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11. Female Reproductive & Gestational Pathology > 8. Gestational disorders > Flashcards

8. Gestational disorders Flashcards

1
Q

Types of gestational disorders

A
  1. Disorders of early pregnancy
    - Spontaneous abortion
    - Ectopic pregnancy
  2. Disorders of late pregnancy
    - Placental inflammation
    - Toxemias of pregnancy
    - Placental abnormalities
  3. Trophoblastic disease
    - Hydatiform moles
    - Invasive mole
    - Choriocarcinoma
  4. Infertility
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2
Q

Definition of spontaneous abortion

A

loss of pregnancy before 20 weeks’ gestation

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3
Q

Etiology of spontaneous abortion

A
  1. Maternal:
    - Abnormalities of the reproductive organs
    i. Septate uterus
    ii. Uterine leiomyomas
    iii. Uterine adhesions
    iv. Cervical incompetence
  • Systemic diseases
    i. diabetes mellitus, hyperthyroidism, hypothyroidism, genetic disorders, infections, hypercoagulability (e.g., antiphospholipid syndrome, which is associated with recurrent miscarriages)
  1. Fetoplacental:
    - Chromosomal abnormalities account for up to half of all spontaneous abortions
    - Congenital anomalies
    - Anembryonic pregnancy
  2. Miscellaneous:
    - Trauma
    - Iatrogenic
    - Environmental
    - Unknown
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4
Q

Complications of spontaneous abortion

A
  1. Septic abortion
    - Complication of a missed, inevitable, or incomplete abortion in which retained products of conception become infected
  2. Retained products of conception result in release of thromboplastin into systemic circulation → disseminated intravascular coagulation
  3. Endometritis
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5
Q

Definition of ectopic pregnancy

A

A pregnancy in which the fertilized egg attaches in a location other than the uterine endometrium

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6
Q

Etiology of ectopic pregnancy

A

Risk factors

  1. Anatomic alteration of the fallopian tubes
    - History of PID (e.g., salpingitis)
    - Previous ectopic pregnancy
    - Surgeries involving the fallopian tubes
    - Endometriosis
    - Ruptured appendix
    - Kartagener syndrome
  2. Nonanatomical risk factors
    - Smoking
    - Advanced maternal age
    - Pelvic inflammatory disease
    - Intrauterine device
    - In vitro fertilization
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7
Q

Clinical features of ectopic pregnancy

A

General symptoms:

  1. Lower abdominal pain and guarding (ectopic pregnancy is often mistaken for appendicitis due to the similarity of symptoms)
  2. Possibly, vaginal bleeding
  3. Signs of pregnancy
    - Amenorrhea
    - Nausea
    - Breast tenderness
    - Frequent urination
  4. Tenderness in the area of the ectopic pregnancy
  5. Cervical motion tenderness, closed cervix
  6. Enlarged uterus

Tubal rupture:

  1. Acute course with sudden and severe lower abdominal pain (acute abdomen)
  2. Signs of hemorrhagic shock (e.g., tachycardia, hypotension, syncope)
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8
Q

Diagnostics for ectopic pregnancy

A
  1. Serum β-hCG level
  2. Transvaginal ultrasound (TVUS)
  3. Endometrial biopsy
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9
Q

Infection of the placenta

A

villitis

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10
Q

Infection of the membranes

A

chorioamnionitis

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11
Q

Infection of the umbilical cord

A

funisitis

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12
Q

Etiology of placental infections

A
  1. STD: Syphilis & Chlamydia
  2. Bacterial: Streptococcus & Listeriosis
  3. Viral: Rubella & Cytomegalovirus
  4. Protozoal: Toxoplasmosis

Ascending infection - through birth canal
Hematogenous - TORCH
T - toxoplasmosis, O - Other (hepatitis B), R - Rubella, C - Cytomegalovirus, H - Herpes simplex virus

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13
Q

Definition of toxaemia of pregnancy

A

A systemic syndrome characterised by widespread maternal endothelial dysfunction

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14
Q

Types of toxaemia of pregnancy

A
  1. Preeclampsia

2. Eclampsia

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15
Q

Definition of preeclampsia

A

New-onset gestational hypertension with proteinuria or end-organ dysfunction

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16
Q

Definition of HELLP syndrome

A

A life-threatening form of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelets

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17
Q

Definition of eclampsia

A

Eclampsia: a severe form of preeclampsia with convulsive seizures and/or coma

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18
Q

Pathophysiology of preeclampsia

A
  1. Overview: Multiple maternal, fetal, and placental factors are involved in placental hypoperfusion, which leads to maternal hypertension and other consequences.
    - Uterine spiral arteries normally develop into high-capacity blood vessels. This process is defective in patients with preeclampsia, which leads to hypoperfusion of the placenta and fetus
    - Arterial hypertension with systemic vasoconstriction causes placental hypoperfusion → release of vasoactive substances → ↑ maternal blood pressure to ensure sufficient blood supply of the fetus
    - Systemic endothelial dysfunction causes placental hypoperfusion → ↑ placental release of factors; → endothelial lesions that lead to microthrombosis
  2. Consequences of vasoconstriction and microthrombosis
    - Organ ischemia and damage
    i. HELLP syndrome; (thrombotic microangiopathy of the liver)
    - Chronic hypoperfusion of the placenta → insufficiency of the uteroplacental unit and fetal growth restriction
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19
Q

Systemic effects of hypertensive pregnancy disorders

A
  1. Kidney: Glomerular endothelial dysfunction and hypertension-induced vasoconstriction
    - Proteinuria
    - Impaired renal function
  2. Liver: Vasoconstriction and microthrombotic obstruction of liver sinusoids → liver cell damage
    - Liver impairment and liver swelling
  3. Brain: Hypertension-induced vasoconstriction and endothelial damage → disruption of cerebral microcirculation with microthrombi → vasospasms in the CNS
    - Seizures
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20
Q

Complications of hypertensive pregnancy disorders

A
  1. Maternal complications
    - Placental abruption
    - DIC
    i. Injury to placenta → tissue factor release → unregulated activation of the coagulation cascade
    ii. ∼ 20% of patients with HELLP syndrome
    - Cerebral hemorrhage, ischemic stroke
    - Acute respiratory distress syndrome (ARDS)
    - Acute renal failure
    - Maternal death
  2. Fetal complications: occur due to insufficient placental perfusion
    - Fetal growth restriction
    - Preterm birth
    - Seizure-induced fetal hypoxia
    - Fetal death
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21
Q

Types of placental abnormalities

A
  1. Placenta previa
  2. Abruptio placentae
  3. Abnormal placentation
    - Placenta accrete
    - Placenta increta
    - Placenta percreta
22
Q

Definition of placenta previa

A

Presence of the placenta in the lower uterine segment; partial or full obstruction of the neck of the uterus with high risk of hemorrhage (rupture of placental vessels) and birth complications

23
Q

Clinical features of placenta previa

A
  1. Sudden, painless, bright red vaginal bleeding
  2. Usually occurs during the 3rd trimester (before rupture of the membranes), stops spontaneously after 1–2 hours, and recurs during birth
24
Q

Definition of abruptio placentae

A

Partial or complete separation of the placenta from the uterus prior to delivery

25
Q

Epidemiology of abruptio placentae

A

Occurs most often in the third trimester

26
Q

Clinical features of abruptio placentae

A
  1. Continuous vaginal bleeding
  2. Concealed abruptio placentae
  3. Sudden-onset abdominal pain or back pain, uterine tenderness
27
Q

Complications of abruptio placentae

A
  1. Intrauterine fetal death
  2. Maternal DIC and hypovolemic shock: occurs as a result of blood loss and massive coagulation; the placenta is rich in tissue thromboplastin, which is released as a result of the placental abruption.
  3. Couvelaire uterus
    - Retroplacental hemorrhage may extend through the uterus into the peritoneum
    - uterine rupture
28
Q

Definition of abnormal placentation

A

Defective decidual layer of the placenta leading to abnormal attachment and separation during postpartum period

29
Q

Placenta accreta

A

Chorionic villi attach to the myometrium (but do not invade or penetrate the myometrium); (up to 75% of cases)

30
Q

Placenta increta

A

Chorionic villi invade or penetrate into the myometrium

31
Q

Placenta percreta

A

Chorionic villi penetrate the myometrium, penetrate the serosa

32
Q

Clinical features of abnormal placentation

A
  1. Abnormal uterine bleeding

2. Postpartum hemorrhage at the time of attempted manual separation of the placenta

33
Q

Classification of gestational trophoblastic disease

A
  1. Hydatidiform mole
    a. Partial mole
    b. Complete mole
  2. Choriocarcinoma
34
Q

Etiology of partial mole

A

Fetal karyotypes: 69XXX, 69XXY, 69XYY

35
Q

Mechanism of partial mole

A

Fertilization of an egg containing a haploid set of chromosomes with two sperms

36
Q

Clinical features in partial mole

A
  1. Vaginal bleeding
  2. No change in uterine size
  3. Pelvic tenderness
37
Q

Diagnostics for partial mole

A
  1. β-hCG
  2. Ultrasound
    - Fetal parts may be visualized.
    - Fetal heart tones may be detectable.
    - Amniotic fluid is present.
    - Increased placental thickness
38
Q

Histopathological exam of partial mole

A
  1. Microscopy:
    - Partial occurrence of hydropic villi, minimal trophoblastic proliferation
  2. P57 staining:
    - Positive
39
Q

Etiology of complete mole

A

Fetal karyotypes: 46XX (∼ 90% of cases), 46XY (∼ 10% of cases)

40
Q

Mechanism of complete mole

A

Fertilization of an empty egg that does not carry any chromosomes

41
Q

Clinical features in complete mole

A
  1. Vaginal bleeding during the first trimester
  2. Uterus size greater than normal for gestational age
  3. Pelvic pressure or pain
  4. Passage of vesicles
  5. Endocrine symptoms (e.g, hyperemesis gravidarum, ovarian theca lutein cysts)
42
Q

Diagnostics in complete mole

A
  1. β-hCG
  2. Ultrasound:
    a. Echogenic mass interspersed with many hypoechogenic cystic spaces (referred to as “snowstorm”)
    b. No fetal parts
    c. Lack of fetal heart tones
    d. No amniotic fluid
    e. Theca lutein cysts
43
Q

Histopathological exam in complete mole

A
  1. Microscopy: Diffuse hydropic villi, marked circumferential trophoblastic proliferation
  2. P57 staining:
    - Negative
44
Q

Etiology of choriocarcinoma

A

Most cases of choriocarcinoma are preceded by hydatidiform mole (50%)

45
Q

Mechanism of choriocarcinoma

A

Malignant transformation of cytotrophoblastic and syncytiotrophoblastic tissue

46
Q

Clinical features of choriocarcinoma

A
  1. Postpartum vaginal bleeding
  2. Inadequate uterine regression after delivery
  3. Multiple theca lutein cysts
  4. Additional symptoms (e.g., dyspnea or hemoptysis from metastases in the lungs)
47
Q

Diagnostics for choriocarcinoma

A
  1. β-hCG
  2. Ultrasound
    a. Mass of varying appearance
    b. Hypervascular on color Doppler
48
Q

Histopathological exam for choriocarcinoma

A

Microscopy:

Cytotrophoblasts and syncytiotrophoblasts without chorionic villi

49
Q

Prognostic factors for choriocarcinoma

A
  1. Distant metastases
  2. Failure of chemotherapy
  3. Choriocarcinoma following term pregnancy
50
Q

Complications / risks of hydatidiform mole

A
  1. Uterine haemorrhage
  2. Coagulopathy
  3. Infection
  4. Continued trophoblastic activity (16% invasive mole; 2.5% choriocarcinoma)
51
Q

Mechanism of invasive mole

A

Trophoblasts invade the myometrium → increased risk of bleeding and hematogenous spread

11. Female Reproductive & Gestational Pathology (8 decks)

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