Some common pathologies of pregnancy

Question 1

What has occurred when progestogen has kept rising

Answer 1

• Egg has been fertilised by sperm
• Trophoblast on exterior of fertilised egg produces b-hCG (beta human gonadotropic hormone)
• b-hCG signals corpus luteum to continue producing progestogen
• Overall prevents endometrium from shedding

Question 2

b-hCG

Answer 2

• Produced by trophoblast cells lining the chorion
• Trophic hormone that targets the corpus luteum
• Stimulates corpus luteum to produce progestogen → prevents decide from shedding
• Provides basis for the pregnancy test → targets b-hCG

Question 3

Chorionic villi

Answer 3

• Finger-like projections of the chorion covered in trophoblast cells
• Moves into the decidua and forms basis of early placenta

Question 4

• Woman, 26 years old
• Missed period
• Positive pregnancy test
• Vaginal bleeding for 7 weeks after missing period

Answer 4

• Miscarriage
• No foetus present in ultrasound but membranes and decidua lining of the uterus present
• Remaining tissue sent to pathology
• No further complications, b-hCG returns to normal (zero

Question 5

Causes of miscarriages

Answer 5

• Unknown
• Chromosomal abnormality
• Infection
• Maternal issues (trauma, ill-health, hormonal irregularities)

Question 6

• Woman, 32 years old
• Missed period
• 8 weeks pregnancy → small amount of vaginal bleeding

Answer 6

• Ectopic pregnancy
• Raised b-hCG
• Ultrasound: thickened endometrial lining of cavity, expanded Fallopian tube on one side
• Consider methotrexate or operative Fallopian tube removal

Question 7

• Woman 23 years old
• Sudden severe abdominal pain and collapses
• Admitted to A & E
• Fast pulse, low BP → shock (susceptive hypovolemic)

Answer 7

• Treatment
  
  • Blood transfusion
  • Emergency laparotomy
• Pathology
  
  • Several litres of blood in abdominal
  • Blood flowing from Fallopian tube → clamped and removed
• Microscopy: Fragments fallopian tube with placenta and sac
• Diagnosis: ruptured ectopic pregnancy
• Follow-up: raised b-hCG after operation, returns to normal and well within 3 weeks

Question 8

Ectopic pregnancy

Answer 8

• Pregnancy in wrong abdominal site (fallopian tube, peritoneal cavity, uterine cavity)
• Lack of proper decidual layer
• Risk: small size of tubes
• Asymptomatic early → unknown that she is pregnant

Question 9

• 32 year old woman
• Positive pregnancy test
• 7 weeks pregnancy with minor bleeding
  
  • Ultrasound: placental tissue in uterine cavity, no fetus, normal fallopian times
• Raised b-hCG

Answer 9

• Diagnosis: miscarriage
• Removal of endometrial tissue
• Pathology: large chorionic villi macroscopically visible as vesicles (small grapes)
• Cause: molar pregnancy

Question 10

Molar pregnancy

Answer 10

• Non-viable pregnancy with an overgrowth of trophoblast cells and large chorionic villi
• A form of pre-cancer of trophoblast cells
• Persistent form leads to choriocarcinoma

Question 11

What causes molar pregnancy

Answer 11

• 2 sperm fertilising egg with no chromosomes
• Leads to imbalance in methylated (switched off genes)
• Too much of male methylated genes leads to placental overgrowth → massive trophoblast cell proliferation

Question 12

Treatment of molar pregnancy

Answer 12

• If b-hCG returns to normal → no further treatmetn
• If b-hCG stays high (persistent disease → methotrexate

Question 13

• 40 year old woman
• 10 weeks pregnancy
• Scan: nuchal thickening

Answer 13

• Amniocentesis: trisomy 21 (Down syndrome)
• Termination of pregnancy for abnormality (TOPFA) at 20 weeks
• Post mortem
  
  • Single palmar crease
  • Duodenal atresia
  • Epicanthic folds
  • Protuberant tongue

Question 14

Decision for a TOPFA for pregnancy pathologies

Answer 14

• Up to the parents
• Must weigh up quality of life with continuing pregnancy

Question 15

Poorly controlled diabetes

Answer 15

• 28 year old mother poorly controlled diabetes mellitus
• Pregnancy sign well until 36 weeks → baby stops kicking
• Scan: No foetal heart movement = Intrauterine death (IUD)
• Trial of labour attempted baby too big → Caesarean section
• Post-mortem: large baby with broad shoulders → diabetic cherub

Question 16

What is the effect of glucose on foetus

Answer 16

• Mother has diabetes
• Glucose crosses placental barrier raising glucose levels in foetus
• Insulin increases in foetus to counteract raised blood glucose
• Baby cannot reduce mothers glucose long-term
• High insulin + glucose → massive growth
• Intrauterine death

Question 17

Diabetes in the different stages of pregnancy

Answer 17

• First trimester → malformation
• Third trimester → intrauterine death (sudden metabolic and hypoxic issues)
• Labour → high baby obstructing labour
• Neonatal → hypoglycaemia

Question 18

Management of diabetes in pregnancy

Answer 18

• Good glucose control before conception (prevents malformations) and all throughout pregnancy (prevent metabolic disturbances)

Question 19

Acute chorioamnionitis

Answer 19

• 35 year kid
• Well throughout pregnancy
• 36 weeks spontaneous labour
• Labour progresses well but with fever
• Heart beat lost minutes before birth
• Resuscitation unsuccessful → fresh stillbirth
• Pathology
  
  • Membranes contain neutrophils
  • Acute inflammation of the cord and placenta
  • Neutrophils produce cytokine storm activating brain cells which become damaged by normal hypoxia of labour
• Caused by ascending infection (perineal or perianal) into the amniotic cavity
• Presentation
  
  • Mother ill → raised neutrophils in blood
  • Intrauterine death
  • Cerebral palsy later in life

Question 20

Mother who is an opiate abuser

Answer 20

• 24 year old
• Intravenous heroin adduct
• Also on methadone, cocaine, temazepam
• Becomes pregnant
• Successful labour and delivery
• Baby admitted to neonatal unit and treated for heroin withdrawal

Question 21

Effect of opiates on pregnancy

Answer 21

• Pregnancy affected if mother is eating well
• Immediate withdrawal from heroin when baby is born
• Later withdrawal from methadone

Question 22

Twisted cord

Answer 22

• 32 year old woman
• Normal pregnancy to term
• Decreased movement of baby at 40 weeks
• Scan: no heart movement → intrauterine death
• Pathology: morphologically normal, over twisted umbilical flow → hypoxia

Question 23

Placental abruption

Answer 23

• 33 year old woman
• Hypertension during pregnancy
• Vaginal bleed at 35 weeks
• Ultrasound
  
  • Separation of part of placenta from uterus with haematoma behind
  • Enlarging haematoma during ultrasound
• Treatment: emergency Caesarean section

Question 24

What is a placental abruption

Answer 24

• Separation of the placenta from the uterine wall
• Results in foetal hypoxia
• Often leads to antepartum haemorrhage in mother
  *