Study of Placental Chorangiosis in a Tertiary Care Centre

Background: Chorangiosis is a condition in which the number of vascular channels in the noninfarcted, nonischemic areas of the placenta increases dramatically. Chorangiosis rarely occurs in normal pregnancies. Aims: To study the demography, maternal and fetal causes of chorangiosis. Study Design: A retrospective descriptive study. Place and Duration of Study: Total of 73 patients with chorangiosis were studied in Department of Pathology Saveetha Medical College,during the period ofAugust 2020 and February 2021. Methodology: Study included 73 patients of placental chorangiosis.The clinical history and demographic data was obtained from the patient’s medical records.Thematernal and fetal causes were studied, and clinico-histopathological correlation was done. Results: This study includes 73 postnatal women,of whichthe rate of cesarean section was noted to be 69.8% and the mean value were obtained showed mean gestational age of 37.5 weeks, 70 live births and 3 neonatal deaths; mean placental weight is 480 grams and birth weight 3970grams.The mean 1 minute and 5 minutes APGAR score is reduced indicatingdisturbance in fetal vitals immediately after birth. Original Research Article Vanishree et al.; JPRI, 33(63B): 92-97, 2021; Article no.JPRI.75846 93 Conclusion: Chorangiosis is a rare illness, which is associated with an increased risk of prenatal and neonatal morbidity and mortality.So, it should be regarded as a key prognostic indicator of poor pregnancy outcomes and should be essentially reported in the histopathological evaluation.


INTRODUCTION
Chorangiosis is a condition in which the number of vascular channels in the noninfarcted, nonischemic areas of the placenta increases dramatically. More than 10 capillaries in more than 10 villi in several areas of the placenta is the traditional description [1]. It's a rare discovery that's usually described as a compensatory response to chronic hypoxia [1], but it's associated to a variety of illnesses, including diabetes, hypertension, and tobacco use.Incidence is higher in women living at high altitudes, in maternal anemia and in smoking women.Also associated with placental abnormalities such as placental abruption, amnion nodosum, villitis and umbilical cord anomalies. Chorangiosis rarely occurs in normal pregnancies. However, its prevalence is 5-7% of all placentas from infants admitted to newborn intensive care units [2] The present study was aimed at determining the association of chorangiosis with pregnancy complications and perinatal outcomes.

METHODOLOGY
A retrospective descriptive study was carried out in line with research regulations. Total of 73 patients with chorangiosis were studied in Saveetha Medical College, during the period of August 2020 and February 2021.The clinical history and demographic data was obtained from the patients medical records. The maternal and fetal causes were studied, and clinichistopathological correlation was done.

RESULTS
Demographic data was obtained from the patient's medical records and clinical findings.
The demographic profile of the 73 chorangiosis cases with complete information is summarized in Table 1. The obstetric outcomes are summarized in Table 2. The rate of cesarean section was noted to be 69.8% with the most common indication being nonreassuring fetal heart rate. Majority of neonates were delivered at term with the average gestational age of 37.5 weeks.
In Table 3 the mean value were obtained showed mean gestational age of 37.5 weeks, 70 live births and 3 neonatal deaths; mean placental weight is 1890 grams and birth weight 3970 grams. In Table 4 the mean value in various gestational age were given showing placental weight and fetal birth weight increases in higher gestational age groups. The mean 1 minute and 5 minutes APGAR score is reduced indicatingdisturbance fetal vitals immediately after birth.Moreover, 1 minute APGAR score is less than 5 minute APGAR score.

DISCUSSION
Chorangiosis is a vascular abnormality in the placenta that affects the terminal chorionic villi. It's caused by long-term, low -grade hypoxia in the placenta, and it is associated with intrauterine growth restriction (IUGR), diabetes, and gestational hypertension throughout pregnancy. Major fetal complications are congenital anomalies or low Apgar index, neuro-compromise, fetal growth restriction, neonatal death. Maternal complications are placental as well as umbilical cord abnormalities including excessively long umbilical cords, true knots, and excessively twisted umbilical cords have also been associated with umbilical cord thrombus.Most common complications are cord compression and circulatory stasis rather than Umbilical vein thrombosis [3].
These findings are associated with fetal, maternal, and placental disorders including preeclampsia, diabetes, hypertension, major congenital anomalies, air pollution, and smoking and has been correlated with fetal morbidity and mortality rates as high as 42% [1]. In recent studies, the pregnancy outcomes are much improved over those suggested by Altshuler in 1984. Adverse events in ourstudy, such as neonatal death at 24 weeks of gestation, are accountedas prematurity without need to invoke chronic hypoxia Suzuki et al. [4] found an association between maternal blood oxygen saturation in intervillous gaps and the development of chorangiosis by using placental tissue oxygen index values [5]. They postulate that low efficiency of oxygen transfer from maternal to fetal circulation facilitates vascular remodeling in adaptation to low oxygen supply, resulting in chorangiosis.
Placental weight and birth weight of the neonate are widely available measures. The ratio of these two variables is a useful marker of foetal nutrition and utero-placental function [6].
The mean placental weight of 480 g in this study is lower compared to 590 g in Panti AA et al. [7] study (Nigerian study) The variations in the mean weight of the placenta may be due to variations in the methodology of preparing and weighing the placenta together with cord clamping time [8].
The mean birth weight of the neonate in this study (3970 g) is higher than 3275g in Panti AA et al. [7] study(Nigerian study) These differences in mean birth weight may be due to altitude; maternal nutrition and maternal diseases [9].
The mean PBWR (placental weight to birth weight ratio) of 14.6% in this study is lower than18.2% as reported in Panti AA et al. [7] study(Nigerian study) An abnormally high PBWR (i.e., low fetal weight relative to the placental weight) is thought to indicate an abnormal placenta with impaired function as in human immune deficiency virus infection, obesity, maternal anemia, cigarettes smoking and low socioeconomic status [10][11][12][13][14][15]. We have shown that cesarean delivery is enriched in patients with placental chorangiosis; however, chorangiosis is not the direct cause. Chorangiosis is a placental marker of antepartum low-grade chronic hypoxia; thus, clinical correlation of entities that may contribute to hypoxia is suggested [16][17][18][19][20][21].  Fetal growth restriction III.
Neonatal death IV.
Congenital malformations

Microscopic features
Normal placenta has Normal villi rarely having > 5 capillaries / villous Criteria for chorangiosis is Altshuler criteria: > 10 capillaries in at least 10 terminal villi in ≥ 10 noninfarcted areas in at least 3 low power fields of the placenta (Fig .1).Capillaries have distinct basement membranes but are not surrounded by a continuous layer of pericytes or associated with stromal fibrosis. Sometimes it may be associated with delayed villous maturation, chorangioma(s), villitis of unknown etiology,fetal vascular malperfusion.

CONCLUSION
Chorangiosis is a rare illness, which is associated with an increased risk of prenatal and neonatal morbidity and mortality.So, it should be regarded as a key prognostic indicator of poor pregnancy outcomes and should be essentially reported in the histopathological evaluation.

CONSENT
It is not applicable.

ETHICAL APPROVAL
This study was approved by Ethics Committee of Saveetha Medical and Hospital. As this study was a retrospective study, there was no patient's privacy data such as patient name, ID number, telephone and address were involved. Only demographic information and laboratory testing data of patients were collected and analyzed in this study.