Year: 2021
Type: letter
Abstract: To the Editor We read with much interest the article by Shanes et al.1 It is a comprehensive study. We appreciate the good number of cases compared with the established publications, which had three to five cases. The selection criterion was universal, with a confirmatory test used (reverse transcription polymerase chain reaction [RT-PCR]). The control group was comparable to the case group as placental pathology was expected. We also appreciate good tabulation of the results with specific statistical analysis of all placental abnormality features. However, there are few areas of concern. Regarding the methodology, the selection of the control group was retrospective. The bias was that the record could be lacking important information on cytomegalovirus, herpes simplex, and other organisms including syphilis, parvovirus, and varicella zoster, known as TORCH syndrome. The underreported concurrent infection may have led to abnormal placenta tissue reaction, thus masking the severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2).2 The control clinical features could have been underdiagnosed due to incomplete data retrieved from the medical records. We feel that the severity of the case symptoms was not elaborated, and it is essential to signify the systemic manifestation of the infection that led to placental abnormality. The included cases were not retested again for RT-PCR despite cases 13 to 16 having an infection interval more than 2 weeks before delivery. Therefore, retesting should have been done to consolidate the findings with the infection. If the retesting had been negative, it should have been excluded. Most of the literature supports retesting to confirm the dynamics of infection and conclude the presence of ongoing infection before analyzing the end product (placenta, amniotic fluid).3 The proportion of changes in the placental tissue area was not analyzed. This is essential to ensure that the severity of infection, whether it involved the whole placenta, one-third of it, or a nonspecific part, may have led to different interpretation.4 We applaud the interesting work by the authors and thank the journal for publishing such an interesting article. Mohd Faizal Ahmad Universiti Kebangsaan Malaysia Medical Centre Kuala Lumpur, Malaysia Srijit Das Sultan Qaboos University Sultanate of Oman The Authors’ Reply We appreciate the correspondence and the opportunity to respond. Active TORCH infections are rare in our population, and we expect the rate will not differ between historic and current cases.1 In addition, the most frequently reported TORCH-associated finding was chronic villitis, which was not elevated in the population with coronavirus disease 2019.2 While we did not address disease severity, other studies have addressed the impact of symptomatic vs asymptomatic SARS-CoV-2 viral infection, albeit without showing significant differences.3 Regarding retesting for SARS-CoV-2 infection at delivery, prolonged RT-PCR positivity has been reported in convalescent patients.4 Our institutional protocol has varied, but patients are currently not retested if they present to labor and delivery within 90 days or the initial positive swab. Direct placental infection appears to be rare, so our proposed mechanism is placental injury due to immune activation, which may persist after viral clearance.5 Therefore, our intent was to examine placentas from women who were infected with SARS-CoV-2 at any time during pregnancy, not necessarily at the time of delivery. We regret we are unable to provide better quantification of lesions for the correspondents. The nature of our diagnosis extraction system only captures quantitation to the extent that it reaches a threshold of diagnosis (eg, 45 avascular villi in high-grade fetal vascular malperfusion).6 We thank the authors for their interest in our work. Jeffery A. Goldstein, MD, PhD Elisheva D. Shanes, MD Leena B. Mithal, MD, MSCI Emily S. Miller, MD, MPH Northwestern University Chicago, IL, USA
DOI: 10.1093/ajcp/aqab079
Authors: Mohd Faizal Ahmad, Srijit Das, Jeffery A Goldstein, Elisheva D Shanes, Leena B Mithal, Emily S Miller
Language: English
Subfield: Obstetrics and Gynecology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W3166586574