ON THE PLACENTA Christiane Fernandes Ribeiroa,*, Va nia Glo ria Silami Lopesb, Patricia Brasilc, Andrea Rodrigues Cordovil Piresd, Roger Rohloff e, Rita Maria Ribeiro Nogueiraf
International Journal of Infectious Diseases 55 (2017) 109112
introduction The occurrence of dengue infection in pregnancy has been reported in the literature since 1948. A recent systematic review reported several cases of antenatal complications associated with dengue, including miscarriage, stillbirth, and premature deliveries. In addition, maternal death due to dengue infection in pregnancy has been reported in Brazil.2,3 In 2013, seven cases of vertical transmission were reported and confirmed by serology, RT-PCR, and immunohistochemistry.4 This study describes the fetal outcomes and the histopatholog- ical and immunohistochemical findings in placenta samples and retained products of conception in pregnant women with confirmed dengue infection. Materials and methods It is a descriptive study of fetal outcome and pathological alterations from 24 pregnant women with laboratory-confirmed dengue.
Nineteen placentas and five ovular remnants were examined.
Pregnant women with seropositivity to HIV infection, hepatitis B, syphilis,
toxoplasmosis, or rubella; preeclampsia and gestational diabetes were excluded. Placental weight and disk measurements and some of the characteristics of the fetal membranes, including :
color and transparency
The distribution and size of the chorionic
vessels were evaluated in the fetus.
The color and appearance of the placental
lobes and tissue sections
The color and thickness of the funicular
vessels.
Whartons jelly were evaluated in the
umbilical cord and the abnormalities recorded. After examination, the placental tissues were excised, and seven sections were obtained: from the umbilical cord, two cross-sections at opposite ends and a longitudinal section in the median region;
from the membrane, a cross-section of the membrane roll;
from the placental disk, a sample of the cord
insertion site and a sample from the middle and outer disks as well as of any other sites considered relevant. All of the tissues sections were stained with hematoxylin- eosin (HE).
The fetal membranes, umbilical cord, chorionic plate, villi,
intervillous space, and decidua basalis were examined under a light microscope. Result Damage to the fetus occurred as miscarriage in 5 cases (20,8%),
The average gestational fetal death in 2 cases (8,3%), age at delivery was 38 3 weeks, and the average birth weight was 2,881 prematurity in 3 cases (12,5%), 543 g.
7 symptomatic new- borns (29%).
Two newborns developed dengue shock syndrome
(DSS) and were discharged without sequelae * Elapsed period between the onset of symptoms and childbirth ** Premature. *** CAPILLARY LEAK SYNDROME IN THE MOTHER: hemoconcentration, hypotension, shock, pleural effusion or ascites **** HYPOXIA: EDEMA OF THE VILLOUS STROMA, PRE-INFARCTION AREAS (INCREASE IN THE NUMBER OF SYNCYTIAL KNOTS AND REDUCED INTERVILLOUS SPACE), OR CHORANGIOSIS. ***** IHC: Immunohistochemistry. ****** PPA: Preterm placental abruption. FIGURE 1 (Light microscopic findings and immunostaining.) A. Loss of trophoblastic epithelium ( ) and inflammatory infiltrate in villous stroma ( ) HE 40X (case 13); B. Immunostaining in villous stroma cells 20 X (case 13); C. Proliferation and congestion of intravilliary vessels ( ) and villous stroma edema ( ) HE 40X (case 18); D. Immunostaining in villous stroma cells 40 X (case 18); E. Fibrin deposit in villi ( ), proliferation and villous vascular congestion ( ) HE 20X (case 10); F, Immunostaining in villous stroma cells and trophoblast 20X (case 10). Figure 2 (Immunostaining in placental tissue)
A-Negative control in liver tissue 20 X;
B- Negative control in placental tissue 20 X; C- Positive control in liver tissue; D- Immunostaining in decidual cells 20 X (case 10); E- Immunostaining in villous stroma cells 40 X (case 17); F- Immunostaining in trophoblast 20X (case 13). The light microscopic findings were The shown in Figure 1. No changes were observed in the umbilical cord immunohistochemical suggestive of maternal blood-borne analysis in 24 samples: infections, even during the vertical In two cases the transmission of type 2 virus confirmed in immunostaining was cases No. 06,09,13, and 24 in newborns negative. and case No. 23 in the fetus.
In 10 cases (41,6%) with
Staining was observed in the positive immunostaining, following placental cells: decidual a correspondence was cells trophoblasts, and villous observed between the stroma cells (Figure 2). All staining area with histological was cytoplasmic. changes and the immunostained area. DISCUSSION In this study, two possible mechanisms of fetal and neonatal morbidity were Of the 17 newborns, 14 proposed: the presence of newborns were at term and hemodynamic changes three were premature during pregnancy that could corroborating the results of affect the placenta and previous studies on the cause fetal hypoxia, or the association between dengue direct effect of infection on virus infection and the fetus. increased prematurity. Pathological changes, related to Two of the six patients hypoxia, were observed: edema of the villous stroma, pre- with sickled erythrocytes infarction areas, chorangiosis, in the intervillous space and infarcted areas. evolved to DSS and died. These findings underline the Accordingly, sickle cell importance of the hemodynamic changes disease has been experienced by pregnant reported to be a risk women during dengue virus factor for severe dengue. infection. CONCLUSION
The hemodynamic changes experienced
by the mother due to capillary leak The positive immunostaining syndrome as well as the vertical in placental samples in 92% transmission of the virus would be responsible to neonatal and fetal (22 cases) opens a new higher morbidity. perspective for the diagnosis of dengue in pregnant women, considering that these samples are easily available, especially when these samples are the only The placenta proved to be an organ material available. that reflects well the inflammatory response, virus presence and the maternal hemo- dynamic alterations. THANK YOU References 1. Pouliot SH, Xiong X, Harville E, Paz-Soldan V, Tomashek KM, Breart G, et al. Maternal dengue and pregnancy outcomes: a systematic review. Obstet Gynecol Surv 2010;65(2):10718. 2. Alvarenga C, Silami V, Brasil P, Boechat ME, Coelho J, Nogueira RM. Dengue during Pregnancy: A Study of Thirteen Cases. Am J Infect Dis 2009;5(4):295 300. 3. Nunes PCG, Paes MV, de Oliveira CAB, Soares ACG, de Filippis AMB, Lima M da RQ, et al. Detection of dengue NS1 and NS3 proteins in placenta and umbilical cord in fetal and maternal death. J Med Virol. agosto de 2016;88(8):144852. 4. Ribeiro CF, Lopes VGS, Brasil P, Coelho J, Muniz AG, Nogueira RMR. Perinatal Transmission of Dengue: A Report of 7 Cases. J Pediatr. novembro de 2013;163 (5):15146. 5. Battaglia FC, Lubchenco LO. A practical classification of newborn infants by weight and gestational age. J Pediatr 1967;71(2):15963. 6. Apgar V. A proposal for a new method of evaluation of the newborn infant. Anesth Analg 1953;32:2607. 7. Basurko C, Carles G, Youssef M, Guindi WEL. Maternal and fetal consequences of dengue fever during pregnancy. Eur J Obstet Gynecol Reprod Biol 2009;147 (1):2932. 8. Fox H, Sebire N. Pathology of the Placenta. 3e. 3o ed. Saunders; 2007 576 p.. 9. Ozono K, Mushiake S, Takeshima T, Nakayama M. Diagnosis of congenital cytomegalovirus infection by examination of placenta: application of polymerase chain reaction and in situ hybridization. Pediatr Pathol Lab Med 1997;17(2):24958. 10. Ribeiro CF, Silami VG, Brasil P, Nogueira RMR. Sickle-cell erythrocytes in the placentas of dengue-infected women. Int J Infect Dis 2012;16(1):e72. 11. Limonta D, Gonzalez D, Capo V, Torres G, Perez AB, Rosario D, et al. Fatal severe dengue and cell death in sickle cell disease during the 2001-2002 Havana dengue epidemic. Int J Infect Dis 2009;13(2):e778.