Josefine Nasiell

The severity of clinical manifestations in preeclampsia correlates with the amount of placental infarction

Objective. To correlate placental histopathology, in particular ischemic changes, with the clinical severity of preeclampsia. Design. A blinded retrospective study. Setting. One Swedish hospital. Sample. One hundred and fifty‐seven women with severe (n= 116) or mild (n= 41) preeclampsia and 157 normotensive women matched according to gestational‐age. Methods: One senior pathologist, blinded to clinical data and group, examined all histological slides. In the statistical analyses, adjustment for gestational week was done when appropriate. Main outcome measures. Placental histopathological findings. Results: Amount of infarction increased with the severity of preeclampsia (p < 0.001). Infarction involving ≥5% of the placental tissue was seen in 39.7% of severe preeclampsia, 17.1% of mild preeclampsia and 5.1% of non‐preeclampsia. When comparing placentas in severe preeclampsia, mild preeclampsia and non‐preeclampsia, there was an increase in the presence of any infarction (80.2%, 61.0%, vs. 20.4%). Also, there was a difference in the presence of decidual arteriopathy (35.3%, 22.0%, vs. 3.8%) and accelerated villous maturation (71.6%, 53.3%, vs. 12.6%). We found no difference in intervillous thrombosis, abruption placenta or placental weight in relation to gestational week. Conclusions. In pregnancies with mild or severe preeclampsia, a large proportion of the placentas had histological signs of pathology, in particular signs of ischemia. The pathology was similar, but more pronounced in severe compared to mild preeclampsia, suggesting mild and severe preeclampsia to have similar underlying etiology.

Severe Preeclampsia With and Without HELLP Differ With Regard to Placental Pathology

The aim of the present study was to evaluate the histopathology in placentas from patients with severe preeclampsia with and without hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. An additional aim was to compare the prevalence of infants born small for gestational age in the 2 groups. The study is retrospective and includes 178 women who have been diagnosed at the Karolinska University Hospital Huddinge or at the Free University Medical Center between 2000 and 2005 with severe preeclampsia. A total of 96 women had severe preeclampsia without signs of HELLP (preeclampsia group), whereas 82 fulfilled the criteria for having HELLP syndrome (HELLP group). Infarction (P=0.014), intervillous thrombosis (P<0.001), and abruption (P=0.002) were more common in the preeclampsia group than in the HELLP group. There was no statistically significant difference in the frequency of accelerated villous maturation (P=0.61), decidual arteriopathy (P=0.27), or chorioamnionitis (P=0.61). Furthermore, there was a higher mean placental weight, adjusted for gestational age, in the Swedish HELLP material than in the preeclampsia group (P<0.001). Finally, mothers in the preeclampsia group gave birth significantly more often to small for gestational age babies than mothers suffering from HELLP syndrome (P<0.001). The histopathologic profile and the range of placental lesions were partly different in the preeclampsia and HELLP patients. Considering the central role that placenta seems to have in preeclampsia, the present result might suggest that different underlying pathogenetic mechanisms and courses can be in play in patients with preeclampsia and HELLP syndrome.

Differences in mRNA expression of endothelin-1, c-fos and c-jun in placentas from normal pregnancies and pregnancies complicated with preeclampsia and/or intrauterine growth retardation

A defect in placental function has been suggested to be associated both with preeclampsia (PE), with or without concomitant intrauterine growth retardation (IUGR), and with IUGR as a single entity. Our aim was to compare the mRNA expression of the growth-related protooncogenes c-fos and c-jun and the vasoconstrictor and growth factor endothelin-1 (ET-1) in placentas from normal pregnancies with those of PE and IUGR. The mRNA expression of c-jun was significantly higher in all groups of complicated pregnancies while ET-1 and c-fos mRNA expression was significantly higher only in the group with IUGR. These results support the concept that an aberrant placental mRNA expression of the ET-1, c-fos and c-jun genes is part of an altered pattern of gene expression in pathological pregnancies.

Placental expression of endothelial constitutive nitric oxide synthase mRNA in pregnancy complicated by preeclampsia

BACKGROUND The role of nitric oxide (NO) in normal pregnancy and pregnancy complicated with preeclampsia (PE) and/or intrauterine growth restriction (IUGR) still remains questionable. The placenta lacks autonomic innervation, therefore blood flow must be regulated by humoral and endothelium derived factors. NO is a potent vasodilator released by endothelial cells. It is synthesized by the catalytic action of the endothelial constitutive nitric oxide synthase (ecNOS). Moreover, the synthesis of NO in normal human placental vasculature has already been established and impairment of the uteroplacental blood flow in pregnancies complicated by PE and/or IUGR has been demonstrated. DESIGN AND METHODS The aim of the present study was to compare the expression of ecNOS mRNA in placenta from women with complicated and normal pregnancies. Placenta was collected from women with PE (n = 13) or small for gestational age (SGA) (n = 8), both PE and SGA (n = 7) and normal pregnancies (n = 41). Total nucleic acids were prepared and a solution hybridization technique was used for mRNA analysis. RESULT The mRNA expression of ecNOS was significantly higher (p<0.05) in all groups of complicated pregnancies compared to normal pregnancies. CONCLUSION Our findings indicate that the increased placental expression of ecNOS mRNA might reflect a compensatory mechanism in the disturbed uterine circulation seen in PE and/or SGA.

Aortic dissection in pregnancy: the incidence of a life-threatening disease

[3] Chi DS, Abu-Rustum NR, Sonoda Y, et al. Ten-year experience with laparoscopy on a gynecologic oncology service: analysis of risk factors for complications and conversion to laparotomy. Am J Obstet Gynecol 2004;191(4):1138–45. [4] Querleu D, Leblanc E, Carton G, et al. Audit of preoperative and early complications of laparoscopic lymph node dissection in 1000 gynecologic cancer patients. Am J Obstet Gynecol 2006;195(5):1287–92.

Aortic dissection in pregnancy: A life-threatening disease and a diagnosis of worth considering

Acute aortic dissection is a life‐threatening disease. To increase the awareness of this diagnosis as a cause of feto‐maternal mortality during pregnancy, we have analyzed risk factors using information from five pregnant women admitted for acute aortic dissection to the Karolinska University Hospital over an eight‐year period (1999–2007). Four of the women died and only one survived. One fetus was stillborn and all newborn infants showed signs of asphyxia at birth. Of the women, who were on average five years above the mean age for delivery in Sweden, three had hypertension, two had first‐degree relatives with aortic dissection which had occurred during the second half of pregnancy (gestational age at diagnosis 26–41 weeks). The most common presenting symptoms were severe back, abdominal and leg pain, and confusion. If a rapid diagnosis is not made, the risk of mortality for both mother and fetus is high. The incidence of aortic rupture during pregnancy in Sweden appears to be 14.5/1,000,000 and the case maternal fatality ratio 4.4/1,000,000.

Selective serotonin reuptake inhibitor use during pregnancy increases the risk of postpartum hemorrhage and anemia: a hospital-based cohort study.

Selective serotonin reuptake inhibitors (SSRIs) are known to increase the risk of gastrointestinal bleeding.

Internet delivered cognitive behavior therapy for antenatal depression : A randomised controlled trial

Major depression occurs in 5-10% of pregnancies and is associated with many negative effects for mother and child, yet treatment options are scarce. To our knowledge, this is the first published randomised controlled trial on Internet delivered Cognitive Behavior Therapy (ICBT) for this group. OBJECTIVE To test the efficacy of a pregnancy adapted version of an existing 10-week ICBT-program for depression as well as assessing acceptability and adherence DESIGN: Randomised controlled trial. SETTING Online and telephone. POPULATION OR SAMPLE Self-referred pregnant women (gestational week 10-28 at intake) currently suffering from major depressive disorder. METHODS 42 pregnant women (gestational week 12-28) with major depression were randomised to either treatment as usual (TAU) provided at their antenatal clinic or to ICBT as an add-on to usual care. MAIN OUTCOME MEASURES The primary outcome was depressive symptoms measured with the Montgomery-Åsberg depression rating scale-self report (MADRS-S). The Edinburgh Postnatal Depression Scale and measures of anxiety and sleep were used. Credibility, satisfaction, adherence and utilization were also assessed. RESULTS The ICBT group had significantly lower levels of depressive symptoms post treatment (p < 0.001, Hedges g =1.21) and were more likely to be responders (i.e. achieve a statistically reliable improvement) (RR = 0.36; p = 0.004). Measures of treatment credibility, satisfaction, utilization, and adherence were comparable to implemented ICBT for depression. LIMITATIONS Small sample size and no long-term evaluation. CONCLUSION Pregnancy adapted ICBT for antenatal depression is feasible, acceptable and efficacious. These results need to be replicated in larger trials to validate these promising findings.

Association between placental pathology and neonatal outcome in preeclampsia: a large cohort study

Objective: To study associations between placental histopathology and neonatal outcome in preeclampsia (PE). Study design: The cohort consisted of 544 singleton pregnancies complicated by PE and managed at Karolinska University Hospital, Stockholm, Sweden during 2000–2009. Evaluation of placental histopathology was made by one senior perinatal pathologist, blinded to outcome. Clinical outcome was obtained from prospectively collected medical registry data and medical records. Main outcome measures were intrauterine fetal death, smallness for gestational age, admission to neonatal unit, major neonatal morbidity (defined as presence of intraventricular hemorrhage ≥grade 3, retinopathy of prematurity ≥grade 3, necrotizing enterocolitis, cystic periventricular leucomalacia and/or severe bronchopulmonary dysplasia) and neonatal mortality. Logistic regression analyses including gestational age were performed. Results: Abnormal placental weight, both low (adjusted odds ratio (OR) [95% confidence interval] 5.2 [1.1–24], p = 0.03) and high (adjusted OR 1048 [21–51 663], p < 0.001) for gestational age, was associated with major neonatal morbidity in preterm infants. Accelerated villous maturation was less prevalent in intrauterine fetal death pregnancies (adjusted OR 0.18 [0.04–0.77], p = 0.02). Decidual arteriopathy increased the odds for admission to neonatal care (adjusted OR 2.7 [1.1–6.5], p = 0.03). Infarction involving ≥5% of the placenta was associated with intrauterine fetal death and small for gestational age infants (adjusted OR’s 75 [5.5–1011], p = 0.001 and 3.2 [1.7–5.9], p < 0.001; respectively). No relations between histological variables and neonatal mortality could be found. Conclusion: Placental pathology in PE reflects adverse perinatal events and deviant placental weight predicts adverse neonatal outcome in preeclamptic women delivering preterm. Placental investigation without delay can contribute to neonatal risk assessment.

Placental pathology in relation to stillbirth and neonatal outcome in an extremely preterm population: a prospective cohort study

To study associations between placental histopathology and stillbirth as well as neonatal outcome in a population born extremely preterm.