Vijesh Patel Gestational & Placental disorders

Epi 50% of all pregnancies are terminated 50% go unnoticies Risk Fetal factors trisomy 16, hydatidiform mole, NTD Maternal factors TORCH Mechanical factors fibroid, septate uterus Endocrine factors diabetes, progesterone, Rh incompatibility, habitual abortion (3 spontaneous
abortions = need Ch studies)

Pathogenesis / Antibodies Occurs before 20th week Occurs after 20th week

S/S

Abortion Spontaneous abortion Still birth

Placentation problems 1. Placenta previa

Most common cause of antepartum bleeding

2. Abruptio placenta

3. Placenta accreta

Implantation close to cervical os - PAINLESS bleeding @ 3rd trim. - Grade 1, 2, 3 based on position Premature separation of placenta forming a retroplacental clot - Cocaine + Smoking - HTN (Eclampsia/ Preeclampsia) - PAINFUL bleeding Placenta attaches to myometrium and is not removed - Decidual layer is defective - Ashermans syndrome (D&C has
caused exposure of myometrium)

Antepartum hemorrhage - Bleeding during pregnancy - Danger to fetus + mother

Rx C-section for grade 3 *Hematoma of 1/3 or more of placenta may result in fetal death

Postpartum hemorrhage - Bleeding after pregnancy - Only danger to mother

*Uterine rupture (15%)

- C-section, endometrial inflammation, loss of decidua Multiple gestation Dizygotic Monozygotic Fraternal twins (1 +2) Identical twins (1 + 2 + 3 + 4) 1. Dichorionic diamnionic 2. Dichorionic diamnionic (fused) 3. Monochorionic diamnionic 4. Monochorionic monoamnionic

Placental infection and inflammation Chorioamnioitis Inflammation of fetal membrane Villitis Infection of chorionic villi Funisitis Inflammation of umbilical cord

Toxemia of Pregnancy (Pregnancy induced HTN)

Common in 1st pregnancy or <35 Begins early w/ - Hydatidiform mole - Pre-existing kidney disease - HTN

Premature rupture of the placenta - Mostly ascending infection from vagina + cervix - TORCH + Group B streptocci (Strep. agalactidae) - Infected fluid neonatal pneumonia, sepsis, meningitis - Can result in spontaneous abortions & malformations Shallow placentation = ischemia - vasoC substances (thobmoxane, angiotensin, endothelin) which results in DIC Rx: Aspirin - risk of retroplacental hematomas - Fatal to mom + baby

Precalpsia Triad: HTN, proteinuria, edema Eclampsia Add: Seizures / fits Rx: Magnesium sulphate

*Complications of DIC: - Liver: periportal fibrosis (peripheral) - HELLP syndrome: haemolytic anemia, elevated liver enzymes, low platelets - Renal: Endotheliosis of cap + fibrin thrombi in glomeruli - Brain: microscopic foci of hemorrhage

Vijesh Patel
Epi Gestational trophoblastic disease Uterus is large for the date - no sounds are heard - no movements detected All 3 diseases have hCG - 1/500 = gestational disease - 1/200 = twin; 1/100 = singlet *Ass w/ - Theca lutein cysts - Spontaneous abortion - Hyperemesis - PIH - Thyrotoxicosis (bCG = mild stimulator of thyroid) Pathogenesis / Antibodies S/S *

Hydatidiform mole

1. Complete

Benign Mostly Asian countries - Diet: carb + protein + folate Cytogenetics 46 XX - all from sperm 69 XXY

Chorionic villi = cluster of grapes - Swollen + avascular Gross Grape like w/ clear vesicles

USG shows snowstorm th PAINLESS vaginal bleeding @ 4 m Micro Villous edma Trophoblast proliferation w/ atypia Few villous edema Trophoblast proliferation no atypia Cancer risk High risk of choriocarcinoma

2. Partial

Grape like w/ fetal parts - Not beyond 8-10 weeks Hydropic villi which penetrate the uterine wall - uterine rupture fatal - Embolize to distant organs Doesnt grow there Trophoblastic tissue only - NO villous tissue - Bizarre nucleus, elongated, pleomorphic - hemorrhage + necrosis Metastasis: - Lung (cannon ball lesions) - Vagina, brain & liver Tumor invading the myometrium - Intermediate trophoblasts - Mononuclear - Lot of eosinophillic cytoplasm

Low risk of choriocarcinoma

Invasive mole

Intermediate

Rx Hysterectomy

Choriocarcionma

Malignant Mostly Asian countries From complete hydatidiform mole

b-hCG

Rx Chemotherapy = 100% curative - Non-gestational choriocarcinoma are resistant to therapy Methotrexate Follow up check for hydatiform moles

Placental site trophoblastic tumor

Rare

HPL - Human placental lactogen