2/20 Gestational Pathology - Merjanian Flashcards
ectopic pregnancy
pregnancy that implants OUTSIDE OF THE UTERUS
- most common cause of maternal mortality in first trimester
- most common place for ectopic implantation: fallopian tube
ectopic pregnancy
risk factors
- salpingitis (PID)
- hx of infertility
- hx of ssisted repro techniques
- tubal surgery (tubal ligation, prior salpingostomy)
- smoking
ectopic pregnancy
presentation
symptoms related to whether ectopic has ruptured
- secondary amenorrhea
- pelvic/abd pain (75%)
- vaginal bleeding
- dizziness, lightheadedness, pleuritic chest pain
pelvic mass on bimanual women (20%)
ectopic pregnancy
dx
managment
dx
- lab tests (BhCG, CBC, type/screen)
- U/S findings
- physical exam findings
mgmt : depends on acuity of presentation
- medical mgmt
- methotrexate (folic acid antagonist → v effective against rapidly proliferating trophoblasts)
- surgical mgmt
- laparoscopy vs laparotomy
gestational trophoblastic disease
aka
molar pregnancies
abnormal proliferation of placental tissue (1st or 2nd trimester)
cancerous and non-cancerous forms
1. non-cancerous forms (hydatidiform moles)
- complete hydatidiform moles (androgenetic pregnancies) : egg with no chromosomes
- partial hydatidiform moles (triploid gestations) : two sperm, one egg
2. cancerous forms (tumors, neoplasia)
- invasive hydatidiform moles : previously benign → malignant and moves to other sites
- choriocarcinoma : v aggressive tumor, occurs up to 15y after last preg
- placental site tumor : often occurs years after last preg
hydatidiform mole
incidence 1/1000 (1/100 in Asian pop)
histo: characterized by varying degrees of trophoblastic proliferation and edema of villous stroma
risk factors:
- maternal age (under 20, over 35)
- previous molar preg
hydatidiform mole
complete vs partial
complete: 46XX or 46XY
partial: 69XXX or 69XXY
hydatidiform mole
clinical feature
- uterine bleeding (almost universal, but amt varies)
- uterine size larger than expected (complete mole)
- no fetal heart tone
- severe n/v
- preeclampsia prior to 20wk gestation
- sx of hyperthyroidism (thyroid-storm due to thyrotropin like effect of BhCG)
- very high BhCG levels (esp complete mole)
hydatidiform mole
treatment
two phases:
- surgical evacuation of mole
- followup for detection of persistent trophoblastic proliferation or malignant change (6mo)
- key: contraception during followup time!
initial eval should include CXR to rule out metastatic pulmo disease
hypertensive disorders of pregnancy
x5
- gestational HTN : elevated bp after 20wk of preg
- preeclampsia : elevated bp after 20wk also assoc with proteinuria or end organ damage
- eclampsia : preeclampsia that progresses to seizures
- chronic HTN : elevated bp prior to 20wk or HTNsive before preg
- preeclampsia superimposed on chronic HTN : HTN + preeclampsia on top of that
deadly triad of pregnancy
- hemorrhage
- infection
- HTNsive disorders
preeclampsia
what is it
pathyphys
risk factors
preg-specific syndrome : systemic reduced organ perfusion secondary to vasospasm and endothelial activation
clinically…
- bp > 140/90 after 20wk
- proteinuria
pathophys
- much more likely to occur in women who are…
- exposed to chorionic villi for first time
- exposed to superabundance of chorionic villi (twins, moles)
- preexisting vascular disease
- predisposed to HTN developing during preg
- could involve placenta and uteroplacental/fetal interface → preeclampsia resolves after delivery
- inadequate UP perfusion → placental ischemia/hypoxia appears to be central to devpt of disease
- failure of cytotrophoblasts to adequately invade uterine spiral arteries → establish low resistance UP circulation that’s needed
risk factors: nulliparous, multi preg, chronic HTN, older than 35, obesity, AfAm, autoimmune
role of uteroplacental ischemia in preeclampsia
ischemia → oxidative and infl stress
results in involvement of secondary mediators leading to…
- endothelial dysfx, cap permability
- vasospasm
- activation of coag system
→→→ widespread vasoconst → hypoxic/ischemic damage in diff vascular beds
preeclampsia
organ systems affected
HELLP
specific form of preeclampsia
- Hemolysis
- Elevated Liver enzymes
- Low Platelets
placental abruption
premature separation of a normally implanted placenta
presents with PAINFUL contractions, vaginal bleeding
risk factors: HTN, incr age and parity, PROM, smoking, cocaine, prior abruption, trauma
mgmt : depends on gestational age and status of mom/baby
- live/mature fetus, vaginal delivery not imminent → emergency C section
- massive external bleeding → resuscitation with blood and ctystalloid, prompt delivery to control hemorrhage to save mom (and hopefully baby)
- dx uncertain, fetus alive/ok → close observation somewhere where immediate intervention possible
- fetus dead/previable → maternal stabilization key, vaginal delivery preferred
placental previa
placental located either directly over or near internal cervical os
presentation: PAINLESS vaginal bleeding
risk factors: adv maternal age, multiparity, prior C-section (worry about accreta, increta, percreta), smoking
placenta accreta/increta/percreta
placenta DOES NOT separate after delivery → life threatening bleeding
Cesarean hysterectomy often needed
accreta: invasion of decidua and some of myometrium uterus
increta: invasion of decidua and more of myometrium of uterus
percreta: invasion through wall of uterus, possibly into other organs
