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
what are the late disorders of pregnancy?
* placental infections * complete interruption of blood flow thru umbilical cord * retroplacental hemorrhage * disruption of fetal vessels * uteroplacental malperfusion * pre-eclampsia * placental previa
26
infections of the placenta? * typically occur when in pregnancy? * are caused by? * can lead to?
* 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
acute chorioaminiotis * definition * morphology * complications
* 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
identify picture, note important features
acute chorioamniotis * placental membranes **white, pale / green semi opaque** * amniotic fluid: **cloudy** d/t neutrophils
29
idnentify the picture, note important features
acute chorioamniotis **many neutrophils** extending above chorionic membrane
30
identify picture, note important features
acute chorioamniotis **many neutrophils** extending above chorionic membrane
31
identify the picture, note important features
acute chorioamniotis * presence of **acute villitis,** in this case d/t hematogenous l*isteria* infection
32
pre-eclampsia * definition * pathogenesis (contrast to normal pregnancy)
* 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
pre-eclampsia - classic clinical presentation
seen after 20 weeks (m/c \> 34) * HTN * proteinuria * edema
34
what makes pre-eclampsia more likely to be severe?
presence of a **hypercoagulable state** (coagulation abnormalities)
35
morphologies of pre-eclampsia
* microscopic * **abnormal decidual vessels with** **fibrinoid necrosis** * **+/- macrophages** * premature maturation of placental villi * gross * **infarcts**: wedge shaped, pale * **retroplacental hematomas**
36
identify the picture, note important features
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
identify the picture, note the important features
pre-eclampsia microscopic * fibrinous necrosis in spiral arteries walls (black curved arrow) * accumulation of foamy macrophages (black open arrows)
38
identify the picture, note important features
pre eclampsia - gross * placental infarct - off white, firm
39
what are the major complications of pre-eclampsia? describe their presentations.
* 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
hydratiform moles * definition / cause * subtypes
* 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
complete hydratiform mole * cause * karyotype * morphology * associated risks
* 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
incomplete hydratiform mole * cause * karyotype * morphology * associated risks
* 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
identify the picture, note important features
complete hydratiform mole - gross * **“grape-like” structures** consisting of edematous polyp * **all villi markedly swollen**
44
identify the picture, note important features
complete hydratiform mole * **“grape-like” structures** consisting of edematous polyp * **all villi markedly swollen**
45
identify picture, note important features
compllete hydratiform mole huge central cistern
46
identify the picture, note important features
complete hydratiform mole ## Footnote marked, circumferential trophoblast proliferation (i.e., every villi effected)
47
identify the picture, note important features
complete hydratiform mole * large villi with scalloping * marked edema
48
identify the picture, not important features
partial hydratiform mole * partial scalloping * isolated trophoblastic inclusion
49
identify picture, note important features
partial hydratiform mole * trophoblast pseudoinclusions
50
identify picture, note important features
partial hydratiform mole * trophoblastic proliferation of one villi surrounded by severe unaffected, smaller villi * flattened central cistern
51
invasive mole * definition * clinical features * morphology
* 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
placental choriocarcinoma * etiology * clinical features * morphology * sequelae
* 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 tumo**r with _large areas of necrosis/extensive hemorrhage_ * microscopic- * **DOES NOT PRODUCE CHORIONIC VILLI**. consists entirely of proliferating cyto and synctio trophoblasts * invading myometrium
53
identify the picture, note important features
invasive mole - microscopic * villi covered in proliferating trophoblast **are invading the myometrium**
54
identify the picture, note important features
invasive mole - gross * **hemorrhagic mass** has invaded half the **thickness of the myometrium**
55
identify the picture, note important features
placnetal choriocarcinoma * extensive necrosis / hemorrhage extending into myometrium
56
identify the picture, note important features
placental choriocarcinoma - microscopic * markedly enlarged trophoblastic nuclei (arrow) but no villi formation
57
compare and contrast incomplete and complete moles in terms of * karyotype * effect on hCG * presence of fetal tissue * associated risks
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