Distribution of cord inflammation in cases with clinical suspicion of chorioamnionitis.

INTRODUCTION: Identification of acute funisitis, a sign of foetal inflammatory response (FIR), is crucial as their presence is associated with ominous neonatal outcomes. Recommendation on which part of umbilical cord should be sampled to facilitate optimal identification of acute funisitis is limited. METHODS: This is a retrospective cross-sectional study over a seven-month duration recruiting all patients with clinical suspicion of chorioamnionitis and/or maternal intrapartum pyrexia. The distribution and the degree of cord inflammation were assessed. The cases were also evaluated for maternal inflammatory response (MIR) and chorionic vasculitis (CV). RESULTS: Of the 191 placentas, 88 (46.1%) had some degree of cord inflammation. Forty-nine (55.7%) had a differential in cord inflammation, with distal cord section (n = 38) demonstrating significant greater inflammation than that of proximal cord section (n = 11) (p<0.001). There were 20 cases with phlebitis only and 8 cases demonstrated arteritis only in either proximal or distal cord sections. Increasing magnitude of cord inflammation was significantly associated with increasing severity of MIR and the rate of CV (p<0.001). CV was observed in 25 (24.3%) cases showing absence of cord inflammation, while 12 (13.6%) cases with cord FIR demonstrated no CV. DISCUSSION: Inflammatory reaction can occur variably throughout the length of the umbilical cord and chorionic plate vessels, with greater inflammation seen in the distal cord section. We affirm the current Amsterdam recommendation of submitting at least two cross sections of the cord representing proximal and distal sites and two sections from placental parenchyma to facilitate the identification of FIR.

MicroRNA profiling in complete and partial hydatidiform moles.

INTRODUCTION: Hydatidiform mole is one of the gestational trophoblastic disease and comprises complete (CM) and partial moles (PM), which carries a risk of developing persistence disease, invasive mole or choriocarcinoma. MicroRNAs (miRNAs) have been discovered in various tissues, including neoplastic tissues. Its role in the pathogenesis of molar pregnancy or as biomarkers are still largely uncertain. The aim of this study is to identify the differentially expressed miRNAs in CM and PM. MATERIALS AND METHODS: Using next-generation sequencing, the miRNAs profiles of CM (n=3) and PM (n=3) moles, including placenta of non-molar abortus (n=3) as control were determined. The differentially expressed miRNAs between each group were analysed. Subsequently, bioinformatics analysis using miRDB and Targetscan was utilised to predict target genes. RESULTS: We found 10 differentially expressed miRNAs in CMs and PMs, compared to NMAs, namely miR- 518a-5p, miR-423-3p, miR-503-5p, miR-302a-3p, and miR-1323. The other 5 miRNAs were novel, not listed in the known database. The 3 differentially expressed miRNAs in CMs were predicted to commonly target ZTBT46 and FAM73B mRNAs. DISCUSSION: miR-518 was consistently observed to be downregulated in CM versus PM, and CM versus NMA. Further bioinformatic analysis to provide insight into the possible role of these miRNAs in the pathogenesis of HMs, progression of disease and as potential diagnostic biomarkers as well as therapeutic targets for HMs is needed.

Diagnostic utility of p57 immunohistochemistry and DNA ploidy analysis by fluorescence in situ hybridisation in hydatidiform moles.

INTRODUCTION: Hydatidiform moles (HMs) include complete and partial moles, are the result of abnormal fertilisation. The accurate classification of HMs and its distinction from non-molar specimens is utmost important for clinical management and risk assessment. It is diagnostically challenging if the distinction is based solely on histomorphology with poor interobserver reproducibility, especially in early gestations. This study aimed to investigate the diagnostic ability of combined p57 immunohistochemistry and DNA ploidy analysis to distinguish between complete moles, partial moles and non-molar abortus. MATERIALS AND METHODS: We included all HMs cases diagnosed in our centre over a six-year period. p57 immunohistochemistry stain was performed. Only nuclear immunoreactivity in >50% of cytotrophoblasts and villous stromal cells was regarded as positive for p57. DNA ploidy status was determined by fluorescence in situ hybridisation. A total of 250 cells from five chorionic villi were counted and were scored as diploid or triploid if more than 10% of nuclei demonstrated two or three signals, respectively. RESULTS: A total of 51 cases originally diagnosed by histomorphology as complete mole (n = 18), partial mole (n = 24) and non-molar abortus (n = 9) were recruited. The cases were reclassified based on the p57 immunostaining pattern and DNA ploidy status, into 27 complete moles (p57-/diploid), 9 partial moles (p57+/triploid) and 15 non-molar abortus (p57+/diploid). The diagnostic accuracy by histomorphological features alone in each category: complete moles, partial moles and non-molar abortus was 78.4%, 70.6% and 88.2% respectively. CONCLUSION: This study highlighted the importance of the utility of combined p57 immunostain and DNA ploidy analysis in arriving at an accurate diagnosis in HMs. An algorithmic approach utilising these ancillary techniques is advocated in routine diagnostic workup for a more refined diagnostic approach to HMs.

Jean W Keeling.

This is a short appreciation of Jean W Keeling as a pediatric pathologist.

Making stillbirths visible: a systematic review of globally reported causes of stillbirth.

BACKGROUND: Stillbirth is a global health problem. The World Health Organization (WHO) application of the International Classification of Diseases for perinatal mortality (ICD-PM) aims to improve data on stillbirth to enable prevention. OBJECTIVES: To identify globally reported causes of stillbirth, classification systems, and alignment with the ICD-PM. SEARCH STRATEGY: We searched CINAHL, EMBASE, Medline, Global Health, and Pubmed from 2009 to 2016. SELECTION CRITERIA: Reports of stillbirth causes in unselective cohorts. DATA COLLECTION AND ANALYSIS: Pooled estimates of causes were derived for country representative reports. Systems and causes were assessed for alignment with the ICD-PM. Data are presented by income setting (low, middle, and high income countries; LIC, MIC, HIC). MAIN RESULTS: Eighty-five reports from 50 countries (489 089 stillbirths) were included. The most frequent categories were Unexplained, Antepartum haemorrhage, and Other (all settings); Infection and Hypoxic peripartum (LIC), and Placental (MIC, HIC). Overall report quality was low. Only one classification system fully aligned with ICD-PM. All stillbirth causes mapped to ICD-PM. In a subset from HIC, mapping obscured major causes. CONCLUSIONS: There is a paucity of quality information on causes of stillbirth globally. Improving investigation of stillbirths and standardisation of audit and classification is urgently needed and should be achievable in all well-resourced settings. Implementation of the WHO Perinatal Mortality Audit and Review guide is needed, particularly across high burden settings. FUNDING: HR, SH, SHL, and AW were supported by an NHMRC-CRE grant (APP1116640). VF was funded by an NHMRC-CDF (APP1123611). TWEETABLE ABSTRACT: Urgent need to improve data on causes of stillbirths across all settings to meet global targets. PLAIN LANGUAGE SUMMARY: Background and methods Nearly three million babies are stillborn every year. These deaths have deep and long-lasting effects on parents, healthcare providers, and the society. One of the major challenges to preventing stillbirths is the lack of information about why they happen. In this study, we collected reports on the causes of stillbirth from high-, middle-, and low-income countries to: (1) Understand the causes of stillbirth, and (2) Understand how to improve reporting of stillbirths. Findings We found 85 reports from 50 different countries. The information available from the reports was inconsistent and often of poor quality, so it was hard to get a clear picture about what are the causes of stillbirth across the world. Many different definitions of stillbirth were used. There was also wide variation in what investigations of the mother and baby were undertaken to identify the cause of stillbirth. Stillbirths in all income settings (low-, middle-, and high-income countries) were most frequently reported as Unexplained, Other, and Haemorrhage (bleeding). Unexplained and Other are not helpful in understanding why a baby was stillborn. In low-income countries, stillbirths were often attributed to Infection and Complications during labour and birth. In middle- and high-income countries, stillbirths were often reported as Placental complications. Limitations We may have missed some reports as searches were carried out in English only. The available reports were of poor quality. Implications Many countries, particularly those where the majority of stillbirths occur, do not report any information about these deaths. Where there are reports, the quality is often poor. It is important to improve the investigation and reporting of stillbirth using a standardised system so that policy makers and healthcare workers can develop effective stillbirth prevention programs. All stillbirths should be investigated and reported in line with the World Health Organization standards.

A difficult conversation? The views and experiences of parents and professionals on the consent process for perinatal postmortem after stillbirth.

OBJECTIVE: To describe the experiences, knowledge and views of both parents and professionals regarding the consent process for perinatal postmortem. DESIGN: Internet-based survey. SETTING: Obstetricians, midwives and perinatal pathologists currently working in the UK. Parents who have experienced a stillbirth in the UK in the previous 10 years. SAMPLE: Obstetricians, midwives and perinatal pathologists registered with their professional bodies. Parents who accessed the Sands website or online forum. METHODS: Online self-completion questionnaire with both fixed-choice and open-ended questions. RESULTS: Responses were analysed from 2256 midwives, 354 obstetricians, 21 perinatal pathologists and 460 parents. The most common reason for parents to request postmortem examination was to find a cause for their baby's death; the prevention of stillbirths in others also ranked highly. Perinatal pathologists possessed greatest knowledge of the procedure and efficacy of postmortem, but were unlikely to meet bereaved parents. The majority of professionals and parents ranked emotional distress and a lengthy wait for results as barriers to consent. The majority of staff ranked workload, negative publicity, religion and cultural issues as important barriers, whereas most parents did not. Almost twice as many parents who declined postmortem examination later regretted their decision compared with those who accepted the offer (34.4 versus 17.4%). CONCLUSION: Emotional, practical and psychosocial issues can act as real or perceived barriers for staff and bereaved parents. Education is required for midwives and obstetricians, to increase their knowledge to ensure accurate counselling, with due regard for the highly individual responses of bereaved parents. The contribution of perinatal pathologists to staff education and parental decision-making would be invaluable.

Hypertrophic cardiomyopathy with cardiac rupture and tamponade caused by congenital disorder of glycosylation type Ia.

Hypertrophic cardiomyopathy (HCM) is a rare presenting feature of congenital disorder of glycosylation type Ia (CDG-Ia). We report two female siblings with CDG-Ia and cardiomyopathy. Patient no. 1 died at 12 days of age from cardiac rupture and tamponade, which has not previously been reported in CDG-Ia. The second patient died at 2 months of age from HCM. The severe cardiac manifestations seen in our patients emphasize the importance of early cardiac assessment in all patients with CDG-Ia.

Estimating umbilical cord flow resistance from measurements of the whole cord.

Measuring umbilical blood pressure in utero is challenging and for this reason non-invasive methods are required. However, the total vessel blood pressure drop can be estimated using numerical and empirical results by studying the mechanics of fluids in coiled and straight tubes. Two key findings emerge from such an analysis. Firstly, the total pressure drop along a vessel at a given blood flow-rate depends on both the tightness of the coils and the total cord length. Relatively short and straight cords exhibit low pressure, while long, tightly coiled cords with large width exhibit high pressure. It follows that an estimate of the pressure requires three measurements: the full cord length, its average width and number of coils. Using this result we propose two prototype indices for clinical testing that estimate umbilical cord flow resistance. The umbilical pressure index (PX) and flow index (QX) quantify the deviation of a cord geometry from defined typical conditions by considering the steady pressure drop and flow-rate, respectively. These indices can be quickly calculated, and require only a single additional measurement to the conventional umbilical coiling index (UCI); namely the cord coiling width. Unlike the UCI, these indices are derived from blood-flow properties and provide a measure of the relative flow-resistance inherent to a cord geometry. Furthermore, the pressure index can be applied to irregularities, including loose true knots, which we show must be accounted for.

Increased lymphocyte micronucleus frequency in early pregnancy is associated prospectively with pre-eclampsia and/or intrauterine growth restriction.

Genome stability is essential for normal foetal growth and development. To date, genome stability in human lymphocytes has not been studied in relation to late pregnancy diseases, such as pre-eclampsia (PE) and intrauterine growth restriction (IUGR), which can be life-threatening to mother and baby and together affect >10% of pregnancies. We performed a prospective cohort study investigating the association of maternal chromosomal damage in mid-pregnancy (20 weeks gestation) with pregnancy outcomes. Chromosome damage was measured using the cytokinesis-block micronucleus cytome (CBMNcyt) assay in peripheral blood lymphocytes. The odds ratio for PE and/or IUGR in a mixed cohort of low- and high-risk pregnancies (N = 136) and a cohort of only high-risk pregnancies (N = 91) was 15.97 (P = 0.001) and 17.85 (P = 0.007), respectively, if the frequency of lymphocytes with micronuclei (MN) at 20 weeks gestation was greater than the mean + 2 SDs of the cohort. These results suggest that the presence of lymphocyte MN is significantly increased in women who develop PE and/or IUGR before the clinical signs or symptoms appear relative to women with normal pregnancy outcomes. The CBMNcyt assay may provide a new approach for the early detection of women at risk of developing these late pregnancy diseases and for biomonitoring the efficacy of interventions to reduce DNA damage, which may in turn ameliorate pregnancy outcome.

Placenta Accreta in an Oragnutan (Pongo abelii) and a Chimpanzee (Pan troglodytes).

Placenta accreta is defined as abnormal adherence of the placenta to the uterine wall. Placenta accreta is recognized as a common problem in human medicine, but has apparently not been reported previously in great apes, despite similarity in their reproductive biology. A 36-year-old multiparous female Sumatran orangutan (Pongo abelii) and a 20-year-old nulliparous female chimpanzee (Pan troglodytes), with gross uterine and histological uterine vascular changes that are characteristic of placenta accreta, are presented.

Histopathological examination of the placenta: key issues for pathologists and obstetricians.

The placenta is often not submitted for histopathological examination and obstetricians may be sceptical of the value of the examination. This article looks at the reasons for histopathological assessment of the placenta, examines what clinical information should be provided to pathologists and reviews what information can be gained from this 'diary of the pregnancy', especially for explaining adverse outcomes and potentially guiding the management of future pregnancies.

Chorion laeve accreta - Another manifestation of morbid adherence.

INTRODUCTION: Smooth muscle in the decidua of fetal membranes (membrane myofibers, MMF) is not mentioned in standard textbooks. METHODS: The current report presents collected observations on 52 patients with MMF at 2 institutions between 2004 and 2017 - including placentas, postpartum curettages, and hysterectomies. RESULTS: Clinical presentations include observation of adherent membranes during delivery, disrupted and incomplete membranes in placentas submitted for examination, postpartum bleeding associated with retained fetal membranes, association with membrane hematomas and membrane hemosiderin, morbidly adherent fetal membranes in hysterectomies; and association with grossly adherent pieces of tissue or nodules in fetal membranes. DISCUSSION: Although MMF can be an incidental microscopic observation in a routine placenta, the suggested diagnostic terminology when there are clinical and/or gross presentations is Chorion Laeve Accreta (ChLA). Further study is needed but MMF appears to be the fetal membrane counterpart of BPMF(basal plate myofibers), possibly due to damage of subjacent myometrium by trophoblastic proteases, so that shear stress during delivery causes myofibers to come out attached to the decidua of fetal membranes. Neither the prevalence of MMF, nor its reliability as a marker for placenta accreta is addressed in this collection. Association of MMF with BPMF, and recurrence of MMF, are documented; but the true frequency of these phenomena remains to be established.

Pressure and flow in the umbilical cord.

A fluid dynamic study of blood flow within the umbilical vessels of the human maternal-fetal circulatory system is considered. It is found that the umbilical coiling index (UCI) is unable to distinguish between cords of significantly varying pressure and flow characteristics, which are typically determined by the vessel curvature, torsion and length. Larger scale geometric non-uniformities superposed over the inherent coiling, including cords exhibiting width and/or local UCI variations as well as loose true knots, typically produce a small effect on the total pressure drop. Crucially, this implies that a helical geometry of mean coiling may be used to determine the steady vessel pressure drop through a more complex cord. The presence of vessel constriction, however, drastically increases the steady pressure drop and alters the flow profile. For pulsatile-flow within the arteries, the steady pressure approximates the time-averaged value with high accuracy over a wide range of cords. Furthermore, the relative peak systolic pressure measured over the period is virtually constant and approximately 25% below the equivalent straight-pipe value for a large range of non-straight vessels. Interestingly, this suggests that the presence of vessel helicity dampens extreme pressures within the arterial cycle and may provide another possible evolutionary benefit to the coiled structure of the cord.

Placental pathology and clinical trials: Histopathology data from prior and study pregnancies may improve analysis.

Placental pathology may explain adverse outcomes and reveal likely recurrent lesions. Stratifying women into intervention arms of a perinatal trial on the basis of the placental histopathological findings of the index pregnancy and evaluating the effect of the interventions against the placental findings at conclusion of a trial may enhance the trial. The Cochrane Central Register of Controlled Trials with "obstetrics" or "perinatal" in the Title, Abstract, or Keywords published in 2015 were classified as to whether placental pathological findings from a previous pregnancy could have been used to stratify the women into the trial and placental pathology (findings) at the end of the study trial could have explained differences in the trial results, and whether these were performed. Two hundred and twenty three of the 275 studies were not relevant. Placental pathology was an outcome measure in 2 of the remaining 52 studies. Seven trials could have benefitted by stratifying women based on previous placental pathology findings, and placental pathology findings at the end of the trial could have explained the trial results but in none of them were these performed. There were 30 trials where placental pathology could have provided an explanation for the result but review of the pathology was not undertaken in any. In the remaining 13 trials, placental pathology was unlikely to be an influence before or after the trial; however, placental pathology would have been of interest or be indicated in most of them. Placental pathology appears to be omitted from perinatal clinical trials. Seventy-four percent (37 of 50) could have benefitted by using placental pathology results of a prior pregnancy to stratify women into intervention arms or incorporating placental pathology results in the evaluation of the interventions.

IFPA meeting 2015 workshop report IV: placenta and obesity; stem cells of the feto-maternal interface; placental immunobiology and infection.

Workshops are an important part of the IFPA annual meeting as they allow for discussion of specialised topics. At the 2015 IFPA annual meeting there were 12 themed workshops, three of which are summarized in this report. These workshops related to various aspects of placental biology and collectively covered areas of obesity and the placenta, stem cells of the feto-maternal interface, and placental immunobiology and infection.

Is endomyometrial injury during termination of pregnancy or curettage following miscarriage the precursor to placenta accreta?

AIMS: To determine the frequency with which myometrium is removed during vacuum terminations of pregnancy or dilatation and curettage after miscarriage, and to relate these findings to subsequent placenta accreta or its proxies. METHODS: Archival tissues from vacuum termination of pregnancy or dilatation and blunt curettage after miscarriage were examined for the presence of myometrium. The subsequent obstetric histories were scrutinised for manual removal of placenta, postpartum haemorrhage, or retained placenta. A retrospective study comparing the frequency of miscarriage and termination in women who had or did not have a manual removal was also performed. RESULTS: Myometrium was seen in the products of conception in 44% and 35% of termination and miscarriage tissues, respectively. One of nine women with myometrium at miscarriage had a postpartum haemorrhage in a subsequent pregnancy whereas, of the 21 women without myometrium at miscarriage, three required manual removal and seven had a postpartum haemorrhage afterwards. A past history of termination and/or miscarriage was more frequent in multigravid women who had a manual removal than those who did not. CONCLUSIONS: Endomyometrial injury is frequent at termination or dilatation and curettage after miscarriage, but the relation to subsequent placenta accreta remains unclear. Women requiring a manual removal of the placenta were likely to have had a past history of termination and/or miscarriage.

Human cytotrophoblast populations studied by monoclonal antibodies using single and double biotin-avidin-peroxidase immunocytochemistry.

Single and double biotin-avidin-peroxidase immunocytochemical methods in conjunction with an anti-trophoblast monoclonal antibody 18B/A5 and an anti-HLA-A,B,C monoclonal antibody W6/32 were used to study various human trophoblast populations. Several combinations of peroxidase substrates were tried in the double-labeling procedure. It was concluded that the use of 4-chloro-1 naphthol to develop the primary sequence peroxidase and of 3-amino-9-ethyl carbazole for the second sequence peroxidase was the most suitable. The significant findings were: Monoclonal antibody 18B/A5 proved to be a useful marker for villous as well as nonvillous trophoblast, which facilitated the identification of these cells particularly in the placental bed. The expression of MHC Class I antigens was not confined to extravillous trophoblast but these antigens were also demonstrable on the villous cytotrophoblast proliferating to form new primary villi. Double labeling revealed that many of these cells, particularly those furthest away from the mesenchymal core, expressed both trophoblast and HLA antigens as shown by a mixing of the colors produced by the two reaction products. A large number of these HLA-A,B,C, positive trophoblast cells were found to infiltrate deep into the uterine myometrium. The hypothesis was put forward that these fetal cells could be the ones that are responsible for maternal sensitization.

Placenta creta and placenta praevia creta.

The placental bed in placenta creta and placenta praevia creta was studied from pregnancy or immediate postpartum hysterectomy specimens. In all cases placental villi were seen in direct contact with myometrium, the sine qua non of placenta creta, but was focal in some cases. There was no apparent diminution of decidua parietalis or, in cases of focal accreta, of adjacent basalis. In all cases the extravillous trophoblast was mainly uninuclear or binuclear, in contrast to the placental bed syncytial giant cells seen in late normal placentation. There was an apparent proliferation of interstitial trophoblast at the junction of placenta with myometrium, but the density of interstitial trophoblast deeper in the myometrium was lower than it is in normal placentation. An unusual uteroplacental vasculature was seen in which physiological changes were present in large arteries of the radial/arcuate system deep in the myometrium, while there were also spiral arteries more superficially without physiological changes. These findings suggest that in placenta creta there is defective interaction between maternal tissues, particularly decidua, and migratory trophoblast in the early stages of placentation resulting in undue adherence of the placenta or penetration into the uterus coupled with the development of an abnormal uteroplacental circulation.

Lack of innervation of human umbilical cord. An immunohistological and histochemical study.

Using a panel of antibodies (monoclonal as well as polyclonal) to nerves, nerve tissue was not identified within the umbilical cord.

On an anatomical basis for the increase in birth weight in second and subsequent born children.

OBJECTIVE: Structural changes of the spiral arteries needed for the pregnancy do not completely resolve following parturition. We tested the hypothesis that these anatomical changes are related to the number of previous pregnancies. METHODS: Video image analysis was performed on Masson-stained sections from 28 hysterectomy specimens, examining the proportion of non-muscular tissue within the spiral arterial walls. Semi-quantitative analysis of changes of the internal elastic lamina was performed on orcein-stained sections. The extent of changes was tested for correlation with parity using regression analysis. RESULTS: Duplication and fragmentation of the internal elastic lamina increased with increasing parity (P=0.019) with differences between nulliparity and parity 1, 2, 3 or 4 but not between other parity pairings. The proportion of non-muscular tissue increased with increasing parity (P=0.010). CONCLUSIONS: These results suggest that pregnancy results in permanent anatomical changes in the spiral arteries that may modify subsequent vascular remodelling in the next pregnancy. This could provide an anatomical basis to explain the epidemiological data showing an increasing birth weight with increasing parity, particularly of the second born.