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Pathology III > Placental and Obstetric Pathology > Flashcards

Placental and Obstetric Pathology Flashcards

1
Q

normal placenta - blood flow

A

blood exchange occurs at intervillous spaces, where:

  • umbilical arteries delivery oxygenated blood
    • which is then picked up by the umbilical vein, and delivered to the fetus
  • umbilical veins drain de-oxgenated blood
    • which came from the fetus via the umbilical artery
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2
Q

normal early term placenta - microscopic morphology

A
  • villi are immature & LARGE. they contain a
    • core of mesenchyme (where vasculature will eventually develop)
    • surrouding thick syncytiotrophoblast & cytotrophoblast layers
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3
Q

identify picture & note important features

A

early term normal placenta (6 weeks)

  • large villi (V) in the lacunae (L)
  • thick syncitio and cyto trophoblast layers
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4
Q

identify the picture, not important features

A

early term normal placenta (6 weeks)

  • large villi filled with mesenchyme cores (M) surrounded by thick cyto (C) and syncitio (S) trophoblast layers
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5
Q

identify the picture, note important features

A

early term normal placenta (6 weeks)

  • thick cyto and syncitio trophoblast layers
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6
Q

term placenta - microscopic morphology

A
  • smaller, highly branched villi (V)
    • presence of vasculature in villi
      • in more mature villi, thinning of surrounding layers (cyto and syncitio trophoblast) allows approximation of fetal capillaries (C) to lacunae blood
  • presence of synctitial knots: (K) aggregated syncytiotrophoblast nuclei
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7
Q

identify the picture, note important features

A

normal term placenta (40 weeks)

  • smaller, highly branched villi
    • some villi have vasculature (dark pink)
  • presence of syncitial knots (dark blue)
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8
Q

identify the picture, note important features

A

normal term placental (40 weeks)

  • thinned outer layers that approximate fetal capillaries (C) to maternal blood in lacunae (L)
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9
Q

identify the picture, note important features

A

normal term placental (40 weeks)

  • presence of vasculature in villi
  • presence of syncitial knots (K)
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10
Q

identify the picture, not eimportant pictures

A

first trimester chorionic villi

  • thick, distinct outer layers (cyto and syncitio trophoblast)
  • villi filled with stroma/mesenchyme
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11
Q

identify the picture, not important features

A

third trimester chorionic villi

  • dense network of villi filled with dilated fetal capillaries
  • thinned out surrounding layers (cyto and syncitio trophoblasts)
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12
Q

describe a normal umbilical cord

A
  • made of 3 vessels
    • two umbilical arteries
    • one umbilical vein
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13
Q

identify the picture, note important features

A

normal umbilical cord

  • made of 3 vessels
    • two umbilical arteries
    • one umbilical vein
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14
Q

what are the two types of twin pregnancies?

A
  • dizygotic twins: two ovum fertilized
  • monozygotic twins: single ovum fertilizted → divides into two
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15
Q

what are the variations of twin placentas? what types of twin pregnancies can be seen in each variation?

A

three variations

  • dichorionic diamniotic (fused and separate version)
    • can occur with either monozygotic or dizygotic twins
  • monochorionic
    • two types: monochorionic monoamniotic, monochorionic diamniotic
      • ONLY occurs with monozygotic twins: single fertilization, is mono vs di amniotic dependent on when embryo split
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16
Q

identify each type of placenta pregnancy

which type of twins can be see in which?

A
  • dichorionic diamniotic (fused and separate version)
    • can occur with either
      • monozygotic twoms
      • dizygotic twins
  • monochorionic
    • ONLY occurs with monozygotic twins: single fertilization, is mono vs di amniotic dependent on when embryo split
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17
Q

twin to twin transfusion

  • what is the cause / setting?
  • what is the implication to the fetus?
A
  • seen only in monozygotic twins
    • vascular anastomoses can form between twins. if blood is shunted to one twin preferentially,
      • one twin is over-perfused & appears
        • plethoric
        • polycythemia
      • one twin is under-perfused and appears
        • pale
        • anemic
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18
Q

identify the picture, note important features

A

twin to twin perfusions

  • vascular anastomoses can form between twins. if blood is shunted to one twin preferentially,
    • one twin is over-perfused & appears
      • plethoric
      • polycythemia
    • one twin is under-perfused and appears
      • pale
      • anemic
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19
Q

placenta previa?

  • definition
  • clinical presentation
  • variations
A
  • condition where placenta implants in the lower uterine segment or cervix
  • presentation: in 3rd trimester
    • +/- bleeding (worse in certain variations)
  • variations:
    • complete placenta previa - in which the placenta covers the internal cervical OS - is the most severe
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20
Q

placenta accreta

  • definition
  • clinical presentation
  • variations
A
  • definition: absence of the decidua (either partial or complete) such that the placenta attaches deeply to the uterine wall
  • presentation: severe post-partum hemorrhage that is potentially life threatening
  • variations
    • placenta increta = placenta attached to uterine muscles
    • placenta perrceta = placenta goes completely through uterine wall
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21
Q

spontaneous abortion

  • definition
  • diagnosis
A
  • defined as: loss of pregnancy prior to 20 weeks of gestation
  • diagnosis: passage of products of conception (chorionic villi) or fetal parts
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22
Q

ectopic pregnancy

  • most important pre-disposing risk factors
  • m/c site of implantation
  • clinical presentation
  • can progress to?
A
  • PID (pelvic inflammatory disease)
  • extrauterine fallopian tube (90% of cases) -i.e. “tubal pregnancy”
  • clinical presentation - typically follows rupture
    • amenorrhea
    • abdominal pain
    • vaginal bleeding
  • can progress to:
    • hematosalpinx: blood filled fallopian tube
    • tubal rupture vs spontaneous regression:
      • tubal rupture more common: can lead to hemorrhagic shock + signs of acute abdomen
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23
Q
A

ruptured fallopian tube

24
Q

what is the most common cause of hematosalpinx?

A

tubal ectopic pregnancy

25
Q

what are the late disorders of pregnancy?

A
  • placental infections
  • complete interruption of blood flow thru umbilical cord
  • retroplacental hemorrhage
  • disruption of fetal vessels
  • uteroplacental malperfusion
  • pre-eclampsia
  • placental previa
26
Q

infections of the placenta?

  • typically occur when in pregnancy?
  • are caused by?
  • can lead to?
A
  • during 3rd trimester (late pregnancy)
  • causes:
    • ascending infection thru birth canal (m/c)
      • almost always bacteria
    • hematogenous infection - less common
      • d/t TORCH group
27
Q

acute chorioaminiotis

  • definition
  • morphology
  • complications
A
  • placental infection that involves the chorio-amniotic membranes
  • morphology
    • gross:
      • placental membranes white, pale / green semi opaque
      • amniotic fluid: cloudy d/t neutrophils
    • microscopic
      • many neutrophils extending above chorionic membrane
  • complications
    • if d/t hematogenous infection - can result in acute villitis (spread to villi)
28
Q

identify picture, note important features

A

acute chorioamniotis

  • placental membranes white, pale / green semi opaque
  • amniotic fluid: cloudy d/t neutrophils
29
Q

idnentify the picture, note important features

A

acute chorioamniotis

many neutrophils extending above chorionic membrane

30
Q

identify picture, note important features

A

acute chorioamniotis

many neutrophils extending above chorionic membrane

31
Q

identify the picture, note important features

A

acute chorioamniotis

  • presence of acute villitis, in this case d/t hematogenous listeria infection
32
Q

pre-eclampsia

  • definition
  • pathogenesis (contrast to normal pregnancy)
A
  • HTN seen > 20 weeks of pregnancy
  • pathogenesis
    • in normal pregnancy:
      • endothelial-type trophoblasts invade maternal decidua & “remodel” decidual vessels
        • they convert maternal endothelium (small caliber resistance vessels) → fetal endothelial type trophoblastic cells, creating “hybrid vessel” have a larger capacity & can meet circulatory demands of late gestation
    • in pre-eclampsia
      • trophoblasts retain “epithelial” instead of endothelial” type and cannot convert decidual vessels into high capacity vessels, leading to
        • hypoxia → release of anti-angiogenic factors → hyperreactivity → vasoconstriction → hypertension
33
Q

pre-eclampsia - classic clinical presentation

A

seen after 20 weeks (m/c > 34)

  • HTN
  • proteinuria
  • edema
34
Q

what makes pre-eclampsia more likely to be severe?

A

presence of a hypercoagulable state (coagulation abnormalities)

35
Q

morphologies of pre-eclampsia

A
  • microscopic
    • abnormal decidual vessels with fibrinoid necrosis
      • +/- macrophages
    • premature maturation of placental villi
  • gross
    • infarcts: wedge shaped, pale
    • retroplacental hematomas
36
Q

identify the picture, note important features

A

pre-eclampsia microscopic

  • abnormal decidual vessels with fibroid necrosis (white open arrow) and adjacent decidual necrosis (black curved arrow)
    • complicated by a recent thrombosis (black open arrow)
37
Q

identify the picture, note the important features

A

pre-eclampsia microscopic

  • fibrinous necrosis in spiral arteries walls (black curved arrow)
  • accumulation of foamy macrophages (black open arrows)
38
Q

identify the picture, note important features

A

pre eclampsia - gross

  • placental infarct - off white, firm
39
Q

what are the major complications of pre-eclampsia? describe their presentations.

A
  • eclampsia
    • defined by central nervous system involvement:
      • headaches
      • visual disturbances
      • possible seizures → coma
  • HELLP syndrome (especially predisposed by a hyper-coagulable state)
    • H- hemolytic anemia
    • EL - elevated liver enzymes
    • LP - low platelets
    • low platelets
40
Q

hydratiform moles

  • definition / cause
  • subtypes
A
  • are a type of gestational trophoblastic disease (group of diseases characterized by proliferation of placenta tissue) involving a fertilization defect.
    • subtypes
      • complete mole: feralization of an egg that lost its chromosomes
      • incomplete mole: fertilization of egg by two sperms
41
Q

complete hydratiform mole

  • cause
  • karyotype
  • morphology
  • associated risks
A
  • cause: fertilization of an egg that has lost its female chromosomes
  • karyotype:
    • 46XX 90% of the time male X chromosome doubled (androgenesis), therefore genetical material entirely paternally derived
    • 46-XY the rest
  • morphology
    • “grape-like” structures consisting of edematous polyp
    • trophoblastic proliferation involving all or most villi.
      • villi are
        • are ENLARGED
        • have a scalloped shape
        • often have cistern: central cavitation
    • empty embryo (not fetal tissue identified)
  • associated risks:
    • persistent hydratiform mole
    • invasive mole
    • choriocarcinoma
42
Q

incomplete hydratiform mole

  • cause
  • karyotype
  • morphology
  • associated risks
A
  • cause: fertilization of an egg with two sperm
  • karotype: triploid (69-XXY) > tetraploid (92-XXXY)
  • morphology:
    • only SOME of villi are affected (focal trophoblastic hyperplasia). these villi are
      • enlarged
      • cisterns seen
      • can contain trophoblast psueodinclusions
    • fetal tissue identified
  • associated risks
    • increased risk of persistent mole
    • NO increased risk of choriocarcinoma
43
Q

identify the picture, note important features

A

complete hydratiform mole - gross

  • “grape-like” structures consisting of edematous polyp
  • all villi markedly swollen
44
Q

identify the picture, note important features

A

complete hydratiform mole

  • “grape-like” structures consisting of edematous polyp
  • all villi markedly swollen
45
Q

identify picture, note important features

A

compllete hydratiform mole

huge central cistern

46
Q

identify the picture, note important features

A

complete hydratiform mole

marked, circumferential trophoblast proliferation (i.e., every villi effected)

47
Q

identify the picture, note important features

A

complete hydratiform mole

  • large villi with scalloping
  • marked edema
48
Q

identify the picture, not important features

A

partial hydratiform mole

  • partial scalloping
  • isolated trophoblastic inclusion
49
Q

identify picture, note important features

A

partial hydratiform mole

  • trophoblast pseudoinclusions
50
Q

identify picture, note important features

A

partial hydratiform mole

  • trophoblastic proliferation of one villi surrounded by severe unaffected, smaller villi
  • flattened central cistern
51
Q

invasive mole

  • definition
  • clinical features
  • morphology
A
  • a mole that penetrates/perforates the myometrium
  • is ALWAYS associated with persistently elevated hCG
  • morphology
    • gross - hemorrhagic mass invading thickness of endometrium
    • microscopic - invasion of myometrium by villi covered by proliferating trophoblasts
52
Q

placental choriocarcinoma

  • etiology
  • clinical features
  • morphology
  • sequelae
A
  • comes from
    • complete hydratiform moles (50%)
    • previous abortions
    • normal pregnancies
  • clinical features
    • incidence is 1 /20,000-30,000
    • presentation
      • irregular vaginal spotting of a bloody, brown fluid
    • high propensity of metastasis
      • m/c site = lungs (50%). next =
        • vagina (30%)
        • bone, liver, bone, kidney
  • morphology
    • gross - soft, fleshy yellow-white tumor with large areas of necrosis/extensive hemorrhage
    • microscopic-
      • DOES NOT PRODUCE CHORIONIC VILLI. consists entirely of proliferating cyto and synctio trophoblasts
      • invading myometrium
53
Q

identify the picture, note important features

A

invasive mole - microscopic

  • villi covered in proliferating trophoblast are invading the myometrium
54
Q

identify the picture, note important features

A

invasive mole - gross

  • hemorrhagic mass has invaded half the thickness of the myometrium
55
Q

identify the picture, note important features

A

placnetal choriocarcinoma

  • extensive necrosis / hemorrhage extending into myometrium
56
Q

identify the picture, note important features

A

placental choriocarcinoma - microscopic

  • markedly enlarged trophoblastic nuclei (arrow) but no villi formation
57
Q

compare and contrast incomplete and complete moles in terms of

  • karyotype
  • effect on hCG
  • presence of fetal tissue
  • associated risks
A

complete

  • 46-XX (90%)
  • always lead to an increase in hCG
  • NO fetal tissue present
  • can lead to persistent mole, invasive mole, choriocarcinoma

incomplete

  • 46-XXY
  • doesnt always lead to increase in hGF
  • fetal tissue present
  • can lead to persistent mole

Pathology III (5 decks)

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