Histopathological Analysis of Patients with Abruptio

HISTOPATHOLOGICAL ANALYSIS OF PATIENTS WITH ABRUPTIO PLACENTA IN A TERTIARY HEALTH CARE CENTRE Dissertation submitted in Partial fulfillment of the regulations required for the award of M.D. Degree in PATHOLOGY - BRANCH III THE TAMILNADU DR.M.G.R.MEDICAL UNIVERSITY CHENNAI MAY 2019 DECLARATION I hereby declare that the dissertation entitled “HISTOPATHOLOGICAL ANALYSIS OF PATIENTS WITH ABRUPTIO PLACENTA IN A TERTIARY HEALTH CARE CENTRE” is a bonafide research work done by me in the Department of Pathology, Coimbatore Medical College during the period from JANUARY 2017 TO JUNE 2018 under the guidance and supervision of Dr.G.S.THIRIVENI BALAJJI, M.D, Associate Professor, Department of Pathology, Coimbatore Medical College. This dissertation is submitted to The Tamilnadu Dr.MGR Medical University, Chennai towards the partial fulfillment of the requirement for the award of M.D., Degree (Branch III) in Pathology. I have not submitted this dissertation on any previous occasion to any University for the award of any Degree. Place : Coimbatore Date : Dr. A. PETER SAMIDOSS CERTIFICATE This is to certify that dissertation entitled “HISTOPATHOLOGICAL ANALYSIS OF PATIENTS WITH ABRUPTIO PLACENTA IN A TERTIARY HEALTH CARE CENTRE” is a bonafide work done by Dr. A. PETER SAMIDOSS, a postgraduate student in the Department of Pathology, Coimbatore Medical College, Coimbatore under guidance and supervision of Dr.G.S.THIRIVENI BALAJJI, M.D, Associate Professor, Department of Pathology, Coimbatore Medical College, Coimbatore in partial fulfillment of the regulations of the Tamil Nadu Dr. M. G. R. Medical University, Chennai towards the award of M.D. Degree (Branch III) in Pathology. <ul style="display: flex;"><li style="flex:1">Guide </li><li style="flex:1">Head of the Department </li></ul>Dr.G.S.THIRIVENI BALAJJI, M.D, Associate Professor, Prof. Dr. C. LALITHA, M.D., Professor and Head, Department of Pathology, Coimbatore Medical College, Coimbatore -14. Department of Pathology, Coimbatore Medical College, Coimbatore -14. Prof. Dr. B.ASOKAN, M.S, M.Ch., Dean, Coimbatore Medical College, Coimbatore -14. ACKNOWLEDGEMENT To begin with, I thank the almighty God for bestowing his blessing on me in this dissertation to be a successful one. I wish to thank our beloved Dean Prof. Dr.B.ASOKAN,M.S.,M.Ch, Coimbatore Medical College and Hospital, Coimbatore for permitting me to conduct this study. I thank Prof. Dr. C.LALITHA, M.D., Professor and Head of the Department, Department of Pathology, Coimbatore Medical College, Coimbatore for her guidance and support. I wish to express my gratitude and sincere thanks to my guide Dr.G.S.THIRIVENI BALAJJI, M.D, Associate Professor, Department of Pathology, Coimbatore Medical College, Coimbatore. This dissertation bears her valuable suggestions and highly professional advice. My heartful thanks to Dr.S.YOGALAKSHMI, M.D, Assistant Professor, Department of Pathology, Coimbatore Medical College, Coimbatore for her timely advice and suggestion through the course of my work. I thank all my Associate Professors and Assistant Professors of Department of Pathology, Coimbatore Medical College, Coimbatore for their opinion and encouragement. I thank Department of Obstetrics &Gynecology, Coimbatore Medical College, Coimbatore, for providing clinical cases, valuable support and guidance which made this dissertation possible. I thank all my patients for their co-operation and support. My deepest and most heart whelming thanks goes to my parents, my father Mr.P.S.AYYAPILLAI and my mother Mrs.A.PADMAVATHY who have showered me with lots and lots of love. My special thanks to my wife Mrs. ANGELIN TISHA B.Tech, whose love, support and constant patience have taught me so much about sacrifice, discipline and compromise. At this juncture, I have a special mention about my elder brother Dr.A.ARUL KAMALRAJ, Ph.D., and my younger brother Mr.A.ANANDHA SELVA REUBEN, MBA., without them, I couldn’t have travelled this far. My heartful thanks to Lab Technicians, Mr. M. SUBRAMANIAN, Mrs. S.J. MUTHUSELVI, Mrs. K. ARULMANI, Mrs. S. SHARMILA DEVI, Mrs.SUNDARAMBAL and typist Mrs.SASIKALA for their help in technical aspects. I thank my junior Dr. D.JENIFER for her help in grossing the specimens. I thank all my non-teaching staffs working in Department of Pathology, Coimbatore Medical College, Coimbatore. I would like to dedicate this book to my family’s little princess A.BRINDHA. I also thank my batch mates and my juniors for their love and support Dr. A. PETER SAMIDOSS CERTIFICATE – II certify that this dissertation “HISTOPATHOLOGICAL ANALYSIS OF PATIENTS <ul style="display: flex;"><li style="flex:1">This </li><li style="flex:1">is </li><li style="flex:1">to </li><li style="flex:1">work </li><li style="flex:1">titled </li></ul>WITH ABRUPTIO PLACENTA IN A TERTIARY HEALTH CARE CENTRE” of the candidate Dr. A. PETER SAMIDOSS with registration number 201613255 for the award of M.D Degree in the branch of PATHOLOGY. I personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file contains from introduction to conclusion pages and result shows 7% percentage of plagiarism in the dissertation. Guide and Supervisor CONTENTS S.NO 1. <ul style="display: flex;"><li style="flex:1">PARTICULARS </li><li style="flex:1">PAGE NO. </li></ul><ul style="display: flex;"><li style="flex:1">1-4 </li><li style="flex:1">INTRODUCTION </li></ul><ul style="display: flex;"><li style="flex:1">2. </li><li style="flex:1">AIM OF THE STUDY </li></ul>OBJECTIVES OF THE STUDY REVIEW OF LITERATURE MATERIALS AND METHODS OBSERVATION AND RESULTS DISCUSSION 5<ul style="display: flex;"><li style="flex:1">3. </li><li style="flex:1">6</li></ul><ul style="display: flex;"><li style="flex:1">4. </li><li style="flex:1">7-37 </li></ul><ul style="display: flex;"><li style="flex:1">5. </li><li style="flex:1">38-45 </li></ul>46-68 69-84 85-92 93-98 99-108 6. 7. <ul style="display: flex;"><li style="flex:1">8. </li><li style="flex:1">SUMMARY </li></ul><ul style="display: flex;"><li style="flex:1">9. </li><li style="flex:1">CONCLUSION </li></ul>10. 11. BIBLIOGRAPHY ANNEXURES I: Proforma and Consent Form II: Master Chart 109-110 111-112 LIST OF TABLES S. NO. PAGE NO. TITLE <ul style="display: flex;"><li style="flex:1">1. </li><li style="flex:1">Age Distribution among cases and controls </li><li style="flex:1">46 </li></ul>2. 3. 4. 5. 6. <ul style="display: flex;"><li style="flex:1">Mean age of the study </li><li style="flex:1">47 </li></ul>48 49 50 51 Correlation of clinical features among cases and control Histopathological features of Acute abruption in the study Histopathological features of chronic abruption in the study Expression of Histopathological features of acute abruption in acute abruption cases and in acute abruption with chronic features cases 7. 8. <ul style="display: flex;"><li style="flex:1">Statistics - Histopathological features of acute abruption </li><li style="flex:1">52 </li></ul><ul style="display: flex;"><li style="flex:1">53 </li><li style="flex:1">Expression of Histopathological features of chronic </li></ul>abruption in acute abruption cases and in cases of Acute abruption with chronic features <ul style="display: flex;"><li style="flex:1">9. </li><li style="flex:1">Statistics - Histopathological features of chronic abruption </li><li style="flex:1">55 </li></ul><ul style="display: flex;"><li style="flex:1">58 </li><li style="flex:1">10. </li><li style="flex:1">Association of paternal smoking with cases of acute </li></ul>abruption and acute abruption with chronic features 11. 12. 13. Gender distribution of children in Placental Abruption Status of children in Placental Abruption 59 60 <ul style="display: flex;"><li style="flex:1">61 </li><li style="flex:1">Correlation between chorioamnionitis and preterm </li></ul>deliveries among Placental Abruption 14. 15. 16. <ul style="display: flex;"><li style="flex:1">Pregnancy Induced Hypertension </li><li style="flex:1">62 </li></ul>63 64 Analysis of gravida between cases and control Histopathological features of acute abruption in Primi gravida and Multi gravida <ul style="display: flex;"><li style="flex:1">17. </li><li style="flex:1">Histopathological features of chronic abruption in Primi </li></ul>gravida and Multi gravida 67 LIST OF CHARTS TITLE <ul style="display: flex;"><li style="flex:1">S. </li><li style="flex:1">PAGE </li></ul><ul style="display: flex;"><li style="flex:1">NO. </li><li style="flex:1">NO </li></ul>1. 2. 3. 4. 5. 6. Age Distribution among Cases and Controls Mean age of the study 46 47 48 49 50 51 Correlation of Clinical features among cases and control Histopathological features of Acute abruption in the study Histopathological features of chronic abruption in the study Expression of Histopathological features of acute abruption in acute abruption cases and in Acute abruption with chronic features cases 7. 8. <ul style="display: flex;"><li style="flex:1">Statistics - Histopathological features of acute abruption </li><li style="flex:1">52 </li></ul><ul style="display: flex;"><li style="flex:1">54 </li><li style="flex:1">Expression of Histopathological features of chronic </li></ul>abruption in acute abruption cases and in cases of Acute abruption with chronic features <ul style="display: flex;"><li style="flex:1">9. </li><li style="flex:1">Statistics - Histopathological features of chronic abruption </li><li style="flex:1">56 </li></ul><ul style="display: flex;"><li style="flex:1">58 </li><li style="flex:1">10. </li><li style="flex:1">Association of Paternal Smoking with cases of acute </li></ul>abruption and acute abruption with chronic features 11. 12. 13. Gender distribution of children in Placental Abruption Status of children in Placental Abruption 59 60 <ul style="display: flex;"><li style="flex:1">61 </li><li style="flex:1">Correlation between chorioamnionitis and preterm </li></ul>deliveries among placental abruption 14. 15. 16. <ul style="display: flex;"><li style="flex:1">Pregnancy Induced Hypertension </li><li style="flex:1">62 </li></ul>63 65 Analysis of gravida between cases and control Histopathological features of acute abruption in Primi gravida and Multi gravida <ul style="display: flex;"><li style="flex:1">17. </li><li style="flex:1">Histopathological Features of Chronic Abruption In Primi </li></ul>gravida and Multi gravida 67 LIST OF COLOUR PLATES <ul style="display: flex;"><li style="flex:1">S.NO </li><li style="flex:1">TITLE </li></ul>1Gross; Placental Abruption Dilated tortuous vessels over the membranes 23Gross; Placental Abruption Maternal surface- indentation and hemorrhagic areas Gross- Placental Abruption Placental infarction with congestion 4Gross – Placental Abruption Retroplacental blood clot with vessel thrombus 5Gross- Placental Abruption Retroplacental hemorrhage 6Microscopy - Placental Abruption - funisitis 7Microscopy - Placental Abruption Squamous mataplasia with moderate chorioamnionitis 8Microscopy - Placental Abruption Squamous mataplasia with moderate chorioamnionitis 9Microscopy - Placental Abruption Mild chorioamnionitis 10 11 12 13 Microscopy - Placental Abruption Moderate chorioamnionitis Microscopy - Placental Abruption Severe chorioamnionitis Microscopy - Placental Abruption moderate chorioamnionitis with haemorrhage Microscopy - Placental Abruption Acute deciduitis with fibrinoid necrosis 14 15 16 Microscopy - Placental Abruption Intervillous haemorrhage Microscopy - Placental Abruption Intervillous and intravillous haemorrhage Microscopy - Placental Abruption Intervillous haemorrhage and adjacent area of acute deciduitis with haemorrhage 17 18 19 20 21 22 23 24 25 26 Microscopy - Placental Abruption Intervillous haemorrhage and acute deciduitis Microscopy - Placental Abruption Intervillous haemorrhage Microscopy - Placental Abruption Villous haemorrhage with large area of haemorrhage Microscopy - Placental Abruption Moderate chorioamnionitis with adjacent area of hemorrhage Microscopy - Placental Abruption Increased syncytiotrophoblastic knotting Microscopy - Placental Abruption Increased syncytiotrophoblastic knotting Microscopy - Placental Abruption Increased syncytiotrophoblastic knotting with multinucleated giant cell Microscopy - Placental Abruption Vasculopathy(vessels with marginal hematoma) Microscopy - Placental Abruption Vessel with thick muscular cuffing and adjacent marginal haematoma Microscopy - Placental Abruption Vessel with thrombus and villous infarction ABBREVIATIONS : Alpha Fetoprotein : Blood Pressure AFP BP : Chronic Abruption-Oligohydramnios Sequence CAOS : Chronic Obstructive Pulmonary Disease : Disseminated Intravascular Coagulation : Diabetes Mellitus COPD DIC DM : Endothelial Nitric Oxide Synthase : Human Leukocyte Antigen : Interleukin-1 eNOS HLA IL-1 : Intra Uterine Growth Retardation : Matrix Metalloproteinases : Natural Killer Cell IUGR MMP NK CELL NO : Nitric Oxide : Pregnancy Associated Plasma Protein A : Red Blood Cell PAPPA-A RBC : T- Helper 1 Lymphocytes TH 1 LYMPHOCYTES TNF-α : Tumor Necrosis Factor-α INTRODUCTION INTRODUCTION BACKROUND OF THE STUDY Abruptio placenta was first described by E Rigby in 1775 by publishing an essay on Uterine hemorrhage which precedes the delivery of the fetus. Placental abruption (also known as abruptio placentae) is a complication of pregnancy, wherein the placental lining has separated from the uterus of the mother prior to delivery. It is the most common pathological cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth. It occurs on average in 0.5% or 1 in 200 deliveries1. In Coimbatore Medical College, the incidence of patients with placental abruption is about 1 to 2 patients per month and Intra Uterine death is 0-1 per month. Preterm deliveries associated with over half of all pregnancies complicated by placental abruption, and it leads to many adverse maternal and fetal outcomes. The etiology of placental abruption remains hypothetical but is thought to be the consequence of abnormal invasion of trophoblast leading to rupture of spiral arteries and premature separation of the placenta2. In spite of being an unique obstetrical condition, specific diagnostic clinical criteria is not available for placental abruption. Histological evidences supportive to chronic process that often go with placental 1abruption has led researchers to hypothesize that the condition is the end result of a chronic process which starts very early in pregnancy, and perhaps even prolonging to the time of implantation. In the presence of vaginal bleeding associated with abdominal pain, uterine tenderness or uterine contractions, placental abruption is first thought to be in the differential clinical diagnosis. Old or freshly adherent blood clots at delivery is diagnostic of abruption. Some of these placentas may have histologic features of placental abruption. Moreover, there have been cases of women diagnosed with placental abruption based on histological markers that showed a clinically unremarkable obstetrical course and outcome. Because of these uncertainties in making the diagnosis of placental abruption, we try to find the correlation between a clinical and histologic diagnosis of placental abruption. Furthermore, we have estimated associations between acute and chronic features with placental abruption. This is to determine if clinical and pathological findings from the placenta may perhaps provide some insight as to whether placental abruption is the result of an acute event or a chronic process. The causes of placental abruption are multifactorial, defective mechanism in early vascularization during placentation, immunologically mediated dysfunction, acute and chronic inflammatory processes might be playing significant roles in the development of placental abruption3. Many 2maternal modifiable risk factors during pregnancy such as pregnancy induced hypertension, polyhydramnios, thrombophilia, preterm premature rupture of membranes, intrauterine infection are associated with increased risk of placental abruption. It has been shown that trophoblast releases a factor that inhibits platelet aggregation (O'Brien et-al 1987) and it has been postulated that this factor is needed for normal placental blood flow, when it is decreased, abruption may take place. Toivonen et a l(2004) found that the low activity haplotype C-A (His 113-His139) of the microsomal epoxide hydrolase gene was less frequent in women with abruptio placenta. Tsegaselassie workalemathu et al (2013, Sep 12) conducted a study by integrating multiple genomic analytical strategies that provides opportunities for identifying novel biological pathways for exploring the underlying molecular mechanisms, for placental abruption4. In addition, genetic risk scores analyses support the promise of using genetic association studies in placental abruption risk prediction. Further efforts are needed to understand placental abruption pathological mechanisms and facilitate the development of prevention strategies5. There are only few studies relating to abruptio placenta in primigravida patients compared to multigravida patients. Present study aims to study the histomorphological features of abruptio placenta of primigravida 3compared to multigravida patients and to analyze the features more associated with Intra Uterine death incidence. This could enlighten us about the pathway leading to grave prognosis and fatality in such patients, thus enabling us to prevent maternal and fetal deaths in abruptio placenta. Also though abruptio placenta is an acute event, it usually has an underlying chronic etiology like deciduitis and decidual vasculopathy. If the pathogenesis is unravelled by studying patients with placental abruption, subsequent pregnancies might be given more attention and preventive measures may be undertaken. Thus, present study analyses the incidence, clinical features and histomorphological features of placenta in abruptio placenta patients. It also intends to compare the features of abruptio placenta with 50 control patients of normal delivery; and also differences in histomorphology of abruptio placenta in primi gravida and multi gravida patients are analysed in present study. 4AIMS AND OBJECTIVES AIM OF THE STUDY To study the incidence, clinical features and histomorphological features of abruptio placenta in a tertiary health care Centre. To compare abruptio placenta with normal placenta and to analyze the differences in histomorphology of abruptio placenta in primi gravida and multi gravida patients. 5OBJECTIVES 1. To analyse the incidence and clinical features of abruptio placenta in a tertiary health care centre. 2. To study the histopathological features of placenta in abruptio placenta and compare with normal placenta. 3. To study the morphological difference of abruptio placenta of primi gravida with that of multi gravida patients. 6REVIEW OF LITERATURE ANATOMY OF NORMAL PLACENTA The only organ with defined end date and which develops in adulthood is placenta. The demand for fetal nutrition increases in its ninth week of development, where major role is played by placenta in facilitating nutrient and gas exchange between the fetal and maternal compartments 6.

Histopathological Analysis of Patients with Abruptio

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