PATHOLOGY EXAMS ARE VALUABLE
Patients: You most often do NOT hear your doctors (OB-Gyn or pediatrician) discuss the pathology report of your baby's placenta! And there is an excellent reason for this. In too many instances, the information causes unwarrented concerns and confusion (see below). Most patients are not emotionally or informationally (they have NO understanding of false positive or false negative [URL = http://www.theeffectivetruth.info/falseposneg.html] diagoses) able to handle the information. EXAMPLE: the clinical (pre-delivery presumptive diagnosis) of acute chorioamnionitis (bacterial infection of the placenta) is low. The broadest category of manifestation is pre-term delivery which the CDC says is 10% in the USA (25% of those pre-term placentae were negative for the histopathological diagnosis of acute chorioamnionitis of any degree)1. This suggests that the maximum incidence of clinical acute chorioamnionits is 7%; whereas, we...below...found an 8% histopathological incidence among just the placentae that would ordinarily have been discarded (had no order by the OB for a pathology exam) without an histopathological exam. So, at least 8% of pregancies would false-negatively have been classified as normal! Yet, could the majority of these occult acute chorioamnionitis cases have no clinical consequence and actually be a variant of normal?
We have followed the evolution of
the importance of placenta pathology exams since 1978 when I took Dr. Doug Shanklin's course in "pathology of the placenta". Pathology residency training programs prior
to that time gave practically no teaching on placental pathology. Most hospitals froze the
placentas for reagent companies ( a sort of primitive form of recycling...before the days of
recycling in our general society) for a tiny reimbursement (which was less than a disposal fee) that was put into a Labor and Delivery fund for special employee events.
A nationwide consensus conference of all
specialties having anything to do with births and placentas was convened in Atlanta in 1990
(attended by our Drs. Shaw & Carter). Recommendations were drafted. The coverage for
placenta exams had already been forefront at Lexington Medical Center, a hospital which
already had Women's Hospital of Lexington.
This URL = http://www.theeffectivetruth.info/placenta.html
OUR FOUR-MONTH STUDY: Our pathology group was challenged by several
obstetricians to develop a process for the pathologic examination...including standardized
microscopic exams...of every placenta from every delivery. In a 4 month period of 1994, 677 placentas were so
examined, only 104 having been "doctor-ordered" (15%). At no financial charge to the patient,
the other 573 were examined without a doctor's order. Of those 573 (which would have here-to-fore been
disposed of), 48 (8%) had unmistakable, unequivocal evidence of chorioamnionitis. Maternal
records review indicated that 26 of the 48 cases (54%) were from pregnancies and labor and
delivery which appeared to be normal (except that 18 failed to progress in labor on their
own.... 9 having labor augmented and 9 having C-section). Therefore, the other 8 of those 26 were entirely normal. It
had been previously presumed that placentae from nearly-normal-to-normal pregnancies were
always normal. We use agar pre-embedding to place 3 sections of cord in one block & with black agar marker desinating one cord end. We never did formally publish our results.
Too much information!...who (among patients) can handle it? But after the study, the doctors felt that the exam of all placentas
was problematic because: (1) the abnormalities were often probably clinically trivial; (2)
the expense of the pathology exam would unwarrantedly add to the overall cost of medical
care; and, (3) there was no standard knowledge base from which to explain to the mother about
the wide variety of findings in "abnormal" placentas BUT in apparently normal pregnancies. A few
doctors had faced hysterical responses from mothers who were frightened by the "diagnoses
of uncertain clinical significance". So, the all-placentas-pathology-exam program was
discontinued. We then performed exams only on those cases sent to pathology by the doctor's order and, later, by departmental protocol criteria.
We then perform a good-faith complete exam especially to rule out occult abnormalities which
could be overlooked because (1) everyone's attention was on an obvious problem such as a
retroplacental clot or (2) that important abnormality was not interpretable...or even
visible...to the naked eye. [a case]
Ironically, the federal government was, at that
very time, creating Pap smear
regulations that would create whole categories of "atypical cells of uncertain
significance" which would drive all of us doctors crazy for at least half of a
decade...because no one could properly & consistently explain the significance to every
In about 2010, the CDC stimulated neonatologists
to use antibiotics with babies born (1) under certain circumstances and/or (2) born to
mothers with certain situations. If pathology could execute a rapid microscopic exam to
diagnose or exclude a diagnosis of acute chorioamnionitis, then the baby could go home under
proper antibiotic therapy or with safe discontinuation of antibiotic therapy. With our
pathology group's prompt help, our hospital quickly adopted this standard. A brief write-up of the evolution of our program is HERE.
False positive vs. false negative: A histopathological study...above...of every single placenta delivered at our central S. C. hospital during a four (4) month period in 1994 was never formally published. Case volume = 677 placentae, 573 of which were examined in the absence of "doctor's orders". Unmistakeable, unequivocal histopathological acute chorioamnionitis (ACA) was found in 48 of those 573 (an 8% incidence in the group of placentae which would ordinarily have been discarded with any pathology exam at all...an 8% incidence of subclinical ACA in "normal" deliveries). "Normal delivery" was a false negative designation but with the ACA diagnosis possibly being a "false positive" in that it fails to predict any as-yet-known adverse consequence in the baby or mother. Though no charge was made for pathology services on the 573, we had a number of OBs complain to us verbally that they resented the UNREQUESTED diagnoses we found when they had already informed the mothers that everything about their hospitalization had gone normally & the difficult position we had put them in as they deliberated each time over whether to share with the patient or not.
Most of this page is posted on YouTube (search YouTube using the search term "all placentae pathology exam"). Our pathology group has a website with
considerable placenta information, with beginning index [here].
- CDC Study, 2015 Incidence of Pre-term Delivery (URL = https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm , HERE.
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(posted 8/3/98; latest addition 30 July
2015; latest adjustment 10 February 2017)