Placenta
Nonneoplastic placental conditions and abnormalities
Noninfectious
Decidual arteriopathy


Minor changes: 4 April 2021

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PubMed Search: "Decidual vasculopathy"

Jasmine Steele, M.D.
Jonathan L. Hecht, M.D., Ph.D.
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Cite this page: Steele J, Hecht JL. Decidual arteriopathy. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/placentadecidualvasculopathy.html. Accessed April 19th, 2021.
Definition / general
  • Pattern of injury to maternal vessels of the decidua that occurs in late pregnancy
  • Features thickening or fibrinoid necrosis of the vessel wall, endothelial swelling and detachment, loose collection of perivascular lymphocytes
Essential features
  • Closely associated with preeclampsia and fetal growth restriction
  • 2 forms: early / hypertrophic type and advanced / severe type with fibrinoid necrosis
  • Alteration is independent of endovascular trophoblast and is best seen away from the placental bed in the membrane roll
  • Likely caused by excess antiangiogenic proteins secreted by trophoblast
Terminology
  • Decidual arteriopathy
  • Decidual vasculopathy
ICD coding
  • ICD-10:
    • O43.109 - malformation of placenta, unspecified, unspecified trimester
    • O36.5190 - maternal care for known or suspected placental insufficiency, unspecified trimester, not applicable or unspecified
Sites
  • Decidua along the placental membranes
Pathophysiology
  • Represents chronic endothelial injury and remodeling in maternal vessels, usually in the setting of preeclampsia or growth restriction with maternal vascular malperfusion
  • Early lesions (hypertrophic type) show mural thickening due to continuous endothelial damage and repair
  • Endothelial damage is caused by trophoblastic secretion of circulating soluble antiangiogenic factors that accumulate in the amniotic fluid, such as soluble fms-like tyrosine kinase (sFLT) and soluble endoglin (sENG), in response to oxidative and hypoxic stress; local inflammatory cytokines such as interferon (INF) gamma may also play a role
  • Independent of trophoblast conversion of spiral arterioles in the implantation site
    • Although both processes are associated with maternal vascular malperfusion, decidual arteriopathy is not a failure of physiologic transformation of spiral arteries
    • Failure of physiologic transformation of spiral arteries involves direct contact between endovascular trophoblast in the implantation site
    • Decidual arteriopathy is a paracrine effect in the decidua of the free membranes (Am J Obstet Gynecol 2017;216:287.e1)
  • Decidual arteriopathy is not a form of hypertension related vascular remodeling; wall thickening in early lesions of decidual arteriopathy is accompanied by loss of smooth muscle (loss of desmin staining) rather than hypertrophy as seen in chronic hypertension
  • Form of hypertrophic decidual arteriopathy has been noted in patients with chronic hypertension unrelated to preeclampsia or growth restriction; such lesions do not seem to progress to acute atherosis
Etiology
Diagnosis
  • Histologic examination of the membranes
Gross description
  • Sections of membrane roll should be taken in areas of preserved decidua (roughened surface of the membranes)
  • Affected vessels may appear prominent on transillumination of the membranes
Microscopic (histologic) description
  • 2 forms: hypertrophic decidual arteriopathy (HDA) and severe decidual arteriopathy with fibrinoid necrosis (SDA)
  • Hypertrophic decidual arteriopathy:
    • Small arteries with thickened walls, swollen endothelial cells that detach into the lumen and a sparse collection of perivascular lymphocytes
  • Severe decidual arteriopathy:
    • Characterized by fibrinoid necrosis of vessel wall (amorphous eosinophilic vessel wall)
    • With or without foamy macrophages (atherosis)
  • Reference: Placenta 2016;42:37
Microscopic (histologic) images

Contributed by Jonathan L. Hecht, M.D., Ph.D.
Normal decidual vessel at 37 weeks

Normal decidual vessel at 37 weeks

Normal muscular decidual arteriole at 8 weeks

Normal muscular
decidual arteriole
at 8 weeks

Normal muscular decidual arteriole at 8 weeks (CD34)

Normal muscular
decidual arteriole
at 8 weeks (CD34)

Hypertrophic decidual arteriopathy

Hypertrophic decidual arteriopathy

Hypertrophic decidual arteriopathy (CD34)

Hypertrophic decidual arteriopathy (CD34)

Severe decidual arteriopathy

Severe decidual arteriopathy



Contributed by Yan Lemeshev, M.D.
Atherosis with fibrinoid necrosis

Atherosis with fibrinoid necrosis

Immunofluorescence description
  • Immunofluorescence is not used for clinical diagnosis
  • Characteristic staining pattern is endovascular deposition of immunoglobulin, complement and perivascular leakage of fibrin
  • Atherosis with deposition of IgM and C3 resembles vascular lesions in transplant rejection, suggesting maternal antifetal rejection (Placenta 1983;4 Spec No:489)
    • However, this pattern can also be seen in the context of diabetes and chronic hypertension due to local intravascular coagulation (Am J Obstet Gynecol 1981;141:773)
Positive stains
Negative stains
Videos

Placental lesions

Sample pathology report
  • Singleton placenta at _ weeks gestational age; _ g (_ percentile):
    • Membranes with decidual arteriopathy
Differential diagnosis
  • Normal muscular decidual arteries:
    • Thick muscular walls
    • Lack endothelial disruption and perivascular lymphocytes
    • Highlighted with desmin
Board review style question #1

34 year old woman who is pregnant with her third child and has 2 children (G3P2002) presents at 39 weeks for delivery. Histologic examination of the membrane roll reveals small arteries with detached endothelial cells and a perivascular lymphocytic infiltrate. Which immunohistochemical stain would best highlight the fragmentation of smooth muscle within the vessel walls?

  1. Caldesmon
  2. Desmin
  3. MyoD1
  4. Myogenin
  5. Smooth muscle actin
Board review style answer #1
B. Desmin

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Reference: Decidual arteriopathy
Board review style question #2
32 year old G3P1102 presents at 39 weeks for delivery. Histologic examination of the membrane roll reveals small arteries with detached endothelial cells and a perivascular lymphocytic infiltrate. Which predisposing factor is this mother most likely to have?

  1. Gestational hypertension
  2. Increased exercise during pregnancy
  3. Infection during pregnancy
  4. Low body weight
Board review style answer #2
A. Gestational hypertension

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Reference: Decidual arteriopathy
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