Original Title: Avis: le placenta, pertinence et indications de transmission des prélèvements au laboratoire d'anatomopathologie aux fins d'analyse

Authors' objectives: Anatomopathological examination of placental tissues may provide information pertinent to the diagnosis of various undesirable fetomaternal conditions and the medical management of future pregnancies. However, the majority of placentas are normal and originate from full-term births following a normal pregnancy without complications for either the mother or the newborn. The systematic transfer of placentas to the anatomical pathology laboratory for analysis thus raises the question of whether diagnostic resources are being used optimally. In the absence of provincial guidelines and considering the lack of an established practice for the handling of placental tissues in Québec institutions, the MSSS mandated INESSS to formulate, for health professionals and the Conseils des médecins, dentistes et pharmaciens (CMDP) and Conseils des sages-femmes (CSF) of Québec, recommendations on the utility of and indications for the transfer of placentas to the anatomical pathology laboratory for analysis.

Authors' results and conclusions: CURRENT SITUATION IN QUÉBEC: In Québec, procedures for the transfer of placentas to the anatomical pathology laboratory for analysis vary from institution to institution. While some systematically transfer and perform a full anatomopathological examination on all placentas, others follow selective transfer or histological analysis policies based on a list of predetermined clinical conditions. INDICATIONS FOR THE TRANSFER OF PLACENTAS TO THE ANATOMICAL PATHOLOGY LABORATORY FOR ANALYSIS: According to the Québec experts surveyed, 21 maternal conditions, 13 fetal or neonatal conditions and 15 placental conditions constitute indications for the transfer of a placenta to the anatomical pathology laboratory for analysis, a total of 49 indications. A list of 21 clinical conditions that do not constitute indications for the placenta transfer to the anatomical pathology laboratory was also compiled. DIFFERENTIAL COST ANALYSIS: Based on an analysis of medico-administrative data, it was estimated that 75 to 79% of placentas could be exempt from transfer to the anatomical pathology laboratory for analysis. According to preliminary experimental data from an institution that recently implemented a selective transfer policy, roughly 35% of placentas were sent to the anatomical pathology laboratory. Based on this information, nearly 53,800 macroscopic examinations could be avoided every year by adopting a selective placenta transfer policy, which represents savings of approximately 9,000 to 18,000 hours of analysis time in anatomical pathology departments in Québec. Following the adoption of a selective placenta transfer policy, cost reductions of approximately $352,000 to $3.1M are predicted, across the province, based on the models and assumptions considered. SUMMARY OF DATA COLLECTED DURING MEETINGS WITH EXPERTS AND STAKEHOLDERS: The experts and stakeholders consulted were in favour of adopting a selective placenta transfer policy based on relevant clinical indications. However, they brought up challenges in clinical practice and organizational and ethical concerns. Among other issues, concerns were raised about transferring responsibility for triage of placentas to clinicians, traceability of placentas not sent to the anatomical pathology laboratory and their temporary storage, as well as time limits and accessibility of placental examination reports for the professionals charged with the medical care of the child. Some of these concerns are addressed by suggestions, but not recommendations, for implementation and are listed under “Other considerations.” The recommendations issued by INESSS will promote wise use of anatomopathological resources, taking into account clinical utility and aspects related to distributive justice. They will facilitate province-wide standardization of procedures for the handling of placental tissue.

Authors' recommendations: 1. INESSS is of the opinion that it would be fair and reasonable to adopt a province-wide selective procedure for sending placentas to anatomical pathology laboratories for analysis. 2. INESSS recommends that a placenta be sent to the anatomical pathology laboratory when at least one of the maternal, fetal, neonatal or placental conditions, as enumerated in the list of 49 indications for anatomopathological examination of a placenta, is present. 3. If a placenta does not present any of the established maternal, fetal, neonatal or placental indications, it may be exempted from transfer to the anatomical pathology laboratory. 4. This implies that every placenta must undergo a triage examination performed by a competent birth professional or, otherwise, by a pathologist. The information from the triage examination must be duly recorded in the mother and child’s file, ideally in a standardized form. 5. Beyond the established indications, a health professional must be able to order the transfer of a placenta to the anatomical pathology laboratory for analysis if, in their clinical judgment, there is any level of uncertainty or concern for the health of the mother or child. 6. In extenuating circumstances, to facilitate change management and the implementation of such a measure, triage may be performed for a limited period within the pathology laboratory in order to ensure the utility of an anatomopathological examination. 7. Placentas not requiring an anatomopathological examination must be kept cold (not frozen) at 4°C for seven days before disposal, to ensure that placental tissue is available should the health of the newborn unexpectedly deteriorate.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/le-placenta-pertinence-et-indications-de-transmission-des-prelevements-au-laboratoire-danatomopathologie-aux-fins-danalyse.html

Year Published: 2019

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/le-placenta-pertinence-et-indications-de-transmission-des-prelevements-au-laboratoire-danatomopathologie-aux-fins-danalyse.html

Requestor: Minister of Health

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: Gouvernement du Québec