Chorionic Plate Research Articles

Incidence of furcate umbilical cord

Abstract Background : Placenta along with its umbilical cord is a vital organ for maintaining pregnancy and promoting normal foetal development. Foetal outcome can be adversely influenced by pathological changes in placenta and also by the variation in the site of attachment of umbilical cord. Aims and Objectives : To study the incidence of furcate umbilical cord insertion over placental chorionic plate in normal full term pregnancy. Materials and methods : This study was conducted in the department of Anatomy Government Medical College Haldwani. 100 freshly delivered placentae were collected from Dr. Sushila Tiwari Government hospital Haldwani. The sample was further categorized according to the parity of mother into two groups primipara (n=39) and multipara (n=61). Placentae included in the study were obtained from full term pregnancy without any complication like diabetes, hypertension etc. Results : The incidence of furcate umbilical cord in the present study was 2.6% in primipara group and 3.3% in multipara group. Conclusion : Variation in the site of insertion of umbilical cord are thought to result from process known as "Trophotropism" in which the chorionic frondosum or the early placenta migrates with advancing gestation to ensure better blood supply from more richly vascularised area. The overall incidence of furcate cord in this study is 3%. We have noticed one furcate cord (2.6%) in primipara group (n=39) and two furcate cords (3.3%) in multipara group (n=61). The neonates delivered were perfectly healthy without any evidence of congenital anomalies.

Decellularized human placenta chorion matrix as a favorable source of small-diameter vascular grafts

Biomaterials based on decellularized tissues are increasingly attracting attention as functional alternatives to other natural or synthetic materials. However, a source of non-cadaver human allograft material would be favorable. Here we establish a decellularization method of vascular tissue from cryopreserved human placenta chorionic plate starting with an initial freeze–thaw step followed by a series of chemical treatments applied with a custom-made perfusion system. This novel pulsatile perfusion set-up enabled us to successfully decellularize the vascular tissue with lower concentrations of chemicals and shorter exposure times compared to a non-perfusion process. The decellularization procedure described here lead to the preservation of the native extracellular matrix architecture and the removal of cells. Quantitative analysis revealed no significant changes in collagen content and a retained glycosaminoglycan content of approximately 29%. In strain-to-failure tests, the decellularized grafts showed similar mechanical behavior compared to native controls. In addition, the mechanical values for ultimate tensile strength and stiffness were in an acceptable range for in vivo applications. Furthermore, biocompatibility of the decellularized tissue and its recellularizationability to serve as an adequate substratum for upcoming recellularization strategies using primary human umbilical vein endothelial cells (HUVECs) was demonstrated. HUVECs cultured on the decellularized placenta vessel matrix performed endothelialization and maintained phenotypical characteristics and cell specific expression patterns. Overall, the decellularized human placenta vessels can be a versatile tool for experimental studies on vascularization and as potent graft material for future in vivo applications. Statement of significanceIn the US alone more than 1million vascular grafts are needed in clinical practice every year. Despite severe disadvantages, such as donor site morbidity, autologous grafting from the patient’s own arteries or veins is regarded as the gold standard for vascular tissue repair. Besides, strategies based on synthetic or natural materials have shown limited success. Tissue engineering approaches based on decellularized tissues are regarded as a promising alternative to clinically used treatments to overcome the observed limitations. However, a source for supply of non-cadaver human allograft material would be favorable. Here, we established a decellularization method of vascular tissue from the human placenta chorionic plate, a suitable human tissue source of consistent quality. The decellularized human placenta vessels can be a potent graft material for future in vivo applications and furthermore might be a versatile tool for experimental studies on vascularization.

The inflammatory milieu of amniotic fluid in acute-chorioamnionitis decreases with increasing gestational age

IntroductionThe inflammatory milieu decreases in the placenta and amniotic fluid (AF) with gestational age (GA). However, there is no information about whether the inflammatory milieu of AF in the setting of the same placental inflammatory condition decreases with GA. We hypothesized that the inflammatory milieu of AF in acute chorioamnionitis would decrease with increasing GA. MethodsThe inflammatory milieu of AF was examined in 617 singleton preterm pregnancies (<36 weeks) delivered within 5 days of amniocentesis. Study population was divided into GA at delivery ≤30 weeks (n = 148), 30–34 weeks (n = 226), and 34–36 weeks (n = 226). Acute-chorioamnionitis was classified according to the severity (i.e., mild, total grade 1; moderate, total grade 2; and severe, total grade 3–6) or involved compartment (i.e., chorionic plate, amnion and chorio-decidua). The inflammatory milieu of AF was determined by matrix metalloproteinase-8 (MMP-8) concentration. Results1) AF MMP-8 concentrations decreased in patients with acute-chorioamnionitis (P < 0.001), but not inflammation-free placenta, with increasing GA; 2) AF MMP-8 concentrations were less intense at higher GA in patients with moderate and severe (each-for P < 0.005), but not mild, acute-chorioamnionitis; 3) AF MMP-8 concentrations decreased in the context of the same involved compartment (i.e., chorionic plate inflammation, amnionitis, or chorio-deciduitis) of acute-chorioamnionitis (each-for P < 0.001) with increasing GA; 4) Moreover, there was a significant inverse relationship between GA and AF MMP-8 concentrations in patients with acute-chorioamnionitis (r = −0.453, P < 0.0000001), but not inflammation-free placenta (r = −0.071, P = 0.170). DiscussionAF MMP-8 concentrations in acute-chorioamnionitis distinctly decrease throughout preterm-gestation. This finding suggests that the inflammatory milieu of AF decrease in acute-chorioamnionitis with GA.

Novel "omics" approach for study of low-abundance, low-molecular-weight components of a complex biological tissue: regional differences between chorionic and basal plates of the human placenta.

Tissue proteomics has relied heavily on two-dimensional gel electrophoresis, for protein separation and quantification, then single protein isolation, trypsin digestion, and mass spectrometric protein identification. Such methods are predominantly used for study of high-abundance, full-length proteins. Tissue peptidomics has recently been developed but is still used to study the most highly abundant species, often resulting in observation and identification of dozens of peptides only. Tissue lipidomics is likewise new, and reported studies are limited. We have developed an "omics" approach that enables over 7,000 low-molecular-weight, low-abundance species to be surveyed and have applied this to human placental tissue. Because the placenta is believed to be involved in complications of pregnancy, its proteomic evaluation is of substantial interest. In previous research on the placental proteome, abundant, high-molecular-weight proteins have been studied. Application of large-scale, global proteomics or peptidomics to the placenta have been limited, and would be challenging owing to the anatomic complexity and broad concentration range of proteins in this tissue. In our approach, involving protein depletion, capillary liquid chromatography, and tandem mass spectrometry, we attempted to identify molecular differences between two regions of the same placenta with only slightly different cellular composition. Our analysis revealed 16 species with statistically significant differences between the two regions. Tandem mass spectrometry enabled successful sequencing, or otherwise enabled chemical characterization, of twelve of these. The successful discovery and identification of regional differences between the expression of low-abundance, low-molecular weight biomolecules reveals the potential of our approach.

P03.09: Management dilemma of complete placenta previa with Breus' mole

Prenatal diagnosis of massive subchorionic thromobohematoma (Breus' mole) is inconsistently reported in the literature. Management of poor prognosis type Breus' mole can be of challenge if combined with potentially life threatening obstetric condition such as placenta previa. We report a 28 year old healthy primigravida of African descent was referred at 19 weeks gestation with ultrasound finding of large placenta. Detailed ultrasound examination revealed posterior placenta away from the cervical os with 4 cm thick, laminated sub-chorionic hematoma extending over the whole length of the placenta “Breus' mole”, severe IUGR fetus with absent end diastolic flow in the umbilical artery. Patient had no history of vaginal bleeding, abdominal pain, trauma and no history of blood disorder. Repeated ultrasound examinations showed enlarged subchorionic hematoma and a complete placenta previa. Given the poor pregnancy outcome, at 28 weeks fetocide using intracardiac KCL was done aiming to devascularise the placenta. Two days later the patient presented to ER with massive antepartum hemorrhage. Emergency Caesarean section was performed. Delivery of a dead male fetus weight 400 gm, the placenta weight 365 gm. Placenta appeared thick, cylindrical with complete circumvallation. A subchorionic hematoma was seen extending from chorionic plate down to decidua basalis. We conclude that despite rare occurrence of Breus' mole; it should be considered a risk factor for placenta previa. There are few case reports indicating less maternal blood loss and decreased morbidity after fetocide through decreased uteroplacental blood flow in cases of complete placenta previa; this does not prove to be the rule with Breus' mole placentas. It's unclear why there would be a tendency to massively bleed after fetocide in cases of placenta previa with Breus' mole. Alternative option of uterine artery embolisation might be considered. Further research on this topic is recommended.

Ultrasound Imaging of Early Extraembryonic Structures

ABSTRACT Transvaginal sonography is the most useful diagnostic method to visualize the early pregnancy, to determine whether it is intrauterine or extrauterine (ectopic), viable or not. Detailed examination of extraembryonic structures allows us to differentiate the types of early pregnancy failures and highlights the backgrounds of vaginal bleeding, as the most frequent symptom of the first trimester of gestation. The reliable ultrasonographic sign of an intrauterine pregnancy is visualization of double decidual ring, which represents the trophoblast's layer. The abnormality in the sonographic appearance of a gestational sac, a yolk sac, and a chorionic plate can predict subsequent embryonic damage and death. How to cite this article Nagy S, Papp Z. Ultrasound Imaging of Early Extraembryonic Structures. Donald School J Ultrasound Obstet Gynecol 2017;11(1):11-19.

Histological chorioamnionitis in placenta and preterm birth

Objective To investigate the causes and mechanism of preterm birth through analysis of the relationship between histological chorioamnionitis (HCA) in placental tissue and preterm birth. Methods Totally, 327 preterm birth cases with report of placental pathologic examination were retrospectively collected from those women who delivered from December 1, 2009 to December 1, 2012 in Peking University First Hospital. According to the etiology of preterm birth, three groups were assigned: iatrogenic group (n=106), spontaneous contraction group (n=56) and premature rupture of membranes (PROM) group (n=165). According to the gestational age at delivery, three subgroups were further divided: early-preterm group (≥28-<32 weeks), mid-preterm group(≥32-<34 weeks) and late-preterm group (≥34-<37 weeks). HCA was confirmed when ≥5 neutrophil infiltration identified on the chorionic plate and amniotic membrane under high power light microscope after HE staining. The relationship between HCA and the different types of preterm birth and the different delivery gestational age were analyzed. Besides, the consistency between clinical chorioamnionitis and HCA was also analyzed. Chi-square test was applied for statistics. Results The incidence of HCA in the spontaneous contraction group was significantly higher than in the iatrogenic group and PROM group [66.1% (37/56) vs 25.5% (27/106) and 33.3% (55/165), χ2=25.27 and 18.44, both P 0.05). Among the three subgroups, the early-, mid- and late-preterm subgroup, the incidence of HCA in the iatrogenic group was 24.0% (6/25), 33.3% (8/24) and 22.8% (13/57) (P>0.05), and 13/17, 5/7 and 59.4% (19/32) in the spontaneous contraction group (P>0.05). However, significantly higher incidence of HCA was shown in the early-preterm subgroup than in the mid- and late-preterm subgroup [70.0% (20/29) vs 41.2% (14/34) and 20.6% (21/102), χ2=4.87 and 24.58, both P<0.05] in the PROM group. Among the subjects in PROM group, those with the latency ≥72 h after the rupture of membranes had a higher incidence of HCA than those with the latency less than 72 h [68.6% (24/35) vs 23.8% (31/130), χ2=24.82, P<0.01]. For all 327 cases in this study, the incidence of clinical chorioamnionitis was 15.9% (52/327), among which 31 cases [59.6% (31/52)] were diagnosed as HCA. Conclusions The occurrence of HCA is closely associated with spontaneous contraction preterm. Some iatrogenic preterm birth might cause HCA. The earlier the preterm birth and the longer the latency after PROM, the higher the incidence of HCA. Differential diagnosis is necessary as the inconsistency between clinical chorioamnionitis and HCA. Key words: Chorioamnionitis; Premature birth; Fetal membranes, premature rupture

Hemangioblastic foci in human first trimester placenta: Distribution and gestational profile

IntroductionThe human placenta is a site of both hematopoiesis and vasculogenesis. There are reports of hemangioblastic foci (HAF) in the first trimester placenta, but little published information about their spatiotemporal incidence. MethodsWe have used semi-thin sections and whole mount staining techniques on archival early pregnancy hysterectomy material as well as freshly-collected termination tissue. ResultsWe report a description of the distribution of HAF, their gestational profile, and some characteristics of the constituent cells. We show crypt-shaped HAF are present in villi at different levels from 4 to 11 weeks and in the chorionic plate from 4 to 9 weeks. In the villous placenta, the foci often approach closely at one end to the trophoblast basement membrane. Morphologically they show remarkable similarity to those found in the yolk sac at similar stages. In some crypts, all cells are CD34+, but CD34 and nestin progressively segregate into the endothelial lineage. Brachyury is present in less differentiated cells. The erythroid lineage is dominant, as shown by the widespread expression of CD235a/glycophorin and characteristic erythroid morphologies, indicating various degrees of differentiation. However, CD41 is also present in non-endothelial cells. Initially a discontinuous UEA-1/CD31-positive endothelium forms at the periphery of the foci. These cells appear to become integrated into the developing vasculogenic/angiogenic vessel network. We also demonstrate that, independent of HAF, vasculogenesis occurs near the tips of growing villi during the first trimester. DiscussionWe suggest HAF interface with the developing vascular network, producing communication channels that allow erythrocytes to enter the placental-embryonic circulation. We speculate that the erythroid cells act as oxygen reservoirs during the period before flow of maternal blood through the intervillous space of the placenta, allowing a slow feed of oxygen-rich cells to the developing embryo.

Intraplacental villous artery resistance indices and identification of placenta-mediated diseases

Placenta-mediated diseases (PMDs) including preeclampsia and fetal growth restriction are often characterized by shallow trophoblast invasion and incomplete spiral artery remodeling leading to impaired placental perfusion. In this context, umbilical artery (UA) Doppler can be used to detect high resistance to flow characteristic of very late-stage placental disease. We propose that evaluation of intraplacental villous artery (IPVA) resistance can provide earlier detection of increased resistance in placental flow. Seventy-five patients were recruited from the Ottawa Hospital. All had scans at 18 to 20, 28 and 34 weeks of gestation. IPVAs arising perpendicular to the chorionic plate in three regions (placental tips 4 cm away from cord insertion and within 1 cm from cord insertion) were sampled at each gestational age for resistance index (RI) and pulsatility index (PI). UA Doppler was also obtained from a free loop of cord. Pregnancy outcomes were collected from a chart review. Data were analyzed using SAS version 9.4 and standard statistic tests (mean±s.d., Student's t-test, mixed-effects modeling). A total of 53 patients completed the study. Of these, 38 had normal pregnancy outcomes (controls) and 15 (cases) developed PMD (preeclampsia, n=8 and low birth weight/intrauterine growth restriction, n=7). Mean birth weight in the study group was 2482.1±518.85 g. At 18 to 20, 28 and 34 weeks gestation, the mean IPVA resistance indices in the control group were 0.86±0.16, 0.81±0.12 and 0.71±0.12 for PI and 0.57±0.07, 0.55±0.06 and 0.49±0.06 for RI, respectively. However, in the cases developing PMDs, the PIs were 1.09±0.17, 0.95±0.21 and 0.78±0.07 and RIs 0.66±0.07, 0.60±0.07 and 0.54±0.04, respectively (P<0.05). UA PI and RI Doppler did not differ between the groups as early as 18 to 20 weeks gestation. Doppler measures of IPVA appear superior to UA in detecting early changes related to PMD. IPVA PI and RI Doppler may be useful in the early identification of patients at risk of PMD.

Placental Features of Late-Onset Adverse Pregnancy Outcome.

ObjectiveCurrently, no investigations reliably identify placental dysfunction in late pregnancy. To facilitate the development of such investigations we aimed to identify placental features that differ between normal and adverse outcome in late pregnancy in a group of pregnancies with reduced fetal movement.MethodsFollowing third trimester presentation with reduced fetal movement (N = 100), placental structure ex vivo was measured. Placental function was then assessed in terms of (i) chorionic plate artery agonist responses and length-tension characteristics using wire myography and (ii) production and release of placentally derived hormones (by quantitative polymerase chain reaction and enzyme linked immunosorbant assay of villous tissue and explant conditioned culture medium).ResultsPlacentas from pregnancies ending in adverse outcome (N = 23) were ~25% smaller in weight, volume, length, width and disc area (all p<0.0001) compared with those from normal outcome pregnancies. Villous and trophoblast areas were unchanged, but villous vascularity was reduced (median (interquartile range): adverse outcome 10 (10–12) vessels/mm2 vs. normal outcome 13 (12–15), p = 0.002). Adverse outcome pregnancy placental arteries were relatively insensitive to nitric oxide donated by sodium nitroprusside compared to normal outcome pregnancy placental arteries (50% Effective Concentration 30 (19–50) nM vs. 12 (6–24), p = 0.02). Adverse outcome pregnancy placental tissue contained less human chorionic gonadotrophin (20 (11–50) vs. 55 (24–102) mIU/mg, p = 0.007) and human placental lactogen (11 (6–14) vs. 27 (9–50) mg/mg, p = 0.006) and released more soluble fms-like tyrosine kinase-1 (21 (13–29) vs. 5 (2–15) ng/mg, p = 0.01) compared with normal outcome pregnancy placental tissue.ConclusionThese data provide a description of the placental phenotype of adverse outcome in late pregnancy. Antenatal tests that accurately reflect elements of this phenotype may improve its prediction.

Structural Organization of Arterial Vessels in Placental Hypoplasia.

Structure of the placental arterial bed was studied using histological and morphometric methods. The formation of smooth muscle regulatory complexes in blood vessels of the chorionic plate and chorionic villi was demonstrated. These complexes are genetically determined and represent a variant of compensatory and adaptive reorganization of the placental arteries for adequate fetoplacental blood supply under normal conditions and placental underdevelopment.

Systematic review of accuracy of ultrasound in the diagnosis of vasa previa.

Vasa previa is an obstetric complication in which the fetal blood vessels lie outside the chorionic plate in close proximity to the internal cervical os. In women with vasa previa, the risk of rupture of these vessels is increased, thus potentially causing fetal death or serious morbidity. Our objective was to assess the accuracy of ultrasound in the prenatal diagnosis of vasa previa. We searched MEDLINE, EMBASE, the Cochrane Library and PubMed for studies on vasa previa. Two reviewers independently selected studies on the accuracy of ultrasound in the diagnosis of vasa previa. The studies were scored on methodological quality using the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2). Data on sensitivity and specificity were subsequently extracted. The literature search revealed 583 articles, of which two prospective and six retrospective cohort studies were eligible for inclusion in the qualitative analysis. All studies documented methods suitable for the prenatal diagnosis of vasa previa. Four out of the eight studies used transvaginal ultrasound (TVS) for primary evaluation, while the remaining four studies used transabdominal ultrasound and performed a subsequent TVS when vasa previa was suspected. The QUADAS-2 tool reflected poor methodology in six of the eight included studies, and prenatal detection rates varied from 53% (10/19) to 100% (total of 442,633 patients, including 138 cases of vasa previa). In the two prospective studies (n = 33,795, including 11 cases of vasa previa), transvaginal color Doppler performed during the second trimester detected all cases of vasa previa (sensitivity, 100%) with a specificity of 99.0-99.8%. The accuracy of ultrasound in the diagnosis of vasa previa is high when performed transvaginally in combination with color Doppler.

Defective pericyte recruitment of villous stromal vessels as the possible etiologic cause of hydropic change in complete hydatidiform mole.

The pathogenetic mechanism underlying the hydropic change in complete hydatidiform moles (CHMs) is poorly understood. A growing body of data suggests that pericytes play a role in vascular maturation. Since maturation of villous stromal vessels in CHMs is markedly impaired at early stages, we postulated that a defect in pericytes around stromal vessels in chorionic villi might cause vascular immaturity and subsequent hydropic change. To investigate this, we examined several markers of pericytes, namely, α-smooth muscle actin (α-SMA), platelet-derived growth factor receptor-β (PDGFR-β), and desmin, in 61 normally developing placentas and 41 CHMs with gestational ages of 4–12 weeks. The ultrastructure of villous stromal vessels was also examined. Mature blood vessels from normal placentas show patent vascular lumens and formed hematopoietic components in the villous stroma. α-SMA and PDGFR-β expression in the villous stroma gradually increased and extended from the chorionic plate to peripheral villous branches. The labeled cells formed a reticular network in the villous stroma and, after week 7, encircled villous stromal vessels. In comparison, α-SMA and PDGFR-β expression in the villous stroma and stromal vessels of CHMs was significantly lower (p<0.05). Ultrastructurally, endothelial cells in villous stromal vessels in normal placentas were consistently attached by pericytes after week 7 when the vessels formed distinct lumen, whereas the villous stromal vessels in CHMs consisted of linear chains of endothelial cells, often disclosing primitive clefts without hematopoietic cells inside, and neither pericytes nor basal lamina surrounded the endothelial cells at any gestational age studied. This suggests that pericytes recruitment around villous stromal vessels is defective in CHMs and links to the persistent vascular immaturity of the villous stroma in CHMs, which in turns leads to hydropic villi.

Male germ-like cell differentiation potential of human umbilical cord Wharton's jelly-derived mesenchymal stem cells in co-culture with human placenta cells in presence of BMP4 and retinoic acid.

Mesenchymal stem cells (MSCs) derived from Wharton's jelly (WJ-MSCs) are now much more appealing for cell-based infertility therapy. Hence, WJ-MSCs differentiation toward germ layer cells for cell therapy purposes is currently under intensive study. MSCs were isolated from human Wharton's jelly and treated with BMP4, retinoic acid (RA) or co-cultured on human amniotic epithelial (HAE) and chorionic plate (HCP) placenta feeder cells. profile of POU5F1, Fragilis, Plzf, DDX4, Piwil2, Stra8, Dazl, β1- and α6-integrins (ITΒ1, ITA6) genes expression as germ cell markers were analyzed using RT-PCR and real-time PCR. Immunocytochemistry of surface markers were conducted. After 3 weeks treatment with different reagents and co-culture system, morphology of WJ-MSCs changed to shiny clusters and germ cell specific markers in mRNA were up-regulated in both placental feeder + RA and BMP4 + RA. Induction of hWJ-MSCs with BMP4 in presence of RA resulted in significant up-regulation (P≤0.05) of all germ cell specific genes (c-Kit; 2.84±0.59, DDX4; 1.69±0.39, Piwil2; 1.14±0.21, Dazl; 0.65±0.25, α6 integrin; 1.26±0.53, β1 integrins; 1.18±0.65) compared to control and placental feeder cells + RA. Our results indicated that HAE and HCP followed by RA treatment were involved in human germ cell development. We demonstrated that under the right conditions, hWJ-MSCs have the ability to differentiate to germ cells and this provides an excellent pattern to study infertility cause and treatment.

Activation of KV7 channels stimulates vasodilatation of human placental chorionic plate arteries

IntroductionPotassium (K+) channels are key regulators of vascular smooth muscle cell (VSMC) excitability. In systemic small arteries, Kv7 channel expression/activity has been noted and a role in vascular tone regulation demonstrated. We aimed to demonstrate functional Kv7 channels in human fetoplacental small arteries. MethodsHuman placental chorionic plate arteries (CPAs) were obtained at term. CPA responses to Kv7 channel modulators was determined by wire myography. Presence of Kv7 channel mRNA (encoded by KCNQ1-5) and protein expression were assessed by RT-PCR and immunohistochemistry/immunofluorescence, respectively. ResultsKv7 channel blockade with linopirdine increased CPA basal tone and AVP-induced contraction. Pre-contracted CPAs (AVP; 80 mM K+ depolarization solution) exhibited significant relaxation to flupirtine, retigabine, the acrylamide (S)-1, and (S) BMS-204352, differential activators of Kv7.1 – Kv7.5 channels. All CPAs assessed expressed KCNQ1 and KCNQ3-5 mRNA; KCNQ2 was expressed only in a subset of CPAs. Kv7 protein expression was confirmed in intact CPAs and isolated VSMCs. DiscussionKv7 channels are present and active in fetoplacental vessels, contributing to vascular tone regulation in normal pregnancy. Targeting these channels may represent a therapeutic intervention in pregnancies complicated by increased vascular resistance.

Placental pathology in asphyxiated newborns treated with therapeutic hypothermia.

To describe the placental findings in asphyxiated newborns treated with hypothermia and to determine their association with the presence and severity of later brain injury. Prospective cohort study of the placentas of asphyxiated newborns treated with hypothermia, in whom later brain injury was defined by brain imaging and/or autopsy results. Of the 142 asphyxiated newborns meeting the criteria for hypothermia, 73% had placenta and brain MRI/autopsy available for analysis. Fifty-one percent of these newborns developed brain injury. Sixty-five percent had microscopic placental findings involving the fetal vascular supply, which were comparable in asphyxiated newborns developing or not developing brain injury. Among the asphyxiated newborns with normal placental growth, the placental microscopic findings tended to be more common in those developing brain injury compared to those who did not: chorionic plate meconium in 50% compared to 36%, chorioamnionitis in 75% compared to 44%, and villitis of unknown etiology in 67% compared to 33%, but this did not reach statistical significance. Antenatal placental processes are common in term asphyxiated newborns treated with hypothermia. The placenta of each asphyxiated term newborn treated with hypothermia should be carefully examined to better understand its role in the progression from perinatal depression to brain injury.

Síndrome de transfusión feto-fetal en un embarazo de trillizos bicorial-tri-amniótico igual sexo manejado con fotocoagulación láser guiada por fetoscopio. Reporte de caso y revisión de la literatura

El síndrome de transfusión feto-fetal complica hasta un 15 % de las gestaciones monocoriales en la mitad del segundo trimestre de embarazo y su resultado es una elevada mortalidad y morbilidad perinatal si no se trata a tiempo. Aunque algunos factores humorales tienen un papel en la fisiopatología de la enfermedad, una distribución desigual de la placenta y la presencia de uniones vasculares placentarias en la placa coriónica, permitiendo cambios de volumen de sangre entre los fetos, son el requisito previo anatómico para esta complicación única para gemelos monocoriónicos. Dentro de las gestaciones monocoriales, es posible identificar un subgrupo de parejas de gemelos en alto riesgo de desarrollar el síndrome de transfusión feto-fetal o restricción de crecimiento intrauterino selectivo durante el curso del embarazo tan pronto como en el primero y segundo trimestre temprano. Si hay una progresiva discrepancia de líquido amniótico avanza el síndrome de transfusión feto-fetal a moderada, y finalmente llega a la etapa severa, la clasificación exacta del cuadro clínico y diagnóstico de la situación hemodinámica fetal, son cruciales para asesorar a los padres sobre las opciones de tratamiento y posibles resultados. Se presenta el caso de una mujer de 27 años de edad primigestante con un embarazo múltiple de trillizos bi-corial-triamniótico y síndrome de transfusión intergemelar estadio III, según Quintero (1), en los fetos 2 y 3, diagnosticado en la semana 22,4 de gestación. El manejo se llevó a cabo con fotocoagulación láser selectiva y secuencial de los vasos comunicantes. Desembarazada en la semana 28 de gestación.

Effects of Power and Time on Ablation Size Produced by Radiofrequency Ablation: In vitro Study in Fresh Human Placenta

Introduction: Radiofrequency (RF) current has been clinically used to coagulate some solid tumors. We investigated the effects of RF on fresh placenta to determine the possibility of its prenatal application in placental tumors. Materials and Methods: Total 196 fresh placentae were interstitially coagulated with a 2-cm RF needle at 14 power-duration combinations. We compared the horizontal length of coagulated area using ultrasound and microscopic measurements. Histological changes were also described. Results: We did not observe any significant change in lesion size from different power levels (p = 0.104 and 0.242 for ultrasound and microscopic measurements, respectively). Mean ± SD lesion length after 5 and 10 min of exposure measured by microscopy are 16.00 ± 2.22 and 17.00 ± 1.82 mm, respectively (p < 0.001). Ultrasound consistently over-measured lesion size by 2.87 ± 3.45 mm. We also observed a collapse of large vessels on chorionic plate adjacent to the RF site. Conclusion: Our in vitro experiment demonstrated placental tissue coagulation and collapse of chorionic vessels from RF. Projecting the area of placental coagulation should be based on duration of RF exposure, and not on the power level. An in vivo animal study is needed before these data are translated into clinical practice.

Therapeutic modalities of twin to twin transfusion syndrome

Twin to twin transfusion syndrome (TTTTS) accounts for approximately 10% of monochorionic twin pregnancies and, if left untreated, is associated with high morbidity and mortality rate. A net transfusion of blood flow from one fetus (donor twin) to the other (recipient twin) via placental vascular anastomoses has been supposed as the major etiology of TTTTS. The donor twin becomes hypovolemic and oliguria, oligohydramnios, and a variable degree of growth restriction develop, whereas the recipient twin manifests polyuria, polyhydramnios, and hydrops in response to hypervolemia. TTTTS can be treated by either serial amniocentesis or selective fetoscopic laser coagulation of the communicating vessels. The rationale for removal of large volumes of amniotic fluid is to prevent preterm delivery secondary to polyhydramnios and to improve fetal circulation by reducing pressure on the chorionic plate. On the other hand, the goal of laser therapy is to occlude vascular anastomoses, thereby interrupting intertwin blood exchange. Although laser treatment is associated with increased survival rate and reduced neurologic complications, compared with amnioreduction, it requires highly specialized centers, whereas serial amniocentesis has the advantage of being performed worldwide. Therefore, the optimal treatment for pregnancies complicated with TTTTS is still controversial.

Description ofLoricyphes froehlichi, a new genus and species of Leptohyphidae (Ephemeroptera) from São Paulo, Brazil

Loricyphes froehlichi gen. et sp. nov. is described and illustrated from nymphs, subimago and eggs. Diagnostic characters include, in the nymph: head, thorax and abdomen with very large and pointed tubercles; maxillary palp absent; femora very long and slender, ratio length/maximum width=5; forefemur without transverse row of setae at dorsum and with few chalazae; tarsal claws with 12–17 marginal denticles, submarginal denticles absent; abdominal segments II–VII very wide and laterally expanded forming a shallow cavity for the dorsal-positioned gills; and in the egg: conic in shape, with one pole truncated and the other acute, polar capsule apparently absent, chorionic plates longitudinally arranged between longitudinal elevated ridges, adhesive filaments absent. The new genus is superficially similar to Coryphorus (Coryphoridae) but presents synapomorphies of Leptohyphidae, and it is probably related to Tricorythodes based on gill morphology.