Immunofluorescence study of the placenta in a case of pemphigoid gestationis: Pathophysiological bases

IntroductionPemphigoid gestationis (PG) is one of the main dermatoses of pregnancy that must be recognized and treated promptly, since it is related to worsening of foetal prognosis. Although skin involvement has been investigated, there is a lack of morphological and functional studies of the placenta in this pathology.Main symptoms and/or clinical findingsErythematous vesicular rash at 32 + 1 weeks of gestation.Main diagnosesPG.Therapeutic interventions and resultsImmunogammaglobulin in severe cases refractory to oral corticosteroids with complete disappearance of the lesions.ConclusionTo our knowledge, this is the first case to report a detailed analysis of IgG and C3 deposits in the basement membrane of the placental villi by means of an immunofluorescence study. These findings could be related to a slight malfunction of the placenta that may explain the adverse neonatal effects.     

Abnormal expression of class II MHC antigens in placentae from patients with pemphigoid gestationis: analysis of class II MHC subregion product expression

Abnormal expression of class II MHC antigens was consistently observed in an immunohistological study on placentae from patients with pemphigoid gestationis. The area affected in all the placentae was the chorionic villi adjacent to the maternal decidua. The villous stroma, and in some cases the chorionic fetal endothelium, had abnormal expression of class II MHC antigens. Monoclonal antibodies specific for the class II MHC subregion products (DR, DP and DQ) were used to analyse the class II MHC antigen expression. Differential expression of the class II MHC subregion products was observed on the villous stroma and chorionic fetal endothelium; DR and DP were always expressed but DQ in some cases was heterogeneous. This abnormal expression of class II MHC antigens may reflect an immunological attack on the placenta in pemphigoid gestationis.     

解整合素金属蛋白酶10在重度子痫前期胎盘中的表达及其意义

目的通过对孕妇胎盘组织中解整合素金属蛋白酶10（a disintegrin and metalloproteinase 10,ADAM10）的检测,探讨ADAM10与子痫前期发病的关系。方法选择2009年9月至2012年3月在北京大学人民医院产科住院分娩的30例重度子痫前期（子痫前期组）和30例正常孕妇（正常妊娠组）,采用反转录聚合酶链反应（RT—PCR）方法检测两组孕妇胎盘组织中ADAM10 mRNA的表达,并采用免疫组化二步法和蛋白质印迹法（Western Blot）检测胎盘组织中ADAM10蛋白的表达。结果ADAM10表达于胎盘组织的细胞滋养细胞和合体滋养细胞的细胞浆和细胞核中。子痫前期组中ADAM10 mRNA及蛋白的表达均明显高于正常妊娠组（P〈0．05）。结论重度子痫前期胎盘组织中ADAM10的过度表达可能与子痫前期的发生和发展有关。     

羊水过少胎盘组织中血栓素受体表达的研究

目的检测羊水过少孕妇静脉血中血栓素B2(thromboxane,TXB2)、6-酮前列腺素(6-Keto-Prostaglandin-F1α,6-keto-PGF1α)及胎盘组织中血栓素受体(thromboxane receptor,TP)的表达,探讨其与羊水过少发病的关系。方法 ELISA法检测孕妇静脉血中血栓素B2、6酮前列环素FIα水平,免疫组织化学法检测TP的表达及分布。结果羊水过少孕妇血浆中TXB2、PGF1α水平无明显变化,但胎盘组织TP蛋白表达增加,主要表达于滋养细胞层、绒毛间质。结论胎盘滋养细胞层、绒毛间质TP表达增加,可能参与羊水过少的发生。     

Intraoperative aortic balloon occlusion in patients with placenta previa and/or placenta accreta: a retrospective study

Objective

To introduce the primary experience of using aortic balloon catheters during cesarean section for placenta previa and/or placenta accreta.

Optimal timing of antenatal corticosteroids in women with bleeding placenta previa or low-lying placenta*

Background: Administrating a single course of antenatal corticosteroids to women at risk of preterm birth between 24 and 34 weeks of gestation has been shown to decrease neonatal morbidity and mortality. There is evidence that the optimal timing for the administration of antenatal corticosteroids is within 1–7 days before birth as the effect of antenatal corticosteroids has been shown to decline 7 days after administration. Therefore, given that antenatal corticosteroids are the single most effective intervention in cases of preterm birth, efforts should be made to optimize the timing of administration of antenatal corticosteroids.

Objective: To test the hypothesis that the timing of antenatal corticosteroids in women with vaginal bleeding due to placenta previa or low-lying placenta can be optimized by identifying women at low risk of imminent delivery.

Study design: This was a retrospective cohort study of all women admitted to a tertiary referral center at 24–34 weeks’ gestation with vaginal bleeding due to placenta previa or low-lying placenta between 2003 and 2014. Multivariable logistic regression analysis was used to identify factors that are independently associated with delivery within 14 days from admission.

Results: A total of 202 women who met the inclusion criteria were admitted with vaginal bleeding in the presence of placenta previa or low-lying placenta during the study period, of whom 31 (15.3%) and 44 (21.8%) gave birth within 7 and 14 days from admission, respectively. The following factors were independently associated with delivery within 14 days from admission: complete placenta previa (odds (OR) 3.57, 95%CI 1.57–9.03), severe bleeding at presentation (OR 17.14, 95%CI 2.92–100.70), uterine contractions at presentation (OR 6.02, 95%CI 1.91–19.00), and cervical length <25?mm at presentation (OR 6.33, 95%CI 1.37–29.11). A predictive test based on the presence of ≥1 of these risk factors was associated with a sensitivity of 90.9% and a negative predictive value of 94.6% for delivery within 14 days of presentation.

Conclusions: In women presenting with vaginal bleeding due to placenta previa or low-lying placenta, it seems possible to identify a subgroup of women in whom the likelihood of delivery within 14 days is low. This information may allow for selective (rather than routine) administration of antenatal corticosteroids in this scenario, and may thereby contribute to the optimization of the timing of administration of antenatal corticosteroids.     

穿透入膀胱的凶险型前置胎盘处理决策

随着孕妇妊娠年龄的增加,以及剖宫产后再次妊娠数量的增加,凶险型前置胎盘合并胎盘植入已经成为相对常见的严重并发症之一。其中临床处理最困难的情况往往是前置胎盘合并胎盘植入并穿透子宫浆膜层侵及膀胱后壁,一般称为“穿透入膀胱的凶险型前置胎盘”。文章基于近期相关病例报道和综述性文献的收集,就穿透入膀胱的凶险型前置胎盘的孕期处理、术前诊断、围手术期的准备以及不同手术方式的介绍、保守性治疗方案等关键问题进行了阐述,提出目前该种病例的诊治尚没有统一的临床指南或规范,往往强调个体化的诊治思路。即以保证孕妇生命安全和生活质量为底线,兼顾胎儿生存,减少术中出血,最大可能保护再生育能力为原则。诊治工作重在预防和早期识别,充分的产前评估及术前准备以及正确的手术策略选择是诊治成功与否的关键。     

HBeAg阳性慢性乙型肝炎孕妇胎盘组织Toll样受体3的表达及意义

目的探讨孕妇胎盘组织Toll样受体3(TLR3)的表达与乙型肝炎病毒(HBV)持续感染的关系。方法2008年11月至2009年5月在南方医科大学南方医院产科选取22例HBeAg阳性(HbeAg阳性组)和24例HBeAg阴性(HBeAg阴性组)慢性乙型肝炎(乙肝)孕妇,及正常孕妇25例。建立实时荧光定量RT-PCR检测胎盘组织中TLR3mRNA水平,同时以免疫组化法检测其在胎盘组织中的表达,并采用实时荧光定量PCR和微粒子酶免疫分析法(MEIA)分别定量检测其血清HBV-DNA和HBeAg水平。结果HBeAg阳性孕妇胎盘组织中TLR3mRNA水平(×10-1)(3.204±0.395)明显低于正常对照组(7.834±0.970)和HBeAg阴性组(5.746±0.580),两组相比P0.01;HBeAg阳性孕妇血清HBeAg及HBV-DNA水平[562.2±337.4和(7.15±3.69)×107copy/mL]明显高于正常对照组(0.29±0.06,1.00×103copy/mL)和HBeAg阴性组[0.35±0.07,(2.40±1.71)×103copy/mL](P0.01);胎盘组织中TLR3mRNA表达与HBeAg水平呈负相关(r=-0.495,P0.05),而与血清HBV-DNA水平无显著相关性。结论胎盘组织中TLR3的表达与其持续感染HBV有一定关系,HBeAg对胎盘组织TLR3表达起负调节作用。     

Difficulty of the surgical management of a case with placenta percreta invading towards parametrium

A 37-year-old woman was admitted due to vaginal bleeding at 25 weeks of gestation to our gynecology unit. Placenta percreta, which stems from posterior wall of the uterus, forming a mass in Douglas cavity and invading towards right parametrium was clinically diagnosed by exploration. Bilateral internal iliac artery ligation and supracervical hysterectomy could not prevent bleeding. A right radical parametrectomy was necessary to remove invaded parametrium and to control bleeding. The placenta percreta invading parametrium may need an extended hysterectomy procedure. Excess bleeding may be prevented by leaving the placenta in situ during surgery if the placenta percreta is diagnosed before termination of pregnancy, A classical incision may help leaving placenta is situ during operation.     

Immunohistochemical study of tissue polypeptide antigen (TPA) and cancer antigen 125 (CA125) in the human and cynomolgus monkey placenta,umbilical cord and decidua

Summary Tissue polypeptide antigen (TPA) and cancer antigen 125 (CA125) were studied immunohistochemically by the avidin-biotin immunoperoxidase technique in human and cynomolgus monkey placentae, membranes, umbilical cords and decidua. In early human placentae, TPA was localized mainly in the cell membranes of villous syncytio- and cyto-trophoblast. The cytoplasm of those trophoblastic cells were weakly stained with TPA. The membrane of basal chorionic trophoblast cells was strongly stained with TPA and the cytoplasm stained weakly. In early cynomolgus placentae, similar immunostaining results were obtained. However, the positive stainings for TPA was more marked in the cytoplasm of villous syncytiotrophoblast and basal chorionic trophoblast, and less marked in the cell membrane of villous cytotrophoblast. In early human and cynomolgus placentae, CA125 was not demonstrated immunohistochemically in the villi and basal chorion. In human and cynomolgus term placentae, the villous syncytiotrophoblast and basal and reflected chorionic trophoblast showed similar immunostaining as the early placentae. In addition, TPA was found in the amniotic epithelium in both sorts of placentae. TPA was not detected immunohistochemically in the umbilical cord and decidual cells. While weakly positive stains for CA125 were observed in decidual cells, CA125 was localized mainly in the membrane and cytoplasm of amniotic epithelium in both human and cynomolgus term placentae. TPA and CA125 are thus oncoplacental antigens and the monkey could serve as a model for their investigation.     

Prediction of spontaneous preterm birth using fetal fibronectin in women with a low-lying placenta

Objective: To determine the effect of a low-lying placenta on the concentration of quantitative fetal fibronectin (qfFN) in the cervicovaginal fluid (CVF), and predictive accuracy for spontaneous preterm birth in asymptomatic high-risk women (18?⁺?⁰–24?⁺?⁰ weeks gestation). Methods: Median concentrations of qfFN were compared in women who had a low-lying placenta, covering the cervical os (n?=?61) to matched controls (n=?61) without a low-lying placenta. Proportions of women with raised qfFN concentrations (>10?ng/ml), and false positive and negative rates (FPR and FNR) for spontaneous preterm delivery were also compared. Results: The median concentration of qfFN in women with low-lying placenta was 5.0?ng/mL, compared with 6.0?ng/mL in controls. Proportion of women with raised levels (>10?ng/mL), positive levels (>50?ng/mL) and very high levels (>200?ng/mL) were similar in both groups (62.3% versus 59.0%, 16.3% versus 22.0% and 6.5% versus 4.9%, p?>?0.05 for all thresholds). The FPR and FNR rate for delivery before 34 and 37 weeks were also comparable (FPR 90.0% versus 85.7% and 80.0% versus 78.6%; FNR 5.8% versus 4.3% and 9.8% versus 8.5%).

Conclusions: CVF qfFN concentrations in asymptomatic high-risk women are not affected by the presence of a low-lying placenta.     

新生儿感染与人类单核细胞表面抗原HLA-DR及CD14的关系

目的　探讨单核细胞表面 CD14、HL A- DR的表达在新生儿感染性疾病发生发展中的作用及与预后的关系。　方法　用双标记流式细胞术对新生儿感染患儿外周血单核细胞 CD14、HL A- DR的表面表达量进行检测 ,检测时间分别为诊断新生儿感染后的第 1、5～ 7天各测 1次 ,同时检测 C-反应蛋白及外周血白细胞。并以 34例非感染新生儿作为对照 ,并分析比较结果。　结果　感染组患儿入院即刻血清 CD14与对照组比较明显降低 (P<0 .0 0 1) ,血清 HL A- DR也显著低于对照组(P<0 .0 0 1) ;感染组患儿经治疗后血清 CD14水平逐渐升高 (P<0 .0 5 ) ,血清 HL A- DR水平较治疗前有所升高 (P<0 .0 1) ;而 2例死亡小儿随着病情的加重 CD14阳性细胞及其细胞中的 HL A- DR发生明显变化 ,呈明显降低趋势。　结论　新生儿感染患儿外周血单核细胞 CD14及 HL A- DR表面表达量均降低 ;且 CD14和 HL A- DR的总体表达水平与患儿病死率呈负相关     

Maternal and neonatal outcomes of placenta increta and percreta from a multicenter study in China

Objective: The objective of this study is to identify the maternal and neonatal outcomes in women with placenta increta or placenta percreta in China.

Materials and methods: We retrospectively analyzed 2219 cases from 20 tertiary care centers in China between January 2011 and December 2015. All cases were diagnosed of placenta increta or placenta percreta, based on either intraoperative findings or histopathological findings.

Results: The incidence of placenta increta and placenta percreta progressively increased from 0.18% in 2011 to 0.78% in 2015. Compared with the placenta increta, placenta percreta was strongly related to serious adverse outcomes: postpartum hemorrhage (65.9% versus 38.6%, p?=?.003), blood transfusion (86.2% versus 46.5%, p?p?p?p?Conclusion: The incidence of placenta increta and placenta percreta is likely to increase in China. The depth of placenta implantation is associated with the severity of outcomes. Placenta percreta tends to have worse maternal and neonatal outcomes.     

经阴道三维超声微泡造影与增强磁共振对胎盘前置状态中孕引产患者胎盘植入诊断价值研究

目的 探讨经阴道三维超声微泡造影与增强磁共振检查对胎盘前置状态中孕引产孕妇胎盘植入的诊断价值.方法 选取2018年1月至2019年12月河南省人民医院48例中孕胎盘前置状态且要求引产的孕妇,均行经阴道三维超声微泡造影检查、增强磁共振检查.比较两种检查方法对中孕胎盘前置状态合并胎盘植入诊断的灵敏度、特异度、假阳性率(误诊...     

Prediction of maternal near-miss in placenta previa: a retrospective analysis from a tertiary center in Ankara,Turkey

Aim: To determine risk factors for severe complications during and after cesarean delivery (CD) in placenta previa (PP).

Methods: We reviewed retrospectively collected data from women with PP who underwent CD during a 6-year study period. We identified the complicated group based on the modified WHO near-miss criteria. Complicated and noncomplicated groups were compared considering clinical, laboratory, and sonographic features.

Results: Thirty-seven of 256 cases classified as near miss consisting of 14 peripartum hysterectomies, 12 uterine balloon placements, 10 great artery ligations, and four B-lynch suture placement procedures without maternal mortality. Perioperative complications included surgical wound infections (n?=?5), bladder injury (n?=?4), pelvic abscess (n?=?1), and uterine rupture (n?=?1). Logistic regression analyses demonstrated following features to be associated with maternal near miss in PP: (1) coexistent abruption (aOR 13.2, 95% CI 5.8–75.3), (2) morbidly adherent placenta (aOR 11.92, 95% CI 3.24–43.82), (3) number of hospitalizations for vaginal bleeding (≥3) (aOR 8.88, 95% CI 3.32–26.69), and (4) transvaginal cervical length (CL) measurement?<10th percentile (aOR 5.5, 95% CI 2.1–15.4).

Conclusion: Short cervical length, recurrent vaginal bleeding, morbidly adherent placenta, and concurrent placental abruption are independent predictors for subsequent severe maternal morbidity in PP cases. Early identification of these risk factors during PP follow-up may improve maternal outcome.     

The effect of tocolytic use in the management of symptomatic placenta previa

Objective: The null hypothesis is that tocolysis has no effect on pregnancy prolongation in the aggressive expectant management of symptomatic preterm placenta previa.Study design: One hundred twelve preterm pregnancies with confirmed placenta previa and an initial episode of acute vaginal bleeding were selected for this retrospective analysis. Exclusion criteria included gestational age ≥ 35 weeks, delivery within 24 hours of admission, prior treatment for bleeding or preterm labor, and containdications to tocolytic use. Tocolysis was prescribed, at the discretion of the treating clinical staff, in selected pregnancies with significant uterine contractions after admission of the patient. The majority of treated patients (85%) received intravenous magnesium sulfate and/or oral or subcutaneous β-sympathormimetics within 24 hours of admission. Most patients remained hospitalized until delivery under this aggressive expectant management protocol. Both treated and untreated control study groups were similar at inclusion with regard to parity, gestational age, contraction frequency, and degree of initial bleeding. Outcome variables for each treatment group were obtained from final chart review. Continuous and categoric variables were compared with Student t test or x² analysis—Fisher's exact test, respectively.Results: The clinical use of tocolysis in symptomatic placenta previa was associated with a clinically significant delay of preterm delivery. Significant improvement in clinical parameters such as interval from admission to delivery (39.2 vs 26.9 days, p < 0.02) and birth weight (2520 vs 2124 gm, p < 0.03) was observed in the tocolysis group. There was no observed statistical difference between the two treatment groups with regard to incidence of recurrent bleeding, interval from admission to first recurrent bleeding, and need for transfusion. There was a trend for patients with multiple bleeding episodes to have been receiving tocolytic therapy (p < 0.10). A trend for requiring a postpartum transfusion was also noted in the tocolysis group (p < 0.09). Treated pregnancies receiving long-term maintenance tocolysis with oral or subcutaneous terbutaline exhibited a greater degree of pregnancy prolongation than those treated with short-term intravenous magnesium alone (43.7 vs 15.3 days, p < 0.02).Conclusions: This retrospective analysis suggests that tocolytic intervention in cases of symptomatic preterm previa may be associated with clinically significant prolongation of pregnancy and increased birth weight. Tocolytic therapy in these cases does not appear to have an impact on frequency or severity of recurrent vaginal bleeding. Further prospective analysis may delineate the role of tocolysis in the aggressive expectant management of symptomaticf placenta previa. 1995; 172:1770–1778.)     

A randomized controlled trial on the value of misoprostol for the treatment of retained placenta in a low-resource setting

Objective

To evaluate the efficacy and safety of misoprostol among patients with retained placenta in a low-resource setting.

Methods

A prospective, multicenter, randomized, double-blind, placebo-controlled trial was carried out in Tanzania between April 2008 and November 2011. It included patients who delivered at a gestational age of 28 weeks or more and had blood loss of 750 mL or less at 30 minutes after delivery. Sublingual misoprostol (800 μg) was compared with placebo as the primary treatment. Power analysis showed that 117 patients would be required to observe a reduction of 40% in the incidence of manual removal of the placenta (MRP; P = 0.05, 80% power), the primary outcome. The secondary outcomes were blood loss and number of blood transfusions.

Results

Interim analysis after recruitment of 95 patients showed that incidence of MRP, total blood loss, and incidence of blood transfusions were similar in the misoprostol (MRP, 40%; blood loss, 803 mL; blood transfusion, 15%) and placebo (MRP, 33%, blood loss 787 mL, blood transfusion, 23%) groups. The trial was stopped because continuation would not alter the interim conclusion that misoprostol was ineffective.

Conclusion

Treatment with misoprostol was found to have no clinically significant beneficial effect among women with retained placenta.Clinical Trial Registration: Current Controlled Trials ISRCTN16104753