Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Placental pathology varies in hypertensive conditions of pregnancy


This study was a comprehensive analysis of placental phenotypes in hypertensive conditions of pregnancy, including recently described placental hypoxic lesions and lesions of shallow placentation. To this end, consecutive placentas from > 21 weeks pregnancies that were signed out by the author at 4 tertiary care centers on 3 continents were included. Twenty-four clinical and 50 placental phenotypes were studied in 6 groups and statistically compared: 91 cases of gestational hypertension, 187 cases of mild preeclampsia, 211 cases of severe preeclampsia, 84 cases of HELLP or eclampsia, 127 cases of chronic hypertension, and 55 cases of preeclampsia superimposed on chronic hypertension. Twenty percent of the placental and clinical phenotypes were statistically significantly different between the groups. Gestational hypertension and chronic hypertension distinguished themselves by having the highest perinatal mortality, lowest cesarean section rates, highest acute chorioamnionitis, and highest fetal vascular ectasia but conspicuously fewer differences in hypoxic and thrombotic lesions. The preeclamptic groups showed the highest rates of decidual arteriolopathy (both hypertrophic and atherosis), uterine pattern of chronic placental injury, villous infarctions, and clusters of maternal floor multinucleate trophoblasts. Based on placental pathology, severe preeclampsia may be more of a placental disease and mild preeclampsia more of a maternal disease; however, the significant overlap among the groups does not make the difference absolute, and the occurrence of decidual arteriolopathy in gestational hypertension and chronic hypertension may indicate that the conditions could be regarded as “occult preeclampsia.”

This is a preview of subscription content, log in to check access.

Fig. 1


  1. 1.

    Brosens I, Pijnenborg R, Vecruysse L, Romero R (2011) The “great obstetrical syndromes” are associated with disorders of deep placentation. Am J Obstet Gynecol 204:193–201

  2. 2.

    Sibai B, Dekker G, Kupferminc M (2005) Pre-eclampsia. Lancet 365:785–799

  3. 3.

    Shamshiraz AA, Paidas M, Krikun G (2012) Preeclampsia, hypoxia, thrombosis, and inflammation. J Pregnancy 2012:374047. https://doi.org/10.1155/2012/374047

  4. 4.

    Eastabrook G, Brown M, Sargent I (2011) The origins and end-organ consequence of pre-eclampsia. Best Pract Res Clin Obstet Gynaecol 25:435–447

  5. 5.

    Roberts DJ, Post MD (2008) The placenta in pre-eclampsia and intrauterine growth restriction. J Clin Pathol 61:1254–1260

  6. 6.

    Aurioles-Garibay A, Hernandez-Andrade E, Romero R, Qureshi F, Ahn H, Jacques SM, Garcia M, Yeo L, Hassan SS (2014) Prenatal diagnosis of a placental infarction hematoma associated with fetal growth restriction, preeclampsia and fetal death: clinicopathological correlation. Fetal Diagn Ther 36:154–161

  7. 7.

    Baergen RN (2005) Manual of Benirschke and Kaufmann’s pathology of the human placenta. Springer, New York

  8. 8.

    Stevens DU, Al-Nasiry S, Bulten J, Spaanderman MEA (2012) Decidual vasculopathy and adverse perinatal outcome in preeclamptic pregnancy. Placenta 33:630–633

  9. 9.

    Helfrich BB, Chilukuri N, He H, Cerda SR, Hong X, Wang G, Pearson C, Burd I, Wang X (2017) Maternal vascular malperfusion of the placental bed associated with hypertensive disorders in the Boston Birth Cohort. Placenta 52:106–113

  10. 10.

    Naicker T, Khedun SM, Moodley J, Pijnenborg R (2003) Quantitative analysis of trophoblast invasion in preeclampsia. Acta Obstet Gynecol Scand 82:722–729

  11. 11.

    Von Dadelszen P, Magee LA, Roberts JM (2003) Subclassification of preeclampsia. Hypertens Pregnancy 22:143–148

  12. 12.

    Nelson DB, Ziadie MS, McIntire DD, Rogers BB, Leveno KJ (2014) Placental pathology suggesting that preeclampsia is more than one disease. Am J Obstet Gynecol 210:66e1–66e7

  13. 13.

    Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap LC III, Wenstrom KD (2005) Williams obstetrics, 22nd edn. McGraw-Hill, New York

  14. 14.

    Egbor M, Ansari T, Morris N, Green CJ, Sibbons PD (2006) Morphometric placental villous and vascular abnormalities in early- and late-onset pre-eclampsia with and without fetal growth restriction. BJOG 113:580–589

  15. 15.

    Gibbins KJ, Silver RM, Pinar H, Reddy UM, Parker CB, Thorsten V, Willinger M, Dudley DJ, Bukowski R, Saade GR, Koch MA, Conway D, Hogue CJ, Stoll BJ, Goldenberg RL (2016) Stillbirth, hypertensive disorders of pregnancy, and placental pathology. Placenta 43:61–68

  16. 16.

    Huppertz B (2008) Placental origins of preeclampsia: challenging the current hypothesis. Hypertension 51:970–975

  17. 17.

    Kovo M, Schreiber L, Ben-Haroush A, Wand S, Golan A, Bar J (2010) Placental vascular lesion differences in pregnancy-induced hypertension and normotensive fetal growth restriction. Am J Obstet Gynecol 202:561.e1–561.e5

  18. 18.

    Ogge G, Chaiworapongsa T, Romero R, Hussein Y, Kusanovic JP, Yeo L, Kim CJ, Hassan SS (2011) Placental lesions associated with maternal underperfusion are more frequent in early-onset than in late-onset preeclampsia. J Perinat Med 39:641–652

  19. 19.

    Parks WT (2015) Placental hypoxia: the lesions of maternal malperfusion. Semin Perinatol 39:9–19

  20. 20.

    Roberts JM, CWG R (1993) Preeclampsia: more than pregnancy-induced hypertension. Lancet 342(8858):1447–1451

  21. 21.

    Kovo M, Schreiber L, Ben-Haroush A, Gold E, Golan A, Bar J (2012) The placental component in early-onset and late-onset preeclampsia in relation to fetal growth restriction. Prenat Diagn 32:632–637

  22. 22.

    Salafia CM, Pezzullo JC, Ghidini A, Lopèz-Zeno JA, Whittington SS (1998) Clinical correlations of patterns of placental pathology in preterm pre-eclampsia. Placenta 19:67–72

  23. 23.

    Moldenhauer JS, Stanek J, Warshak C, Khoury J, Sibai B (2003) The frequency and severity of placental findings in women with preeclampsia are gestational age dependent. Am J Obstet Gynecol 189:1173–1177

  24. 24.

    Stanek J, Biesiada J (2012) Clustering of maternal/fetal clinical conditions and outcomes and placental lesions. Am J Obstet Gynecol 206:493.a1–493.a9

  25. 25.

    Stanek J, Biesiada J, Trzeszcz M (2014) Clinicoplacental phenotypes vary with gestational age: an analysis by classical and clustering methods. Acta Obstet Gynecol Scand 93:392–398

  26. 26.

    Stanek J (2014) Comparison of placental pathology in preterm, late-preterm, near-term, and term births. Am J Obstet Gynecol 210:234.e1–234.e6

  27. 27.

    Stanek J (2013) Hypoxic patterns of placental injury: a review. Arch Pathol Lab Med 137:706–720

  28. 28.

    Stanek J (2011) Chorionic disc extravillous trophoblasts in placental diagnosis. Am J Clin Pathol 136:540–547

  29. 29.

    Stanek J (2011) Placental membrane and placental disc microscopic chorionic cysts share similar clinicopathologic correlations. Pediatr Dev Pathol 14:1–9

  30. 30.

    Stanek J, Biesiada J (2012) Sensitivity and specificity of finding of multinucleate trophoblastic giant cells in decidua in placentas from high-risk pregnancies. Hum Pathol 43:261–268

  31. 31.

    Stanek J, Drummond Z (2007) Occult placenta accreta: the missing link in the diagnosis of abnormal placentation. Pediatr Dev Pathol 10:266–262

  32. 32.

    Stanek J, Biesiada J (2014) Relation of placental diagnosis in stillbirth to fetal maceration and gestational age at delivery. J Perinat Med 42:457–471

  33. 33.

    Khong TY, Mooney EE, Ariel I, Balmus NCM, Boyd TK, Brundler MA et al (2016) Sampling and definitions of placental lesions. Amsterdam placental workshop group consensus statement. Arch Pathol Lab Med 140:698–713

  34. 34.

    Maloney KF, Heller D, Baergen RN (2012) Types of maternal hypertensive disease and their association with pathologic lesions and clinical factors. Fetal Pediatr Pathol 31:319–323

  35. 35.

    Zhang J, Klebanoff MA, Lvine RJ, Puri M, Moyer P (1999) The puzzling association between smoking and hypertension during pregnancy. Am J Obstet Gynecol 181:1407–1413

  36. 36.

    Stanek J (2017) Decidual arteriolopathy with or without associated hypertension modifies the underlying histomorphology in placentas from diabetic mothers. J Obstet Gynaecol Res 43:839–847

  37. 37.

    Zhang P, Schmidt M, Cook L (2006) Maternal vasculopathy and histologic diagnosis of preeclampsia: poor correlation of histologic changes and clinical manifestation. Am J Obstet Gynecol 194:1050–1056

  38. 38.

    Pathak S, Lees CC, Hackett G, Jessop F, Sebire NJ (2011) Frequency and clinical significance of placental histological lesions in an unselected population at or near term. Virchows Arch 459:565–572

  39. 39.

    Fox H, Sebire NJ (2007) Pathology of the placenta. Saunders, London

  40. 40.

    Kraus FT, Redline RW, Gersell DJ, Nelson DM, Dicke JM (2004) Placental pathology. American Registry of Pathology, Washington

  41. 41.

    Sebire NJ, Goldin RD, Regan L (2005) Term preeclampsia is associated with minimal histopathological placental features regardless of clinical severity. J Obstet Gynaecol 25:117–118

  42. 42.

    Smulian J, Shen-Schwartz S, Scorza W, Kinzler W, Vintzileos A (2004) A clinicohistopathologic comparison between HELLP syndrome and severe preeclampsia. J Matern Fetal Neonatal Med 16:287–293

  43. 43.

    Vinnars MT, Wijnaendts LC, Westgren M, Bolte AC, Papadogiannakis N, Nasiell J (2008) Severe preeclampsia with and without HELLP differ with regard to placental pathology. Hypertension 51:1295–1299

Download references

Author information

Correspondence to Jerzy Stanek.

Ethics declarations

This study was approved by the institutional board (IRB #2016-7942).

Conflict of interest

The author declares that he has no conflict of interest.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Stanek, J. Placental pathology varies in hypertensive conditions of pregnancy. Virchows Arch 472, 415–423 (2018). https://doi.org/10.1007/s00428-017-2239-3

Download citation


  • Gestational hypertension
  • Preeclampsia
  • Chronic hypertension
  • Superimposed preeclampsia
  • Placenta