Maternal Floor Infarction and Massive Perivillous Fibrin Deposition: Histological Definitions, Association with Intrauterine Fetal Growth Restriction, and Risk of Recurrence

Abstract

Maternal floor infarction (MFI) is a poorly understood placental lesion reportedly associated with intrauterine growth restriction (IUGR) and recurrence. In this study of MFI and the related placental disorder, massive perivillous fibrin deposition (MFD), semiquantitative histologic criteria for these diagnoses are defined and rates of IUGR and recurrence are assessed. Pathologic slides of 80 placentas diagnosed as MFI or MFD at the Brigham and Women's Hospital (1989-99) were reviewed and reclassified as classic MFI, transmural MFD, borderline MFD, or neither MFI or MFD. The prevalence of IUGR was determined, and placental slides from additional pregnancies were reviewed to evaluate recurrence. Among 25 cases originally diagnosed as MFI, 5 (20%) were reclassified by study criteria as classic MFI, 9 (36%) as transmural or borderline MFD, and 11 (44%) as neither lesion. Among 55 cases originally diagnosed as MFD, 27 (49%) were reclassified as transmural or borderline MFD, 4 (7%) as classic MFI, and 24 (44%) as neither lesion. IUGR was identified in no case with classic MFI, in 31% of cases with transmural or borderline MFD (P = 0.02), and in 11% of cases with neither lesion. Recurrence was documented in 1 of 7 (14%) second- or third-trimester placentas. Possible recurrence was suggested in 3 of 6 (50%) first-trimester spontaneous abortion specimens. Classification of intraplacental fibrin is subjective and problematic; almost half of potential cases of MFI or MFD did not fulfill our study's diagnostic criteria. MFD may be more common and more strongly associated with IUGR than classic MFI. Recurrence of these lesions appears to be infrequent among second- and third-trimester placentas, but may be relatively common in first-trimester spontaneous abortions.

Evidence of an imbalance of angiogenic/antiangiogenic factors in massive perivillous fibrin deposition (maternal floor infarction): a placental lesion associated with recurrent miscarriage and fetal death

“…4 Naeye et al described an association between MPFD and stillbirth as well as fetal growth restriction. 4 Subsequently, additional case reports and case series have reported this pathologic finding in pregnancies with spontaneous abortion, 1, 5 spontaneous preterm delivery, 2, 5 and early-onset fetal growth restriction. 2 In a case-series reported by Andres et al, among 60 pregnancies with MPFD, the prevalence of fetal death was 40% and among the live-born infants, 40% delivered preterm and 58% had birthweights below 10 th percentile for gestational age.…”

“…1 This condition was first described by Benirschke and Driscoll in 1967 and its frequency is 0.09-0.5%. 1-4 MPFD is associated with recurrent serious adverse pregnancy outcomes including spontaneous abortion, 1, 5 fetal growth restriction, 1, 2, 4, 6-12 and fetal death.…”

“…1 This condition was first described by Benirschke and Driscoll in 1967 and its frequency is 0.09-0.5%. 1-4 MPFD is associated with recurrent serious adverse pregnancy outcomes including spontaneous abortion, 1, 5 fetal growth restriction, 1, 2, 4, 6-12 and fetal death. 2, 4-7, 10, 11, 13-16 The proposed etiologies include autoimmunity (such as anti-phospholipid 6, 10, 11 or anti-urokinase antibodies) 6 and cytotoxicity due to proliferation of “X-cells” which are extravillous trophoblasts that can produce major basic protein similar to that of eosinophil granules.…”

“…3, 14 Subsequently, Katzman and Genest proposed to subdivide this pathologic condition into 3 categories: 1) maternal floor infarction (MFI); 2) transmural MPFD; and 3) borderline MPFD. 1 The diagnosis of MPFD in the current study required the identification of fibrinoid material encasing at least 50% of the villi on a minimum of one slide, and included either cases with fibrinoid material only on the maternal floor of the placenta or cases with transplacental fibrinoid deposition (extending from maternal to fetal surfaces). Therefore, MPFD cases included in the current study would have been classified as either classic MFI or transmural MPFD, but we did not include cases that would be in the borderline MPFD category, as described by Katzman and Genest 1 .…”

Correlation of preterm infant illness severity with placental histology

“…Maternal malperfusion was delineated by four features: placental size ≤10 th percentile, distal villous hypoplasia, severe maternal decidual vasculopathy (fibrinoid necrosis and/or acute atheromatous changes) and ≥2 infarcts [14]. Full thickness perivillous fibrin was noted when at least one slide demonstrated an exaggeration of Langhan’s stria encasing both stem villi and regional distal villi from the chorionic plate to basal fibrin [15]. Two features of chronic inflammation (chronic chorionitis and basal chronic villitis, and parenchymal chronic villitis), were chosen as features of an aberrant maternal immune response.…”