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ER2-1 > Lecture 8.1: Gestational and Placental Disorders > Flashcards

Lecture 8.1: Gestational and Placental Disorders Flashcards

1
Q

Spontaneous abortion (aka miscarriage) is defined as pregnancy loss before ______ weeks of gestation

A

20 weeks of gestation (most often occurs before week 12)

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2
Q

What are 2 common fetal chromosomal anomalies associated with spontaneous abortion?

A

Turner Syndrome (45, XO) and trisomy 16

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3
Q

What are some maternal endocrine factors which may lead to spontaneous abortion?

A
  • Luteal-phase defect
  • Poorly controlled diabetes
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4
Q

Which systemic disorder of the vascular is associated with spontaneous abortions and a false positive syphilis test?

A

Antiphospholipid antibody syndrome

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5
Q

What is the most important predisposing condition (35-50%) for ectopic pregnancy?

A

Chronic salpingitis secondary to PID –> intralumenal fallopian tube scarring

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6
Q

What are some of the risk factors for ectopic pregnacy?

A
  • Chronic salpingitis secondary to PID
  • Scarring of fallopian tubes due to: appendicits, endometriosis, and/or prior surgery
  • IUD use = 2x ↑ risk
  • Smoking
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7
Q

Why is it important to recognize a potential ectopic pregnancy?

A
  • Rupture of tubal pregnancy = emergency!
  • May lead to intraperitoneal hemorrhage –> hemorrhagic shock –> DEATH!
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8
Q

Diagnosis of ectopic pregnancy is based on what?

A
  • ↑ serum levels of hCG
  • Pelvic sonography
  • Endometrial biopsy showing decidua w/o chorionic villi or implantation site
  • Laparoscopy
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9
Q

Typical clinical presentation of ectopic pregnancy?

A

Onset of moderate-severe abdominal pain + vaginal bleeding 6-8 weeks after last menstrual period

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10
Q

What are the 3 basic types of twin placentas?

A
  • Diamnionic dichorionic (may be fused)
  • Diamnionic monochorionic
  • Monoamnionic monochorionic
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11
Q

Twin-twin transfusion syndrome is a complication of what type of twin placenta; what occurs in this syndrome?

A
  • Complication of monochorionic twin pregnancy
  • Monochorionic placentas have vascular anastomoses that connect the circulation of each fetus; sometimes including one or more AV shunts
  • Shunt preferentially ↑ blood flow to one twin (polyhydramnios) at expense of other (oligohydramnios)
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12
Q

What is the placenta previa; leads to what complications?

A
  • Placenta implants in lower uterine segment or cervix, often leads to serious 3rd trimester bleeding
  • Complete placenta previa covers internal cervical os and requires delivery via C-section
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13
Q

What is placenta accreta; leads to what complication?

A
  • Partial or complete absence of the decidua, such that placental villous tissue adheres directly to myometrium
  • Leads to failure of placental separation at birth —> important cause of severe, life-threatening postpartum bleeding
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14
Q

Which pathway is the most common for placental infections and is caused by what?

A

Ascending infections caused by bacteria i.e., Gonorrhea and Chlamydia

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15
Q

Preeclampsia is what type of syndrome and due to dysfunction of what?

A

SYSTEMIC syndrome due to endothelial dysfunction

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16
Q

What is the triad of preeclampsia?

A
  1. HTN (endothelial dysf. –> vasoconstriction)
  2. Edema (↑ vascular permeability)
  3. Proteinuria (↑ vascular permeability)
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17
Q

Development of what makes preeclampsia become eclampsia?

A

Develop hyperreflexia and convulsions

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18
Q

Preeclampsia usually occurs in what trimester and which women are at greater risk?

A
  • Third trimester (after 34 weeks gestation)
  • Most common in primiparas (women pregnant for 1st time)
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19
Q

How is preeclampsia distinguished from gestational HTN?

A

Gestational HTN lacks proteinuria

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20
Q

Some women w/ severe preeclampsia can develop HELLP syndrome, which stands for what?

A
  • Microangiopathic Hemolytic anemia
  • _E_levated _L_iver enzymes
  • _L_ow _p_latelets
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21
Q

Abnormal placental vasculature formation as part of the pathogenesis of preeclampsia is due to what 2 major events?

A
  • Abnormal trophoblastic implantation
  • Failure of physiologic remodeling of the maternal vessels
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22
Q

In response to hypoxia the ischemic placenta releases what 2 placenta-derived antiangiogenic factors into maternal circulation and what does each antagonize the effects of?

A
  • soluble FMS-like tyrosine kinase (sFltl) antagonizes VEGF
  • Endoglin antagonizes TGF-β
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23
Q

Preeclampsia is associated with a hypercoagulable state that may lead to formation of thrombi in the arterioles and capillaries of what main sites?

A

Liver + kidneys + brain + pituitary

24
Q

Hypercoagulablity in preeclampsia is related to what factors?

A
  • ↓ endothelial prod. of PGI2 (potent antithrombic factor)
  • Prod. of PGI2 is normally stimulated by VEGF, which is being antagonizd by sFlt1
25
What 4 microscopic changes are seen in the placenta in women with preeclampsia?
1. **Infarcts**, which are **larger** and **more numerous** 2. **Exaggerated ischemic change** of chorionic villi and trophoblasts, consisting of **↑ syncytial knots\*\*\*** 3. **Frequent retroplacental hematomas** 4. **Abnormal decidual vessels** w/ thrombi, **fibrinoid necrosis**, or intraintimal lipid deposits (**acute atherosis**)\*\*
26
When liver lesions are present with preeclampsia what is seen?
- **Intraparenchymal hemorrhage** - **Fibrin thrombi** in **portal capillaries** and **foci** of **hemorrhagic necrosis**
27
What are the features of kidney lesions associated with preeclampsia, specifically the glomeruli?
- **Swelling** of **endothelial** cells - **Amorphous dense deposits** on endothelial side of **BM** - **Mesangial cell hyperplasia**
28
What will immunofluorescent studies of the kidney in preeclampsia show an abundance of?
**Fibrin** in **glomeruli**
29
Preeclampsia will present earlier (before 34 weeks gestation) in women w/ what 4 underlying conditions?
- **Hydatidiform mole** - **Preexisting kidney disease** - **HTN** - **Coagulopathies**
30
Which sx's assoc. w/ preeclampsia are serious events indicative of severe preeclampsia often requiring delivery?
**Headaches** and **visual disturbances**
31
How is preeclampsia managed based on gestational age and severity?
- **Term pregnancies**, delivery is **tx of choice**, regardless of severity - **Pre-term** requires **close monitoring**; if severe sx's arise, delivery is indicated regardless of gestational age - **Anti-HTN's** do **NOT** improve outcomes!!!
32
What are some of the possible long-term complications of mother who had preeclampsia?
- **20%** develop **HTN** and **microalbuminuria** within **7 years** of pregnancy - **2x** ↑ risk of **vascular disease** of **heart** and **brain**
33
The diagnosis of acute fatty liver of pregnancy rests on biopsy showing what?
Diffuse **microvesicular steatosis** of **hepatocytes**
34
Pathogenesis of acute fatty liver of pregnancy is due to what type of dysfunction?
- **Mitochondrial**; fetus produces **metabolites** that cannot be broken down by mother - Deficiency of **mitochondrial long-chain 3-hydroxyacyl CoA dehydrogenase**
35
In preeclampsia/eclampsia, what catastrophic event may happen to blood under pressure inside the liver?
Coalesce and expand to form **hepatic hematoma**; dissection of blood under **Glisson capsule** ---\> **catastrophic hepatic rupture**
36
Why are Hydatidiform moes important to recognize?
Assoc. w/ ↑ risk of **persistent trophoblastic disease (invasive mole)** or **choriocarcinoma**
37
Hydatidiform moles are characterized histologically by what?
**Cystic swelling** of the **chorionic villi** accompanied by variable **trophoblastic proliferation**
38
When and how are Hydatidiform moles usually diagnosed; there is an ↑ risk in which age groups?
- Diagnosed **early** in preg. (**average 9 weeks**) by **sonogram (US)** - ↑ incidence in **teens** and btw **40-50 y/o**
39
Hydatidiform moles are more common in what part of the world?
**2x more common** in **Southeast Asia**
40
What does a complete mole result from and what are the karyotypes seen?
- **Fertilization** of an egg that has **lost** its **female chromosomes**; as result genetic material is **_completely paternally_** derived - **90%** = **46,XX** from duplication of genetic material from **one** sperm - **NO fetal tissue**
41
What occurs in a Partial mole and what is the resultant karyotype?
- **Fertilization** of an egg with **2 sperm** - **Karyotype** = **triploid** (i.e., **69,XXY**) or **tetraploid** (i.e., **92,XXXY**)
42
How do complete moles differ from partial moles in terms of presence of fetal tissue and risk of future complications?
- **Complete** moles ↑ risk for **choriocarcinoma** and **persistent** or **invasive mole; no fetal tissue** - **Partial** moles will usually have **fetal tissue present**; are **not** associated with **choriocarcinoma**
43
What is the classic morphological appearance of hydatidiform moles?
**Delicate**, friable mass of **thin-walled**, translucent, cystic, **grapelike** structure w/ **swollen edematous (hydropic) villi**
44
Most women with partial and early complete moles present how?
- **Spontaneous miscarriage** or - Undergo **curettage** because of US findings of **abnormal villous enlargment**
45
Levels of what will be greatly increased with complete moles and this level can be used to monitor for successful removal?
**β**-**hCG levels**
46
Continous elevation of β-hCG after removal of a hydatiform mole likely indicates what?
**Persistent** or **Invasive** mole
47
Invasive hydatidiform moles are characterized by invasion where and what events follow?
- Penetration or perforation of **uterine wall**; invasion of **myometrium** by **hydropic chorionic villi** - Proliferation of both **cyto-** and **syncytiotrophoblasts** - Tumor is **locally destructive** and may **invade** parametrial tissue and **blood vessels** --\> hydropic villi may **embolize** to sites, such as **lung** and **brain**
48
What are signs/sx's and tx for invasive mole?
- **Vaginal bleeding** + **irregular uterine enlargement** - Responds to **chemo** but may result in **uterine rupture** and necessitate **hysterectomy**
49
What is a choriocarcinoma, which cells are involved and is it benign or malignant?
- **Malignant** neoplasm of **_trophoblastic_** cells derived from previously **normal** or **abnormal** pregnancy - **Rapidly invasive** and **metastasize widely**, but responds **well** to **chemo**
50
List 4 conditions which most often precede development of choriocarcinoma?
- **50%** arise in **complete mole** - **25%** arise in **previous abortion** - **22%** after **normal pregnancy** - Remainder in **ectopic pregnancy**
51
How does choriocarcinoma appear grossly?
**Soft, fleshy, yellow-white** tumor w/ large **pale** areas of **necrosis** and **extensive hemorrhage**
52
What is the typical presentation of a choriocarcinoma?
- Irregular **vaginal spotting** of **bloody, brown** fluid - Sometimes sx's don't arise until months after preceding event - **hCG** is typically ↑↑↑, unless tumor is **necrotic** they may be low
53
Choriocarcinoma has a high propensity for what route of spread and what are the most common site of metastasis?
- **Hematogenous** - **Lungs** (50%) and **vagina** (30-40%)l followed by **brain \> liver \> bone** and **kidney**
54
What is the tx for choriocarcinoma and the prognosis?
- Depends on stage and usually consists of **evacuation** of the **uterus** contents + **chemotherapy** - Nearly **100% remission** and **high cure rate** w/ **chemotherapy**
55
Placental site trophoblastic tumor is composed of what cells?
Neoplastic proliferation of **extravilous trophoblasts** (aka **intermediate trophoblasts**)
56
Which hormone is produced by normal extravillous trophoblasts and may be ↑ in placental site trophoblastic tumor?
**Human placental lactogen (hPL)**
57
Histologically what is seen with placental site trophoblastic tumors?
**Malignant** trophoblastic cells diffusely infiltrating the **endomyometrium**

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