Obstetrics and Gynaecology

Question 1

Gartner duct cysts are relatively common lesions found along the lateral walls of the vagina that are derived from …

Answer 1

Gartner duct cysts are relatively common lesions found along the lateral walls of the vagina that are derived from wolffian (mesonephric) duct rests.

Question 2

High-risk HPVs

Answer 2

HPV-16 and HPV-18

HPV-16 alone accounts for almost 60% of cervical cancer cases, and HPV-18 accounts for another 10% of cases; other HPV types contribute to less than 5% of cases, individually.

High-risk HPVs are also implicated in squamous cell carcinomas arising at many other sites, including the vagina, vulva, penis, anus, tonsil, and other oropharyngeal locations. As noted earlier, low oncogenic risk HPVs are the cause of sexually transmitted vulvar, perineal, and perianal warts (condyloma acuminatum).

Question 3

The ability of HPV to act as a carcinogen depends on?

Answer 3

Viral E6 and E7 proteins, which interfere with the activity of the key tumor suppressor proteins, p53 and RB, respectively.

Question 4

Classification Systems for Squamous Cervical Precursor Lesions.

Answer 4

Question 5

The average age of patients with invasive cervical carcinoma is between 45 and 50 years.

x is the most common histologic subtype, accounting for approximately x% of cases. The second most common tumor type is x, which constitutes about x% of cervical cancer cases and develops from a precursor lesion called x.

Answer 5

Squamous cell carcinoma is the most common histologic subtype, accounting for approximately 80% of cases. The second most common tumor type is adenocarcinoma, which constitutes about 15% of cervical cancer cases and develops from a precursor lesion called adenocarcinoma in situ. Adenosquamous and neuroendocrine carcinomas are rare cervical tumors that account for the remaining 5% of cases.

Question 6

Natural History of Squamous Intraepithelial Lesions With Approximate 2-Year Follow-Up i.e LSIL/HSIL %persist, regress and progress.

Answer 6

Question 7

The diagnosis of chronic endometritis rests on the identification of x cells in the stroma

Answer 7

plasma cells

Question 8

Endometriosis is defined by the presence of “ectopic” endometrial tissue at a site outside of the uterus. The abnormal tissue most commonly includes both endometrial glands and stroma, but may consist only of stroma in some cases.

It occurs in the following sites, in descending order of frequency:

Answer 8

(1) ovaries
(2) uterine ligaments
(3) rectovaginal septum
4) cul de sac
(5) pelvic peritoneum
(6) serosa of the large and small bowel and appendix
7) mucosa of the cervix, vagina, and fallopian tubes
(8) laparotomy scars.

Question 9

There are three types of endometriosis:

Answer 9

1) Superficial peritoneal endometriosis
2) Ovarian endometriosis
3) Deep infiltrating endometriosis

*The superficial and ovarian forms of endometriosis are uncommonly associated with the development of malignancy, whereas it is extremely rare for the deep infiltrating form to undergo malignant transformation.

Question 10

Endometrial hyperplasia. Associated conditions include the following:

Answer 10

• Obesity (peripheral conversion of androgens to estrogens)
• Menopause
• Polycystic ovarian syndrome
• Functioning granulosa cell tumors of the ovary
• Excessive ovarian cortical function (cortical stromal hyperplasia)
• Prolonged administration of estrogenic substances (estrogen replacement therapy)

Question 11

Inactivation of the x tumor suppressor gene is a common genetic alteration in both endometrial hyperplasias and endometrioid endometrial carcinoma.

Answer 11

PTEN

*Of note, patients with Cowden syndrome, which is caused by germline mutations in PTEN, have a high incidence of endometrial carcinoma and certain other tumors, particularly breast cancer.
*PTEN tumor suppressor gene is mutated in approximately 20% of endometrial hyperplasias.

Question 12

The classification of endometrial hyperplasia according to the WHO includes two major categories, x and x which differ in appearance and propensity to progress to carcinoma.

Answer 12

Typical hyperplasia and atypical hyperplasia

Typical hyperplasia has a wide-range of appearances, but the cardinal feature is an increased gland-tostroma ratio. The glands show variation in size and shape and may be dilated. These lesions are caused by persistent estrogen stimulation and rarely progress to adenocarcinoma (approximately 1% to 3%). Hyperplasia may evolve into cystic atrophy when estrogen is withdrawn.

Atypical hyperplasia (endometrial intraepithelial neoplasia) is composed of complex patterns of proliferating glands displaying nuclear atypia. The glands are commonly back-to-back and often have complex outlines due to branching structures. Individual cells are rounded and lose the normal perpendicular orientation to the basement membrane. In addition, the nuclei have open (vesicular) chromatin and conspicuous nucleoli. The features of atypical hyperplasia have considerable overlap with those of well-differentiated endometrioid adenocarcinoma, and accurate distinction from cancer may not be possible without hysterectomy. Indeed, up to 50% of women with a diagnosis of atypical hyperplasia are found to have carcinoma when a hysterectomy is performed.

Question 13

Asherman syndrome, also known as uterine synechiae.

Answer 13

Condition characterised by the formation of intrauterine adhesions, which are usually sequela from injury to the endometrium, and is often associated with infertility.

Epidemiology
There is a tendency for the condition to develop soon after pregnancy (usually within four months). The incidence is thought to be increasing probably as a result of increased use of intrauterine interventions.

Clinical presentation
Patients may present with infertility, pregnancy loss, menstrual abnormalities (e.g. 2ry amenorrhoea, hypomenorrhoea, dysmenorrhoea) or abdominal pain.

Pathology
Intrauterine adhesions result secondary to trauma to the basal layer of the endometrium with subsequent scarring. This may be from a previous pregnancy, dilation and curettage, surgery, or infection (e.g. TB endometritis).

Question 14

Characteristics of Type I and Type II Endometrial Carcinoma

Answer 14

Question 15

Sequencing of the genomes of endometrioid carcinomas has shown that the most common mutations act to increase signaling through the …

Answer 15

PI3K/AKT pathway

Question 16

Serous endometrial carcinoma is highly associated with disruptive mutations in the …

Answer 16

TP53 tumor suppressor gene.

Question 17

Suppurative salpingitis may be caused by any pyogenic organism; in some cases more than one organism is involved. x is the causative organism in more than 60% of cases, with x being responsible for many of the remaining cases.

Answer 17

Gonococcus
Chlamydiae

Tuberculous salpingitis is rare in the United States, accounting for not more than 1% to 2% of all forms of salpingitis. It is more common in parts of the world where tuberculosis is prevalent and is an important cause of infertility in these areas.

Question 18

Polycystic ovarian syndrome (PCOS) is a complex endocrine disorder characterized by …

Answer 18

hyperandrogenism, menstrual abnormalities, polycystic ovaries, chronic anovulation, and decreased fertility

Question 19

Regarding polycystic ovarian syndrome

affects x% of reproductive age women worldwide
**polycystic ovaries are detected in x% of all women, so this finding is not specific.
**due to an increase in free serum estrone levels, women with PCOS are at risk for x and x

Answer 19

affects 6% to 10% of reproductive age women worldwide
**polycystic ovaries are detected in 20% to 30% of all women, so this finding is not specific.
**due to an increase in free serum estrone levels, women with PCOS are at risk for endometrial hyperplasia and carcinoma

Question 20

Ovarian tumours. Which most commonly present with bilateral ovarian tumours?

Answer 20

Question 21

WHO Classification of Ovarian Neoplasms

Answer 21

Question 22

Ovarian ca

Risk factors for serous tumors?

Answer 22

Risk factors for malignant serous tumors (serous carcinomas) are also not completely understood, but nulliparity, family history, and heritable mutations play a role in tumor development.

Question 23

x% of dermoid cysts undergo malignant transformation

Answer 23

1%, most commonly SCC

Question 24

Dysgerminoma - markers

Answer 24

Most of these tumors have no endocrine function. A few produce elevated levels of chorionic gonadotropin

?LDH

Question 25

Yolk sac tumours - markers

Answer 25

AFP

Question 26

Choriocarcinoma - ovarian

Aggressive and have usually metastasized hematogenously to the x, x, x, and other sites by the time of diagnosis.

Like all choriocarcinomas, they elaborate high levels of x

Answer 26

Aggressive and have usually metastasized hematogenously to the lungs, liver, bone, and other sites by the time of diagnosis.

Like all choriocarcinomas, they elaborate high levels of chorionic gonadotropins.

*Ovarian not responsive to chemotherapy

Question 27

Granulosa cell tumors are of clinical importance for two reasons: (1) they sometimes elaborate large amounts of x, and (2) they may behave like x

Answer 27

(1) they sometimes elaborate large amounts of estrogen
(2) they may behave like low-grade malignancies.

*All granulosa cell tumors are potentially malignant. It is difficult to predict their biologic behavior from histology. The likelihood of malignant behavior (recurrence, extension) ranges from 5% to 25%.

**Indolent tumors, but may recur 10 to 20 years after resection of the primary tumor.

***Associated with hyperestrinism, leading to an elevated risk of endometrial carcinoma.

Question 28

x, found in about 40% of cases in which the tumors measure more than 6 cm in diameter. Uncommonly there is also a x, usually only on the x side. This combination of findings is designated Meigs syndrome.

Answer 28

ascites, found in about 40% of cases in which the tumors measure more than 6 cm in diameter. Uncommonly there is also a hydrothorax, usually only on the right side. This combination of findings (ovarian tumor, hydrothorax, and ascites) is designated Meigs syndrome.

Question 29

The incidence of recurrence or metastasis by x tumors is less than 5%. These neoplasms may cause defeminization of women, manifest by x. The syndrome may progress to striking x (x) associated with x

Answer 29

The incidence of recurrence or metastasis by Sertoli-Leydig cell tumors is less than 5%. These neoplasms may block normal female sexual development in children and may cause defeminization of women, manifest by atrophy of the breasts, amenorrhea, sterility, and loss of hair. The syndrome may progress to striking virilization (hirsutism) associated with male hair distribution, hypertrophy of the clitoris, and voice changes.

A few have estrogenic effects.

Question 30

Metastatic tumors of the ovary (restricted to female pelvis) are derived from tumors of x origin: the x, x, x, or x.

The most common tumours metastatic to the ovary are carcinomas of the x and x, including x, x, x, and x. Also included in this group are rare cases of pseudomyxoma peritonei, derived from appendiceal tumors.

Answer 30

Metastatic tumors of the ovary are derived from tumors of müllerian origin: the uterus, fallopian tube, contralateral ovary, or pelvic peritoneum.

The most common extra-müllerian tumors metastatic to the ovary are carcinomas of the breast and gastrointestinal tract, including colon, stomach, biliary tract, and pancreas. Also included in this group are rare cases of pseudomyxoma peritonei, derived from appendiceal tumors.

Question 31

Ovarian hyperstimulation syndrome (OHSS) is a complication of controlled ovarian stimulation, which is an assisted reproduction technique used for in vitro fertilisation (IVF). Rarely, it may also occur spontaneously in pregnancy.

It consists of x

Answer 31

It consists of ovarian enlargement with an extravascular accumulation of fluid leading to variable weight gain, ascites, pleural effusion, intravascular volume depletion, and oliguria.

Question 32

TORCH group

Answer 32

Toxoplasmosis and others [syphilis, tuberculosis, listeriosis], rubella, cytomegalovirus, herpes simplex

Question 33

Preeclampsia …(describe)

It occurs in about x% of pregnant women, usually in the x trimester and more commonly in women x.

Other complications stemming from systemic endothelial dysfunction include x, x, and x.

Approximately x% of women with preeclampsia develop microangiopathic hemolytic anemia, elevated liver enzymes, and low platelets, referred to as the HELLP syndrome. Preeclampsia should be distinguished from gestational hypertension that can develop in pregnancy without proteinuria.

Answer 33

A systemic syndrome characterized by widespread maternal endothelial dysfunction that presents during pregnancy with hypertension, edema, and proteinuria.

It occurs in about 3% to 5% of pregnant women, usually in the last trimester and more commonly in women pregnant for the first time (primiparas).

Other complications stemming from systemic endothelial dysfunction include hypercoagulability, acute renal failure, and pulmonary edema.

Approximately 10% of women with preeclampsia develop microangiopathic hemolytic anemia, elevated liver enzymes, and low platelets, referred to as the HELLP syndrome. Preeclampsia should be distinguished from gestational hypertension that can develop in pregnancy without proteinuria.

Question 34

Effects of preeclampsia on organs

Answer 34

The placenta reveals several microscopic changes, most of which reflect malperfusion, ischemia, and vascular injury.

These include (1) infarcts, which are larger and more numerous than those that may be seen in normal full-term placentas
(2) exaggerated ischemic changes in the chorionic villi and trophoblast, consisting of increased syncytial knots
(3) frequent retroplacental hematomas due to bleeding and instability of uteroplacental vessels,
(4) abnormal decidual vessels, which may show thrombi, lack of normal physiologic conversion, fibrinoid necrosis, or intimal lipid deposition (acute atherosis)

The liver lesions, when present, take the form of irregular, focal, subcapsular, and intraparenchymal hemorrhages. On histologic examination, there are fibrin thrombi in the portal capillaries and foci of hemorrhagic necrosis.

The kidney lesions are variable. The glomeruli show marked swelling of endothelial cells, amorphous dense deposits on the endothelial side of the basement membrane, and mesangial cell hyperplasia. Immunofluorescent studies show abundant fibrin deposition in glomeruli. In advanced cases, fibrin thrombi are present in the glomeruli and capillaries of the cortex. If widespread and severe, these thrombi may produce bilateral renal cortical necrosis, leading to complete destruction of the cortices. The brain may have gross or microscopic foci of hemorrhage along with small-vessel thromboses. Similar changes are often found in the heart and the anterior pituitary gland.

Question 35

Preeclampsia most commonly starts after x weeks of gestation but begins earlier in women with x,x, x, or x.

Answer 35

Preeclampsia most commonly starts after 34 weeks of gestation but begins earlier in women with hydatidiform mole (discussed later) or preexisting kidney disease, hypertension, or coagulopathies.

Question 36

Hydatidiform moles are important to recognize because they are associated with an increased risk of x or x.

Answer 36

Persistent trophoblastic disease (invasive mole) or choriocarcinoma.

Question 37

Molar pregnancy - risk is higher in x.

More common in which group?

Answer 37

Molar pregnancy - risk is higher in teenagers and between 40 and 50 years of age.

For unknown reasons, the incidence varies considerably in different parts of the world. Hydatidiform mole occurs in about 1 in 1000 to 2000 pregnancies in the United States, but it is twice as common in Southeast Asia.

Question 38

Complete mole results from x

x% have a x karyotype. The remaining x% result from x; these may have a x karyotype.

Patients have x% risk of subsequent choriocarcinoma and a x% risk of persistent or invasive mole.

Answer 38

Complete mole results from fertilization of an egg that has lost its female chromosomes, and as a result the genetic material is completely paternally derived.

90% have a 46,XX karyotype stemming from the duplication of the genetic material of one sperm (a phenomenon called androgenesis). The remaining 10% result from the fertilization of an empty egg by two sperm; these may have a 46,XX or 46,XY karyotype.

Patients have 2.5% risk of subsequent choriocarcinoma and a 15% risk of persistent or invasive mole.

Question 39

Partial moles result from x

In these moles, the karyotype is x

Fetal tissues are typically x.

Partial moles have an increased risk of x.

Answer 39

Partial moles result from fertilization of an egg with two sperm.

In these moles, the karyotype is triploid (e.g., 69,XXY) or occasionally tetraploid (92,XXXY).

Fetal tissues are typically present.

Partial moles have an increased risk of persistent molar disease but are not associated with choriocarcinoma.

Question 40

Gestational choriocarcinoma may be preceded by several conditions; x% arise in complete hydatidiform moles, x% in previous abortions, approximately x% follow normal pregnancies, with the remainder occurring in x

Answer 40

Choriocarcinoma may be preceded by several conditions; 50% arise in complete hydatidiform moles, 25% in previous abortions, approximately 22% follow normal pregnancies, with the remainder occurring in ectopic pregnancies

Question 41

Gestational choriocarinoma

Widespread metastases are characteristic; the most common sites are the x and x, followed by, in descending order of frequency, the brain, liver, bone, and kidney.

Answer 41

Widespread metastases are characteristic; the most common sites are the lungs (50%) and vagina (30% to 40%), followed by, in descending order of frequency, the brain, liver, bone, and kidney.

Question 42

Fetal hydrops refers to x.

In the past, x was the most common cause, but x is more common.

Answer 42

Fetal hydrops refers to the accumulation of edema fluid in the fetus during intrauterine growth.

In the past, hemolytic anemia caused by Rh blood group incompatibility between mother and fetus (immune hydrops) was the most common cause, but with the successful prophylaxis of this disorder during pregnancy, nonimmune hydrops is more common.

The intrauterine fluid accumulation can be quite variable, from progressive, generalized edema of the fetus (hydrops fetalis), a usually lethal condition, to more localized edema, such as isolated pleural and peritoneal effusions, or postnuchal fluid accumulation (cystic hygroma) that are compatible with life.

Question 43

The underlying basis of immune hydrops is x.

The initial exposure to Rh antigen evokes the formation of x antibodies that unlike x antibodies, do not cross the placenta.

Of the numerous antigens included in the Rh system, only the x antigen is a major cause of Rh incompatibility.

Answer 43

The underlying basis of immune hydrops is the immunization of the mother by blood group antigens on fetal red cells and the free passage of antibodies from the mother through the placenta to the fetus (Fig. 10.10). Fetal red cells may reach the maternal circulation during the last trimester of pregnancy, when the cytotrophoblast is no longer present as a barrier, or during childbirth itself. The mother thus becomes sensitized to the foreign antigen. The initial exposure to Rh antigen evokes the formation of IgM antibodies that unlike IgG antibodies, do not cross the placenta. Thus, Rh disease is uncommon with the first pregnancy. Exposure during a subsequent pregnancy generally leads to a brisk IgG antibody response and the risk of immune hydrops.

Of the numerous antigens included in the Rh system, only the D antigen is a major cause of Rh incompatibility. Several factors influence the immune response to RhDpositive fetal red cells that reach the maternal circulation.

• Concurrent ABO incompatibility protects the mother against Rh immunization because the fetal red cells are promptly coated and removed from the maternal circulation by anti-A or anti-B IgM antibodies that do not cross the placenta.
• The antibody response depends on the dose of immunizing antigen; hence, hemolytic disease develops only when the mother has experienced a significant transplacental bleed (>1 mL of Rh-positive fetal red cells).

The incidence of maternal Rh isoimmunization has decreased significantly since the use of Rhesus immune globulin (RhIg) containing anti-D antibodies. Administration of RhIg at 28 weeks of gestation and within 72 hours of delivery to Rh-negative mothers significantly decreases the risk for hemolytic disease in Rh-positive neonates

Question 44

The three major causes of nonimmune hydrops include x

Answer 44

The three major causes of nonimmune hydrops include cardiovascular defects, chromosomal anomalies, and fetal anemia.

Among the chromosomal anomalies, 45,X karyotype (Turner syndrome) and trisomies 21 and 18 are associated with fetal hydrops because of the accompanying structural cardiac anomalies.

Fetal anemia, not caused by Rh- or ABO-associated antibodies, can also result in hydrops. In fact, in some parts of the world (e.g., Southeast Asia), severe fetal anemia due to homozygous α-thalassemia, resulting from deletion of all four α-globin genes, is probably the most common cause of nonimmune hydrops.

Transplacental infection by parvovirus B19 is rapidly emerging as an important cause of hydrops.

Approximately 10% of cases of nonimmune hydrops are related to monozygous twin pregnancies and twin-to-twin transfusion occurring through anastomoses between the two circulations. In up to 20% of cases, the cause remains unknown.

Question 45

Placenta membranacea x

Answer 45

Placenta membranacea, also known as a placenta diffusa, is an extremely uncommon variation in placental morphology in which the placenta develops as a thin membranous structure occupying the entire periphery of the chorion.

Question 46

Placental chorioangiomas are x

Answer 46

Placental chorioangiomas are benign vascular tumours of placental origin. It is the most common tumour of the placenta and is usually found incidentally.