Gestational Pathology Study Guide

Gestational pathology is pathology of the placenta or embryo.

Gestational pathology includes:

Ectopic pregnancy
Spontaneous abortion
Placenta previa
Placental abruption
Placenta accreta
Preeclampsia
Eclampsia
Hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome
Sudden infant death syndrome (SIDS)
Hydatidiform mole
Choriocarcinoma

Ectopic Pregnancy

Ectopic pregnancy happens when fertilized ovaries are being implanted anywhere other than the uterine wall.

Ectopic pregnancy most frequently occurs in the fallopian tube which transmits eggs from the ovaries to the uterus is the site of an ectopic pregnancy.

Key risk factors for ectopic pregnancy include:

Scarring the secondary to pelvic inflammatory disease
Endometriosis

A few weeks after a missed period, women who have an ectopic pregnancy may experience irregular bleeding and lower abdominal pain or pelvic pain.

Ectopic pregnancy is considered a surgical emergency.

Major complications of ectopic pregnancy include:

Bleeding into the fallopian tube (hematosalpinx)
Rupture

Ectopic Pregnancy. Laparoscopic view, looking from superiorly to inferiorly in the peritoneal cavity which has been pumped up with carbon dioxide gas to visualize the uterus (marked by blue arrows). On the left Fallopian tube there is an ectopic pregnancy and hematosalpinx (marked by red arrows). The right tube is normal. Mikael Häggström. Not altered. CC BY-SA 3.0
(a) Laparoscopic view of the left Fallopian tube, containing the ectopic pregnancy (arrow). (b) Laparoscopic view of the right Fallopian tube, presenting a congestive dilatation mimicking an ectopic pregnancy (arrow). (c) Histological section of the left Fallopian tube which is distended and contains many chorionic villi (upper left part of the image), confirming extrauterine tubal pregnancy (hematoxylin and eosin stain; original magnification 25x). (d) Histological section of the right Fallopian tube which is distended by an oedematous mucosa with congestive blood vessels, with no chorionic villi (hematoxylin and eosin stain; original magnification 25x). Laparoscopic excision of coexisting left tubal and right pseudotubal pregnancy after conservative management of previous ectopic pregnancy with methotrexate: an unusual clinical entity. Xiromeritis P, Margioula-Siarkou C, Miliaras D, Kalogiannidis I - Case reports in surgery (2015). Not Altered. CC.

Spontaneous Abortion

Spontaneous abortion is fetal miscarriage that occurs before 20 weeks of pregnancy.

Spontaneous abortion typically occurs in the first trimester.

Spontaneous abortion is common and happens up to 1/4 of recognizable pregnancies.

Symptoms of spontaneous abortion include:

Vaginal bleeding
Cramp-like pain
Passage of fetal tissues

Causes of spontaneous abortion include:

Chromosomal anomalies
Hypercoagulable states
Antiphospholipid syndrome
Teratogens

Effects of teratogens depend on the timeframe of exposure:

First two weeks of gestation – spontaneous abortion
Weeks 3-8 – risk of organ malformation
Months 3-9 – risk of organ hypoplasia

Spontaneous Abortion. Transvaginal ultrasonography after an episode of heavy bleeding in an intrauterine pregnancy that had been confirmed by previous ultrasonography. There is some widening between the uterine walls, but no sign of any gestational sac, thus, in this case, being diagnostic of a complete miscarriage. Mikael Häggström. Not altered. CC0
Intrauterine fetal demise with traumatic decapitation after a spontaneous incomplete abortion. A foreign body in the cervix after spontaneous abortion: a rare case of a traumatic fetal decapitation. Holland D, Sheele J - Case reports in emergency medicine (2014). Not Altered. CC.

Placenta Previa

Placenta previa is a pregnancy problem that occurs when the placenta totally or partially blocks the uterine entrance (cervix).

Placenta previa usually presents as third-trimester bleeding.

Placenta previa often requires cesarean section, which is a procedure of delivering a baby through surgical incisions made in the abdomen and uterus.

Placental Abruption

Placental abruption is when the placenta is separated from the decidua before the fetus is delivered.

Placental abruption is a common cause of stillbirth.

The latter trimester of pregnancy, particularly the final few weeks before delivery, is when placental abruption is most prone to happen.

Symptoms of placenta abruption include:

Uterine soreness
Abdominal pain
Vaginal bleeding

Placental Abruption. Gross pathology of a uterus which has been opened to show a placental abruption, with a hematoma separating the placenta from the uterus. Mikael Häggström, M.D. Not altered. CC0

Placenta Accreta

Placenta accreta is a serious pregnancy condition wherein there is an improper placenta-myometrium implantation with minimal to no intervening decidua.

Placenta accreta is often recognized during labor with difficult delivery of the placenta and postpartum bleeding.

C-section and/or hysterectomy may be needed to treat placenta accreta.

Placenta Accreta. A diagram illustrating the different types of placenta accreta. TheNewMessiah at English Wikipedia - Transferred from en.wikipedia to Commons. not altered Public Domain

Preeclampsia

Preeclampsia is edema, proteinuria, and hypertension are conditions brought on by pregnancy often appear in the third trimester and affect about 5% of pregnancies.

In preeclampsia the hypertension may be severe, leading to headaches and visual abnormalities.

Preeclampsia is due to an abnormality of the maternal-fetal vascular interface in the placenta.

Preeclampsia resolves with delivery.

Preeclampsia. High magnification micrograph of hypertrophic decidual vasculopathy, as seen in pregnancy-induced hypertension. H&E stain. Related images Intermed. mag. Low mag. Nephron. Not altered. CC BY-SA 3.0
Abnormal placentation in preeclampsia. In normal pregnancies, extravillous cytotrophoblasts of fetal origin invade the uterine spiral arteries of the decidua and myometrium. These invasive cytotrophoblasts replace the endothelial layer of the maternal spiral arteries, transforming them from small, high-resistance vessels into large-caliber vessels (A). However, in preeclampsia, this transformation is incomplete. Cytotrophoblast invasion of the spiral arteries is limited to the superficial decidua and does not reach the myometrium (B) (From Lam et al. [5], with permission from Wolters Kluwer Health). Pathogenesis and promising non-invasive markers for preeclampsia. Kim YJ - Obstetrics & gynecology science (2013). Not Altered. CC.
TMA samples preparation and immunohistochemical staining of LXRα and endoglin expression in decidual cells and trophoblast cells from placentas of preeclampsia. Expression of LXRα in preeclampsia decidual tissue (a membrane, b cytoplasm). (B) Expression of LXRα in preeclampsia villous trophoblastic tissue (a membrane, b cytoplasm). (C) Expression of LXRα in normal decidual tissue. (D) Expression of LXRα in normal villous trophoblastic tissue. (E) Expression of endoglin in preeclampsia decidual tissue. (F) Expression of endoglin in preeclampsia villous trophoblastic tissue. (G) Expression of endoglin in normal decidual tissue. (H) Expression of endoglin in normal villous trophoblastic tissue. Original magnification X400. Relationship of Liver X Receptors α and Endoglin Levels in Serum and Placenta with Preeclampsia: PLoS ONE. Not altered. CC.

Eclampsia

Eclampsia is preeclampsia with seizures.

Histological changes in placenta in cases of preeclampsia and eclampsia. Study of structural changes in placenta in pregnancy-induced hypertension. Salmani D, Purushothaman S, Somashekara SC, Gnanagurudasan E, Sumangaladevi K, Harikishan R, Venkateshwarareddy M - Journal of natural science, biology, and medicine (2014). Not Altered. CC.
Posterior reversible encephalopathy syndrome (PRES) in a woman presenting with eclampsia and HELLP syndrome at 28 weeks of gestation. (A) CT scan at the onset eclampsia showing multiple low signal density areas including the bilateral putamen, external capsule, thalami, and left occipital lobe. The pons was also involved. (B) Fluid-attenuated inversion recovery (FLAIR) images showing multiple hyperintense regions/spots, which completely disappeared in the follow-up images taken 1 month after treatment. CT and MR imaging findings of systemic complications occurring during pregnancy and puerperal period, adversely affected by natural changes: Himoto Y, Kido A, Moribata Y, Yamaoka T, Okumura R, Togashi K - European journal of radiology open (2015). Not altered. CC.

HELLP Syndrome

Hemolysis, elevated liver enzymes and low platelets syndrome (HELLP syndrome) is preeclampsia in combination with liver-related thrombotic microangiopathy.

Both eclampsia and HELLP syndrome usually warrant immediate delivery.

Sudden Infant Death Syndrome (SIDS)

Sudden infant death syndrome (SIDS) occurs when infants ages one month old to one-year-old who suddenly died without apparent cause.

Sudden infant death syndrome is usually associated with issues with a baby’s inability to wake up and expire during sleep.

Risk factors for sudden infant death syndrome include:

Exposure to cigarette smoke
Prematurity
Sleeping on stomach

Sudden Infant Death Syndrome.SIDS rate from 1988 to 2006 This graph was obtained from here, the National Institute of Child Health and Human Development website. It is a product of a United States agency, the Department of Health and Human services, and is thus in the public domain and falls under no copyright. SIDS rates and back sleeping (1988-2006). Not altered Public Domain
The mechanisms underlying sudden unexpected death in epilepsy (SUDEP) remain unclear. Wandschneider et al. reveal increased amygdalo-hippocampal volume in cases of SUDEP and in individuals at high risk, compared to individuals at low risk and people without epilepsy. Findings are consistent with histopathological reports in sudden infant death syndrome. Structural imaging biomarkers of sudden unexpected death in epilepsy. Wandschneider B, Koepp M, Scott C, Micallef C, Balestrini S, Sisodiya SM, Thom M, Harper RM, Sander JW, Vos SB, Duncan JS, Lhatoo S, Diehl B - Brain : a journal of neurology (2015). Not Altered. CC.
Sudden Infant Death Syndrome (SIDS). Left ventricular hypertrabeculation in a three month old infant, presenting as sudden infant death syndrome. It is postulated that the apical area of hypertrabeculation acted as the source of a fatal arrhythmia. Sudden infant death syndrome and left ventricular hypertrabeculation-hidden arrhythmogenic entity? Ker J, Toit-Prinsloo LD, van Heerden WF, Saayman G - Clinical Medicine Insights. Cardiology (2010). Not Altered. CC.

Hydatidiform Mole

A hydatidiform mole is the condition that is marked by enlarged, swollen, and edematous villi and trophoblast growth.

A hydatidiform mole is known as molar pregnancy.

A hydatidiform mole causes the uterus to expand as though a normal pregnancy is present, but it is significantly larger and higher than predicted for the gestational age.

Hydatidiform moles are detected during prenatal care with routine ultrasonography in the early first trimester, which show absence of fetal heart sounds and the ultrasound classically shows a ‘snowstorm’ appearance.

A hydatidiform mole may be recognized on physical exam as a grape-like lumps passing through the vaginal canal.

Hydatidiform moles are classified as:

Complete hydatidiform mole (Diploid, 45 XX)
Partial hydatidiform mole (Triploid, 69 XXY)

Treatment of hydatid moles includes dilatation and curettage (D&C).

To guarantee adequate mole removal and to check for the emergence of choriocarcinoma, follow-up monitoring is crucial.

A hydatidiform mole, a normal pregnancy, or a spontaneous germ cell tumor can all result in choriocarcinoma as a gestational complication.

Hydatidiform mole. Histopathogic image of hydatidiform mole (complete type). H & E stain.KGH (talk | contribs Not altered. CC BY-SA 3.0

Choriocarcinoma

Choriocarcinoma may also arise as a spontaneous germ cell tumor.

Choriocarcinoma is treated with chemotherapy.

Chemotherapy is more effective in treating choriocarcinomas that develop along the gestational pathway opposed to choriocarcinomas that develop via the germ cell pathway.

Hematoxylin and eosin pathologic stain of epidural tumor. (a) Low-power view showing diffuse hemorrhages common in choriocarcinoma. (b) High-power view highlighting syncytiotrophoblasts and large, pleomorphic malignant single cells.Metastatic choriocarcinoma to the lumbar spine: Case report and review of literature. Skoch J, Kobylanski K, Rice JM, Baaj AA - Surgical neurology international (2014). Not Altered. CC
Endometrial biopsy showing choriocarcinoma with decidual reaction. Choriocarcinoma in a 73-year-old woman: a case report and review of the literature. Desai NR, Gupta S, Said R, Desai P, Dai Q - Journal of medical case reports (2010). Not Altered. CC.
Choriocarcinoma. Very high magnification micrograph of choriocarcinoma. H&E stain. Choriocarcinomas consist of two cell populations: Cytotrophoblasts. Pale/clear cytoplasm. Syncytiotrophoblasts. Hyperchromatic cytoplasm. Typically multinucleated. Traditionally, the syncytiotrophoblasts are said to produce the beta-hCG;[1]however, it has been determined that cytotrophoblast also produce some.[2] The syncytiotrophoblasts are often arranged around the outside of cytotrophoblast cell clusters, reminicent of the arrangement in the placenta. On placental villi, the syncytiotrophoblasts are superficial to and, early in pregnancy, cover the cytotrophoblast. Choriocarcinoma is classified as a germ cell tumour. It can arise in the testis or ovary and from a hydatidiform mole. It may be part of a mixed germ cell tumour. Related images Intermed. mag. High mag. Very high mag. High mag. Very high mag. References (2010). "Biological functions of hCG and hCG-related molecules.". Reprod Biol Endocrinol 8: 102. DOI:10.1186/1477-7827-8-102. (Aug 2002). "Trophoblast origin of hCG isoforms: cytotrophoblasts are the primary source of choriocarcinoma-like hCG.". Mol Cell Endocrinol 194 (1-2): 147-55. Nephron. not altered. CC BY-SA 3.0
Choriocarcinoma. Very high magnification micrograph of choriocarcinoma. H&E stain. Choriocarcinomas consist of two cell populations: Cytotrophoblasts. Pale/clear cytoplasm. Syncytiotrophoblasts. Hyperchromatic cytoplasm. Typically multinucleated. Traditionally, the syncytiotrophoblasts are said to produce the beta-hCG;[1]however, it has been determined that cytotrophoblast also produce some.[2] The syncytiotrophoblasts are often arranged around the outside of cytotrophoblast cell clusters, reminicent of the arrangement in the placenta. On placental villi, the syncytiotrophoblasts are superficial to and, early in pregnancy, cover the cytotrophoblast. Choriocarcinoma is classified as a germ cell tumour. It can arise in the testis or ovary and from a hydatidiform mole. It may be part of a mixed germ cell tumour. Related images Intermed. mag. High mag. Very high mag. High mag. Very high mag. References (2010). "Biological functions of hCG and hCG-related molecules.". Reprod Biol Endocrinol 8: 102. DOI:10.1186/1477-7827-8-102. (Aug 2002). "Trophoblast origin of hCG isoforms: cytotrophoblasts are the primary source of choriocarcinoma-like hCG.". Mol Cell Endocrinol 194 (1-2): 147-55. Nephron. Not altered. CC BY-SA 3.0
(A) Magnetic resonance imaging showing the metastatic choriocarcinoma involving the rectosigmoid colon. (B) Sigmoidoscopy display a lobulating mass which was confirmed as choriocarcinoma. (C) Positron emission tomography scan showing increased fludeoxyglucose (FDG) uptake in the rectosigmoid colon which is consistent with malignant tissue. Choriocarcinoma with syncytiotrophoblastic and cytotrophoblastic elements which metastasized to the colon. (D) There is extensive inflammatory response with no chorionic villi. The left side is the mucosal aspect, and the right side is the serosal aspect (H&E, ×200). Chemo-resistant choriocarcinoma metastatic to colon cured by low-anterior resection. Ryu JH, Choi CH, Kim TJ, Lee JW, Kim BG, Bae DS - Journal of gynecologic oncology (2011). Not Altered. CC.