04-14 Disorders of Implantation Flashcards
SAB and Ectopic Pg 1. Describe the different types of abortion 2. Recite the epidemiology of first trimester pregnancy loss 3. Discuss the usual presentation of spontaneous abortion and how the diagnostic methods relate to the pathophysiology of spontaneous abortion 4. Distinguish presentation and diagnostic findings of spontaneous abortion from ectopic pregnancy GESTATIONAL TROPHOBLASTIC NEOPLASMS 1. Discuss the genetics of molar pregnancy. 2. Recite the mechanism of normal placen
OBJECTIVE: Describe the different types of abortion
- Complete: all fetal & placental tissue is expelled
-
Incomplete: passage of some but not all “ “
- may require D&C
-
Threatened: uterine bleeding from a gestation w/o cerv dil
- usually light bleeding w/o discomf
- occurs in 20-50% pgs
- only half abort
-
Inevitable: uterine bleeding from gestation accompanied by dilation
- no expulsion thru cervix (?yet)
- Missed: fetal death w/o any expulsion for a least 8 wks
- Septic: any type of abortion accompanied by uterine infx
OBJECTIVE: Recite the epidemiology of first trimester pregnancy loss
15-20% of recognized pregnancies end in SAB
OBJECTIVE: Discuss the usual presentation of spontaneous abortion and how the diagnostic methods relate to the pathophysiology of spontaneous abortion
Usually presents w/ bleeding and contractions (unless missed)
Break down dx in:
Fetal causes
- defective implantation
- genetic (50% of all SABs)
Maternal causes
- inflamm/infx
- toxo, mycoplasma, listeria, viruses
- uterine abnl
- leiomyoma i.e. “fibroid”
- anatomic e.g. Müllerian anomalies
- Hormonal/metab
OBJECTIVE: Distinguish presentation and diagnostic findings of spontaneous abortion from ectopic pregnancy
Spontaneous Abortion
- may or may not have sx
- cramping, dilation, contractions w/ pain etc.
Ectopic Presentation
- usu. 1st tri
- abd pain: none-severe
- Vag bleeding: light, may be < nl period
- IP bleed: none-light-threatening
OBJECTIVE: Discuss the genetics of molar pregnancy.
See respective cards
OBJECTIVE: Recite the mechanism of normal placentation
.
OBJECTIVE: Describe the clinical implications of placenta accreta
- Also, what is it?
What is it?
Placenta accreta is a disorder of implantation in which the placenta implants directly into the myometrium (i.e. not the decidua).
- There are different degrees of accreta depending on how deep the implantation.
- increta: only invades myometrium
- percreta: invasion through the myometrium and serosa, and occasionally into adjacent organs, such as the bladder
Implications
- Can cause severe post-partum uterine hemorrhage.
- ACOG FYI:*
- The incidence of placenta accreta has increased and seems to parallel the increasing cesarean delivery rate. Researchers have reported the incidence of placenta accreta as 1 in 533 pregnancies for the period of 1982–2002 (5). This contrasts sharply with previous reports, which ranged from 1 in 4,027 pregnancies in the 1970s*
Pre-Eclampsia and Eclampsia
- Pathogenesis
- Presentation
- Incidence
- Risk Factors
- Management
Pre-Eclampsia and Eclampsia
Pathogenesis: (see image)
- diffuse endothel dysfxn
- vascon → HTN
- ↑ vasc perm → edema, proteinuria
- assoc w/ ↑ sFlt-1 (a.k.a. sVEGFR-1)
Presentation: Multi-system disease (think pathogenesis)
- usu in 3rd trimester
- CNS: h/a, hallucination, visual ∆s, sz*, hyperreflexia
- *If sz: becomes ECLAMPSIA
- Renal: HTN, oliguria, proteinuria
- Heme: thrombocyotpen.; hemoconc, intravasc hemolysis
- Extremities: edema
- Hepatic: ↑ LFTs, liver capsule rupture
Incidence
- 7-10% of all pgs
Risk Factors
- G1P0
- pre-exist, idiopathic HTN (PIH)
- gluc. intol. of pg (GIP)
- thrombophilia
- mutlifetal
Management
- supportive (tx BP, but not w/ diuretic i think; hydrate them)
- delivery
HELLP
HELLP is ?cousin to pre-eclampsia
- Hemolysis
- Elevated Liver enzymes
- Low Platelet count
Gestational Trophoblastic Dz (GTD, a.k.a. ____________) is caused by two sets of ____________ imprinted genes, and occurs in subtypes _____ and _____.
Gestational Trophoblastic Dz (GTD, a.k.a. MOLAR PREG) is caused by two sets of PATERNALLY imprinted genes, and occurs in subtypes: —COMPLETE HYDATIDIFORM MOLE —PARTIAL HYDATIDIFORM MOLE —Non-met GTD —met good-prog GTD —met bad-prog GTD (incl choriocarcinoma, CC)
Dermoid cysts of the ovary are caused by two sets of ________ imprinted genes.
MATERNALLY
Complete Hydatitidiform Mole
- Presentation
- Pathology
- Treatment
- Risks
—Most common GTD, 1/1250 Western pg’s
—Diploid w/ Only PATERNAL chromosomal DNA
- But maternal m(ito)DNA
- double fert w/ two sperm + enucleation of egg ?MoA
—promotes placental tissues w/o fetus
Presentation
- delayed menses/dx of pg
- exaggerated n/v b/c sky high hCG
- may exhibit hyperthyroidism b/c hCG has some TSH activity
Pathology
- large amts of hydropic placental villi
- no fetal tissue
Treatment
- Evacuation of uterine contents or elective hyst
- Check hCG qWeek until 0
- then q6mos
- If plateaus or incr, full-body CT for mets
- No preg for 6 months
- recurrence very sensitive to anti-folate (MTX) or actinomycin D
- Even in metastatic
Risk Factors
- BIGGEST: Age extremes
- < 15 y/o
- > 40 y/o
- h/o prior CHM or SAB
- maternal balanced chromosomal translocation
- professional occupation
- ?deficient animal fat
- ?deficient carotene
Partial Hydatitidiform Mole
- Presentation
- Pathology
- Associations
Presentation
- SAB in late 1st, early 2nd trimester
Pathology
- triploid XXY (dianrdy)
- often s/p fert w/ a single diploid sperm
- prolif villi + fetus
- villous hydropic changes less pronounced than CHM
- may be missed on pre-natal U/S
Associations
- older mothers
- much less common to have progression to metastisize
Dermoid Tumors
- A.K.A.?
- What is it?
- Pathology
- Risk of progression?
Dermoid Tumors (a.k.a. benign ovarian teratomas)
What Is It?
- parthenogenetically activated oocyte
- mitosis of oocyte w/o male pronucleus
- all chromosomes are maternally-derived and imprinted
- can be seen in the fetus/newborn
Pathology
- disorganized growth of any part that could be in a fetus (hair, bone, cartilage, adipose, glandular derivatives)
Gestational Choriocarcinoma
- Follow what events?
- Comprised of which tissues?
- Secretes what factor?
- Path?
- Mets to where?
- Curability?
Gestational Choriocarcinoma
- Follow:
- hydatidiform moles (50%)
- spont abortion (25%)
- normal pg (22%)
- ectopic pg (3%)
- Comprised of synctio- and cytotrophoblast
- Secretes hCG
- Path: much more vasc than mole
- gives bloody gross appearance
- Mets to lung, brain and liver
- Curability - most cured, use chemo
Placental Site Trophoblastic Tumor
- What is it?
- Originates from?
- Markers?
- Curability?
Placental Site Trophoblastic Tumor
- A rare GTD that…
- …Originates from intermed trophoblast cell
- No synctio- or cyto-trophoblast
- Markers for it include hPL
- hCG is very LOW
- Curability is less esp when metastatic
- Not sensitive to chemo
