Jurnal Reading

Pathological findings in placentas from term and preterm intrauterine fetal death pregnancies
Adviser : Dr. Tigor P. Simanjuntak SpOG Student : Arya Sakti Andhika P.S (06-152)

Abstract
To compare pathological findings of placentas from term and preterm pregnancies complicated by intrauterine fetal death (IUFD).

Objective

Abstract
A retrospective cohort study
Study Design

Comparison

placentas from term and preterm placentas delivered before and after 34 weeks gestation

Abstract

Results
849 placentas of IUFD were examined Gross and microscopic pathological finding were noted

Abstract

Conclusions
A vast majority of IUFD placentas reveal numerous pathological findings that reflect uteroplacental insufficiency and abnormal blood supply

Introduction Definition of IUFD

World Health Organisation (WHO)
United Kingdom (UK) SOROKA Medical Centre (Israel)
pregnancy loss after 20 completed weeks of gestation or birth weight of 500 g or more

pregnancy loss after 24 completed weeks of gestation

Pregnancy loss after 22 complete gestational weeks or a fetus weighing more than 500 gr

Introduction Incidence
In the United States

6.4/1000 births (2002)

Afro-American Population

12.1/1000 births
Caucasians Population

5.5/1000 births
In Israel (SOROKA Medical Centre)

3.6 per 1000 births

Material and Methods

Method
A retrospective cohort study

Definition of IUFD
Sample Number of Samples

pregnancy loss after 22 complete gestation weeks or birth weight > 500 g Deliveries between 1995 and 2004 at the Soroka University Medical Center

849 placentas of IUFD

Tabel I. Demografi dan Karakteristik Klinis Pada Pasien dengan IUFD

Result
Characteristic Study group

[Mean Standard Deviation (n)] Maternal age

Gravidity Parity

29 (years) 6.87 (849)

4.49 3.40 (849) 3.85 3.00 (849)

Ethnicity
Jewish Arab Bedouins 37.1 % (315) 62.9 % (534)

Nulliparity
Gestational age Placental weight

21.2 % (180)
31.67 (weeks) 5.68 (849) 547.57 (gr) 586.688 (749)

Tabel II. Karakteristik Maternal, Janin dan Plasenta Pada Kehamilan Aterm dan Preterm IUFD

Result

Karakteristik Usia Ibu Gravida Paritas Golongan darah Ibu A B AB O Rhesus Positif Negatif Serum Ibu Kadar Hemoglobin Jenis Kelamin Janin Laki-laki Perempuan Berat Lahir berdasarkan Usia Kehamilan SGA / KMK AGA / SMK LGA / BMK

IUFD Preterm 16.2 12.9 4.4 0.1 3.7 0.1 30.4 % 24.2 % 4.8 % 40.5 % 88.5 % 11.5 % 11.10.07 49.9 % 50.1%

IUFD Aterm 29.9 0.5 4.8 0.2 4.3 0.2 31.6 % 23.6 % 7.1 % 37.8 %

p 0.52 0.89 0.012 0.57

0.29 85.8 % 14.2 % 0.004 11.5 0.1 0.72 51.3 % 48.7 % < 0.001 27.9 % 67.9 % 4.2 % 35.1 % 54.1 % 10.8 %

Tabel III. Temuan Kelainan Patologis Makroskopik dari Plasenta Preterm dan Aterm IUFD

Result
(n)

Kelainan Makroskopik

Preterm IUFD

Aterm IUFD

(n)
4.1% (7) 0.148

Insersi Tali Pusat Abnormal

1.9% (9)

Kalsifikasi
SUA Mekonium Pembengkakan Perdarahan infark

15.8% (81)
5.5% (27) 40.4% (21) 51.6% (210) 5.4% (28) 15.2% (78)

33.5% (59)
4.1% (7) 36.4% (8) 77.3% (116) 5.7% (10) 13.6% (24)

< 0.001
0.455 0.746 < 0.001 0.906 0.620

Tabel IV. Temuan Kelainan Patologis Mikroskopik dari Plasenta Preterm dan Aterm IUFD

Result

Kelainan Mikroskopis Vaskularisasi Yang Buruk Metaplasia Infark Sumbatan Vaskular Trombosis Intravaskular Knot Penebalan Dinding Perdarahan Kalsifikasi Korioamnionitis

Preterm IUFD (n) Aterm IUFD (n) 86.5% (160) 55.5% (111) 44% (88) 25.5% (51) 4.5% (9) 4.5% (9) 91% (182) 12.5% (25) 12.5% (25) 33% (66) 65.9% (56) 70.8% (63) 53.9% (48) 13.5% (12) 9% (8) 3.4% (3) 91% (81) 16.9% (15) 10.1% (9) 30.3% (27)

p < 0.001 0.014 0.118 0.022 0.134 0.657 0.998 0.322 0.561 0.655

Tabel V. Temuan Kelainan Patologis Makroskopik dari Plasenta yang lahir Sebelum dan Sesudah Usia kehamilan 34 Minggu

Result
Kelainan Makroskopik IUFD Sebelum
34 Minggu (n) Insersi Tali Pusat Abnormal Kalsifikasi SUA Mekonium Pembengkakan 1.1% (4) 14% (57) 5.2% (20) 55% (22) 47.6% (157)

IUFD Setelah
34 Minggu (n) 4.5% (12) 29.2% (83) 5.1% (14) 67.6% (23) 74.4% (169)

0.006 < 0.001 0.997 0.267 < 0.001

Perdarahan
infark

5.7% (23)
14% (57)

5.3% (15)
15.8% (45)

0.828
0.511

Tabel VI. Temuan Kelainan Patologis Mikroskopik dari Plasenta yang lahir Sebelum dan Sesudah Usia kehamilan 34 Minggu

Result

Kelainan Mikroskopis

IUFD Sebelum

IUFD Setelah

34 Minggu (n)
Vaskularisasi Yang Buruk Metaplasia Infark Sumbatan Vaskular Trombosis Intravaskular Knot 86.2% (125) 57.1% (89) 41% (64) 28.8% (45) 3.2% (5) 3.8% (6)

34 Minggu (n)
72.8% (91) 63.9% (85) 54.1% (72) 13.5% (18) 9% (12) 4.5% (6) 0.015 0.235 0.026 0.005 0.036 0.778

Penebalan Dinding
Perdarahan Kalsifikasi Korioamnionitis Funisitis Insufisiensi Uteroplasenta

91% (142)
12.2% (19) 12.8% (20) 33.3% (52) 5.8% (9) 91.7% (143)

91% (121)
15.8% (21) 10.5% (14) 30.8% (41) 6.8% (9) 86.5% (115)

0.989
0.376 0.546 0.649 0.726 0.154

Tabel VI. Temuan Kelainan Patologis Mikroskopik dari Plasenta yang lahir Sebelum dan Sesudah Usia kehamilan 34 Minggu

Result

100 80

60 40 20 0
Vaskularisasi Yang Buruk Sumbatan Vaskular Infark IUFD Sebelum Kehamilan 34 Minggu IUFD sedudah Kehamilan 34 Minggu

Discussion
The main finding of this study is
vast majority of IUFD placentas demonstrate pathological characteristics associated with uteroplacental insufficiency

Over 90% of preterm (537 weeks) and over 83% of term IUFD placentas were associated with uteroplacental insufficiency

Discussion

In this study uteroplacental insufficiency define as

placental infarct poor vascularity of the chorionic villi intravascular thrombi Vascular occlusion

Discussion
Placental lesions leading to obstruction of the fetal circulation are an important cause of adverse pregnancy outcomes

When sufficiently extensive thrombosis may in some cases, be the consequence of stasis or vascular wall damage

The most common cause of stasis is compromised umbilical blood flow secondary to chronic partial or recurrent intermittent umbilical cord compression

it is possible that the rate and severity of cord compression increases with gestational age