Study of Placenta in Intrauterine Growth Restricted PregnancyLaxmichaya D. Sawant*and Shirin VenkatDepartment of Obstetrics and Gynecology, Grant Medical Foundation, India

Received date: October 24, 2017; Accepted date: November 14, 2017; Published date: November 17, 2017

ABSTRACT

Background: Pregnancy with intrauterine growth restricted fetus is at greater risk for poor Perinatal and long-term outcomethan babies with normal weight. Therefore, intrauterine growth restriction is a major global health concern especially in poorand developing Countries. The placental examination can be a great help in identifying growth restricted foetuses.

Research problem or aim: The objective of this study is to examine various morphometric and histopathological changesincluding inflammation in placentae of growth restricted fetuses along with screening for infections, and to correlate theseFindings with the etiology and fetal outcome in intrauterine growth restriction.

Method: In the current study, 53 placentae of normal fetus were compared with 53Placentae of fetus with intrauterinegrowth restriction. The criteria for intrauterine growth restriction were gestational age more than 32 weeks and all fetuseswith weight Less than 10th percentile for that gestation. Histopathological examination along with 2 laboratory screening forinfections and inflammation was carried out on placentae. Similarly, fetal outcome were determined in normal versusintrauterine growth restricted pregnancy.

Results: The placental examination showed calcification in intrauterine growth restricted Pregnancy as well as in normalpregnancy. However, calcification in placenta associated with intrauterine growth restriction was much denser as compare toplacenta from normal pregnancy. The absence of intrauterine infection and inflammation along with good antenatal andpostnatal care can deliver favourable outcome in pregnancies with intrauterine growth restriction.

Conclusion: This research study reaffirms that best prenatal and antenatal clinical practices can overcome social,epidemiological, and pathological determinants in intrauterine growth restriction to deliver better obstetric results inpregnancy and ensuring Good quality of postnatal life for mother and fetus.

Keywords: Intra Uterine Growth Restriction (IUGR), Fetal growth restriction, High risk pregnancy, Placental calcification,TORCH, HIV infections.

INTRODUCTIONIntrauterine growth restriction or fetal growth

restriction is defined as a fetus whose birth weight ismarkedly below the normal weight (less than 10thpercentile) for that gestational age [1,2]. Intrauterinegrowth restriction occurs in 5–10% of all pregnancies andis associated with significant morbidity and mortality inthe perinatal period causing a major public healthproblem affecting maternal and child health around worldespecially 3 in less developed part of the world. [1-5].Intrauterine growth restriction could arise due to severalfetal and maternal factors and one of the importantreasons for failure of a fetus to attain its geneticallydetermined growth potential could be a placenta [1-6].

The placenta is a vital organ needed for mammaliandevelopment with distinctive characteristics such as thelifetime of placenta is short and its size and functionchanges continuously during the course of gestation. Anormal healthy placenta is necessary for overall growthand well-being of fetus, which eventually will lead tofavourable out-come in pregnancy [Figure 1A]. Hence, it isthe most accurate record of an infant’s pre-natalexperience and it provides insight into the pre-natalhealth of the fetus and mother [2,6-8]. Brief summaries ofmore recent analysis support the long-standingappreciation of the importance of maternalanthropometry to achieve optimal birth weight [9,10].Earlier studies have shown that by demonstrating theeffects of maternal anthropometry on birth Weight are

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Research Article

Corresponding Author:Laxmichaya D. Sawant, Department of Obstetrics andGynecology, Grant Medical Foundation, Ruby Hall Clinic,Pune, MS, India ,E-mail drlaxmisawant@gmail.com

DOI:10.4103/2278-960X.194509

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likely mediated by the effects of both pre-pregnantmaternal weight and maternal weight gain on placentalvolume. These effects operate early in pregnancy andalter both the absolute placental volume at 14 weeks andthe rate of placental growth between 17-20 weeks ofgestation [7,8,10]. The importance of the outlinedetiological Factors affecting the placenta has been wellunderstood. Hence, the further study of placentalmorphology of fetal growth restriction has been selectedto determine the value of its association to fetal birthweight. In this study we aim to cover the placentalchanges in IUGR. Also, it is a well-known fact fromprevious studies that intrauterine infection andinflammation in placenta along with dense placentalcalcification [Figure 1B] can have detrimental effects ongrowing fetus [5,7,8]. Therefore, the objective of this studyis to study various histopathological changes includinginflammation in placentae of growth [4] restricted fetusesalong with screening for txoplasmosis, oher (syphilis,varicella zoster, Parvovirus B19), rubella, cytomegalovirus,Herpes simplex (TORCH) and Human ImmunodeficiencyVirus (HIV) infections and to correlate these findings withthe etiology and fetal outcome in IUGR.

Figure 1A : Image Showing Normal Healthy Placenta.

Figure 1B: Image Showing Gross Dense Calcification in Placenta.

MATERIALS AND METHODSThe Director of Academics and Research office at Grant

Medical Foundation Ruby Hal Clinic, Pune, India wasconsulted and approval was taken before conducting thisresearch study in the Department of Obstetrics andGynecology at Ruby Hall Clinic Pune. In the present study,all the patients that were examined were registered cases

in Ruby Hall Clinic and Urban-Rural Health Centre of RubyHall Clinic, Pune, India an appropriate informed consentwere taken from the subjects involved in the study. Thetotal number of deliveries reported from February 2007to February 2008 was 820, and Out of which 53 caseswere of intrauterine growth restriction. As a part ofroutine antenatal check-up and care, all the subjectpatients in the study were examined for physical signsand symptoms such as fever, excessive weight loss,Hepatosplenomegaly, Lymphadenopathy, Jaundice, andskin rash. Along with their clinical examination, all thepatients in the study group were also screened forspecific TORCH antigens and HIV infection by doingenzyme-linked immunosorbent assay (ELISA). And theselaboratory tests were also part of routine clinicalinvestigation during antenatal check-up and care for allthe registered obstetric patients at our hospital. In thecurrent study, 53 placentas of Normal fetuses werecompared with 53 placentas of fetuses with intrauterinegrowth restriction. The criteria for intrauterine growthrestriction were gestational age more than 32 weeks andall fetuses with weight less than 10th percentile for thatgestation [5]. After carefully selecting the cases, placentasof such patients were studied. About 100 placentae werestudied with regards to placental weight with fetalweight. Mothers were screened in the antenatal periodand those who were diagnosed having complicatingfactors such as gestational hypertension, anaemia, andheart disease were admitted in the ward. They weregiven appropriate treatment after doing relevantinvestigations and were followed up to delivery. Afterdelivery the neonatologist examined baby. Baby wasweighed, sex was noted and the gestational age of fetuswas estimated. Placentae of those deliveries werecollected for the study. On delivery the placenta wasexamined immediately in fresh state and the excess bloodwas washed out under running water. The placenta wasweighed and the shape, dimension and colour was noted,attachment of cord to the placenta was examined andtotal cord length was measured, colour of the cord andmembranes, presence of true and false knots, andcondition of the blood vessels was examined. Next thefetoplacental weight ratio was calculated by usingfollowing formula: F/P = Weight of fetus in grams/weightof the placenta in grams. The deciduae and number ofcotyledons were examined gross infarcts; haemorrhages,necrotic areas and calcific deposits were looked for. Nextthe cord and placenta were immersed in 10% formalin forten days. After the fixation the placenta was examined into and then cut into sections longitudinally formicroscopic evaluation, sections were taken from thecentre, periphery, and cord. Additional sections weretaken from any abnormal areas and slides were prepared.These slides were stained with haematoxylin and eosinand were mounted under cover slips and finally examinedunder microscope. On microscopy the following pointswere noted such [6] as placental infarcts, calcifications,

Citation: Sawant LD, Venkat S.Study of Placenta in Intrauterine Growth Restricted Pregnancy doi: 10.4103/2278-960X.194509

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leucocyte infiltration, hyaline change, villus changes, andhaemorrhages.

STASTISTICAL ANALYSISIn the present study the data was analysis statistically

using SPSS software version 11 (chi-square test, Z-test)and value <0.05 was considered as statisticallysignificant.

RESULTSThe results for all the obstetric patients in the study

group tested for TORCH and HIV infections werenegative. In the current study, the total number ofdeliveries that took place during the period of study fromFebruary 2007 to February 2008 was 820, out of which53 cases was diagnosed intrauterine growth restriction.This gives an incidence of 6.4% for intrauterine growthrestriction in our study. In our study, examination of riskfactors showed gestational hypertension 13% in growthrestricted fetuses while 5.66% in normal fetuses [Figure2]. Even though, gestational hypertension is seen more inIUGR pregnancies compare to normal pregnancies, thedata is not statistically significant. The placental weightwere predicted according to gestational age byultrasound and compared with actual placental weights inthe study group which showed a difference ofapproximately 70-80 g in predicted placental weight andactual placental weight in grams. It also showed thatplacental weight is 1/5th of fetal weight [Figure 3]. ThePlacental thickness was also compared between normalfetuses and IUGR, and it demonstrated that placentalthickness is decreased in IUGR [Figure 4], however thisdata was not statistically significant. In the study groupthe incidence of central cord insertion is 44.34% in IUGR,while 42.45% in normal fetuses compared to marginalinsertion among normal and IUGR (9-7%) that showedhigh incidence of central cord insertion in [7] study group[Figure 5] with no statistically significance. Thehistopathological evaluation of placenta in the studygroup demonstrated that increase in placentalcalcification in IUGR (22 %) compared to normal placenta(19%) [Figure 6], but statistically this data was notsignificant (>0.05). Although the placenta from both thegroups showed calcification, the placenta from fetalgrowth restricted pregnancy has dense calcification percotyledon compare to the placenta from the normalpregnancy. Also in this study we failed to quantify thecalcification in placenta, because that would have shownthe higher density of calcification in IUGR pregnanciescompare to normal pregnancies. The fetal outcome inIUGR was also studied which showed that 3.77% offetuses suffered from Jaundice while 1.89% suffered fromRespiratory Distress Syndrome (RDS) and 1.89%hadperinatal death approximately 93% fetuses were normalwith no anomaly, and TORCH and HIV infections [Figure7] with no statistically significance. The results presented

in this study were not statistically significance, when Pvalue was <0.05. However, if the P value is<0.10, thenmost of the above results showed statisticallysignificance. This demonstrates that the current studyneeds more sample size to get statistically significantdata to evaluate different variables and their associationwith IUGR pregnancies and then compare those variableswith normal pregnancies. Nevertheless, the current studyhighlights important parameters regarding placentalmorphology, along with infection and inflammationassociated during pregnancies, and co-morbid conditionsthat pre-exist in women during pregnancies such asgestational hypertension and heart disease.

Figure 2: Multiple bar diagram showing Risk factors in study group.

Figure 3: Multiple bar diagram showing GA wise predicted and actualplacental weight in study group.

Figure 4: Bar diagram showing comparision of placental thickness inthe study group

Citation: Sawant LD, Venkat S.Study of Placenta in Intrauterine Growth Restricted Pregnancy doi: 10.4103/2278-960X.194509

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Figure 5 : Multiple bar diagram showing type of cord insertion instudy groups

Figure 6 : Multiple bar diagram showing histopathological evolutionof placenta in study group.

Figure 7: Bar Diagram showing fetal outcome in IUGR Fetus

DISCUSSIONA normal placental structure and function is required

for the development of a normal Healthy fetus at theterm. However, if there is an abnormality in placentaldevelopment, then that could hamper fetal growth andwellbeing resulting in severe complication ranging fromIUGR to death of fetus [6,7,11]. IUGR is a commondiagnosis seen in obstetrics patients that increases therisk of perinatal mortality and morbidity [2,3]. In mostinstances, no obvious maternal or fetal cause could beassigned to IUGR, yet gravid mothers present with severeweight loss in fetuses. In such cases, researchers haveimplicated placenta to be culpable in causingdisproportionately low fetal weight resulting in IUGR[2,12] . The placenta is the only vital organ of perinatal life,which can be examined, without hazards to the mother

and the baby. However, the placenta provides aparadox asit is one of the most readily available structures forexamination, but is one of the least known [8,13,14]. In theearlier study, we had compared placental weight in thestudy group and it showed that placental weight innormal pregnancy was significantly higher than that inIUGR. We have also shown that feto-placental weightratio is significantly decreased in IUGR as compare tonormal pregnancy. Also, both maximum and minimumdiameters of placentae were studied and studied showedthat the placental diameters were less in IUGR ascompared to normal fetuses. So, our previous study haveshown that indeed the placental anthropometriccharacteristics such as weight, diameter long with feto-placental weight ratio is closely associated the normalgrowth and development of the fetus [2]. In the presentstudy, 53 placentae from normal pregnancy werecompared with 53 placentae from pregnancies with IUGR.In this study we did measure the placental thickness inthe study group, and we determined that placentalthickness was less in [9] IUGR compare to normal fetuses.However, this difference was not statistically significant.Also, the small difference in the thickness that weobserved between IUGR and normal placentae couldbecome insignificant due to progressive are borization ofthe Villous branching to provide adequate nutrient tosupport normal fetal growth [7]. Placental disc thickness isan indirect measure of the extent of development of thenutrient exchange surface of the placenta essential to itssuccessful support of fetal growth. Any abnormal changein the thickness either thin or thick placentae have beencorrelated to adverse pregnancy outcome [7,15]. We alsostudied the position of umbilical cord insertion in to theplacenta. And we observed that most of IUGR placentaswere with umbilical cord inserted centrally as comparedto marginal. None of the IUGR placentae showedEccentric or villamentous insertion. However studiesdone by Bjoro, and Davis et al. , showed villamentous andmarginal insertion for umbilical cord respectively aremore common in IUGR [6,16,17]. In the histopathologicalexamination we came across more cases of placentalcalcification in IUGR as compare to normal placentae;however, the data was not statistically significant. Wealso noticed the amount of calcification in placenta percotyledons was much higher in IUGR as compared tonormal pregnancy. But this high incidence of calcificationthat we observed in IUGR in our study could be due tomaternal factor such as gestational hypertension [14,18,19].Also based on this study results, we recommend toquantify the calcification in placenta as oppose to justgrossly visualize the presence of calcification, becausequantifying the density of calcification per cotyledon ofthe placenta would correctly determine the extent ofcalcification in placenta from IUGR pregnancies compareto normal pregnancies. Some studies have shown [10]

placental infarction and ischemia in IUGR; however, in ourstudy we could not see any fresh infarction or signs ofischemia in the IUGR placentae. Along with these factors,

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we have also done studies looking for inflammation andinfection in the placenta. We were not able todemonstrate any significant inflammation orcharacteristics of inflammatory process such as leucocyteinvasion profoundly visible in the IUGR placentae [11,14,20].

Earlier studies have shown fibrin deposits, infarcts, andover growth of trophoblastic tissue in IUGR placentae.The study also showed nonspecific inflammation ofplacental villi with loss of vascular bed atsyncytiotrophoblast layer resulting in ischemic damage tothe placenta [12]. Placental ischemia and infarcts wereoften seen in women with hypertension and with theincrease in the severity of toxaemia in pregnancy, all theplacental changes are exaggerated. However, similar formof placental changes can be even found in normotensivewomen [18,19]. Moreover, it has also been demonstratedthat pregnancy with IUGR that is further complicated bymaternal gestational hypertension, shows tremendousaugmentation in placental aging with exponentialdecrease in its functional capacity, leading to an abnormalchanges and placental inflammation [14,19]. Moreover, wealso carried out laboratory tests looking for infectioncommonly affecting placenta and fetal growth, resultingin to IUGR. We tested our patients for TORCH and HIVinfection screening. TORCH screening involves testing forvarious specific antigens for TORCH pathogens. ELISAscreening test was carried out for the HIV infection. Andsince screening tests were negative, no further tests suchas PCR, serology, staining, and culture of placenta weredone. Along with these laboratory investigations, we alsocarried out clinical examination of all the subjectspatients in the study group for any physical signs andsymptoms related to infections. And we did not find anyof the above infections [11] in the IUGR patients in ourstudy groups. These screenings for TORCH and HIVInfections are necessary because these viral infectionscan cause serious harm to the growing fetus. TORCHpathogens that stand for Toxoplasma Gondi others likeTreponema palladium, Parvovirus B19, Varicella zostervirus, Rubella virus, Cytomegalovirus, and Herpes simplexvirus, can even lead to fetal death, organ damage and orserious complications depending on the specificinfectious agents. Rubella or German measles inparticular can affect multiple organ systems such ascataracts, microphthalmia in eye, cardiac defect, andneurologic defects such as deafness, mental retardation.Intrauterine HIV infection can cause seriouscomplications ranging from spontaneous abortion to stillbirth. It can also cause IUGR and preterm birth withneurodevelopmental delay in newborns [21,22]. Also, manyresearchers have shown strong correlation betweenchronic villitis, acute chorioamnionitis, and abnormalvaginal microflora with IUGR. These intrauterineinfections can release various pro-inflammatory cytokinesthat can initiate an inflammatory response resulting inpreterm labor, and injury to the fetal lung and brain alongwith increased risk of developing Type 1 diabetes inchildhood [7,21,22]. Furthermore, in this study, we have

also examined various maternal factors such asgestational hypertension and heart disease that havebeen previously implicated in IUGR [3,5]. In our study,cases of gestational hypertension were seen in IUGRcompare to maternal heart disease; however, due to lesssample size, this data was not statistically significance.The accumulating evidence shows that deviations in birthweight are associated with a host of life long risk thathave improved our understanding of the determinants ofbirth weight essential to appraise major public healthrisks like [12] hypertension and cardiovascular diseaseaffecting communities worldwide [2,4,5]. The number ofdeliveries during the study period was 820 among which53 were fetal grow the stricted pregnancies. Therefore,the incidence in our study was 6.4%, which wascomparatively much lower than average incidence ofIUGR (10-30%) in our specific geographic region of theworld including Southeast Asia [2,4,5]. Subsequently, wealso compared predicted placental weight with the actualplacental weight for that particular gestational agedetermined by USG. And we found that in our studygroup, the actual placental weight was always greaterthan predicted placental weight. Additionally, we alsostudied the fetal outcome in IUGR. The parameters takeninto consideration were jaundice, respiratory DistressSyndrome (RDS), anomaly, infections, and perinatal death.Also we found that only 3.77% fetuses presented withjaundice, 1.89% with RDS, and 1.89% died perinatally.However, majority of the fetuses with 94.3% wereabsolutely normal with no anomaly, infection, and had nocomplications. Thus, in our study the low incidence ratealong with greater actual weight of placenta than thepredicted weight and finally the favourable outcome inpregnancies related to IUGR was due to good obstetriccare, NICU facilities and good health care professionalstaff in the Department of Obstetrics and Gynecology atour hospital that were well trained to manage such highrisk pregnancy and obstetric emergency. Moreover, thesignificance of this article is that the authors of thisresearch study promote a 360° intervention inovercoming this prevalent but preventable public healthissue through better health care professional-pregnantwoman partnership during pregnancy. These all-roundedinterventional strategies are based on good clinicalpractices and preventive medicine foundation that willdemonstrate that [13] early intervention in pregnancyduring antenatal visits by incorporating early assessmentof placental morphology along with histopathologicalexamination for placental infection and inflammation inconjunction with good obstetric and perinatal care canlead to good prognosis in pregnancy with intrauterinegrowth restriction. Moreover, the article alsorecommends that the health care professionals such asphysicians, physician assistants (PA’s), nurses, andmidwives working in the rural and underserved areaswith poor medical infrastructure and clinical facilitiesshould be trained properly to diagnose fetal well-beingon the basis of placental morphological and histological

Citation: Sawant LD, Venkat S.Study of Placenta in Intrauterine Growth Restricted Pregnancy doi: 10.4103/2278-960X.194509

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changes. Furthermore, academically, more emphasisshould be given on incorporating advance knowledgeabout the placental anatomy, pathophysiology andclinical importance in medical curriculum. Therefore, themedical and allied health students from PA, nursing, andmidwifery studies programs will be well versed with theimportance of placenta in determining fetal well-being. Inaccordance with above policy, the authors also suggestthat more basic science as well as clinical researchinvolving in-depth study of placenta in IUGR pregnanciesshould be carried out and presented. It would then serveas an excellent educational tool for medical and alliedhealth care students and budding clinicians by impartingvaluable knowledge about intrauterine fetal growthrestriction along with importance of placenta and itsclinical implications in deciding outcome of thepregnancy. The other important components of this 360degree interventional program are maternal educationand nutrition. This can be achieved through stronger tiesa partnership between health care professionals andpatient population (pregnant women) by bringing thesetwo groups together through initiating health literacy,wellness education, and increasing competency in clinicalpractice. As a part of health literacy [14] program, healthcare professionals such as physician, PA, nurses, andpublic health professionals should initiate dialogue andoffer health counselling for women of childbearing agestating different aspects of normal pregnancy and itscomplications such as IUGR. Also, educating mothers andtheir family members regarding maternal nutrition and itseffects on placental morphology, which in turn will affectthe growth and development of their fetuses, should bepart of the mother-baby wellness program during theirantenatal visits.

CONCLUSIONIn summary, the structural and functional

characteristics of the placenta provide insight into theprenatal health of fetus and mother. Also, we know fromearlier studies that IUGR is serious obstetric complicationand a global health problem especially in less developedregion of the world such as Africa, Latin America, andSoutheast-Asia. Also the public health issues duringantenatal periods such as social factors like maternalpoverty, education, and biological factors such asmaternal nutrition, infection ,inflammation, and otherpredisposing conditions like gestational hypertension canplay a major role in increasing the prevalence andincidence of IUGR in and around this geographicaldistribution [2-5]. Therefore, the significance of thisresearch study is that it reaffirms that best clinicalpractices that includes prompt diagnosis andmanagement can Overcome epidemiological, socio-behavioural and other pathological determinants in IUGRand deliver better obstetric results encompassing bothmaternal and child health. The current study of placentalmorphology at gross and microscopic level along with its

functional status in IUGR is an important indicator ofintra-uterine growth environment irrespective ofantenatal high risk factors. Placental assessment providesa useful [15] parameter against which the relative value ofvarious antenatal tests for insufficiency can be reviewed.Unfortunately, none of these tests in itself is completelyreliable. But, by helping to delineate the problem of IUGRand by assessing extent of placental growth failure,pathological change in the placenta or a combination ofboth, a more basic approach to the problem can beachieved. In addition, it should be possible to examinethe above placental changes in mothers with knownclinical condition and eventually, observe these women insubsequent pregnancies to determine which type ofinsufficiency is likely to recur. Apart from of placentalsize, changes in placental function would also modifyfetal growth. However, in future more studies needed tobe done on various qualitative and quantitative aspectslooking for structural, functional and metabolic changesin placenta in IUGR and incorporating socio-behaviouraland socio-cultural elements affecting maternal health inthe study. Thus, we conclude that the basic study ofplacental morphology and histopathological examinationlooking for placental infection and inflammation in IUGRcarried out by skilled medical professionals’ forms anintegral part of good prenatal and obstetric care. Thisclinical intervention during pregnancy along withmaternal wellness program including reproductive healthliteracy would provide a unified action encompassing 360degree interventional program targeted towardscurtailing IUGR, and promoting favourable fetal outcomein pregnancy. Acknowledgements We would like to thankthe administration of Grant Medical Foundation, Ruby HalClinic, Pune, India, for the approval, and the staffmembers from the Department of Obstetrics andGynecology, Ruby Hall Clinic for their co-operation insuccessfully completing this research study [16].

DISCLOSUREAuthors have no conflict of interest to disclose.

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