jzb - diseases of pregnancy 2011

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

jzb - diseases of pregnancy 2011

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