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A practical guide to placental examination for forensic pathologists

Abstract

The placenta is a complex interface organ that may hold clues to the reasons for fetal, neonatal or maternal demise. For this reason, placental examination should be a mandatory part of all perinatal or maternal autopsies. While published protocols for the examination of the placenta exist, they are often not adopted. The following review provides practical guidelines for placental examination, with discussion of specific medical conditions that can negatively impact upon the fetus, neonate or mother involving placental pathology to cause death. The review aims to discuss concepts, with illustrations, that forensic pathologists may not routinely focus on in death investigations that may either contribute or mask the cause of a fetal or neonatal death, or are associated with a recurrence risk. While it is recognized that many forensic facilities do not have formal guidelines for placental examination, involvement of local perinatal pathology services in cases is one way of obtaining additional specialist expertise.

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Change history

  • 08 January 2020

    The Publisher would like to correct the introduced formatting errors caused by production on figures 16 and 23 of the original article. The errors are purely typesetting mistakes and the corrections made to the figures did not impact upon the veracity and content of the overall text of the article in any way.

References

  1. 1.

    Dragoi SG, Dinca I, Melinte RP, Diaconu C, Silcca G. Forensic and anatomic signification of phenotype transformations inside fetus membranes. Part one: amnion and Lamina chorionica. Rom J Leg Med. 2009;3:173–86.

  2. 2.

    Dragoi SG, Dinca I, Melinte RP, Silca G, Radu L, Diaconu C. Forensic and anatomic signification of phenotype transformations inside fetus membranes. Part two: trophoblastic membrane. Rom J Leg Med. 2009;4:257–64.

  3. 3.

    Dragoi SG, Dinca I, Melinte RP, Silca G, Zimta D. The signification of the time and space distribution, distribution of the fibrinoid substance during the genesis and evolution of human placenta. Forensic implication. Rom J Leg Med. 2010;18:95–102.

  4. 4.

    Zimta D, Melinte RP, Dinca I. Dragoi Sg. Anatomic markers for the retrospective and prospective evaluation of pathology involving the feto-placentar circulatory systems inside human placenta. Rom J Leg Med. 2012;20:19–32.

  5. 5.

    Melinte RP, Dragoi SG, Paitici P, Dinca I, Patrascu E. Intrauterin antepartum fetal death. Medical, social and forensic implications. Rom J Leg Med. 2015;23:69–80.

  6. 6.

    Fox H. Perivillous deposition in the human placenta. Am J Obstet Gynecol. 1967;98:245–51.

  7. 7.

    Fox H. Effect of hypoxia on trophoblast in organ culture. Am J Obstet Gynecol. 1970;107:1058–64.

  8. 8.

    Jaiman S. Gross examination of the placenta and its importance in evaluating an unexplained intrauterine fetal demise. J Fetal Med. 2015;2:113–20.

  9. 9.

    Chang KT. Pathological examination of the placenta: raison d'être, clinical relevance and medicolegal utility. Singap Med J. 2009;50:1123–33.

  10. 10.

    Avagliano L, Massa V, Bulfamante GP. (Histology of Human Placenta. http://www.smgebooks.com/histopathology/chapters/HISPATH-16-04.pdf.

  11. 11.

    Molteni RA, Stys SJ, Battaglia FC. Relationship of fetal and placental weight in human beings: fetal/placental weight ratios at various gestational ages and birth weight distribution. J Reprod Med. 1978;21:327–34.

  12. 12.

    Kent AL, Dahlstrom JE. Placental assessment: simple techniques to enhance best practice. Aust NZ J Obstet Gynaecol. 2006;46:32–7.

  13. 13.

    https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/resources/policies/investigation+of+stillbirths+sa+protocol+-+sa+perinatal+practice+guidelines. Accessed 7 Nov 2019.

  14. 14.

    Royal College of Pathologists of Australasia. Placenta single. In: RCPA Macroscopic cut up manual. https://www.rcpa.edu.au/Manuals/Macroscopic-Cut-Up-Manual/Gynaecology-and-perinatal/Placenta/Placenta-single. Accessed 20 July 2019.

  15. 15.

    Maternal and Perinatal Mortality Committee. Maternal and Perinatal Mortality in South Australia 2015. Adelaide: SA Health, Government of South Australia, 2017. Accessed 10 December 2019

  16. 16.

    Kaplan C. Gross examination of the placenta. Surg Pathol Clin. 2013;6:1–26.

  17. 17.

    Khong TY, Mooney EE, Arial I, Balmus NC, Boyd TK, Brundler MA, et al. Sampling and definitions of placental lesions: Amsterdam placental workshop group consensus statement. Arch Pathol Lab Med. 2016;140:698–713.

  18. 18.

    Langston C, Kaplan C, Macpherson T, Manci E, Peevy K, Clark B, et al. Practice guideline for examination of the placenta: developed by the placental pathology practice guideline development task force of the College of American Pathologists. Arch Pathol Lab Med. 1997;121:449–76.

  19. 19.

    Downey A, Hore K, McAuliffe FM, Mooney E. Umbilical cord shortening: quantification post-delivery and post-fixation. Pediatr Dev Pathol. 2014;17:327–9.

  20. 20.

    Perinatal Society of Australia and New Zealand (PSANZ). Placenta histopathology reporting form. https://sanda.psanz.com.au/assets/Uploads/Appendix-P-Placental-histopathology-reporting-form2.pdf. Accessed 20 July 2019.

  21. 21.

    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;7:443–52.

  22. 22.

    Redline RW, Pappin A. Fetal thrombotic vasculopathy: the clinical significance of extensive avascular villi. Hum Pathol. 1995;26:80–5.

  23. 23.

    Redline RW. Clinical and pathological umbilical cord abnormalities in fetal thrombotic vasculopathy. Hum Pathol. 2004;35:1494–8.

  24. 24.

    Tantbirojn P, Saleemuddin A, Sirois K, Crum CP, Boyd TK, Tworoger S, et al. Gross abnormalities of the umbilical cord: related placental histology and clinical significance. Placenta. 2009;30:1083–8.

  25. 25.

    Ariel I, Anteby E, Hamani Y, Redline RW. Placental pathology in fetal thrombophilia. Hum Pathol. 2004;35:729–33.

  26. 26.

    Mousa HA, Alfirevic Z. Do placental lesions reflect thrombophilia state in women with adverse pregnancy outcome? Hum Reprod. 2000;15:1830–3.

  27. 27.

    Dahms BB, Boyd T, Redline RW. Severe perinatal liver disease associated with fetal thrombotic vasculopathy. Pediatr Dev Pathol. 2002;5:80–5.

  28. 28.

    Lian DW, Lam JC, Aung AC, Li FX, Chang KT. Intestinal atresia occurring in association with placental fetal thrombotic vasculopathy: a case report with literature review. Pediatr Dev Pathol. 2013;16:28–31.

  29. 29.

    McDonald DG, Kelehan P, McMenamin JB, Gorman WA, Madden D, Tobbia IN, et al. Placental fetal thrombotic vasculopathy is associated with neonatal encephalopathy. Hum Pathol. 2004;35:875–80.

  30. 30.

    Chang KT, Keating S, Costa S, Machin G, Kingdom J, Shannon P. Third trimester stillbirths: correlative neuropathology and placental pathology. Pediatr Dev Pathol. 2011;14:345–52.

  31. 31.

    Saleemuddin A, Tantbirojn P, Sirois K, Crum CP, Boyd TK, Tworoger S, et al. Obstetric and perinatal complications in placentas with fetal thrombotic vasculopathy. Pediatr Dev Pathol. 2010;13:459–64.

  32. 32.

    DeSa DJ. Intimal cushions in foetal placental veins. J Pathol. 1973;110:347–52.

  33. 33.

    Roescher AM, Timmer A, Erwich JJ, Bos AF. Placental pathology, perinatal death, neonatal outcome, and neurological development: a systematic review. PLoS One. 2014;9:e89419.

  34. 34.

    Pijnenborg R, Dixon G, Robertson WB, Brosens I. Trophoblastic invasion of human decidua from 8 to 18 weeks of pregnancy. Placenta. 1980;1:3–19.

  35. 35.

    Genest DR. Estimating the time of death in stillborn foetuses: II. Histologic evaluation of the placenta; a study of 71 stillborns. Obstet Gynecol. 1992;80:585–92.

  36. 36.

    Labarrere CA. Acute atherosis. A histopathological hallmark of immune aggression? Placenta. 1988;9:95–108.

  37. 37.

    Naeye RL. Do placental weights have clinical significance? Hum Pathol. 1987;18:387–91.

  38. 38.

    De Wolf F, Brosens I, Renaer M. Fetal growth retardation and the maternal arterial supply of the human placenta in the absence of sustained hypertension. Br J Obstet Gynaecol. 1980;87:678–85.

  39. 39.

    Elsasser DA, Ananth CV, Prasad V, Vintzileos AM, New Jersey-Placental Abruption Study Investigators. Diagnosis of placenta abruption: relationship between clinical and histopathological findings. (Eur J Obstet Gynecol Reprod Biol 2010;148:125–130.

  40. 40.

    Redline RW, Wilson-Costello D. Chronic peripheral separation of placenta. The significance of diffuse chorioamnionic hemosiderosis. Am J Clin Path. 1999;111:804–10.

  41. 41.

    Van der knoop BJ, van der Voorn JP, Nikkels P, Zonnenberg IA, van Weissenbruch MM, Vermeulen RJ, et al. Placental histology after minor trauma in pregnancy: a pilot study. Pediatr Dev Pathol. 2019;22:221–8.

  42. 42.

    Sepkowitz S. Influence of the legal imperative and medical guidelines on the incidence and management of the meconium-stained newborn. Am J Dis Child. 1987;141:1124–7.

  43. 43.

    Nathan L, Leveno KJ, Carmody TJ 3rd, Kelly MA, Sherman ML. Meconium: a 1990s perspective on an old obstetric hazard. Obstet Gynecol. 1994;83:329–32.

  44. 44.

    Greenwood C, Lalchandani S, MacQuillan K, Sheil O, Murphy J, Impey L. Meconium passed in labor: how reassuring is clear amniotic fluid? Obstet Gynecol. 2003;102:89–93.

  45. 45.

    Funai EF, Labowsky AT, Drewes CE, Kliman HJ. Timing of fetal meconium absorption by amniotic macrophages. Am J Perinatol. 2009;26:93–7.

  46. 46.

    Meydanli MM, Dilbaz B, Caliskan E, Dilbaz S, Haberal A. Risk factors for meconium aspiration syndrome in infants born through thick meconium. Int J Gynaecol Obstet. 2001;72:9–15.

  47. 47.

    Redline RW, O'Riordan MA. Placental lesions associated with cerebral palsy and neurologic impairment following term birth. Arch Pathol Lab Med. 2000;124:1785–9.

  48. 48.

    Altshuler G, Arizawa M, Molnar-Nadasdy G. Meconium-induced umbilical cord vascular necrosis and ulceration: a potential link between the placenta and poor pregnancy outcome. Obstet Gynecol. 1992;79:760–6.

  49. 49.

    Altshuler G, Hyde S. Meconium-induced vasocontraction: a potential cause of cerebral and other fetal hypoperfusion and of poor pregnancy outcome. J Child Neurol. 1989;4:137–42.

  50. 50.

    Fujikura T, Klionsky B. The significance of meconium staining. Am J Obstet Gynecol. 1975;121:45–50.

  51. 51.

    Gugino LJ, Buerger PT, Wactawski-Wende J, Fisher J. Chorioamnionitis: the association between clinical and histological diagnosis. Prim Care Update Ob Gyns. 1998;5:148.

  52. 52.

    Bhola K, Al-Kindi H, Fadia M, Kent AL, Collignon P, Dahlstrom JE. Placental cultures in the era of peripartum antibiotic use. Aust N Z J Obstet Gynaecol. 2008;48:179–84.

  53. 53.

    McCuaig R, Wong D, Gardiner FW, Rawlinson W, Dahlstrom JE, Robson S. Periodontal pathogens in the placenta and membranes in term and preterm birth. Placenta. 2018;68:40–3.

  54. 54.

    Nakayama M. Significance of pathological examination of the placenta, with a focus on intrauterine infection and fetal growth retardation. J Obstet Gynaecol Res. 2017;43:1522–35.

  55. 55.

    Gibbs RS, Roberts DJ. Case records of the Massachusetts General Hospital. Case 27-2007. A 30 -year -old pregnant woman with intrauterine fetal death. N Engl J Med. 2007;357:918–25.

  56. 56.

    Moscuzza F, Belcari F, Nardini V, Bartoli A, Domenici C, Cuttano A, et al. Correlation between placental histopathology and fetal/ neonatal outcome: chorioamnionitis and funisitis are associated to intraventricular haemorrage and retinopathy of prematurity in preterm newborns. Gynecol Endocrinol. 2011;27:319–23.

  57. 57.

    Mueller-Heubach E, Rubinstein DN, Schwarz SS. Histologic chorioamnionitis and preterm delivery in different patient populations. Obstet Gynecol. 1990;75:622–6.

  58. 58.

    Shigeta N, Ozaki K, Hori K, Ito K, Nakayama M, Nakahira K, et al. An Arthrobacter spp. bacteremia leading to fetal death and maternal disseminated intravascular coagulation. Fetal Pediatr Pathol. 2013;31:25–31.

  59. 59.

    Redline RW. Clinically and biologically relevant patterns of placental inflammation. Pediatr Dev Pathol. 2002;5:326–8.

  60. 60.

    Russell P. Inflammatory lesions of the human placenta III. The histopathology of villitis of unknown aetiology. Placental. 1980;1:227–44.

  61. 61.

    Vigliani MB, Bakardjiev AI. Intracellular organisms as placental invaders. Fetal Matern Med Rev. 2014;25:332–8.

  62. 62.

    Mysorekar IU. Zika virus takes a transplacental route to infect fetuses: insights from an animal model. Mo Med. 2017;114:168–70.

  63. 63.

    Fahey JO. Clinical management of intra-amniotic infection and chorioamnionitis: a review of literature. J Midwifery Womens Health. 2008;53:227–35.

  64. 64.

    Tita AT, Andrews WW. Diagnosis and management of clinical chorioamnionitis. Clin Perinatol. 2010;37:339–54.

  65. 65.

    Chang KT. Examination of the placenta: medico-legal implications. Semin Fetal Neonatal Med. 2014;19:279–84.

  66. 66.

    Redline RW, Patterson P. Villitis of unknown etiology is associated with major infiltration of fetal tissue by maternal inflammatory cells. Am J Pathol. 1993;143:473–9.

  67. 67.

    Lebarrere CA, Faulk WP. MHC class II reactivity of human villous trophoblast in chronic inflammation of unestablished etiology. Transplantation. 1990;50:812–6.

  68. 68.

    Bos M, Nikkels PGJ, Cohen D, Schoones JW, Bloemenkamp KWM, Bruiin JA, et al. Towards standardized criteria for diagnosis chronic intervillositis of unknown etiology: a systematic review. Placenta. 2018;61:80–8.

  69. 69.

    Vernof KK, Benirschke K, Kephart GM, Wasmoen TL, Gleich GJ. Maternal floor infarction: relationship to X cells, major basic protein, and adverse perinatal outcome. Am J Obstet Gynecol. 1992;167:1355–63.

  70. 70.

    Naeye RL. Umbilical cord length: clinical significance. J Pediatr. 1985;107:278–81.

  71. 71.

    Ferreira CR, Gahl WA. Lysosomal storage diseases. Transl Sci Rare Dis. 2017;2:1–71.

  72. 72.

    Alexander A, Samlowski WE, Grossman D, Bruggers CS, Harris RM, Zone JJ, et al. Metastatic melanoma in pregnancy: risk of transplacental metastases in the infant. J Clin Oncol. 2003;21:2179–86.

  73. 73.

    Tolar J, Coad JE, Neglia JP. Transplacental transfer of small-cell carcinoma of the lung. N Engl J Med. 2002;346:1501–2.

  74. 74.

    Chen Y, Li Y, Wang H, Lu J, Jin M, Zhang Z. Maternal gastric carcinoma with metastasis to the placenta: a case report. Oncol Lett. 2014;8:2509–10.

  75. 75.

    Jauniaux E, Collins S, Burton GJ. Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging. Am J Obstet Gynecol. 2018;218:75–87.

  76. 76.

    d’Aloja E, Müller M, Paribello F, Demontis R, Faa A. Neonatal asphyxia and forensic medicine. J Matern Fetal Neonatal Med. 2009;22:54–6.

  77. 77.

    Boyd TK. The placenta in intrauterine demise. APIMS. 2018;126:621–5.

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Acknowledgements

We wish to acknowledge the scientific, medical and mortuary staff of Department of Anatomical Pathology, The Canberra Hospital their support.

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Correspondence to Jane E. Dahlstrom.

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The original version of this article was revised: 1) In Figure 16, panel d was not captured in the final version. 2) In Figure 23, panel c was not captured in the final version.

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Mittal, N., Byard, R.W. & Dahlstrom, J.E. A practical guide to placental examination for forensic pathologists. Forensic Sci Med Pathol (2019). https://doi.org/10.1007/s12024-019-00214-2

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Keywords

  • Placenta
  • Neonate
  • Maternal
  • Fetal
  • Forensic
  • Sudden death
  • Stillbirth