Virchows Archiv

, Volume 472, Issue 3, pp 415–423 | Cite as

Placental pathology varies in hypertensive conditions of pregnancy

  • Jerzy Stanek
Original Article


This study was a comprehensive analysis of placental phenotypes in hypertensive conditions of pregnancy, including recently described placental hypoxic lesions and lesions of shallow placentation. To this end, consecutive placentas from > 21 weeks pregnancies that were signed out by the author at 4 tertiary care centers on 3 continents were included. Twenty-four clinical and 50 placental phenotypes were studied in 6 groups and statistically compared: 91 cases of gestational hypertension, 187 cases of mild preeclampsia, 211 cases of severe preeclampsia, 84 cases of HELLP or eclampsia, 127 cases of chronic hypertension, and 55 cases of preeclampsia superimposed on chronic hypertension. Twenty percent of the placental and clinical phenotypes were statistically significantly different between the groups. Gestational hypertension and chronic hypertension distinguished themselves by having the highest perinatal mortality, lowest cesarean section rates, highest acute chorioamnionitis, and highest fetal vascular ectasia but conspicuously fewer differences in hypoxic and thrombotic lesions. The preeclamptic groups showed the highest rates of decidual arteriolopathy (both hypertrophic and atherosis), uterine pattern of chronic placental injury, villous infarctions, and clusters of maternal floor multinucleate trophoblasts. Based on placental pathology, severe preeclampsia may be more of a placental disease and mild preeclampsia more of a maternal disease; however, the significant overlap among the groups does not make the difference absolute, and the occurrence of decidual arteriolopathy in gestational hypertension and chronic hypertension may indicate that the conditions could be regarded as “occult preeclampsia.”


Gestational hypertension Preeclampsia HELLP Chronic hypertension Superimposed preeclampsia Placenta 


Compliance with ethical standards

This study was approved by the institutional board (IRB #2016-7942).

Conflict of interest

The author declares that he has no conflict of interest.


  1. 1.
    Brosens I, Pijnenborg R, Vecruysse L, Romero R (2011) The “great obstetrical syndromes” are associated with disorders of deep placentation. Am J Obstet Gynecol 204:193–201CrossRefPubMedGoogle Scholar
  2. 2.
    Sibai B, Dekker G, Kupferminc M (2005) Pre-eclampsia. Lancet 365:785–799CrossRefPubMedGoogle Scholar
  3. 3.
    Shamshiraz AA, Paidas M, Krikun G (2012) Preeclampsia, hypoxia, thrombosis, and inflammation. J Pregnancy 2012:374047. Google Scholar
  4. 4.
    Eastabrook G, Brown M, Sargent I (2011) The origins and end-organ consequence of pre-eclampsia. Best Pract Res Clin Obstet Gynaecol 25:435–447CrossRefPubMedGoogle Scholar
  5. 5.
    Roberts DJ, Post MD (2008) The placenta in pre-eclampsia and intrauterine growth restriction. J Clin Pathol 61:1254–1260CrossRefPubMedGoogle Scholar
  6. 6.
    Aurioles-Garibay A, Hernandez-Andrade E, Romero R, Qureshi F, Ahn H, Jacques SM, Garcia M, Yeo L, Hassan SS (2014) Prenatal diagnosis of a placental infarction hematoma associated with fetal growth restriction, preeclampsia and fetal death: clinicopathological correlation. Fetal Diagn Ther 36:154–161CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Baergen RN (2005) Manual of Benirschke and Kaufmann’s pathology of the human placenta. Springer, New YorkGoogle Scholar
  8. 8.
    Stevens DU, Al-Nasiry S, Bulten J, Spaanderman MEA (2012) Decidual vasculopathy and adverse perinatal outcome in preeclamptic pregnancy. Placenta 33:630–633CrossRefPubMedGoogle Scholar
  9. 9.
    Helfrich BB, Chilukuri N, He H, Cerda SR, Hong X, Wang G, Pearson C, Burd I, Wang X (2017) Maternal vascular malperfusion of the placental bed associated with hypertensive disorders in the Boston Birth Cohort. Placenta 52:106–113CrossRefPubMedCentralGoogle Scholar
  10. 10.
    Naicker T, Khedun SM, Moodley J, Pijnenborg R (2003) Quantitative analysis of trophoblast invasion in preeclampsia. Acta Obstet Gynecol Scand 82:722–729CrossRefPubMedGoogle Scholar
  11. 11.
    Von Dadelszen P, Magee LA, Roberts JM (2003) Subclassification of preeclampsia. Hypertens Pregnancy 22:143–148CrossRefGoogle Scholar
  12. 12.
    Nelson DB, Ziadie MS, McIntire DD, Rogers BB, Leveno KJ (2014) Placental pathology suggesting that preeclampsia is more than one disease. Am J Obstet Gynecol 210:66e1–66e7CrossRefGoogle Scholar
  13. 13.
    Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap LC III, Wenstrom KD (2005) Williams obstetrics, 22nd edn. McGraw-Hill, New YorkGoogle Scholar
  14. 14.
    Egbor M, Ansari T, Morris N, Green CJ, Sibbons PD (2006) Morphometric placental villous and vascular abnormalities in early- and late-onset pre-eclampsia with and without fetal growth restriction. BJOG 113:580–589CrossRefPubMedGoogle Scholar
  15. 15.
    Gibbins KJ, Silver RM, Pinar H, Reddy UM, Parker CB, Thorsten V, Willinger M, Dudley DJ, Bukowski R, Saade GR, Koch MA, Conway D, Hogue CJ, Stoll BJ, Goldenberg RL (2016) Stillbirth, hypertensive disorders of pregnancy, and placental pathology. Placenta 43:61–68CrossRefPubMedGoogle Scholar
  16. 16.
    Huppertz B (2008) Placental origins of preeclampsia: challenging the current hypothesis. Hypertension 51:970–975CrossRefPubMedGoogle Scholar
  17. 17.
    Kovo M, Schreiber L, Ben-Haroush A, Wand S, Golan A, Bar J (2010) Placental vascular lesion differences in pregnancy-induced hypertension and normotensive fetal growth restriction. Am J Obstet Gynecol 202:561.e1–561.e5CrossRefGoogle Scholar
  18. 18.
    Ogge G, Chaiworapongsa T, Romero R, Hussein Y, Kusanovic JP, Yeo L, Kim CJ, Hassan SS (2011) Placental lesions associated with maternal underperfusion are more frequent in early-onset than in late-onset preeclampsia. J Perinat Med 39:641–652CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Parks WT (2015) Placental hypoxia: the lesions of maternal malperfusion. Semin Perinatol 39:9–19CrossRefPubMedGoogle Scholar
  20. 20.
    Roberts JM, CWG R (1993) Preeclampsia: more than pregnancy-induced hypertension. Lancet 342(8858):1447–1451CrossRefGoogle Scholar
  21. 21.
    Kovo M, Schreiber L, Ben-Haroush A, Gold E, Golan A, Bar J (2012) The placental component in early-onset and late-onset preeclampsia in relation to fetal growth restriction. Prenat Diagn 32:632–637CrossRefPubMedGoogle Scholar
  22. 22.
    Salafia CM, Pezzullo JC, Ghidini A, Lopèz-Zeno JA, Whittington SS (1998) Clinical correlations of patterns of placental pathology in preterm pre-eclampsia. Placenta 19:67–72CrossRefPubMedGoogle Scholar
  23. 23.
    Moldenhauer JS, Stanek J, Warshak C, Khoury J, Sibai B (2003) The frequency and severity of placental findings in women with preeclampsia are gestational age dependent. Am J Obstet Gynecol 189:1173–1177CrossRefPubMedGoogle Scholar
  24. 24.
    Stanek J, Biesiada J (2012) Clustering of maternal/fetal clinical conditions and outcomes and placental lesions. Am J Obstet Gynecol 206:493.a1–493.a9CrossRefGoogle Scholar
  25. 25.
    Stanek J, Biesiada J, Trzeszcz M (2014) Clinicoplacental phenotypes vary with gestational age: an analysis by classical and clustering methods. Acta Obstet Gynecol Scand 93:392–398CrossRefPubMedGoogle Scholar
  26. 26.
    Stanek J (2014) Comparison of placental pathology in preterm, late-preterm, near-term, and term births. Am J Obstet Gynecol 210:234.e1–234.e6CrossRefGoogle Scholar
  27. 27.
    Stanek J (2013) Hypoxic patterns of placental injury: a review. Arch Pathol Lab Med 137:706–720CrossRefPubMedGoogle Scholar
  28. 28.
    Stanek J (2011) Chorionic disc extravillous trophoblasts in placental diagnosis. Am J Clin Pathol 136:540–547CrossRefPubMedGoogle Scholar
  29. 29.
    Stanek J (2011) Placental membrane and placental disc microscopic chorionic cysts share similar clinicopathologic correlations. Pediatr Dev Pathol 14:1–9CrossRefPubMedGoogle Scholar
  30. 30.
    Stanek J, Biesiada J (2012) Sensitivity and specificity of finding of multinucleate trophoblastic giant cells in decidua in placentas from high-risk pregnancies. Hum Pathol 43:261–268CrossRefPubMedGoogle Scholar
  31. 31.
    Stanek J, Drummond Z (2007) Occult placenta accreta: the missing link in the diagnosis of abnormal placentation. Pediatr Dev Pathol 10:266–262CrossRefPubMedGoogle Scholar
  32. 32.
    Stanek J, Biesiada J (2014) Relation of placental diagnosis in stillbirth to fetal maceration and gestational age at delivery. J Perinat Med 42:457–471CrossRefPubMedGoogle Scholar
  33. 33.
    Khong TY, Mooney EE, Ariel I, Balmus NCM, Boyd TK, Brundler MA et al (2016) Sampling and definitions of placental lesions. Amsterdam placental workshop group consensus statement. Arch Pathol Lab Med 140:698–713CrossRefPubMedGoogle Scholar
  34. 34.
    Maloney KF, Heller D, Baergen RN (2012) Types of maternal hypertensive disease and their association with pathologic lesions and clinical factors. Fetal Pediatr Pathol 31:319–323CrossRefPubMedGoogle Scholar
  35. 35.
    Zhang J, Klebanoff MA, Lvine RJ, Puri M, Moyer P (1999) The puzzling association between smoking and hypertension during pregnancy. Am J Obstet Gynecol 181:1407–1413CrossRefPubMedGoogle Scholar
  36. 36.
    Stanek J (2017) Decidual arteriolopathy with or without associated hypertension modifies the underlying histomorphology in placentas from diabetic mothers. J Obstet Gynaecol Res 43:839–847CrossRefPubMedGoogle Scholar
  37. 37.
    Zhang P, Schmidt M, Cook L (2006) Maternal vasculopathy and histologic diagnosis of preeclampsia: poor correlation of histologic changes and clinical manifestation. Am J Obstet Gynecol 194:1050–1056CrossRefPubMedGoogle Scholar
  38. 38.
    Pathak S, Lees CC, Hackett G, Jessop F, Sebire NJ (2011) Frequency and clinical significance of placental histological lesions in an unselected population at or near term. Virchows Arch 459:565–572CrossRefPubMedGoogle Scholar
  39. 39.
    Fox H, Sebire NJ (2007) Pathology of the placenta. Saunders, LondonGoogle Scholar
  40. 40.
    Kraus FT, Redline RW, Gersell DJ, Nelson DM, Dicke JM (2004) Placental pathology. American Registry of Pathology, WashingtonGoogle Scholar
  41. 41.
    Sebire NJ, Goldin RD, Regan L (2005) Term preeclampsia is associated with minimal histopathological placental features regardless of clinical severity. J Obstet Gynaecol 25:117–118CrossRefPubMedGoogle Scholar
  42. 42.
    Smulian J, Shen-Schwartz S, Scorza W, Kinzler W, Vintzileos A (2004) A clinicohistopathologic comparison between HELLP syndrome and severe preeclampsia. J Matern Fetal Neonatal Med 16:287–293CrossRefPubMedGoogle Scholar
  43. 43.
    Vinnars MT, Wijnaendts LC, Westgren M, Bolte AC, Papadogiannakis N, Nasiell J (2008) Severe preeclampsia with and without HELLP differ with regard to placental pathology. Hypertension 51:1295–1299CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Deutschland 2017

Authors and Affiliations

  1. 1.Division of PathologyCincinnati Children’s Hospital Medical CenterCincinnatiUSA

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