Interobserver Reliability for Identifying Specific Patterns of Placental Injury as Defined by the Amsterdam Classification.

CONTEXT.­: Placental pathology is an essential tool for understanding neonatal illness. The recent Amsterdam international consensus has standardized criteria and terminology, providing harmonized data for research and clinical care. OBJECTIVE.­: To evaluate the interobserver reliability of these criteria between pathologists at different levels of experience using digitally scanned slides from placentas in a birth population including a large proportion of normal deliveries. DESIGN.­: This was a secondary analysis of selected placentas from a large case-control study of placental lesions associated with neonatal encephalopathy. Histologic slides from 80 placentas were digitally scanned and blindly evaluated by 6 pathologists. Interobserver reliability was assessed by positive and negative agreement, Fleiss κ, and interrater correlation coefficients. RESULTS.­: Overall agreement on the diagnosis, grading, and staging of acute chorioamnionitis and villitis of unknown etiology was moderate to good for all observers and good to excellent for a subset of 4 observers. Agreement on the diagnosis and subtyping of fetal vascular malperfusion was poor to fair for all observers and fair to moderate for the subset of 4 pathologists. Agreement on accelerated villous maturation was poor. CONCLUSIONS.­: This study critically evaluates interobserver reliability for lesions defined by the Amsterdam consensus using scanned images with a low frequency of pathologic lesions. Although reliability was good to excellent for inflammatory lesions, lower reliability for vascular lesions emphasizes the need to more explicitly define the specific histologic features and boundaries for these patterns.

Postmortem Assessment of Isolated Congenital Heart Defects Remains Essential Following Termination of Pregnancy.

OBJECTIVES: To investigate the correlation between prenatal ultrasound (US) and autopsy findings in pregnancies terminated due to isolated congenital heart defects (CHDs), including CHDs associated with heterotaxy syndrome. MATERIALS AND METHODS: The material consists of 67 fetuses with prenatally detected isolated CHDs or CHDs associated with heterotaxy syndrome at a tertiary center in Norway between 1985 and 2014. The main CHDs were categorized into subdiagnoses of CHDs in accordance with ICD-10. The US and autopsy findings were categorized according to degree of concordance. RESULTS: Gestational age at termination was 12 + 0-22 + 6 weeks. Hypoplastic left heart syndrome was the most common main diagnosis among the 67 fetuses (32.8%). There was full agreement between US and autopsy findings in 97.4% (222/228) of all subdiagnoses. The discrepant findings in three fetuses had no influence on the decision to terminate the pregnancy. CONCLUSIONS: The correlation was high between prenatal US and postmortem findings in fetuses with isolated CHDs. Meticulous assessment of cardiac anatomy is particularly necessary when the decision to terminate relies on isolated CHDs. The trend of earlier termination challenges verification of diagnoses at autopsy. Consequently, the fetus should be examined at a tertiary center with fetal medicine specialists, pediatric cardiologists and perinatal pathologists.

Autopsy Findings of Central Nervous System Anomalies in Intact Fetuses Following Termination of Pregnancy After Prenatal Ultrasound Diagnosis.

OBJECTIVES: Central nervous system (CNS) anomalies are the second most frequent category of congenital anomalies after congenital heart defects (CHDs). In this study, the aim was to investigate the distribution of different CNS anomalies with associated anomalies and karyotype in a fetal autopsy population of terminated pregnancies over a 30-year period and to correlate the ultrasonographic diagnoses of CNS anomalies with autopsy findings. MATERIALS AND METHODS: This study includes 420 intact fetuses with CNS anomalies terminated at gestational ages 11+ 0 to 33+ 6 over a 30-year period from 1985 to 2014. An ultrasound (US) examination was performed at the National Centre for Fetal Medicine, St. Olavs Hospital, Trondheim. The autopsies were performed at the Department of Pathology at the same hospital or a collaborating hospital. The anomalies were subcategorized according to the classification by the World Health Organization. RESULTS: Neural tube defects such as anencephaly (22.4%, 107/477) and spina bifida (22.2%, 106/477) constituted the most common CNS anomalies, followed by congenital hydrocephalus (17.8%, 85/477). In total, the karyotype was abnormal in 21.0% of all termination of pregnancies (TOPs), with trisomy 18 as the most frequent abnormal karyotype. CHDs, skeletal anomalies, and urinary anomalies were the most common associated organ anomalies. Throughout the study period, there was full agreement between US and postmortem findings of CNS anomalies in 96.9% (407/420) of TOPs. CONCLUSION: In this study of autopsy findings of CNS anomalies in intact fetuses terminated after prenatal US diagnosis, neural tube defects were most common. About half of the fetuses had isolated serious CNS anomalies, while the other half were CNS anomalies associated with structural and/or chromosomal anomalies. The prenatal US diagnoses were in good concordance with autopsy findings. In particular, due to challenges of diagnoses made early in pregnancy, it is necessary to continue the validation practice.

The Placenta in Neonatal Encephalopathy: A Case-Control Study.

OBJECTIVE: We assessed whether specific histologic placental lesions were associated with risk for neonatal encephalopathy, a strong predictor of death or cerebral palsy. STUDY DESIGN: Case-control study of singletons with gestational ages ≥35 weeks. Data were abstracted from a prospectively collected database of consecutive births at a hospital in which placental samples from specified sites are collected and stored for all inborn infants. Placentas of infants with neonatal encephalopathy were compared with randomly selected control infants (ratio of 1:3). Placental histologic slides were read by a single experienced perinatal pathologist unaware of case status, using internationally recommended definitions and terminology. Findings were grouped into inflammatory, maternal, or fetal vascular malperfusion (FVM) and other lesions. RESULTS: Placental samples were available for 73 of 87 (84%) cases and 253 of 261 (97%) controls. Delivery complications and gross placental abnormalities were more common in cases, of whom 4 died. Inflammation and maternal vascular malperfusion did not differ, and findings consistent with global FVM were more frequent in case (20%) than control (7%) placentas (P = .001). There was a trend toward more segmental FVM and high-grade FVM (fetal thrombotic vasculopathy) among cases. Some type of FVM was observed in 24% of placentas with neonatal encephalopathy. In infants with both neonatal encephalopathy and placental FVM, more often than in infants with neonatal encephalopathy without FVM, electronic fetal monitoring tracings were considered possibly or definitely abnormal (P = .028). CONCLUSIONS: Vascular malperfusion of subacute or chronic origin on the fetal side of the placenta was associated with increased risk of neonatal encephalopathy.

Unrecognized viral infections and chromosome abnormalities as a cause of fetal death - examination with fluorescence in situ hybridization, immunohistochemistry and polymerase chain reaction.

Fifteen to 50% of fetal deaths remain unexplained after post-mortem examination depending on inclusion criteria and classification systems. Our aim was to examine a selection of unexplained fetal deaths in order to investigate whether any common chromosome aberrations or viral infections were present. Reports from 351 fetal autopsies performed at the Department of Pathology and Medical Genetics at St. Olavs University Hospital from 2001 through 2010 were reviewed. Of these, 105 fetal deaths were classified as unexplained. Tissue samples from 30 cases were further examined with fluorescence in situ hybridization (FISH) to detect abnormalities in chromosomes 13, 18, and 21. The samples were also examined with immunohistochemistry (IHC) and polymerase chain reaction (PCR) to detect infections with cytomegalovirus, parvovirus B19, herpes simplex virus 1 and 2, enterovirus, and parechovirus. In two cases, a possible trisomy 13 mosaicism was found. No viruses were detected. In our selection of 30 unexplained cases, possible trisomy 13 mosaicism was found in two cases, and no viruses were detected. High degree of maceration and missing placental examination often complicate the investigation of fetal death, and extensive ancillary examinations do not necessarily contribute to a more specific diagnosis.

Colposcopy and additive diagnostic value of biopsies from colposcopy-negative areas to detect cervical dysplasia.

INTRODUCTION: We evaluated colposcopy in the routine diagnostic workup of women with abnormal cervical cytology, as well as the diagnostic value of endocervical curettage material and biopsies taken from colposcopy-positive and colposcopy-negative quadrants of the cervix. MATERIAL AND METHODS: This cross-sectional study included 297 nonpregnant women with abnormal cervical cytology and no prior treatment for cervical dysplasia or cancer. All women underwent gynecological examination, colposcopy, endocervical curettage, and had cervical biopsies taken. Colposcopy was considered satisfactory if the squamocolumnar junction was fully visible, and biopsies were taken from all four quadrants of the cervix, regardless of colposcopy results. RESULTS: In all, 130 of the women in our study had satisfactory colposcopy results and were diagnosed with cervical intraepithelial neoplasia grade 2 or worse (CIN2+), 61% via a colposcopy-positive biopsy and 39% via a colposcopy-negative biopsy. Eighty-seven of them had positive colposcopy results, but CIN2+ was histologically verified from colposcopy-positive biopsies in 91% (n = 79) and from colposcopy-negative biopsies in 9% (n = 8). The remaining 43 women with CIN2+ had negative colposcopy findings, so their diagnosis was verified in colposcopy-negative biopsies. The sensitivity of colposcopy alone to detect CIN2+ was 61% (95% CI 52-69). CONCLUSIONS: In the present study, colposcopy was not a stand-alone diagnostic method. Colposcopy-negative biopsies had a clear additive value, identifying a substantial proportion of women with both positive and negative colposcopy results with treatment-worthy cervical dysplasia. Endocervical curettage material had little diagnostic value in this study.

Explaining Fetal Death--What Are the Contributions of Fetal Autopsy and Placenta Examination?

The aim of our study was to categorize fetal deaths by different diagnostic groups and see to what extent an autopsy of a presumably normal fetus contributes to the final diagnosis and how many unexplained fetal deaths remain unexplained after examination of the placenta. We reviewed autopsy reports of 351 fetuses with a gestational age of 12 or more weeks at the Department of Pathology and Medical Genetics at St Olavs Hospital during the years 2001 through 2010. In our records, 38.5% (135 of 351) of the deaths were due to noninfectious placenta causes, 31.6% (111 of 351) were caused by infections, and 29.9% (105 of 351) of the fetal deaths remained unexplained after autopsy. We also found that an inconclusive report was more common early in pregnancy. The incidence of fetal loss due to circulatory disturbances in the placenta increased toward term. Infections were evenly distributed in intrauterine fetal deaths, although in spontaneous abortions, they were more frequent during the second trimester. For both explained and unexplained deaths, we observed a bimodal distribution, with peaks in the early second trimester and late third trimester toward term.

The identification of distinct high-frequency oscillations during spikes delineates the seizure onset zone better than high-frequency spectral power changes.

OBJECTIVE: Interictal high-frequency oscillations (HFOs, 80-500Hz) can predict the seizure onset zone (SOZ), but visual detection of HFOs is time consuming. Time-frequency analysis can reveal large high-frequency (HF) power changes (80-500Hz) associated with inter-ictal spikes. The present study determines how well the rate of HFOs and spike-related HF power changes were co-localized with SOZ. METHODS: We analyzed 583 channels (68 in the SOZ) sampled from 14 patients who underwent intracranial EEG recording. We determined if the rate of visually-marked HFOs and spike-related HF power changes differed between SOZ and non-SOZ. RESULTS: Significantly higher rates of HFOs were found in SOZ. The degree of spike-related HF power augmentation failed to differ between SOZ and non-SOZ, whereas that of post-spike HF power attenuation was significantly more severe in SOZ compared to in non-SOZ. Regions showing HFOs and large spike-related HF-changes showed a partial overlap in distribution in 7/14 patients. CONCLUSIONS: Strong HF augmentation during spikes and high HFO rates occurred over different brain locations. The rate of HFOs showed the best performance in identifying SOZ. Post-spike HF power attenuation may represent increased inhibition in these channels and should be investigated further. SIGNIFICANCE: Strong HF power changes during spikes and HFOs per se seem to reflect distinct phenomena.

Prenatal examination and postmortem findings in fetuses with gastroschisis and omphalocele.

OBJECTIVE: This study compares prenatal ultrasound examination and autopsy findings in fetuses and infants with gastroschisis and omphalocele. METHOD: Criteria for inclusion in the study were an autopsy of fetuses/infants with gastroschisis or omphalocele performed between January 1985 and December 2009 and a prenatal ultrasound examination performed in a tertiary referral center. The results were organized into five categories depending on the degree of agreement. RESULTS: Of 11 cases with gastroschisis, only one was not detected at the prenatal ultrasound examination, and the rest had full agreement. Of 70 fetuses with omphalocele, two were not diagnosed at the prenatal ultrasound examination. Four (15%) had major autopsy findings not detected prenatally. The main diagnosis was correct in 64/70 (91%) and improved from 85% to 95% during this study period. The number of cases with major and minor autopsy findings not detected by ultrasound examination was reduced from 48% to 21%. Full agreement occurred in 46/70 (66%). CONCLUSION: This study shows that the correlation between prenatal ultrasound findings and postmortem examination is good and has improved over time. Comparing full agreement during the first 10 years with the last 15 years showed an improvement (p = 0.05) for fetuses with omphalocele.

Maternal and fetal insulin levels at birth in women with polycystic ovary syndrome: data from a randomized controlled study on metformin.

CONTEXT: Metformin is suggested to reduce pregnancy complications in women with polycystic ovary syndrome (PCOS). Metformin crosses the placenta and therapeutic concentrations are measured in the fetal circulation. Whether metformin treatment in pregnant PCOS women affects maternal and fetal insulin concentrations at birth is not clarified. OBJECTIVES: To investigate the possible effect of metformin on insulin concentrations in umbilical cord blood and the possible association between maternal and fetal insulin concentrations. DESIGN: Post-hoc analysis of a subgroup of PCOS women participating in a double-blind randomized controlled trial. SETTING: University hospital setting. PARTICIPANTS: Women with PCOS (n=118), aged 19-39 years. MAIN OUTCOME MEASURES: Maternal and umbilical cord insulin concentrations immediately after birth. RESULTS: At delivery women randomized to metformin had lower insulin concentrations than those randomized to placebo (259±209 vs 361±261 pmol/l; P=0.020). No difference was found in insulin concentrations in umbilical venous (P=0.95) and arterial (P=0.39) blood between the metformin and placebo groups. The arteriovenous difference was also equal between the groups (P=0.38). Insulin concentrations were higher in the umbilical vein than in the umbilical artery independent of randomization (70±51 vs 45±48 pmol/l; P<0.0005). CONCLUSIONS: In PCOS, metformin treatment during pregnancy resulted in lower maternal insulin concentrations at delivery. Metformin treatment did not affect fetal insulin concentrations. Higher insulin concentrations in the umbilical vein indicate that the placenta somehow secretes insulin to the fetus. The possibility of placental insulin secretion to the fetus deserves further investigations.

Thanatophoric dysplasia: autopsy findings over a 25-year period.

The aim of our study was to retrospectively assess morphological findings in thanatophoric dysplasia, particularly, in how many cases were cerebral manifestations with temporal lobe dysplasia identified. We also wanted to register and analyze the proportions between lung, brain, and body weight. Criteria for inclusion were an autopsy performed during the period ranging from 1985 to 2009 with a diagnosis of thanatophoric dysplasia. During a 25-year period 25 cases of thanatophoric dysplasia were registered. Temporal lobe dysplasia was recognized in 52% of the cases, and after 1998 temporal lobe dysplasia was described in all cases. In 19 cases the brain/body weight ratio was increased, and in all cases the lung/body weight ratio was below the corresponding ratio calculated according to standard measurements. In all but one case the ratio of brain to lung weight was increased. This study focuses on morphological findings, stressing the importance of temporal lobe dysplasia in confirming a diagnosis of thanatophoric dysplasia. Lung/body, brain/body, and brain/lung weight ratios confirm macrocephaly and lung hypoplasia, which are constant findings in cases involving thanatophoric dysplasia. Femur and brain morphology inclusive histology remains the ultimate tool for confirmation of this lethal condition, although it has to be seen in a context inclusive of radiological examination.

Longitudinal diffusion tensor and manganese-enhanced MRI detect delayed cerebral gray and white matter injury after hypoxia-ischemia and hyperoxia.

BACKGROUND: Hypoxia-ischemia (HI) induces delayed inflammation and long-term gray and white matter brain injury that may be altered by hyperoxia. METHODS: HI and 2 h of hyperoxia (100% O2) or room air (21% O2) in 7-d-old (P7) rats were studied by magnetic resonance imaging at 7 Tesla during 42 d: apparent diffusion coefficient (ADC) maps on day 1; T(1)-weighted manganese-enhanced images on day 7; diffusion tensor images on days 21 and 42; and T2 maps at all time points. RESULTS: The long-term brain tissue destruction on T2 maps was more severe in HI+hyperoxia than HI+room air. ADC was lower in HI+hyperoxia vs. HI+room air and sham and was correlated with long-term outcome. Manganese enhancement indicating inflammation was seen in both the groups along with more microglial activation in HI+hyperoxia on day 7. Fractional anisotropy (FA) in corpus callosum was lower and radial diffusivity was higher in HI+hyperoxia than that in HI+room air and sham on day 21. From day 21 to day 42, FA and radial diffusivity in HI+hyperoxia were unchanged, whereas in HI+room air, FA increased and radial diffusivity decreased to values similar to sham. CONCLUSION: Hyperoxia caused a more severe tissue destruction, delayed irreversible white matter injury, and increased inflammatory response resulting in a worsening in the trajectory of injury after HI in developing gray and white matter.

How important is placental examination in cases of perinatal deaths?

Research on stillbirths and placental pathology has traditionally been given low priority, causing a lack of understanding of the mechanisms leading to death. The purpose of this study was to gain knowledge on how many perinatal deaths relate to morphologic changes in the placenta, and what role the placenta plays in the pathogenesis of intrauterine, intrapartum, and neonatal deaths. The autopsy reports from 104 consecutive perinatal deaths in a 5-year period (2004-2008) were reviewed. Intrauterine, intrapartum, and neonatal deaths ranging from gestational age of 22 weeks up to 7 days postpartum were included. The following three questions were considered: Could placental examination (with autopsy) explain fetal/infant death; could the cause of death be explained by placental examination alone; and could the cause of death be explained with autopsy alone? The distribution of pathologic findings in the placenta was registered. The placenta had changes that could explain fetal/infant death in 69.2% of the cases. The cause of death could be explained by placental examination alone, without autopsy, in 48.1% of the cases. Only 16.3% of the deaths could be explained by autopsy alone. The most frequently observed diagnoses were infection (22.1%), degenerative changes (13.5%), and abruptio placentae (12.5%). To conclude, our study shows that placental examination in addition to autopsy is necessary in investigating the causes of perinatal deaths. Further research, including maternal and environmental factors, is needed to clarify the underlying causes of placental malfunction.

Platinum species in the pores of NaX, NaY and NaA zeolites studied using EPR, XAS and FTIR spectroscopies.

The results of X-band EPR, X-ray absorption and Fourier transform infrared spectroscopy on Pt(NH(3))(4)(2+) exchanged NaX, NaY and NaA zeolites reveal after oxygen calcination at 573 K that diamagnetic Pt(2+) is not the only product. Calcination provides Pt(3+) cations, but depending on the heating rate, the decomposition of amino groups during calcination also produces hydrogen that reduces Pt(3+) to Pt(2+) and Pt(+). NaX (Si/Al = 1.23) has a more negative framework charge than NaY (Si/Al = 2.31), so Pt(3+) can be stabilized only in NaX, whereas lower oxidation states of Pt such as Pt(+) can be stabilized in both, NaX and NaY, and neither of the paramagnetic Pt cations are stabilized in NaUSY (Si/Al = 3). The autoreduction process allows controlling the number of Pt(3+) and Pt(+) in the NaX zeolite by changing the calcination heating rate: a heating rate of 1.25 K min(-1) gives only Pt(+), but 0.5 K min(-1) gives a Pt(3+)/Pt(+) ratio close to 1. The structure of the support is also important for the synthesis of Pt species. While isolated paramagnetic Pt ions were stabilized in faujasite zeolites (NaX and NaY), a paramagnetic Pt dimer was obtained in a Linde type A zeolite (LTA, Si/Al = 1) by applying the same preparation methods. The fraction of paramagnetic Pt species which were characterized by X-band EPR spectroscopy amounts to 2-18% of the total Pt in the zeolites, the remaining Pt must be diamagnetic.