Obstetric Pathology Flashcards by Wei Shynn Tan

What is the clinical definition of spontaneous abortion/miscarriage?

Loss of pregnancy before 20wks of gestation without outside intervention

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What are 5 causes of miscarriage?

1) Endocrine factors
2) Fetal chromosomal anomalies

Uterine defects:
3) Fibroids
4) Polyps

Systemic disorders:
5) HTN
6) DM

Infections:
7) TORCH

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What are 2 indications for chromosomal analysis?

1) Habitual/recurrent abortions
- spontaneous sequential loss of 3 or more pre-viable pregnancies

2) Malformed fetus

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What are 5 predisposing factors of ectopic pregnancy?

1) Chronic salpingitis (gonococcal)
2) Peritubal adhesions (appendicitis)
3) Leiomyomas
4) Previous surgery
5) Benign cysts and tumours of tube
6) IUCD

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What are 4 sites of ectopic pregnancies? (90% within tubes)

1) Intratubal
2) Ovarian
3) Cornual
4) Abdominal

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What 4 clinical features of ectopic pregnancy?

1) Ameorrhoea 6-8 weeks
2) Abdominal pain
3) Vaginal bleeding
4) Haemorrhagic shock

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What are 3 ways to diagnose an ectopic pregnancy?

1) hCG titres
2) Pelvic US
3) Endometrial biopsy

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What are 2 disorders of early pregnancy?

1) Spontaneous abortion
2) Ectopic pregnancy

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What are 3 disorders of late pregnancy?

1) Placental inflammations
2) Toxemias of pregnancy
3) Placental abnormalities

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What is villitis?

Inflammation of the placenta most commonly due to infection

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What is chorioammionitis?

Inflammation of the placental membranes most commonly due to infection

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What is funisitis?

Inflammation of the umbilical cord most commonly due to infection

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What are 2 ways infections spread to the placenta?

1) Ascending infections (through birth canal)

2) Hematogenous (transplacental)
- eg. TORCH

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What are the TORCH infections?

T - Toxoplasmosis
O - Others (eg. Syphillis, Hep B)
R - Rubella
C - CMV
H - HSV

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What are 4 consequences of antenatal infections?

1) Intrauterine growth restriction
2) Low birth weight
3) Premature delivery
4) Congenital abnormalities
5) Deafness

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What are 5 causative organisms of placental infections?

STD:
1) Syphillis
2) Chlamydia

Viral:
3) Rubella
4) CMV

Bacterial:
5) Strep
6) Listeriosis

Protozoal:
7) Toxoplasmosis

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What is toxaemia of pregnancy?

Systemic syndrome characterised by widespread maternal endothelial dysfunction:

1) Preeclampsia
- HTN, proteinuria, oedema

2) Eclampsia
- Convulsion
- DIVC

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What are 3 complications of toxaemia of pregnancy?

1) Hypercoagulability
2) ARF
3) Pulmonary edema

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Toxaemia of pregnancy EPC:
- Occurs in _____% of pregnant women
- usually in _________ trimester
- most common in which child?

Toxaemia of pregnancy EPC:
- Occurs in 5-10% of pregnant women
- usually in 3rd trimester
- most common in 1st child (primapara)

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What are the critical abnormalities of preeclampsia and their pathogenesis?

Altered placentation → Organic/functional obstruction of spiral arterioles → ↓uteroplacental perfusion → ↓PGI/PGE + ↑Renin/AT2 + ↑ TXA

1) Diffuse endothelial dysfunction + vasoconstriction → HTN

2) ↑vascular permeability → proteinuria + edema

How would toxaemia of pregnancy appear in the (i) Liver (ii) Kidney and (iii) Brain?

Toxaemia → DIVC
i) Irregular, focal , subcapsular and interparenchymal haemorrhages

ii) Glomeruli show marked swelling of endothelial cells and fibrin thrombi

iii) Gross/microscopic foci of haemorrhage along with small-vessel thromboses

What are 3 features of acute toxaemia-placenta?

1) Infarcts
2) Hematomas
3) Fibrinoid necrosis of vessels

What are 3 placental abnormalities?

1) Placenta previa
2) Abruptio placentae
3) Placenta accreta

What is placenta previa?

Implantation of placenta over/near internal
- usually results in antepartum haemorrage
- necessitates delivery of placenta before fetus (usually perform cesarean section)

What is abruptio placentae?

Premature separation of normally positioned placenta from uterine wall during pregnancy

What are 3 complications of abruptio placenatae?

1) Concealed/revealed bleeding 2) Hemorrhagic shock 3) DIVC 4) Severe fetal distress → death

What is placenta accreta?

Adhesion of placenta villi to uterine wall due to absence of decidual plate between villi and myometrium → failure of placenta to separate in 3rd stage of lavour

What are the 3 forms of placenta accreta?

1) Accreta (75-78%) - invades endometrium 2) Increta (17%) - invades myometrium 3) Percreta (5%) - invades serosa

What is the main concern of placenta accreta and how is it circumvented?

Failure of placental separation → severe postpartum haemorrhage → shock Hysterectomy to arrest bleeding

What are gestational trophoblastic disease?

Spectrum of tumours/tumour-like conditions characterised by proliferation of placental tissue (villous/trophoblastic)

Trophoblastic diseases EPC: Geographical locations: ____________________ Age: ____________________ Obstetric Hx: ____________________

Trophoblastic diseases EPC: Geographical locations: Asia, Africa, Latin America Age: - Extreme ages of reproductive age → ↑ risk - ↑ Age → ↑risk of malignant sequelae Obstetric Hx: - Term pregnancy and live births have protective effects - Hx of previous mole → ↑risk

What are 3 forms of gestational trophoblastic diseases?

1) Hydatidiform mole (partial or complete) 2) Invasive mole 3) Choriocarcinoma

What are 4 clinical features of hydatidiform moles?

1) Vaginal bleeding 2) Uterus > dates 3) Preeclamptic toxaemia 4) Passage of molar vesicles 5) Hyperemesis 6) Pulmonary embolisation 7) Hyperthyroidism 8) ↑hCG on serology

What are 3 complications of hydatidiform moles?

1) Uterine hemorrhage 2) Coagulopathy 3) Infection 4) Continued trophoblastic activity (eg. invasive mole, choriocarcinoma)

What are 5 differences between complete and partial hydatidiform moles?

1) Uterine size: C: Large for date P: Small for date 2) Serum HCG C>P 3) Karyotype C: Diploid P: Triploid 4) Embryo/fetus C: absent P: present 5) Trophoblastic hyperplasia C: diffuse P: focal 6) Behaviour C: 10-30% persistent GTD P: 4-11% persistent GTD

How are hydatidiform moles diagnosed and differentiated?

p57 - surrogate marker for maternal genome p57- → Complete (androgenetic diploidy) p57+ → Non-molar or partial

What is an invasive hydatidiform mole?

Mole which hydropic villi invade myometrium/blood vessels/transported to extrauterine sites

True or false: Despite been shown to metastasise to the lungs, vuvla, broad ligament, etc. most invasive hydatidiform moles are locally aggressive with low metastatic risk and thus mostly confined to the uterus, only penetrating into the myometrium with hydropic villi and trophoblastic proliferation.

True

True or false: Invasive hydatidiform moles are highly radiosensitive and are self-limiting with 4-15% deaths in pre-radiotherapy days.

False. Highly chemosensitive - but yes self-limiting with 4-15% deaths in pre-chemotherapy days

How do invasive hydatidiform moles result in death?

1) Uterine perforation 2) Intraperitoneal bleeding

What is a choriocarcinoma?

Malignant epithelial tumour arising from trophoblast of any gestation event, most commonly from a hydatidiform mole. - mainly biphasic proliferation of syncytio-cytotrophoblasts

What is the (i) gross and (ii) histological appearance of gestational choriocarcinoma?

i) Hemorrhagic friable mass in uterine cavity ii) Hemorrhage and necrosis, anaplastic trophoblast, vascular invasion

What are 3 clinical features of choriocarcinoma?

1) Abnormal uterine bleeding 2) ↑HCG in serology 3) Distant metastasis → hemorrhagic events - hematogenous >>>> lymphatic

What is the general prognosis of gestational choriocarcinomas and what are the influencing factors?

Good prognosis (80-90% with chemotherapy) 1) Distant metastasis 2) Failure of chemotherapy 3) Choriocarcinoma following term pregnancy

How are gestational trophoblastic diseases staged?

FIGO staging: I - confined to uterus II - extends by metastasis or direct extension (eg. vagina, ovaries, broad ligament, fallopian tubes) III - Metastases to lungs IV - Other distant metastases with or without lung involvment

What are the 2 most common sites of metastasis of gestational choriocarcinomas?

1) Lungs 2) Vagina 3) Others: brain, liver, marrow

What are 5 Ix for female infertility?

1) Hormonal assay 2) Endometrial sampling 3) Laproscopy 4) Hysteroscopy 5) Hysterosalpingography 6) Microbiologic studies

True or false: The majority of gestational choriocarcinomas arising from ectopic pregnancies.

False: Mole: 50% Abortion: 25% Normal pregnancy: 22.5% Ectopic pregnancy: 2.5%