[Show abstract][Hide abstract] ABSTRACT: We explored the prevalence of syringomyelia in a series of 113 cases of fetal dysraphism and hindbrain crowding, of gestational age ranging from 17.5 to 34 weeks with the vast majority less than 26 weeks gestational age. We found syringomyelia in 13 cases of Chiari II malformations, 5 cases of Omphalocele/Exostrophy/Imperforate anus/Spinal abnormality (OEIS), 2 cases of Meckel Gruber syndrome and in a single pair of pyopagus conjoined twins. Secondary injury was not uncommon, with vernicomyelia in Chiari malformations, infarct like histology, or old hemorrhage in 8 cases of syringomyelia. Vernicomyelia did not occur in the absence of syrinx formation. The syringes extended from the sites of dysraphism, in ascending or descending patterns. The syringes were usually in a major proportion anatomically distinct from a dilated or denuded central canal and tended to be dorsal and paramedian or median. We suggest that fetal syringomyelia in Chiari II malformation and other dysraphic states is often established prior to midgestation, has contributions from the primary malformation as well as from secondary in utero injury and is anatomically and pathophysiologically distinct from post natal syringomyelia secondary to hindbrain crowding.
[Show abstract][Hide abstract] ABSTRACT: Heparin is often prescribed during pregnancy with the intention of improving perinatal outcomes on the basis that it exerts an anticoagulant action in the inter-villous space. Accumulating in-vitro and in-vivo evidence indicates that heparin's beneficial effects in pregnancy may result from 'non-anticoagulant' effects including the promotion of angiogenesis.
[Show abstract][Hide abstract] ABSTRACT: Fetal skeletal dysplasias are a heterogeneous group of rare genetic disorders, affecting approximately 2.4-4.5/10,000 births. We performed a retrospective review of the perinatal autopsies conducted between the years 2002-2011at our centre. The study population consisted of fetuses diagnosed with skeletal dysplasia with subsequent termination, stillbirth and live-born who died shortly after birth. Of the 2,002 autopsies performed, 112 (5.6%) were diagnosed with skeletal dysplasia. These 112 cases encompassed 17 of the 40 groups of Nosology 2010. The two most common nosology groups were osteogenesis imperfecta [27/112 (24%)] and the FGFR3 chondrodysplasias [27/112 (24%)]. The most common specific diagnoses were thanatophoric dysplasia (TD) type 1 [20(17.9%)], and osteogenesis imperfecta (OI) type 2 [20 (17.9%)]. The combined radiology, pathology, and genetic investigations and grouping the cases using Nosology 2010 resulted in a specific diagnosis in 96/112 of the cases.
[Show abstract][Hide abstract] ABSTRACT: To determine the incidence of temporal lobe dysplasia (TLD) detected on prenatal ultrasound in thanatophoric dysplasia (TD) over an 11-year period in a tertiary referral centre.
An 11-year retrospective review of perinatal autopsies was performed from 2002 to 2013 to identify cases of TD. The ultrasound images and corresponding reports of all TD cases were reviewed for TLD. The same set of images subsequently underwent a retrospective review by a perinatal radiologist with knowledge of the TLD feature to determine whether they could be identified.
There were 31 TD cases that underwent perinatal autopsy. Prenatal ultrasound imaging was available to review in 24/31 (77%) cases. Mean gestational age (GA) of TD diagnosis was 21.3 weeks (range: 18-36 weeks). TLD was identified and reported in 6/24 (25%) cases; all six cases occurred after 2007. Retrospective interpretation of the ultrasound images identified features of TLD in 10 additional cases. In total, 16/24 (67%) cases displayed sonographic evidence of TLD. Temporal trends show that TLD features were present in 50% (5/10) of all TD cases from 2002-2006 and in 79% (11/14) of the cases from 2007-2013.
Currently, the detection rate of TLD by ultrasound is low but may be increased by modified brain images that enhance visualization of the temporal lobes. Prenatal identification of TLD may help in the prenatal diagnosis of TD and thus provide more accurate prenatal counseling and guide molecular investigations to confirm the specific diagnosis of TD.
Ultrasound in Obstetrics and Gynecology 02/2014; · 3.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction
Decidual leukocytes are critical to the development of the fetomaternal interface, regulating tolerance to the semi-allogeneic fetus and vascular transformation of the uterine spiral arteries. Despite the continuation of these processes beyond the first trimester of pregnancy, the second trimester has largely been unstudied, with investigation focusing on early gestation and term tissues. We sought to characterize changes in decidual leukocyte populations from first to second trimester.
Multicolour flow cytometry was performed on isolated decidual leukocytes from elective terminations of pregnancy between 6 and 20 weeks of gestation for study of first (6-12 weeks) and second trimesters (13-20 weeks). Specific subpopulations were identified by comparison to isotype and fluorescent-minus-one (FMO) controls.
Decidual natural killer cells (CD56+CD16-CD3-) did not change in number, although a population of dNK with decreased CD56 brightness was observed in second trimester decidua. CD14+HLA-DR+ macrophage numbers declined from first to second trimester (p = 0.031), yet a CD163+CD206+ subset designating alternatively activated M2-like macrophages increased during the same period (p = 0.015). Intermediate CD205+ dendritic cells demonstrated significant decline (p = 0.022), but immature CD209+ and mature CD83+ dendritic cells did not differ between trimesters. Total CD3+ and CD3+CD4+ T lymphocytes increased (p = 0.0079, p = 0.0028); CD3+CD8+ T cells trended towards increase but did not differ significantly.
Several changes in leukocyte subsets are observed in the second trimester that promote a tolerogenic and angiogenic decidual microenvironment through mid-gestation.
[Show abstract][Hide abstract] ABSTRACT: To describe the prenatal sonographic features and the results of DNA analysis on three fetuses with Dyssegmental Dysplasia, Silverman-Handmaker Type (DD-SH).
A retrospective review of three fetuses with confirmed DD-SH was conducted. The fetal ultrasound findings, radiological characteristics and results of the mutation analysis of the HSPG2 gene were reviewed.
There were 3 cases in two families with DD-SH diagnosed prenatally. The main prenatal ultrasound and radiological features of DD-SH were severe limb shortening and vertebral segmentation and fusion defects (anisospondyly). DNA analysis of the HSPG2 gene showed that the two affected fetuses in a non-consanguineous family had a compound heterozygote for the c.646G > T transversion in exon 7 and a c.5788C > T transition in exon 46. The fetus born to the consanguineous couple had a homozygous mutation c.1356-27_1507 + 59del.
DD-SH can be diagnosed prenatally using fetal ultrasound as early as 13 weeks. Fetal X-rays and DNA analysis of the HSPG2 gene are important for confirmation of the diagnosis and for pre-implantation and prenatal diagnosis in pregnancies at risk. This article is protected by copyright. All rights reserved.
[Show abstract][Hide abstract] ABSTRACT: Severely-growth discordant monochorionic (MC) twins offer a unique opportunity to study fetal and placental growth based on a similar genetic background and maternal host environment where the healthy twin serves as an ideal control. Differences in development of monochorionic twins may therefore be due to differential epigenetic regulation of genes involved in placental development and function. Growth-discordant twins are known for abnormal angio-architecture in the placenta of the smaller twin. Since the reasons for this phenotype are mostly unknown this study was aimed to investigate expression and regulation of genes known to be involved in angiogenesis.We studied 10 severely growth-discordant monochorionic twin placentas (birth weight difference≥20%) without twin-twin-transfusion syndrome (TTTS) and 5 growth-concordant monochorionic twin placentas. Growth discordant twin placentas were phenotyped by histology. Placental mRNA expression of 88 angiogenesis related genes were measured by PCR array. Enzyme-linked immuno-sorbent assay (ELISA) and immuno-histochemistry were used to confirm PCR results. EpiTYPTER for DNA methylation was used to determine if methylation ratios were responsible for differential gene expression.The PCR array analysis showed significant mRNA up-regulation in the placental share of the smaller twin for several genes. These included Leptin (24.6 fold, p=0.017), Flt1 (fms-like tyrosine kinase 1, 2.4 fold, p=0.016) and Eng (Endoglin, 1.86 fold, p= 0.078). None of the other 84 angiogenesis related genes showed significant differences. ELISA confirmed significantly increased Leptin protein expression (49.22 vs. 11.03 pg/mL, p=0.049) in the smaller twin of the discordant growth cohort. Leptin expression in smaller twins' placentas was associated with elevated DNA methylation of the Leptin promotor region suggesting the inhibition of binding of a transcriptional activator / inhibitor in that region. We attempted to overcome the limitation of sample size by careful patient selection. We minimized any bias in placental sampling by random sampling from two different sites and by avoiding sampling from areas with grossly visible abnormalities using a standardized sampling protocol.In conclusion, the smaller twin's placenta is characterized by differentially-increased gene expressions for Flt1 and Eng mRNA that may be causally-associated with the villous pathology driven by abnormal feto-placental angiogenesis. The substantial up-regulation of Leptin mRNA may be epigenetically conferred and relevant to the post-natal risk of metabolic syndrome in IUGR offspring with placental pathology. Growth discordant MC twins offer unique insights into the epigenetic basis of perinatal programming.
Molecular Human Reproduction 07/2013; · 4.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: To review the association between associated ultrasound findings, placental pathology and prognosis in pregnancies complicated by massive subchorionic thrombo-hematoma(MTH)/Breus' mole. METHOD: We identified 14 cases of MTH from January 2004 to December 2012. MTH was defined by: > 1 cm thickness hematoma, and extensive (≥ 50%) involvement of the fetal surface of the placenta. Patient information, details of initial presentation and perinatal outcome were obtained from the manual and electronic chart records. Ultrasound findings were related to pregnancy outcomes and associated placental pathology. Participants were stratified based on birth outcome into survivors (live births, n = 7) and non-survivors (NND or IUFD/TOP, n = 7). RESULTS: All 14 cases of MTH were suspected on ultrasound and confirmed by pathology assessment. All cases in the non-survivors group had abnormal umbilical artery Doppler waveforms compared to none in the survivors (p = 0.02). All cases in the non-survivor group had extreme preterm deliveries (p = 0.02). Birth weight was significantly reduced in the non-survivor group (p = 0.001), and 5/7 cases were diagnosed with severe intrauterine growth restriction, compared to none in the survivor group (p = 0.02). CONCLUSION: MTH/Breus' mole may be diagnosed in the second trimester by ultrasound assessment of the placenta. Normal fetal growth and umbilical artery Doppler waveforms are associated with perinatal survival. This article is protected by copyright. All rights reserved.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: To report 3 different antenatal therapeutic approaches for fetal lung masses associated with hydrops. METHODS: Three prospectively followed cases are described and all 17 previously published minimally invasive cases of fetal therapy for hydropic lung masses are reviewed. RESULTS: Three hydropic fetuses with large intra-thoracic lung masses presented at 17, 21 and 24 weeks gestation, respectively. An aortic feeding vessel was identified in each case and thus a broncho-pulmonary sequestration (BPS) was suspected. Under ultrasound guidance, the feeding vessel was successfully occluded with: (1) interstitial laser; (2) thrombogenic coil embolisation and (3) radio-frequency ablation (RFA). Complete (1&3) or partial (2) resolution of the lung mass and hydrops was observed in all cases. An healthy infant was born at term after laser therapy (1), and the involved lung lobe was resected at day on day 2 of life. Despite technical success in complete vascular occlusion with coils, a stillbirth ensued 2 days after embolisation. In case 3, hydrops resolved completely following RFA, but an iatrogenic congenital diaphragmatic hernia and abdominal wall defect became apparent 4 weeks later. The neonate died from sepsis following spontaneous preterm labour at 33 weeks. CONCLUSIONS: The natural history of large microcystic or echogenic fetal chest masses associated with hydrops is dismal. This has prompted attempts at treatment by open fetal surgery, with mixed results, high risk of premature labor and consequences for future pregnancies. We have demonstrated the possibility of improved outcome following ultrasound-guided laser ablation of the systemic arterial supply. Despite technical success, RFA and coil embolisation led to procedure related complications and need further evaluation.
Ultrasound in Obstetrics and Gynecology 05/2013; · 3.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective: To assess the effectiveness of a multidisciplinary team approach to reduce severe maternal morbidity in women with invasive placenta previa. Methods: We conducted a prospective study of 33 women with placenta previa and increta-percreta (diagnosed by ultrasound and/or magnetic resonance imaging) delivering at Mount Sinai Hospital, Toronto, following the introduction in January 2008 of a team-based approach to women with this condition. We included women who delivered by June 2012. We reviewed antenatal outpatient and inpatient records for use of six pre-defined team components by the attending staff obstetrician: (1) antenatal maternal-fetal medicine consultation, (2) surgical gynaecology consultation, (3) antenatal MRI, (4) interventional radiology consultation and preoperative placement of balloon catheters in the anterior divisions of the internal iliac arteries, (5) pre-planned surgical date, and (6) surgery performed by members of the invasive placenta surgical team. Antenatal course, delivery, and postpartum details were recorded to derive a five-point composite severe maternal morbidity score based on the presence or absence of: (1) ICU admission following delivery, (2) transfusion > 2 units of blood, (3) general anaesthesia start or conversion, (4) operating time in highest quartile (> 125 minutes), and (5) significant postoperative complications (readmission, prolonged postpartum stay, and/or pulmonary embolism). Results: All 33 women survived during this time period. Two thirds (22/33) had either five or six of the six components of multidisciplinary care. Increasing use of multidisciplinary team components was associated with a significant reduction in composite morbidity (R2 = 0.228, P = 0.005). Conclusion: Team-based assessment and management of women with invasive placenta previa is likely to improve maternal outcomes and should be encouraged on a regional basis.
Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 05/2013; 35(5):417-25.
[Show abstract][Hide abstract] ABSTRACT: To determine the utility of measuring maximum placental length in the second trimester to predict a small for gestational age placenta by weight at delivery in clinically high-risk women.
Placental dimensions determined by 2-dimensional (2-D) real-time ultrasound at 19-23 weeks' gestation were compared to post-natal placental weights and pathology in 95 high-risk patients with singleton pregnancies.
Maximum placental length <10.0 cm performed poorly (false positive rate 25.5%) for the detection of a small placenta by weight at delivery. Placental pathology examination revealed eccentric cord insertion to be an important explanation for poor screening test result, since this finding was significantly more common in the false negative group (length ≥10.0 cm, weight <10th percentile) compared with the true negative group (length ≥10.0 cm, weight ≥10th percentile) (15/28 vs. 9/38, Fisher's exact test, p = 0.005).
Prediction of reduced placental weight by 2-D ultrasound determination of maximum placental length in clinically high-risk pregnancies confounded by the phenomenon of asymmetric chorion regression. Refinement of 2-D ultrasound methods to include orthogonal plane measurements, or replacement by 3-D techniques is predicted to significantly improve the effectiveness of diagnosing small placentas in-utero.
[Show abstract][Hide abstract] ABSTRACT: Distal villous hypoplasia is a form of placental villous maldevelopment that has the potential to cause significant intrauterine growth restriction with adverse consequences for fetal viability, neurodevelopmental outcome and adult cardiovascular health. It is characterized by a sparse, poorly developed distal villous tree with abnormally shaped, elongated, slender villi and widening of the intervillous space. Generally, villi show widespread trophoblast abnormalities with thinning of the villous trophoblast layer, reduction in cytotrophoblast numbers, evidence of a widespread increase in syncytiotrophoblast nuclear senescence and wave-like syncytial knots. Investigation of pregnancies with false positive serum screening tests for fetal aneuploidy/structural defects can help identify pregnancies at risk of placental insufficiency, particularly when combined with ultrasound assessment of placental morphology at 19–22 weeks. Identification of pregnancies with multiple abnormal tests of placental function permits high-risk specialist referral to optimize maternal-fetal outcome.
[Show abstract][Hide abstract] ABSTRACT: Since pregnancies with a male fetus have higher perinatal complications attributed to placental dysfunction, including severe pre-eclampsia and intrauterine growth restriction, the objective of our study was to formally evaluate placental pathology for a placental origin of these sex-specific differences.
Retrospective study at Mount Sinai Hospital in Toronto, Canada. Identification of 262 singleton pregnancies affected by severe pre-eclampsia and/or intrauterine growth restriction who delivered between 22 and 32 weeks' gestation from 2000 to 2010. Detailed placental pathology was reviewed, and data from 140 pregnancies with male fetuses were compared with 122 pregnancies with female fetuses. A comparison group of 40 unaffected pregnancies who delivered in the same gestational range was used to determine baseline rates of placental pathology.
Detailed placental pathology, including placental development/differentiation, velamentous umbilical cord insertion, maternal-fetal interface pathology, villous infarction, hemorrhagic lesions, villous development, and fetal vascular under-perfusion.
Impaired placental development and differentiation was equally common amongst males (73/140, 52.1%) and females (69/122, 56.6%). Male placentas exhibited significantly higher rates of chronic deciduitis (17.9% vs. 9.0%; relative risk [RR] 1.98, 95% confidence interval [CI] 1.02-3.86) and velamentous umbilical cord insertion (9.5% vs. 1.7%; RR 5.66, 95% CI 1.30-24.6), and a significantly lower frequency of villous infarction (55.4% vs. 73.7%; RR 0.75, 95% CI 0.62-0.90) than female placentas. No significant differences were noted for other lesions.
Fetal sex exerts a differential effect on the placental pathology that mediates severe pre-eclampsia and/or IUGR. Placental pathology at birth may provide insight into the mechanisms linking adverse in utero events with long-term adult disease since, for example, a male tendency to an inflammatory pathology at the maternal-fetal interface may be linked to the excess risk of coronary artery disease.
[Show abstract][Hide abstract] ABSTRACT: The placental microvasculature is essential for efficient transfer of gases, nutrients and waste between the mother and fetus. Microvascular hypoplasia of the terminal villi is a common pathology in severe Intra Uterine Growth Restriction (IUGR). We used novel methods to obtain placental micro-vascular endothelial cells (PlMEC) from preterm control placentas (n = 3) and placentas from pregnancies with severe IUGR (n = 6) with absent or reversed end-diastolic velocity in the umbilical artery. Distal placental villous tissue was collected to enrich for intermediate and terminal villi. Tissue was digested and PlMEC positively selected using tocosylated magnetic Dynabeads labeled with Human Endothelial Antigen lectin. The purity of the PlMEC (94 ± 2 SD %) was assessed by CD31 and vimentin immunocytochemistry. RNA was extracted from the PlMEC samples and subjected to Affymetrix microarray analysis (U133Plus2 array chips). Comparison of preterm and IUGR PlMEC gene expression profiles identified BTNL9 and NTRK2 transcripts to be upregulated and SAA1 and SLAMF1 transcripts to be downregulated in all 6 IUGR cases relative to preterm controls. A third downregulated gene GNAS was identified to be near significance. Changes were demonstrated to be significant at the mRNA level by Real Time PCR in the PlMEC samples. Changes in the IUGR endothelium were confirmed at the protein level by immunohistochemistry for the 3 with available antibodies. We used a tissue microarray constructed from an independent cohort of placental samples from severe IUGR (n = 7), preeclamptic (n = 7), preterm control (n = 6) and term control (n = 6) pregnancies. Results confirmed differential endothelial expression of BTNL9, NTRK2 and SLAMF1 in IUGR versus preterm and term samples. These studies are the first to characterize PlMEC gene expression profiles thus we have advanced our understanding of the molecular basis of placental micro-vascular pathophysiology in fetal growth restriction.
[Show abstract][Hide abstract] ABSTRACT: PURPOSE
The purpose of this study is to determine the distribution of various fetal skeletal disorders in a tertiary care centre, based on the 2006 Nosology and Classification of Genetics Skeletal Disorders1. The study will provide additional information on rare skeletal disorders and will further characterize pathologic and radiological features of these disorders.
METHOD AND MATERIALS
A retrospective review of 1806 perinatal autopsies from 2002-2009 at Mount Sinai Hospital, Toronto, ON was performed. The study population consisted of stillborns fetuses in their second and third trimesters as well as live born infants who died shortly after birth. Pathological, genetic, clinical and radiological information were reviewed and utilized to achieve a final diagnosis.
Of the 1806 autopsies performed, 91 received a final diagnosis of a skeletal disorder and encompassed 15 out of the 37 groups according to the 2006 Nosology classification1. The frequency of skeletal disorders was 1:20 autopsies. Out of the 91 cases, 75 (82.5%) had a complete autopsy (photographs, x-rays, gross physical and histopathological analysis with or without biopsy) while limited autopsy was performed in 16 (17.6%) of cases. Genetic analysis was available in 81/91 (95.6%) cases and chromosome analysis was available in 12/91 (13.2%). There was a slightly increased ratio of males to females (1.33:1). Of the 91 cases, 49.5% were stillbirths. Mean gestational age at termination was 26.1 wks (range 15-37). Thanatophoric dysplasia type 1 accounted for 17/91(18.7%) and osteogenesis imperfecta type 2 accounted for 15/91(16.5%).
Five percent of all fetal autopsies at a single tertiary referral centre have an underlying skeletal disorder. The most common disorders were Thanatophoric Dysplasia Type 1 (17/91, 18.7%) and Osteogenesis Imperfecta Type 2 (15/91, 16.5%). A combination of radiographic features, gross morphology, histopathology and genetics are required in order to diagnose these rare skeletal dysplasias.
Familiarity with imaging findings, the distribution and lethality of various fetal skeletal dysplasias is crucial in order to provide appropriate counselling for both current and future pregnancies.
Radiological Society of North America 2011 Scientific Assembly and Annual Meeting; 11/2011
[Show abstract][Hide abstract] ABSTRACT: To conduct a pilot randomized controlled trial of unfractionated heparin (UFH) in women considered at high risk of placental insufficiency in the second trimester.
Women with either false-positive first trimester (pregnancy-associated placental protein-A [PAPP-A] < 0.35 MoM) or second trimester (alpha-fetoprotein [AFP] > 2.0 MoM, inhibin > 3.0 MoM, human chorionic gonadotropin > 4.0 MoM) serum screening tests or medical/obstetric risk factors were screened for placental insufficiency by sonographic evaluation of the placenta and uterine artery Doppler between 18 and 22 weeks. Thrombophilia screen-negative women with two or three abnormal test categories were randomized by 23+6 weeks to self-administration of subcutaneous unfractionated heparin (UFH) 7500 IU twice daily until birth or 34 weeks, or to standard care. Maternal anxiety and other maternal-infant outcomes were determined.
Thirty-two out of 41 eligible women consented, with 16 women randomized to UFH and 16 to standard care. There was no statistically significant difference identified between the two treatment groups (standard care vs. UFH) for the following: maternal anxiety score (mean [standard deviation]), 14.2 [± 1.6] vs. 14.0 [± 1.8]; birth weight (median [range]), 1795 [470-3295]g vs. 1860 [730-3050]g; perinatal death, 3 vs. 0; severe preeclampsia, 2 vs. 6; placental weight < 10th percentile, 7 vs. 4; or placental infarction, 4 vs. 3.
Our study design identified women at high risk of adverse maternal-infant outcomes attributable to placental insufficiency. Women with evidence of placental insufficiency were willing to undergo randomization and self-administration of UFH without increased maternal anxiety.
Journal of Thrombosis and Haemostasis 06/2011; 9(8):1483-92. · 6.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Seckel syndrome is a rare autosomal recessive disorder characterized by intrauterine growth retardation, dwarfism, microcephaly and mental retardation. Pathological descriptions of fetal stage Seckel syndrome are rare and pre-date the evolving understanding of the genetic and molecular mechanisms involved. The autopsy findings in a case of fetal Seckel syndrome at 30 weeks gestation are presented, with detailed description of the neuropathological findings. Severe neurological abnormalities in a male fetus were observed that included microencephaly, cortical neuronal migration disorder, white matter tract hypoplasia/aplasia, premature depletion of the germinal matrix with cystic transformation and patchy absence of the external granular cell layer of the cerebellum. The striking neuropathological finding in this case was evidence of failure of the developing brain's germinal elements, providing rare morphological insight into the abnormal development of the Seckel syndrome fetal brain. The selective failure of this proliferating cell population correlates with the emerging molecular evidence that Seckel syndrome is caused by defects in ATR-dependent DNA damage signaling with resultant premature death of proliferating cells.
Brain & development 06/2011; 34(3):238-43. · 1.74 Impact Factor