Female repro (FGT) pathology Flashcards

Question

Vaginal adenosis

Answer 1

* Girls (10 years) whose mother received DES during pregnancy to prevent abortion * focal persistance of columnar epithelium in upper 1/3 of vagina (should be squamous) * Endocervical type glands in vaginal wall * Some girls develop clear cell adenocarcinoma (10 – 35 years)

Answer 2

* Exophytic, polypoidal, fungating mass * Pelvic or inguinal nodes based on location * Poor prognosis

Answer 3

* aka Embryonal rhabdomyosarcoma * \< 5 years * Bunch of grapes hanging in the vagina * Highly malignant **Dx (Pathoma)** * malignant cell called rhabdomyoblast * cytoplasmic cross-striations * +ve IHC stain for desmin and myoglobin

Answer 4

* Acute inflammation on the inferior part of labium major- bartholin gland (adjacent to vaginal canal) * Blocking due to inflammation * Abscess formation * Strep, Staph, Gonococii, E. Coli

Answer 5

Genital herpes Clinical image showing painful, erythematous vesicles on the mucosa or skin of female genitals. Histological (H&E) image of vesicle (top) Tzanck smear (bottom) **Morphology** * Primary or recurrent mucocutaneous lesions; vesicular and painful. * Presence of intraepithelial vesicles accompanied by necrotic cellular debris, neutrophils, and cells harboring characteristic intranuclear viral inclusions (top) and Cowdry type A inclusion appears as a light purple, homogeneous intranuclear structure surrounded by a clear halo, 3M Margination, multinucleation, moulding (bottom) **Etiopath** * HSV-2 and, less commonly, HSV-1 can cause genital infections. Initial (primary) infection causes painful, erythematous, intraepithelial vesicles on the mucosa and skin of external genitalia, along with regional lymph node enlargement. * Histology shows the vesicles of HSV infection contain necrotic cells and fused multinucleate giant cells with intranuclear inclusions (Cowdry type A). * Infected cells commonly fuse to form multinucleate syncytia. Virus blocks effects of interferon, prevents CD8 T-cell recognition of infected cells, escapes antibody neutralization and clearance by going into “hiding” during latent infection. * Latent infections (neurons); Viral re-activation due to stress, hormones, UV radiation * HSV is actively shed during symptomatic period. **Sx** * Sx: dysuria, urethral discharge, local lymph node enlargement and tenderness, and systemic manifestations, such as fever, muscle aches, and headache. * Signs and sx may last for several weeks during the primary phase of disease **C&C** * Neonatal herpes can be life-threatening and occurs in children born to mothers with genital herpes. * Affected infants have generalized herpes, often associated with encephalitis and consequent high mortality.

Answer 6

* can lead to carcinoma that is non-HPV related * Lichen sclerosiss * – Kraurosis vulvae: cutaneous condition characterized by atrophy and shrinkage of the skin of the vagina and vulva often accompanied by a chronic inflammatory reaction in the deeper tissues * – **postmenopausal**, scaly plaques, **thin parchment like**, dense collagen * – very low malignant potential, autoimmune nature. * Hyperplastic dystrophy (Lichen Simplex Chronicus) * post menopausal, * localized hyperplastic epidermis -\> leukoplakia w thick, leathery vulvar skin * no malignant potential.

Answer 7

* carcinoma in situ * leukoplakia or reddish brown plaque **Sx** * flat, erythema * papule, gray**-white** or reddish brown plaque * needs surgical excision

Answer 8

* Risk factors: HPV mainly 16, 18, 31, 33 * Age: Mean 40 years * Smoking * Immunosuppressed patients * Multifocal – 50-80% * 50 – 60% have synchronous lesions in the cervix, vagina, urethra, anus * 35 – 50% recur after local treatment * Some patients regress (younger age) * Progression to invasion in 4 – 7% after treatment * VIN grade I, II, III * High risk HPV related * May be associated with cervical carcinoma

Answer 9

* \>60 years * Plaque, nodule, ulcer * Anterior 2/3 of labia majora * **Squamous cell carcinoma** **Etiopath (Pathoma):** * HPV-related -\> VIN from HPV16, 18 _or_ * non-HPV related -\> long standing lichen sclerosis (\> 70 yo) **Sx** * Inguinal and pelvic nodes * Squamous Cell Carcinoma – Invasive * ulcer with raised edges (base of right labium minorum) * presents as leukoplakia (Pathoma)

Answer 10

Placental villi surrounded by maternal blood – embryonic vessel contains nucleated red cells but if still see nucleated RBC beyond 20 wk gestation -\> indiciates ischemic infarct in placenta – surrounded by loose mesenchyme – covered by cytotrophoblast and syncitiotrophoblast

Answer 11

* 1% of all pregnancies * ↑ because of PID with tubal adhesions, * endometriosis with fibrosis is also a risk factor * fibrosis blocks the passage of fertilized ovum (50% idiopathic) * Lack of space, poor vasculature, limited placental size. * Ruptures 2 – 6 weeks after fertilization. * Embryo dies, rarely implanted in abdomen * *Sx:** - right iliac pain - vaginal bleeding - nausea * Severe hemorrhage, shock * Mimics acute appendicitis if right sided * Ultrasound, absence of appropriate uterine enlargement * Expansion of adnexa * Peritoneal aspiration yields blood **Dx** * βhCG elevated due to pregnancy * Once the embryo dies, βhCG drops * ↓ βhCG leads to degeneration of corpus luteum * Leadto↓estrogenandprogesterone * Endometrium breaks down leading to bleeding. * Arias Stella rxn showing endometrial glands tortuous, irregular branching and budding. * Uterus small compared to amenorrhea * Endometrial curettings show no chorionic villi but have hypersecretory glands * R/O spontaneous abortion (chorionic villi)

Answer 12

* Delivery of embryo (8 weeks) or fetus up to 20 weeks * (20–40weeks)–premature delivery * Usually defective chromosomes * Vaginal bleeding – rapid, severe (shock) * Lower abdominal pain due to uterine contraction * Demonstrate chorionic villi or embryo for diagnosis. * Causes: chromosomal anomalies, hypercoagulable state, congenital infections, teratogens.

Answer 13

Placenta Previa: abn placental implantation, implants on LUS, internal OS, 3rd trimester * placental overlies cervical os

Answer 14

Abruptio Placenta: * premature separation of placenta -\> clots on maternal surface of placenta (Pathoma image below) * ante partum hemorrhage (3rd trimester); * shock * DIC, * premature labour & stillbirth.

Answer 15

Placenta Accreta: * occurs when all or part of the placenta attaches abnormally to the myometrium (the muscular layer of the uterine wall) * difficult delivery & post-partum bleeding * often requires hysterectomy

Answer 16

* Gestational Edema with Proteinuria and Hypertension - GEPH * Syndrome: E, P, H usually in third trimester. * Distinct from a hypertensive person becoming pregnant * 5% of pregnancies * 10% of PE develop seizures (Eclampsia) * Induce labor or do Caesarian section disappears after labor **Predisposing factors** * Primigravida, over 35 years age * Multiple pregnancies * Hydramnios * Preexisting hypertension * Hydatidiform mole **Possible Etiopath** * Placental ischemia leading fibrinoid necrosis * Autoimmune reaction to placenta * ↓ production of PGE2 and NO by placenta – increased sensitivity to renin angiotensin * DIC – in eclampsia w seizures (due to thromboplastic tissue factor and thrombaxane released by ischemic placenta) * Diffuse endothelial dysfunction; vasoconstriction (HT) * Increased vascular permeability (proteinuria, edema) * Degenerated placenta (ischemia) – hyaline, calcification, congestion, infarcts, thrombosed spiral arteries, hemorrhage (spiral arteries fail to dilate and thin out like in normal pregnancy due to lack of smooth muscle coat) * Acute atherosis – foamy macrophages in necrotic vessel wall (characteristic) later – macrophages and lymphocytes * Kidneys (mother) - glomerular endothelial swelling, mesangial proliferation, fibrin thrombi, cortical necrosis * Liver periportal hemorrhage * Other organs – edema, hemorrhages * HELLP (Pathoma) * preeclampsia w thrombotic microangiopathy involving liver * Hemolysis, Elevated Liver enzyme, Low Platelets

Answer 17

* Hydatidiform mole (Molar Pregnancy) – complete, incomplete * Invasive mole (chorioadenoma destruens) * Gestational choriocarcinoma * Placental site trophoblastic tumor * βhCG levels more important than anatomic classification (urine, serum) Microscopic image below: - structure to maximize surface area - inner: cytotrophoblast - outer: syncytiotrophoblast

Answer 18

Hydatidiform Mole **Gross:** * swollen and edmatous villi w proliferation of trophoblasts * **grape-like masses** * *Microscopic:** - stroma has bluish myxoid material -\> degeneration of stroma - non-uniform (circumferential) proliferation of trophoblastic cells **Etiopath** - 2 extremes of reproductive life - Far east like South-East Asia * Partial or complete * ultimately resulting in deficiency of fetal blood vessel * uterus expands as if nl pregnancy Complete molar pregnancy (dyspermy): empty ovum; * Genotype paternally derived chromosome * fertilized by two sperms or a SINGLE diploid sperm * 46XX, rarely XY * Embryo dies early, no fetal parts seen * 2% develop choriocarcinoma Partial mole: triploid * Ovum (23x) fertilized by two sperms 23 X and 23 Y * So moles are triploid (69 XXY) * Ovum fertilized by 2 different sperms one with X Chr and one with Y Chr- triploidy * Embryo develops for a short period, fetal parts may be seen * Molar changes partial, uterus minimally enlarged * No risk of malignancy **Sx** * Amenorrhea, vomiting, pregnancy test +ve * Uterus larger compared to amenorrhea (large for date); DDx w ectopic (where uterus is not enlarged) * At 3 – 4 months vaginal bleeding, grape like structures; and **snow storm appearance on US** * U/S – enlarged cystic placenta, absent fetus * βhCG greatly elevated in serum, urine * Curettage to remove the lesion * Monitor βhCG for 2% that develop choriocarcinoma * *Dx:** - incr in beta-HCG (1e5 SI units) - pregnancy sx * *C&C** - invasive into myometrium, lungs, brain - bilateral thecal lutein cyst

Answer 19

* 10% of complete moles develop invasive feature * Deep invasion of villi and trophoblasts into myometrium * Associated necrosis, hemorrhage of myometrium * Uterus may rupture, villi may embolize to lungs (regress) * Treat with chemotherapy

Answer 20

Gestational choriocarcinoma * tumour of trophoblasts **Gross:** Friable hemorrhagic mass **Microscopic:** - cytotrophoblast (pale) - no choronic villi present - complete anaplasia - multi-nucleation * 1:40,000 pregnancies, high in Asia and Africa (1:2000) * 50% follow a mole * 25% follow abortion * 23% follow normal pregnancy * 2% follow ectopic pregnancy **Etiopath** * Extensive infiltration and metastasis – lung, brain, liver * Malignant cyto and syncitiotrophoblasts * Hemorrhage and necrosis (bloody discharge per vagina) * NO CHORIONIC VILLI * βhCG elevated, confirm diagnosis by biopsy * **Chemotherapy yields good results- cure** (contract w non-gestational CC which does not respond to chemo) * Followup βhCG levels monitored

Answer 21

* Rare * Proliferation of intermediate trophoblasts and cytotrophoblasts in uterus * Follows abortion or normal pregnancy * No villi, no fetal parts, no * syncitiotrophoblasts * Cells have raised human placental lactogen (hPL) but very little βhCG * Cured by curettage