gestational and placental disorders Flashcards
defined as pregnancy loss before 20 weeks of gestation
spontaneous abortion or “miscarriage”
what are the most important causes of spontabous abortion
- fetal chromosomal anomalies: most common Turner (45X)
- Maternal endocrine factors
- Physical defects of the uterus
- Systemic disorders affecting the maternal vasculature (antiphospholipid syndrome)
- infections
most common site for ectopic pregnancy
extrauterine fallopian tube
What is the most important predisposing condition for ectopic pregnancy
-prior pelvic inflammatory disease resulting in intraluminal fallopian tube scarring (chronic salpingitis)
what else besides PID increases risk for ectopic pregnancy
- peritubal scarring and adhesions: may be casued by appendicitis, endometriosis, previous surgery
- intrauterine contraceptive device . . 2x increase
- smoking
what is the most common cause of hematosalpinx (blood in fallopian tube)?
Tubal pregnancy . . should always be suspected when a tubal hematoma is present
rupture of a tubal pregnancy is a medical ______?
emergency
The clinical course of an ectopic tubal pregnancy is characterized by what?
- onset of moderate to severe abdominal pain
- vaginal bleeding 6 to 8 weeks after last menstrual period, correlating with distention and then rupture of the fallopian tube
diagnosis of ectopic pregnancy is based on what
- determination of chorionic gonadotropin titers (hCG)
- pelvic sonography
- endometrial biopsy
what are the most common microorganisms implicated in intrauterine infections leading to preterm labor
- ureaplasma urealyticum
- mycoplasma hominis
- Gardnerella vaginalis
- trichomonas
- Gonorrhea
- Chlamydia
developing countries: malaria and HIV
infections that cause spontaneous abortion
- viruses (CMV, HSV2, parvovirus, rubella)
- Toxo
- Mycoplasma
- Listeria
- chlamydia
- Ureaplasma
spontaneous abortion occurs due to what
ascending infections in second trimester or hematogenous dissemination
what ultrasound sign is found with ectopic pregnancy
donut sign
disorders that occur in the third trimester of pregnancy are related to what?
the complex anatomy of the maturing placenta
what is abruptio placentae
retroplacental hemorrhage at the interface of placenta and myometrium that threatens both mother and fetus
what is a common cause of second trimester fetal loss
infections (ascending most common)
- chorioamnionitis –> PROM
- fetal response is vasculitis of cord (funisitis)
- TORCH infections
what are the TORCH infections
- Toxoplasma
- Other: syphilis, listeria, HIV, VZV, Parvovirus B19, Coxsackievirus
- Rubella
- Cytomegalovirus
- Herpes
What can cause Uteroplacental Malperfusion? or Uteroplacental Vascular Insufficiency (UPVI)
- diabetes
- HTN
- maternal conditions predisposing to blood clots
- smoking
- cocaine or other drugs
when you get imbalanced blood flow between twins in utero
Twin-Twin transfusion syndrome (TTTS)
A condition in which the placenta implants in the lower uterine segment or cervix, often leading to serious third trimester bleeding
placenta previa
A complete placenta previa covers the internal cervical os and thus requires what
delivery via cesarean section
caused by partial or complete absence of the decidua, such that the placental villous tissue adheres directly to the myometrium, which leads to failure of placental separation at birth
Placenta accreta
Placenta accreta is an important cause of what
severe, potentially life threatening postpartum bleeding
common predisposing factors to placenta accreta
- placenta previa
- history of previous cesarean sections
infections in the placenta develop by what two pathways
- ascending infections through the birth canal
- hematogenous (transplacental) infection
a systemic syndrome characterized by widespread maternal endothelial dysfunction that presents during pregnancy with HTN, edema, and proteinuria
Preeclampsia
preeclampsia is usually in who
- last trimester
- more common in primiparas (first pregnancy)
what is eclampsia
women with preeclampsia develops convulsions
what are the critical abnormalities in preeclampsia
- diffuse endothelial dysfunction
- vasoconstriction
- increased vascular permeability
What factors are higher in women with preeclampsia
- sFltl (antagonized VEGF)
- endoglin (antagonizes TGF-beta –>decreased NO)
what are the microscopic changes of the placenta associated with preeclampsia
- infarcts
- exaggerated ischemic changes in chorionic villi and trophoblast, consisting of increased syncytial knots
- frequent retroplacental hematomas
- abnormal decidual vessels
what are the risk factors for preeclampsia
- age over 40
- black
- FH
- multiple gestation
- chronic renal disease
- chronic HTN
- DM
- clotting disorders
- 1st pregnancy
what syndrome can develop in women with preeclamsia
HELLP in 10-20%
describe the hypercoaguable state in preeclampsia
- reduced endothelial production of PGI2
- leads to thrombi in arterioles and capillaries throughout the body
- particularly in liver, kidneys, brain, and pituitary
when does preeclampsia start
- most commonly after 34 weeks gestation
- earlier in women with hydatidiform mole or preexisting kidney disease, HTN, or coagulopathies
describe the onset of preeclampsia
- typically insidious, characterized by HTN and edema with proteinuria following within several days
- headaches and visual disturbances are serious events
what are the hallmarks of HELLP syndrome
- Hemolysis
- elevated liver enzymes
- low platelets
This encompasses a spectrum of tumors and tumor like conditions characterized by proliferation of placental tissue, either villous or trophoblastic
gestational trophoblastic disease
Hydatidiform moles are important to recognized because they are associated with an increased risk of what?
- persistent trophoblastic disease (invasive mole)
- choriocarcinoma
moles are characterized histologically by what
cystic swelling of the chorionic villi accompanied by variable trophoblastic proliferation
What are the major gestational trophoblastic disease
- hydatidiform (noninvasive) mole (complete or partial)
- invasive mole
- choriocarcinoma
- placental site trophoblastic tumor
increased risk of molar pregnancy in who
- teens
- and age 40-50
Hydatidiform mole is diagnosed when and how
- early in pregnancy (average of 9 weeks)
- by sonogram
where are molar pregnancies more common?
2x more common in southeast asia
this type of mole is fertilization of an empty egg
complete
complete moles have what karyotype
- 46XX (90%)
- or 46 XY
complete mole increases risk for what
- choriocarcinoma
- invasive mole
partial moles are NOT associated with choriocarcinoma but are at increased risk for persistent invasive mole
morphology of complete mole
grapelike clusters
which mole has NO maternal DNA or fetal tissue?
which usually has fetal tissue?
- complete
- partial
karyotype of partial mole
- -69XXY
- 92,XXXY
clinical presentation for molar pregnancy
- spontaneous miscarriage or ultrasound abnormality
- elevate beta-hCG and increased rate of rise (especially complete mole)
defined as a mole that penetrates or even perforates the uterine wall
-invasive mole
invasive mole is manifested clinically by what
- vaginal bleeding and
- irregular uterine enlargement
- persistently elevated hCG
A rapidly invasive malignant neoplasm of trophoblastic cells derived from a previous normal or abnormal pregnancy
-choriocarcinoma . .also called gestational choriocarcinoma
what conditions can choriocarcinoma arise from
- complete mole (50%)
- previous abortion (25%)
- normal pregnancy (22%)
- ectopic pregnancy (rest)
clinical presentation of choriocarcinoma
- irregular vaginal bleeding of bloody, brown fluid (not related to menstruation)
- Enlarged uterus
- May present with mets to lung, vagina, brain, liver, bone, kidney
- hCG USUALLY VERY HIGH, unless tumor is necrotic
treatment for choriocarcinoma
chemo very effective. . 100% cure
neoplastic proliferations of extravillous trophoblasts, also called intermediate trophoblasts
placental site trophoblastic tumor (PSTT)
clinical presentation of PSTT
- uterine mass with bleeding or amenorrhea
- MODERATE HCG ELEVATION, INCREASE
- 1/2 follow normal pregnancy
- also seen after spontaneous abortion or molar pregnancy
prognosis for PSTT
if localized then excellent
