Successful pregnancy following treatment of recurrent chronic histiocytic intervillositis

Abstract

Chronic histiocytic intervillositis (CHI) is a rare placental lesion associated with adverse obstetric outcomes and high recurrence rate. We report a case of six consecutive pregnancies in one woman, where CHI was detected following an intrauterine death in the fifth pregnancy, after being missed in four earlier losses. The successful sixth pregnancy was treated with a combination of immunosuppressive and antithrombotic agents. While low-molecular-weight heparin (LMWH) and aspirin had been shown to improve pregnancy outcome in recurrent pregnancy loss, there was limited evidence of improved outcome in CHI. It has been suggested that CHI may result from a maternal immunological process and there have been a few reports of the use of corticosteroids because of this possibility, though without convincing evidence of efficacy. We too tried a corticosteroid, in combination with LMWH and aspirin. Comparative histopathological analysis of the placentae supported post-treatment effectiveness of our intervention strategy.

Placental pathologic lesions with a significant recurrence risk – what not to miss!

“…Recurrences have been reported to range from nearly 70% to 100% although was noted less frequently at 18% in one large study . Recurrences often present at earlier gestational ages than the initial case . Treatment clearly seems to decrease recurrence and some complications.…”

“…We have noticed that in early gestations, the involvement is generally limited (Fig. B) and is often only ‘picked up’ upon review after a recurrence . Early cases often have a more conspicuous fibrin component .…”

“…The clinical diagnosis can be suggested with a maternal history of a previous affected pregnancy, early onset and severe IUGR, and potentially elevated serum markers. Due to the high incidence of some type of poor outcome many clinicians opt for early delivery or early treatment with immunosuppressive or antithrombotic therapy .…”

Chronic histiocytic intervillositis in three consecutive pregnancies in a single patient: Differing clinical results and pathology according to treatment used

“…The current evidence, however, is still insufficient to enable the drawing of conclusions as to the practical management of CHI, especially given that the efficacy of each treatment remains unclear. Reports of CHI occurring more than twice in a single patient are rare . The detailed clinical description of the present case provides useful information for managing and understanding CHI.…”

“…In the seventh pregnancy better clinical results were obtained when the extent of the affected areas was restricted by replacing heparin with immunosuppressive therapy. Although the evidence remains limited, immunosuppressive treatments are thought to be effective because a maternal immunological dysfunction such as allogeneic humoral rejection is most likely the etiology of CHI . In five previously reported cases complicated by more than two occurrences of CHI, four patients successfully gave birth on prednisone or combined treatment including prednisone, but one patient had repeated, severe, early onset FGR despite receiving prednisolone plus LDA .…”