Why is placenta sent to pathology

An umbilical cord typically has a median length of A short umbilical cord 30 centimeters or less or a long umbilical cord centimeters can be associated with neonatal problems. Sometimes the umbilical cord is abnormally short at birth because the cord is cut at birth and the placental pathologist does not have the umbilical cord in its entirety.

An abnormally short umbilical cord can be caused by neurodevelopmental syndromes. Fetal movements increase the length of the umbilical cord and if the umbilical cord is short, there is a presumption that the baby did not move in utero. The gross and microscopic examination of the placenta is recommended and considered to be an essential part of the evaluation following any stillbirth. In a publication by the American Congress of Obstetricians and Gynecologists ACOG on placental examination, no specific recommendations were given.

In , the College of American Pathologists CAP published guidelines for placental pathological examination following delivery. These guidelines have been adopted at many academic centers; however, many practicing obstetricians and labor and delivery nursing staff are not aware of the specific CAP guidelines for pathological evaluation of the placenta.

Several studies have shown a very low sensitivity but high specificity in the likelihood of placental examinations based on CAP guidelines. The primary purpose of this study was to determine the frequency of appropriate placental pathological examinations in a university hospital.

The actual indications for which placental pathological examinations were being performed in a university setting and whether they met criteria set in place by the CAP guidelines were evaluated as well. Additionally, the frequency of no examination on noneligible placentas also was analyzed.

This is a retrospective review of all obstetrical deliveries that resulted in a live birth and all placentas submitted for pathologic examination at the University of Arkansas for Medical Sciences UAMS between July 1, and December 31, Obstetrical records from the delivery logs and the electronic medical records were reviewed for the clinical birth history on each obstetrical delivery case, including whether or not the placenta was submitted to pathology for examination.

Information was obtained from all placental requisitions and placental diagnostic reports generated by the Department of Pathology at UAMS during that same time interval. The pathology requisitions and the pathology reports from all of the submitted placentas were then reviewed by a single perinatal pathologist to determine whether the placentas met the CAP-recommended guidelines for pathologic examination.

Comparisons were made between guidelines for placental pathological studies and actual indications for examination. Each case was categorized as a true or false positive on the basis of the CAP guidelines for placental examination. Additionally, descriptive analyses of key demographic data using independent t -tests and Chi-square tests, as appropriate, were used to compare patients whose placental pathological evaluations were verified with those whose evaluations were not verified.

These categories were examined for significant differences between the individual categories and the likelihood that the placenta was sent for examination. All statistical analyses were performed using SAS 9. Of these, were correctly identified by medical record number and are the basis of this review.

A total of placentas were sent for pathological evaluation. Review of the records by a perinatal pathologist following the CAP guidelines revealed that placentas Of the placentas ascertained by the perinatal pathologist as not needing to be sent for pathological examination, Association between College of American Pathologists indications and whether or not the placenta was sent for examination.

Potential benefits of pathological examination of the placenta include the evaluation and explanation of the etiology associated with an adverse pregnancy outcome, the formulation of a plan of management for future pregnancies, the capability to predict the risk for long-term neonatal neurodevelopmental problems, and medical—legal risk assessment of an adverse pregnancy outcome.

In our study, over a 6-month period of time in , Among all deliveries, Of these, placental examination was undertaken in Among the placentas that did not need pathologic examination per the CAP guidelines, These findings differ from CAP guideline compliance evaluations undertaken at other universities 5—10 years earlier. In a South Australian study of deliveries that occurred over the course of 3 months in , In a US investigation, Curtin et al 8 reviewed more than deliveries over the same time period in and found that On the clinical side, there is lack of clarity regarding which placentas to submit and what placental diagnoses mean.

In some pathology departments, there is an appalling lack of diagnostic accuracy and clinical other subspecialty. This article discusses the logistics of getting the right placentas to the right pathologists and briefly reviews the most important patterns of placental pathology.

The focus here is on 6 common categories of placental injury, 2 rare lesions of extreme severity and high recurrence risk, and 2 placental findings that reflect underlying fetal processes and how they each relate to different adverse pregnancy outcomes. Specialized topics such as multiple gestation, congenital infections, and hydrops fetalis are beyond the scope of this review.

Detailed consideration of these and other topics can be found in standard textbooks. Four categories of placental pathology have clinical utility: 1 findings relevant to the immediate care of the mother or baby; 2 findings predictive of possible recurrence that could guide care in subsequent pregnancies; 3 diagnoses that help explain adverse pregnancy outcomes; and 4 findings that may be important in medicolegal investigation of perinatal mortality and long-term morbidity.

An example of a pathologic finding relevant to immediate care would be a peripheral abscesses on the surface of the umbilical cord in a premature placenta. That is diagnostic for Candida infection, information that should be immediately communicated to the neonatal intensive care unit NICU so that antifungal therapy can be initiated. Pertinent to the last 2 categories of placental pathology is neonatal encephalopathy leading to cerebral palsy CP , which is among the most devastating pregnancy outcomes.

Fetal thrombotic vasculopathy indicates antenatal as opposed to intrapartum causation, which can help explain a confusing clinical picture and be informative for both parents and physicians. The goal is to ensure that the right placentas get to the right pathologist in a timely manner. Guidelines for placental submission were published in by a task force of pathologists and obstetricians sponsored by the College of American Pathologists Table 1. Not every placenta from each category needs to be submitted and some placentas that fall outside the guidelines will reveal important findings.

Because some babies present with problems in the days following apparently normal deliveries, it is prudent to develop a system for short-term retention of all placentas on the labor and delivery floor.

Placentas can be stored unfixed in a refrigerator for up to 7 days without compromising placental pathology. The importance of providing the pathologist with appropriate clinical history cannot be overemphasized.

At a minimum, gestational age, gravidity, parity, birth weight, Apgar scores, and relevant clinical conditions should always be included. Timely reporting is critical for patient care. If the pathology department receives a placenta by noon, it is not unreasonable to expect a final diagnosis by the end of the next business day. If there are concerns about the accuracy or relevance of the initial placental diagnoses, it may be necessary to discuss the findings with the pathologist and solicit an expert review.

Looking down the road, slide scanning technologies that allow for online consultation may facilitate development of regional centers with specific expertise in placental diagnosis. Described below are the constellation of histopathologic findings that either directly affect placental function or serve as biomarkers for processes occurring in the mother or fetus.

Figure 1 illustrates their site of action and Table 2 summarizes their correlation with selected important adverse pregnancy outcomes. The relative importance of particular lesions varies in reports by different authors because of varying clinical material, definitions used, and statistical approaches. Maternal arterial malperfusion develops as a consequence of deficient trophoblastic invasion and remodeling of the spiral arterioles in early pregnancy.

It is less common with FGR at term. In some studies, it is a risk factor for CP. Complications include development of maternal preeclampsia due to release of antiangiogenic mediators by ischemic villous trophoblast and abruptio placentae secondary to rupture of inadequately remodeled spiral arterioles.

Placentas affected by maternal arterial malperfusion may be small, both in absolute weight and relative to fetal weight. Histologically, it is characterized by increased syncytial knotting, intervillous fibrin deposition, and villous agglutination.

When severe, it is also often accompanied by patchy hypoplasia of the distal villous tree and 1 or more villous infarcts. Features of increased extravillous trophoblasts and multinucleated trophoblasts at the maternal floor also may be evident. Abruptio placenta is characterized by large central retroplacental hematomas, often with overlying intravillous hemorrhage or recent villous infarction. Marginal abruptions are common causes of spontaneous preterm birth, particularly in the context of ascending infection, and when chronic can be associated with FGR.

Chronic abruption is associated with organizing marginal or subchorionic hematomas, circumvallate membrane insertion, and deposition of hemoglobin pigments usually hemosiderin in the placental membranes. Chronic fetal vascular obstruction , as reflected by the pathologic finding of significant numbers of avascular villi AV , is a clinically silent process strongly associated with adverse clinical outcome. Larger foci of AV indicate thrombosis of major chorionic or stem villous vessels fetal thrombotic vasculopathy.

Although maternal diabetes and inherited fetal thrombophilias can be associated with fetal thrombotic vasculopathy, the major risk factor is stasis, again related to compromised umbilical blood flow. The frequent finding of large areas of contiguous AV with degenerative changes antedating the estimated time of fetal demise suggests that chronic fetal vascular obstruction is also a major cause of stillbirth at term.

Histologic chorioamnionitis is the gold standard for defining the maternal and fetal inflammatory responses to microbial organisms in the amniotic fluid. Clinical symptoms such as fever and leukocytosis are notoriously unreliable in this context. Chorioamnionitis is the major cause of spontaneous preterm birth and other neonatal complications. Recognizing specific patterns of inflammation can suggest specific organisms, such as Candida or Listeria, that require special attention.