Villous Edema Research Articles

Diagnosis of placental abruption: relationship between clinical and histopathological findings

Objective We evaluated the extent to which histologic lesions bearing a diagnosis of abruption conform to a diagnosis based on established clinical criteria. We further examined the profile of chronic and acute histologic lesions associated with clinical abruption. Methods Data from the New Jersey-Placental Abruption Study – a multi-center, case-control study – were utilized to compare the clinical and histologic criteria for abruption. The study was based on 162 women with clinically diagnosed abruption and 173 controls. We examined the concordance between clinical indicators for abruption with those of a histopathological diagnosis. The clinical criteria for a diagnosis of abruption included (i) evidence of retroplacental clot(s); (ii) abruption diagnosed on prenatal ultrasound; or (iii) vaginal bleeding accompanied by nonreassuring fetal status or uterine hypertonicity. The pathological criteria for abruption diagnosis included hematoma, fibrin deposition, compressed villi, and hemosiderin-laden histiocytes in cases with older hematomas. Acute lesions included chorioamnionitis, funisitis, acute deciduitis, meconium stained membranes, villous stromal hemorrhage, and villous edema. Chronic lesions included chronic deciduitis, decidual necrosis, decidual vasculopathy, placental infarctions, villous mal-development (delayed or accelerated maturation), hemosiderin deposition, intervillous thrombus, and chronic villitis. Results Of clinically diagnosed cases, the sensitivity and specificity for a histologic confirmation of abruption were 30.2% and 100%, respectively. Presence of retroplacental clots remained the single most common finding (77.1%) among clinically diagnosed cases. Among the acute lesions, chorioamnionitis and funisitis were associated with abruption. The only chronic histologic lesion associated with abruption was placental infarctions. Conclusions The concordance between clinical and pathologic criteria for abruption diagnosis is poor. The criteria for diagnosing a clinical abruption should include sonographic visualization of abruption, evidence of retroplacental clots, or vaginal bleeding accompanied by nonreassuring fetal status or uterine hypertonicity.

Effects of Chemotherapy during Pregnancy on the Placenta

Whereas the effects of chemotherapy during pregnancy for mother and fetus are well described, its effects on the placenta remain largely undetermined. We performed a retrospective clinicopathologic analysis of the placenta following chemotherapy. Charts were reviewed for type of malignancy, type and timing of chemotherapy, and fetal and pregnancy outcome. Placentas were studied by standard pathologic analysis as well as computer-assisted morphometry and fluorescence in situ hybridization (FISH) analysis. Patients (n = 13) underwent chemotherapy during pregnancy for carcinoma of breast (3), ovary (2), cervix (2), salivary gland (1), lymphoma/leukemia (4), or rhabdomyosarcoma (1). Eleven patients were treated with DNA-active cytotoxic agents during the 2nd and/or 3rd trimesters; their placentas showed nonspecific findings, including villous hypermaturity, distal villous hypoplasia, villous edema, and excessive extravillous trophoblast, and 4/11 (36%) were small-for-age. In one case (rhabdomyosarcoma), the mother was exposed to cytotoxic agents throughout the entire pregnancy. In this case, associated with severe congenital anomalies, the placenta showed striking nuclear pleomorphism of the extravillous trophoblast of the chorion laeve, associated with FISH-demonstrated hyperpolyploidy. One patient was treated with the targeted tyrosine kinase inhibitor, imatinib, in 2 consecutive pregnancies; these placentas showed no specific anomalies. Our findings suggest that chemotherapy during the 1st trimester induces excessive polyploidization of the chorion laeve trophoblast, likely representing an adaptive response to intraamniotic toxins. Second and 3rd trimester exposure to cytotoxic agents may predispose to placental underdevelopment. However, without appropriate controls (untreated patients with equivalent malignancies), the specific effects of chemotherapy in this group are difficult to assess.

Ultrastructural features of a human placenta with acute chorioamnionitis

Portions of several human placentas were processed for light and transmission electron microscopy at the OSU‐CHS electron microscopy lab. Such placentas were characterized as 120g with acute placental abruption, acute chorioamnionitis, increased fetal nucleated red blood cells, villous edema and focal acute intravillous hemorrhages. In our study of the placenta, we were able to define the various parts of the placenta: decidual basal plate, chorionic plate, and chorion frondosum. The chorionic plate is the extra‐embryonic mesoderm of the chorion, bordering the amnionic cavity and lined by the amnion. The chorionic plate represents the embryonic contribution to the placenta. The chorionic plate is the site of histological abnormalities or pathology in these cases. This area was infiltrated with structures having a dark center and a clear surrounding area as revealed by light microscopy. These structures varied in size from 2–4 μm. Macrophages and neutrophils contained several dense spherical structures ranging in size from 0.2–0.5 μm. Several aggregates of these dense spherical bodies were observed. Some larger granular vesicles measured about l μm in size. Literature studies indicate a strong correlation with stages of the parachlamidiae organism. Further ultrastructural and histochemical analysis of these placental structures is currently in progress. OSU‐CHS Intramural Funding

Development of a capsule endoscopy scoring index for small bowel mucosal inflammatory change

Capsule endoscopy can identify small bowel mucosal inflammatory change. However, there has been no validated index for capsule endoscopy findings. This manuscript documents the development of such an index. To develop a capsule endoscopy scoring index for small bowel mucosal inflammatory change. The index was created in four separate steps. First, parameters and descriptors of inflammatory change were identified. Secondly, blinded readers prospectively graded the presence or absence of each parameter on de-identified videos and graded a perceived global assessment of overall severity. Thirdly, the individual parameters and descriptors were ranked in order of severity. Fourthly, values for each parameter were created using the descent gradient methodology. The premise was to assure that the final numerical score reflected the global assessment and that the global assessment agreed with the ranking of finding severity. Results were compiled for the three categories: no or clinically insignificant change, mild change, and moderate or severe change. Thresholds were determined. The final index includes three parameters: villous oedema, ulcer and stenosis. A score <135 is designated normal or clinically insignificant mucosal inflammatory change, a score between 135 and 790 is mild, and a score > or = 790 is moderate to severe. This capsule endoscopy score provides a common language to quantify small bowel inflammatory changes.

The National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network Beneficial Effects of Antenatal Repeated Steroids study: impact of repeated doses of antenatal corticosteroids on placental growth and histologic findings

In utero exposure to repeated doses of antenatal corticosteroids (ACSs) has been shown to reduce fetal growth. Our goal was to evaluate whether weekly betamethasone (R-ACS) alters placental growth and histologic findings. In a multicenter randomized controlled trial of R-ACS vs a single course of ACS followed by weekly placebo (S-ACS), placentas were weighed after removal of the membranes and umbilical cord. A single pathologist who was masked to study group and pregnancy outcomes performed histologic evaluation for placental calcifications, infarction, fibrin deposition, and hemorrhage or thrombus formation, acute and chronic chorioamnionitis, fibromuscular vascular hyperplasia, nucleated red blood cells, and villous crowding, edema, fibrosis, or fibrinoid necrosis. Findings were compared between study groups and according to the number of courses of ACS. One hundred ninety-four placentas were available for evaluation. Univariable analyses revealed no differences between study groups in any of the 19 evaluated histologic parameters between R-ACS and S-ACS groups overall or in analyses that were restricted to deliveries at < 32 or > or = 32 weeks of gestation. Calcifications were more common (P = .045) in the R-ACS group after controlling for other factors. Multivariable analysis revealed increasing gestational age at delivery, but not increasing ACS courses, to be associated with decreasing chorionic inflammation, villous edema, and fibrosis and with increasing villus crowding, fibrin deposition, and calcifications. Ninety-three placentas were weighed before formalin fixation. After controlling for delivery gestation and infant gender, placental weight was significantly lower in the R-ACS group (P = .017) and was related inversely to the number of ACS courses (P = .037). This finding was confirmed only for deliveries at > or = 32 weeks of gestation (525 vs 441 g for R-ACS and S-ACS group, respectively; P = .036). Repeated antenatal corticosteroid treatments in pregnancy are associated with decreased placental growth in a dose-dependent fashion, but not with evident differences in histologic markers of placental inflammation, ischemia, or infarction. Histologic placental abnormalities should not be attributed to repeated courses of corticosteroids.

Placental Lesions as Predictors of Cerebral Palsy and Abnormal Neurocognitive Function at School Age in Extremely Low Birth Weight Infants (&lt;1 kg)

Extremely low birth weight (ELBW) infants (<1 kg) have high rates of neurodisability. Although previous studies have implicated placental lesions in adverse short-term neurologic outcomes in this population, none have assessed their effects in these children once they reach school age. We conducted a secondary analysis of placental pathology in a cohort study of inborn singleton ELBW infants born between 1992 and 1995 and evaluated for cerebral palsy (CP) and abnormal neurocognitive testing at 8 years of age (N = 129). The neurocognitive tests were the Kaufman Assessment Battery for Children (K-ABC) and 6 subtests of the NEPSY: A Developmental Neuropsychological Assessment. We found that placental lesions associated with maternal vascular underperfusion (increased syncytial knots and acute atherosis) were risk factors for CP, while villous edema was associated with low scores on both neurocognitive tests. Histologic chorioamnionitis (HCA) was not predictive of outcome in the population as a whole, but a severe fetal vascular response was associated with a lower NEPSY score in the subpopulation with HCA (N = 69). Placentas with increased syncytial knots, villous edema, and those with neither finding constituted nonoverlapping subgroups with distinct pathologic and perinatal characteristics. Among infants with villous edema (N = 25), those with neurologic impairment had lower gestational ages and more severe degrees of HCA. However, by logistic regression these other factors were not independent risk factors for abnormal neurocognitive testing, and only HCA with a severe fetal vascular response decreased the association of villous edema with low test scores for NEPSY, but not K-ABC.

Microscopic Chorionic Pseudocysts in Placental Membranes: A Histologic Lesion of in Utero Hypoxia

Grossly apparent and microscopically intermediate trophoblast-lined subchorionic, septal, and cell island cysts are relatively common placental findings. To analyze the clinicopathologic correlations of histologically similar but grossly inapparent microscopic chorionic pseudocysts (lakes) arising in the chorion laeve of placental membranes (mccpm), selected placental and clinical parameters of all 172 consecutive placentas with mccpm (study group, sg) and all consecutive 3743 placentas without mccpm (comparative group, cg) from years 1994 through 2005 were statistically compared; mccpm were observed in 4.3% of all placentas and in 14.9% of placentas from preeclamptic mothers from 24- to 42-week pregnancies, their gestational weeks' distribution almost mirroring that of the distribution of preeclampsia, with a peak in the middle of the 3rd trimester. Microscopic chorionic pseudocysts (lakes) arising in the chorion laeve of placental membranes were statistically significantly more common in patients with preeclampsia and maternal diabetes mellitus. In placentas with mccpm, decidual arteriolopathy, homogeneous placental maturation, global hypoxic pattern of placental injury, chorangiosis, placental infarction, laminar necrosis of membranes, stem obliterative endarteritis, erythroblasts of fetal blood, and decidual hemosiderosis were statistically significantly more common, while acute chorioamnionitis, villous fibrosis, and villous edema were less common (P < or = 0.05). There were no statistically significant differences between sg and cg in meconium staining, retroplacental hematoma, perivillous fibrin deposition, intervillous thrombi, chronic villitis, chorangiomas, placenta accreta, amnion nodosum, and marginate/vallate placenta. Highly statistically significant associations of mccpm with preeclampsia and a cluster of placental lesions known to be linked to placental hypoxia indicate that the mccpm form in response to hypoxia, particularly in patients with preeclampsia; mccpm should therefore be regarded and reported as a hypoxia-associated placental lesion.

Role of capsule endoscopy in inflammatory bowel disease

Capsule endoscopy (CE) is an innovative technological breakthrough that for the first time provides a noninvasive method to obtain high-resolution imaging of the entire small bowel. Since its recent inception, the diagnostic utility of CE has become well established for the evaluation of diverse ulcerative and inflammatory disorders of the jejunum and ileum. The incredible resolution of its lens (0.1 mm) detects focal villous edema or atrophy, denuded, as well as ulcerated mucosal lesions missed by other imaging techniques. CE has been shown by meta-analysis to be a more sensitive method to investigate patients for small bowel Crohn's disease, with an incremental yield above 30% versus other imaging modalities. In patients with indeterminate colitis, CE is useful in distinguishing between ulcerative and Crohn's colitis. Among patients with established Crohn's disease, CE may be employed to determine: (1) the extent and severity of small bowel involvement, (2) postoperative recurrence, (3) post-therapy mucosal healing, and (4) whether active small bowel inflammatory lesions exist in the clinical setting of functional bowel disorder. Complications are rare and include capsule retention at stricture sites. The new patency capsule can diminish the risk of the latter problem in at-risk patients. CE can also serve as a guide to sites that require biopsies or dilatation by push or double-balloon enteroscopy. However, other causes of small bowel lesions may mimic Crohn's disease. A standard terminology system has thus been developed, and a CE Crohn's disease severity scoring index is currently undergoing validation studies.

Impact of repeated doses of antenatal corticosteroids on placental growth and histology

GROWTH AND HISTOLOGY JORAM SAWADY, BRIAN MERCER, for the NICHDMFMU Network, Bethesda, Maryland OBJECTIVE: In-utero exposure to repeated doses of antenatal corticosteroids (R-ACS) has been shown to reduce fetal growth in animals and humans. Our goal was to evaluate whether R-ACS alters placental growth and histologic findings, within the context of a placebo-controlled RCT. STUDY DESIGN: In a multicenter RCT of R-ACS (betamethasone weekly to 34 wks for up to 4 additional courses) vs a single course followed by weekly placebo (S-ACS), placentas were weighed after removal of the membranes and umbilical cord. A pathologist masked to study group and pregnancy outcomes performed histologic evaluation for: placental calcifications, infarction, fibrin deposition, and hemorrhage or thrombus formation, acute and chronic chorioamnionitis, fibromuscular vascular hyperplasia, nucleated RBC’s, and villous crowding, edema, fibrosis, or fibrinoid necrosis. Findings were compared between study groups and according to number of courses of ACS (#ACS). RESULTS: 194 placentas were available for evaluation. We found no differences between study groups in any of 21 evaluated histologic parameters between R-ACS and S-ACS groups overall, or in analyses restricted to those delivering !32 or R32 wks. 94 placentas were weighed before formalin fixation. After controlling for delivery gestation and infant gender, placental weight was significantly reduced in the R-ACS group (p=0.02) and was inversely related to #ACS courses (p=0.045). For those delivering R32 wks, placentas were smaller in the RACS group(525 vs 447 gm, p=0.049). Calcifications were more common (p=0.045) in the R-ACS group after controlling for other factors. Multivariable analysis revealed increasing delivery gestation, but NOT increasing ACS courses, to be associated with decreasing chorionic inflammation, villous edema and fibrosis, and with increasing villus crowding, fibrin deposition and calcifications. CONCLUSION: R-ACS in pregnancy may be associated with decreased placental growth in a dose dependent fashion, but did not lead to evident differences in histologic markers of placental inflammation, infarction, or necrosis.

Development and Validation of a Capsule Endoscopy Scoring Index for Small Bowel Mucosal Disease Activity

Purpose: Capsule endoscopy (CE) has been shown to have the highest yield in diagnosing small bowel (SB) mucosal disease compared to other modalities. However, there is no standardized and validated SB mucosal disease scoring index that can be applied to CE mucosal findings, including inflammation and ulceration. Therefore, the aim of this study was to develop and validate a simple, user-friendly CE scoring index for SB mucosal disease activity. Methods: Using an iterative process over a 2 year period, a CE scoring index was developed and tested by a working group of CE experts. Seven endoscopic variables were initially evaluated: erythema, edema, nodularity, villous appearance, denuded mucosa, ulceration, and stenosis. The number of lesions were categorized as single, few, or multiple. The distribution of lesions were characterized as local, patchy or diffuse. The longitudinal extent of SB disease was described as short, long, or whole segment. Ulcer shape was judged as circular, linear, or irregular. Ulcer size was judged by the amount of wall circumference involved. Stenosis was judged by whether traversed by the capsule and if ulcerated. Scoring was performed per tertile. The index was prospectively tested in a blinded fashion using four readers (IG, RD, ES, JL) initially on 40 full length CE videos and on 10 thumbnailed studies. Results: Based upon interobserver agreement, the final proposed scoring index includes 3 endoscopic variables: villous edema, ulceration, and stenosis. Index parameters are measured by number, longitudinal extent and other descriptors (See Table). Initial prospective evaluation of the index showed excellent interobserver agreement for these variables (78.2%, 79.8% and 88.8%).TableConclusions: The Lewis Score CE scoring index may prove useful in measuring SB mucosal disease activity and allow for the objective scoring of small bowel disease states. Additional prospective validation studies are warranted.

Neonatal morbidity and placental pathology

To investigate the association between gestational age, placental pathology and outcome among preterm births. Medical records and placental pathology results of 165 preterm infants (gestational age pound 34 weeks) were used to analyze the development of intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), patent ductus arteriosus (PDA) and sepsis, in association with placental findings in the gestational age categories of 22-27 (n=71) and 28-33 (n=93) weeks. Significant differences were found in placental findings based on gestational age and neonatal morbidity. Lower gestational age was associated with increased infection-related lesions such as chorionic vasculitis (47.9%, P< 0.001) and acute chorioamnionitis (67.6%, P< 0.001). Placental lesions reflecting disturbances of fetal-placental blood flow (infarction, chorionic plate thrombi and basal perivillous fibrin) were predominantly seen in the 28-33 week gestational age category (P< 0.05-0.01). Despite the high prevalence of chorioamnionitis (38.8%), no significant association was found between this lesion and the tested preterm morbidity after controlling for gestational age. Only, villous edema and chorionic vasculitis were identified as independent predictors for the development of IVH (49.2%, ORA 2.57, 95% CI 1.01, 6.58 and 39.3%, ORA1.95, 95% CI 1.01, 4.21, respectively). Villous edema and chorionic vasculitis are significant risk factors for the development of the IVH among neonates born at gestational age pound 34 weeks.

Association of placental villous edema with neonatal outcome in pregnancies with histologic chorioamnionitis and funisitis

surviving to surgical repair was 1.85 per 10,000 live births. Incidence by region varied significantly (p!0.01). The Central Coast had the lowest rate, at 1.24 per 10,000. The highest incidences were in the Mountain Region and Inland Desert with 2.69 and 2.80 per 10,000. These differences cannot be explained using maternal demographics including age, race, or education. CONCLUSION: Gastroschisis incidence in California is skewed by region of maternal residence during pregnancy. Further research is needed to identify possible maternal characteristics or exposures which explain this discrepancy.

Role of bile in intestinal barrier function and its inhibitory effect on bacterial translocation in obstructive jaundice in rats

Background. Our previous study using genetically labeled Escherichia coli strain JNW14 revealed that obstructive jaundice promotes bacterial translocation in rats and that the absence of bile in the intestinal tract is considered to be a factor inducing bacterial translocation. The aim of this study was to investigate the role of bile and bile acids in intestinal barrier function against bacterial translocation. Materials and methods. Eight-week-old male specific-pathogen-free Wistar rats were subjected to ligation of their common bile ducts (CBDL). The CBDL rats were treated with bacitracin, neomycin sulfate, and streptomycin sulfate, and the intestinal tract was colonized with E. coli strain JNW14, which was genetically labeled with resistant markers against the above three antibiotics, to monitor the bacterial translocation. The rats were then administered saline, cholic acid (20 mg/100 g BW), taurocholic acid (TCA: 5–50 mg/100 BW), or bile (1.5–6 mL/day) via a duodenal catheter. The degree of bacterial translocation of E. coli strain JNW14 to the mesenteric lymph nodes was compared. Histopathological examination of the terminal ileum and intestinal permeability test using phenolsulfonphthalein was also performed. Results. Both cholic acid and TCA showed no inhibitory effect on bacterial translocation at any of the doses tested in CBDL rats, although TCA significantly decreased the numbers of E. coli strain JNW14 in the cecum. However, bile administration reduced the numbers of E. coli strain JNW14 in the cecum and mesenteric lymph nodes in CBDL rats although the inhibitory effect was weak. The integrity and permeability of the intestinal mucosa were kept at normal levels by bile administration in CBDL rats whereas the morphological changes, such as villous atrophy, villous edema, and lacteal canal dilatation, were observed in other CBDL rats. Conclusion. Bile plays an important role in maintaining the intestinal barrier function to prevent the invasion of enteric bacteria to the underlying tissues, suggesting that the intestinal administration of bile to patients with obstructive jaundice is a useful way to reduce infectious complications by inhibiting bacterial translocation from the intestine to other organs.

Histological characteristics of placentas from assisted reproduction programs.

Placentas from assisted reproduction programs are a poorly investigated research material. The aim of this investigation was to perform microscopic examination of placentas from assisted reproduction programs and to compare them with placentas from spontaneous pregnancies. The investigation comprised 12 placentas from assisted reproduction programs and 12 placentas from spontaneous pregnancies. We found a statistically significant increase of villous edema in investigated placentas (p = 0.001). We also found a statistically significantly increased incidence of microcalcifications in placentas from assisted reproduction programs (p = 0.04). There was no statistically significant difference between the two groups in regard to syncytial knots (X2 = 0.67, p > 0.25). Microscopic examination showed that placentas from assisted reproduction programs present with more frequent pathological findings. Further investigations of placentas from assisted reproduction programs could provide better understanding of different pathological conditions of pregnancies and labor in women with artificial insemination.

Very low birthweight Infant's placenta and its relation to pregnancy and fetal characteristics.

Our objective was to relate pathology of the very low birthweight (VLBW) infant's placenta to pregnancy and fetal characteristics. We correlated the pathologic features of 1146 placentas from infants with birth weights of 500-1500 g who were born between 1/1/91 and 12/31/93 to the number of gestations per pregnancy, initiator of preterm delivery, gestational age, birth weight Z score, and duration of rupture of membrane (ROM). Placental correlates of acute inflammation and villous edema were associated with preterm labor (PTL), prelabor premature rupture of membranes (PROM), lower gestational age, and higher birth weight Z score. In PTL pregnancies delivered within 1 h of membrane rupture, 61% of placentas already had membrane inflammation. Placental correlates of pregnancy-induced hypertension (PIH) were seen more commonly with PIH pregnancies, older gestational age, and lower birth weight Z score. We found a more prominent histopathologic signature for singleton than for multiple gestation placentas. The placental pathologic findings associated with the clinical diagnoses of infection, PIH, and low-birth weight Z scores in our VLBW/preterm population are similar to those in the literature regarding term pregnancies. The presence of multiple histologic findings consistent with inflammation in placentas of PTL pregnancies with duration of ROM lasting <1 h suggests that some cases of PTL are precipitated by a more long-standing infection than that previously suspected. Morphologic placental features appear to be correlates of the phenomena leading to premature delivery. Examination of the VLBW infant's placenta provides insight into the etiology and management of VLBW/preterm deliveries.

The relationship between placental and other perinatal risk factors for neurologic impairment in very low birth weight children.

Placental abnormalities reflect antenatal disease processes that may interact with other perinatal risk factors to affect long-term outcome. We performed a nested case control analysis of placental and clinical risk factors associated with neurologic impairment (NI) at 20-mo corrected age (60 cases and 59 controls) using data collected in a prospective study of very low birth weight (less than 1500 g) infants born between 1983 and 1991. In a preliminary analysis we explored the relationship between clinical infection and histologic chorioamnionitis (CA). Only histologic CA with a fetal vascular response correlated with either clinical CA or early onset neonatal sepsis. We then assessed the relative contribution of the nine risk factors (four placental and five clinical) associated with NI at the univariate level by multiple logistic regression. Three risk factors were independent predictors of NI: severe cranial ultrasound abnormalities (odds ratio 13.6, 95% confidence intervals 4.5-66.7), multiple placental lesions (odds ratio 13.2, 95% confidence intervals 1.3-137.0), and oxygen dependence at 36 wk (odds ratio 4.2, 95% confidence intervals 1.2-14.6). Finally, a series of logistic regressions was conducted with the dependent variable changing as we moved back along the causal chain to explore the relationships between risk factors operating at different stages. This analysis suggested that antenatal variables that were not independent predictors of NI by multiple logistic regression exerted their effects through the following intermediate pathways: fetal grade 3 histologic CA via chorionic vessel thrombi, clinical CA via grade 3 villous edema, and grade 3 villous edema via severe cranial ultrasound abnormalities.

All that scallops is not celiac disease

Background: Scalloping of duodenal folds as well as a mosaic mucosal pattern, decreased folds, and increased vascularity are markers of duodenal mucosal injury, the most common cause being celiac disease. We have recognized scalloping in patients with a variety of conditions other than celiac disease. Methods: Clinical, endoscopic and histologic data were reviewed from selected patients with endoscopically visualized scalloped folds along with testing for endomysial antibodies. Biopsy specimens were examined histologically for villous:crypt ratio, intraepithelial lymphocytes, and inflammation. Results: Thirteen patients with scalloped folds underwent endoscopy for the following reasons: family history of celiac disease and osteoporosis, gastrointestinal bleeding, dyspepsia (2), B 12/ folate deficiency (4), and diarrhea (8). Histologic examination was abnormal in all but 1 patient. Villous atrophy or flattening as evidenced by reduced villous:crypt ratio was seen in 11 of 13 patients. Other abnormalities were edematous or broadened villi (10), intraepithelial lymphocytosis (7), and infiltration of lamina propria (6). An infectious organism was identified in 6 patients (46%). Celiac disease was excluded by the lack of specific biopsy findings combined with endomysial antibody testing. Final diagnoses were normal (1), eosinophilic enteritis (1), giardiasis (1), tropical sprue (4), human immunodeficiency virus–related diseases (6) including human immunodeficiency virus enteropathy (1). Conclusion: We conclude that scalloping is not specific for celiac disease but rather a predictor of mucosal disease as evidenced by villous atrophy, widening, and edema. (Gastrointest Endosc 2000;51:717-20.)

Placental Teratoma: A Case Report and Review of the Literature

Teratoma is a complex tumor composed of a collection of heterogeneous cells and/or organoid structures reminiscent of normal derivatives of the germ cell. It occurs in both male and female genital systems and other organs along the midline of the body, with similar morphology and classification. Ovarian teratomas constitute 15%-20% of all ovarian tumors, yet teratomas are very rare in the placenta. Benign mature teratoma has mature tissue deriving from two or more germ cell layers, while immature malignant teratoma has both mature and immature elements, especially immature neuroepithelial elements. Furthermore, the third variant, the monodermal teratoma, is composed of only one specialized tissue, such as thyroid tissue. Benign mature teratoma is the only variant described in the placenta. The main interest in this tumor of the placenta is to differentiate it from fetus acardius amorphus. This paper reports the first case of benign placental teratoma in Saudi Arabia.

A case of partial mole associated with trisomy 13

The majority of second-trimester partial moles are found in association with triploidy. Rarely are they associated with tetraploidy or other aneuploidies and, to our knowledge, this is the first reported case of the prenatal diagnosis of partial mole in a pregnancy presenting with trisomy. The patient was referred at 21 weeks of gestation after a routine ultrasound examination had shown fetal and placental features suggesting a partial mole triploidy. Owing to the severe structural malformations and poor prognosis, the parents requested termination. Prenatal and postnatal cytogenetic investigations demonstrated an additional chromosome 13. Histopathological examination of the placenta showed focal areas of villous edema but no evidence of trophoblastic dysplasia. The maternal serum human chorionic gonadotropin level was within the normal range at all times. This case shows that trisomy can resemble a triploid partial mole in utero without the potential long-term risk to the mother of persisting trophoblastic disease, as villous molar changes can obviously develop without trophoblastic dysplasia.

Autosomal dominantly inherited Diamond-Blackfan anemia resulting in nonimmune hydrops

Autosomal dominant inheritance of Diamond-Blackfan syndrome has been considered an uncommon occurrence. The onset of anemia is characteristically within the first year of life, with 10% of cases presenting at birth. Hydrops fetalis has been reported rarely. Two women with Diamond-Blackfan anemia had uncomplicated pregnancies without important exacerbation of their anemia. Each delivered an edematous infant affected with Diamond-Blackfan anemia, both of whom required immediate transfusions. One infant is currently 7 years old with transfusion-dependent Diamond-Blackfan anemia. The second infant died 2 days after birth; autopsy showed severe erythroid hypoplasia with absence of extramedullary hematopoiesis and placental villous edema. Diamond-Blackfan anemia may result in severe fetal anemia requiring transfusion. Among women with this disorder, a greater percentage than previously suspected are at risk for having an infant with substantial anemia in both the fetal and perinatal periods. Because the penetrance of the disorder is variable, pregnant women with a history of Diamond-Blackfan anemia should be considered at risk.