Gynae and obs: gestational, placental disorders

Question 1

disorders of early pregnancy (2)

Answer 1

• Spontaneous abortion

- Ectopic pregnancy

Question 2

Disorders of late pregnancy (3)

Answer 2

• Placental abnormalities
• Placental inflammations
• Toxemias of pregnancy

Question 3

trophoblastic diseases (3)

Answer 3

• hydatidiform moles (partial/complete)
• Invasive mole
• Choriocarcinoma

Question 4

spontaneous abortion

- which part of pregnancy does it usually happen

Answer 4

before 12 weeks

Question 5

spontaneous abortion causes

Answer 5

• Uterine defects: fibroids, polyps
• Endocrine factors
• Systemic disorders: HTN, Diabetes
• Fetal chromosomal anomalies
• Infections: TORCH (congenital):
  toxoplasmosis, rubella, cytomegalovirus, herpes simplex

Question 6

ectopic pregnancy definition

Answer 6

Implantation of the fetus in any site other than a normal uterine location

Question 7

risk factors for ectopic pregnancy (6)

Answer 7

• Chronic salpingitis (gonococcal infection)
• Peritubal adhesions (appendicitis)
• Leiomyomas
• Previous surgery
• Benign cysts and tumours of tube
• IUCD (intra uterine contraceptive device)

Question 8

ectopic pregnancy clinical features (4)

Answer 8

• Amenorrhoea (6-8 weeks)
• Abdominal pain
• Vaginal bleeding
• Hemorrhagic shock

Question 9

ectopic pregnancy complications (4)

Answer 9

• rupture
• haemorrhage
• > Haematosalpinx (bleeding in FT)
• > Haemoperitoneum (bleeding into peritoneal cavity)
• spontaneous regression of pregnancy
• tubal abortion

Question 10

ectopic pregnancy diagnostic methods (3)

Answer 10

• hCG titres: indicate pregnancy
• pelvic ultrasound: dilation of FT
• endometrial biopsy: pregnancy like changes but no placenta

Question 11

placental inflammation

• possible sites (3)
• how infection get to the placenta

Answer 11

• placenta: villitis
• membranes: chorioamnionitis
• umbilical cord: funisitis
• ascend through birth canal
• hematogenous

Question 12

organisms causing placental infections (4 groups + special pneumonic!*)

Answer 12

• STD: syphilis, chlamydia
• bacteria: strep, listeriosis
• viral: rubella, CMV, HSV*
• protozoa: toxoplasmosis*

TORCH**

Question 13

consequences of antenatal (before birth) infections

Answer 13

• IUGR (Intrauterine growth restriction)
• low birth weight
• premature birth
• congenital anormalies
• deafness

Question 14

complications of toxemia of pregnancy (blood poisoning by toxins)

Answer 14

• Preeclampsia: Hypertension, proteinuria, edema
• eclampsia: (severe)
  Convulsion (sudden involuntary contraction of muscles)
  DIC (disseminated intravascular coagulation: causes blood clots to form throughout the body)

Question 15

toxemia of pregnancy

• which part of pregnancy does it usually happen
• who does it affect more

Answer 15

last trimester

primiparas (pts giving birth for the 1st time)

Question 16

pathogenesis of preeclampsia

Answer 16

• Diffuse endothelial dysfunction and vasoconstriction -> hypertension
• Increased vascular permeability -> proteinuria and edema

Question 17

toxemia effects on liver

Answer 17

irregular, focal, subcapsular, and intraparenchymal hemorrhages

Question 18

toxemia effects on kidney

Answer 18

marked swelling of endothelial cells and fibrin thombi of glomeruli

Question 19

toxemia effects on brain

Answer 19

hemorrhage and small-vessel thromboses

Question 20

placenta abnormalities (3)

Answer 20

• Placenta Previa
• Abruptio Placentae
• Placenta Accreta

Question 21

placenta previa

- definition

Answer 21

Implantation of placenta over or near the internal os, necessitating delivery of placenta before foetus
(instead of the placenta being at the top: baby delivered -> deliver placenta, placenta is at the bottom covering the cervix: need to remove placenta first before can access the baby)

Question 22

placenta previa

• complications
• treatment

Answer 22

• Antepartum hemorrhage

- Cesarean section usually performed

Question 23

Abruptio Placentae

- definition

Answer 23

Premature incomplete or complete separation of normally positioned placenta from uterine wall during pregnancy or before delivery

Question 24

Abruptio Placentae

- complications

Answer 24

• bleeding (concealed/revealed)
  shock/ DIC (blood clots)
  severe fetal distress -> death

Question 25

Placenta Accreta definition

Answer 25

Adhesion of normal placental villi to uterine wall due to absence of decidual plate between villi and myometrium (sticks entirely to the uterine wall) cause of failure of placenta to separate in 3rd stage of labor Normal > accreta > increta > percreta accreta: infiltrate endometrium - adhere to myometrium increta: infiltrate myometrium percreta: infiltrate serosa layer

Question 26

Placenta Accreta complications + treatment

Answer 26

- severe PPH (post-partum hemorrhage) -> shock | - Hysterectomy (removal of the uterus)

Question 27

trophoblastic diseases (3)

Answer 27

- hydatidiform mole – partial & complete - Invasive mole - Choriocarcinoma caused by abnormal proliferation of trophoblastic cells (the outermost layer of cells of the blastocyst that attaches the fertilized ovum to the uterine wall and serves as a nutritive pathway for the embryo)

Question 28

trophoblastic diseases | - who has higher risk (geography, age, history)

Answer 28

- Asia, Africa and Latin America - Extremes of reproductive age: Malignant sequelae frequent in older patients - history of previous mole increases risk previous success pregnancies gives protection = lower risk

Question 29

complete vs partial hydatidiform mole

Answer 29

mole = clump of growing tissue complete: fertilization of an egg in which the nucleus is lost or inactivated (no maternal chromosomes, XY both paternal) fetus is absent partial: 69 chromosomes (instead of usual 46) - triploid fetus can be present

Question 30

hydatidiform mole | diagnostic test + clinical symptoms

Answer 30

clinical symptoms: - vaginal bleeding - Hyperemesis, pulmonary embolization and hyperthyroidism ``` diagnostic test: - serology: raised hCG levels - PET scan - see tissue growth - genome testing (p57 - maternal genome) if p57 negative = complete mole ```

Question 31

hydatidiform mole complications

Answer 31

- Uterine hemorrhage - Coagulopathy - Infection - Continued trophoblastic activity (progress into invasive mole/ choriocarcinoma)

Question 32

Invasive mole - definition - metastasis - complication

Answer 32

hydropic villi invade the myometrium or blood vessels, or are transported to extrauterine sites - low metastatic risk, but still probable (to lungs/ vulva/ broad ligament) - locally aggressive - uterine perforation - intraperitoneal bleeding leads to death

Question 33

gestational choriocarcinoma - malignancy & aggressiveness - pathogenesis

Answer 33

malignant epithelial tumour arising from trophoblast of any gestational event (hydatidiform mole/ abortion/ pregnancy) It consists mainly of biphasic proliferation of syncytio-cytotrophoblast - aggressive and malignant - mostly progression from complete mole

Question 34

gestational choriocarcinoma - gross and micro appearance - metastasis

Answer 34

- gross: hemorrhagic friable mass in uterine cavity - micro: Hemorrhage and necrosis, anaplastic trophoblast, vascular invasion - metastasis: widespread metastasis via blood affects lungs/ vagina/ brain/ liver

Question 35

gestational choriocarcinoma - clinical symptoms - survival - prognostic factors

Answer 35

- Abnormal uterine bleeding - hemorrhagic events distally caused by distant metastases high HCG levels high survival with chemotherapy prognosis depends on: distant metastases, success of Chemotherapy, choriocarcinoma following term pregnancy

Question 36

staging of gestational choriocarcinoma

Answer 36

I - confined to the uterus II - metastases or direct extension to other GENITAL structures (vagina, ovaries, broad ligament or fallopian tubes) III- Metastases to the lungs IV - distant metastases further than lung