A healthy placenta is essential for fetal survival as well as for ensuring maternal adaptation to pregnancy. Challenges in real-time pregnancy assessment due to the placenta’s inaccessible location have hindered studies, and thus the placenta is known as the “least comprehended” human organ. A careful examination of the placenta, along with a microscopic examination, is a valuable tool of great clinical importance that can quite often shed light on many risk factors and on the pathogenesis of adverse maternal, neonatal, and fetal events. Furthermore, the examination of the placenta aids in the prevention of these events as well as in the provision of treatment that can be offered in future pregnancies. Placental pathologic examination aids as well in the resolution of medico-legal issues in malpractice cases. Because many placentas are normal, the examination of all placentas may not be warranted and may be impractical due to time and resource constraints, particularly in hospitals with a high volume of deliveries. The CAP guidelines with recommendations on sending a placenta for pathologic examination were developed by a multidisciplinary group of pathologists, maternal–fetal medicine specialists, and neonatologists to aid the obstetricians’ decision making [
7]. These guidelines are intended to be a standardized approach to be used when certain maternal, fetal, and placental conditions indicate the need for a pathologist to interpret the placenta grossly and microscopically. The sensitivity and specificity of the pathologic examination of the placenta in conformity to the CAP guidelines were 63.4% and 91.6%, respectively [
10]. Despite the clarity and practicality of these guidelines, many obstetricians are either unaware of them or not adhering to them. This conclusion can be drawn by considering the falling number of placentas submitted to pathologic examination. For example, Aljhdali et al. studied the practice of placenta submission for histopathological examination in a teaching/tertiary Hospital in Saudi Arabia; out of 8929 deliveries, 1444 (16.2%) placentas met the CAP guidelines, and only 583/1444 placentas (40.4%) were sent for pathologic examination [
9]. Similar findings were reported in Aysha and Rafaat’s 2020 retrospective study in the United States, which indicated that 213 (42.6%) of 500 placentas should have been submitted for pathology evaluation, but only 135 (27% of the total) were submitted [
10]. These studies and others showed a significant number of placentas that were not submitted for pathological studies, even though they met the CAP criteria [
9]. These observations were the basis of our study which aimed to uncover the CAP guidelines understanding status among obstetricians of different training/experience levels who practice in different clinical settings. In our study, most participants perceived the utility of the pathology report and were encouraged to continue to send placentas for examination, regardless of their level of training or years of experience. However, only 34.4% of them were aware of the CAP guidelines, reflecting the possibility of inappropriate request for pathologic examination and their poor knowledge of the indications for placenta examination due to possible inadequate training or an outdated curriculum. Surprisingly, 80.9% of our respondents found the CAP guidelines clinically useful. The discrepancy between not knowing the guidelines and finding them clinically useful might be due to the general belief that all guidelines help in clinical decisions and eliminate a vague practice. In agreement with our results, only 36% of the Odibo et al. [
6] study participants were aware of the CAP guidelines. In that study, an increased level of awareness of the CAP guidelines was associated with higher levels of experience [
6]; in contrast, our study revealed an indifferently low awareness of the CAP guidelines regardless of the level of training, the years of experience, or the host institution’s type of the participants. As the CAP guidelines are very detailed, our participants might have been aware of the main categories in the guidelines but were unaware of the sub-categories. Using different guidelines or methods (such as gross examination) to determine the need to send a placenta might also explain the low awareness of the CAP guidelines. Regardless of the CAP guidelines, most obstetricians in our study requested a placental pathologic examination for fetal anomalies. In contrast, most obstetricians in the Odibo et al. [
6] study requested a placental pathologic examination for infections. A variation in the prevalence of infections and fetal anomalies might have influenced these ratios. A study showed that placentas were more commonly examined for fetal indications than for maternal ones [
3]. However, in another study, the maternal indications were the most common for a placental pathological examination [
10]. The study of Booth et al. [
11] showed that the maternal and fetal conditions suggested by the CAP guidelines were the least likely reasons to send a placenta for examination, compared to surgical delivery and low birth weight. Gestational age, mode of delivery, infant admission to the neonatal intensive care unit, maternal fever, and gross placental abnormalities were also reported as factors affecting the obstetricians’ decision to send a placenta for pathologic examination [
5]. It is unclear if the decision was based on a hospital policy or on the obstetricians’ clinical judgment. In our study, there was no difference in the rates of sending placentas for examination in the different institutions, an observation that was not in agreement with that of the Odibo et al. [
6] study, where the obstetricians working in community hospitals used to send the placentas for a pathologic examination more frequently. The low number of participants from university hospitals might have falsely influenced our results. As mentioned earlier, a lack of awareness of the CAP guidelines was evident in all institutions, explaining the consistently low rates of sending placentas for a pathologic examination.
The placental reports are supposed to provide the clinician with enough information to counsel the parents and clarify the possible pathophysiological pathways that gave rise to an adverse outcome, the risks of recurrence, and the treatment options available in future conceptions. Presently, the standard practice for placental pathology is narrative reporting, which is prone to bias and quality issues. As a result, the quality of placental reporting is known to vary significantly, ranging from extremely simplistic to extremely detailed, with a high level of variations in the reported findings. This may complicate the obstetrician’s understanding and defy the purpose of the report. This has at times even caused clinicians to misunderstand pathologists’ reports, resulting in medical errors [
12]. This is particularly true for less experienced practitioners and residents. While one study showed no difference in the understanding of the report’s nomenclature between obstetricians with different levels of training [
6], we found that higher levels of training and working experience in a university hospital were associated with routinely reviewing pathology reports and having a good understanding of the report’s nomenclature. A similar observation by Walsh et al. was reported, indicating that experienced clinicians read placental pathology reports at a significantly higher rate (46/47 [97.9%]) than less experienced clinicians (11/15 [73.3%];
p = 0.01) [
2]. Contrary to our hypothesis, which suggested a poor understanding of the pathology report’s nomenclature by the majority of the obstetricians, only 27.4% of our participants declared that they had difficulties understanding the pathology report. More than half of the consultants and specialists could understand the pathology report’s terminology; however, the residents were the least likely to review the pathology reports, and only half of them could understand them. These observations make it crucial to explore the possible reasons for these knowledge gaps between obstetricians working in different institutions and between those with different experiences. One of the possibilities is inadequate knowledge delivery during the training years. Poor communication between obstetricians and pathologists in government hospitals, which might have influenced their understanding, is another potential cause. The obstetricians are encouraged to consult with pathologists about placental reports, particularly if there is a disparity between the clinical evaluation and the reported diagnoses. Finally, the use of synoptic pathology reports with a standardized diagnostic nomenclature, rather than the narrative one, would improve the understanding of the report and its benefits, as a survey among obstetricians on the utility of the placental pathology reports found that a more streamlined report, with findings organized by lesion category, outperformed the narrative reporting format in terms of improving the interpretation and implementation of the findings into clinical practice [
2].
An obvious limitation of our study is the small sample size. Despite the surveys being distributed to more than 6000 obstetricians, only 292 obstetricians responded (4.4% of the target population). Moreover, our sample included an extremely low number of obstetricians working in university hospitals and no participants from private hospitals. We are aware that despite the important findings, our results cannot be generalized. Therefore, further studies should be conducted to include a more significant number of obstetricians working in universities and private hospitals.