Pathology of the_placenta_-_lecture

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Uma apresem ntação muito boa sobre Patologia placentária, especialmente abordando alterações da maturação.

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Pathology of the_placenta_-_lecture

  1. 1. Placenta pathology associated with maturation abnormalities and late intra uterine foetal death. PETER G.J. NIKKELS Dept. of Pathology UMC Utrecht, the Netherlands
  2. 2. Anatoom Frederick Ruysch, J. van Neck 1683
  3. 3. Perinatal death• Perinatal death occurs in 1,5% of all birth• Frequency of stillbirth in western Europe approximately 2,2-4,4 / 1000 life birth• Riskfactors: multiple pregnancy, prematurity, first or second pregnancy, hypertension or pre-eclampsia of the mother, congenital abnormalities (20-40%) and inflammation
  4. 4. Causes of IUFD• Placenta or umbilical cord pathology 62%• Congenital abnormalities 17%• Intra-uterine infection 2%• Trauma 1%• Miscellaneous (tumors, storage disorder) 3%• Unexplained (12/47 no placenta) 15%• Horn et al. Identification of the causes of intrauterine death during 310 consecutive autopsies. European Journal of Obstetrics & Gynaecology and Reproductive Biology 113 (2004), 134-8. University Hospital Leipzig, IUFD from 22-42 6/7 weeks.
  5. 5. Causes of IUFD• Placenta or umbilical cord pathology 62%• Utero-placental pathology 38%• Dysmaturity of parenchym 23%• Inflammation 14%• Umbilical cord 22% (Compression, bleeding, haematoma)• Miscellaneous 3% (TTTS, chorangioma etc.)• Horn et al. Identification of the causes of intrauterine death during 310 consecutive autopsies. European Journal of Obstetrics & Gynaecology and Reproductive Biology 113 (2004), 134-8. University Hospital Leipzig, IUFD van 22-42 6/7 weeks.
  6. 6. Main cause of IUFDDisturbance in delivering oxygen to the foetus• Not enough or loss of parenchyma – Small placenta Placental bed pathology – Placental infarcts – Chronic inflammation – Foetal thrombosis• Diffusion distance too long – Fibrin deposition – Abnormal maturation• Umbilical cord pathology
  7. 7. Normal development of the placenta parenchyma• Placenta: the fastest growing organ of the human body• from 1 tot 5 x 1010 cells in 38 weeks
  8. 8. Placental weightRatio of placental weight and foetal weight
  9. 9. Normal development of placental parenchymaFIRST TRIMESTER – In first 12 weeks only mesenchymal villi – Development of immature intermediate villi with two layers of trophoblast – Development of stem villi with central fibrous core Amniotic cavityYolk sac
  10. 10. Normal 13 weeks
  11. 11. Normal 13 weeks
  12. 12. Normal maturation of placental parenchyma• SECOND TRIMESTER – Parenchyma consists of immature intermediate villi, there is some development of mature intermediate villi – Largest variation in villus shape and diameter – Mesenchymal stroma alongside stem villi disappears and occasionally some fibrinoid material can be seen
  13. 13. Normal 23 weeks
  14. 14. Normal 23 weeks
  15. 15. Normal 25 weeks
  16. 16. Normal 25 weeks
  17. 17. Normal 31 weeks
  18. 18. Normal 31 weeks
  19. 19. Normal maturation of the placental parenchyma• THIRD TRIMESTER – Development of terminal villi – At 40 weeks 40% of the villous volume are terminal villi – Terminal villi have syncytio-vascular membranes – Stem villi are covered with fibrinoid material
  20. 20. Normal 35 weeks
  21. 21. Normal 35 weeks
  22. 22. Normal 40 weeks
  23. 23. Normal 40 weeks
  24. 24. Abnormal maturation of the placenta parenchyma• Accelerated maturation• Delayed maturation and dysmaturity
  25. 25. Accelerated maturation• Utero-placental pathology decreased blood flow to the placenta due to abnormalities in spiral arteries maternal hypertension or pre-eclampsia Sometimes also abnormalities in vessels in the membranes or in the decidua (acute atherosis)• Multiple pregnancy placenta (two or more)• Recipient of the twin-transfusion syndrome
  26. 26. Normal spiral arteries
  27. 27. Multinucleated trophoblast
  28. 28. Spiral artery
  29. 29. Acute atherosis in artery of membranes
  30. 30. Accelerated maturation histology• Premature formation of terminal villi with syncytio-vascular membranes• Stem villi with aspect normal for pregnancy duration• Distal villous hypoplasia with long slender villi and increased space between villi• Hyperchromasia of trophoblast• Increased syncytial knotting
  31. 31. NRBC
  32. 32. Other abnormalities of utero-placental / placental bed pathology• Infarcts• (partial) solutio• (Massive) subchorionic haematoma• Intervillus thrombi / haematoma
  33. 33. Recent infarct
  34. 34. Old infarct with central hemorrhage
  35. 35. Accelerated maturation• Recipiënt of twin-twin transfusion syndrome• CS at 30 weeks because of worsening foetal condition after multiple amniotic drainage
  36. 36. recipiënt 30 weeks donor
  37. 37. Delayed maturation and dysmaturityLess terminal villi as expected.From 30 weeks onwards terminal villi recognisable.At 40 weeks 40% of the villi are terminal villi.• Maternal diabetes• Macrosomia without diabetes• Chronic villitis• Defective placental maturation• Congenital and / or chromosomal abnormality• Donor of twin-twin transfusion syndrome• Foetal anaemia of low colloid osmotic pressure• Foetal cardiac decompensation
  38. 38. Delayed maturation, maternal diabetes• Small groups of immature villi and hydropic villi• Chorangiosis• Fibrinoid necrosis of the villous stroma• Increase of NRBCs
  39. 39. NRBC
  40. 40. Variable maturation example 1 Bichorionic twin placenta at 38 weeksSmall placental part heavy placental part
  41. 41. Main cause of IUFDDisturbance in delivering oxygen to the foetus• Not enough or loss of parenchyma – Small placenta Placental bed pathology – Placental infarcts – Chronic inflammation – Foetal thrombosis• Diffusion distance too long – Fibrin deposition – Abnormal maturation• Umbilical cord pathology
  42. 42. Loss of parenchyma, chronic inflammationSevere villitis of unknown etiology• Destruction of villi, less mature• Infiltrate with macrophages and T-cells• High recurrence risk of IUGR and IUFD – Recently some case reports with favorable outcome after treatment with corticosteroids and antitromboticsBoog et al. J Gynecol Obstet Biol Reprod (Paris). 2006 Jun;35(4):396-404. [Combining corticosteroid andaspirin for the prevention of recurrent villitis or intervillositis of unknown etiology]
  43. 43. CD 68 CD 3
  44. 44. Loss of parenchyma, chronic inflammationChronic intervillositis• Massive histiocytic infiltrate in maternal compartment• Perinatal mortality 29%, IUGR 77%• High recurrence risk of abortion, IUGR and IUFD – Recently some case reports of favorable outcome after treatment with corticosteroids and antitromboticsBoog et al. J Gynecol Obstet Biol Reprod (Paris). 2006 Jun;35(4):396-404. [Combining corticosteroid andaspirin for the prevention of recurrent villitis or intervillositis of unknown etiology]
  45. 45. CD 68 CD 3
  46. 46. Loss of parenchyma, foetal trombosis• Groups of avascular villi• Histology similar as in IUFD• Incidence – Normal placenta’s 2% – Placenta’s with overcoiled cord 20% – Pre-eclampsia 20-30% – Macrosomia without DM 30-40%• Occasionally in association with CMV or trombophilia disorder
  47. 47. CMV
  48. 48. Diffusion distance too long, fibrinGitter infarct, maternal floor infarct• Massive perivillous fibrin deposition• High recurrence risk• High risk of IUGR and IUFD• Sometimes associated with VUE
  49. 49. Diffusion distance too long, maturationDefective placental maturation• Absence of terminal villi, no syncytio-vascular membranes• Occurs after 35-36 weeks GA• No IUGR• Severe hypoxia and increase of NRBC’s at the end of pregnancyStallmach et al. Rescue by birth: defective placental maturation andlate fetal mortality. Obstet Gynecol. 2001 Apr;97(4):505-9.
  50. 50. IUFD at 39 weeks GA IUFD at 40 weeks GAPlacenta with normal weight Placenta with low normal weight
  51. 51. Other placental causes of IUFDHaemorrhage: feto-maternal transfusion – Usually no abnormalities visible in the placentaInflammation – Ascending infection: e.g. bacterial • Chorioamnionitis and funisitis • Acute villitis and microabscesses – Haematogenous infection: e.g. viral, toxoplasmosis • Chronic villitis
  52. 52. Placenta abnormalities and time of deathTime between death abnormalities in the placentaand birth6-36 hr Nuclear dust in foetal circulation and villous stroma12 hr Degeneration of smooth muscle cells of the umbilical cord vessel wall2 days Focal obliteration of vessels in the placental parenchyma2 weeks Extensive obliteration of vessels and villous stromal fibrosis
  53. 53. IUFD 6-36 hr Nuclear dust
  54. 54. IUFD 12 hr - Degeneration of smooth muscle
  55. 55. IUFD 12 hr - granulocytes Degeneration of smooth muscle cells
  56. 56. IUFD 2 days - weeks
  57. 57. IUFD 2 days - weeks Loss of basophilia in smooth muscle cells
  58. 58. IUFD 2 days - weeks
  59. 59. IUFD 2 days - weeks
  60. 60. Umbilical cord pathology• Too short, too long• Knots• Strangulation• Thrombosis• Haemangioma• Meconium induced necrosis• Coiling
  61. 61. Too long with true knot
  62. 62. strangulation
  63. 63. Cord coiling• Umbilical cord: Wharton’s jelly, usually two arteries and a vein• Wharton’s jelly: hyaluronic acid, chondroitin sulphate, collagen• Vessels: form a helix,• Normal coiling approximately between 1 and 3 coils per 10 cm• Abnormal coiling associated with severe perinatal morbidity and mortality
  64. 64. Umbilical cord with Umbilical cord withundercoiling overcoiling
  65. 65. Cord coilingStudy of 885 placenta from UMCU, de Laat et al. Undercoiled cords IUFD Apgarscore < 7 after 5 minutes Congenital / chromosomal abnormality Trisomie (13 / 18 / 21) Premature birth, not corrected Premature birth corrected for amnionitis Single umbilical artery 0.1 0.5 1 5 10 20 30 Odds Ratio (95% CI) de Laat et al. Umbilical coiling index in normal and complicated pregnancies. Obstet Gynecol. 2006 May;107(5):1049-55.
  66. 66. Cord coilingStudy of 885 placenta from UMCU, de Laat et al. Overcoiled cords IUFD asfyxia Umbilical arteriel pH < 7.05 IUGR Trisomie (13 / 18 / 21) Congenital / chromosomal abnormality Single umbilical artery 0.1 0.5 1 5 10 20 30 Odds Ratio (95% CI) de Laat et al. Umbilical coiling index in normal and complicated pregnancies. Obstet Gynecol. 2006 May;107(5):1049-55.
  67. 67. Cord coiling and mortality Perinatal Congenital Solutio, small Unknown Mortality anomaly placenta or prematurityUndercoiled 44 % 48 % 40 % 12 %(133) 58/133 28/58 23/58 7/58Normal 22 % 46 % 49 % 5%(492) 110/492 51/110 53/110 6/110Overcoiled 38 % 39 % 24 % 37 %(99) 38/99 15/38 9/38 14/38
  68. 68. HAVE FUN WITH YOUR PLACENTAS PETER NIKKELS

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