Placentitis

Placentitis is an inflammation of the placenta that occurs under the influence of non–infectious and infectious factors. Pathology of the placenta can manifest itself at any time, the symptoms depend on the severity of inflammation. Placentitis leads to dysfunction of the fetoplacental complex, its outcome is placental insufficiency, fetal development delay, intrauterine infection. The risk of premature birth and death of a newborn increases significantly. Ultrasound is used for diagnosis, which allows you to notice a violation of the structure of the placenta, placental blood flow. Placentitis is treated with antibiotics, as well as drugs that improve the function of the placenta.

ICD 10

O43.8 Other placental disorders

General information

Placentitis is an infectious and inflammatory disease, most often the result of the upward spread of infection. In 98% of women, it leads to an unfavorable course of pregnancy and the development of complications. The threat of termination associated with placentitis is noted in 76% of pregnant women. In most cases, the fetus suffers from intrauterine hypoxia, 9% of children are born with signs of hypotrophy. Infection causes untimely outpouring of water in 38% of pregnant women, in a third of women this leads to anomalies of labor activity. The risk of intrauterine infection exists in 6% of children who develop placentitis.

Causes

All pregnant women have physiological immunosuppression caused by increased progesterone production. In the presence of foci of chronic or acute infection, it can spread to the placenta. Most often, infection occurs in an ascending way from the vagina through the cervix. Placentitis is caused by various types of microorganisms and the action of non-infectious factors:

• Bacteria. In women with placentitis, group B streptococci (Streptococcus agalactiae) and other pyogenic bacteria are found in the genitourinary tract. The causative agents of placentitis can be listeria, spirochetes. Mycobacterium tuberculosis penetrates the placenta hematogenically and causes specific inflammation.
• Viruses. In 7-25% of cases of viral placentitis, the cause of inflammation is the herpes simplex virus. Morphological changes in the type of placentitis are characteristic of parvovirus (B19V), respiratory syntial infection, cytomegalovirus, HIV infection.
• The simplest. The cause of placentitis may be toxoplasmosis. In pregnant women, the infection can occur in an acute or asymptomatic form, leading to severe complications. Placentitis caused by malarial plasmodium is rarely recorded. This infection is typical for hot countries, infection of a pregnant woman can occur during travel.
• Non-infectious causes. The inflammatory response of placental tissues is possible with a change in the pH of amniotic waters, which is normally 7.0-7.5. With acute or chronic fetal hypoxia, premature aging of the placenta, post term pregnancy, placentitis leads to the appearance of meconium in the amniotic fluid.

Pathogenesis

Inflammation can occur in different layers of the placenta. The inflammatory reaction is accompanied by migration of leukocytes and infiltration of tissues, circulatory disorders caused by microthrombosis of the interstitial space, microinfarcts, ischemia of the terminal villi. The fullness and swelling of the stroma is also determined. Depending on the involved layer , the following forms of placentitis are distinguished:

• Basal deciduitis is an inflammation in the basal plate of the placenta. It is characterized by necrotic changes, cell dystrophy, proliferative changes in the walls of spiral arteries and veins.
• Intevillusitis – placentitis of the interstitial space, focal lesion of part of the villi with migration of inflammatory cells.
• Villusitis is an inflammation of chorionic villi, can be terminal or stem, depending on the type of damaged structures.
• Placental chorioamnionitis is a more severe form, which is accompanied by intervillusitis and angiitis of the umbilical cord vessels.

Placentitis does not always lead to infection of the fetus, but it can affect the condition of the endometrium after childbirth and worsen the prognosis for subsequent pregnancies. At the same time, an intrauterine infection in a child may occur without signs of placentitis. This variant of the course is observed in some viral infections. Each type of pathogen is characterized by its own histological picture.

Symptoms

Pathology can be a consequence of acute or chronic infection. It has no specific manifestations, with a latent course, symptoms may not be present at all. Given the ascending path of infection, a pregnant woman may be concerned about vaginal discharge. They can be white, with a yellowish or grayish tint, with or without an unpleasant odor. In the acute course of vaginitis, dysuric disorders appear due to the close location of the urethra. A woman complains of unpleasant sensations during urination, trips to the toilet are becoming more frequent. Discharge is accompanied by itching and burning, redness of the labia.

Pain in the lower abdomen is a consequence of inflammation. With placentitis and the threat of premature birth, pain appears in the lower part of the uterus. They are pulling, aching, can give in the perineum or lower back. The appearance of the threat of termination of pregnancy is indicated by the tone of the uterus, cramping pain. The fetus reacts to the lack of oxygen by increasing motor activity or reducing the number of movements. Alertness should be caused by the leakage of amniotic fluid or their prenatal outpouring. This is an occasion to urgently seek medical help in the gynecological department for up to 22 weeks, and at a later date – in the maternity hospital.

Complications

Placentitis causes pregnancy complications, some of them become indications for early delivery. Every 5th pregnant woman has a premature discharge of amniotic fluid. Pregnant women with placentitis are characterized by placental insufficiency. With decompensation of the condition, the fetus develops acute hypoxia, which can lead to antenatal death or severe damage to the child’s central nervous system. The earlier placentitis occurred, the higher the probability of severe complications. The course of pregnancy can be complicated by gestosis, intrauterine infection of the child, premature birth.

Diagnostics

In case of a violation of well-being, abdominal pain, the appearance of discharge from the genital tract of a pregnant woman, it is necessary to consult an obstetrician-gynecologist, with whom she is registered. The scope of diagnostic procedures is selected individually, based on clinical manifestations, anamnesis data and previous studies. The basic diagnosis of placentitis is carried out by noninvasive instrumental methods:

• Gynecological examination. There are pathological vaginal discharge, signs of inflammation in the form of edema and hyperemia of the mucosa. But with viral placentitis, there may be no changes in the genital tract. With the threat of termination of pregnancy, blood is released from the cervix. The presence of a clear liquid in the vagina indicates the leakage of water. If there was an antenatal outpouring of water, the adjacent part of the fetus descends into the pelvic cavity and is well palpated.
• Obstetric examination. The uterus is in high tone, excitable. With long-term placentitis, in severe cases, there may be a lag in the size of the uterus from the gestation period, which indicates intrauterine developmental delay. The muffled tones of the fetal heart speak of hypoxia. The absence of a heartbeat and stirring is a sign of antenatal death.
• Ultrasound of the fetus. The thickening of the placenta, cystic cavities, calcifications are determined. At an early stage, there may be an expansion of the interstitial space. An unfavorable sign is segmental contractions of the uterus, signs of aging of the placenta. With the development of fetoplacental insufficiency, the fetus lags behind in size from the gestation period, its motor activity is reduced.
• Dopplerometry of placental vessels. Hemodynamic disorders are recorded. With placentitis, which affects the fetal or maternal part of the placenta, its hypovascularization is noted. In diffuse placentitis, a compensatory reaction leads to hypervascularization of the placenta. The severity of placentitis is judged by the index of vascularization and blood flow.
• Laboratory diagnostics. In the general blood test, signs of inflammation are acceleration of ESR, an increased number of white blood cells. Viral placentitis is characterized by an increase in lymphocytes. In the leukocyte formula, there is a shift to the left due to the formation of young forms of leukocytes. A biochemical blood test shows an elevated C-reactive protein.
• Placentitis after childbirth is confirmed. The fetal place with membranes and umbilical cord is sent for histological examination. According to its results, it is possible to assume the type of infection if the examination was not carried out during pregnancy. For normal recovery in the postpartum period and prevention of endometritis, treatment is prescribed.

Treatment

A woman with placentitis is hospitalized for a qualitative examination, treatment and choice of obstetric tactics. Conservative therapy is justified in case of premature pregnancy and signs of an immature fetus, but while maintaining its normal hemodynamics. With non-canceling acute fetal hypoxia and in other severe cases, early delivery by caesarean section is indicated. With placentitis , it is carried out:

• Antibacterial therapy. Broad-spectrum antibiotics from the group of protected penicillins, cephalosporins, macrolides are used. In severe conditions, they are injected with a subsequent transition to oral forms. The course is 7-14 days. Antibiotics are necessarily prescribed with an anhydrous interval of more than 12 hours for the prevention of chorioamnionitis.
• Tocolytics. They are necessary to reduce the tone of the uterus and prolong pregnancy. Magnesium sulfate is prescribed drip, the use of hexaprenaline is allowed as an emergency remedy. But according to clinical recommendations, preference is given to phenoterol. Tocolytics are not used after the outpouring of water.
• Glucocorticoids. They are prescribed in cases where there is a high probability of early delivery or after the discharge of waters for a period of less than 36 weeks. They are necessary to accelerate the maturation of the fetal lungs and prevent the disease of the hyaline membranes of the newborn. The scheme and duration of therapy is selected individually.
• Antiplatelet agents and anticoagulants. They are necessary to improve blood flow in the placenta, prevent thrombotic complications. Apply curantil, pentoxifylline in tablets for a long course. According to indications, low-molecular-weight heparins are prescribed in the form of injections. The use is discontinued 2 weeks before the expected delivery.

Prognosis and prevention

With placentitis, the prognosis depends on the duration of the development of inflammation and the body’s ability to compensate for vascular disorders. For the fetus, placental insufficiency increases the risk of developmental delay, intrauterine infection and hypoxia, which can result in intrauterine death. Prevention of placentitis consists in pre-gravidar preparation, timely treatment of chronic inflammatory processes of the genitals. Smears for vaginal cleanliness, which are taken when registering, allow you to notice inflammatory changes in time, conduct additional examination and treatment.