Gestational and Placental - Dobson Flashcards
Hormonal and immunologic functions of placenta
- Produces hCG and hPL
- Down-regulates antigen expression from baby (prevent maternal Ab attack)
Problems with pregnancy before 20 weeks (early)
- Spontaneous abortion
- Ectopic pregnancy
Most spontaneous abortions occur when?
Before 12 weeks
Known causes of spontaneous abortion (5 groups - w/ causes w/in each group)
- Chromosomal abnormalities (50+%)
- Uterus defects (submucosal leiomyoma, uterine polyps, uterine septum/didelphys)
- Infections (Toxo, Mycoplasma, Listeria, CMV, HSV2, Parvo, Rubella, Chlamydia, Ureaplasma)
- Endocrine (luteal-phase defect, maternal DM, thyroid)
- Systemic vascular disorders (APS, coagulopathies, HTN)
A woman cannot get pregnant, and blood tests show a false positive syphilis test. Dx?
Antiphospholipid antibody syndrome
A woman has a second-trimester spontaneous abortion. Most likely infection?
Ascending (chlamydia, etc.)
A woman has repetitive miscarriages. Potential cause?
Antiphospholipid antibody syndrome
Most common site of ectopic pregnancy
Fallopian tube ampulla (90%)
Ectopic pregnancy often occurs because ___ is damaged
Causes?
Fallopian tube (scarring/adhesions)
PID, appendicitis, endometriosis, surgery
Non-pathology increased risk factors for ectopic pregnancy
IUD, smoking
Most serious consequence of ectopic pregnancy
Hematosalpinx –> tubal rupture –> intraperitoneal hemorrhage
Severe abdominal pain, vaginal bleeding 6-8 weeks after last menstrual period, hypotension, shock
Ectopic pregnancy
How to confirm an ectopic pregnancy?
Ultrasound, laparoscopy
Function of hCG
Maintain corpus luteum, thus maintaining progesterone
Ultrasound finding for ectopic pregnancy
Donut sign (round object w/ dark center)
Treating ectopic pregnancy
Methotrexate, surgery
Problems w/ pregnancy after 20 weeks (3rd trimester) (5)
- Cord problem (knot, nuchal, prolapse)
- Abruptio placenta
- Disruption of placental fetal vessels
- Uteroplacental malperfusion (abnormal placement or development, maternal vascular disease)
- Ascending infections (bacterial usually)
Causes of uteroplacental malperfusion, which can lead to late pregnancy issues
Uteroplacental vascular insufficiency (UPVI)
DM, HTN, coagulation, smoking, cocaine/drugs
Misplaced uterus (previa, accreta)
Baby is born prematurely. Amniotic fluid is cloudy with purulent exudate, w/ infiltrate of neutrophils, edema, and congested vessels
Cause?
What if it was chronic inflammatory cell infiltrate in chorionic villi?
Placental infection (chorioamnionitis)
Ascending bacterial infection
Hematogenous spread of TORCH infection to the embryo
Fetal response to placental infection?
Vasculitis of cord (funisitis)
TORCH infections spread to placenta how?
Cause what?
Hematogenous
Chronic inflammation in chorionic villi (lymphocytic)
Congenital syphilis - classic symptoms (6)
Other symptoms (4)
Rash of palms and soles Saber shins (ant. bowing of tibia) Saddle-shaped nose Hutchison teeth (notched incisors) Mulberry molars (enamel outgrowths) Deafness
Hepatomegaly, pulmonary interstitial fibrosis, rhinitis, rash
Twin-twin transfusion syndrome
Requires what type of twinning?
Uneven shunting of blood to one vs. the other –> flushed, edematous child + pale, shrunken child
Monochorionic (vascular anastamoses btwn the 2 circulations
Placenta previa vs. Placenta accreta
Previa - placenta blocking cervical os
Accreta - placenta directly attached to myometrium (no decidua)
Placenta previa - symptom
Placental accreta - symptom
3rd trimester bleeding
Postpartum bleeding/hemorrhaging
Pregnant woman (34+ weeks) w/ HTN, edema, and proteinuria
Most important complication?
More common in who?
Preeclampsia
Seizures (–> eclampsia)
Primiparas (delivering for 1st time)
What is preeclampsia? Cause?
SYSTEMIC endothelial dysfunction in the mother during pregnancy, caused by placenta-derived factors that alter the mother’s endothelium
Molecular mechanisms of preeclampsia (3)
- Extravillous trophoblastic cells DON’T destroy vascular SM of maternal decidual vessels, causing increased resistance and low blood flow (ischemia)
- Ischemic placenta releases ***sFltl –> antagonizes VEGF–> low PGI2 –> low anticoagulation –> hypercoaguability
- Ischemic placenta releases ***endoglin –> antagonizes TFG-beta –> low N.O. –> hypertension and hypoperfusion
HELLP syndrome
10-20% of preeclampsia also develops:
- hemolytic anemia, elevated liver enzymes, low platelets
Hypercoaguable state in preeclampsia can lead to what else?
Thrombi in liver (hematoma), kidneys (diffuse cortical necrosis), brain, and pituitary (hypopituitarism)
After preeclampsia…
Risk of HTN and microalbuminuria w/in 7 years
2x risk of vascular diseases of heart and brain
Gestational trophoblastic diseases - what are they?
Examples
Proliferation of placental tissue (villous or trophoblastic)
Molar pregnancy, invasive mole, choriocarcinoma, PSST
Woman comes in with very high hCG level. An ultrasound shows abnormal villous enlargement. No fetal tissues are found.
Chromosomal finding? How for each?
Complete hydatidiform mole
46 XX - empty egg + 1 sperm that duplicates its DNA
46 XY - empty egg + 2 sperm (could also by 46 XX)
Translucent, cystic, grape-like structures w/in uterus. Path shows swollen villous tissue covered completely by extensive trophoblastic cells
How to tell this from the other kind?
Complete mole
Partial mole = only SOME enlarged villi w/ less trophoblastic hyperplasia
Partial mole - chromosomal findings (why?)
Fetal tissue?
69 XXY - normal egg + 2 sperm
92 XXXY - ???
Some
Complete vs. partial mole:
- hCG
- Risk of choriocarcinoma
Complete - higher hCG, risk of choriocarcinoma
Partial - not as high hCG, no risk of choriocarcinoma
Invasive mole - what is it?
Molar pregnancy –> penetrates/perforates uterine wall w/ proliferation of cytotrophoblasts AND syncytiotrophoblasts
Invasive mole - presentation
Vaginal bleeding, irregular uterine enlargement, persistently high hCG
Woman w/ irregular vaginal bleeding, bloody/brown fluid, enlarged uterus, hCG VERY high; masses in lung
What is it?
Gestational choriocarcinoma
Invasive malignant neoplasm of trophoblastic cells after a normal OR abnormal pregnancy
Gestational choriocarcinoma - most commonly following what?
Complete mole
Patient presents w/ uterine mass, maybe bleeding, moderately elevated hCG, and increased hPL
Often follows what? (3)
Placental site trophoblastic tumor (PSTT)
Normal pregnancy, spontaneous abortion, or molar pregnancy
