Prosessrelatert, klinisk relevant placentaklassifikasjon

Senter for barne- og

svangerskapsrelatert patologi

Prosessrelatert, klinisk relevant placentaklassifikasjon

Kurs O-30185 Perinatalpatologi inkludert placenta,

13.10.2015

Gitta Turowski, overlege og PhD kandidat, Senter for barne-

og svangerskapsrelatert patologi, OUS-Ullevål



Placenta er et dynamisk

organ som regulerer

sin vekst og modning

etter behov

- oppfattes som ‘fetal

diary’

Forskning om placenta

er nødvendig for å

bedre forståelsen av

samspill mellom mor –

placenta – og barn

bedre.



Utfordringer i placentadiagnostikk

• 2 (eller flere) individ, 2 (og flere) sirkulasjonssysteme (maternell og føtal)

• Dynamisk organ (modning og modningsforstyrrelse)

• Infeksjon

• Metabolisk forstyrrelse

• Genetikk



Hvorfor er det viktig å vurdere forandringene mikroskopisk?

Inflammasjon

Vurdering av føtal sirkulasjon (navlesnorkar,

placenta/tottekar)

Vurdering av maternell sirkulasjon

Tottemodning

Implantasjonsfeil



Ingen internasjonal akseptert

klassifikasjonssystem!



Samling av criteria

Standardisering

Diskusjon om formulering og form av

report

Klassifikasjons system for placenta

diagnostikk

Lett forståelig

(obstetriker,

sykepleier,

jordmødre,

neonatologer,

andre patologer

Klinisk

relevant

Prosess-

relatert

Forskning



Diagnose kategorier i placenta

1. Normal placenta

2. Placenta med akutt chorioamnionitt

3. Placenta med villititt og intervillositt

4. Placenta med maternell vaskulær malperfusjon

5. Placenta med føtal vaskulær malperfusjon

6. Placenta med modningsforstyrrelse

7. Placenta, suspekt på genetisk feil

8. Placenta med feil implantasjon

9. AnnetAlle diagnoser inkluderer en patophysiologisk vurdering og diskusjon av alle

funn i en klinisk patologisk korrelasjon



1. Normal placenta for gestasjonslengdeVillous

maturation

Branching from primary to secondary and tertiary villi with smaller diameter

Vascular

maturation

Central fetal capillaries to vasculosyncytial membranes.

Arterial fibro-muscular hyperplasia in primary villi

Stromal

maturation

Dominant embryonic, loose stroma with Hofbauer cells to sparse stroma dominated by fetal capillaries in tertiary villi

Fibromuscular stroma in primary villi

Gestational week

Villi in %

16 20 24 28 32 36 40

Stem villi:

Reticular stroma with fetal

vessels, paravascular

collagen

17 13 10 9 11 10 9

Intermediate villi,

immature type:

Embryonic stroma, many

Hofbauer cells

54 51 32 16 10 5 1

Intermediate villi, mature

type:

Cellular stroma, scattered

Hofbauer cells

29 35 50 56 52 47 32

Terminal villi:

Stroma with fetal capillaries

dominated by

vasculosyncytial membranes

0 1 8 19 27 38 58

Vogel M. Atlas der morphologischen Plazentadiagnostik. second ed. Berlin: Springer; 1996.

BECKER V. [Functional morphology of the placenta]. Arch Gynakol 1963;198:3-28.



1. Normal placenta

• Normal moding for gestasjonslengde



Infeksjoner i placenta

Placenta

1. Oppadstigende (fra vagina): chorioamnionitter

2. Transplacentære (blodbårne): villitter

1Decidua

basalis

2

Annetine Staff



2. Akutt chorioamnionittInvasion of neutrophilic granulocytes in chorion and amnion

Maternal response

(stadium 1-3, grade 1-2)

Fetal response

(Stadium 1-3, Grade 1-2)

Redline. "Inflammatory response in acute chorioamnionitis." Semin.Fetal Neonatal Med. (2011).

Redline "Inflammatory responses in the placenta and umbilical cord." Semin.Fetal Neonatal Med. 11.5 (2006): 296-301.



2. Akutt og kronisk chorioamnionitt

Acute Maternal response Fetal response

Stage 1 Neutrophils in subchorionic/chorionic fibrin

Grade 1 or 2

Umbilical phlebitis and /or chorionic vasculitits

Grade 1 or 2

Stage 2 Neutrophils in chorionic plate and

membranes

Grade 1 or 2

Umbilical arteritis and phlebitis

Grade 1 or 2

Stage 3 Karyorrhexis and amniocyte necrosis

Grade 1 or 2

Umbilical concentric periphlebitis/necrotizing

funisitis

Grade 1 or 2

Grade 1: slight to moderate

Grade 2: intense, > 30 neutrophils in chorionic plate and sub-/chorionic micro abscess

Subacute Invasion of acute and chronic inflammatory cells between amnion and chorion

Necrosis

Chronic Lymphocytes in the chorionic trophoblast layer or chorioamniotic connective tissue

Stage 1 Amniotropic lymphocytic invasion confined to the chorionic trophoblast layer

Stage 2 Lymphocytic invasion into the chorioamniotic connective tissue

Grade 1 =>3 foci or patchy inflammation

Grade 2 Diffuse inflammation

Redline RW. Inflammatory response in acute chorioamnionitis. Semin Fetal Neonatal Med 2012 Feb;17(1):20-5

Lee J, Romero R, Dong Z, Xu Y, Qureshi F, Jacques S, et al. Unexplained fetal death has a biological signature of maternal anti-fetal

rejection: chronic chorioamnionitis and alloimmune anti-human leucocyte antigen antibodies. Histopathology 2011 Nov;59(5):928-38.



3. Villitit og intervillosittChronic villitis, including villitis of unknown etiology (VUE) and infectious etiology

Microscopic criteria Low grade High grade

Chronic villous inflammation 5-10 villi/focus,

multifocal

>10 villi/focus

Associated lesions Focal groups of fibrous villi

Obliterated fetal vessels

Extensive perivillous fibrin

Active component (neutrophils)

Decidual plasmacells

Intervillositis Macroscopic findings Microscopic findings

Acute Green and/or opaque

membranes

Pale and/or firm yellow

basal plate

Neutrophils in villi/intervillous space

Fibrin

Chronic Small placentas Diffuse intervillous invasion of lymphocytes,

monocyte-macrophages, eosinophils

Villous necrosis and perivillous fibrin

Histiocytic Small placentas Diffuse intervillous invasion of histiocytes

Benirschke K, Kaufmann P, Baergen RN. Pathology of the Human Placenta. Fifth edition ed. New York: Springer; 2006

Baergen RN. Manual of Pathology of the Human Placenta. second ed. New York: Springer; 2011.

Kraus FT, Redline RW, Gersell DJ, Nelson DM, Dicke JM. Placental Pathology. Washington, DC: American Registry of Pathology in

collaboration with the Armed Forces Institute of Pathology; 2004.

Redline RW. Infections and other inflammatory conditions. Semin Diagn Pathol 2007 Feb;24(1):5-13.

Redline RW. Villitis of unknown etiology: noninfectious chronic villitis in the placenta. Hum Pathol 2007 Oct;38(10):1439-46.

Boog G. Chronic villitis of unknown etiology. Eur J Obstet Gynecol Reprod Biol 2008 Jan;136(1):9-15.



3. Villitis and intervillositis

Low grade High grade

< 10 villi per focus

focal > 1 focus /slide

multifocal > 1 slide

> 10 villi per focus

patchy: > 1 focus

diffuse: > 5% of all villi

Intervillositis: Acute/chronical

CD 3

CD 68

CD 8

AFIP Placenta Fascicle, 2004Redline "Villitis of unknown etiology: noninfectious chronic villitis in the placenta." Hum.Pathol. 38.10 (2007): 1439-46.



4. Maternell vaskulær malperfusjonChronology of infarction/ischemia Acute (hours - 2 days) Subacute (>2 days) Chronic (>1week)

Villous capillary stasis with/without

hemorrhage

Trophoblastic necrosis and/or villous

necrosis

Fibrin deposition intra-/intervillous

Trophoblastic proliferation in the

infarction borders

Demarcation of neutrophils

Maternal

malperfusion:

Increased syncytial knots (estimated according to gestational age)

Villous agglutination (clusters of adherent distal villi)

Increased intervillous fibrin

Distal villous hypoplasia

Atherosis of decidual arteries

Placental weight < 10th percentile

Pathology Macroscopy Microscopy

Cotyledon infarct Acute Basal/ intermediate

Dark red

Sharply demarcated

Intravillous hemorrhage

Congestion of villous capillaries

Collapse of the intervillous space

Subacute Brownish Trophoblastic necrosis

Intra-/intervillous fibrin deposition

Demarcation by maternal neutrophils

Chronic Yellow to white

Sharply demarcated

Pyknosis, karyorrhexis

Ghost villi

Intervillous fibrinoid

Intervillous

thrombe

Acute Red, often shiny Intervillous hemorrhage

Chronic White

Sharply demarcated

Laminated fibrin

Abruption Acute Dark red and soft

Clots adhered to maternal surface

Compressed underlying villous tissue

Intravillous hemorrhage,

Capillary stasis and edema

Chronic Brown, basal impression Chorioamnionic hemosiderin-

macrophages


Stanek J. Placental membrane and placental disc microscopic chorionic cysts share similar clinicopathologic associations. Pediatr Dev Pathol

2011 Jan;14(1):1-9.



4. Placenta med maternell vaskulær malperfusjon

Infarkt

Intervilløse fibrinavleiringer

Intervilløs trombe (føtomaternell

hemorrhagi (identifiserbare

føtale erytrocytter), maternell

trombophili eller preeklampsi

Perivilløs fibrinoidavleiring

Maternal floor infarct - ?

Evt. påvisbar maternell karpatologi i

decidua

Abruptio

Placental Malperfusion." Manual of Benirschke and Kaufmann's Pathology of the human placenta. 1 ed. New York: Springer, 2005. 232-350.Pathology of the placenta. VI. Circulation disorders of the placenta. Maternal circulation (intervillous space)." Zentralbl.Pathol. 137.4 (1991): 316-24.Redline, R. W., et al. "Maternal vascular underperfusion: nosology and reproducibility of placental reaction patterns." Pediatr.Dev.Pathol. 7.3 (2004): 237-49.

Stanek, J. and H. A. Al-Ahmadie. "Laminar necrosis of placental membranes: a histologic sign of uteroplacental hypoxia." Pediatr.Dev.Pathol. 8.1 (2005): 34-42.



Maternal floor infarction

- decidual floor infiltrated by fibrinoid

- thick, yellow floor

- villous tissue diffuse penetrated

- fibrinoid encases viable villi in a netlike

pattern

- reduced blood flow, obstructed

materno-fetal exchange

congenital infection, immune-mediated

rejection

IUGR, neurologic impairment

recurrent risk 30%



5. Føtal vaskulær malperfusjonPatterns of fetal vascular thrombosis (FVT)

Luminal thrombosis Microscopic findings, vessel and

vessel wall

Microscopic findings, villous stroma

Acute thrombosis Fibrin deposits with/without

occlusion

Endothelial edema

Karyorrhexis

Erythrocyte extravasation

Iron deposits in the basement membrane

Subacute thrombosis Thrombe attached to vessel wall Fibrosis in proximal villi

Chronic Thrombosis Thrombe organization

Recanalization

Calcification

Clusters of distal avascular and fibrous

villi close to affected stem villi

Mural thrombosis Microscopic findings of the vessel

Intimal fibrin cushion Laminated pale blue fibrin between vascular smooth muscle and

endothelium (+/- calcification)

Hemorrhagic

endovasculitis

Rupture of fetal vessels in primary villi with hemorrhage and inflammatory

cells. Active lesion: Inflammatory villous infiltrates = hemorrhagic villitis

Fibrinous vasculosis

(endangiopathia

obliterans)

Edema in the fetal vessel wall

Obliteration/thrombosis

Endothelial cushionLocalized proliferating fibroblasts (intramural fibrin, erythrocytes)

With/without secondary calcification


Kraus FT, Redline RW, Gersell DJ, Nelson DM, Dicke JM. Placental Pathology. Washington, DC: American Registry of Pathology

in collaboration with the Armed Forces Institute of Pathology; 2004.

Redline RW, Ariel I, Baergen RN, Desa DJ, Kraus FT, Roberts DJ, et al. Fetal vascular obstructive lesions: nosology and

reproducibility of placental reaction patterns. Pediatr Dev Pathol 2004 Sep;7(5):443-52.

Emmrich P. [Pathology of the placenta. V. Circulatory disorders of the placenta. Fetal vascular system]. Zentralbl Pathol

1991;137(2):97-104.

Redline RW. Placental pathology and cerebral palsy. Clin Perinatol 2006 Jun;33(2):503-16.



Føtal trombotisk malperfusjonassosiert med:

• Preeklampsi

• FGR

• IUFD

• Neonatal trombose beskrevet i CNS, lunge, nyre



5. Placenta med føtal vaskulær malperfusjon

Thrombe i føtale kar

Rekanalisasjon

Endothelial cushin

Vasculitt

Endarteriitt obliterans

Hemorrhagisk endovaskulitt

Redline R. Placental pathology and cerebral palsy. Clin.Perinatol. 33.2 (2006): 503-16.

Redline Placental pathology: a systematic approach with clinical correlations. Placenta 29 Suppl A (2008): S86-S91.



Patogenese av tromber

(Baergen, R.N., Manual of Benirschke and Kaufmann’s Pathology of the Human Placenta. Springer 2004.)

• Lang navlesnor

• Knute

• Spiralisering

• Velamentøs navlesnorfeste

• Mekanisk obstruksjon

• Thrombose i arterie forårsaket av abnormal koagulasjon i mor eller

barn: Factor V Leiden mutasjon, aktivert protein C resistance, protein S

deficiency, protein C deficiency, lupus anticoagulant, antiphospholipid

antibodies



6. Modningsforstyrrelse (delayed maturation)

Microscopy

Maturation disorder Villi Fetal vessels

Villous maturation arrest

(delayed villous maturation,

distal villous immaturity)

Focal imbalance of villous branching

Predominance of villi with increased diameter

Excessive cellular stroma

Excessive extracellular matrix

Increased number of centrally localized

capillaries

Reduced vasculosyncytial membranes

Benirschke K, Kaufmann P, Baergen RN. Pathology of the Human Placenta. Fifth edition ed. New York: Springer; 2006

Emmrich P. [Pathology of the placenta. III. Maturation disorders of the placenta]. Zentralbl Allg Pathol 1990;136(7-8):643-56.

BECKER V. [Functional morphology of the placenta]. Arch Gynakol 1963;198:3-28.

Higgins M, McAuliffe FM, Mooney EE. Clinical associations with a placental diagnosis of delayed villous maturation: a retrospective

study. Pediatr Dev Pathol 2011 Jul;14(4):273-9.

Redline RW. Distal villous immaturity. Diagnoistic Histopathology 2012;18-5(Placental and trophoblastic pathology):189-94.



week 9week 22

week 30 week 40

Normal modning

Becker, V.: Funktionelle Morphologie der Plazenta. Verh. Ges. Gynaekol.1963; 34: 3-28. Emmrich, P.: Pathology of Placenta. III. Maturation disorders.

Zentralbl. Allg. Pathol. Pathol. Anat. 1990; 136: 643-656. Gustav Fischer Verlag Jena.

Emmrich, P. Pathology of the placenta. IV. Maturation disorders of the placenta under special clinical conditions. Zentralbl.Pathol. 137.1 (1991): 2-13.Vogel M. Zottenreifungsstoerungen." Atlas der morphologischen Plazentadiagnostik. 2 ed. Berlin: Springer, 1996. 82-91.

Placenta med modningsforstyrrelse

Benirschke K, Kaufmann P. Pathology of the human Placenta, 4.th ed. Sprimger



Mikroskopiske funn i placenta ved GDM

Desoye, Kaufmann: The human placenta in diabetes. Diabetology of Pregnancy Basel, Karger, 2005; vol 17: pp 94-109.Kos, Vogel: Morphological findings in infants and placentas of diabetic mothers. Diabetology of Pregnancy. Basel, Karger, 2005; Vol 17, pp127-143Stallmach et al: Rescue by birth: Defective Placental Maturation and late fetal mortality. Obstetrics and Gynecology 2001; vol 97, no 4, pp505-509

normal

Maternell sirkulasjonssvikt

diabetes

barnets kar i placentavilli



7. Funn, suspekt på genetisk aberration

Diagnosis Genetic

characteristics

Macroscopic

characteristics

Microscopic characteristics

Complete

hydatidiform mole

Paternal

Diploid

(46 xx or 46 xy)

Translucent vesicles Apolar trophoblastic hyperplasia

Intraepithelial microcysts

Cellular atypia

Hydropic villi with central cisterns

Absence of fetally-derived tissue

Partial

hydatidiform mole

Triploid

(69 xxx, 69 xxy, 69

xyy)

Normal villous tissue

intermixed with translucent

vesicles

Partly normal, partly complete mole

Trisomi 13 Non-disjunction/or

mosaic

Often SUA (single umbilical

artery),

hydropic

Scalloping avascular villi

Villous inclusions

Dysmature villi


mosaic

Often SUA

Reduced vascularity

Very small placentas

Marked increase in villous stromal cells

Dysmature villi

Villous inclusions

Increased syncytial knots


mosaic

Sometimes increased weight Hydropic change

Atypical trophoblastproliferation

Tetraploidy Voluminous/poorly vascularized villi

Endovillous migration of trophoblastcells

Mesenchymal

dysplasia

Possible mosaicism Often large for gestational

age

Enlarged primary villi, stemvilli with fibroblastic stroma

Increased vascularization

Cystic degeneration without trophoblast hyperplasia

Multifocal or localized lesions

Horn LC, Vogel M. [Gestational trophoblastic disease. Non-villous forms of gestational trophoblastic disease]. Pathologe

2004 Jul;25(4):281-91.

Kraus FT, Redline RW, Gersell DJ, Nelson DM, Dicke JM. Placental Pathology. Washington, DC: American Registry of

Pathology in collaboration with the Armed Forces Institute of Pathology; 2004.



7. Placenta med funn, suspekt på genetisk aberration

Kliman, H. J. and L. Segel.The placenta may predict the baby.J.Theor.Biol. 225.1 (2003): 143 45.

Vogel, M. and L. C. Horn. "[Gestational trophoblastic disease, Villous gestational trophoblasticdisease]."

Pathologe 25.4 (2004): 269-79.

- komplett hydatidiform mola

- partial hydatidiform mola

- trisomi, tetraploidy, mosaics

> Trophoblastic proliferasjon

> Trophoblastic invagination/-

inclusion

> Stroma cisterns



8. ImplantasjonsfeilMacroscopy Microscopy

Accreta Various Villi directly implanted onto the

myometrium (no decidua)

Increta Various Villi implanted into the myometrium

Percreta Placenta protruding through the

uterine wall

Villi penetrating the whole uterine wall

(to / throu serosa)

Extrachorialis/

Circumvallata

Fetal surface less than maternal

surface

Membranes inserted on the fetal

plate

Peripheral parenchyma without

membranes

Fibrin deposition/necrosis

Duplication of the membranes

Hemorrhage, hemosiderin/fibrin

deposition/necrosis

Other form variation and umbilical cord variation

Umbilical cord Disc

Velamentous

umbilical cord

Cord insertion in membranes Normal

Insertio

furcuata

Splitting of umbilical cord vessels

above the placental surface (no

Whartons’jelly)

Normal

Bipartita Velamentous insertion Two/three placental discs connected by

membranes

Bi-/multilobata Normal Two or many placental lobes

Membranacea Normal Flat, membrane like disc

<5 mm thick

Sometimes villous fibrosis

Succenturiata Umbilical cord insertion on the main

placenta

One or more placentas connected by

vessel bridges in the membranes

Baergen RN. Manual of Pathology of the Human Placenta. second ed. New York: Springer; 2011

Kraus FT, Redline RW, Gersell DJ, Nelson DM, Dicke JM. Placental Pathology. Washington, DC: American Registry of

Pathology in collaboration with the Armed Forces Institute of Pathology; 2004.




8. Placenta med implantasjonsfeil

- formvariasjon (circumvallata)

- velamentøs festet navlesnor

- placenta accreta/increta/percreta



9. Andre lesjoner

Macroscopy Microscopy

Gitterinfarct White irregular shaped areas

with solid consistency

Inter- and perivillous fibrin

masses

Maternal floor infarct Yellow rim of pallor

involving the villous tissue

adjacent to the maternal

surface

Netlike organized fibrinoid

around viable villi near

basal plate

Chronic deciduitis Plasmacell invasion and necrosis in the decidua

Retention phenomenas <= 1 week few weeks more weeks

Chorionic epithelium Eosinophilic syncytium

Increased amount of syncytial

knots

Karyorrhexis in the

syncytium

Perivillous fibrin

Lost of epithelium

Perivillous fibrin

Intervillous space obturated

Villous stroma Minor stroma condensation Swelling of collagen

High collagen amount

Hydropic/mucoid

degeneration

Collagen tissue cells Pyknosis Pyknosis

Cell proliferation

Lost of cells


Kraus FT, Redline RW, Gersell DJ, Nelson DM, Dicke JM. Placental Pathology. Washington, DC: American Registry of Pathology in collaboration with the Armed Forces

Institute of Pathology; 2004.




Diagnosis Macroscopy Microscopy

Chorangioma (hamartoma) Solitary or multifocal

Sharply demarcated

Reddish

Proliferation of fetal vessels

Myxomatous/fibrous stroma

Choriocarcinoma Hemorrhage, necroses Solid sheets of cytotrophoblasts

Multinucleated syncytium without stroma

Syncytiotrophoblast with irregular,

hypochromatic nuclei

Dense, eosinophilic cytoplasm

Invasive mole (subsequent to molar

pregnancies)

Focal bleeding in the myometrium wall Mole like villi in the myometrium

Apolar trophoblastic proliferation

Placental disc Partition Vessel anastomosis (risk

of TTT)

Separated Dichorionic-diamnionic None

Merged Dichorionic-diamnionic Exceptionally

Merged Monochorionic-diamnionic Frequently

Merged Monochorionic-

monoamnionic

Always

Anastomosis Macroscopy Microscopy

Chronic a-v/a-a in parenchyma

rarely v-v on chorionic

plate

Donor Parenchyma huge, pale

grayish

Thin umbilical cord

Clinics: oligo-hydramnion

Delayed mature villi

Fibrous stroma

Sclerotic vessels in primary

villi, stem villi

Regressive trophoblast

Inter-/perivillous fibrin

deposition

Amnion nodosum

Recipient Parenchyma small, red-

grayish

Thick umbilical cord

(edema)

Clinics: poly-hydramnion

Dissociated villous

maturation

Tertiary villi with increased

branching angiogenesis

Villous stromal edema

Acute a-a/v-v on chorionic plate

and parenchyma

Donor Pale Poor vascularization

Recipient Red Rich vascularization

TTT=Twin-Twin Transfusion: a-a=artery-artery anastomosis, v-v=vein-vein anastomosis, a-v=artery-vein

anastomosis

9



Placenta med andre lesjoner

Neoplasi (Chorangiom,

Chorioncarcinom)

Gitterinfarkt (!)

Maternal floor infarkt (!)

Kronisk deciduitt

Retensjon

Twin-twin transfusion

Wallenburg, H. C. "Chorioangioma of the placenta. Thirteen new cases and a review of the literature from 1939 to 1970 with special reference

to the clinical complications." Obstet.Gynecol.Surv. 26.6 (1971): 411-25.

Baergen, R. N. "Choriocarcinoma." Manual of Benirschke and Kaufmann's Pathology of the human placenta. 1 ed. New York: Springer, 2004. 436-46.

Monique W. M. de Laat, Gwendoline T. R. Manten,Peter G. J. Nikkels,Philip Stoutenbeek

Hydropic Placenta as a First Manifestation of Twin-Twin Transfusion in a Monochorionic Diamniotic Twin Pregnancy JUM March 2009 28:375



Test av mikroskopiske kriteria på 315 placentas of IUFD og 31 kontroller(placentas av levende fødte på:

User-

friendliness

Reproducibility

(kappa value to

each diagnosis

category)

G. Turowski et al. / Placenta 33 (2012) 1026-1035



Resultater

• Inter observer agreement av histologiske kriterier er generell god

• Kappa values reflekterer nøyaktighet av histologiske kriterier, som

‘very good’ for akutt chorioamnionitt

• Maternell (good) og føtal (moderate) malperfusjon veldig dårlig kappa

values

• Villititt og modningsfeil veldig dårlig

Feedback av klinikerne veldig positiv:

• Diagnoser lett forståelig

• Diagnoser nyttig for the patients follow up (barn, mor, far)

• 85% vil beholde klassifikasjonssystemet

C.A. Walsh, F.M. McAuliffe, G.Turowski, B.Roald, E.E. Mooney: A survey of

obstetricians’ views on placental pathology reporting. International Journal of

Gynecology and Obstetrics. Vol.121. pp275-277. June 213

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Placenta biopsier mellom 2001 og 2014

0

200

400

600

800

1000

1200

1400

Placenta

2002 2003 2004 200720062005 2013 20142001



Prioritierungssystem

1. Samtlige rekvirenter får en stempel, der det

krysses av klinisk informasjon om pasienten med

relevans

2. Placenta makroskopisk vurdert

3. Paraffin blokker arkiveres

4. Prøvesvar sendes på grundlag av makroskopiske

funn

5. Ved spesiell klinisk spørsmålstilling undersøkes

materialet histologisk og ny diagnose sendes som

‘tillegg’



Det kliniske spørsmålet til patologen:

Apgar :

Barnets fødselsvekt (g):

Gestasjonsuke: Ønsket prioritering til patologen: (sett kryss)

CITO (calling nr.) ☐

Høy ☐

Lav (primært kun makrovurdering) ☐

Diagnosegruppe (settkryss):

Hypertoni / PE……. ☐Diabetes ………….… ☐

Inflammatorisk/ Autoimmun ……….. ☐Infeksjon ……………. ☐Placenta patologi /blødning…………..… ☐Født <37 uker / Fødselsvekt<2,5kg.. ☐Annet……………….….. ☐

Prioritering av placenta



0

50

100

150

200

250

EP7000 EP7100 EP7200 EP7300 EP7400 EP7500 EP7600 EP7700 EP7800 EP7900

Besvarte placentaprøve hittil i år, EP kode funnkode 1.

An

tall

Diagnose fordeling, Oktober 2014



Hvor er vi i dag?

Placenta diagnostikk er viktig:

• Stillbirth Conference, September 2014 i Amsterdam:

Placenta diagnostic skal bli en essentiell del i Stillbirth

classification…even more….agreement on international

classification

• IFPA Placenta meeting, September 2014 i Paris: klinikerne

påperker klinisk relevans av placenta diagnostikk I IUFD

(Haezell, etc) i forskjellige ´workshops´ og presentasjoner

> continued in Brisbane i 2015

• PPS meeting, September 2014, Birmingham



Internasjonal arbeidsgruppe som utarbeiderdiagnostiske kriterier i 2014 i Amsterdam(Redline, Keeting, Mooney, Khong, Desoye, Nikkels, Sebire, Boyd, …….……. Turowski)

Diskusjon om sampling og terminologi, som

MVP (maternal vascular malperfusion, out:

maternal vascular underperfusion)

FVM (fetal vascular malperfusion, out: fetal

thrombotic vasculopathy)

acute chorioamnionitis (´acute subchorionitis´)

Maturation disorders – Distal villous hyplasia,

delayed villous maturation – ongoing discussion

Article accepted in Archives of Pathology & Laboratory

Medicine.





Kasus 1

• Nigeriansk kvinne, 27 år gammel 1.gangs gravid i

uke 22, på besøk i Norge

• Spontanabort hjemme

• Innlagt på sykehuset med tegn til infeksjon





Diagnose

Akutt chorioamnionitt.Vurdering: Chorioamnion viser akutt tegn til maternell

inflammatorisk respons på en oppadstigende infeksjon.

Navlesnorkar med akutt inflammasjon indikerer føtal

respons på mors infeksjon. Blødning i decidua tyder på

partiell placentablødning med løsning, som står i direkt

sammenheng med infeksjon og abort.



Kasus 2

• 39 gammel kvinne, gravida 4, para 3

• kjent gestasjonsdiabetes

• forhøyet blodstrøm i a. umbilikalis

• barnet vekstretardert

• indusert fødsel i uke 37

• barn levende født



CD 31

Masson-TrichromHE



Diagnose

Vekstretardert placenta med

modningsforstyrrelse.Vurdering: Basalflate (maternell flate) er mindre enn 10.-

persentil i uke 37. Parenchymet viser tegn til

modningsforstyrrelse med sentral i stroma plasserte

føtale kar, som passer med metabolske forandringer.

Det fantes kun lite antall vasculosyncytiale membraner.



Thanks to:Norwegian group of perinatal and placental pathologists (head

Gitta Turowski)

Ekstrastiftelsen Helse og Rehabilitering (H&R) and Landsforening

for Uvented Barnedød (LUB)

Branka M. Yli, prof. Dr. med. obstetrics, OUS Rikshospitalet

Annetine Staff, prof. Dr. med., obstetrics OUS-Ullevål, IFPA

Placentology award 2013

Patji Alnæs Katjaviwi, resident, obstetrics, PhD student, OUS

Ullevål

Borghild Roald, prof. Dr. med., Pathology, Head of the center for

pediatric and pregnancy related pathology, OUS-Ullevål



Mange takk!

Documents

Prosessrelatert, klinisk relevant placentaklassifikasjon