Data from: Placental pathology findings in unexplained pregnancy losses
Cite this dataset
Kliman, Harvey; Thompson, Beatrix; Holzer, Parker (2022). Data from: Placental pathology findings in unexplained pregnancy losses [Dataset]. Dryad. https://doi.org/10.5061/dryad.3xsj3txks
Abstract
There are approximately 5 million pregnancies per year in the United States, with 1 million ending in miscarriage (a loss occurring prior to 20 weeks of gestation) and over 20,000 ending in stillbirth at or beyond 20 weeks of gestation. As many as 50% of these losses are unexplained. Our objective was to evaluate the efficacy of expanding the placental pathology diagnostic categories to include the explicit categories of 1) dysmorphic chorionic villi and 2) small placenta to decrease the unexplained fraction. Using a clinical database of 1,256 previously unexplained losses at 6–43 weeks of gestation, the most prevalent abnormality associated with each loss was determined through examination of its placental pathology slides. Of 1,256 cases analyzed from 922 patients, there were 878 (69.9%) miscarriages and 378 (30.1%) antepartum stillbirths. We determined the pathologic diagnoses for 1,150/1,256 (91.6%) of the entire series, 777/878 (88.5%) of the miscarriages (<20 weeks’ gestation), and 373/378 (98.7%) of the stillbirths (≥20 weeks’ gestation). The most common pathologic feature observed in unexplained miscarriages was dysmorphic chorionic villi (757 cases; 86.2%), a marker associated with genetic abnormalities. The most common pathologic feature observed in unexplained stillbirths was a small placenta (128 cases; 33.9%). Our classification system reinforced the utility of placental examination for elucidating potential mechanisms behind pregnancy loss. The improved rate of diagnosis appeared to be the result of filling a gap in previous pregnancy loss classification systems via inclusion of the categories of dysmorphic chorionic villi and small placenta.
Methods
Cases
A case series of 1,527 singleton pregnancies that ended in loss were identified from our tertiary-care consult service. Cases were excluded if the cause of loss could be elucidated from the clinical records alone, such as the presence of aneuploidies. Available demographic, clinical data, and gross description were abstracted from the clinical records when submitted with the consult request. Hematoxylin and eosin placental slides (no autopsy slides) were reviewed by the senior author (HJK). The analysis of this retrospective case series was approved by the Yale University Human Research Protection Program Institutional Review Board (protocol ID 2000029781).
Excluded cases
Cases with missing pathology slides, or an absence or insufficient number (fewer than five cross sections) of chorionic villi in the placental sample (Fig. 1) were excluded. The second exclusion criterion was an inability to date the clinical gestational age (GA), determined by the patient’s last menstrual period (LMP). In the absence of an LMP, the GA was approximated by chorionic villus histologic criteria [42-44]. The remaining cases in which gestational age could not be reliably estimated were excluded from further analysis. All subsequent references to GA are related to LMP dating.
Pathologic evaluation
The placental pathology of included cases was re-reviewed following the Amsterdam Placental Workshop Group Consensus Statement [45], with the following modifications. This Statement does not include the diagnostic categories of dysmorphic chorionic villi, trophoblast inclusions (TIs), and/or invaginations (Fig. 2). TIs were first described by Boyd and Hamilton in 1964 [46], and later linked specifically to placentas from triploid losses in 1969 [47, 48]. Over time other investigators found that TIs were not a specific marker of triploidy but rather were seen in a wide range of karyotypic and non-karyotypic genetic abnormalities [25, 27-30, 49, 50], and adverse pregnancy outcomes, including stillbirth [20]. Importantly, the frequency of TIs in normal control placentas is very low [51-53]. Therefore, we added dysmorphic chorionic villi (not to be confused with villous dysmaturity [45]) as a diagnostic category, defined as identification of at least one TI and/or multiple invaginations in the examined slides. Additionally, based on normative curves developed by Pinar et al [54], we added the explicit category of small placenta, defined as fixed trimmed disk weight below the 10th percentile for cases ≥20 weeks. Values below the 10th percentile were mathematically extrapolated from the primary Pinar data.
Identifying a nonacute cord accident required evidence of cord compression, as manifested by: 1) the presence of squamous metaplasia [55-57] on the umbilical cord surface (Fig. 3A); 2) fetal hypoxia defined as an abnormal increase in fetal nucleated RBCs [58]; 3) and thrombosis within the fetal circulation [59]. A loss was only identified as being caused by an infection when a fetal inflammatory response was observed, evidenced by either fetal neutrophil migration through the fetal chorionic plate vessels and/or through the umbilical cord vessels (funisitis) (Fig. 3B) [60]. A maternal inflammatory response alone, as evidenced by maternal neutrophils migrating into and through either the chorionic plate or external membranes, was not sufficient to identify a loss as being caused by an infection. Maternal immunologic rejection was identified when significant numbers of maternal T-cells infiltrated the chorionic villi (chronic villitis, Fig. 3C) [61-64], or monocytes filled the intervillous space (chronic histiocytic intervillositis; CHI) [65-67]. Abruption occurred when a clear, well-developed fibrin clot was adherent to the maternal surface of the placenta [68]. Fetal maternal hemorrhage was identified when intervillous fibrin forming layered lines of Zahn (indicative of blood clot formation in flowing blood [69]) was admixed with blood containing nucleated red blood cells (indicative of a fetal bleeding source) (Fig. 3E) [70, 71]. In contrast, massive perivillous fibrin (a manifestation of maternal intervillous blood thrombosis [72-74]) was identified when the intervillous space was largely filled with fibrin (Fig. 3F).
Classification system
After pathologic examination, we identified the most prevalent abnormality associated with the loss. First, any clear and marked case of abruption, cord accident, or fetal bleed was assigned. Next, we identified all cases with evidence of thrombosis or fetal inflammatory response.
After losses associated with the above five abnormalities were identified, the remaining cases with a placental weight <10th percentile for its corresponding gestational age were categorized as a small placenta and sorted into four etiologic sub-categories: small placenta with evidence of maternal immunologic rejection, small placenta with dysmorphic chorionic villi, small placenta with evidence of uteroplacental insufficiency, or small placenta with no other pathologic findings.
Next, remaining cases with indication of maternal immunologic rejection were classified. Cases that showed dysmorphic chorionic villi with no other etiology were then assigned. The remaining “other” defined abnormalities included viral stigmata revealed on pathologic examination [75, 76], uteroplacental insufficiency without a concomitantly small placenta [77], maternal and/or fetal sickle cell disease (Fig. 3D) [78], premature inappropriate maternal perfusion prior to 8 weeks of gestation [79], complete mole [27], and severe intraamniotic fluid infection without apparent fetal inflammatory responses [80]. Cases revealing no pathologic findings remained unexplained.
Statistical analysis
We displayed the distribution of pregnancy losses across gestational age and associated abnormalities using kernel density estimation [81, 82]. This can be thought of as a smoothed version of a histogram, where each individual data point is replaced with a Gaussian and the total density plot is the sum of all such Gaussians. We found that when these Gaussians had a spread of 1.5 gestational days, there was a good balance between under- and over-smoothing of the data. For each individual category, all corresponding gestational ages were used to create a density estimate of that associated abnormality. Then, to account for how some abnormalities occur more frequently than others, we multiplied the density of each cause by the proportion of cases with that associated abnormality.
To analyze the frequencies of small and large placentas in our series, we converted placental weight percentiles to z-scores, allowing us to visualize this loss cohort against the standard z-score distribution of placentas from normal term or uncomplicated preterm deliveries [54].
We conducted an analysis of patients with multiple losses to investigate whether their associated abnormalities were correlated. More precisely, the null hypothesis to be tested was that the abnormality identified in the second loss was not related to that of the first loss. We tested this against the alternative hypothesis that the abnormality identified in the second loss was the same as that of the first. To perform this hypothesis test, we used a permutation test [83]. Specifically, we randomly shuffled the order of all second losses and calculated what proportion of them matched the findings in the unshuffled first loss causes. Repeating this 500,000 times via computer algorithm gave an estimate of the distribution for the proportion of matching abnormalities when the null hypothesis was true.
Statistical analysis was performed using R version 4.0.4 (R Foundation for Statistical Computing, Vienna, Austria) and the Python packages of Scikit-learn [84] and Matplotlib [85].
References
42. Baergen RN. Chorionic Villi: Histology and Villous Development. In: Baergen RN, editor. Manual of Pathology of the Human Placenta: Second Edition. Boston, MA: Springer US; 2011. p. 69-83.
43. Roberts L, Sebire NJ, Fowler D, Nicolaides KH. Histomorphological features of chorionic villi at 10-14 weeks of gestation in trisomic and chromosomally normal pregnancies. Placenta. 2000;21(7):678-83. doi: 10.1053/plac.2000.0553. PubMed PMID: 10985971.
44. Hakvoort RA, Lisman BA, Boer K, Bleker OP, van Groningen K, van Wely M, Exalto N. Histological classification of chorionic villous vascularization in early pregnancy. Hum Reprod. 2006;21(5):1291-4. Epub 20060112. doi: 10.1093/humrep/dei456. PubMed PMID: 16410335.
45. Khong TY, Mooney EE, Ariel I, Balmus NC, Boyd TK, Brundler MA, Derricott H, Evans MJ, Faye-Petersen OM, Gillan JE, Heazell AE, Heller DS, Jacques SM, Keating S, Kelehan P, Maes A, McKay EM, Morgan TK, Nikkels PG, Parks WT, Redline RW, Scheimberg I, Schoots MH, Sebire NJ, Timmer A, Turowski G, van der Voorn JP, van Lijnschoten I, Gordijn SJ. Sampling and Definitions of Placental Lesions: Amsterdam Placental Workshop Group Consensus Statement. Arch Pathol Lab Med. 2016;140(7):698-713. Epub 2016/05/26. doi: 10.5858/arpa.2015-0225-CC. PubMed PMID: 27223167.
46. Boyd JD, Hamilton WJ. Stromal Trophoblastic Buds. J Obstet Gynaecol Br Commonw. 1964;71:1-10. Epub 1964/02/01. doi: 10.1111/j.1471-0528.1964.tb04235.x. PubMed PMID: 14117233.
47. Philippe E, Boue JG. [The placenta in lethal chromosome aberrations]. Ann Anat Pathol (Paris). 1969;14(3):249-66. Epub 1969/07/01. PubMed PMID: 5351906.
48. Philippe E, Boue J. [Anatomo-pathologic character of human placentas according to chromosome anomalies]. C R Acad Hebd Seances Acad Sci D. 1969;269(4):535-7. PubMed PMID: 4981105.
49. Philippe E, Boue JG. [Placenta and chromosome aberrations in spontaneous abortion]. Presse Med. 1970;78(14):641-6. Epub 1970/03/21. PubMed PMID: 5440102.
50. Katz J, Holzer PH, Kliman HJ. Genetics, not the uterine environment, drive the formation of trophoblast inclusions: Insights from a twin study. Placenta. 2021. doi: https://doi.org/10.1016/j.placenta.2021.04.010.
51. Walker CK, Anderson KW, Milano KM, Ye S, Tancredi DJ, Pessah IN, Hertz-Picciotto I, Kliman HJ. Trophoblast inclusions are significantly increased in the placentas of children in families at risk for autism. Biological psychiatry. 2013;74(3):204-11. Epub 2013/04/30. doi: 10.1016/j.biopsych.2013.03.006. PubMed PMID: 23623455; PubMed Central PMCID: PMCPMC3755347.
52. Szulman AE, Philippe E, Boue JG, Boue A. Human triploidy: association with partial hydatidiform moles and nonmolar conceptuses. Hum Pathol. 1981;12(11):1016-21. Epub 1981/11/01. doi: 10.1016/s0046-8177(81)80259-6. PubMed PMID: 7319489.
53. Kliman HJ, McSweet JC, Franco A, Ying X, Zhao Y, Stetten G. Trophoblast inclusions are rare in elective terminations and normal deliveries, but common in cases with karyotypic abnormalities. Fertility and Sterility. 2003;80:88.
54. Pinar H, Sung CJ, Oyer CE, Singer DB. Reference values for singleton and twin placental weights. Pediatr Pathol Lab Med. 1996;16(6):901-7. Epub 1996/11/01. doi: 10.1080/15513819609168713. PubMed PMID: 9025888.
55. Mrklic I, Bendic A, Pogorelic Z, Karaman I, Glavina Durdov M, Druzijanic N, Tomic S. Squamous metaplasia of the peritoneum: report of a case. Int J Surg Pathol. 2013;21(1):82-4. doi: https://dx.doi.org/10.1177/1066896912450316. PubMed PMID: 22723504.
56. Jongyotha K, Sriphrapradang C. Squamous Cell Carcinoma of the Renal Pelvis as a Result of Long-Standing Staghorn Calculi. Case rep. 2015;8(3):399-404. doi: https://dx.doi.org/10.1159/000440764. PubMed PMID: 26557077.
57. Schatz JE, Colgan TJ. Squamous metaplasia of the peritoneum. Archives of Pathology & Laboratory Medicine. 1991;115(4):397-8. PubMed PMID: 1707265.
58. Christensen RD, Lambert DK, Richards DS. Estimating the nucleated red blood cell 'emergence time' in neonates. J Perinatol. 2014;34(2):116-9. Epub 20130912. doi: 10.1038/jp.2013.113. PubMed PMID: 24030675.
59. Tantbirojn P, Saleemuddin A, Sirois K, Crum CP, Boyd TK, Tworoger S, Parast MM. Gross abnormalities of the umbilical cord: related placental histology and clinical significance. Placenta. 2009;30(12):1083-8. Epub 2009/10/27. doi: 10.1016/j.placenta.2009.09.005. PubMed PMID: 19853300.
60. Kim CJ, Romero R, Chaemsaithong P, Chaiyasit N, Yoon BH, Kim YM. Acute chorioamnionitis and funisitis: definition, pathologic features, and clinical significance. Am J Obstet Gynecol. 2015;213(4 Suppl):S29-52. Epub 2015/10/03. doi: 10.1016/j.ajog.2015.08.040. PubMed PMID: 26428501; PubMed Central PMCID: PMCPMC4774647.
61. 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(2):473-9. PubMed PMID: 8342596; PubMed Central PMCID: PMCPMC1887041.
62. Yusuf K, Kliman HJ. The fetus, not the mother, elicits maternal immunologic rejection: lessons from discordant dizygotic twin placentas. J Perinat Med. 2008;36(4):291-6. Epub 2008/07/05. doi: 10.1515/JPM.2008.054. PubMed PMID: 18598117.
63. Redline RW. Villitis of unknown etiology: noninfectious chronic villitis in the placenta. Hum Pathol. 2007;38(10):1439-46. Epub 2007/09/25. doi: 10.1016/j.humpath.2007.05.025. PubMed PMID: 17889674.
64. Kim CJ, Romero R, Chaemsaithong P, Kim JS. Chronic inflammation of the placenta: definition, classification, pathogenesis, and clinical significance. Am J Obstet Gynecol. 2015;213(4 Suppl):S53-69. Epub 2015/10/03. doi: 10.1016/j.ajog.2015.08.041. PubMed PMID: 26428503; PubMed Central PMCID: PMCPMC4782598.
65. Marchaudon V, Devisme L, Petit S, Ansart-Franquet H, Vaast P, Subtil D. Chronic histiocytic intervillositis of unknown etiology: clinical features in a consecutive series of 69 cases. Placenta. 2011;32(2):140-5. Epub 2010/12/25. doi: 10.1016/j.placenta.2010.11.021. PubMed PMID: 21183219.
66. Traeder J, Jonigk D, Feist H, Brocker V, Langer F, Kreipe H, Hussein K. Pathological characteristics of a series of rare chronic histiocytic intervillositis of the placenta. Placenta. 2010;31(12):1116-9. Epub 2010/10/16. doi: 10.1016/j.placenta.2010.09.012. PubMed PMID: 20947163.
67. Boyd TK, Redline RW. Chronic histiocytic intervillositis: a placental lesion associated with recurrent reproductive loss. Hum Pathol. 2000;31(11):1389-96. Epub 2000/12/09. PubMed PMID: 11112214.
68. Elsasser DA, Ananth CV, Prasad V, Vintzileos AM, New Jersey-Placental Abruption Study I. Diagnosis of placental abruption: relationship between clinical and histopathological findings. Eur J Obstet Gynecol Reprod Biol. 2010;148(2):125-30. Epub 2009/11/10. doi: 10.1016/j.ejogrb.2009.10.005. PubMed PMID: 19897298; PubMed Central PMCID: PMCPMC2814948.
69. Rashidi A, Gilles S, Linden MA. Lines of Zahn in the Splenic Vein. Thromb Haemost. 2018;118(6):957-8. Epub 2018/04/22. doi: 10.1055/s-0038-1642610. PubMed PMID: 29679949.
70. Biankin SA, Arbuckle SM, Graf NS. Autopsy findings in a series of five cases of fetomaternal haemorrhages. Pathology. 2003;35(4):319-24. PubMed PMID: 12959768.
71. Ravishankar S, Migliori A, Struminsky J, Has P, Sung CJ, He M. Placental findings in feto-maternal hemorrhage in livebirth and stillbirth. Pathology, Research & Practice. 2017;213(4):301-4. PubMed PMID: 28238383.
72. Redline RW. Extending the Spectrum of Massive Perivillous Fibrin Deposition (Maternal Floor Infarction). Pediatric & Developmental Pathology. 2021;24(1):10-1. doi: https://dx.doi.org/10.1177/1093526620964353. PubMed PMID: 33023403.
73. Kim EN, Lee JY, Shim JY, Hwang D, Kim KC, Kim SR, Kim CJ. Clinicopathological characteristics of miscarriages featuring placental massive perivillous fibrin deposition. Placenta. 2019;86:45-51. Epub 2019/07/22. doi: 10.1016/j.placenta.2019.07.006. PubMed PMID: 31326089.
74. Romero R, Whitten A, Korzeniewski SJ, Than NG, Chaemsaithong P, Miranda J, Dong Z, Hassan SS, Chaiworapongsa T. Maternal floor infarction/massive perivillous fibrin deposition: a manifestation of maternal antifetal rejection? Am J Reprod Immunol. 2013;70(4):285-98. Epub 2013/08/03. doi: 10.1111/aji.12143. PubMed PMID: 23905710; PubMed Central PMCID: PMCPMC4122226.
75. Heifetz SA, Bauman M. Necrotizing funisitis and herpes simplex infection of placental and decidual tissues: study of four cases. Hum Pathol. 1994;25(7):715-22. Epub 1994/07/01. doi: 10.1016/0046-8177(94)90306-9. PubMed PMID: 8026831.
76. Silingardi E, Santunione AL, Rivasi F, Gasser B, Zago S, Garagnani L. Unexpected intrauterine fetal death in parvovirus B19 fetal infection. Am J Forensic Med Pathol. 2009;30(4):394-7. Epub 2009/11/11. doi: 10.1097/PAF.0b013e3181c17b2e. PubMed PMID: 19901803.
77. Salafia CM, Minior VK, Pezzullo JC, Popek EJ, Rosenkrantz TS, Vintzileos AM. Intrauterine growth restriction in infants of less than thirty-two weeks' gestation: associated placental pathologic features. Am J Obstet Gynecol. 1995;173(4):1049-57. Epub 1995/10/01. doi: 10.1016/0002-9378(95)91325-4. PubMed PMID: 7485292.
78. Bloomfield RD, Suarez JR, Malangit AC. The placenta: a diagnostic tool in sickle cell disorders. J Natl Med Assoc. 1978;70(2):87-8. Epub 1978/02/01. PubMed PMID: 702553; PubMed Central PMCID: PMCPMC2537050.
79. Jauniaux E, Watson AL, Hempstock J, Bao YP, Skepper JN, Burton GJ. Onset of maternal arterial blood flow and placental oxidative stress. A possible factor in human early pregnancy failure. Am J Pathol. 2000;157(6):2111-22. Epub 2000/12/07. doi: 10.1016/S0002-9440(10)64849-3. PubMed PMID: 11106583; PubMed Central PMCID: PMCPMC1885754.
80. Lau J, Magee F, Qiu Z, Hoube J, Von Dadelszen P, Lee SK. Chorioamnionitis with a fetal inflammatory response is associated with higher neonatal mortality, morbidity, and resource use than chorioamnionitis displaying a maternal inflammatory response only. Am J Obstet Gynecol. 2005;193(3 Pt 1):708-13. Epub 2005/09/10. doi: 10.1016/j.ajog.2005.01.017. PubMed PMID: 16150264.
81. Parzen E. On Estimation of a Probability Density Function and Mode. The Annals of Mathematical Statistics. 1962;33(3):1065-76.
82. Davis RA, Lii K-S, Politis DN. Remarks on Some Nonparametric Estimates of a Density Function. In: Davis RA, Lii K-S, Politis DN, editors. Selected Works of Murray Rosenblatt. New York, NY: Springer New York; 2011. p. 95-100.
83. Anderson MJ. Permutation tests for univariate or multivariate analysis of variance and regression. Canadian Journal of Fisheries and Aquatic Sciences. 2001;58(3):626-39. doi: 10.1139/f01-004.
84. Pedregosa F, Varoquaux G, Gramfort A, Michel V, Thirion B, Grisel O, Blondel M, Prettenhofer P, Weiss R, Dubourg V, Vanderplas J, Passos A, Cournapeau D, Brucher M, Perrot M, Duchesnay E. Scikit-learn: Machine Learning in Python. Journal of Machine Learning Research. 2011;12:2825-30.
85. Hunter JD. Matplotlib: A 2D Graphics Environment. Computing in Science & Engineering. 2007;9(3):90-5. doi: 10.1109/MCSE.2007.55.
Usage notes
Microsoft Excel
Funding