What are Potential Problems with Placental Abnormalities?

Patient Presentation
A 2-week-old male came to clinic for his health supervision visit. He was a 36 week gestation infant born by planned cesarean section to a 32 year old, G2 now P2 mother. The pregnancy was complicated with placenta accreta along with a low-lying placenta that was identified on second trimester ultrasound examination. The father had no concerns and was very comfortable feeding and caring for the infant in the office. The baby had been delivered and the mother had undergone hysterectomy.

The pertinent physical exam showed a well appearing male whose weight was 48 grams past birthweight. He was 25% for all growth parameters. His examination was normal with a almost completely well-healing circumcision.

The diagnosis of a healthy male was made. The father said that they were a little overwhelmed, “We made the decision to have him and then she had a planned hysterectomy. My wife has done well but it’s really hard taking care of her, my other 2 year old and this one. Thank heavens that my in-laws are here and helping. That way we have one adult to help take care of each of them. I’m supposed to go back to work in a couple of days, but my work is really understanding and I have at least another week off and my mother-in-law is going to stay until my wife is better. She wanted to breastfeed this one like she did the first, but it’s too much right now. Formula is just fine. I’m just so thankful he is growing and that my wife is safe and healthy too.”

Discussion
“The placenta is a unique organ that sits at the interface of, and facilitates nearly all interactions between, maternal and fetal physiology. It is the sole source of oxygen and nutrition for the fetus, and provides a protective barrier against external insults. The placenta is also a highly adaptable organ that is capable of showing a wide range of pathological changes in response to various maternal and fetal factors and stressors.” The placenta has 3 layers: the amnion (fetal side), the chorion, and decidua (maternal side). In addition to making observations about the maternal and fetal sides, cord variations (i.e. size, length, twists, number of vessels, insertion location) can be observed. Even with these these possible variations, most placentas are normal.

Learning Point
There are some important placental abnormalities which are clinically, and potentially critically important for maternal and fetal outcomes.

  • Location problems
    • Placenta previa is a placenta that overlies the cervical os to some extent. Those that are near but do not overlie are termed low-lying placentas.
      • Incidence 1:200
      • Diagnosis: found on routine ultrasound or painless vaginal bleeding usually in 3rd trimester
      • Treatment: cesarean section prior to labor, often before term
      • Maternal problems: hemorrhage which has its own risks such as blood transfusions, septicemia, thrombophlebitis, admission to intensive care unit, hysterectomy, maternal death
      • Neonatal problems: prematurity – up to ~45% delivered before 37 weeks gestation
    • Vasa previa are fetal blood vessels that are attached but unprotected which traverse the fetal membranes near or over the cervical os
      • Incidence 1:2500-5000
      • Diagnosis: found on ultrasound
      • Treatment: cesarean section prior to labor and before rupture of membranes
      • Maternal problems: emergency care and its attendant complications including surgical complications
      • Neonatal problems: severe fetal blood loss and ensuing mortality, compromised umbilical blood flow and its attendent risks, prematurity
    • Placenta accreta is the placenta attaching to the myometrium without decidua in between. If the placenta invades the myometrium it is termed placenta increta, and if it extends outside the uterus it is termed placental percreta. Placenta accreta is also used sometimes to refer to this entire spectrum.
      • Incidence 1:300-2500
      • Diagnosis: found on ultrasound and more common with subsequent births after cesarean section or any procedure where the endometrium would be instrumented
      • Treatment: various, but planned intervention before labor is important
      • Maternal problems: severe maternal hemorrhage and potential mortality, and risks from hemorrhage
      • Neonatal problems: prematurity
  • Vascular problems
    • Maternal vascular malperfusion
      • Vascular problems on the maternal side of the placenta. This can anffect the entire or part of the placenta and the placenta is small.
      • Maternal problems: preeclampia, antiphospholipid syndrome, autoimmune disease, pregestational diabetes
      • Neonatal problems: fetal growth restriction
    • Fetal vascular malperfusion
      • Vascular problems on the fetal side of the placenta.
      • Neonatal problems: fetal distress, fetal demise, intrauterine growth restriction, cardiac abnormalities and coagulopathies
  • Infection
    • Acute chorioamnionitis
      • Usually microorganisms invade via the ascending route from the vagina, breech the placenta into the amniotic fluid. There is a fetal and maternal inflammatory response. It is a clinical diagnosis but laboratory testing may be helpful.
      • Maternal problems: endometritis, sepsis
      • Neonatal problems: sepsis, respiratory problems, neurodisability, necrotizing enterocolitis
    • Chronic villitis also known as Villitis of Unknown Etiology
      • Affects the chorionic villi but there is no identifiable organism
      • Neonatal problems: intrauterine growth restriction
    • Villitis
      • Affects the chorionic villi with an identifiable organism
      • There are many, but common examples are:
        • TORCH infections – Toxoplasmosis, Other agents including Syphilis, Rubella, Cytomegalovirus, Herpes simplex
        • Listeria
        • Zika
      • Miscellaneous
        • COVID-19 intrauterine transmission has been documented but is considered rare. Most cases of neonatal COVID are from infected caregivers.
          For breastfeeding, “Replication- competent SARS-CoV-2 has not been detected in breastmilk, although breastmilk samples are occasionally polymerase chain reaction positive.” Given the current information available and weighting risks and benefits “Most guidelines support the rooming in of the newborn with an infected mother, particularly when the mother is afebrile and asymptomatic.”

Questions for Further Discussion
1. What other maternal complications can cause problems for the fetus and newborn?
2. What resources to you use to answer your question about maternal or fetal medicine?
3. What are indications for consultation with a neonatologist?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Silver RM. Abnormal Placentation: Placenta Previa, Vasa Previa, and Placenta Accreta. Obstet Gynecol. 2015;126(3):654-668. doi:10.1097/AOG.0000000000001005

Ravishankar S, Redline RW. What Obstetricians Need to Know About Placental Pathology. Obstet Gynecol Clin North Am. 2020;47(1):29-48. doi:10.1016/j.ogc.2019.10.007

Komine-Aizawa S, Takada K, Hayakawa S. Placental barrier against COVID-19. Placenta. 2020;99:45-49. doi:10.1016/j.placenta.2020.07.022

Jamieson DJ, Rasmussen SA. An update on COVID-19 and pregnancy. Am J Obstet Gynecol. 2022;226(2):177-186. doi:10.1016/j.ajog.2021.08.054

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

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At What Age Do Children Have Imaginary Friends?

Patient Presentation
A 6-year-old female came to clinic for her health maintenance visit. She was reportedly developing normally and her first grade teacher had no concerns. Her mother asked, “She has an imaginary friend and I’m not sure how much I should give in to this idea. Most of it is just normal play like playing dolls, but she is demanding the little stuffed toy has to be buckled up in the car too, and gets really upset if the toy doesn’t come with us.”

The pertinent physical exam showed a normal female with growth parameters around 75% for height and weight. The examination was normal.

The diagnosis of a healthy female with an imaginary friend was made. The physician asked several more questions which confirmed normal play patterns with the toy, and did not reveal any concerns for the child’s mental health or development. He recommended to take a practical approach. “The imaginary friend is really normal for kids but they can stay around for a long time and can be very important to the children. I would let her lead the way but there are limits in the real world. For example, she can have the friend in her school backpack so it is available, and you even could put it in a small box which can be the friend’s car seat. Obviously the friend does not get their own real car seat in your car.” “You can also try to see if she can come up with her own creative ideas about whatever the issue is too. That can help her learn to negotiate in the real world. But let me know if she seems to be having more concerning mental health issues or the problems are escalating,” he counseled.

Discussion
Paracosms are imaginary worlds or societies and is a creative activity in middle childhood. Storytelling and narrative activities are believed to help people “…to promote insight into behavior, contribute to empathy, help us find meaning in life events, and extend our experience beyond personal circumstance.” These narrative activities are public or private and based in real or fictional experiences. They can be communicated verbally or acted out and can focus on the character or the plot of the narrative. There is not a great deal of research on paracosms and much is asking adults to remember to their own childhoods where some type of paracosm is endorsed by about 40% of the individuals in the particular research group. In two studies of 8-12 year olds, there was a ~17% prevalence of a paracosm. Those with and without a paracosm did not differ in many ways, but those with a paracosm had more inhibitory control and had higher creativity scores especially in storytelling tasks and potentially in creative ways to make new friends.

Imaginary friends (IFs), invisible friends, imaginary companions, etc. are often a part of a paracosm and may “…facilitate the development of social competence, particularly with respect to the regulation of emotion and the acquisition of interpersonal skills useful in adulthood, such as cooperation and perspective taking.” There is no prototype for an IF. An IF “is a character, sometimes invisible and sometimes embodied in an object such as a stuffed animal or doll, which is animated by the child and treated as real.” IFs come in all forms, shapes, sizes, genders, appearances, and ages. Invisible IF can be based on real people or fictional characters or be entirely unique. The longevity of the IF also varies from short time periods, but also to months or years with consistency in the description of the IF. The child often will incorporate the IF into daily routines and their relevance and importance to the child commonly is persistent over long time periods.

IFs provide relational benefits and social supports to the child that is similar to what occurs with real best friends and these tend to be more egalitarian relationships. IFs that are personified objects may have hierarchies such as the child playing the role of parent to the object. Some children create idealized interactions while others have IFs who have difficult behaviors or even are imaginary enemies. Both positive and negative IFs are seen in typically developing children. IFs allow opportunities for creating, exploring and maintaining friendship and relational skills, practicing such skills, and coping with emotional difficulties and emotionally charged situations. They also are used to explore social situations and negotiate social roles that may be practical experiences in the real world.

The child’s IF and their relationship with the IF should be respected, but do not necessarily need to be catered to. For example, the child says that she and the IF are only going to have ice cream for breakfast. The parent can simply say, “Ok. We don’t have any ice cream. Here is your cereal this morning,” where the parent simply acknowledges but asserts their authority.

Learning Point
IFs overall are common in early and middle childhood. Paracosms appear to peak around age 9 years and wane by around age 12 years. In the two studies of 8-12 years old regarding paracosms, ~50% endorsed an IF. Having an IF was more common if the child also had a paracosm (~80%) than if they did not (~40%). IFs also occur across a wide range of cultures, but prevalence or incidence varies. One study of non-predominantly western industrialized countries with children 3-8 years old found overall 21% had an IF but had a range of 5-34% in children depending on the country studied.

Questions for Further Discussion
1. What symptoms might indicate that the child with the IF may need mental health services?
2. How is anxiety diagnosed in children?
3. How is depression diagnosed in children?
4. What are some of the benefits of play for children and adolescents?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Child Development.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Gleason TR. The psychological significance of play with imaginary companions in early childhood. Learn Behav. 2017;45(4):432-440. doi:10.3758/s13420-017-0284-z

Wigger JB. Invisible friends across four countries: Kenya, Malawi, Nepal and the Dominican Republic. Int J Psychol. 2018;53 Suppl 1:46-52. doi:10.1002/ijop.12423
Taylor M, Mottweiler CM, Aguiar NR, Naylor ER, Levernier JG. Paracosms: The Imaginary Worlds of Middle Childhood. Child Dev. 2020;91(1):e164-e178. doi:10.1111/cdev.13162

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Why Does Norovirus Spread So Easily?

Patient Presentation
A 19-month-old male came to clinic with a 24-hour history of emesis and diarrhea. He has vomited 3 times but was having frequent watery stools that were non-bloody. His mother said she was changing his diaper as soon as she was able to and would estimate that the diaper was 1/4-1/2 soaked with fluid. His mother wasn’t sure if he was having wet diapers but said that she thought she could smell urine with some of the diapers. He was still drinking and she had started offering him flavored oral rehydration solution. He did attend daycare and the mother said she knew of several other children with diarrheal illnesses. The past medical history was non-contributory.

The pertinent physical exam showed a slightly tired boy. His weight was up 350 grams from a weight 6 weeks previously, and his vital signs were normal. His capillary refill was 1-2 seconds with moist lips and tearing. His examination was otherwise unremarkable with a soft abdomen but increased bowel sounds.

The diagnosis of acute gastroenteritis was made. The mother was counseled to monitor him closely for potential dehydration and increased symptoms. A stool culture was performed to identify the potential outbreak and norovirus was identified the following day. The mother was contacted and said that the diarrhea had already markedly decreased and he had not had any more emesis. Public health was contacted about the norovirus in the daycare setting.

Discussion
Norovirus is a Caliciviridae family member. They were first observed by electron microscopy during a 1968 outbreak in Norwalk Connecticut (hence the alternative name of Norwalk virus). There are 3 genogroups and many genotypes within each genogroup. “Noroviruses are the leading cause of acute gastroenteritis in people of all ages worldwide, and are estimated to cause 12-24% of community-based or clinic-based cases…, 11-17% of emergency room or hospital cases, and approximately 70,000-200,000 deaths annually.” Seventy percent of cases occur in the 6-23 month age range. They have caused pandemics usually at 2-3 year intervals over the past 20+ years.

Clinically patients may be asymptomatic and it not be recognized and they can also have several infections overtime as the active immunity wanes overtime. Patients often have non-bloody diarrhea, emesis, abdominal cramps and fever. Severe diarrhea can lead to dehydration and its severe complications of hypotension and shock. Incubation period is 12-72 hours with a duration of symptoms being self-limited (12-48 hours) but up to 2-5 days in immunocompromised individuals. However it can last much longer. Norovirus cannot be specifically differentiated without testing, usually by direct viral detection.

Treatment includes prevention measures including hand-hygiene and general sanitation. Disinfection of surfaces can be accomplished with a chlorine bleach solution of 1:50-1:10 dilution of household bleach (of 5-25%). Oral rehydration is a mainstay to prevent or treat diarrhea. Intravenous fluids may also be needed for fluid resuscitation. Again hygiene procedures and exclusion of ill persons are important. As food preparation is a common transmission method, use of gloves for preparing and distributing food in public settings is important. Immunity to infection does occur but usually is limited. Culturing of the virus has also been difficult until more recently. Therefore it is has been difficult to develop vaccines. However, candidate vaccines are being evaluated in clinical trials.

Learning Point
As norovirus is spread in feces, the transmission is through the fecal-oral route, including hands, utensils, ready-to-eat foods, and it is thought that oysters can concentrate norovirus from contaminated water.
Norovirus is highly contagious because:

  • Low numbers of 18-1000 particles can cause an infection
  • Extended time period of viral shedding (usually 2-5 days but up to weeks)
  • Particles are hearty and can remain in the environment including a wide range of temperatures (0 – 60°C)
  • Virus is mutable so new strains can emerge

Questions for Further Discussion
1. What are other common causes of acute gastroenteritis?
2. What infectious causes of acute gastroenteritis are reportable to public health in your area?
3. What electrolyte balance is recommended for oral rehydration solutions?

Related Cases

    • Disease:

Norovirus Infection

    • |

Gastroenteritis

    • Symptom/Presentation:

Diarrhea

    • |

Vomiting

    • Specialty:

General Pediatrics

    • |

Infectious Diseases

    • Age:

Toddler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Norovirus Infections and Gastroenteritis.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Shah MP, Hall AJ. Norovirus Illnesses in Children and Adolescents. Infect Dis Clin North Am. 2018;32(1):103-118. doi:10.1016/j.idc.2017.11.004

Banyai K, Estes MK, Martella V, Parashar UD. Viral gastroenteritis. Lancet. 2018;392(10142):175-186. doi:10.1016/S0140-6736(18)31128-0

Cates JE, Vinje J, Parashar U, Hall AJ. Recent advances in human norovirus research and implications for candidate vaccines. Expert Rev Vaccines. 2020;19(6):539-548. doi:10.1080/14760584.2020.1777860

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa