clinical and histological features of placental abruption and is ameliorated with concomitant Par4 deficiency. Our findings unveil a causal link between maternal thrombophilia, uterine hemorrhage, and placental abruption and identify Par4 as a potential target of therapeutic intervention.

SARS-CoV-2 infection of the placenta

BACKGROUNDThe effects of the novel coronavirus disease 2019 (COVID-19) in pregnancy remain relatively unknown. We present a case of second trimester pregnancy with symptomatic COVID-19 complicated by severe preeclampsia and placental abruption.METHODSWe analyzed the placenta for the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through molecular and immunohistochemical assays and by and electron microscopy and measured the maternal antibody response in the blood to this infection.RESULTSSARS-CoV-2 localized predominantly to syncytiotrophoblast cells at the materno-fetal interface of the placenta. Histological examination of the placenta revealed a dense macrophage infiltrate, but no evidence for the vasculopathy typically associated with preeclampsia.CONCLUSIONThis case demonstrates SARS-CoV-2 invasion of the placenta, highlighting the potential for severe morbidity among pregnant women with COVID-19.FUNDINGBeatrice Kleinberg Neuwirth Fund and Fast Grant Emergent Ventures funding from the Mercatus Center at George Mason University. The funding bodies did not have roles in the design of the study or data collection, analysis, and interpretation and played no role in writing the manuscript.

Effect of homocysteine on pregnancy: A systematic review

Research purpose was to put together the available pieces of present scientific data and to close the gap in the knowledge of Hcy levels in pregnancy and its association with some pregnancy complications. Scientific data were taken from research papers published between January 1990 and December 2017, and found on the Internet (PubMed, ClinicalKey and Embase databases) by the following tags entered in English, Russian, French and German languages: pregnancy, homocysteine, pregnancy complications, pregnancy loss, preeclampsia, intrauterine growth restriction, and placental abruption. The review showed that Hcy levels range in uncomplicated pregnancy. Upon that, Hcy level tends to decrease during the second and third trimesters. Some studies have revealed a link between polymorphism and abortion. Sufficient data were obtained indicating the relationship between HHcy and PE. Placental abruption was also associated with high Hcy levels increasing the risk 5.3-fold, but still there are data not supporting the hypothesis that Hcy levels correlate with placental abruption.

Placental abruption: etiopathogenic aspects, diagnostic and therapeutic implications

The severe form of retroplacental hematoma is a serious accident in the second stage of pregnancy and at birth with frightening for the mother and fetus that often lead to death. The pathological mechanism presumes conditions for a "special ground" capital for the "efficiency" of the acute intradecidual vascular accident with the rupture of the uterus-placental arterioles. The complete clinical picture of this severe form of retroplacental hematoma - the placental abruption, observed and mentioned by the classics (vascular drama of Couvelaire) consists of five syndromes, 18 signs and symptoms, four paradoxes, phenomena not fully met in the other forms of retroplacental hematoma (minor and intermediate). The rate of incidence of retroplacental hematoma is in between 0.13-1.38% and depends on the environment, on the socio-economic and medical conditions, on the "obstetric education" and associated pathology. Our study aims at re-evaluating the clinico-paraclinical phenomenon imposed by the dramatism of the phenomenon of in utero placental apoplexy, the impact on neonatal mortality and on the functional prognosis from the point of view of surgical climax.

MRI findings of chronic abruption-oligohydramnios sequence (CAOS): report of three cases

Chronic abruption-oligohydramnios sequence (CAOS), characterized by chronic vaginal hemorrhage and oligohydramnios, is a rare clinical condition of pregnancy. Because CAOS is associated with preterm delivery and lung injury to the infant, it is a major clinical concern. This report describes three CAOS cases which presented characteristic MRI findings reflecting CAOS pathological mechanisms and pathological findings. First, in all cases, the placenta detached from the uterus at the peripheral portion of the placenta because of placental marginal hematoma. Because the cause of CAOS is presumed to be chronic peripheral separation of the placenta developing from bleeding from the peripheral vein of the placenta, the MRI finding corresponds to the CAOS pathophysiology. Second, the placental marginal hematoma spread extensively along the decidua. This MRI finding can explain the vaginal hemorrhage of CAOS patients. Finally, the amniotic fluid of all patients showed high signal intensity on T1-weighted images, suggesting that amniotic fluid contains blood-derived products. In CAOS patients, chronic venous bleeding engenders the release of blood-derived products into the amniotic cavity. The aspiration of these products might be a cause of lung injury to the fetus. We presented these MRI findings with radiologic-pathologic correlation.

Is pathologic confirmation of placental abruption more reliable in cases due to chronic etiologies compared with acute etiologies?

BACKGROUND

Pathology laboratories often receive requests for confirmation of abruption; however, pathologically, abruption can only be confirmed by the presence of adherent blood clot on the maternal surface that is indenting the underlying placental parenchyma.

DESIGN

We evaluated whether abruptions due to more chronic underlying medical conditions are more likely to have a retained indenting retroplacental clot that is detectable by the pathologist than abruptions due to acute etiologies. This was a retrospective review from January 1995 to June 2012 of cases with a clinical and/or pathologic diagnosis of abruption. Data were analyzed utilizing Fisher's exact test.

RESULTS

Ninety-six cases had sufficient available information for analysis. There was a significant association between pathologic identification of abruption and chronic risk factors (P=0.03). Twenty-five percent of cases with acute risk factors and 60% of cases with chronic risk factors had abruption confirmed at pathologic evaluation (P=0.12).

CONCLUSION

Pathologically confirmable abruption is associated with chronic risk factors. There was a trend towards chronic risk factors leading to greater likelihood of pathologic confirmation of abruption than acute risk factors, but it did not reach statistical significance.

Involvement of human decidual cell-expressed tissue factor in uterine hemostasis and abruption

Vascular injury increases access and binding of plasma-derived factor VII to perivascular cell membrane-bound tissue factor (TF). The resulting TF/VIIa complex promotes hemostasis by cleaving pro-thrombin to thrombin leading to the fibrin clot. In human pregnancy, decidual cell-expressed TF prevents decidual hemorrhage (abruption). During placentation, trophoblasts remodel decidual spiral arteries into high conductance vessels. Shallow trophoblast invasion impedes decidual vascular conversion, producing an inadequate uteroplacental blood flow that elicits abruption-related placental ischemia. Thrombin induces several biological effects via cell surface protease activated receptors. In first trimester human DCs thrombin increases synthesis of sFlt-1, which elicits placental ischemia by impeding angiogenesis-related decidual vascular remodeling. During pregnacy, the fibrillar collagen-rich amnion and choriodecidua extracellular matrix (ECM) provides greater than additive tensile strength and structural integrity. Thrombin acts as an autocrine/paracrine mediator that degrades these ECMs by augmenting decidual cell expression of: 1) matrix metalloproteinases and 2) interleukin-8, a key mediator of abruption-associated decidual infiltration of neutrophils, which express several ECM degrading proteases. Among the cell types at the maternal fetal interface at term, TF expression is highest in decidual cells indicating that this TF meets the hemostatic demands of labor and delivery. TF expression in cultured term decidual cells is enhanced by progestin and thrombin suggesting that the maintenance of elevated circulating progesterone provides hemostatic protection and that abruption-generated thrombin acts in an autocrine/paracrine fashion on decidual cells to promote hemostasis via enhanced TF expression.

[Placental chorangiosis associated with abruption and hypoxia]

Chorangiosis is a rare abnormality of placental capillary proliferation, associated with hypoxia in utero. A 23-year-old primigravida developed placental abruption at 33 weeks' gestation, and an emergency cesarean section was performed. Placental histology revealed chorangiosis. The infant was in critical state and died on the next day. Our case confirms that perinatal mortality can be associated with chorangiosis. This diagnosis should be considered especially when no other significant obstetric incident is identified. Placentas should be monitored for placental abruption, a known consequence of chorangiosis.

[Analysis of risk factors for uteroplacental apoplexy complicating placental abruption]

OBJECTIVE

To study the clinical characteristics, the outcome of pregnancy and the risk factors of uteroplacental apoplexy complicating severe placental abruption.

METHODS

A retrospectively study of the 52 cases of placental abruption who had delivered in our hospital from Jan. 2002 to Dec. 2006 was conducted. These cases were divided into 2 groups: 17 cases of uteroplacental apoplexy complicating placental abruption as observation group, the others with no uteroplacental apoplexy as control group. The risk factors of disease, clinical characteristics and the outcome of pregnancy between the two groups were compared.

RESULTS

(1) The incidence of placental abruption was 0.15% (52/35 049) among the total deliveries patients with uteroplacental apoplexy complicating placental abruption took up 0.05% (17/35 049) of all deliveries and 33% (17/52) of all abruption cases. (2) General information and delivery: There were no significant differences (P > 0.05) regarding their mean age and BMI in two groups. All women in observation group had C-section delivery, which were 21 in control group. 14 women had vaginal delivery. The incidence of premature labour was 88% (15/17) in observation group, and 49% (17/35) women in control group delivered after 37 weeks. Significant differences were observed regarding delivery methods and gestational weeks (P < 0.01). (3) RISK FACTORS: the incidence of preeclampsia, 71% (12/17), and the duration of disease, 6.4 hours, in observation group were more than those in control group, 20% (7/35) and 4.2 hours (P < 0.01). There were no significant differences between two groups in premature rupture, polyhydroamnions (P > 0.05). (4) Clinical characteristics in two groups: bloody amniotic fluid, fetal distress, hematometra and postpartum hemorrhage occurred in 82% (14/17) vs 26% (9/35), 65% (11/17) vs 29% (10/35), 35% (6/17) vs 6% (2/35), and 59% (10/17) vs 11% (4/35), with a significant difference (P < 0.01), but no statistical difference existed between indices such as abdominal pain, vaginal bleeding and abdominal tension (P > 0.05). (5) Placenta sites and abruption areas: placenta sites were distributed from anterior or posterior of uterine body 5/17 vs 24/35, the fundus or cornu of uterus 12/17 vs 11/35 (P < 0.01). All cases in observation group presented abruption areas > 1/3, and 9 cases >or= 2/3, 27 cases abruption areas < 1/3 and 8 cases abruption areas 1/3 - 2/3 in control group (P < 0.01). (6) Other complications and outcome: Hemorrhagic shock 3 vs 0, DIC 3 vs 0, hysterectomy 1 vs 0, intrauterine fetal death 3 vs 2, neonatal asphyxia 8 vs 5 and neonatal death 1 vs 0. There were significant differences (P < 0.01) between the two groups.

CONCLUSIONS

Preeclampsia, long duration of disease and fundal or cornual placenta a risk factors for uteroplacental apoplexy complicating placental abruption, which may lead to a poor maternal-fetal prognosis.

Are clinical symptoms more predictive than laboratory parameters for adverse maternal outcome in HELLP syndrome?

BACKGROUND

To determine the risk factors for adverse maternal outcome among women with HELLP syndrome.

METHODS

Sixty-one pregnancies with hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome diagnosed antenatally were reviewed between 2003 and 2005. Maternal outcomes analyzed included eclampsia, abruptio placentae, disseminated intravascular coagulopathy (DIC), acute renal failure, need for transfusion of blood products, cesarean delivery and maternal death. Risk factors included maternal age, parity, gestational age at diagnosis, mean arterial blood pressure, headache, visual changes, nausea-vomiting, epigastric pain, blood platelet count (<or=50,000 versus >50,000 cells/mm3), and peak serum levels of aspartate aminotransferase.

RESULTS

Eclampsia was present in 52%, abruptio placentae in 11%, and DIC in 8% of 61 women with HELLP syndrome. 23% women required transfusion of blood products, 15% had acute renal failure, and 73% had cesarean section. Women with eclampsia had significantly more headache, nausea-vomiting, visual changes and epigastric pain (p<0.05). Transfusion was significantly more frequent among women with blood platelet counts <or=50,000 cells/mm3 (33 versus 21%; p<0.05). Women with a platelet count <or=50,000 cells/mm3 had a higher rate of DIC compared to women with a platelet count >50,000 cells/mm3 (33.3 versus 3.8%; p<0.05). In women with acute renal failure and abruptio placentae, there were no significant differences in all the variables studied between those with and without these complications.

CONCLUSIONS

Clinical symptoms, such as headache, visual changes, epigastric pain and nausea-vomiting, are more predictive than laboratory parameters for adverse maternal outcomes.

The influence of maternal cigarette smoking on placental pathology in pregnancies complicated by abruption

OBJECTIVE

The purpose of this study was to evaluate the effect of maternal cigarette smoking on placental histology in women with abruption.

STUDY DESIGN

Data were derived from the New Jersey-Placental Abruption Study (NJ-PAS)--an ongoing, case-control study, conducted since August 2002 in 2 large hospitals in NJ. Abruption cases were identified based on a clinical diagnosis. Histologic evaluations were performed by 2 perinatal pathologists who were blinded to the abruption status. Maternal smoking during pregnancy was determined based on patient's self-report. Among abruption cases, histologic findings were compared between smokers and nonsmokers, and the association expressed as odds ratio (OR) with 95% confidence interval (CI). All analyses were adjusted for potential confounders.

RESULTS

A total of 189 abruption cases were available for analysis, of which 10.6% (n = 20) were smokers. Intervillous thrombus was more common in women who smoked (20%) than in nonsmokers (3.0%) (OR, 17.5; 95% CI, 3.1-99.4). However, placental infarcts were seen less frequently among smokers than nonsmokers (10.0% vs 32.5%; OR, 0.2; 95% CI, 0.1-0.8).

CONCLUSION

These findings suggest that different pathologic mechanisms may be responsible for the histologic findings between smokers and nonsmokers diagnosed with placental abruption.

Placental shelf - a common, typically transient and benign finding on early second-trimester sonography

OBJECTIVE

Placental shelves are believed to represent circumvallate placentae. It is thought that circumvallate placenta may be associated with adverse perinatal outcome when present at delivery. The objective of this study was to determine the prevalence, persistence and significance of placental shelves detected in the early second trimester.

METHODS

In 152 consecutive anomaly scans performed between 13 and 16 weeks of gestation, special attention was directed to placental structure and the presence of a placental shelf. When present, a mid-gestation scan was performed to verify if the finding persisted. If so, a third-trimester scan was performed. Delivery charts were reviewed for all cases initially diagnosed with a placental shelf, recording any placenta-related complications.

RESULTS

In 17 of 152 (11.2%) early second-trimester scans a placental shelf was detected. In three of these 17 cases the shelf persisted to the 20-22-week scan. In the two cases that presented for the third-trimester scan the shelf was no longer present. In all 17 cases the perinatal outcome was good.

CONCLUSIONS

In our study group early second-trimester placental shelves rarely persisted to mid-gestation and never to the third trimester. There were no placenta-related perinatal problems. Early second-trimester placental shelf appears to be a common, benign and transient sonographic finding.

Intrapartum stillbirths in hospital unrelated to uteroplacental vascular insufficiency

The aim of this study was to investigate the causes of intrapartum asphyxia and its relationship to placental abnormalities. Twenty intrapartum fetal death autopsies carried out over a 10-year period in one hospital pathology department associated with a large obstetric unit were reviewed. All the intrapartum fetal deaths occurred in the hospital, while the mothers were being monitored during and after labor. On morphologic grounds, all the fetal deaths were thought to be caused by intrapartum asphyxia. Seven of the intrapartum fetal deaths were associated with intrauterine infection causing funisitis, and in 6 of these cases, chorioamnionitis was present as well. Two cases were caused by placental abruption, and 1 case was caused by cord compression. In 8 of the 10 remaining cases in which the placenta was examined, a minor placental abnormality was detected in only 1 case. Five of the 10 cases had a mild astrocytosis in the intracerebral periventricular white matter, suggestive of intrauterine ischemia at least 12 hours before death. Five of the 10 cases were thought by the delivering obstetrician to have umbilical cord abnormalities. The main conclusions from this study are that, except in cases of intrauterine infection, placental vascular abnormalities are unlikely to be associated with intrapartum asphyxia leading to fetal death during labor. The number of cases with umbilical cord abnormalities raises the possibility that cord accidents may be a significant cause of intrapartum stillbirth.

The Scottish Perinatal Neuropathology Study-clinicopathological correlation in stillbirths

OBJECTIVE

To examine the neuropathology of fetuses dying before birth, to determine the timing of any brain damage seen and to ascertain clinical associations of pre-existing brain damage.

DESIGN

Population-based observational study.

SETTING

All 22 delivery units within Scotland, 1995-1998.

SAMPLE

All stillborn fetuses > or =24 weeks of gestation excluding those with chromosomal abnormality or central nervous system/cardiothoracic malformation.

METHODS

Clinical detail was collected on all stillborn fetuses. Requests for postmortem included separate request for detailed neuropathological examination. Stillborn fetuses were classified as full term antepartum (normal growth/growth restricted), preterm antepartum (normal growth/growth restricted), intrapartum (full term/preterm), multiple births and stillborn fetuses following abruptions. Clinicopathological correlation attempted to define the timing of brain insult. Placentas were examined for each case where available.

MAIN OUTCOME MEASURES

Presence of established and/or recent brain damage. RESULTS Clinical details were available for 471 stillborn fetuses, and detailed neuropathology was possible in 191 cases. Of these 191, 13 were multiple births, 9 died following abruption, 12 were intrapartum deaths and 157 were antepartum stillborn fetuses (99 preterm and 58 full term). Recent or established brain damage was seen in 66% of the entire cohort. Thirty-five percent of all cases showed well-established hypoxic damage predating the last evidence of fetal life, and this was more common in preterm fetuses (P = 0.015), those fetuses with evidence of recent damage (P < 0.001), in pregnancies complicated by pregnancy-induced hypertension (P = 0.044) and those in whom the placenta was <10th centile (P = 0.002).

CONCLUSIONS

Brain damage is commonly seen in stillborn infants, and in around one-third of cases, damage predates the period immediately before death. Factors suggesting suboptimal placental function are associated with such damage. Early identification of placental impairment may lead to improved pregnancy outcome.

[Uterine pathomorphology in abruptio placentae]

15 uteri removed surgically because of abruptio placentae (AP) were studied morphologically. AP develops as a process due to a combination of maternal (endometritis, gestosis, adenomyosis), placental (pathology of microvilli, hypercoagulation of venous blood) and hemorheological (thrombosis of placental bed veins, partial blockade of venous circulation) factors. These factors result in the formation of retroplacental hematoma and progressing intrauterine fetal hypoxia.

Abruptio Placentae during Fetal Myelomeningocele Repair

Myelomeningocele (MM) is a congenital neural tube defect with serious consequences, including hydrocephaly. An important hope for intrauterine repair is that hydrocephaly may be prevented by reversing the Arnold-Chiari malformation. Three medical centers in the United States are doing trials with this objective. We describe an intrauterine correction of MM in a Brazilian research center of fetal medicine, which resulted in abruptio placentae and fetal death, to illustrate factors that influence fetal-maternal risks during this surgical procedure.

Mechanisms of abruption-induced premature rupture of the fetal membranes: thrombin-enhanced interleukin-8 expression in term decidua

Recent evidence has linked preterm premature rupture of the fetal membranes (PPROM) to placental abruption. Because neutrophils are a rich source of proteases that can degrade extracellular matrix in abruption-associated PPROM, we examined whether decidual neutrophil infiltration complicates abruption-associated PPROM. Accordingly, immunostaining for the neutrophil marker CD15 was performed in placentas obtained after overt abruption (decidual hemorrhage) with or without PPROM and in control placentas. Abruptions were associated with a marked decidual neutrophil infiltration that peaked after PPROM, whereas decidua from gestational age-matched controls were virtually devoid of neutrophils. Neutrophil infiltrates co-localized with fibrin deposition. Because abruptions elicit intense decidua-enhanced thrombin production, we examined the regulation of abruption-induced neutrophil infiltration. Expression of the primary neutrophil chemoattractant interleukin-8 (IL-8) was evaluated in leukocyte-free term decidual cells incubated with estradiol (E2; control) or with E2+medroxyprogesterone acetate (to mimic pregnancy)+/-thrombin. After 24 hours, enzyme-linked immunosorbent assay measurements indicated that thrombin (0.1 to 2.5 U/ml) elicited a dose-dependent elevation in secreted IL-8 (P<0.05) with 2.5 U/ml of thrombin increasing IL-8 levels by >14-fold in E2 and E2+medroxyprogesterone incubations. Results were validated by Western blot and quantitative reverse transcriptase-polymerase chain reaction. In summary, thrombin-enhanced IL-8 expression in term decidual cells may explain how abruption-associated PPROM promotes decidual neutrophil infiltration.

Risk and risk estimation of placental abruption

OBJECTIVE

Several variables related to increased risk of placental abruption are also risk factors for venous thromboembolism. Prior second trimester-, third trimester, and repeated fetal loss are reported to be associated to thrombophilias. However, it is yet not known if they are also related to placental abruption.

STUDY DESIGN

A retrospective case-control study of 161 women with placental abruption and 2371 unselected gravidae without placental abruption. The medical files were scrutinized and the selected variables were investigated in relation to the development of placental abruption.

RESULTS

As compared to controls, previous second trimester-, third trimester-, repeated fetal loss, and prior placental abruption were related to a 3-, 13-, 3-, and a 25-fold increased risk of placental abruption, respectively. Several other factors were associated with a roughly three-fold increased risk such as: preeclampsia, IUGR, high maternal age (>35), family history of venous thromboembolism, smoking, and multiple birth. A risk score was created and as compared with those with no risk factors present, the risk of placental abruption was increasing from 2.5-fold for those with risk score=1, to almost 100-fold for risk score 4 or above.

CONCLUSION

Easily obtainable information might be used to classify the risk of placental abruption.

[Placenta in gestational hypertension]

At an incidence of 3.2-4% world-wide, pregnancy-induced hypertension (PIH) is the most common disease of pregnancy. Since this holds a risk, not only for the mother, but also for the child, the placenta should undergo pathological-anatomical examination in every case. Pathomorphological findings can be described in the feto-maternal border zone as well as in the fetal placenta. These are not, however, specific, nor do they offer diagnostic proof. Pathomorphological findings in the feto-maternal border zone: defective invasion of the extravillous cytotrophoblast, hyperplastic arterio-/arteriolopathy, acute atherosclerosis, and fibrinoid necrosis of endothelium. Disorders of the fetal part of placenta: infarctions/fibrin deposits, obliterative angiopathy, stromal fibrosis/fibrinoid degeneration, syncytiotrophoblastic nodes (Tenney-Parker-phenomenon), and disturbances of maturation of the villi. There is a general lack of correlation between the seriousness of the disease and the morphology. The only exception in this respect are the findings in the vessels both of the placental bed and of the chronic villi. These show a high correlation with doppler sonographic findings.

M385T polymorphism in the factor V gene, but not Leiden mutation, is associated with placental abruption in Finnish women

This study determines whether genetic variability in the gene encoding factor V contributes to differences in susceptibility to placental abruption. Allele and genotype frequencies of three single nucleotide polymorphisms (SNPs) in the factor V gene leading to nonsynonymous changes (M385T in exon 8, and R485K and R506Q [Leiden mutation] in exon 10) were studied in 116 Caucasian women with placental abruption and 112 healthy controls. Single-point analysis was expanded to haplotype analysis and haplotype frequencies were estimated using an expectation-maximisation (EM) algorithm. Comparison of single-point allele and genotype distributions of SNPs in exon 8 and exon 10 of the factor V gene revealed statistically significant differences in M385T allele (P = 0.021) and genotype ( P = 0.013) frequencies between the patients and the control subjects. The C allele of SNP M385T was significantly less frequent among the patients (7%) vs. the control subjects (13%), at an odds ratio of 0.48 (95% CI 0.25-0.91). Allele and genotype differences between the patients and control subjects as regards R485K and Leiden mutation were not significant. In haplotype estimation analysis, there was a significantly lower frequency of haplotype T-R-R encoding the T385-R485-R506 variant in the group with placental abruption vs. the control group (P = 0.038) at an odds ratio of 0.519 (95% CI 0.272-0.987). We conclude that T385 is less frequent among the patient group than in the control group. The M385T variant in the factor V gene other than the Leiden mutation may play a role in disease susceptibility.

Perinatal outcome in women with severe pregnancy complications and multiple thrombophilias

Hypercoagulability leading to placental thrombosis has been implicated in severe pregnancy complications. We compared the perinatal outcome in women with severe preeclampsia, intrauterine growth retardation (IUGR) and severe abruptio placentae and multiple acquired and inherited thrombophilias (study group, n=22) to matched women with similar complications and single thrombophilia (control group, n=22). Gestational age at delivery and birth weight were significantly lower in the study group compared to the control group (p<0.01) and among the study women with severe preeclampsia and IUGR. Severe pregnancy complications may occur earlier during pregnancy and more seriously affect perinatal outcome in women with multiple thrombophilias.

The frequency and severity of placental findings in women with preeclampsia are gestational age dependent

OBJECTIVE

The purpose of this study was to evaluate placental lesions found in women with preeclampsia compared with normotensive control subjects and to determine whether the presence of these lesions are related to gestational age at delivery.

STUDY DESIGN

Placental disease of women with preeclampsia at 24 to 42 weeks of gestation was compared with the placental disease of normotensive gestational age-matched control subjects. The placental lesions that were studied specifically included decidual arteriolopathy, thrombi in the fetal circulation, central infarction, intervillous thrombi, and hypermaturity of villi. Data analysis involved the chi(2) test, the Student t test, and logistic regression; odds ratios and CIs were estimated.

RESULTS

Placentas from women with preeclampsia (n=158) and normotensive control subjects (n=156) were evaluated. Among women with preeclampsia, 67% had severe disease. Placental lesions were studied according to gestational age at delivery: <28, 28 to 32, 33 to 36, and >or=37 weeks of gestation. Of the placental lesions that were studied, decidual arteriolopathy (odds ratio, 23.8, 95% CI 10.0-57.0), hypermaturity of villi (odds ratio, 12.4; 95% CI 5.3-29.2), intervillous thrombi (odds ratio, 1.95;95% CI 1.0-3.7), central infarction (odds ratio, 5.9; 95% CI 3.1-11.1), and thrombi in the fetal circulation (odds ratio, 2.8; 95% CI 1.2-6.6) were found to have significantly higher rates in the preeclamptic group. In contrast, the rate of chorioamnionitis was significantly lower in the preeclamptic group (odds ratio, 0.2; 95% CI 0.1-0.4). The rates of abruptio placentae and meconium staining were not different between the two groups. Within the preeclamptic group, the rates of decidual arteriolopathy (P<.0001), central infarction (P=.0001), and hypermaturity of villi (P<.0001) were higher the earlier the gestational age at delivery.

CONCLUSION

Placentas in women with preeclampsia have increased amounts of disease. The rate is increased with lower gestational ages at the time of delivery for women with preeclampsia.

[Pathomorphological changes in the uterine wall in gestosis]

With the purpose of studying a morphological substrate of the uterine contractile function disorder in gestosis, an investigation was conducted designed to study biopsy specimens of the uterine wall having been taken during the cesarean section in 80 parturient women. The womb of those parturient women having mild and severe gestosis complicated by uterine inertia (40 observations) or premature dethachement of the normally situated placenta (8 cases) was studied together with that of controls (32 cases). The indentified micro-circulatory disturbances and alterative changes in the myometrium structures in gestosis are regarded as one of the generalized blood circulation disorders, hemostasis (dissaminated intravascular blood coagulation) and systemic abnormalities of metabolism presenting as a multiorgan failure developing in the pathology under consideration. Microcirculatory disturbances and hypoxia-related dystrophic changes in the smooth myoblasts and connective tissue leading to its fibrosis--all these constitute a morphological substrate of changes in the contractile function of the womb.

Placental abruption and perinatal mortality in the United States

Placental abruption is an uncommon obstetric complication associated with high perinatal mortality rates. The authors explored the associations of abruption with fetal growth restriction, preterm delivery, and perinatal survival. The study was based on 7,508,655 singleton births delivered in 1995 and 1996 in the United States. Abruption was recorded in 6.5 per 1,000 births. Perinatal mortality was 119 per 1,000 births with abruption compared with 8.2 per 1,000 among all other births. The high mortality with abruption was due, in part, to its strong association with preterm delivery; 55% of the excess perinatal deaths with abruption were due to early delivery. Furthermore, babies in the lowest centile of weight (<1% adjusted for gestational age) were almost nine times as likely to be born with abruption than those in the heaviest (> or =90%) birth weight centiles. This relative risk progressively declined with higher birth weight centiles. After controlling for fetal growth restriction and early delivery, the high risk of perinatal death associated with abruption persisted. Even babies born at 40 weeks of gestation and birth weight of 3,500-3,999 g (where mortality was lowest) had a 25-fold higher mortality with abruption. The link between fetal growth restriction and abruption suggests that the origins of abruption lie at least in midpregnancy and perhaps even earlier.

Fetal death from abruptio placentae associated with incorrect use of a seatbelt

A female driver, 24 weeks pregnant, was wearing a three-point seatbelt in the manner usual for nonpregnant women, when her automobile collided head-on with another vehicle. A cardiotocographic examination after the accident revealed the fetus to be alive. Five days after the accident, however, a cardiotocographic examination showed fetal death. At that time, a transverse ecchymotic band on the lower abdominal wall that had not been observed at the first examination was noticed. Eight days after the accident, the mother delivered a macerated female fetus. At autopsy, the baby showed no abnormality, but there was a hematoma on the placental surface toward the uterus. These results suggest that the fetus died of abruptio placentae associated with incorrect placement of the lap belt.

Superfecundation and dual paternity in a twin pregnancy ending with placental abruption

A case of superfecundation and dual paternity in a twin pregnancy is presented. Placental abruption developed at week 33 of gestation and the two boys had to be saved by emergency cesarean section. As they shared one placenta, had almost identical weight and had the same sex, they were assumed to be monozygotic. However, a subsequent paternity suit led to the conclusion, based on DNA-analysis, that the twin brothers had been fathered by two different men. Obstetrical implications are discussed.

Placental pathology casebook. Chorangiosis of the placenta increases the probability of perinatal mortality

Two apparent acute problems that may occur in labor, nuchal cord and placental abruption, were associated with chorangiosis of the placenta. The importance of complete placental examination in perinatal mortality is re-emphasized. The association of apparent acute obstetrical conditions, e.g., nuchal cord and placental abruption with chorangiosis of the placenta, may be the cause of fetal-newborn deaths that were previously assumed to be issues of labor management.

Abruptio placentae and chorioamnionitis-microbiological and histologic correlation

BACKGROUND

To determine the association of chorioamnionitis with placental abruption.

SUBJECT AND METHOD

Fifty pregnant women admitted with abruptio placentae were compared to an equally large control group in spontaneous labor with no history of antepartum hemorrhage. Swabs from the cervix and placental membranes were cultured for aerobic and anaerobic organisms. Placental membranes were studied histologically in 40 women of study group and 35 of control group for any evidence of chorioamnionitis.

RESULTS

Specific organisms were isolated in 22 (44%) women in the study group and 19 (38%) women in the control group. The cervical swab microbiological flora was similar in both groups but isolation of specific organisms from placental membrane culture was higher in the study group (40%) compared to the controls (18% p<0.05). Evidence of histologic chorioamnionitis was higher in the study group 12/40 (30%), than in the control group 8/35 (22.85%), but the difference was not significant.

CONCLUSION

The incidence of silent chorioamnionitis (placental membrane culture positivity) is higher in the abruptio placentae.

Thrombomodulin: a new marker for placental abruption

Thrombomodulin (TM), a marker of endothelial cell damage, has been localized to the placental syncytiotrophoblast. A prospective cohort study of twenty-five pregnant women who were admitted with a clinical diagnosis of placental abruption was undertaken. Abruption was confirmed after delivery in eight cases (Group 1). Group 2 consisted of seventeen patients with no clinical or pathologic evidence of placental abruption after delivery. TM was significantly elevated in Group 1 (71.59+/-5.35 vs. 48.29+/-3.53 ng/ml, p = 0.001). The sensitivity and specificity of TM > or =60 ng/ml as a marker for abruption was 87.5 and 76.5%, respectively. In comparison, the sensitivity of an abnormal coagulation profile, maternal Kleihauer-Betke and ultrasound in patients with abruption was 0, 16.7 and 28.6%, respectively. TM is a highly sensitive and specific marker for acute placental abruption.

[Morphologic findings in fetuses and placentas of late abortion in the 2nd trimester]

To investigate possible causes of abortion (and intrauterine foetal death) we reviewed clinical and morphological data of foetuses and placentas morphologically from 830 spontaneous abortions seen during a 12 years period (1978-1989) at the Institute of Pathology, University of Leipzig, and the Pathological Institute of Hoyerswerda. Our review showed that definite and possible causes of foetal death and abortion could be classified as placental, foetal maternal, and clinical. Placental changes, which included infection of the foetal membranes, disturbances of the uteroplacental circulation (abruptio placentae with bleeding) and placental dysmaturity, were the most important causes and accounted for 73.8% of the cases. Foetal causes mainly comprised multiple twin pregnancies and foetal malformations. In 20 cases (2.4%) we found malformations as a cause of foetal death and consecutive abortion. Overall, malformations were found in 7.5% of the cases examined. Maternal and obstetric complications of pregnancy were less frequent. In 16.5% of our cases, the cause of the abortion or intrauterine death remained obscure. However, since 1989, genetic analysis and prenatal diagnostic procedures have improved, bringing a greater knowledge on the spectrum and aetiology of possible developmental disorders in the foetus. This should reduce the number of unexplained abortions.

Abruptio placentae. A "classic" dedicated to Elizabeth Ramsey

The syndrome of abruptio placentae was originally described in 1997. Total hysterectomy was advocated by Couvelaire in 1991. The placenta is fixed to the uterine wall by anchoring villi. When spiral arteries lack the physiologic trophoblast invasion, like in case of maternal hypertension placental infarcts/abruption might occur. Infusion of thromboplastic material induces disseminated intravascular coagulation. The uterus "en bois" representing hypertonicity and polysystolia probably safe-guard the entrance of further thromboplastic material into the maternal circulation. Prompt restoration of the intravascular volume with full blood avoids hysterectomy. Preventive measures are avoidance of the supine position, cocaine and smoking. Treatment of hyperhomocysteinemia probably can prevent vascular damage.

Is pregnancy-related acute renal failure a disappearing clinical entity?

The actual disappearance of pregnancy-related acute renal failure (PR-ARF) is a common "feeling" for nephrologists. The aim of this study was to exactly quantify this event by evaluating epidemiology and the extent of renal damage in PR-ARF. From 1958 to 1994, 84 cases of PR-ARF were observed (5.8% of total number of ARF needing dialysis). In four successive periods (1956-67, 1968-77, 1978-87, 1988-94), the incidence of PR-ARF fell from 43% to 0.5% with respect to the total number of ARF, and from 1/3000 to 1/18,000 with respect to the total number of pregnancies. Maternal mortality in the past was high (31%), but no cases of death in the last period were seen. Irreversible renal damage was recorded in 11.1% of PR-ARF, and, in particular, in 18.7% of cases of preeclampsia-eclampsia (PE-E). The worst maternal and renal prognosis occurred in PE-E that was complicated by abruptio placentae (AP). Neither disseminated intravascular coagulation (DIC), microangiopathic hemolytic anemia, nor prostacyclin imbalance were significantly related to the severity of renal damage. Heparin therapy did not modify DIC evolution and renal outcome and was aggravated by severe hemorragic complications. Support therapy with plasma infusion, antithrombin III, and antiplatelet agents seems to be helpful. In conclusion, PR-ARF has become a rare occurrence and, in our experience, no cases of death or irreversible renal damage were observed in the last 7 years. The most important reasons for this favorable evolution seem to be an improved medical care and more effective measures of careful prevention, mainly regarding tempestive delivery.

The very low birthweight infant: maternal complications leading to preterm birth, placental lesions, and intrauterine growth

The placental lesions of the very low birthweight (VLBW) infant were investigated in relation to clinical complications leading to preterm birth and evidence of growth impairment. The 249 singleton gestations yielding infants less than 1500 g were grouped according to the clinical complications leading to preterm birth as premature membrane rupture (116/249, 47%) preterm labor (55/249, 22%), pregnancy-induced hypertension (PIH, 54/249, 22%), and normotensive abruption (ABR, 24/249, 10%). Specifically excluded from this data set were cases with greater than 2 weeks discordance, fetal congenital anomalies, placenta previa, and maternal medical or gestational diseases such as chronic hypertension and diabetes mellitus, and intrauterine growth retardation (IUGR) as a primary indication for delivery. Placental weight and lesions including decidual vasculopathy and related villous lesions, chronic villitis/intervillositis, and decidual plasmacytosis were considered as variables in analyses in which raw birthweight was the dependent variable and gestational age a confounder. Of the 195 VLBW, 79 (41%) infants from normotensive mothers had lesions of decidual vasculopathy or chronic inflammation. In the VLBW infants from hypertensive mothers, growth restriction was related to markers of decidual vasculopathy. In the absence of maternal hypertension the growth restriction was independently associated with chronic villitis. Decidual vasculopathy (characteristic of PIH) and chronic intrauterine inflammation underlie the complications of many normotensive VLBW infants. The placental lesions in VLBW-IUGR depend on the presence or absence of maternal hypertension. In the absence of maternal hypertension, VLBW-IUGR is associated with chronic inflammation and is independent of decidual vasculopathy. In the presence of maternal hypertension, VLBW-IUGR is directly related to decidual vasculopathy.

Placental bed biopsies in placental abruption

OBJECTIVE

To investigate structural changes in the uteroplacental blood vessels in association with placental abruption.

DESIGN

Prospective descriptive study.

SUBJECTS

18 women with clinical evidence of severe placental abruption delivered by caesarean section.

INTERVENTIONS

Placental bed biopsies were obtained at caesarean section and studied histologically.

RESULTS

Six specimens did not include trophoblast in the myometrium and were therefore not representative of the placental bed. Of the 12 representative specimens, seven demonstrated absence of physiological transformation of the utero-placental arteries (four of these were from hypertensive patients). Four biopsies showed abnormal vascular structures deep in the myometrium. One of these abnormal vessels included a fresh plug and extensive surrounding intramyometrial haemorrhage.

CONCLUSIONS

Vascular malformations in association with placental abruption may be the result of trophoblastic invasion and could be the site of vessel rupture. Further descriptive and comparative studies are needed.

Placental abruption in the preterm gestation: an association with chorioamnionitis

Thirty-seven women with acute severe preterm placental abruption were compared with a control group of 51 women requiring preterm delivery for a medical complication of pregnancy. Histologic chorioamnionitis and funisitis were present significantly more often in patients with abruption than in control patients (41 versus 4%; P less than .0001). No patient in either group had clinical evidence of chorioamnionitis. We conclude that a significant association exists between preterm placental abruption and histologic chorioamnionitis.

Amniotic fluid infection syndrome and abruptio placentae

The incidence of amniotic fluid infection syndrome, as assessed by the presence of an acute inflammatory infiltrate of the placenta, umbilical cord, and membranes at birth, was 23.3% in pregnancies complicated by severe abruptio placentae. This was not significantly higher than that noted in uncomplicated pregnancies. These data therefore fail to support the proposal that amniotic fluid infection predisposes to placental abruption.

Peripheral placental separation: a possible relationship to premature labor

This investigation was undertaken to determine the relationship, if any, between peripheral placental separation and idiopathic premature labor. Ninety placentas from prematurely delivered patients (who had had no antepartum bleeding) were examined grossly and microscopically. Criteria for antepartum peripheral placental separation included adherent clot, with fibrin deposition and lamination, as well as polymorphonuclear infiltration and marginal decidual necrosis. Forty-nine placentas showed unequivocal evidence of previous peripheral separation. Another three placentas showed presumptive evidence of previous peripheral separation. It is suggested that this separation is of venous origin, and that it may play a role in the process of premature labor. This is not necessarily a cause and effect relationship.

Placental patterns as seen on ultrasonography

The first exciting days of being able to see the placenta in utero and localize the site of implantation are over. It is now commonplace to ask about the placental site automatically when requesting an ultrasonogram of a pregnant uterus, and it is taken for granted that this will be mentioned in the report. However, with the new and more sophisticated ultrasound equipment now in use, it is today incumbent on the ultrasonologist to give a short report on the placenta and the umbilical cord, in addition to the report on the fetus.