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Flashcards in Gestational Pathology Deck (17)
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1

What is an ectopic pregnancy? Where can it occur? What is they key risk factor? How do patients classically present and what is this presentation clinically mistaken for? How do we treat it?

- ectopic pregnancy is the implantation of the fertilized egg into a site other than the uterus; it is the MOST common cause of pregnancy related mortality in the 1st trimester
- 90% occur in the fallopian tube (ampulla > isthmus > fimbriae > ovary > abdomen)
- key risk factor is scarring (via PID, endometriosis, etc.)
- patients classically present with sudden lower quadrant abdominal pain weeks after a missed period (this is clinically mistaken for appendicitis!)
- look for a lower-than-expected rise in beta-hCG
- treat with methotrexate and/or surgery

2

What is the definition of spontaneous abortion? What is the most common cause of spontaneous abortion? What are some other causes? How do patients present?

- spontaneous abortion is the miscarriage of a fetus before the 20th week of gestation (fetus is not viable)
- most commonly caused by chromosomal abnormalities in the fetus
- other causes: teratogens, congenital infection, hypercoagulability
- patients present with vaginal bleeding, cramping, and passage of fetal tissue
- spontaneous abortion is quite common, and occurs in up to 25% of pregnancies

3

What is placenta previa? What does it usually mean in terms of delivery? What are two major risk factors? How does it classically present?

- placental previa is when the placenta attaches to the lower part of the uterus and covers the internal cervical os
- this makes natural delivery difficult or impossible, and usually requires a C-section
- risk factors: multiparity and prior C-section
- classically presents with PAINLESS vaginal bleeding; fetal distress is usually not an issue

4

What is placental abruption? How do patients present? What are some risk factors?

- placental abruption is a life-threatening condition for both mother and fetus in which the placenta prematurely separates from the uterine wall (usually due to a retroplacental clot)
- patients present with an abrupt PAINFUL bleed (can be very large and lead to shock, fetal distress); usually in the 3rd trimester
- it is the most common cause of late pregnancy bleeding
- risk factors: trauma, placenta previa, smoking, HTN, preeclampsia, cocaine abuse

5

What is placenta accreta? Placenta increta? Placenta percreta? How do patients present and what do they usually require?

- all 3 are due to a defective/thin decidual layer leading to the abnormal attachment of the placenta
- placenta Accreta: Attaches to myometrium, no penetration (most common type)
- placenta INcreta: penetrates INto myometrium
- placenta PERcreta: PERforates through the myometrium and through the serosa, can attach to the rectum or bladder
- patients present with a normal fetal delivery but a complicated/impossible placental delivery often with a massive hemorrhagic bleed (can be life-threatening for the mother)
- usually requires a hysterectomy

6

What is pre-eclampsia? What precedes it? What can it develop into? How is it treated?

- pre-eclampsia is a condition of HTN, proteinuria, and edema (mainly of the face and extremities) in the 3rd trimester/after 20 weeks of gestation
- it is preceded by gestational HTN without proteinuria or edema
- can progress into eclampsia: pre-eclampsia and maternal seizures (extremely dangerous)
- treatment is removal of the placenta (AKA immediate delivery) if severe; if mild, can try antihypertensives and magnesium sulfate (to prevent seizures)

7

What is HELLP syndrome? How can we diagnose it?

- HELLP syndrome is the manifestation of severe pre-eclampsia as hepatic microangiopathy (occurs in 10% of cases of pre-eclampsia)
- Hemolysis, Elevated Liver enzymes, Low Platelets
- immediate delivery is indicated in patients presenting with HELLP
- Dx with LFTs and blood smear (will show hemolysis)

8

What is the pathophysiology behind pre-eclampsia?

- (not entirely well understood)
- pre-eclampsia is due to HTN and increased vascular permeability in the setting of insufficient maternal blood flow to the placenta (placental hypoperfusion is the underlying trigger)
- the insufficiency is secondary to the failure of the spiral arteries to be remodeled (normally, the spiral arterial wall is invaded by trophoblasts, which results in the dilation of the arteries into the vascular sinusoids; this doesn't occur in pre-eclampsia)

9

Which organisms can cross the placenta and infect the fetus? By what other mechanism can the placenta get infected? Which is more common?

- ToRCHeS
- Toxoplasmosis, Rubella, CMV, HIV and HSV, syphilis
- this is via hematogenous spread; the other mechanism is via ascending infection (this is actually the more common mechanism)

10

What are the three morphologies of gestational trophoblastic disease? What characterizes this group of diseases? In which countries are these disease most common?

- gestational trophoblastic disease is a spectrum of diseases involving the trophoblast
- hydatidiform mole (complete or partial)
- invasive mole
- choriocarcinoma
- all three are characterized by raised beta-hCG levels (even more so than would be expected in a normal pregnancy)
- most common in Asian countries

11

What is a hydatidiform mole? What are the two types? How do patients present?

- (this is a gestational trophoblastic disease)
- AKA molar pregnancy
- this is due to abnormal conception, resulting in trophoblastic proliferation; essentially, instead of growing a fetus, the patient grows abnormal placental tissue
- 2 types: complete and incomplete
- patients believe to be pregnant (as the uterus and body respond in a similar fashion); abnormally elevated beta-hCG and a lack of fetal heart sounds
- complete: classic triad of vaginal bleeding, hyperemesis, and hyperthyroidism; also an abnormally enlarged uterus, and "snowstorm" appearance on USS
- partial: vaginal bleeding and abdominal pain

12

Compare a complete molar pregnancy to a partial molar pregnancy. Which main genotype is found in each?

- complete: 2 sperm fertilize an empty ovum (completely dad), 46XX way more common than 46XY for some reason, no fetal tissue (completely molar), all villi are edematous (complete involvement), diffuse trophoblastic proliferation (complete proliferation); increased risk for developing choriocarcinoma, massive increase in beta-hCG
- partial: 2 sperm fertilize a normal ovum, 69XXY most common, fetal tissue is present, some villi are normal, focal trophoblastic proliferation; very minimal risk for developing choriocarcinoma, increase in beta-hCG

13

What percentage of hydatidiform moles are invasive? What percentage will progress to choriocarcinoma? How do we treat invasive moles?

- 10-15% of molar pregnancies are invasive
- 2-3% progress to choriocarcinoma
- treat invasive moles with chemotherapy (although they are not malignant, curettage is often not sufficient enough; very sensitive to chemo)

14

What is choriocarcinoma? What are the major risk factors? How does choriocarcinoma classically act? How do we treat it?

- choriocarcinoma is a very rare malignancy of the trophoblasts
- it is extremely aggressive with early widespread vascular involvement (note that this is VASCULAR spread, lymphatic spread is uncommon for this cancer)
- major risk factors are gestational trophoblastic disease (molar pregnancy) and abortion
- although highly malignant, choriocarcinoma responds extremely well to chemotherapy and prognosis is usually quite good even with distant metastases
- (note that there is a sporadic form of this cancer that is unrelated to gestation, and that it does NOT respond nearly as well to chemo)

15

Why do patients with a complete molar pregnancy classically present with hyperthyroidism?

- this is because of the massive amounts of beta-hCG released by the mole
- beta-hCG shares an alpha subunit with TSH, FSH, and LH (the beta subunits of each are different)
- the similarity to TSH results in the potentiality for hyperthyroidism to develop

16

To help prevent seizures in pre-eclamptic and eclamptic women, large amounts of magnesium sulfate is given - what are the major signs of magnesium toxicity we should watch out for?

- the 1st major sign is a decrease in deep tendon reflexes
- this is followed by drowsiness and flushing
- eventually, respiratory and cardiac depression develop and death can occur

17

What are the most common causes of direct deaths associated with pregnancy? What about indirect deaths?

- amniotic fluid embolism is most common cause of direct death, followed by VTE, postpartum hemorrhage, eclampsia, and sepsis
- indirect deaths: cardiac disease and renal disease