Placenta Pathology Questions

[konayossie]

I received my birth records last week finally and have been poring over them trying to make some sense (I have no medical background).

I have some questions on my placenta pathology report. My placenta was sent to pathology b/c my baby had IUGR. The report says my placenta was 322 grams, and showed the following
*acute chorioamnionitis, stage I
*acute villous ischemic change, focal.
*intervillous hemorrhage, focal, with nucleated red blood cells, consistent with fetomaternal hemorrhage.
*villitis, acute and chronic, multifocal, moderate, with intervillositis
*small for dates placenta, 5th percentile for 38 weeks (I was 38w5d)
*acute and chronic deciduitis

The pathologist's comment says, "If infectious etiology can be excluded, then the diagnosis of villitis of unknown etiology might be considered. However, this diagnosis is usually associated with chronic villitis only, so the presence of acute inflammation would be unusual and favors an infectious etiology."

The report includes other info like color and cord length, etc., but I am guessing the "impressions and comments" are the imp't part.

I googled these terms individually, but not having a med background am having a hard time putting the whole picture together.

Nagging questions I have: is my IUGR likely to repeat again (ie, is it related to some unknown health condition on my part) or was it a fluke, related to some infection I picked up in the late part of my pregnancy?

Can you tell from this report when the infection likely occurred? The IUGR got Dx (or become suspected) at 36 weeks when my fundal height hadn't grown. U/S showed baby in the 5th percentile and his head/abdomen circum. ratio was way off at that point.

Here are some notable issues from the pregnancy (don't know if they're relevant):
I had bleeding at 11 weeks--U/S at that time that showed everything to be fine. More bleeding at around 16 weeks (I think). OB found "significant tearing" at my cervix and used the silver nitrous(?) to stop the bleeding. She had us do a U/S at the peri on the really good machines to be cautious, and he said everything looked great. OB dx "friable cervix" and put me on pelvic rest for the duration of the pregnancy. I kept to that until week 37 and was looking at an induction for the IUGR so started having sex frequently for the prostoglandins.

I had my membranes swept at 37 weeks and 38 weeks, but between 16 and 37 weeks, nothing was in my vagina. Just mentioning that since what I read about the infections is that typically move up from the vagina...

I was also negative for Group B, and I really had no illness at all during my pregnancy. I actually felt better than normal.

I am assuming my placenta started malfunctioning earlier than 36 weeks, so I'm guessing that the sweeping/sex were not what introduced an infection. Is it likely just some random infection I never knew I had or might it have come from the OB's working on my cervix at 16 weeks (or the sex I had prior to that)?

Thanks for any insight anyone has! My CNM was pretty unhelpful. Her entire commentary on the issue was "you placenta looked like a pancake" and that it showed signs of infection.

[konayossie]

Anyone? Too specialized?

[Naturallove]

I am a nursing student and I am unfamiliar with those specific terms however, I can tell you that ischemic means deprived of oxygen which results in inadequate blood flow. And the ending -itis means infection. This is not very helpful, but it's all I got. Maybe we have an OB/CNM or a mother/baby nurse on the boards that could help decipher...

[Naturallove]

Okay, so I am a total nerd and am interested in what these term meant so I looked up Chorioamnionitis and this is what I got... is an inflammation of the fetal membranes due to a bacterial infection. It typically results from bacteria ascending into the uterus from the vagina and is most often associated with prolonged labour. Risk of developing chorioamnionitis increases with each vaginal exam during final month of pregnancy and during labor.

So, based on that definition it sounds like the infection could have resulted from the exams or from having sex.

(If I post a few more times its only because I can't/haven't figured out how to look at your post while I am responding)

[mylocat]

I’m a placental pathologist. I can offer some comments on what your report says. However, without seeing the placenta and slides myself, you should not take my comments as a diagnosis. Placental pathology still has many unknowns, and often we can comment on probability but not on definite pathological processes. You could consider having your midwife or OB discuss your question about recurrence risk with the pathologist, who might have some helpful thoughts or might be able to suggest appropriate testing for an infectious etiology.

With those disclaimers stated, here are a few of my thoughts. It sounds like the placenta was small for dates (322 grams is about 3rd percentile weight for 38+5 weeks). Having not seen the placenta and slides for myself, I am most impressed by the diagnosis of “villitis, acute and chronic, multifocal, moderate, with intervillositis” as a possible explanation for the small size and the IUGR. (By the way, was there true IUGR?)

There are several infectious causes of chronic villitis, some of which can also cause the acute villitis mentioned in the report. Collectively, they’re referred to as TORCH infections (Toxoplasmosis, Rubella, Cytomgalovirus and Herpes simplex). Your CNM/OB can perform a blood test to see whether you’ve been recently exposed to any of them, and you might want to ask about that – the antibodies will still be in your blood if you delivered recently. Cytomegalovirus infection can cause a plasmacytic villitis, and you might consider asking your pathologist (via your CNM/OB) whether there was any evidence of CMV. Toxoplasmosis, herpes simplex virus and varicella (the chickenpox virus) can do it too, and you could also ask about those – there are special stains the pathologist can do for all of these if there’s high suspicion. Syphilis can also cause this appearance, but you were likely tested for it as part of your first-trimester prenatal testing (look for the RPR test result). There a few rarer infectious things, too, but unless your history pointed to it, I wouldn’t go looking for Chagas’ disease (Latin America and Texas), rubella (no vaccine and exposure) or vaccinia (recent smallpox vaccine). Occasionally Gram-negative bacteria, Coxiella and Q fever can cause acute villitis but the chronic villitis doesn’t really go with that, and usually mom is acutely ill.

If your placental findings and IUGR were caused by a TORCH infection, most of these are unlikely to cause a problem in subsequent pregnancies. Untreated syphilis and Chagas’ disease would be exceptions. CMV and HSV remain in your body after infection but are the most likely to affect the placenta and baby during primary (first) infection.

In the absence of evidence of a TORCH infection, as the comment says, chronic villitis and intervillositis (with lymphocytes and histiocytes) is most often caused by an entity called “villitis of uncertain etiology,” or VUE. VUE is seen in 3-5% of placentas (although only 1/3 of these have a clinically significant degree of VUE) and is associated with an increased risk of IUGR as well as other bad pregnancy outcomes, including, in some studies, early spontaneous abortion, preterm delivery and intrauterine fetal death. However, I have seen many placentas with significant VUE and NONE of these findings! VUE is the most common placental lesion identified in nonhypertensive term pregnancies with IUGR, and usually seems to affect the placenta after 35 weeks or so. Placentas with VUE are often small for dates.

The risk of recurrence in a subsequent pregnancy if there is DIFFUSE (widespread) villitis is reported to be 10-25%. I’m not sure what is meant by “multifocal and moderate” in your case, but if it is less than diffuse, your recurrence risk for significant villitis (and, therefore, bad outcomes) may be lower than that.

Finally, you wonder how infection got to the placenta. Most of the TORCH infections are spread through the bloodstream, not by direct invasion through the vagina. Most are things that would be very difficult, if not impossible, to prevent (aside from the sexually transmitted diseases, which sound unlikely, given your history). The chorioamnionitis may or may not be related, and may have occurred very late in the game (even intrapartum, if labor was long enough). If it were my baby and placenta, I would ask about a search for specific TORCH agents, with serological testing and/or another look at the placenta. In a subsequent pregnancy, I would suggest careful antenatal monitoring of fetal growth.

Good luck, and congratulations on your new baby! Hope this helps.

-mylocat

[MsBlack]

Naturallove--to keep a post in front of you while you respond, hit the 'quote' button instead of 'reply'. The entire post will appear on your reply-screen; you can then delete or highlight parts of it to clarify what you are referring to in your response. There are even ways to quote several posts at once, but I don't know how.

Konayossie--

Ok, so it sounds like there is some confusion about this term 'itis'. It is true that when we hear a word with 'itis' attached, like appendicitis, we think 'infection'.

However, infection is not always the case--as even noted by the pathologist, who allows that his path findings do not determine the presence of infection. He also introduces the term 'inflammation', which is important to understand in this context:

""If infectious etiology can be excluded, then the diagnosis of villitis of unknown etiology might be considered. However, this diagnosis is usually associated with chronic villitis only, so the presence of acute inflammation would be unusual and favors an infectious etiology."

"Itis", more specifically, refers to signs of Inflammatory Response from the mother's immune system....and the immune system can bring on that response EVEN WITHOUT any germs causing infection. Most of us, when we think of 'inflammation', we think of redness, swelling, heat (whether a general fever or just greater heat in one affected part). And those things are part of inflammatory response, yes--but the immune system makes use of inflammatory response even when there is no infection by germs.

So the pathologist is saying that the placenta shows signs of inflammatory response that is newly developed (acute) rather than existing a long time (chronic). I would venture that s/he could not, at the time of writing the report, verify the presence of pathogens because of saying 'if infectious etiology can be excluded' (it's just not clear whether there was an actual bacterial infection that caused the inflammation--the question is left open). For comparison, placental/membrane pathology might show signs of inflammatory response in most any woman whose membranes have been ruptured for a long time, even if she and baby are perfectly fine. Her immune system recognized the ruptured membranes as a potential threat, and activated in preparation for fighting pathogens.

I'd say you are right that the issues with your placenta started before 36 wks--possibly long before; possibly placenatation was a problem from the beginning of the pregnancy. Meaning that possibly, the initial attachment and growth of the placenta was sub-optimal--which is why you bled at 11 wks in the first place. Or, the 11 wk bleed, caused by 'something else', affected the further development and hormone production of your placenta, which had a generally negative effect on the pregnancy on the whole. We think of the placenta as the organ that feeds the baby, but it is really much more than that! It is a major hormone-factory, responsible for causing and helping to maintain all kinds of changes in maternal physiology that are needed to maintain a healthy pregnancy. Sometimes, as essentially a 'fluke' with no underlying cause, placentas do not develop optimally from the beginning. Sometimes it's more about 'events' that occur in pregnancy (such as your bleed) that impact the further development and ongoing functioning of the placenta.

Anyway--infections in moms often come from vag exams or any vag penetration. Sometimes they arise from internal sources--such as a dental infection, or other low-grade systemic infection a mom has. By far most frequently, true infectious chorioamnionitis is brought about through vag penetration of all sorts (usually w/membranes ruptured, though). It really doesn't sound to me from this report that any bacteria had been cultured from the placenta/membranes--that you did NOT have an intrauterine infection.

All the rest of the report, as far as I can tell, generally refers to things that are common with an IUGR baby--a placenta that has suffered some damage and is not functioning as well as it should Sounds like circulation between you and baby was compromised for a long time--not in a great enough way to cause fetal demise, but enough to have a negative impact on baby's growth.

With the measurement markers of true IUGR, you can be glad though, that pregnancy works so incredibly well: the fact that a baby's head is larger than usual compared to the rest of baby, tells us that pregnancy's 'brain sparing effect' was in operation, giving baby's brain as much nutrition as possible. This made baby smaller on the whole--but bones/bodies can grow later. Brains will grow some later too--but brains have GOT to be 'grown and ready enough' at birth, so that baby's functions are all good, and catching up on full growth later, is possible.

[konayossie]

Wow! Thanks to the three of you for taking time to wade through the report and backstory and offer your thoughts.

Originally Posted by mylocat

(By the way, was there true IUGR?)

Yes, DS was 4lb 15 oz at birth, 4#8oz when we left the hospital. He had the typical IUGR look of the little old man, wrinkly loose skin and so very, very thin.

Originally Posted by mylocat

There are several infectious causes of chronic villitis, some of which can also cause the acute villitis mentioned in the report. Collectively, they’re referred to as TORCH infections (Toxoplasmosis, Rubella, Cytomgalovirus and Herpes simplex). Your CNM/OB can perform a blood test to see whether you’ve been recently exposed to any of them, and you might want to ask about that – the antibodies will still be in your blood if you delivered recently.

Hmm, I don't think I would have had any of these--I was/am fully vaxed (but not smallpox). No syphilis, STDs, or any of the other infections you mentioned. I also am guessing they don't have my placenta on ice anywhere to recheck (unless they do keep them forever?? IDK). DS is almost 19 mos now. I just now got around to ordering my records and trying to figure things out myself.
Sounds like TORCH infection was unlikely. (Also, wouldn't I have realized I was sick if I had had any of those?)

Originally Posted by mylocat

The risk of recurrence in a subsequent pregnancy if there is DIFFUSE (widespread) villitis is reported to be 10-25%. I’m not sure what is meant by “multifocal and moderate” in your case, but if it is less than diffuse, your recurrence risk for significant villitis (and, therefore, bad outcomes) may be lower than that.

This is interesting and good to know since my CNM was dismissive of the possibility of IUGR recurring in future pregnancies.

Originally Posted by mylocat

Hope this helps.
-mylocat

Yes, thanks much for your interpretation of the report!

Originally Posted by MsBlack

For comparison, placental/membrane pathology might show signs of inflammatory response in most any woman whose membranes have been ruptured for a long time, even if she and baby are perfectly fine.

I did have SROM about 36 hours before DS was finally delivered via CS, so I'm guessing that's long enough to show an inflammatory response. Makes sense...

Originally Posted by MsBlack

I'd say you are right that the issues with your placenta started before 36 wks--possibly long before; possibly placenatation was a problem from the beginning of the pregnancy. Meaning that possibly, the initial attachment and growth of the placenta was sub-optimal--which is why you bled at 11 wks in the first place. Or, the 11 wk bleed, caused by 'something else', affected the further development and hormone production of your placenta, which had a generally negative effect on the pregnancy on the whole.

Again, this is very interesting because both the CNM and the perinatologist said the 11 week bleed was unrelated, but DH and I have always wondered if it might have started then. (Not that anything different could have been done, but knowing possibilities does give me more of a sense of control.)

Originally Posted by MsBlack

With the measurement markers of true IUGR, you can be glad though, that pregnancy works so incredibly well: the fact that a baby's head is larger than usual compared to the rest of baby, tells us that pregnancy's 'brain sparing effect' was in operation, giving baby's brain as much nutrition as possible. This made baby smaller on the whole--but bones/bodies can grow later. Brains will grow some later too--but brains have GOT to be 'grown and ready enough' at birth, so that baby's functions are all good, and catching up on full growth later, is possible.

Yes, I read about the "brain sparing" mechanism when I was first diagnosed, and it is rather amazing--actually, the perinat. explained that IUGR babies tend to be further developed overall with regard to functions as the stress hormones they are experiencing in utero work like the steroids they give to babies that are in danger of being born prematurely. Pretty cool when you think about how body works to make the baby as ready as possible even though things aren't going smoothly.

Thanks again to all of you! It is really helpful to hear other opinions as I am TTC #2 and certainly would like to be prepared if I have an increased possibility for recurrent IUGR.

[mylocat]

Paraffin-embedded sections of the placenta are kept for at least 10 years (and many places keep them for longer than that). If there were a convincing reason to do it, a pathologist could get the blocks back out and perform special stains for CMV, HSV, and I think Toxoplasma. Primary CMV and Toxo infections are often accompanied by "flulike" symptoms (fever, malaise, fatigue, sometimes rash) but can be asymptomatic. At this point, I think I'd just go the "careful monitoring" route on the next pregnancy. And remember, if there's a 10% chance of recurrence, that means that there's a 90% chance of normal!

Good luck!

[MsBlack]

I am guessing that 'mulitfocal and moderate' is less than 'diffuse', in terms of placenatal vilitis. "Mulitfocal" will mean that there were several spots of vilitis found (some new--acute--some old--chronic)...and of course 'moderate' means a 'medium amount' of these spots. I guess that 'diffuse' would mean more widespread/generalized, harder to pinpoint than focal spots would be.

Glad to help. I hope you don't worry too much about this as you TTC #2...learn all you can about health during pregnancy, and apply that learning. Whatever happens, the healthier you are, the more benefits to your babies. I have to guess that at least in some cases--which cannot be accounted for in research very well--mamas who repeat IUGR are also repeating some lifestyle habits that are not as beneficial to themselves/babies as they could be. KWIM?

[konayossie]

Originally Posted by MsBlack

Glad to help. I hope you don't worry too much about this as you TTC #2...learn all you can about health during pregnancy, and apply that learning. Whatever happens, the healthier you are, the more benefits to your babies. I have to guess that at least in some cases--which cannot be accounted for in research very well--mamas who repeat IUGR are also repeating some lifestyle habits that are not as beneficial to themselves/babies as they could be. KWIM?

Yeah, I have spent a lot of time checking out IUGR and just general health during pregnancy. I consider myself to be fairly educated by layperson standards about childbirth and pregnancy, and that's what freaks me out about the IUGR--I didn't have any of the risk factors (I am a healthy-weight, healthy eater, non-smoker who gets moderate exercise). I was also told after my son's birth that I will never be able to birth vaginally (a subject for a whole 'nother thread), and I think that combined with the IUGR is making me really paranoid about my body's ability to do pregnancy/birth normally or well. I did just recently discover that I am a little bit hypothyroid, and I'm wondering if that might be related to the IUGR--planning to be sure and try to get my #s in line before I conceive again.

[MsBlack]

Originally Posted by konayossie

Yeah, I have spent a lot of time checking out IUGR and just general health during pregnancy. I consider myself to be fairly educated by layperson standards about childbirth and pregnancy, and that's what freaks me out about the IUGR--I didn't have any of the risk factors (I am a healthy-weight, healthy eater, non-smoker who gets moderate exercise). I was also told after my son's birth that I will never be able to birth vaginally (a subject for a whole 'nother thread), and I think that combined with the IUGR is making me really paranoid about my body's ability to do pregnancy/birth normally or well. I did just recently discover that I am a little bit hypothyroid, and I'm wondering if that might be related to the IUGR--planning to be sure and try to get my #s in line before I conceive again.

I'm sure it would make me a little paranoid, too!

Looking into your thyroid function is a great idea. You may never know for sure if your thyroid was 'at fault' with that pregnancy, but the thyroid DOES impact all body functioning. So having a healthy amount of circulating thyroid hormones is important. Another topic--but if you find you are 'borderline' hypothyroid, you may benefit enough from iodine supplementing and be able to skip the artificial supplementation. I hope you'll look into it before making any decisions....those thyroid supplements can be great, but like anything they have risks--IMO, best to take natural routes toward balance first, and see if it's enough.

As for 'never birth vaginally', well that is something else I hope you will investigate thoroughly before accepting that dictate! Reminds me of when I had a 6wk pp doc visit after my 2nd baby. I'd had a pp intrauterine infection after my UC, that I'd treated successfully w/herbs. Doc said that one tube was now blocked 'with scarring and serous fluid, most likely', the other was most likely scarred though not blocked--and that I would probably have great difficulty conceiving again. What a horrible thing to say! I saw a homeopath later--who gave me a remedy that cleared the issues totally. I went on to have 4 more kids...and believe me, 'trying to conceive' was NEVER an issue TTA was always harder for extra-fertile me.

Just saying that in my case--probably also true for yours--the doc was speaking from her experience and training. She knew nothing of homeopathy, for instance--or any other way to understand the body, it's issues and what can heal it. I dismissed her words after some moments of dismay, and I'm so glad I did. Take that comment from the doc with a LARGE grain of salt, and seek other input.