{"id":1606,"date":"2018-11-11T20:28:40","date_gmt":"2018-11-11T19:28:40","guid":{"rendered":"http:\/\/www.newslab.sk\/2018\/11\/11\/chorangioza-placenty-postihnutie-placenty-nejasnej-etiologie-kazuistika-a-prehlad-sucasneho-poznania\/"},"modified":"2018-11-11T20:30:47","modified_gmt":"2018-11-11T19:30:47","slug":"chorangioza-placenty-postihnutie-placenty-nejasnej-etiologie-kazuistika-a-prehlad-sucasneho-poznania","status":"publish","type":"post","link":"https:\/\/www.newslab.sk\/en\/chorangioza-placenty-postihnutie-placenty-nejasnej-etiologie-kazuistika-a-prehlad-sucasneho-poznania\/","title":{"rendered":"Chorangiosis of Placenta – Disorder of Unclear Etiology (Case Report and Overview of Current Knowledge)"},"content":{"rendered":"

*All tables, charts, graphs and pictures that are featured in this article can be found in the .pdf attachment at the end of the paper.<\/span><\/strong><\/p>\n

 <\/p>\n

\u00davod<\/strong><\/p>\n

Za fyziologick\u00fdch okolnost\u00ed zachyt\u00edme na reze termin\u00e1lnym klkom placenty 2 \u2013 5 cievnych priestorov. Vil\u00f3zna hypervaskularita je charakterizovan\u00e1 zv\u00fd\u0161en\u00fdm po\u010dtom cievnych priestorov, nes\u00favisiacich s ich dilat\u00e1ciou ani venost\u00e1zou. V roku 1984 Altshuler definoval krit\u00e9ri\u00e1 pre chorangi\u00f3zu ako mnohopo\u010detn\u00e9 kapil\u00e1rne vaskul\u00e1rne k\u013eu\u010dky v koncov\u00fdch klkoch placenty s n\u00e1lezom minim\u00e1lne 10 cievnych l\u00famenov\u00a0 v 10 klkoch v 10 neinfarktov\u00fdch ploch\u00e1ch placenty hodnoten\u00fdch pri zv\u00e4\u010d\u0161en\u00ed objekt\u00edvu 10x v 3 a viacer\u00fdch kotyled\u00f3noch(1). Incidencia chorangi\u00f3zy st\u00fapa so zvy\u0161uj\u00facim sa \u0161t\u00e1diom gravidity(2). Abnormality cievneho z\u00e1sobenia placent\u00e1rnych klkov tvoria heterog\u00e9nnu skupinu chorobn\u00fdch zmien placenty, vy\u017eaduj\u00facu pozorn\u00fd pr\u00edstup pri hodnoten\u00ed a interpret\u00e1cii patol\u00f3gom.<\/p>\n

 <\/p>\n

Kazuistika<\/strong><\/p>\n

Opisujeme pr\u00edpad 23-ro\u010dnej prvorodi\u010dky, u ktorej do\u0161lo\u00a0 v 25. t\u00fd\u017edni tehotnosti k abrupcii placenty s n\u00e1sledn\u00fdm potratom m\u0155tveho plodu. Makroskopicky bola placetna prekrv\u00e1can\u00e1 s retroplacent\u00e1rnou krvnou zrazeninou, rozmerov 14 x 12 x 2,5 cm a hmotnosti 222 g. Pupo\u010dn\u00edk odstupoval centr\u00e1lne, na reze boli pr\u00edtomn\u00e9 dve cievy.<\/p>\n

V mikroskopickom n\u00e1leze sme pozorovali zv\u00e4\u010d\u0161en\u00e9 klky s po\u010detn\u00fdmi cievami (10 a viac na jeden klk). Imunohistochemick\u00fdm vy\u0161etren\u00edm s pou\u017eit\u00edm endotelov\u00e9ho markera CD34 sme potvrdili zmno\u017eenie mal\u00fdch cievnych l\u00famenov v jednotliv\u00fdch klkoch. Na z\u00e1klade histologick\u00e9ho a imunohistochemick\u00e9ho n\u00e1lezu bol n\u00e1lez uzavret\u00fd ako chorangi\u00f3za placenty s n\u00e1lezom dvojcievneho pupo\u010dn\u00edka.<\/p>\n

 <\/p>\n

Diskusia<\/h4>\n

Chorangi\u00f3za je vaskul\u00e1rna zmena placenty s nejasnou etiol\u00f3giou. Definovan\u00e1 je n\u00e1lezom minim\u00e1lne 10 cievnych l\u00famenov v 10 klkoch v 10 neinfarktov\u00fdch ploch\u00e1ch placenty hodnoten\u00fdch pri zv\u00e4\u010d\u0161en\u00ed objekt\u00edvu 10x v 3 a viacer\u00fdch kotyled\u00f3noch (1). Aj ke\u010f p\u00f4vodn\u00e9 krit\u00e9ri\u00e1 hovorili o hodnoten\u00ed v termin\u00e1lnych klkoch, boli nesk\u00f4r upraven\u00e9 vzh\u013eadom na skuto\u010dnos\u0165, \u017ee je prakticky nemo\u017en\u00e9 odl\u00ed\u0161i\u0165 hypervaskul\u00e1rne termin\u00e1lne klky od hypervaskul\u00e1rnych zrel\u00fdch intermedi\u00e1lnych klkov(3).<\/p>\n

Za fyziologick\u00fdch okolnost\u00ed obsahuj\u00fa zrel\u00e9 termin\u00e1lne klky placenty zvy\u010dajne 2 \u2013 5 kapil\u00e1r, ktor\u00e9 s\u00fa dilatovan\u00e9 a vyp\u013a\u0148aj\u00fa \u010das\u0165 klku(4). Placenta zohr\u00e1va k\u013e\u00fa\u010dov\u00fa \u00falohu v transporte plynov medzi materskou a fet\u00e1lnou cirkul\u00e1ciou. Formovanie a vznik nov\u00fdch kapil\u00e1r v placente prebieha dvoma mechanizmami v z\u00e1vislosti od gesta\u010dn\u00e9ho veku plodu. V skorom \u0161t\u00e1diu prv\u00e9ho trimestra vznikaj\u00fa kapil\u00e1ry vaskulogen\u00e9zou, vytvoren\u00edm endotelov\u00fdch progenitorov\u00fdch buniek \u2013 angioblastov v extraembryon\u00e1lnom mezoderme. V neskor\u0161\u00edch \u0161t\u00e1di\u00e1ch tehotnosti vznikaj\u00fa kapil\u00e1ry angiogen\u00e9zou z u\u017e existuj\u00facich ciev(5). Placenta je za norm\u00e1lnych okolnost\u00ed vysokovaskularizovan\u00e9 tkanivo, d\u013a\u017eka kapil\u00e1rnej siete norm\u00e1lnej placenty je odhadovan\u00e1 na 550 km(6).<\/p>\n

Spustenie obidvoch procesov novotvorby ciev z\u00e1vis\u00ed od p\u00f4sobenia viacer\u00fdch rastov\u00fdch faktorov, s nenahradite\u013enou \u00falohou rastov\u00e9ho faktora pre endotel (VEGF), ktor\u00fd sa uvo\u013e\u0148uje z mezenchym\u00e1lnych aj trofoblastov\u00fdch buniek vplyvom r\u00f4znych stimulov vr\u00e1tane hypoxie. Predpoklad\u00e1 sa, \u017ee pla- centa m\u00e1 schopnos\u0165 adapt\u00e1cie na nepriazniv\u00e9 okolnosti prostredia a je schopn\u00e1 zv\u00fd\u0161i\u0165 kapacitu v\u00fdmeny plynov d\u00f4le\u017eit\u00fa pre v\u00fdvoj plodu. Placenta sa takto m\u00f4\u017ee prisp\u00f4sobi\u0165 napr\u00edklad hypoxick\u00fdm podmienkam u obyvate\u013eov v extr\u00e9mnych nadmorsk\u00fdch v\u00fd\u0161kach prostredn\u00edctvom vaskul\u00e1rnej hyperpl\u00e1zie v koncov\u00fdch choriov\u00fdch klkoch(7).<\/p>\n

Etiologicky sa preto uva\u017euje najm\u00e4 o v\u00fdzname hypoxie\u00a0 v etiol\u00f3gii chorangi\u00f3zy(8,9). Toto tvrdenie by mohli podporova\u0165 pr\u00e1ve poznatky o patofyziol\u00f3gii tvorby placent\u00e1rnych ciev. T\u00e1to hypot\u00e9za v\u0161ak nebola nikdy jednozna\u010dne potvrden\u00e1.\u00a0 V s\u00falade s touto hypot\u00e9zou je vy\u0161\u0161ia incidencia chorangi\u00f3zy u \u017eien \u017eij\u00facich vo vy\u0161\u0161\u00edch nadmorsk\u00fdch poloh\u00e1ch a u \u017eien s \u0165a\u017ek\u00fdmi anemick\u00fdmi poruchami(4,10). In\u00e9 \u0161t\u00fadie v\u0161ak signifikantn\u00fa spojitos\u0165 medzi hypoxiou a vznikom chorangi\u00f3zy nena\u0161li(10,11). Zd\u00e1 sa, \u017ee zmno\u017eenie kapil\u00e1r nevyhnutne nezvy\u0161uje schopnos\u0165 placenty zabezpe\u010di\u0165 v\u00fdmenu kysl\u00edka(12).<\/p>\n

Chorangi\u00f3za je \u010dasto asociovan\u00e1 s r\u00f4znymi fet\u00e1lno-matern\u00e1lnymi a placent\u00e1rnymi zmenami, ako s\u00fa n\u00e1lezy pupo\u010dn\u00edkov\u00fdch abnormal\u00edt vr\u00e1tane pr\u00edtomnosti len jednej umbilik\u00e1lnej art\u00e9rie(4) aj vroden\u00fdch v\u00fdvojov\u00fdch ch\u00fdb srdca plodu(13). \u010castej\u0161ie sa vyskytuje v s\u00favislosti s preeklampsiou, hypertenziou alebo diabetom mellitom u matky, kde sa d\u00e1va do s\u00favislosti so zmenami produkcie VEGF(14). Tieto stavy s\u00fa spojen\u00e9 so zvy\u0161uj\u00facou sa fet\u00e1lnou a neonat\u00e1lnou morbiditou aj mortalitou(15). Zd\u00e1 sa v\u0161ak, \u017ee chorangi\u00f3za tu predstavuje sk\u00f4r ved\u013eaj\u0161\u00ed n\u00e1lez, ktor\u00fd vznik\u00e1 ako n\u00e1sledok choroby matky. Rizikov\u00fdm faktorom je aj faj\u010denie (16). Jedna z \u010fal\u0161\u00edch pr\u00ed\u010din vzniku chorangi\u00f3zy m\u00f4\u017ee by\u0165 aj hyperkapilariz\u00e1cia spojen\u00e1 so vzostupom tlaku ako n\u00e1sledok ob\u0161trukcie pupo\u010dn\u00edkovej \u017eily(10). Mo\u017en\u00fd je aj genetick\u00fd alebo environment\u00e1lne z\u00edskan\u00fd nes\u00falad medzi rastov\u00fdmi faktormi(17). Op\u00edsan\u00e1 je i kazuistika chorangi\u00f3zy asociovan\u00e1 so zv\u00fd\u0161enou hladinou choriogonadotropn\u00e9ho horm\u00f3nu (hCG) v s\u00e9re matky v neskor\u0161om \u0161t\u00e1diu tehotnosti(18).<\/p>\n

Probl\u00e9m v diferenci\u00e1lnej diagnostike m\u00f4\u017ee predstavova\u0165 venost\u00e1za placenty spojen\u00e1 s dilat\u00e1ciou ciev bez zv\u00fd\u0161enia ich po\u010dtu. Samotn\u00e1 isch\u00e9mia tkaniva taktie\u017e m\u00f4\u017ee vies\u0165 k zmen\u00e1m klkov v podobe ich \u201ezo\u0161\u00faverenia\u201c (shrinkage), ktor\u00e9 s\u0165a\u017euj\u00fa hodnotenie vaskulariz\u00e1cie a m\u00f4\u017eu vies\u0165 k jej nadhodnoteniu(19). Imunohistochemick\u00e9 farbenie endotelov\u00fdch markerov CD31 a CD34 umo\u017e\u0148uje lep\u0161ie a presnej\u0161ie hodnotenie po\u010dtu kapil\u00e1r v porovnan\u00ed so \u0161tandardn\u00fdm farben\u00edm hematoxyl\u00ednom a eoz\u00ednom. Probl\u00e9m pri hodnoten\u00ed m\u00f4\u017ee sp\u00f4sobova\u0165 aj kolaps ciev po p\u00f4rode, \u010dasto v s\u00favislosti s nevhodnou fix\u00e1ciou placenty(1).<\/p>\n

D\u00f4le\u017eit\u00e9 je aj\u00a0 odl\u00ed\u0161enie\u00a0 chorangi\u00f3zy\u00a0 od\u00a0 chorangi\u00f3mu\u00a0 a chorangiomat\u00f3zy. Chorangi\u00f3m predstavuje dobre ohrani\u010den\u00e9 lo\u017eisko vyrastaj\u00face z kme\u0148ov\u00e9ho klku, podobaj\u00face sa kapil\u00e1rnemu hemangi\u00f3mu. V postihnut\u00fdch klkoch doch\u00e1dza k prolifer\u00e1cii kapil\u00e1rnych \u0161trukt\u00far, pr\u00edtomn\u00e9 s\u00fa endotelov\u00e9 bunky, pericyty aj myofibroblastov\u00e9 strom\u00e1lne bunky(20). Cievne \u0161trukt\u00fary pri chorangiomat\u00f3ze maj\u00fa hrub\u00fa stenu obsahuj\u00facu hladkosvalov\u00e9 bunky pozit\u00edvne na akt\u00edn s podporn\u00fdm tkanivom tvoren\u00fdm zv\u00fd\u0161en\u00fdm mno\u017estvom kolag\u00e9nu, pri\u010dom nie s\u00fa viazan\u00e9 len na termin\u00e1lne klky, ale obklopuj\u00fa aj v\u00e4\u010d\u0161ie cievy v kme\u0148ov\u00fdch klkoch(19). Kapil\u00e1ry s\u00fa taktie\u017e ohrani\u010den\u00e9 kontinu\u00e1lnou vrstvou pericytov pozit\u00edvnych na \u0161pecifick\u00fd svalov\u00fd akt\u00edn, na rozdiel od chorangi\u00f3zy, kde pericyty netvoria kontinu\u00e1lnu vrstvu okolo kapil\u00e1r(10). Celkovo mo\u017eno poveda\u0165, \u017ee v\u0161etky placenty s chorangi\u00f3zou s\u00fa fok\u00e1lne hypervaskul\u00e1rne, ale nie v\u0161etky hypervaskul\u00e1rne placenty vznikaj\u00fa v d\u00f4sledku chorangi\u00f3zy.<\/p>\n

Opisuje sa, \u017ee chorangi\u00f3m a fok\u00e1lna alebo segment\u00e1lna chorangiomat\u00f3za s\u00fa \u010dastej\u0161ie pr\u00edtomn\u00e9 v 32. \u2013 36. t\u00fd\u017edni tehotnosti. Multifok\u00e1lnu\u00a0 chorangiomat\u00f3zu\u00a0 pozorujeme\u00a0 u\u017e v gesta\u010dnom veku ni\u017e\u0161om ako 32. t\u00fd\u017ede\u0148. Incidencia chorangi\u00f3zy je n\u00edzka v 2. trimestri a st\u00fapa v 3. trimestri, s maximom v\u00fdskytu v neskor\u0161\u00edch \u0161t\u00e1di\u00e1ch tehotenstva(3,21). Viacer\u00ed autori op\u00edsali, \u017ee chorangi\u00f3za, ktor\u00e1 vznik\u00e1 v posledn\u00fdch \u0161t\u00e1di\u00e1ch tehotenstva a nie je sprev\u00e1dzan\u00e1 in\u00fdm patologick\u00fdm stavom, nevpl\u00fdva negat\u00edvne na v\u00fdvoj plodu ani na priebeh gravidity(3).<\/p>\n

 <\/p>\n

Z\u00e1ver<\/h4>\n

Celkov\u00e1 vaskulariz\u00e1cia klkov placenty st\u00fapa so \u0161t\u00e1diom gravidity. Predpoklad\u00e1 sa, \u017ee chorangi\u00f3za vyskytuj\u00faca sa bez n\u00e1lezu in\u00fdch pr\u00edznakov hypoxie, fet\u00e1lnej alebo matern\u00e1lnej hypoperf\u00fazie nepredstavuje riziko pre tehotnos\u0165 ani ju jednozna\u010dne nemo\u017eno pova\u017eova\u0165 za pr\u00ed\u010dinu potratu alebo in\u00fdch komplik\u00e1ci\u00ed tehotnosti. Naopak, r\u00f4zne choroby matky m\u00f4\u017eu zvy\u0161ova\u0165 pravdepodobnos\u0165 n\u00e1lezu chorangi\u00f3zy, ktor\u00e1 by tak mohla predstavova\u0165 sk\u00f4r faktor adapt\u00e1cie placenty na zhor\u0161en\u00e9 podmienky prostredia. Napriek v\u0161etk\u00fdm te\u00f3ri\u00e1m ost\u00e1va pr\u00ed\u010dina vzniku chorangi\u00f3zy nezn\u00e1ma. Jej n\u00e1lez pri histologickom vy\u0161etren\u00ed placenty by mohol napom\u00f4c\u0165 v \u00fazkej spolupr\u00e1ci patol\u00f3ga a gynekol\u00f3ga p\u00f4rodn\u00edka pri odhalen\u00ed chor\u00f4b matky, ktor\u00e9 m\u00f4\u017eu komplikova\u0165 tehotnos\u0165.<\/p>\n

 <\/p>\n

Po\u010fakovanie<\/em><\/strong><\/p>\n

Tento <\/em>\u010dl\u00e1nok vznikol v\u010faka podpore v r\u00e1mci OP V\u00fdskum a v\u00fdvoj pre projekt: Dobudovanie technickej infra\u0161trukt\u00fary v oblasti v\u00fdskumu diagnostick\u00fdch postupov a met\u00f3d v r\u00e1mci v\u010dasnej diagnostiky naj\u010dastej\u0161\u00edch onkologick\u00fdch ochoren\u00ed u \u017eien, ITMS 26210120026, spolufinancovan\u00fd zo zdrojov Eur\u00f3pskeho fondu region\u00e1lneho rozvoja.<\/em><\/p>\n

This article was created thanks to support of the OP Research and Development for the project: Completion of technical infrastructure in the field of research of diagnostic procedures and methods in early diagnosis of the most common oncological women diseases, ITMS 26210120026, 2013\/1. 1.\/02-SORO, co-financed by the European Regional Development Fund.<\/em><\/p>\n

 <\/p>\n

 <\/p>\n

LITERAT\u00daRA<\/strong><\/p>\n

    \n
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  2. Stanek Comparison of placental pathology in preterm, late-preterm, near-term, and term births. Am J Obstet Gynecol 2014; 210(3): 234 e1-6.<\/li>\n
  3. Stanek Chorangiosis of Chorionic Villi: What Does It Really Mean? Arch Pathol Lab Med 2016; 140(6): 588-593.<\/li>\n
  4. Srinivasan AP, Omprakash BO, Lavanya K, et A prospective study of villous capillary lesions in complicated pregnancies. J Pregnancy 2014; 2014: 193925.<\/li>\n
  5. Chen DB, Zheng Regulation of placental angiogenesis. Microcirculation 2014; 21(1): 15-25.<\/li>\n
  6. Staribratova D, Milchev N. [Placental chorangiosis associated with abruption and hypoxia]. Akush Ginekol (Sofiia) 2009; 48(5): 44-6.<\/li>\n
  7. Ogino S, Redline Villous capillary lesions of the placenta: distinctions between chorangioma, chorangiomatosis, and chorangiosis. Hum Pathol 2000; 31(8): 945-954.<\/li>\n
  8. Stanek J, Biesiada Clustering of maternal-fetal clinical conditions and outcomes and placental lesions. Am J Obstet Gynecol 2012; 206(6): 493 e1-8.<\/li>\n
  9. Mayhew TM, Jackson MR, Haas Microscopical morphology of the human placenta and its effects on oxygen diffusion: a morphometric model. Placenta 1986; 7(2): 121-131.<\/li>\n
  10. Rychik J, Goff D, McKay E, et Characterization of the Placenta in the Newborn with Congenital Heart Disease: Distinctions Based on Type of Cardiac Malformation. Pediatr Cardiol 2018.<\/li>\n
  11. Suzuki K, Itoh H, Kimura S, et Chorangiosis and placental oxygenation. Congenit Anom (Kyoto) 2009; 49(2): 71-76.<\/li>\n
  12. Soma H, Murai N, Tanaka K, et Angiogenesis in villous chorangiosis observed by ultrastructural studies. Med Mol Morphol 2013; 46(2): 77-85.<\/li>\n
  13. Bhattacharjee D, Mondal SK, Garain P, et Histopathological study with immunohistochemical expression of vascular endothelial growth factor in placentas of hyperglycemic and diabetic women. J Lab Physicians 2017; 9(4): 227-233.<\/li>\n
  14. Gupta R, Nigam S, Arora P, et Clinico-pathological profile of 12 cases of chorangiosis. Arch Gynecol Obstet 2006; 274(1): 50-53.<\/li>\n
  15. Akbulut M, Sorkun HC, Bir F, et Chorangiosis: the potential role of smoking and air pollution. Pathol Res Pract 2009; 205(2): 75-81.<\/li>\n
  16. Bendon B. Chorangiosis?<\/li>\n
  17. Stroustrup Smith A, Huang WY, Wong G, et Placental chorangiosis associated with markedly elevated maternal chorionic gonadotropin. A case report. J Reprod Med 2003; 48(10): 827-830.<\/li>\n
  18. Caldarella A, Buccoliero AM, Taddei Chorangiosis: report of three cases and review of the literature. Pathol Res Pract 2003; 199(12): 847-50.<\/li>\n
  19. Amer HZ, Heller Chorangioma and related vascular lesions of the placenta–a review. Fetal Pediatr Pathol 2010; 29(4): 199-206.<\/li>\n
  20. Stanek J, Biesiada J, Trzeszcz Clinicoplacental phenotypes vary with gestational age: an analysis by classical and clustering methods. Ac- ta Obstet Gynecol Scand 2014; 93(4): 392-398.<\/li>\n
  21. Burton GJ, Jauniaux Sonographic, stereological and Doppler flow velocimetric assessments of placental maturity. Br J Obstet Gynaecol 1995; 102(10): 818-25.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

    *All tables, charts, graphs and pictures that are featured in this article can be found in the .pdf attachment at the end of the paper.   \u00davod Za fyziologick\u00fdch okolnost\u00ed zachyt\u00edme na reze termin\u00e1lnym klkom placenty 2 \u2013 5 cievnych priestorov. Vil\u00f3zna hypervaskularita je charakterizovan\u00e1 zv\u00fd\u0161en\u00fdm po\u010dtom cievnych priestorov, nes\u00favisiacich s ich dilat\u00e1ciou ani venost\u00e1zou.<\/p>\n","protected":false},"author":7,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_mi_skip_tracking":false,"footnotes":""},"categories":[297],"tags":[1064,1065,1062],"class_list":["post-1606","post","type-post","status-publish","format-standard","hentry","category-pathology","tag-chorangiosis","tag-chorionic-villi-vascularisation","tag-placenta-en","typ_clanku-casuistry"],"acf":{"abstrakt":"

    Chorangiosis is a placental vascular lesion affecting chorionic villi, accompanied by a rise in the number of vessels. The etiology of chorangiosis is not fully known. However, the widely accepted hypothesis is related to the long-term placental hypoxia. It is a rare disease associated with various feto-maternal and placental changes. It is also quite common in pre-eclampsia, hypertension, or diabetes mellitus in the mother. We are describing the case of a 23 year old woman with an abortion in the 25th week of pregnancy and with finding of umbilical anomaly and placental chorangiosis.<\/p>\n

    Key words:<\/strong> chorangiosis, placenta, chorionic villi vascularisation<\/p>\n","casopis":[{"ID":1513,"post_author":"7","post_date":"2018-11-05 11:53:53","post_date_gmt":"2018-11-05 10:53:53","post_content":"

      \r\n \t
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    • Molecular \u2013 genetic diagnostics of Human Papillomavirus (HPV) and monitoring of HPV patients<\/li>\r\n \t
    • Laboratory diagnostic possibilities for Clostridium difficile infections<\/li>\r\n \t
    • Chorangiosis of Placenta - Disorder of Unclear Etiology (Case Report and Overview of Current Knowledge)<\/li>\r\n \t
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