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Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 449-451

Hydropic placenta in a case of malaria

Department of Pathology, Yenepoya Medical College, Yenepoya (Deemed to be University), Mangaluru 575018, Karnataka, India

Date of Submission10-Nov-2021
Date of Acceptance25-Nov-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Dr. Prema Saldanha
Department of Pathology, Yenepoya Medical College, Yenepoya (Deemed to be University), Mangaluru 575018, Karnataka.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mgmj.mgmj_93_21

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Malarial infection can be life-threatening to both the mother and the developing fetus. The placenta can show various histological changes, and the presence of mature parasites or malarial pigment in the placenta is necessary to define placental malaria. This is a case of a 28-year-old multigravida who presented with malaria and was found to have a hydropic fetus on ultrasonography. Hydropic change has not been reported so far in placental malaria.

Keywords: Hydropic change, malaria, placenta

How to cite this article:
Saldanha P. Hydropic placenta in a case of malaria. MGM J Med Sci 2021;8:449-51

How to cite this URL:
Saldanha P. Hydropic placenta in a case of malaria. MGM J Med Sci [serial online] 2021 [cited 2022 Oct 1];8:449-51. Available from: http://www.mgmjms.com/text.asp?2021/8/4/449/333335

  Introduction Top

Malarial infection is endemic in many tropical countries including India and can be dangerous to both the mother and the developing fetus. Malaria can result in complications such as abortion, stillbirth, intrauterine growth retardation, and low birth weight. The placenta can show various histological changes. This case highlights a rare finding in the placenta in the case of malaria.

  Case report Top

A 28-year-old patient, multigravida, presented with fever and vomiting at 18 weeks of gestation. The patient also gave a history of fever 1 month back and had tested positive for malarial parasites (Plasmodium vivax and falciparum).

Ultrasonography suggested hydrops fetalis with ascites and pleural effusion. The patient was advised termination of the pregnancy. The fetus was found to be macerated and the placenta was edematous. The placenta was sent for histopathological examination.

Grossly the specimen of the placenta weighed 480 g and measured 16 × 12×4.5 cm. The umbilical cord was attached centrally and the cross-section showed three blood vessels. The placenta appeared black and was edematous and heavy and showed multiple cysts ranging in size from 0.5 to 1.5 cm [Figure 1]. No infarcts were seen. Membranes were unremarkable. On microscopic examination, all the villi were enlarged, edematous, and showed the formation of cisternae [Figure 2]. The villi were also avascular. Increased intervillous fibrin was noted. Many of the lining cytotrophoblasts and Hofbauer cells showed black pigment [Figure 3], which was negative for Prussian blue reaction excluding hemosiderin pigment. No parasites were found in the erythrocytes. No trophoblastic proliferation was noted.
Figure 1: Gross appearance of the placenta showing multiple cystic structures

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Figure 2: Histology showing edematous villi. The cytotrophoblast shows blackish pigment (hematoxylin & eosin ×10)

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Figure 3: Black pigment seen within the cytotrophoblastic cells (hematoxylin & eosin ×40)

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  Discussion Top

Malaria in pregnancy poses a great health risk to the mother and her fetus. In malaria-endemic areas, it is estimated that at least 25% of pregnant women are infected with malaria. Malaria is transmitted transplacentally and results in complications, such as abortion, stillbirth, intrauterine growth retardation, and low birth weight.[1]

It has been observed that woman who is pregnant for the first time is more susceptible to malarial infection than a woman who is multigravidae. This resistance to the malarial infection in multigravidae is due to the development of placental parasite-specific immunity in subsequent pregnancies.[1],[2] However, in our case, the patient was multigravida.

Histological evidence of Plasmodium in the placenta is indicative of placental malaria, a condition associated with severe outcomes for mother and child. Evidence of mature parasites or parasite products (hemozoin pigment) in the placenta is considered a defining feature of placental malaria.[2],[3] The heavy infiltration of Plasmodium falciparum-infected RBCs in the intervillous spaces of the placenta seems to be responsible for all the complications observed. The placenta turns black due to the deposition of the malarial pigment.[1] The accumulation of parasites occurs in the intervillous space, a region in the placenta where the maternal blood bathes the syncytiotrophoblast (the site of maternal fetal transfer).[2]

Histological lesions found in placentas from Plasmodium-exposed women include syncytial knotting, thickening of the placental barrier, necrosis of villous tissue, and intervillositis. These histological changes have been associated with P. falciparum infections, but little is known about the contribution of Plasmodium vivax to such changes.[2]

Hydropic change in the placenta has been reported in some infections such as syphilis, parvovirus B19, herpes simplex virus, cytomegalovirus, and HIV[4],[5] but not reported in malarial infection to date. It is possible that the hydropic change could be secondary to severe anemia induced by the malarial parasites or the thickening of the trophoblastic basement membrane and could be responsible for causing a mechanical blockage of oxygen and nutrients transport across the placenta.[1],[2],[3]

Hydropic villi and cystic change are also seen in hydatidiform mole and placental mesenchymal dysplasia (PMD). Hydatidiform mole, complete or partial, represents an abnormal placenta characterized by enlargement of chorionic villi caused by central edema of the stroma. Variable hyperplasia of the villous trophoblastic cells is present, and this hyperplasia may be marked.[6] Trophoblastic proliferation was not seen in our case.

PMD is a rare condition, characterized by vascular and villous stromal placenta malformation. Most are seen in association with intrauterine growth restriction or fetal demise. It is characterized by placentomegaly and grape-like vesicles resembling hydatidiform mole by ultrasonography. The classic gross finding is the presence of macroscopic cysts. Microscopically, the villi are enlarged with increased stromal connective tissue and cyst formation. The stem villous vessels are characteristically thick-walled and can show thrombosis or dilation.[7] Other than hydropic change, the histological findings characteristic of this lesion were not seen in our case.

  Conclusion Top

This case represents a rare finding in placental malaria. Histologically, the presence of malarial pigment, and the absence of other features characteristic of molar pregnancy and PMD, suggests that this change was secondary to malarial infection.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Sharma L, Shukla G. Placental malaria: A new insight into the pathophysiology. Front Med (Lausanne) 2017;4:117.  Back to cited text no. 1
Souza RM, Ataíde R, Dombrowski JG, Ippólito V, Aitken EH, Valle SN, et al. Placental histopathological changes associated with Plasmodium vivax infection during pregnancy. Plos Negl Trop Dis 2013;7:e2071.  Back to cited text no. 2
Parekh FK, Davison BB, Gamboa D, Hernandez J, Branch OH. Placental histopathologic changes associated with subclinical malaria infection and its impact on the fetal environment. Am J Trop Med Hyg 2010;83:973-80.  Back to cited text no. 3
Rodríguez MM, Chaves F, Romaguera RL, Ferrer PL, de la Guardia C, Bruce JH. Value of autopsy in nonimmune hydrops fetalis: Series of 51 stillborn fetuses. Pediatr Dev Pathol 2002;5:365-74.  Back to cited text no. 4
Laar AK, Grant FE, Addo Y, Soyiri I, Nkansah B, Abugri J, et al. Predictors of fetal anemia and cord blood malaria parasitemia among newborns of HIV-positive mothers. BMC Res Notes 2013;6:350.  Back to cited text no. 5
Kurman RJ, Ellenson LH, Ronnett BM, editors. Blaustein’s Pathology of the Female Genital Tract. 6th ed. New York: Springer; 2011.  Back to cited text no. 6
Ulker V, Aslan H, Gedikbasi A, Yararbas K, Yildirim G, Yavuz E. Placental mesenchymal dysplasia: A rare clinicopathologic entity confused with molar pregnancy. J Obstet Gynaecol 2013;33:246-9.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3]


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