The correlation between sampling site and gene expression in the term human placenta.

Using oligonucleotide microarrays we recently identified a set of transcripts that were up-regulated in hypoxic human trophoblasts. To test the hypothesis that expression of hypoxia-related placental transcripts depends on sampling site we analyzed nine different sites from term human placentas (n=6), obtained after uncomplicated pregnancies. These sites spanned the placental center to the lateral border and the basal to the chorionic plate. Relative gene expression at each site, determined using quantitative PCR, was correlated with villous histology. The expression of vascular endothelial growth factor (VEGF) and connective tissue growth factor (CTGF), the cytoskeleton proteins lamininA3 and alpha-tubulin, and the signal transduction protein Rad was enhanced in the subchorionic lateral border compared to medial basal site (1.6-2.9 fold, p<0.05). In contrast, the expression of NDRG1, adipophilin and human placental lactogen was unchanged. Enhanced villous maturation, syncytial knots and fibrin deposits were more frequent in the subchorionic placental lateral border, and correlated with up-regulation of hypoxia-related transcripts (p<0.05). The association between sample site and expression level was not observed in placentas with marginal cord insertion. The expression of hypoxia-related genes in the term human placenta is dependent on sampling site within the placental disk, likely reflecting local differences in villous perfusion.

Fetal thrombotic vasculopathy in the placenta: cerebral thrombi and infarcts, coagulopathies, and cerebral palsy.

Thrombi in the fetal circulation of the placenta cause a pattern of clustered fibrotic villi called fetal thrombotic vasculopathy (FTV), which has been associated with serious injuries to neonates, especially brain injuries. Correlation of FTV with visceral thrombi in autopsy specimens might lead to a more accurate estimate of the prevalence of somatic thrombi as a significant and underrecognized cause of prenatal injury or perinatal death, and show the potential validity of placental FTV as an indicator of thrombotic lesions in the fetus and newborns who survive. Clinicopathologic correlation was used to perform a 3-year retrospective autopsy review. We identified 16 cases (19%) among 84 perinatal autopsy specimens in which placental FTV was associated with stillbirth, intrapartum, or neonatal death. Two liveborn neonates survived 2.5 hours, and one for 24 hours; there was one intrapartum death, and the rest were stillborn. Clinical evidence of severe central nervous system (CNS) injury to two of the liveborn infants was evident at birth. Twelve stillborns died from 12 to 48 hours before delivery. Placental FTV had features of organization that clearly antedated the fetal death. Autopsy findings confirmed somatic thrombi in six cases (37.5%) of the 16 with FTV, including cerebral thrombi or infarcts (three cases), renal thromboemboli (three cases), and pulmonary thromboemboli (two cases). One mother had history of deep vein thrombosis, and four of eight tested had abnormal coagulation test results. Placental FTV indicates a significant probability of thrombi in the fetus and represents an important, possibly underrecognized cause of perinatal mortality and neonatal injury. Parental coagulopathy as a significant factor in prenatal injury and death deserves more comprehensive study. The placenta remains an undervalued and underutilized surgical specimen in the evaluation of perinatal injury, especially cerebral palsy.

Omental endosalpingiosis with endometrial-type stroma in a woman with extensive hemorrhagic pelvic endometriosis.

A 38-year-old woman with extensive hemorrhagic endometriosis causing back pain, pelvic masses, and hydronephrosis also had a palpable omental mass composed of abundant endometrial-type stroma in which the epithelial component was entirely tubal type glandular cells; the stroma in this area did not bleed. This difference in bleeding behavior supports the concept that patterns of differentiation of heterotopic müllerian tissues may depend in part on the influence of local factors and that endometrial epithelium may produce a local trophic or paracrine factor that is absent in tubal epithelium.

Thrombophilia: a mechanism of disease in women with adverse pregnancy outcome and thrombotic lesions in the placenta.

The purpose of this study was to examine the relationship among adverse pregnancy outcome, the presence of thrombotic lesions in the placenta, and the frequency and type of laboratory abnormalities consistent with the presence of a thrombophilic state. A retrospective cohort study was designed to determine the frequency of laboratory abnormalities consistent with thrombophilia among patients with thrombotic lesions of the placenta and adverse pregnancy outcome. The workup for a thrombophilic state included anticardiolipin antibodies, lupus anticoagulant, protein C and antithrombin III activities, protein S total and free, activated protein C resistance ratio, and Factor V Leiden mutation. Thrombotic lesions were identified by histopathologic examination of the placenta. Thirteen patients met the study criteria over an 11-month period. Seven patients were heterozygous for Factor V Leiden mutation (53.8%). Protein S deficiency was found in three cases (23.0%), and no hemostatic abnormality was detected in three cases (23.0%). Mothers with an adverse pregnancy outcome and thrombotic lesions of the placenta often have laboratory abnormalities indicative of a thrombophilic state. We propose that thrombophilia leading to thrombosis in the maternal and/or fetal circulations is a significant mechanism of disease during pregnancy.

DNA ploidy by image cytometry and karyotype in spontaneous abortion.

We compared the DNA content (DI) by cell image analysis with the karyotype and morphological phenotype of paraffin-embedded tissues from 51 spontaneous abortions. The study included 21 cases with triploid, 19 cases with diploid, and 11 cases with aneuploid (monosomic, trisomic, or mosaic) karyotype. Measurements were performed by image analysis on the trophoblastic and stromal cells of chorionic villi using 5-microm-thick, Feulgen-stained sections. At least 200 cells were analyzed. Results were interpreted using DI ranges of 1.3 to 1.7 for triploid and 0.9 to 1.1 for a diploid profile. All 21 cases with a cytogenetically confirmed triploid karyotype had DI values within the triploid range, and all 19 cases with a diploid karyotype had DI values within the diploid range. All of the trisomies and monosomies also had a DNA mass within the diploid range. However, eight cases with a triploid karyotype also had a peak in the diploid range: one case with a diploid karyotype and one case with a trisomic karyotype each had an additional peak in the triploid range. We did not find a morphological correlation either with image analysis or with karyotype. We conclude that cell image analysis is a reliable method for detection of triploidy in spontaneous abortions. This relatively rapid method allows visual discrimination of the areas to be analyzed, avoids the problem of maternal cell contamination, and may unmask mosaic karyotypes that would go unrecognized by cytogenetic studies alone.

Uterus-like mass arising in the broad ligament: a metaplasia or mullerian duct anomaly?

A 46-year-old woman presented with a large abdominopelvic mass. Exploration revealed a large cystic mass that arose from the posterior leaf of the right broad ligament. The mass was lined by endometrial-like tissue and had an outer layer of smooth muscle that resembled myometrium. The inner wall was focally composed of a thick layer of intermixed smooth muscle and endometrial glands comparable to adenomyosis. This is the fourth reported case of "a uterus-like mass" and the first that is clearly extraneous to the ovary. We hypothesize that these masses may arise from subperitoneal mesenchymal cells that retain the ability to duplicate mullerian duct structures; other cases may represent mullerian duct fusion defects.

Cerebral palsy and thrombi in placental vessels of the fetus: insights from litigation.

Fetal vessels in the placentas of 11 of 15 infants with cerebral palsy contained thrombi. An alternate basis for the injury was identified in the four placentas without thrombi. Autopsy findings in one infant who died at age 1 month confirmed the presence of cerebral thrombi and infarcts. It is concluded that thrombotic events in utero may explain the pathogenesis of many instances of cerebral palsy and that identification of a coagulopathy in parents could potentially identify those at risk and provide a basis for preventive treatment during pregnancy.

Lateral hemostatic sutures in cold knife conization of the cervix. What do they accomplish?

OBJECTIVE: The purpose of cold knife conization is to ligate the descending cervical branch of the uterine artery and thus to decrease bleeding. The aim of this study was to investigate the actual frequency of ligation. STUDY DESIGN: Two lateral sutures were placed in the cervix at the 3 and 9 o'clock positions in 97 patients (194 sutures) as part of vaginal hysterectomy. The position of each suture was determined during evaluation of the surgical specimen. RESULTS: Because the specimens from 10 patients contained only single sutures, only 184 sutures were actually evaluated. Upon microscopic examination, 50 of the 184 (27%) appeared to contain no artery. Of the remaining 134 sutures, 95 (71%) enclosed an artery, and 9 (7%) lay within a 10 x field of a branch. Only 30 sutures (22%) missed the artery entirely. Thus, in the 73% of cases where an artery of significant size could be identified, the artery lay within a lateral stitch 71% of the time. CONCLUSION: If the descending cervical branch of the uterine artery supplies most of the blood to the cervix, advance placement of lateral sutures would be expected to reduce blood loss during conization.

Placental thrombi and related problems.

The complex double circulation of the placenta adds diversity to the kinds of changes caused by thrombi and bleeding. Different lesions may have different clinical implications for the mother and fetus. The clinical history may be extremely important in directing the pathologic examination and in evaluating the significance of vascular lesions.

Placental thrombi and other vascular lesions. Classification, morphology, and clinical correlations.

Vascular lesions, most often mediated by thrombi, are second only to infections as a cause of fetal injury in the later weeks of pregnancy. In our experience many pathologists who examine placentas fail to conduct a proper search for vascular lesions and some even fail to recognize those exposed by their examination. This review is intended to define the typical clinical background or circumstances that suggest the presence of significant vascular problems, to define techniques calculated to display them well, and to identify criteria for diagnosis. Further research is needed to evaluate the prevalence of maternal and fetal hypercoagulable states and thrombi as a cause of fetal injury.

Maternal placental vasculopathy and infection: two distinct subgroups among patients with preterm labor and preterm ruptured membranes.

OBJECTIVE: Our aim was to find out whether patients delivered preterm because of preterm labor or preterm premature rupture of membranes can be categorized according to clinical characteristics and placental pathologic findings. STUDY DESIGN: We performed a case-control study of 105 patients who were delivered preterm, 42 because of preterm labor and 63 because of premature rupture of membranes, and 105 patients who were delivered at term after uncomplicated pregnancies. RESULTS: Maternal placental vascular lesions were present in 14 (34.1%) patients with preterm labor, 19 (35.1%) patients with premature rupture of membranes, and 9 (11.8%) control patients (odds ratios 3.8 and 4.0, 95% confidence intervals 1.3 to 11.1 and 1.5 to 10.8, p = 0.0065 and 0.0022, respectively). Infection of the products of conception was found in 16 patients (38%) with preterm labor, 23 patients (36.5%) with premature rupture of membranes, and 19 control patients (18%) (odds ratios 2.7 and 2.6, 95% confidence intervals 1.1 to 6.6 and 1.2 to 5.6, p = 0.017 and 0.01, respectively). Patients with maternal placental vasculopathy had significantly different characteristics compared with those of infected patients. CONCLUSIONS: It is possible to identify two subgroups of patients among those who are delivered preterm because of preterm labor or premature rupture of membranes, one with infection of the products of conception and another with maternal placental vasculopathy.

The mystique of the mistake. With proposed standards for validating proficiency tests in anatomic pathology.

Variability in classification in anatomic pathology does not necessarily indicate that a mistake has been made. It is usually an artifact, created when pathologists choose a single category from among two or more justifiable alternatives. This is most common when standard classifications with uniform terminology are not used. It also can occur when classification systems are not constructed so as to insure mutual exclusivity of categories. It is proposed that a proficiency test in anatomic pathology should not be considered scientifically valid until a professional organization primarily concerned with anatomic pathology has endorsed its proposed classification system as having categories that are close to 100% mutually exclusive in the hands of expert pathologists not involved in developing the system. All possible precautions should be taken to insure that the "right answers" for any proficiency test are generated in a way that excludes the possibility of multiple justifiable alternatives.

Localized asymptomatic giant cell arteritis of the female genital tract.

Three postmenopausal patients with giant cell arteritis involving the female genital tract are presented. None of these patients had a prior history of vasculitis. The giant cell arteritis was confined to the myometrium in one patient, involved the cervix and myometrium in another, and involved all the internal genital organs in the third patient. Based on follow-up of our patients and analysis of similar cases in the literature, we conclude that asymptomatic patients may best be managed by close follow-up and monitoring of erythrocyte sedimentation rate levels, but that treatment may be unnecessary.

Chorioangiomas of intermediate size and intrauterine growth retardation.

Very large chorioangiomas are a rare but well recognized cause of neonatal morbidity, while small ones are clinically insignificant. This study emphasizes that some chorioangiomas of intermediate size may be causally related to intrauterine growth retardation, and that they may be surprisingly difficult to detect in the unfixed placenta.

Vulvovaginal polyps. Histologic appearance, ultrastructure, immunocytochemical characteristics, and clinicopathologic correlations.

A clinicopathologic study of 18 vulvovaginal fibroepithelial polyps with a comparison to normal stroma is presented. Twelve cases were analyzed by immunohistochemical methods for the presence of vimentin, desmin, muscle-specific actin, myoglobin, S-100 protein, alpha 1-antitrypsin (AAT), alpha 1-antichymotrypsin (ACHT), cytokeratin (AE1/AE3), and epithelial membrane antigen. Stromal cells reacted with vimentin antiserum in eight cases. Desmin reactivity was detected in five of 12 cases, four of which coexpressed vimentin. Two cases exhibited muscle-specific actin reactivity, and a single case weak AAT reactivity. The stromal cells were unreactive with S-100 protein, epithelial membrane antigen, cytokeratin, ACHT, and myoglobin. Ultrastructurally, the stromal cells of four fibroepithelial polyps resembled fibroblasts and myofibroblasts. Our immunohistochemical and ultrastructural data suggest that the stromal cells of fibroepithelial polyps are a collection of functional fibroblasts that may be capable of differentiating along two or more cell lines. Dramatically elongated cytoplasmic processes extend from both normal vulvovaginal stromal cells and the cells of the polyps. The cell attachments to each other and to bundles of collagen suggest a potential for a physiologic role in tissue contractility, especially in the immediate postpartum state. The common association with pregnancy may represent a local exuberant response to some presently unidentified trophic or stimulating factor.

Evaluation of the reproducibility of the World Health Organization classification of common ovarian cancers. With emphasis on methodology.

Seven pathologists independently classified 50 slides of ovarian tumors using category I of the World Health Organization classification (WHO I), each case being seen twice under different random code numbers. Intraobserver reproducibility and interobserver reproducibility, based on consistent interpretations, were both suboptimal. However, scrutiny suggested that no pathologist was a source of excessive variability, nor was suboptimal interobserver reproducibility simply due to intraobserver variability. Neither could excessive variability be attributed to skewing of results by a subgroup of unclassifiable cases. However, clearcut sources of variability were identified among the categories of WHO I, namely, mixed epithelial, unclassified epithelial, and undifferentiated carcinoma. There was also considerable variability in distinguishing serous and endometrioid neoplasms, and in identifying tumors of low malignant potential. These findings should not be misconstrued as implying that pathologists in routine practice cannot diagnose common ovarian cancers reproducibly for patient care purposes. Availability of clinical and macroscopic data, extensive sampling, histochemistry, and consultation combine, in an uncontrolled and highly individualistic fashion, to render routine service work very different from this highly controlled formal exercise. Furthermore, at the current state of the therapeutic art, many of the taxonomic problems identified in this study may have little clinical significance. Nonetheless, this study has strengthened the evidence that there may be important problems in classifying common ovarian cancers reproducibly using WHO I, and that WHO I may require greater clarity to enhance reproducibility. Current emphasis on quality assurance dictates reconsideration of the literature on reproducibility of histopathologic taxonomy, which has tended to inculpate pathologists as sources of variability. Virtually all of this literature is subject to some degree of skepticism due to deficiencies in methodology. Consideration of the question of how to measure reproducibility in anatomic pathology leads us to suggest that the community of pathologists should address the need to decrease ambiguity in classification systems as an important step toward optimizing reproducibility.