Endo/Repro - Placental Pathologies; Prenatal Testing Flashcards
Name the three layers of the placenta extending from the fetus outward.
Amnion
Chorion
Decidua
Which layer of the placenta (amnion, chorion, decidua) is the major site of exchange between the maternal and fetal circulation?
Chorion
The ________trophoblasts of the placenta secrete ________ and ________.
The syncytiotrophoblasts of the placenta secrete beta-HCG and human placental lactogen.
What is the most common cause of hematosalpinx?
Tubal pregnancy
(hematosalpinx is very common - 1:150)
Hematosalpinx presentation: onset of severe abdominal pain at ___ weeks after a previous normal menstrual period.
Hematosalpinx presentation: onset of severe abdominal pain at 6 weeks after a previous normal menstrual period.
Why can tubal pregnancies result in fallopian thinning/rupture and massive intraperitoneal hemorrhage?
Lack of a decidua (for implantation)
~_____ spiral arterioles open into the mature intervillous space of the placenta.
~100 spiral arterioles open into the mature intervillous space of the placenta.
Which is closer to the fetus, the chorion or the amnion?
The amnion
The chorion begins developing on day _____ of embryonic development.
The chorion begins developing on day 4 of embryonic development.
The amnion begins developing on day ____ of embryonic development.
The amnion begins developing on day 9 of embryonic development.
Monozygotic twins are most at-risk for being conjoined if splitting occurs after ______ days.
Monozygotic twins are most at-risk for being conjoined if splitting occurs after 12 days (chorion and amnion already formed).
Which form of twins can only be dichorionic and diamniotic?
Dizygotic twins
If a trophoblastic growth is benign, it is a(n) ___________.
If a trophoblastic growth is invasive, it is a(n) ___________.
If a trophoblastic growth is malignant, it is a(n) ___________.
If a trophoblastic growth is benign, it is a hydatidiform mole.
If a trophoblastic growth is invasive, it is an invasive mole.
If a trophoblastic growth is malignant, it is a choriocarcinoma.
Mola is Greek for what?
(In relation to molar pregnancies)
‘False pregnancy’
Placental trophoblastic tumors can be identified as secreting what?
Human placental lactogen
(also known as human chorionic somatomammotropin)
Which is the more common form of molar pregnancy, a complete hydatidiform mole or a partial hydatidiform mole?
Complete
Which parental chromosomes are present in a complete hydatidiform mole?
Paternal only (two copies)
Which parental chromosomes are present in a partial hydatidiform mole?
Paternal (two copies) and maternal (one copy)
Which type of hydatidiform mole is more associated with an abnormally enlarged uterus?
Complete moles
What changes about parturition in a woman with placenta previa?
C-section is required for delivery
Preeclampsia is characterized clincally by a combination of __________ and __________.
Preeclampsia is characterized clincally by a combination of hypertension and proteinuria.
What blood pressure and urine abnormality are indicative of preeclampsia?
≥ 140/90 mmHg
≥ 300 mg protein / day
Severe preeclampsia is preeclampsia associated with 1+ of what?
(Just name as many as you can.)
BP > 160/110 mmHg
Proteinuria > 5 g / day
Oliguria
Severe headaches, mental status change, visual disturbances
RUQ pain
Pulmonary edema or cyanosis
Thrombocytopenia
Hepatocellular injury
Fetal growth restriction
CVA
Chronic hypertension begins before week _____ of pregnancy.
Gestational hypertension is elevated BP that begins after week _____ of pregnancy.
Chronic hypertension begins before week 20 of pregnancy.
Gestational hypertension is elevated BP that begins during/after week 20 of pregnancy.
A woman with chronic hypertension becomes pregnant.
22 weeks into the pregnancy, she develops proteinuria.
Does she have preeclampsia?
Yes.
New-onset proteinuria in a woman with chronic HTN is still considered preeclampsia.
A woman develops hypertension at 21 weeks of pregnancy.
She has no protein in her urine.
Does she have preeclampsia?
No.
This is gestational hypertension.
What is the suspected cause of preeclampsia / eclampsia?
Failure of proper spiral arteriole dilatation
Eclampsia is defined as new-onset __________ during pregnancy, or within ____ weeks postpartum in a woman with preeclampsia.
Eclampsia is defined as new-onset grand mal seizures during pregnancy, or within 4 weeks postpartum in a woman with preeclampsia.
The incidence and fetal mortality of abruptio placentae are ___:___ and ____%, respectively.
The incidence and fetal mortality of abruptio placentae are 1:130 (fairly common) and 0.2%, respectively.
What is the hallmark sign of placental abruption?
Painful vaginal bleeding in the third trimester
~50% of women with abruptio placentae have underlying ___________.
~50% of women with abruptio placentae have underlying hypertension.
What are the S/Sy of placental abruption?
Vaginal bleeding, uterine tenderness, uterine contractions, fetal distress
True/False.
Delivery of twin #2 has some association with placental abruption.
False.
Delivery of twin #1 has some association with placental abruption (due to sudden decompression of the uterus).
Why might coagulation studies be important in a woman in her 34th week of pregnancy who presents with painful vaginal bleeding?
To check for DIC
(as a result of placental abruption)
_____________ testing is an acid elution test that measures the amount of fetal hemoglobin (Hb) in a mother’s bloodstream.
Kleihauer-Betke testing is an acid elution test that measures the amount of fetal hemoglobin (Hb) in a mother’s bloodstream.
Kleihauer-Betke testing identifies ______________ in _____________.
Kleihauer-Betke testing identifies fetal hemoglobin (HgF) in maternal blood.
Kleihauer-Betke testing can be used to determine the dosing of what?
Rhogam
(to prevent hydrops erythroblastosis)
Preeclampsia (and pregnancy in general) is associated with a _____coagulable state.
Preeclampsia (and pregnancy in general) is associated with a hypercoagulable state.
Intrauterine growth retardation is measured by relatively ______ ______ circumference.
(If occipital-frontal circumference is > 1 cm more than crown-rump length, this signifies intrauterine growth retardation.)
Intrauterine growth retardation is measured by relatively large** **head circumference.
(If occipital-frontal circumference is > 1 cm more than crown-rump length, this signifies intrauterine growth retardation.)
What amniotic or chorionic state implies monozygotic twins?
Monochorionic placentas
_____________ refers to an infection of the amniotic fluid.
Chorioamnionitis refers to an infection of the amniotic fluid.
Placental infection is the leading cause of premature delivery at < ___ weeks.
Placental infection is the leading cause of premature delivery at < 32 weeks.
_______________ is the leading cause of premature delivery at < 32 weeks.
Placental infection is the leading cause of premature delivery at < 32 weeks.
The majority of amniotic fluid infections occur through the __________ route (as opposed to the __________ route).
The majority of amniotic fluid infections occur through the ascending** route (as opposed to the **hematogenous route).
Cases of chorioamnioniitis are rarely a cause of neonatal death, with the exception of untreated ___________________ infection.
Cases of chorioamnioniitis are rarely a cause of neonatal death, with the exception of untreated group B streptococcal infection.
Is the umbilical cord considered part of the fetus or mother or both?
The fetus
Miscarriage is fetal demise _______ weeks gestation (timeframe).
Miscarriage is fetal demise before 20 weeks gestation.
Stillbirth is fetal demise _______ weeks gestation (timeframe).
Stillbirth is fetal demise after 20 weeks gestation.
Neonatal Death is occurring up to _______ after birth (timeframe).
Neonatal Death is occurring up to 28 days after birth.
Name the TORCH infections.
Toxoplasmosis
Other (e.g. congenital syphillis and viruses)
Rubella
CMV
HIV / HSV
How might you assess for TORCH infections?
Use test panels for IgG or IgM antibody of the TORCH organisms.
(Note: never rely on a single test!)
Which of the following is not a gestational trophoblastic disease?
a. Complete hydatidiform mole
b. Partial hydatidiform mole
c. Invasive mole
d. Placental-site trophoblastic tumor
e. Teratoma
f. Choriocarcinoma
Which of the following is not a gestational trophoblastic disease?
a. Complete hydatidiform mole
b. Partial hydatidiform mole
c. Invasive mole
d. Placental-site trophoblastic tumor
e. Teratoma
f. Choriocarcinoma
What is an egg (without DNA) and 2 sperm (46,YY)?
a. Abortus
b. Complete mole
c. Intermediate trophoblast
d. Gestational choriocarcinoma
e. Placental site trophoblastic tumor
What is an egg (without DNA) and 2 sperm (46,YY)?
a. Abortus
b. Complete mole
c. Intermediate trophoblast
d. Gestational choriocarcinoma
e. Placental site trophoblastic tumor
Which implies a monozygotic pregnancy?
a. Diamnionic dichorionic
b. Diamnionic monochorionic
c. Monoamnionic dichorionic
Which implies a monozygotic pregnancy?
a. Diamnionic dichorionic
b. Diamnionic monochorionic
c. Monoamnionic dichorionic
Where do you find a cornual pregnancy?
a. Intrauterine portion of the fallopian tube
b. Extrauterine portion of the fallopian tube
c. Fimbriated portion of the fallopian tube
d. Extruded through the fimbriated end into the abdominal cavity
e. Complete placenta previa
Where do you find a cornual pregnancy?
a. Intrauterine portion of the fallopian tube
b. Extrauterine portion of the fallopian tube
c. Fimbriated portion of the fallopian tube
d. Extruded through the fimbriated end into the abdominal cavity
e. Complete placenta previa
When is the most common time to find an ectopic tubal pregnancy?
a. 6 weeks
b. 16 weeks
c. 20 weeks
d. 26 weeks
e. 36 weeks
When is the most common time to find an ectopic tubal pregnancy?
a. 6 weeks
b. 16 weeks
c. 20 weeks
d. 26 weeks
e. 36 weeks
Which of the following is not a TORCH infection?
a. Toxoplasmosis
b. Syphilis
c. Tuberculosis
d. Gonorrhea
e. Listeriosis
f. Rubella
g. Cytomegalovirus
h. Herpes simplex
Which of the following is not a TORCH infection?
a. Toxoplasmosis
b. Syphilis
c. Tuberculosis
d. Gonorrhea
e. Listeriosis
f. Rubella
g. Cytomegalovirus
h. Herpes simplex
TORCH infections are hematogenous infections manifesting as?
a. Chronic villitis
b. Acute cervicitis
c. Uterine necrosis
d. Fetal necrosis
e. Vessel reformation
TORCH infections are hematogenous infections manifesting as?
a. Chronic villitis
b. Acute cervicitis
c. Uterine necrosis
d. Fetal necrosis
e. Vessel reformation
When does preeclampsia commonly manifest?
a. 4 weeks of gestation
b. 14 weeks of gestation
c. 24 weeks of gestation
d. 34 weeks of gestation
e. 44 weeks of gestation
When does preeclampsia commonly manifest?
a. 4 weeks of gestation
b. 14 weeks of gestation
c. 24 weeks of gestation
d. 34 weeks of gestation
e. 44 weeks of gestation
Which is most associated with DIC?
a. Preeclampsia
b. Eclampsia
c. Abruptio placentae
d. Ectopic pregnancy
e. Placenta accrete
Which is most associated with DIC?
a. Preeclampsia
b. Eclampsia
c. Abruptio placentae
d. Ectopic pregnancy
e. Placenta accrete
Which has no villi?
a. Gestational choriocarcinoma
b. Cisterns
c. Spontaneous abortion
d. Chorioamnionitis
e. Complete mole
Which has no villi?
a. Gestational choriocarcinoma
b. Cisterns
c. Spontaneous abortion
d. Chorioamnionitis
e. Complete mole
Which produces massive human placental lactogen (hPL)?
a. Gestational choriocarcinoma
b. Invasive mole
c. TORCH infection
d. Placenta accrete
e. Placental site trophoblastic tumor
Which produces massive human placental lactogen (hPL)?
a. Gestational choriocarcinoma
b. Invasive mole
c. TORCH infection
d. Placenta accrete
e. Placental site trophoblastic tumor
What is the name given to the composition of highly variable prenatal screening tests into one useful median value?
Multiple of median (MoM)
How many multiple of median tests does one receive?
One per week of gestation
How is the multiple of median (MoM) calculated?
Multiple of median (MoM) = AFPActual / AFPExpected
What are the three major uses of ultrasound in the perinatal period?
Estimate gestational age;
identify vaginal bleeding etiology;
screen for developmental disorders
β-hCG peaks during gestation peaks and levels off around week ___.
β-hCG peaks during gestation peaks and levels off around week 10.
What type of β-hCG is produced in the majority of pregnancies?
Regular
What type of β-hCG is produced by non-invasive molar pregnancies?
Regular
What type of β-hCG is produced by invasive molar pregnancies and choriocarcinomas?
Hyperglycosylated
What type of β-hCG may be present after the removal of a hydatidiform mole?
Nicked
What gestational abnormalities produce regular β-hCG?
Ectopic pregnancy,
non-invasive mole
What gestational abnormalities produce hyperglycosylated β-hCG?
Invasive molar pregnancies, choriocarcinomas
When might you see nicked β-hCG?
Following removal of a hydatidiform mole
Elevated serum levels of ______ (normally seen in pregnancy) may indicate testicular malignancy.
Elevated serum levels of β-hCG (normally seen in pregnancy) may indicate testicular malignancy.
Name some of the uses of ultrasound during the first trimester.
1. Estimate/confirm gestational age
2. Detect fetal abnormalities
3. Measure nuchal translucency
- Aid in catheter placement for chorionic villi sampling
What improper use of an at-home pregnancy test is associated with inaccurate results?
(Are there others?)
Improper storage
(also, urine concentration/dilution issues, renal failure, certain tumors, heterophilic antibodies, etc.)
What are the two steps in confirming and evaluating a pregnancy?
1. Positive β-hCG test
2. Ultrasound of gestational sac
β-hCG doubles every ___ days during the 5 – 8 weeks period.
β-hCG doubles every 2 days during the 5 – 8 weeks period.
A slowing rate of β-hCG growth in the early phases of pregnancy might indicate what?
Impending spontaneous abortion
True/False.
Ectopic pregnancies are a surgical emergency.
True.
In hydatidiform moles (gestational tumors), β-hCG levels are _______ (low/high) and hPL leves are _______ (low/high).
In hydatidiform moles (gestational tumors), β-hCG levels are high** and hPL leves are **low (or absent).
A woman presents with elevated β-hCG and absent human placental lactogen. This may be a sign of what gestational abnormality?
Hydatidiform mole
Name the three major types of prenatal test that can be used in the second trimester.
1. Prenatal congenital test (e.g. quad, triple, combined, integrated, etc.)
2. Amniocentesis
3. Chorionic villi sampling
How is a section of chorion removed in chorionic villi sampling?
Via a catheter inserted through the vagina into the uterus
How is amniotic fluid accessed in an amniocentesis?
Via a needle inserted through the maternal abdomen to the amniotic sac
How early can chorionic villi sampling be performed?
The 11th week of gestation
How early can amniocentesis be performed?
The 15th week of gestation
Chorionic villi sampling can be used to analyze amniotic fluid for __________, but it also increases the risk of __________ and __________.
Chorionic villi sampling can be used to analyze amniotic fluid for genetic abnormalities** but it also increases the risk of **miscarriage** and **limb defects.
Amniocentesis can be used to analyze amniotic fluid for __________, but it also increases the risk of __________.
Amniocentesis can be used to analyze amniotic fluid for fetal abnormalities** but it also increases the risk of **miscarriage.
Which has a 3x higher risk of causing miscarriage than the other, chorionic villi sampling or amniocentesis?
Chorionic villi sampling
Which screening procedure can be used to allow one to make a decision to terminate their pregnancy during the earlier stages (i.e. weeks 11 - 13)?
Chorionic villi sampling
True/False.
Prenatal tests for congenital disease such as the triple, quadruple, and combined tests are all used to assess amniotic fluid and thus diagnose fetal abnormalities.
False.
Prenatal tests for congenital disease such as the triple, quadruple, and combined tests are all used to assess maternal blood*** and thus ***indicate risk of fetal abnormalities.
Which biomarkers are assessed in the maternal blood via the prenatal triple test?
AFP
UE3 (estriol)
β-hCG
Which biomarkers are assessed in the maternal blood via the prenatal quadruple test?
AFP
UE3 (estriol)
β-hCG
Inhibin A
Which are the components of the prenatal combined test?
Ultrasound + maternal blood test
Which are the components of the prenatal integrated test and for what does it test?
Measurements obtained during 1st and 2nd trimester combined into a single risk estimate of Down Syndrome or spina bifida
Which of the prenatal screening tests (e.g. triple, quadruple, integrated, and combined tests) has the highest sensitivity and highest specificity?
The integrated prenatal test
What quad screen results indicate Down Syndrome?
β-hCG – High
Inhibin A – High
AFP – Low
UE3 (estriol) – Low
What quad screen results indicate Edward’s Syndrome?
β-hCG – Low
Inhibin A – Low
AFP – Low
UE3 (estriol) – Low
What quad screen results indicate neural tube defects?
β-hCG – N/A
Inhibin A – N/A
AFP – Low
UE3 (estriol) – N/A
You note low levels of alpha-fetoprotein on a triple screen.
What fetal anomaly is at the top of your differential?
Down syndrome
You note high levels of alpha-fetoprotein on a triple screen.
What fetal anomaly is at the top of your differential?
Neural tube defect
Name the two major forms of neural tube defect.
Spina bifida, anencephaly
True/False.
Prenatal ultrasound is useful in detecting abnormalities associated with Down syndrome.
True.
Triple testing in a woman carrying a fetus with an open neural tube defect will yield a result of ______ (low/high) AFP and an MoM of ______.
Triple testing in a woman carrying a fetus with an open neural tube defect will yield a result of high** AFP and an MoM of **> 2.
What does ultrasound reveal in a fetus with spina bifida?
Hydrocephalus,
abnormal frontal bones and cerebellum,
spinal bone “splaying” behind the vertebrae
A fetus with an open neural tube defect will yield the following results upon amniocentesis:
______ levels of AFP and an increase in ____________.
A fetus with an open neural tube defect will yield the following results upon amniocentesis:
high** levels of AFP and an increase in **acetylcholinesterase.
What is a relatively common pulmonary complication of the third trimester?
Neonatal respiratory distress syndrome
In the third trimester analysis of fetal lung development, a lecithin/sphingomyelin ratio of _____ is indicative of fetal lung immaturity.
In the third trimester analysis of fetal lung development, a lecithin/sphingomyelin ratio of _____ is indicative of fetal lung maturity.
In the third trimester analysis of fetal lung development, a lecithin/sphingomyelin ratio of < 2 is indicative of fetal lung immaturity.
In the third trimester analysis of fetal lung development, a lecithin/sphingomyelin ratio of > 2 is indicative of fetal lung maturity.
What common method is used to retrieve fetal fluids to check lecithin/sphingomyelin ratios (for assessing lung maturity)?
Amniocentesis
Name a fast method to analyze fetal phosphatidylglycerol (PG) that is used as a replacement for lecithin/sphingomelin ratios.
Latex agglutination
Latex agglutination detects what substance in amniotic fluid?
Phosphatidylglycerol (PG)
Phosphatidylglycerol is undetectable in the amniotic fluid until lung maturity just prior to what event?
Birth
Fetal and placental viability tests are used to assess the ______ and ______ viability by correlating fetal heart rate and fetal movement.
Fetal and placental viability tests are used to assess the fetal** and **placental viability by correlating fetal heart rate and fetal movement.
Fetal and placental viability tests are used to assess the fetal and placental viability by correlating ____________ and ____________.
Fetal and placental viability tests are used to assess the fetal and placental viability by correlating fetal heart rate** and **fetal movement.
When is fetal placental viability testing performed?
Between week 28 and gestation
What is measured in a fetal placental viability test? Where are these biomarkers?
Estriol (UE3) and/or human placental lactogen;
maternal serum
What does the amount of human placental lactogen indicate about a particular gestation?
Placental weight / function
(hPL is only produced by the placenta)
A fetal placental viability test in the 32nd week shows declining values of hPL. What does this indicate?
Fetal jeopardy
What fetal substance can be measured to check for increased risk of premature delivery? Where is it found?
Fetal fibronectin;
cervicovaginal secretions
When might you check for fetal fibronectin in cervicovaginal secretions?
Between gestational weeks 21 and 37
If there is a negative fFN test, there is <___% chance of premature delivery in the next two weeks.
If there is a negative fFN test, there is < 1 % chance of premature delivery in the next two weeks.
