Michal Kovo

Placental vascular lesion differences in pregnancy-induced hypertension and normotensive fetal growth restriction.

OBJECTIVEnPregnancy-induced hypertension/preeclampsia (PIH) and fetal growth restriction (FGR) share a common placental origin. The pathologic classification that divides placental lesions to maternal or fetal origin was compared between these disorders.nnnSTUDY DESIGNnPlacentas from pregnancies that were complicated by PIH, normotensive FGR, or by both (combined) were analyzed, and lesions were classified as those consistent with maternal under-perfusion and with fetal thromboocclusive disease.nnnRESULTSnMaternal vascular lesions were more common in the PIH group and combined group (61% and 59%, respectively), compared with the FGR group (16.2%; P < .001), and villous lesions were more common in the combined group, compared with the FGR and PIH groups (79.5%, 53.5%, and 46.9%, respectively; P = .004). Fetal villous changes were observed in 16.2% in the FGR group, compared with 3.1% in the PIH group (P = .03), and chronic villitis was 15.2% in the FGR group vs 1.6% in the PIH group (P = .004).nnnCONCLUSIONnPlacental lesions correspond with different clinical presentations.

Placental vascular pathology as a mechanism of disease in pregnancy complications.

Inadequate placental development results in pregnancy complications. The extent and the degree of defective deep placentation may explain why a similar insult would result in different clinical presentations. The relative new categorization of the placental lesions, separating the non-infectious lesions into lesions that are consistent with maternal and fetal circulation abnormalities, and the infectious lesions into maternal and fetal inflammatory responses, provides us an additional tool to determine the placental maternal and fetal role in the various pregnancy complications. Placental vascular lesions are different in pregnancies complicated by preeclampsia (predominant maternal vascular supply lesions), by fetal growth restriction (FGR) (predominant fetal vascular supply lesions), and by preeclampsia with FGR (both maternal and fetal compartments are involved). Moreover, placental vascular lesions are also different in relation to gestational age at disease onset, as in early- and late-onset preeclampsia, FGR, Fetal death and preterm labor.

The placental component in early‐onset and late‐onset preeclampsia in relation to fetal growth restriction

To identify pathological placental differences between early‐onset and late‐onset preeclampsia, in relation to fetal growth restriction (FGR).

Carrier‐mediated transport of metformin across the human placenta determined by using the ex vivo perfusion of the placental cotyledon model

Metformin is a polar positively charged compound. The aim of the study was to characterize its permeability across the human placenta using the ex vivo placental perfusion model.

Association of non-reassuring fetal heart rate and fetal acidosis with placental histopathology.

OBJECTIVEnTo investigate the association between different placental lesions and non-reassuring fetal heart rate (NRFHR) pattern and fetal acidosis in labor.nnnSTUDY DESIGNnPlacentas from 213 women who underwent cesarean section because of NRFHR with or without fetal acidosis (pH < 7.2) were classified by histopathologic findings: consistent with maternal circulation abnormalities i.e., namely, marginal or retroplacental hemorrhage (M0), maternal underperfusion, vascular (M1) or villous changes (M2), and those consistent with fetal thrombo-occlusive disease due to vascular (F1) or villous (F2) changes. Lesions were also analyzed by maternal (MIR) or fetal (FIR) origin of inflammatory responses.nnnRESULTSnCord blood pH was normal in 169 neonates (7.29 ± 0.04; control group) and <7.2 in 44 (7.10 ± 0.07; study group). The study group had higher rates of histologic chorioamnionitis; MIR was detected in 34.1% compared to17.8% of controls (p = 0.018), and FIR, in 18.2% compared to 6.5% (p = 0.016). Neonates in the study group had lower Apgar scores and longer hospitalization.nnnCONCLUSIONSnPlacental MIR and FIR are associated with cord blood acidosis in neonates delivered by cesarean section for NRFHR tracings in labor.

Neonatal outcome in polycystic ovarian syndrome patients treated with metformin during pregnancy

Objective.u2003The present study aimed to evaluate the effect of metformin exposure during pregnancy on neonates of polycystic ovarian syndrome (PCOS) patients. Method.u2003Neonatal outcomes of 33 women with PCOS treated with metformin during pregnancy were compared to neonatal outcomes of 66 normal healthy women in a retrospective case–control study. Results.u2003The mean birth weight percentile of neonates exposed to metformin in utero during the first trimester was significantly lower than that of neonates delivered to normal healthy matched controls. After controlling for pregnancy complications, this observation became only marginally statistically significant. Conclusion.u2003Although metformin is an attractive option for induction of ovulation in PCOS patients, there is a need for more evidence related to its safety during pregnancy.

The placental component and obstetric outcome in severe preeclampsia with and without HELLP syndrome

OBJECTIVEnWe aimed to compare obstetric outcome and placental-histopathology in pregnancies complicated by preeclampsia with severe features with and without HELLP syndrome.nnnMETHODSnLabor, maternal characteristics, neonatal outcome and placental histopathology of pregnancies complicated with severe preeclampsia during 2008-2015 were reviewed. Results were compared between those without signs of HELLP syndrome (severe preeclampsia group) and those with concomitant HELLP syndrome (HELLP group). Placental lesions were classified to maternal vascular lesions consistent with malperfusion, fetal vascular lesions consistent with fetal thrombo-occlusive disease, and inflammatory lesions. Small-for-gestational-age (SGA) was defined as birth-weight ≤10th% and ≤5th%. Composite adverse neonatal outcome was defined as one or more early neonatal complications.nnnRESULTSnCompared to the severe preeclampsia group (nxa0=xa0223), the HELLP group (nxa0=xa064) was characterized by earlier gestational-age, 34.1xa0±xa02.7 vs. 35.3xa0±xa03.4 weeks, pxa0=xa00.010, higher rates of multiple pregnancies (pxa0=xa00.024), and thrombophilia (pxa0=xa00.028). Placentas in the HELLP group had higher rates of vascular and villous lesions consistent with maternal malperfusion (pxa0=xa00.023, pxa0=xa00.037 respectively). By multivariate logistic regression analysis models, vascular and villous lesions of maternal malperfusion were independently associated with HELLP syndrome (aOR 1.9, aOR 1.8, respectively). SGA was also more common in the HELLP group, both below the 10th percentile (pxa0=xa00.044) and the 5th percentile (pxa0=xa00.016). Composite adverse neonatal outcome did not differ between the groups.nnnCONCLUSIONnSevere preeclampsia and HELLP syndrome have similar placental histopathologic findings. However, HELLP syndrome is associated with higher rates of placental maternal vascular supply lesions and SGA suggesting that the two clinical presentations share a common etiopathogenesis, with higher placental dysfunction in HELLP syndrome.

Ovarian reserve following cesarean section with salpingectomy vs tubal ligation: a randomized trial

BACKGROUND: Epithelial ovarian cancer is assumed to derive from the fallopian tube. Salpingectomy has been previously demonstrated to reduce the risk of ovarian cancer, and may be used as a means of sterilization. OBJECTIVE: We aimed to compare short‐term ovarian reserve and operative complications in cases of salpingectomy and tubal ligation during cesarean section. STUDY DESIGN: Study patients who underwent elective cesarean section at our institution and requested sterilization were randomized to bilateral salpingectomy or tubal ligation. Prior to surgery, blood samples were obtained for antimüllerian hormone. Surgical course was noted, including overall time, complications, and postoperative hemoglobin. Repeat antimüllerian hormone samples were obtained from patients 6‐8 weeks following surgery. RESULTS: In all, 46 patients were recruited for participation, of whom 33 completed a follow‐up visit, and for whom repeat antimüllerian hormone levels were available. Patients in the salpingectomy group were slightly older (37.0 ± 3.9 vs 34.3 ± 4.1 years, P = .02). No differences were noted in patient parity, body mass index, or gestational age between the groups. Pregnancy and postdelivery antimüllerian hormone levels were not significantly different between the groups, with an average increase of 0.58 ± 0.98 vs 0.39 ± 0.41 ng/mL in the salpingectomy and tubal ligation groups, respectively (P = .45). Surgeries including salpingectomy were longer by an average 13 minutes (66.0 ± 20.5 vs 52.3 ± 15.8 minutes, P = .01). No difference was demonstrated between the groups regarding surgical complications and postoperative hemoglobin decrease. CONCLUSION: Sterilization by salpingectomy appears to be as safe as tubal ligation regarding operative complications and subsequent ovarian reserve. As salpingectomy offers the advantage of cancer risk reduction, it may be offered in the settings of elective preplanned surgeries.

The Effect of Maternal Obesity on Pregnancy Outcome in Correlation With Placental Pathology

Objectives: To investigate the effect of maternal obesity on pregnancy outcome and placental histopathology. Study Design: Pregnancy outcome and placental histology from term pregnancies were reviewed. Women were divided according to their prepregnancy body mass index (BMI, kg/m2) as normal weight (18-24.9) and obese (≥30). Pregnancy outcome and placental histology were compared between obese and normal weight women with complicated pregnancies, and with uncomplicated pregnancies, matched by mode of delivery. Placental lesions were classified as lesions of maternal or fetal vascular supply and maternal (MIR) and fetal (FIR) inflammatory responses. Results: Of the 1047 complicated pregnancies analyzed, 615 were with normal weight (BMI 21.7 ± 1.8) and 221 were obese (BMI 35.2 ± 4.3). Obesity was associated with higher rates of diabetes and hypertensive disorders (P = .001 for both), birth weight >90th, P < .001, and cesarean delivery, P < .001. Placental weight was higher in obese than in normal weight women, P < .001. No difference was observed in the rate of placental lesions related to maternal or fetal vascular supply and MIR or FIR between the groups. However, higher rate of maternal placental vascular lesions (46.8% vs 28.2%, P = .012) was observed in uncomplicated obese women (n = 62) as compared with healthy normal weight (n = 124) uncomplicated controls. Conclusion: Pregnancy outcome is worse without different placental component in obese versus normal weight women, with complicated pregnancies. In uncomplicated pregnancies, more maternal placental vascular supply lesions exist in obese versus normal weight women, suggesting background placental compromise.

Intraoperative findings, placental assessment and neonatal outcome in emergent cesarean deliveries for non-reassuring fetal heart rate

OBJECTIVEnTo correlate between intraoperative findings, placental histopathology and neonatal outcome in emergent cesarean deliveries (ECD) for non-reassuring fetal heart rate (NRFHR).nnnSTUDY DESIGNnData on ECD for NRFHR were reviewed for labor, documented intraoperative findings, neonatal outcome parameters and placental histopathology reports. Results were compared between those with and without intraoperative findings. Placental lesions were classified to those related to maternal underperfusion or fetal thrombo-occlusive disease, and those related to maternal (MIR) and fetal (FIR) inflammatory responses. Neonatal outcome consisted of low Apgar score (≤7 at 5 min), cord blood pH<7.0, and evidence of respiratory distress, necrotizing enterocolitis, sepsis, transfusion, ventilation, seizure, hypoxic-ischemic encephalopathy, phototherapy, or death.nnnRESULTSnIntraoperative findings were observed in 49.5% of 543 women, mostly cord complications (77%). Placental lesions were more common in those without intraoperative findings as compared to those with intraoperative findings: placental lesions related to maternal under-perfusion, vascular lesions, 9.1% vs. 4.1%, p=0.024, and villous changes, 39.2% vs. 30.7%, p=0.047, lesions consistent with fetal thrombo-occlusive disease, 13.6% vs. 7.4%, p=0.024, and inflammatory lesions, MIR and FIR, p=0.033, p=0.001, respectively. By using multivariate logistic regression analysis, adverse neonatal outcome was found to be dependent on maternal age, gestational age, preeclampsia placental weight <10th%, and MIR.nnnCONCLUSIONnNRFHR necessitating ECD may originate from different underlying mechanisms. In about half, the insult is probably acute and can be identified intraoperatively. In the remaining half, underlying placental compromise may be involved.