presentasjon 14 placenta klassifikasjon
Prosessrelatert, klinisk relevant placentaklassifikasjon Kurs O-30185 Perinatalpatologi inkludert placenta, 13.10.2015 Gitta Turowski, overlege og PhD kandidat, Senter for barneog svangerskapsrelatert patologi, OUS-Ullevål Senter for barne- og svangerskapsrelatert patologi Placenta er et dynamisk organ som regulerer sin vekst og modning etter behov - oppfattes som ‘fetal diary’ Forskning om placenta er nødvendig for å bedre forståelsen av samspill mellom mor – placenta – og barn bedre. Senter for barne- og svangerskapsrelatert patologi Utfordringer i placentadiagnostikk • 2 (eller flere) individ, 2 (og flere) sirkulasjonssysteme (maternell og føtal) • Dynamisk organ (modning og modningsforstyrrelse) • Infeksjon • Metabolisk forstyrrelse • Genetikk Senter for barne- og svangerskapsrelatert patologi Hvorfor er det viktig å vurdere forandringene mikroskopisk? Inflammasjon Vurdering av føtal sirkulasjon (navlesnorkar, placenta/tottekar) Vurdering av maternell sirkulasjon Tottemodning Implantasjonsfeil Senter for barne- og svangerskapsrelatert patologi Ingen internasjonal akseptert klassifikasjonssystem! Senter for barne- og svangerskapsrelatert patologi Samling av criteria Standardisering Diskusjon om formulering og form av report Klassifikasjons system for placenta diagnostikk Lett forståelig (obstetriker, sykepleier, jordmødre, neonatologer, andre patologer Klinisk relevant Prosessrelatert Senter for barne- og svangerskapsrelatert patologi Forskning Diagnose kategorier i placenta 1. 2. 3. 4. 5. 6. 7. 8. 9. Normal placenta Placenta med akutt chorioamnionitt Placenta med villititt og intervillositt Placenta med maternell vaskulær malperfusjon Placenta med føtal vaskulær malperfusjon Placenta med modningsforstyrrelse Placenta, suspekt på genetisk feil Placenta med feil implantasjon Annet Alle diagnoser inkluderer en patophysiologisk vurdering og diskusjon av alle funn i en klinisk patologisk korrelasjon Senter for barne- og svangerskapsrelatert patologi 1. Normal placenta for gestasjonslengde Villous maturation Vascular maturation Stromal maturation Branching from primary to secondary and tertiary villi with smaller diameter Central fetal capillaries to vasculosyncytial membranes. Arterial fibro-muscular hyperplasia in primary villi Dominant embryonic, loose stroma with Hofbauer cells to sparse stroma dominated by fetal capillaries in tertiary villi Fibromuscular stroma in primary villi Gestational week Villi in % Stem villi: Reticular stroma with fetal vessels, paravascular collagen Intermediate villi, immature type: Embryonic stroma, many 16 20 24 28 32 36 40 17 13 10 9 11 10 9 54 51 32 16 10 5 1 29 35 50 56 52 47 32 0 1 8 19 27 38 58 Hofbauer cells Intermediate villi, mature type: Cellular stroma, scattered Hofbauer cells Terminal villi: Stroma with fetal capillaries dominated by vasculosyncytial membranes Vogel M. Atlas der morphologischen Plazentadiagnostik. second ed. Berlin: Springer; 1996. BECKER V. [Functional morphology of the placenta]. Arch Gynakol 1963;198:3-28. Senter for barne- og svangerskapsrelatert patologi 1. Normal placenta • Normal moding for gestasjonslengde Senter for barne- og svangerskapsrelatert patologi Infeksjoner i placenta Placenta 1. Oppadstigende (fra vagina): chorioamnionitter 2 Annetine Staff Decidua basalis 1 2. Transplacentære (blodbårne): villitter Senter for barne- og svangerskapsrelatert patologi 2. Akutt chorioamnionitt Invasion of neutrophilic granulocytes in chorion and amnion Maternal response (stadium 1-3, grade 1-2) Fetal response (Stadium 1-3, Grade 1-2) Redline. "Inflammatory response in acute chorioamnionitis." Semin.Fetal Neonatal Med. (2011). Redline "Inflammatory responses in the placenta and umbilical cord." Semin.Fetal Neonatal Med. 11.5 (2006): 296-301. Senter for barne- og svangerskapsrelatert patologi 2. Akutt og kronisk chorioamnionitt Acute Maternal response Fetal response Stage 1 Neutrophils in subchorionic/chorionic fibrin Grade 1 or 2 Umbilical phlebitis and /or chorionic vasculitits Grade 1 or 2 Stage 2 Neutrophils in chorionic plate and membranes Grade 1 or 2 Umbilical arteritis and phlebitis Grade 1 or 2 Stage 3 Karyorrhexis and amniocyte necrosis Grade 1 or 2 Umbilical concentric periphlebitis/necrotizing funisitis Grade 1 or 2 Grade 1: slight to moderate Grade 2: intense, > 30 neutrophils in chorionic plate and sub-/chorionic micro abscess Subacute Invasion of acute and chronic inflammatory cells between amnion and chorion Necrosis Chronic Lymphocytes in the chorionic trophoblast layer or chorioamniotic connective tissue Stage 1 Amniotropic lymphocytic invasion confined to the chorionic trophoblast layer Stage 2 Lymphocytic invasion into the chorioamniotic connective tissue Grade 1 =>3 foci or patchy inflammation Grade 2 Diffuse inflammation Redline RW. Inflammatory response in acute chorioamnionitis. Semin Fetal Neonatal Med 2012 Feb;17(1):20-5 Lee J, Romero R, Dong Z, Xu Y, Qureshi F, Jacques S, et al. Unexplained fetal death has a biological signature of maternal anti-fetal rejection: chronic chorioamnionitis and alloimmune anti-human leucocyte antigen antibodies. Histopathology 2011 Nov;59(5):928-38. Senter for barne- og svangerskapsrelatert patologi 3. Villitit og intervillositt Chronic villitis, including villitis of unknown etiology (VUE) and infectious etiology Microscopic criteria Low grade High grade Chronic villous inflammation 5-10 villi/focus, multifocal >10 villi/focus Associated lesions Focal groups of fibrous villi Obliterated fetal vessels Extensive perivillous fibrin Active component (neutrophils) Decidual plasmacells Intervillositis Macroscopic findings Microscopic findings Acute Neutrophils in villi/intervillous space Fibrin Chronic Green and/or opaque membranes Pale and/or firm yellow basal plate Small placentas Histiocytic Small placentas Diffuse intervillous invasion of histiocytes Diffuse intervillous invasion of lymphocytes, monocyte-macrophages, eosinophils Villous necrosis and perivillous fibrin Benirschke K, Kaufmann P, Baergen RN. Pathology of the Human Placenta. Fifth edition ed. New York: Springer; 2006 Baergen RN. Manual of Pathology of the Human Placenta. second ed. New York: Springer; 2011. Kraus FT, Redline RW, Gersell DJ, Nelson DM, Dicke JM. Placental Pathology. Washington, DC: American Registry of Pathology in collaboration with the Armed Forces Institute of Pathology; 2004. Redline RW. Infections and other inflammatory conditions. Semin Diagn Pathol 2007 Feb;24(1):5-13. Redline RW. Villitis of unknown etiology: noninfectious chronic villitis in the placenta. Hum Pathol 2007 Oct;38(10):1439-46. Boog G. Chronic villitis of unknown etiology. Eur J Obstet Gynecol Reprod Biol 2008 Jan;136(1):9-15. Senter for barne- og svangerskapsrelatert patologi 3. Villitis and intervillositis Low grade High grade < 10 villi per focus focal > 1 focus /slide multifocal > 1 slide > 10 villi per focus patchy: > 1 focus diffuse: > 5% of all villi Intervillositis: Acute/chronical CD 8 CD 3 CD 68 Redline "Villitis of unknown etiology: noninfectious chronic villitis in the placenta." Hum.Pathol. 38.10 (2007): 1439-46. Senter for barne- og svangerskapsrelatert patologi AFIP Placenta Fascicle, 2004 4. Maternell vaskulær malperfusjon Chronology of infarction/ischemia Acute (hours - 2 days) Subacute (>2 days) Villous capillary stasis with/without hemorrhage Trophoblastic necrosis and/or villous necrosis Fibrin deposition intra-/intervillous Trophoblastic proliferation in the infarction borders Demarcation of neutrophils Maternal Increased syncytial knots (estimated according to gestational age) malperfusion: Villous agglutination (clusters of adherent distal villi) Increased intervillous fibrin Distal villous hypoplasia Atherosis of decidual arteries Placental weight < 10th percentile Pathology Macroscopy Cotyledon infarct Acute Basal/ intermediate Dark red Sharply demarcated Subacute Brownish Chronic Yellow to white Sharply demarcated Intervillous thrombe Acute Chronic Abruption Acute Red, often shiny White Sharply demarcated Dark red and soft Clots adhered to maternal surface Chronic Brown, basal impression Chronic (>1week) Microscopy Intravillous hemorrhage Congestion of villous capillaries Collapse of the intervillous space Trophoblastic necrosis Intra-/intervillous fibrin deposition Demarcation by maternal neutrophils Pyknosis, karyorrhexis Ghost villi Intervillous fibrinoid Intervillous hemorrhage Laminated fibrin Compressed underlying villous tissue Intravillous hemorrhage, Capillary stasis and edema Chorioamnionic hemosiderinmacrophages Baergen RN. Manual of Pathology of the Human Placenta. second ed. New Senter for barneog York: Springer; 2011. Stanek J. Placental membrane and placental disc microscopic chorionic cystspatologi share similar clinicopathologic associations. Pediatr Dev Pathol svangerskapsrelatert 4. Placenta med maternell vaskulær malperfusjon Infarkt Intervilløse fibrinavleiringer Intervilløs trombe (føtomaternell hemorrhagi (identifiserbare føtale erytrocytter), maternell trombophili eller preeklampsi Perivilløs fibrinoidavleiring Maternal floor infarct - ? Evt. påvisbar maternell karpatologi i decidua Abruptio Stanek, J. and H. A. Al-Ahmadie. "Laminar necrosis of placental membranes: a histologic sign of uteroplacental hypoxia." Pediatr.Dev.Pathol. 8.1 (2005): 34-42. Placental Malperfusion." Manual of Benirschke and Kaufmann's Pathology of the human placenta. 1 ed. New York: Springer, 2005. 232-350. Pathology of the placenta. VI. Circulation disorders of the placenta. Maternal circulation (intervillous space)." Zentralbl.Pathol. 137.4 (1991): 316-24. Redline, R. W., et al. "Maternal vascular underperfusion: nosology and reproducibility of placental reaction patterns." Pediatr.Dev.Pathol. 7.3 (2004): 237-49. Senter for barne- og svangerskapsrelatert patologi Maternal floor infarction - decidual floor infiltrated by fibrinoid thick, yellow floor villous tissue diffuse penetrated fibrinoid encases viable villi in a netlike pattern - reduced blood flow, obstructed materno-fetal exchange congenital infection, immune-mediated rejection IUGR, neurologic impairment recurrent risk 30% Senter for barne- og svangerskapsrelatert patologi 5. Føtal vaskulær malperfusjon Patterns of fetal vascular thrombosis (FVT) Luminal thrombosis Microscopic findings, vessel and vessel wall Microscopic findings, villous stroma Acute thrombosis Fibrin deposits with/without occlusion Endothelial edema Karyorrhexis Erythrocyte extravasation Iron deposits in the basement membrane Subacute thrombosis Thrombe attached to vessel wall Fibrosis in proximal villi Chronic Thrombosis Thrombe organization Recanalization Calcification Clusters of distal avascular and fibrous villi close to affected stem villi Mural thrombosis Microscopic findings of the vessel Intimal fibrin cushion Laminated pale blue fibrin between vascular smooth muscle and endothelium (+/- calcification) Hemorrhagic endovasculitis Rupture of fetal vessels in primary villi with hemorrhage and inflammatory cells. Active lesion: Inflammatory villous infiltrates = hemorrhagic villitis Fibrinous vasculosis (endangiopathia obliterans) Edema in the fetal vessel wall Obliteration/thrombosis Endothelial cushion Localized proliferating fibroblasts (intramural fibrin, erythrocytes) With/without secondary calcification Baergen RN. Manual of Pathology of the Human Placenta. second ed. New York: Springer; 2011. Kraus FT, Redline RW, Gersell DJ, Nelson DM, Dicke JM. Placental Pathology. Washington, DC: American Registry of Pathology in collaboration with the Armed Forces Institute of Pathology; 2004. 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 Sep;7(5):443-52. Emmrich P. [Pathology of the placenta. V. Circulatory disorders of the placenta. Fetal vascular system]. Zentralbl Pathol 1991;137(2):97-104. Senter barne- og Redline RW. Placental pathology and cerebral palsy. ClinforPerinatol 2006 Jun;33(2):503-16. svangerskapsrelatert patologi Føtal trombotisk malperfusjon assosiert med: • • • • Preeklampsi FGR IUFD Neonatal trombose beskrevet i CNS, lunge, nyre Senter for barne- og svangerskapsrelatert patologi 5. Placenta med føtal vaskulær malperfusjon Thrombe i føtale kar Rekanalisasjon Endothelial cushin Vasculitt Endarteriitt obliterans Hemorrhagisk endovaskulitt Redline R. Placental pathology and cerebral palsy. Clin.Perinatol. 33.2 (2006): 503-16. Redline Placental pathology: a systematic approach with clinical correlations. Placenta 29 Suppl A (2008): S86-S91. Senter for barne- og svangerskapsrelatert patologi Patogenese av tromber (Baergen, R.N., Manual of Benirschke and Kaufmann’s Pathology of the Human Placenta. Springer 2004.) • • • • Lang navlesnor Knute Spiralisering Velamentøs navlesnorfeste • Mekanisk obstruksjon • Thrombose i arterie forårsaket av abnormal koagulasjon i mor eller barn: Factor V Leiden mutasjon, aktivert protein C resistance, protein S deficiency, protein C deficiency, lupus anticoagulant, antiphospholipid antibodies Senter for barne- og svangerskapsrelatert patologi 6. Modningsforstyrrelse (delayed maturation) Microscopy Maturation disorder Villi Fetal vessels Villous maturation arrest (delayed villous maturation, distal villous immaturity) Focal imbalance of villous branching Predominance of villi with increased diameter Excessive cellular stroma Excessive extracellular matrix Increased number of centrally localized capillaries Reduced vasculosyncytial membranes Benirschke K, Kaufmann P, Baergen RN. Pathology of the Human Placenta. Fifth edition ed. New York: Springer; 2006 Emmrich P. [Pathology of the placenta. III. Maturation disorders of the placenta]. Zentralbl Allg Pathol 1990;136(7-8):643-56. BECKER V. [Functional morphology of the placenta]. Arch Gynakol 1963;198:3-28. Higgins M, McAuliffe FM, Mooney EE. Clinical associations with a placental diagnosis of delayed villous maturation: a retrospective study. Pediatr Dev Pathol 2011 Jul;14(4):273-9. Redline RW. Distal villous immaturity. Diagnoistic Histopathology 2012;18-5(Placental and trophoblastic pathology):189-94. Senter for barne- og svangerskapsrelatert patologi Placenta med modningsforstyrrelse Normal modning week 22 week 9 week 40 week 30 Vogel M. Zottenreifungsstoerungen." Atlas der morphologischen Plazentadiagnostik. 2 ed. Berlin: Springer, 1996. 82-91. Emmrich, P. Pathology of the placenta. IV. Maturation disorders of the placenta under special clinical conditions. Zentralbl.Pathol. 137.1 (1991): 2-13. Becker, V.: Funktionelle Morphologie der Plazenta. Verh. Ges. Gynaekol.1963; 34: 3-28. Emmrich, P.: Pathology of Placenta. III. Maturation disorders. Zentralbl. Allg. Pathol. Pathol. Anat. 1990; 136: 643-656. Gustav Fischer Verlag Jena. Benirschke K, Kaufmann P. Pathology of the human Placenta, 4.th ed Sprimger Senter for barne- og svangerskapsrelatert patologi . Mikroskopiske funn i placenta ved GDM Maternell sirkulasjonssvikt barnets kar i placentavilli normal diabetes Desoye, Kaufmann: The human placenta in diabetes. Diabetology of Pregnancy Basel, Karger, 2005; vol 17: pp 94-109. Kos, Vogel: Morphological findings in infants and placentas of diabetic mothers. Diabetology of Pregnancy. Basel, Karger, 2005; Vol 17, pp127-143 Stallmach et al: Rescue by birth: Defective Placental Maturation and late fetal mortality. Obstetrics and Gynecology 2001; vol 97, no 4, pp505-509 Senter for barne- og svangerskapsrelatert patologi 7. Funn, suspekt på genetisk aberration Diagnosis Genetic characteristics Macroscopic characteristics Microscopic characteristics Complete Paternal hydatidiform mole Diploid (46 xx or 46 xy) Translucent vesicles Partial Triploid hydatidiform mole (69 xxx, 69 xxy, 69 xyy) Trisomi 13 Non-disjunction/or mosaic Normal villous tissue intermixed with translucent vesicles Often SUA (single umbilical artery), hydropic Often SUA Reduced vascularity Very small placentas Apolar trophoblastic hyperplasia Intraepithelial microcysts Cellular atypia Hydropic villi with central cisterns Absence of fetally-derived tissue Partly normal, partly complete mole Trisomi 18 Non-disjunction/or mosaic Trisomi 21 Non-disjunction/or mosaic Sometimes increased weight Tetraploidy Mesenchymal dysplasia Possible mosaicism Often large for gestational age Scalloping avascular villi Villous inclusions Dysmature villi Marked increase in villous stromal cells Dysmature villi Villous inclusions Increased syncytial knots Hydropic change Atypical trophoblastproliferation Voluminous/poorly vascularized villi Endovillous migration of trophoblastcells Enlarged primary villi, stemvilli with fibroblastic stroma Increased vascularization Cystic degeneration without trophoblast hyperplasia Multifocal or localized lesions Horn LC, Vogel M. [Gestational trophoblastic disease. Non-villous forms of gestational trophoblastic disease]. Pathologe 2004 Jul;25(4):281-91. Kraus FT, Redline RW, Gersell DJ, Nelson DM, Dicke JM. Placental Pathology. Washington, DC: American Registry of Pathology in collaboration with the Armed Forces Institute of Pathology; 2004. Senter for barne- og svangerskapsrelatert patologi 7. Placenta med funn, suspekt på genetisk aberration - komplett hydatidiform mola - partial hydatidiform mola - trisomi, tetraploidy, mosaics > Trophoblastic proliferasjon > Trophoblastic invagination/inclusion > Stroma cisterns Kliman, H. J. and L. Segel.The placenta may predict the baby.J.Theor.Biol. 225.1 (2003): 143 45. Vogel, M. and L. C. Horn. "[Gestational trophoblastic disease, Villous gestational trophoblasticdisease]." Pathologe 25.4 (2004): 269-79. Senter for barne- og svangerskapsrelatert patologi 8. Implantasjonsfeil Accreta Macroscopy Various Increta Percreta Various Placenta protruding through the uterine wall Extrachorialis/ Fetal surface less than maternal Circumvallata surface Membranes inserted on the fetal plate Peripheral parenchyma without membranes Fibrin deposition/necrosis Other form variation and umbilical cord variation Umbilical cord Velamentous Cord insertion in membranes umbilical cord Insertio Splitting of umbilical cord vessels furcuata above the placental surface (no Whartons’jelly) Bipartita Velamentous insertion Bi-/multilobata Membranacea Normal Normal Succenturiata Umbilical cord insertion on the main placenta Microscopy Villi directly implanted onto the myometrium (no decidua) Villi implanted into the myometrium Villi penetrating the whole uterine wall (to / throu serosa) Duplication of the membranes Hemorrhage, hemosiderin/fibrin deposition/necrosis Disc Normal Normal Two/three placental discs connected by membranes Two or many placental lobes Flat, membrane like disc <5 mm thick Sometimes villous fibrosis One or more placentas connected by vessel bridges in the membranes Baergen RN. Manual of Pathology of the Human Placenta. second ed. New York: Springer; 2011 Kraus FT, Redline RW, Gersell DJ, Nelson DM, Dicke JM. Placental Pathology. Washington, DC: American Registry of Pathology in collaboration with the Armed Forces Institute of Pathology; 2004. Vogel M. Atlas der morphologischen Plazentadiagnostik. second ed. Berlin: Springer; 1996. Senter for barne- og svangerskapsrelatert patologi 8. Placenta med implantasjonsfeil - formvariasjon (circumvallata) - velamentøs festet navlesnor - placenta accreta/increta/percreta Senter for barne- og svangerskapsrelatert patologi 9. Andre lesjoner Gitterinfarct Maternal floor infarct Macroscopy Microscopy White irregular shaped areas with solid consistency Inter- and perivillous fibrin masses Netlike organized fibrinoid around viable villi near basal plate Chronic deciduitis Yellow rim of pallor involving the villous tissue adjacent to the maternal surface Plasmacell invasion and necrosis in the decidua Retention phenomenas <= 1 week few weeks more weeks Chorionic epithelium Eosinophilic syncytium Increased amount of syncytial knots Karyorrhexis in the syncytium Perivillous fibrin Lost of epithelium Perivillous fibrin Intervillous space obturated Villous stroma Minor stroma condensation Collagen tissue cells Pyknosis Swelling of collagen High collagen amount Hydropic/mucoid degeneration Pyknosis Cell proliferation Lost of cells Baergen RN. Manual of Pathology of the Human Placenta. second ed. New York: Springer; 2011. Kraus FT, Redline RW, Gersell DJ, Nelson DM, Dicke JM. Placental Pathology. Washington, DC: American Registry of Pathology in collaboration with the Armed Forces Institute of Pathology; 2004. Vogel M. Atlas der morphologischen Plazentadiagnostik. second ed. Berlin: Springer; 1996. Senter for barne- og svangerskapsrelatert patologi 9 Diagnosis Chorangioma (hamartoma) Macroscopy Solitary or multifocal Sharply demarcated Reddish Hemorrhage, necroses Choriocarcinoma Invasive mole (subsequent to molar pregnancies) Placental disc Focal bleeding in the myometrium wall Partition Microscopy Proliferation of fetal vessels Myxomatous/fibrous stroma Solid sheets of cytotrophoblasts Multinucleated syncytium without stroma Syncytiotrophoblast with irregular, hypochromatic nuclei Dense, eosinophilic cytoplasm Mole like villi in the myometrium Apolar trophoblastic proliferation Vessel anastomosis (risk of TTT) None Exceptionally Frequently Separated Merged Merged Dichorionic-diamnionic Dichorionic-diamnionic Monochorionic-diamnionic Merged MonochorionicAlways monoamnionic Macroscopy Donor Parenchyma huge, pale grayish Anastomosis a-v/a-a in parenchyma rarely v-v on chorionic plate Microscopy Chronic Delayed mature villi Fibrous stroma Sclerotic vessels in primary Thin umbilical cord villi, stem villi Regressive trophoblast Clinics: oligo-hydramnion Inter-/perivillous fibrin deposition Amnion nodosum Recipient Parenchyma small, redDissociated villous grayish maturation Thick umbilical cord Tertiary villi with increased (edema) branching angiogenesis Clinics: poly-hydramnion Villous stromal edema Acute a-a/v-v on chorionic plate Donor Pale Poor vascularization and parenchyma Recipient Red Rich vascularization TTT=Twin-Twin Transfusion: a-a=artery-artery anastomosis, v-v=vein-vein anastomosis, a-v=artery-vein anastomosis Senter for barne- og svangerskapsrelatert patologi Placenta med andre lesjoner Neoplasi (Chorangiom, Chorioncarcinom) Gitterinfarkt (!) Maternal floor infarkt (!) Kronisk deciduitt Retensjon Twin-twin transfusion Baergen, R. N. "Choriocarcinoma." Manual of Benirschke and Kaufmann's Pathology of the human placenta. 1 ed. New York: Springer, 2004. 436-4 Wallenburg, H. C. "Chorioangioma of the placenta. Thirteen new cases and a review of the literature from 1939 to 1970 with special reference to the clinical complications." Obstet.Gynecol.Surv. 26.6 (1971): 411-25. Monique W. M. de Laat, Gwendoline T. R. Manten,Peter G. J. Nikkels,Philip Stoutenbeek Hydropic Placenta as a First Manifestation of Twin-Twin Transfusion in a Monochorionic Diamniotic Twin Pregnancy JUM March 2009 28:375 Senter for barne- og svangerskapsrelatert patologi Test av mikroskopiske kriteria på 315 placentas of IUFD og 31 kontroller (placentas av levende fødte på: Userfriendliness Reproducibility (kappa value to each diagnosis category) G. Turowski et al. / Placenta 33 (2012) 1026-1035 Senter for barne- og svangerskapsrelatert patologi Resultater • Inter observer agreement av histologiske kriterier er generell god • Kappa values reflekterer nøyaktighet av histologiske kriterier, som ‘very good’ for akutt chorioamnionitt • Maternell (good) og føtal (moderate) malperfusjon veldig dårlig kappa values • Villititt og modningsfeil veldig dårlig Feedback av klinikerne veldig positiv: • Diagnoser lett forståelig • Diagnoser nyttig for the patients follow up (barn, mor, far) • 85% vil beholde klassifikasjonssystemet C.A. Walsh, F.M. McAuliffe, G.Turowski, B.Roald, E.E. Mooney: A survey of obstetricians’ views on placental pathology reporting. International Journal of Gynecology and Obstetrics. Vol.121. pp275-277. June 213 Senter for barne- og svangerskapsrelatert patologi Placenta biopsier mellom 2001 og 2014 Placenta 1400 1200 1000 800 600 400 2001 2002 2003 2004 2005 2006 200 0 Senter for barne- og svangerskapsrelatert patologi 2007 2013 2014 Prioritierungssystem 1. Samtlige rekvirenter får en stempel, der det krysses av klinisk informasjon om pasienten med relevans 2. Placenta makroskopisk vurdert 3. Paraffin blokker arkiveres 4. Prøvesvar sendes på grundlag av makroskopiske funn 5. Ved spesiell klinisk spørsmålstilling undersøkes materialet histologisk og ny diagnose sendes som ‘tillegg’ Senter for barne- og svangerskapsrelatert patologi Prioritering av placenta Gestasjonsuke: Apgar : Barnets fødselsvekt (g): Det kliniske spørsmålet til patologen: Diagnosegruppe (sett kryss): Hypertoni / PE……. ☐ Diabetes ………….… ☐ Inflammatorisk/ Autoimmun ……….. ☐ Infeksjon ……………. ☐ Placenta patologi /blødning…………..… ☐ Født <37 uker / Fødselsvekt<2,5kg.. ☐ Annet……………….….. ☐ Senter for barne- og svangerskapsrelatert patologi Ønsket prioritering til patologen: (sett kryss) CITO (calling nr.) ☐ Høy ☐ Lav (primært kun makrovurdering) ☐ Diagnose fordeling, Oktober 2014 250 200 Antall 150 100 50 0 EP7000 EP7100 EP7200 EP7300 EP7400 EP7500 EP7600 EP7700 Besvarte placentaprøve hittil i år, EP kode funnkode 1. Senter for barne- og svangerskapsrelatert patologi EP7800 EP7900 Hvor er vi i dag? Placenta diagnostikk er viktig: • Stillbirth Conference, September 2014 i Amsterdam: Placenta diagnostic skal bli en essentiell del i Stillbirth classification…even more….agreement on international classification • IFPA Placenta meeting, September 2014 i Paris: klinikerne påperker klinisk relevans av placenta diagnostikk I IUFD (Haezell, etc) i forskjellige ´workshops´ og presentasjoner > continued in Brisbane i 2015 • PPS meeting, September 2014, Birmingham Senter for barne- og svangerskapsrelatert patologi Internasjonal arbeidsgruppe som utarbeider diagnostiske kriterier i 2014 i Amsterdam (Redline, Keeting, Mooney, Khong, Desoye, Nikkels, Sebire, Boyd, …….……. Turowski) Diskusjon om sampling og terminologi, som MVP (maternal vascular malperfusion, out: maternal vascular underperfusion) FVM (fetal vascular malperfusion, out: fetal thrombotic vasculopathy) acute chorioamnionitis (´acute subchorionitis´) Maturation disorders – Distal villous hyplasia, delayed villous maturation – ongoing discussion Article accepted in Archives of Pathology & Laboratory Medicine. Senter for barne- og svangerskapsrelatert patologi Senter for barne- og svangerskapsrelatert patologi Kasus 1 • Nigeriansk kvinne, 27 år gammel 1.gangs gravid i uke 22, på besøk i Norge • Spontanabort hjemme • Innlagt på sykehuset med tegn til infeksjon Senter for barne- og svangerskapsrelatert patologi Senter for barne- og svangerskapsrelatert patologi Diagnose Akutt chorioamnionitt. Vurdering: Chorioamnion viser akutt tegn til maternell inflammatorisk respons på en oppadstigende infeksjon. Navlesnorkar med akutt inflammasjon indikerer føtal respons på mors infeksjon. Blødning i decidua tyder på partiell placentablødning med løsning, som står i direkt sammenheng med infeksjon og abort. Senter for barne- og svangerskapsrelatert patologi Kasus 2 • • • • • • 39 gammel kvinne, gravida 4, para 3 kjent gestasjonsdiabetes forhøyet blodstrøm i a. umbilikalis barnet vekstretardert indusert fødsel i uke 37 barn levende født Senter for barne- og svangerskapsrelatert patologi HE Masson-Trichrom CD 31 Senter for barne- og svangerskapsrelatert patologi Diagnose Vekstretardert placenta med modningsforstyrrelse. Vurdering: Basalflate (maternell flate) er mindre enn 10.persentil i uke 37. Parenchymet viser tegn til modningsforstyrrelse med sentral i stroma plasserte føtale kar, som passer med metabolske forandringer. Det fantes kun lite antall vasculosyncytiale membraner. Senter for barne- og svangerskapsrelatert patologi Thanks to: Norwegian group of perinatal and placental pathologists (head Gitta Turowski) Ekstrastiftelsen Helse og Rehabilitering (H&R) and Landsforening for Uvented Barnedød (LUB) Branka M. Yli, prof. Dr. med. obstetrics, OUS Rikshospitalet Annetine Staff, prof. Dr. med., obstetrics OUS-Ullevål, IFPA Placentology award 2013 Patji Alnæs Katjaviwi, resident, obstetrics, PhD student, OUS Ullevål Borghild Roald, prof. Dr. med., Pathology, Head of the center for pediatric and pregnancy related pathology, OUS-Ullevål Senter for barne- og svangerskapsrelatert patologi Mange takk! Senter for barne- og svangerskapsrelatert patologi
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