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Immune cells are critically involved in placental development and functioning, and inadequate regulation of the maternal immune system is associated with placental pathology and pregnancy complications. This study aimed to explore numbers of decidual immune cells in pregnancies complicated with fetal growth restriction (FGR) and stillbirth (SB), and in placentas with histopathological lesions: maternal vascular malperfusion (MVM), fetal vascular malperfusion (FVM), delayed villous maturation (DVM), chorioamnionitis (CA), and villitis of unknown etiology (VUE). Placental tissue from FGR ( n  = 250), SB ( n  = 64), and healthy pregnancies ( n  = 42) was included. Histopathological lesions were classified according to criteria developed by the Amsterdam Placental Workshop Group. Tissue slides were stained for CD68 (macrophages), CD206 (M2-like macrophages), CD3 (T cells), FOXP3 [regulatory T (Treg) cells], and CD56 [natural killer (NK) cells]. Cell numbers were analyzed in the decidua basalis using computerized morphometry. The Mann-Whitney  U -test and Kruskal Wallis test with the Dunn's as  post-hoc  test were used for statistical analysis. Numbers of CD68 +  macrophages were higher in FGR compared to healthy pregnancies ( p  < 0.001), accompanied by lower CD206 + /CD68 +  ratios ( p  < 0.01). In addition, in FGR higher numbers of FOXP3 +  Treg cells were seen ( p  < 0.01) with elevated FOXP3 + /CD3 +  ratios ( p  < 0.01). Similarly, in SB elevated FOXP3 +  Treg cells were found ( p  < 0.05) with a higher FOXP3+/CD3+ ratio ( p  < 0.01). Furthermore, a trend toward higher numbers of CD68 +  macrophages was found ( p  < 0.1) in SB. Numbers of CD3 +  and FOXP3 +  cells were higher in placentas with VUE compared to placentas without lesions ( p  < 0.01 and  p  < 0.001), accompanied by higher FOXP3 + /CD3 +  ratios ( p  < 0.01). Elevated numbers of macrophages with a lower M2/total macrophage ratio in FGR suggest a role for a macrophage surplus in its pathogenesis and could specifically indicate involvement of inflammatory macrophages. Higher numbers of FOXP3 +  Treg cells with higher Treg/total T cell ratios in VUE may be associated with impaired maternal-fetal tolerance and a compensatory response of Treg cells. The abundant presence of placental lesions in the FGR and SB cohorts might explain the increase of Treg/total T cell ratios in these groups. More functionality studies of the observed altered immune cell subsets are needed.

Altered Levels of Decidual Immune Cell Subsets in Fetal Growth Restriction, Stillbirth, and Placental Pathology