Pediatric and Developmental Pathology

, Volume 7, Issue 5, pp 443–452 | Cite as

Fetal Vascular Obstructive Lesions: Nosology and Reproducibility of Placental Reaction Patterns

  • Raymond W. Redline
  • Ilana Ariel
  • Rebecca N. Baergen
  • Derek J. deSa
  • Frederick T. Kraus
  • Drucilla J. Roberts
  • C. Maureen Sander
  • the Society for Pediatric Pathology, Perinatal Section, Fetal Vascular Obstruction Nosology Committee
Original article

Abstract

The purpose of this study was to assemble and test the reliability of a complete set of the placental reaction patterns seen with chronic fetal vascular obstruction in the hope that this might provide a standardized diagnostic framework useful for practicing pathologists. Study cases (14 with fetal vascular obstructive lesions, 6 controls) were reviewed blindly by seven pathologists after agreement on a standard set of diagnostic criteria. Majority vote served as the gold standard and 80% of the 180 diagnoses rendered (9 diagnoses each for 20 cases) were agreed upon by at least six of the seven scores. The sensitivity of individual diagnosis relative to the group consensus averaged 83% (range, 69–100%) and specificity averaged 91% (range, 86–100%). Reproducibility was measured by unweighted kappa-values and interpreted as follows: < 0.2, poor; 0.2–0.6, fair/moderate; > 0.6, substantial. Kappa values for lesions of distal villi were generally superior to those for lesions involving large fetal vessels: avascular villi (0.49), villous stromal-vascular karyorrhexis (0.58), and villitis of unknown etiology (VUE) with stem villitis and avascular villi (0.65) versus large vessel thrombi (any vessel, 0.34; chorionic plate vessel, 0.40) and intimal fibrin cushions (recent, 0.47; remote, 0.78). Reproducibility for a global impression of any villous change consistent with chronic fetal vascular obstruction was substantial (0.63), while that for a more severe subgroup was moderate (0.44). Three points are worthy of emphasis. Our system separately recognizes, but later combines, uniformly avascular villi and villous stromal-vascular karyorrhexis as manifestations of the same underlying process. We propose that this combined group of villous lesions be dichotomized with the terms fetal thrombotic vasculopathy or extensive avascular villi (and/or villous stromal-vascular karyorrhexis) being reserved for the group with 15 or more affected terminal villi per section. Scattered foci of avascular villi (and/or villous stromal-vascular karyorrhexis) could be used to describe less severe cases. Finally, we distinguish VUE with stem villitis and avascular villi (obliterative fetal vasculopathy) as a distinct process with substantial perinatal morbidity.

Keywords:

avascular villi fetal thrombotic vasculopathy hemorrhagic endovasculitis nomenclature placenta reproducibility villitis of unknown etiology 

References

  1. 1.
    Gruenwald, P 1961Abnormalities of placental vascularity in relation to intrauterine deprivation and retardation of fetal growth: significance of avascular chorionic villiNY State J Med6114871513Google Scholar
  2. 2.
    Redline, RW, Patterson, P 1994Patterns of placental injury: correlations with gestational age, placental weight, and clinical diagnosisArch Pathol Lab Med118698701PubMedGoogle Scholar
  3. 3.
    Redline, RW, Pappin, A 1995Fetal thrombotic vasculopathy: the clinical significance of extensive avascular villiHum Pathol268085CrossRefPubMedGoogle Scholar
  4. 4.
    Sander, CH 1980Hemorrhagic endovasculitis and hemorrhagic villitis of the placentaArch Pathol Lab Med104371373PubMedGoogle Scholar
  5. 5.
    Sander, CH, Kinnane, L, Stevens, NG 1985Hemorrhagic endovasculitis of the placenta: a clinicopathologic entity associated with adverse pregnancy outcomeCompr Ther116674PubMedGoogle Scholar
  6. 6.
    Kraus, FT 1997Cerebral palsy and thrombi in placental vessels of the fetus: insights from litigationHum Pathol28246248CrossRefPubMedGoogle Scholar
  7. 7.
    Kraus, FT, Acheen, VI 1999Fetal thrombotic vasculopathy in the placenta: cerebral thrombi and infarcts, coagulopathies, and cerebral palsyHum Pathol30759769CrossRefPubMedGoogle Scholar
  8. 8.
    Rayne, SC, Kraus, FT 1993Placental thrombi and other vascular lesions: classification, morphology, and clinical correlationsPathol Res Pract189217CrossRefPubMedGoogle Scholar
  9. 9.
    Redline, R, Shah, D, Sakar, H, Schluchter, M, Salvator, A 2001Placental lesions associated with abnormal growth in twinsPediat Dev Pathol4473481CrossRefGoogle Scholar
  10. 10.
    Dahms, BB, Boyd, T, Redline, RW 2002Severe perinatal liver disease associated with fetal thrombotic vasculopathyPediatr Dev Pathol58085CrossRefPubMedGoogle Scholar
  11. 11.
    Langston, C, Kaplan, C, Macpherson, T,  et al. 1997Practice guideline for examination of the placentaArch Pathol Lab Med121449476PubMedGoogle Scholar
  12. 12.
    Landis, JR, Koch, GG 1977The measurement of observer agreement for categorical dataBiometrics33159174CrossRefPubMedGoogle Scholar
  13. 13.
    Sun, CC, Revell, VO, Belli, AJ, Viscardi, RM 2002Discrepancy in pathologic diagnosis of placental lesionsArch Pathol Lab Med126706709PubMedGoogle Scholar
  14. 14.
    Khong, TY, Staples, A, Bendon, RW,  et al. 1995Observer reliability in assessing placental maturity by histologyJ Clin Pathol48420423CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Khong, TY, Bendon, RW, Qureshi, F,  et al. 2000Chronic deciduitis in the placental basal plate: definition and inter-observer reliabilityHum Pathol31292295CrossRefPubMedGoogle Scholar
  16. 16.
    Grether, JK, Eaton, A, Redline, R, Bendon, R, Benirschke, K, Nelson, K 1999Reliability of placental histology using archived specimensPaediat Perinat Epidemiol13489495CrossRefGoogle Scholar
  17. 17.
    Beebe, LA, Cowan, LD, Hyde, SR, Altshuler, G 2000Methods to improve the reliability of histopathological diagnoses in the placentaPaediatr Perinat Epidemiol14172178CrossRefPubMedGoogle Scholar
  18. 18.
    Redline, RW, Faye-Petersen, O, Heller, D, Qureshi, F, Savell, V, Vogler, C 2003Amniotic infection syndrome: nosology and reproducibility of placental reaction patternsPediatr Dev Pathol6435448CrossRefPubMedGoogle Scholar
  19. 19.
    Redline RW, Boyd T, Campbell V, et al. (2004) Maternal vascular underperfusion: nosology and reproducibility of placental reaction patterns. Pediatr Dev Pathol 7: 237–239PubMedGoogle Scholar
  20. 20.
    DeSa, DJ 1971Rupture of fetal vessels on placental surfaceArch Dis Child46495501CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    DeSa, DJ 1973Intimal cushions in foetal placental veinsJ Pathol110347352CrossRefGoogle Scholar
  22. 22.
    Benirschke, K, Emery, SC 2004Immunohistochemical characterization of placental vascular intimal cushions: evidence against organizing thrombiLab Invest84328329A (Abst)Google Scholar
  23. 23.
    Scott, JM 1983Fibrinous vasculosis of the human placentaPlacenta487100CrossRefPubMedGoogle Scholar
  24. 24.
    Benirschke, K, Driscoll, SG 1967Pathology of the Human PlacentaSpringer-Verlag BerlinHeidelberg, GermanyGoogle Scholar
  25. 25.
    Fox, H 1978Pathology of the PlacentaW.B. SaundersLondonGoogle Scholar
  26. 26.
    Sander, CM, Gilliland, D, Akers, C, McGrath, A, Bismar, TA, Swart-Hills, LA 2002Livebirths with placental hemorrhagic endovasculitis: interlesional relationships and perinatal outcomesArch Pathol Lab Med126157164PubMedGoogle Scholar
  27. 27.
    Redline, RW, O’Riordan, MA 2000Placental lesions associated with cerebral palsy and neurologic impairment following term birthArch Pathol Lab Med12417851791PubMedGoogle Scholar
  28. 28.
    Genest, DR 1992Estimating the time of death in stillborn fetuses. 2. Histologic evaluation of the placenta—a study of 71 stillbornsObstet Gynecol80585592PubMedGoogle Scholar
  29. 29.
    Baergen, RN, Malicki, D, Behling, C, Benirschke, K 2001Morbidity, mortality, and placental pathology in excessively long umbilical cords: retrospective studyPediatr Dev Pathol4144153CrossRefPubMedGoogle Scholar
  30. 30.
    Redline, RW, Wilson-Costello, D, Borawski, E, Fanaroff, AA, Hack, M 1998Placental lesions associated with neurologic impairment and cerebral palsy in very low birth weight infantsArch Pathol Lab Med12210911098PubMedGoogle Scholar
  31. 31.
    Fritz, MA, Christopher, CR 1981Umbilical vein thrombosis and maternal diabetes mellitusJ Reprod Med26320324PubMedGoogle Scholar
  32. 32.
    Chacko, S, Edersheim, T, Etingen, O, Hutson, J, Baergen, R 2001Thrombophilias in pregnancy: does treatment improve outcomePediatr Dev Pathol4413414Google Scholar
  33. 33.
    De Tar, MW, Klohe, E, Grosset, A, Rau, T 2002Neonatal alloimmune thrombocytopenia with HLA alloimmunization: case report with immunohematologic and placental findingsPediatr Dev Pathol5200205CrossRefPubMedGoogle Scholar
  34. 34.
    van der Molen, EF, Verbruggen, B, Novakova, I, Eskes, TK, Monnens, LA, Blom, HJ 2000Hyperhomocysteinemia and other thrombotic risk factors in women with placental vasculopathyBr J Obstet Gynaecol107785791CrossRefGoogle Scholar
  35. 35.
    Vern, TZ, Alles, AJ, KowalVern, A, Longtine, J, Roberts, DJ 2000Frequency of factor V-Leiden and prothrombin G20210A in placentas and their relationship with placental lesionsHum Pathol3110361043CrossRefPubMedGoogle Scholar
  36. 36.
    Mooney, E, Vaughan, J, Ryan, F,  et al. 2003Placental thrombotic vasculopathy is not associated with thrombophilic mutationsLab Invest83303A (Abst)Google Scholar
  37. 37.
    Redline RW. Hemorrhagic and thrombotic lesions of the placenta. In: Bick RL. Hematologic Complications in Obstetrics, Pregnancy, and Gynecology. Cambridge, UK: Cambridge University Press (in press)Google Scholar
  38. 38.
    Altshuler, G, Russell, P 1975The human placental villitides: a review of chronic intrauterine infectionCurr Top Pathol6063112Google Scholar
  39. 39.
    Labarrere, CA, McIntyre, JA, Faulk, WP 1990Immunohistologic evidence that villitis in human normal term placentas is an immunologic lesionAm J Obstet Gynecol162515522CrossRefPubMedGoogle Scholar
  40. 40.
    Redline, RW, Patterson, P 1993Villitis of unknown etiology is associated with major infiltration of fetal tissue by maternal inflammatory cellsAm J Pathol143473479PubMedPubMedCentralGoogle Scholar
  41. 41.
    Labarrere, CA, Faulk, WP 1995Maternal cells in chorionic villi from placentae of normal and abnormal human pregnanciesAm J Reprod Immunol335459CrossRefPubMedGoogle Scholar
  42. 42.
    Ariel, J,  et al. 2004Placental pathology in fetal thrombophilin.Hum Pathol35729733CrossRefPubMedGoogle Scholar

Copyright information

© Society for Pediatric Pathology 2004

Authors and Affiliations

  • Raymond W. Redline
    • 1
  • Ilana Ariel
    • 2
  • Rebecca N. Baergen
    • 3
  • Derek J. deSa
    • 4
  • Frederick T. Kraus
    • 5
  • Drucilla J. Roberts
    • 6
  • C. Maureen Sander
    • 7
  • the Society for Pediatric Pathology, Perinatal Section, Fetal Vascular Obstruction Nosology Committee
  1. 1.Department of PathologyUniversity Hospitals of Cleveland and Case Western Reserve UniversityClevelandUSA
  2. 2.Department of PathologyHadassah University HospitalJerusalemIsrael
  3. 3.Department of PathologyNew York—Presbyterian Hospital—Weill Cornell Medical CenterNew YorkUSA
  4. 4.Department of PathologyBritish Columbia Children’s HospitalVancouverCanada
  5. 5.Department of Obstetrics and GynecologyWashington University School of MedicineSt. LouisUSA
  6. 6.Department of PathologyMassachusetts General HospitalBostonUSA
  7. 7.Placental Tissue RegistryMichigan State UniversityEast LansingUSA

Personalised recommendations