Understanding decidual vasculopathy and the link to preeclampsia: A review.

Preeclampsia is the archetype of a spectrum of clinical disorders related to abnormal placental development or function, characterized by placental histological lesions. Among those lesions, decidual vasculopathy is a term used to describe lesions of maternal spiral arteries, which are encountered on placental examination in about half of the women with preeclampsia. The morphological features of the lesions include perivascular lymphocytic infiltration, fibrinoid necrosis and foam cell incorporation within the vessel wall. Due to the resemblance of the latter characteristic to atherosclerosis, they are alternatively termed acute atherosis. Decidual vasculopathy correlates with worse maternal and neonatal outcomes, as well as placental pathology. In this article, we review the available literature on decidual vasculopathy and address the pitfalls in histological analysis of the lesions, including the varying definitions of the lesions and sample collection methods. We also discuss the current evidence on the etiology of the lesions and propose a novel hypothesis linking the three etiological pathways to the formation of decidual vasculopathy and, ultimately, the emergence of the heterogeneous group of placental dysfunction disorders, known as the great obstetric syndromes.

Prevalence of hypertensive disorders in women after preeclamptic pregnancy associated with decidual vasculopathy.

OBJECTIVE: A subgroup of preeclamptic women has spiral artery lesions termed decidual vasculopathy (DV) which relate to worse clinical outcome. We aimed to determine whether a history of preeclampsia (PE) with DV is associated with adverse overall and future pregnancy outcome, including increased recurrence risk of hypertensive diseases of pregnancy. METHODS: Via posted survey women with PE and DV (DV positive) in the index pregnancy were compared to those without the lesions (DV negative) on overall and future pregnancy outcome. RESULTS: DV positive cases showed a higher incidence of chronic hypertension both preconceptionally and at time of survey, adjusted odds ratio 4.8 (2.0-11.9). The DV positive group had a higher overall incidence of pregnancies with gestational hypertension (22% vs 13%, p = 0.04), preterm birth (59% vs 45%, p = 0.02) and a lower birth weight centile (30 vs 39, p = 0.02). There was no difference in outcome of future pregnancies, irrespective of the use of prophylactic aspirin. CONCLUSION: Women with DV-associated PE have a higher overall incidence of adverse obstetric outcome and of chronic hypertension, indicating an underlying vascular pathology, putting them at risk for pregnancy and cardiovascular complications. These women constitute a target group for counseling, monitoring and possibly lifestyle or pharmacological interventions.

Decidual vasculopathy in preeclampsia: lesion characteristics relate to disease severity and perinatal outcome.

OBJECTIVE: In a proportion of patients with preeclampsia, unremodeled spiral arteries develop additional pathological changes, termed decidual vasculopathy (DV), or acute atherosis. DV has been correlated to adverse clinical outcome and increased placental pathology. However, it was unclear whether these effects pertained to individual features of DV. METHODS: We performed a reanalysis of placental samples from preeclamptic pregnancies (n = 76), recording the number of vessels with DV, their location in the decidua and their morphological features. Results were correlated with clinical and placental parameters, using Spearman's rho test. P-value < 0.05 was considered significant. RESULTS: Total number of vessels with DV (totalDV) correlated with higher diastolic blood pressure, higher urine protein-to-creatinine ratio, shorter gestational age, lower birth weight, 5 min APGAR score and umbilical artery pH, and with increased accelerated villous maturity, infarction and hematoma formation, but not with HELLP syndrome markers. Additionally, there was a striking correlation of increased perinatal mortality with the number of vessels located in the decidua basalis (DVbas), and with vessels showing DV with thrombosis (DVthrom). Other morphological features, such as foam cell infiltration, did not increase correlation strength. DISCUSSION: In our study of preeclamptic placental samples, totalDV related to worse clinical outcome and increased placental pathology. Moreover, DVbas and DVthrom related to perinatal death. DV could be a manifestation of an underlying (vascular) pathology, increasing the risk of adverse pregnancy outcome. CONCLUSIONS: In preeclampsia, totalDV, DVbas and DVthrom correlated with increased placental pathology and adverse maternal and fetal outcome, most relevantly with perinatal mortality.

Decidual vasculopathy and adverse perinatal outcome in preeclamptic pregnancy.

OBJECTIVE: Decidual vasculopathy (DV) describes pathological findings seen in the spiral arteries in preeclampsia (PE). Morphologically, DV is characterized by fibrinoid necrosis and foamy macrophages within the vessel walls. The impact of the lesions on clinical outcome and placental pathology is unclear. We compared cases with DV to cases without these lesions on clinical outcome and placental histology in PE. STUDY DESIGN: Placental sections from 107 patients admitted with PE at the Radboud University Nijmegen Medical Centre, during the years 1995-2000, were analyzed. 25 cases were excluded due to incomplete records or multiple pregnancy. Cases with DV (n = 41) and without DV (n = 41) were compared for various clinical and placental histological parameters, using Mann-Whitney test. P-value < 0.05 was considered significant. RESULTS: Clinically, DV related to higher diastolic blood pressure, shorter gestational age, lower birth weight and lower umbilical artery pH. Histologically, DV related to more accelerated villous maturity and perivascular inflammatory cell infiltration. No differences were found in maternal biochemical variables (protein-to-creatinine ratio, constituents of HELLP syndrome), fetal-maternal interface parameters (placenta weight, infarctions, hematoma, calcifications), or neonatal outcome measures (birth weight centile, APGAR scores, and perinatal death). CONCLUSIONS: In PE, the presence of DV related to placental accelerated villous maturity, perivascular inflammatory cell infiltration, and adverse maternal and fetal outcome without affecting neonatal survival. Whether or not DV results from or raises the risk on severe preeclampsia remains to be elucidated.