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8/6/2019 JZB - Diseases of Pregnancy 2011
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Diseases of Pregnancy
Jill Zyrek-Betts, MD
Department of PathologyApril 21, 2011
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Objectives
Review disorders of early and late pregnancy Spontaneous abortion
Ectopic pregnancy
Twin placentas
Abnormal placental implantation Placental infections
Preeclampsia and eclampsia
List important clinical and histologic features of
trophoblastic neoplasia
Hydatidiform mole
Choriocarcinoma
Placental-site trophoblastic tumor
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Spontaneous Abortion
(Miscarriage) Pregnancy loss before 20 weeks ofgestation
10-15% of pregnancies
Fetal causes: chromosomal anomalies Found in approximately 50% of cases
Maternal causes: endocrine disorders,
uterine defects (leiomyomas), systemicdisorders (vasculature), infections,trauma
Unknown causes
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Ectopic Pregnancy
Implantation of the fetus in any site other thanthe uterus 90% within fallopian tube
Ovary, abdominal cavity and intrauterine portion of
the fallopian tube (cornu)
1 out of 150 pregnancies 35-50% of patients have history of PID
Most common cause of hematosalpinx
Severe abdominal pain, usually 6 weeks afterlast normal menstrual period, when rupturedtube leads to pelvic hemorrhage Medical emergency
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Twin Placentas
Monochorionic twinsare always monozygotic The time of splitting
determines whether oneor two amnions arepresent
Twin-twin transfusionsyndrome possible
complication Dichorionic twins maybe monozygotic ordizygotic
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Abnormalities of Placental
Implantation Placenta previa
Implantation in LUS or cervix
3rd trimesterbleed
When covering the internal os, requires cesarean
section to prevent placental rupture and maternal
hemorrhage
Placenta accreta
Absent decidua with adherence of placenta to
myometrium failure of placental separation at
birth postpartum hemorrhage
Associated with placenta previa and previous
cesarean sections
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Placental Infections
Ascending
More common
Usually bacterial
Hematogenous
(transplacental)
TORCH
Chorioamnionitis Funisitis
Placentitis or villitis
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Preeclampsia
Systemic syndrome with widespread maternalendothelial dysfunction Hypertension, edema and proteinuria
Hypercoaguability, ARF, pulmonary edema
3-5% of pregnancies, during 3rd trimester
Typically starts at 34 weeks gestation Earlier with hydatidiform mole or preexisting kidney disease,
hypertension or coagulopathies
Eclampsia More severe form with convulsions, DIC and organ damage
HELLP syndrome 10% of women with severe preeclampsia
Hemolysis, Elevated Liver enzymes, Low Platelets
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Pathogenesis of Preeclampsia
Exact mechanism unknown, but symptoms disappearafter delivery of placenta Management depends on gestational age and severity of
disease
Diffuse endothelial dysfunction, vasoconstriction andincreased vascular permeability
Abnormal placental vasculature Decidual spiral arteries are not converted to large capacity
vessels poor placental blood flow placental ischemia
Endothelial dysfunction Placental ischemia release of vasoconstrictors and factors
that decrease angiogenesis earlier than normal
Coagulation abnormalities Decreased production of anti-thrombotic factors & increased
release of coagulation factors hypercoaguable state
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Uterine Spiral Arteries
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Preeclampsia
Placenta
Ischemic infarctions
Hematomas
Fibrinoid necrosis and lipid
deposits in vessels Acute atherosis
Liver, brain, heart,
anterior pituitary
Hemorrhages
Fibrin thrombi in vessels
Kidney
Fibrin depositionAcute atherosis of uterine vessels
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Hydatidiform Mole
Cystic swelling of the chorionicvilli with trophoblasticproliferation
Grossly appears as clusters ofgrapes
1/1,000 pregnancies Teens or 40-50 yrs
Earlier diagnosis than in past
Vaginal bleeding, enlargeduterus and high HCG
Associated with increased riskof invasive mole orchoriocarcinoma
10% of moles develop intopersistent or invasive moles
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Complete Mole
Fertilization of egg
without chromosomes
All genetic material is from
sperm
Most or all villi enlarged
and edematous
Lack of vessels
Diffuse trophoblast
hyperplasia
No fetal parts
Increased risk of invasive
mole or choriocarcinoma
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Hydatidiform Mole
Partial Mole
Complete Mole
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Invasive Mole
Invasion of myometriumby hydropic chorionic villi May perforate uterus
May invade surroundingtissues
May embolize to lungs andbrain
No growth; eventuallyregress
Presents as vaginal bleedand uterine enlargementwith persistently elevatedHCG
Treated withchemotherapy
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Choriocarcinoma
Malignant tumor of trophoblastic cells followingnormal or abnormal pregnancy 1/20,000 pregnancies
50% from moles, 25% from abortions, 22% from
normal pregnancies, 3% ectopic pregnancies Irregular vaginal discharge with high HCG
Rapidly invasive with widespread metastases tolungs, vagina, brain, liver and kidneys
Proliferation of malignant syncytiotrophoblastsand cytotrophoblasts without chorionic villi
Treated with chemotherapy
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Choriocarcinoma
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Placental-Site Trophoblastic Tumor
Malignant transformation of intermediatetrophoblasts that normally populate nonvilloustissues Implantation site, placental parenchyma, chorionic
plate, placental membranes Uterine mass with increased HCG and abnormalbleed or amenorrhea
Follows normal pregnancy (50%), spontaneousabortion (15%) or molar pregnancy (20%)
Tumors < 2yr post pregnancy or localized havegood prognosis
Tumors arising > 4yr post pregnancy oradvanced stage have poor prognosis
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PSTT
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