Redline Raymond W, Boyd Theonia, Campbell Valarie, Hyde Scott, Kaplan Cynthia, Khong T Yee, Prashner Heather R, Waters Brenda L
Department of Pathology, University Hospitals of Cleveland and Case Western Reserve University, 1100 Euclid Avenue, 44106, USA.
Pediatr Dev Pathol. 2004 May-Jun;7(3):237-49. doi: 10.1007/s10024-003-8083-2. Epub 2004 Mar 17.
Placental examination can be a useful tool for specifying the etiology, prognosis, and recurrence risk of pregnancy disorders. The purpose of this study was to test the reliability of a predetermined set of placental reaction patterns seen with maternal vascular underperfusion in the hope that this might provide a useful diagnostic framework for practicing pathologists. Study cases (14 with clinical and pathologic evidence of maternal underperfusion plus 6 controls) were evaluated for the presence or absence of 11 lesions by eight perinatal pathologists. After analysis of initial results, diagnostic criteria were refined and a second, overlapping set of cases was reviewed. The collective sensitivity, specificity, and efficiency of individual assessments for the 11 lesions relative to the group consensus ranged from 74-93% (22/33 > 90%). Reproducibility was measured by unweighted kappa-values and interpreted as follows: < 0.2 poor, 0.2-0.6 fair/moderate, > 0.6 substantial. Kappa values for lesions affecting villi and the intervillous space were increased syncytial knots (any -0.42, severe -0.50), villous agglutination (0.42), increased intervillous fibrin (0.25), and distal villous hypoplasia (0.57). Individual estimates of percent involvement for syncytial knots, intervillous fibrin, and distal villous hypoplasia were correlated with placental and fetal weight for gestational age. Extent of increased intervillous fibrin showed the strongest correlation with both placental weight ( R = -0.64) and fetal weight ( R = -0.45). Kappa values for lesions affecting maternal vessels and the implantation site were acute atherosis (0.50), mural hypertrophy of membrane arterioles (0.43), muscularized basal plate arteries (0.48), increased placental site giant cells (0.54), and immature intermediate trophoblast (0.36). Correlation of maternal vessel and implantation site lesions with the clinical diagnosis of preeclampsia showed that excessive placental site giant cells and immature intermediate trophoblast were more sensitive and efficient predictors, whereas atherosis and muscularized basal plate arteries were more specific. Kappa value for a thin umbilical cord, a possible indicator of fetal volume depletion, was 0.61. Reproducibility for a global impression of maternal vascular underperfusion, taking into account all of the above lesions, was moderate (kappa 0.54) and improved after inclusion of additional pathologic and clinical data (kappa 0.68). Adoption of this clearly defined, clinically relevant, and pathologically reproducible terminology could enhance clinicopathologic correlation and provide a more objective framework for future clinical research.
胎盘检查对于明确妊娠疾病的病因、预后及复发风险可能是一项有用的工具。本研究的目的是检验一组预先确定的、在母体血管灌注不足时出现的胎盘反应模式的可靠性，希望这能为执业病理学家提供一个有用的诊断框架。八名围产期病理学家对研究病例（14例有母体灌注不足的临床和病理证据，外加6例对照）进行了11种病变的有无评估。在对初步结果进行分析后，对诊断标准进行了完善，并对另一组重叠病例进行了复查。相对于组内共识，对11种病变的个体评估的总体敏感性、特异性和效率范围为74% - 93%（22/33 > 90%）。通过非加权kappa值测量可重复性，并按以下方式解释：< 0.2为差，0.2 - 0.6为一般/中等，> 0.6为高度一致。影响绒毛和绒毛间隙的病变的kappa值为合体结节增加（任何程度 - 0.42，重度 - 0.50）、绒毛凝集（0.42）、绒毛间隙纤维蛋白增加（0.25）和远端绒毛发育不全（0.57）。合体结节、绒毛间隙纤维蛋白和远端绒毛发育不全的个体受累百分比估计值与胎龄的胎盘和胎儿体重相关。绒毛间隙纤维蛋白增加的程度与胎盘重量（R = - 0.64）和胎儿体重（R = - 0.45）的相关性最强。影响母体血管和着床部位的病变的kappa值为急性动脉粥样硬化（0.50）、绒毛膜小动脉壁肥厚（0.43）、基底板动脉肌化（0.48）、胎盘部位巨细胞增加（0.54）和未成熟中间滋养层细胞（0.36）。母体血管和着床部位病变与子痫前期临床诊断的相关性表明，胎盘部位巨细胞过多和未成熟中间滋养层细胞是更敏感和有效的预测指标，而动脉粥样硬化和基底板动脉肌化则更具特异性。细脐带（可能是胎儿容量减少的一个指标）的kappa值为0.61。考虑到上述所有病变，对母体血管灌注不足的整体印象的可重复性为中等（kappa 0.54），在纳入更多病理和临床数据后有所改善（kappa 0.68）。采用这种明确界定、临床相关且病理可重复的术语可以增强临床病理相关性，并为未来的临床研究提供一个更客观的框架。
