Presentation is loading. Please wait.

Presentation is loading. Please wait.

New Frontiers in Pathology Case 2: Fetal Demise Associated With Influenza A Infection Richard W. Lieberman, M.D. Departments of Pathology and Obstetrics.

Similar presentations


Presentation on theme: "New Frontiers in Pathology Case 2: Fetal Demise Associated With Influenza A Infection Richard W. Lieberman, M.D. Departments of Pathology and Obstetrics."— Presentation transcript:

1 New Frontiers in Pathology Case 2: Fetal Demise Associated With Influenza A Infection
Richard W. Lieberman, M.D. Departments of Pathology and Obstetrics & Gynecology

2 Case Presentation 30 yo G1 presents with intrauterine fetal demise followed by induction of labor, and delivery of a 19+ weeks technically 2nd trimester abortion Antenatal Course: Quad Screen at 14 weeks MSAFP – 7 MOM* inhibin A – 3.4 MOM estradiol & hCG < 1 MOM Two abnormal markers impart a 9 fold increase risk of fetal loss prior to 24 weeks. Ultrasound Assessment EGA by dates: EGA by U/S: 15+6 EGA by dates: EFW < 3rd %ile oligohydramnios and IUGR *MOM=multiple of the median Lieberman

3 Case Presentation (cont’d)
Additional Prenatal Labs O positive Rubella immune Social History healthcare worker first trimester exposure to numerous patients with upper respiratory “flu” asymptomatic(?) 1st trimester dizziness influenza vaccine not yet available Jan 3, 2008: EGA by dates: EGA by U/S: 15+6 Jan 14, 2008: EGA by dates: EFW < 3rd %ile Lieberman

4 Post-Partum Workup for Fetal Loss
TORCH Serologies negative CMV and Toxoplasmosis Thrombophilia Protein S & C: normal Factor V Leiden: negative Chromosome Analysis: 46 XY Pathology: Fetopsy & Placenta Evaluation Lieberman

5 Placenta Gross Lieberman

6 Histopathology Lieberman

7 Lieberman

8 Lieberman

9 Lieberman

10 Fetopsy – GI Tract Lieberman

11 Lieberman

12 Final Diagnosis Intrauterine fetal demise
second trimester spontaneous abortion Diffuse villous fibrosis, perivillous and intravillous fibrin deposition Focal trophoblastic hyperplasia Chronic villitis and intervillositis (placentitis), histiocytic type Lieberman

13 Can we find a cause for this loss
Can we find a cause for this loss? What’s up with the sheets of histiocytes? what else can be done? Immunohistochemistry very limited selection of antibodies not cost effective to use multiple antibodies unless you have an idea of the causative pathogen what about electron microscopy? not readily available primarily used in renal diagnostics requires special expertise operation AND analysis Lieberman

14 Identified area from slide
Identified area from slide. Paraffin gouge, thick section review, selecting for intervillous histiocytosis Note the hypodensities along the nuclear membrane Lieberman

15 electron hypodense areas Cytoplasm
Nucleus electron hypodense areas Cytoplasm relatively uniform electron densities Lieberman

16 Lieberman

17 Lieberman

18 Influenza A Virion Hx Nx: Influenza A serotyping Lieberman

19 * *http://www.nimr.mrc.ac.uk/elecmicroscopy/examples/staining/
The typical EM takes cultured or ground fresh tissue and ultrcentrifuges. Formalin fixation does have an effect on the appearance, hence they are not easily found. Lieberman *http://www.nimr.mrc.ac.uk/elecmicroscopy/examples/staining/

20 Confirmation of Influenza A
immunofluorescence* antibody to Inf A H1N1 (USSR) Antibody specific to H1N1 viral protein dual staining Keratin mix [FITC green] Viral antibody [Cy5 red] RT-PCR* Total RNA extracted from formalin fixed paraffin embedded tissue RT reaction performed with random decamers primers specific for M1 cDNA & GAPDH GAPDH housekeeping gene positive in all cells Glyceraldehyde-3-phosphate dehydrogenase (GADPH) is an important enzyme in glycolysis ... GADPH is responsible for catalyzing the reversible conversion *performed by Dr. Dafydd Thomas Lieberman

21 Lieberman H1N1: 69% A/Solomon Isles/3/2006 (In 2007 Vaccine)
H1N1: 24% A/Brisbane/59/ (Not In Vaccine) H3N2: 22% A/Wisconsin/67/2005 (In 2007 Vaccine) H3N2: 71% A/Brisbane/10/2007 (In Southern Hemisphere Vaccine Only) Lieberman

22 Influenza A M1 cDNA Protein
Four placental blocks from this case. RNA extracted from all four blocks with positive and negative controls Pos ctrl: respiratory cells commercially available with Inf A & B. Inf A extracted from control Lieberman

23 Fetal Lung Immunofluorescence
antibody to Inf A H1N1 (USSR) Antibody specific to H1N1 viral protein dual staining Keratin mix [FITC green] Viral antibody [Cy5 red] Lieberman

24 Final Diagnosis Intrauterine fetal demise
second trimester spontaneous abortion Diffuse villous fibrosis, perivillous and intravillous fibrin deposition Chronic villitis and intervillositis (placentitis), histiocytic type. Influenza A virus infection (H1N1) with ultrastructural, immunohistochemical, and PCR confirmation transplacental passage of Influenza A (H1N1) to fetus placental: intravillous (hematogenous or direct) intra-amnionic: ingested and inhaled (surface epithelial positive) Lieberman

25 Pathology of Fetal Loss -- Classification
pre-placental (maternal) maternal vascular obstruction/disruption developmental implantation site inflammatory mixed placental (maternal-fetal interface) fetal vascular obstruction/disruption post-placental (fetal) fetal inflammatory response meconium cord related congenital infection hydrops fetalis developmental anatomic chromosomal Lieberman

26 Stillbirth or Abortion?
stillbirth: “delivery of an infant with no sign of life between 20 weeks gestation and term” perinatal loss* before 20 weeks ~15 per 1000 live births between 20 weeks & term ~6 per 1000 live births Our Case: Best EGA = 19+2 weeks initial discrepencies between the pathology requisition and the medical record were resolved after careful chart review. Best EGA was 19+2 weeks gestation Rate is per 1000 live births *Centers for Disease Control and Prevention. National Center for Health Statistics. VitalStats. (2003-4) Lieberman

27 Causes of Perinatal Death
Following fetopsy, placenta path & record review: unresolved: ~50% cord related: 5-28% infectious: 10-25% more likely at early GA vasculopathy: ~15% fetal-maternal hemorrhage: 3-14% genetic: 6-12% Problem: No placental evaluation in 10-44% of all intrapartum deaths Unresolved cases may also include Maternal Conditions like advanced maternal age, or adolescent pregnancy Am J Obset Gynecol p , May 2007 Placenta 29:71-80, 2008 Lieberman

28 Placental Chronic Villitis
Etiologies undetermined – 90% TORCH toxoplasmosis other = parvovirus b19 rubella cytomegalovirus herpesvirus varicella Enterovirus (Coxsackie) EBV … and Influenza(?) VUE – villitis of undetermined etiology Lieberman

29 Placental Viral Infections: Australian Study
Multiplex PCR of 105 Placentas CMV, Parvo, Human Herpes Virus (HHV), mycoplasma & ureaplasma Low Risk Group (asymptomatic) CMV 4%, Parvo 1%, Ureaplasma 1% High Risk Group (preg. loss or seroconversion) CMV 64%, HHV 9% Histological changes only in high risk group J Med Virol 78: p , 2006 Lieberman

30 Ultrastructural Analysis of Chronic Villitis
Rarely Studied Ireland: EM of VUE (n=34) 41 % with viral particles (c/w rotavirus, coronavirus, HPV, enterovirus and adenovirus) so far, abstract only (Placenta 26: A38, 2005) Parvovirus B19 used fresh tissue and immune EM (2 & 6) 38 cases of parvo, 8 cases with ultrastructural evaluation increased size of viral particles with formalin fixation Scattered case reports of rubella, hepatitis, RSV… No mention of Influenza virus Lieberman

31 Influenza Virus Infection in Pregnancy
Seasonal Influenza A or B 11-25% of pregnant women affected “dearth of accurate information regarding the biological consequences of maternal virus infection” Br J Obstet Gynecol 107: p , 2000 Influenza Outbreak Stats ( ) association with increase in maternal mortality ACOG recommends Influenza Vaccine for ALL pregnant women no association with  stillbirth, neonatal death, or malformation observation of possible  rate of miscarriage in first trimester H1N1: 69% A/Solomon Isles/3/2006 (In 2007 Vaccine) H1N1: 24% A/Brisbane/59/ (Not In Vaccine) H3N2: 22% A/Wisconsin/67/2005 (In 2007 Vaccine) H3N2: 71% A/Brisbane/10/2007 (In Souther Hemisphere Vaccine Only) Public Health Reports 78(1): 1-11, 1963 Lieberman

32 Transplacental Passage of Influenza?
Br J Obstet Gyencol 107: p , 2000 2nd and 3rd trimester exposure common significant increase in complications, but no “specific” complication no evidence of transplacental passage Am J Obstet Gynecol 149(8):p856-9, 1984 case report: viral particles identified in amniocentesis fluid with seroconversion of mother & baby Arkh Patol (Russian abstract) 49(9):p19, 1987 Influenza A/B virus antigen in 32 of 186 placentas immunofluorescence and light microscopy noted in trophoblast, decidual cells and villous endothelium Lieberman

33 Case 2 Summary First report: mid-trimester fetal loss (abortion) associated with Influenza A (H1N1) Q: cause-effect? … compelling time-course with 1st trimester exposure Novel use of Electron Microscopy analysis of histiocytic proliferation and identification of budding fully packaged viruses morphology consistent with Influenza virus directed selection of pathogen for confirmatory testing not practical for routing testing Immunofluorescence and PCR confirmation transplacental passage of virus by identifying capsid protein in both the maternal and fetal space The Future? multiplex PCR or DNA microarray “chip” primers for “common” pathogens effecting pregnancy and placental function Lieberman

34 Extra Slides Lieberman

35 Abnormal Quad Screen & Outcome
Two abnormal markers impart a 9 fold increase risk of fetal loss prior to 24 weeks. Lieberman

36 Lieberman

37 Lieberman

38 Lieberman

39 Lieberman


Download ppt "New Frontiers in Pathology Case 2: Fetal Demise Associated With Influenza A Infection Richard W. Lieberman, M.D. Departments of Pathology and Obstetrics."

Similar presentations


Ads by Google