9 Placenta 1

PLACENTAL ABNORMALITIES:
PLACENTA ACCRETA:
- Partial/complete absence of Decidua: Placenta binds to myometrium
- Post Partum bleeding: Do to failure of placental separation
- Associated with Placenta Previa
- Symptoms: Severe bleeding following the removal of the placenta because the placental villi invaded
the myometrium
PLACENTA PREVIA:
- Placenta develops in lower uterine segment  delivery of placenta First
- M.C symptoms is Painless vaginal bleeding
ABRUPTIO PLACENTAE:
- Is the separation of placenta from wall before the delivery
- Symptoms:
o Retro-placental clot’s, Uterine Rigidity, Abdominal pain & shock
o Associated with D.I.C or risk of amniotic fluid embolism
- Risk factors: Hypertension, Preeclampsia, Smoking, Cocaine
TOXEMIA OF PREGNANCY:
PREECLAMPSIA: (usually after 32nd week – Earlier if Hydatiform mole present)
- Findings: Diastolic HTN, Proteinuria, Edema,  Liver enzymes,  Platelets
- Pathogenesis:
o Genetic predisposition  Inadequate trophoblastic invasion of the uterus
 (Abnormality of placentation  Placental Ischemia)
o Decreased utero-Placental perfusion induces:
 Stimulation of vasoconstrictor substances (Thromboxane, Angiotensin, endothelin)
 Inhibition of vasodilators (Prostaglandin I & E)
- Risk factors: Primigravida, > 35 yrs. old
- Morphology:
o Placental infarcts (normal, but here are Larger and more numerous)
o Increased frequency of retroplacental hematoma’s
o Increased villous ischemia  Prominent syncytial knots, thickening trophoblastic basement
membrane
o Fibrinoid necrosis & intramural lipid deposition in uterine vessel walls
ECLAMPSIA: Preeclampsia + convulsions (usually in later pregnancy)
GESTATIONAL TROPHOBLASTIC DISEASES:
CHORIOCARCINOMA:
- Is an epithelial malignancy of trophoblastic cells (Responsive to chemo)
- Risk factors: (preceded by several conditions):
o 50% arise in Hydatiform moles
o 25% in previous abortions
o 22% in normal pregnancies
- Gross: Soft, fleshy, yellow/white, Area’s of hemorrhage/necrosis/degeneration
- Micro:
o No chorionic villi
o Abnormal proliferation of cytotrophoblasts & syncytiotrophoblasts
- Spread: Invasion to Myometrium, Lung, Vagina, brain, Liver, kidney
- Clinical features:
o NO bulky mass, Usually presents as a metastasis (Lung)
o Irregular spotting of brown, foul smelling fluid
o hCG are elevated (even more than a Mole)
 hCG & HPL are secreted by the Trophoblasts
 9 Placenta 2

HYDATIFORM MOLE:
- Is a cystic swelling of chorionic villi w/variable proliferation of trophoblasts
- Clinical findings:
o Uterus is mostly larger than expected for that period of pregnancy
o Abnormal bleeding in early pregnancy
o Passage of small grape like vesicles
- Diagnosis: Ultrasound (Diagnostic) + hCG levels are high
o Ultrasound shows “Snow storm appearance”
- Treatment: Curettage (avoid left over tissue  choriocarcinoma)
- 2 types:
Complete Mole Partial mole
Karyotype 46 XX or XY (Only paternal) Triploid (maternal & paternal)
Fetal Parts None Present
Villous Edema All villi affected Some villi
Trophoblasts Diffuse proliferation Focal proliferation
Atypia Often Absent
Serum hCG Elevated greatly Less so
Tissue hCG Elevated Less so
Behavior: 2%  Choriocarcinoma Rare sequela
- Invasive Moles:
o Penetrates & may even perforate the uterine wall (local destruction)
 Invasion of myometrium by hydropic chorionic villi
 Proliferation of cytotrophoblasts & syncytiotrophoblasts
o Associated with Persistent  in hCG & luteinization of ovaries

ECTOPIC PREGNANCY:
- Ampulla of the fallopian tube is the M.C place
- PID (M.C) or Endometriosis patients are at greatest risk
- Labs: High hCG or Vaginal ultrasound (absence of amniotic sac in the uterus)
- Clinical features:
o Acute lower abdomen pain 6 weeks from last period
o Triad: Vaginal Bleeding, Pelvic Pain, Adnexal mass
o Surgical emergency – M.C cause of death in early pregnancy