Pathology Of Placenta

Front 1

What is a temporary organ connecting fetus and mother providing the equivalent of respiratory (and renal) services?

Back 1

Placenta

Front 2

What is a membranous sac surrounding the fetus containing serous fluid essential for

Back 2

Amnion

Front 3

What is a plate-shaped tissue under part of amniotic sac containing fetal blood vessels that branch into villi projecting into space filled with maternal blood?

Back 3

Chorion

Front 4

What is an outer layer of blastocyst (from fertilized ovum) that implants in uterus and forms placenta?

Back 4

Trophoblast

Front 5

What is the outer layer of placenta that normally peels off myometrium?

Back 5

Decidua

Front 6

What is syncytium of cells forming outer covering of chorionic villi, which thin out their cytoplasm and let their clumped nuclei hang off villi in “syncytial knots” to minimize diffusion barrier?

Back 6

Syncytiotrophoblast

Front 7

Draw this out.

Back 7

Front 8

What is this?

Back 8

Amniotic sac

Front 9

What is this? What is the fetal side of the placenta? What is the maternal side?

Back 9

Top = normal fetal (amniotic) side of placenta

Bottom = maternal side of placenta

Front 10

What is the trimester of each?

What are the chorionic villi covered by during the first trimester?

What are some blood vessel, interstitium, trophoblast changes to the villi during the third trimester?

Back 10

Front 11

What is shown? Around what weeks?

Back 11

Front 12

What is implantation of a pregnancy anywhere besides normal intrauterine location?

How often does this occur? Where do 90% occur?

What is the most common pathogenesis (up to 50%)? What is another cause?

Back 12

Front 13

What is the most common presentation of ectopic pregnancy? (pain where, why?, blood, how long, can lead to what two serious things?)

How do you diagnose? (four things)

What is the treatment? Is the prognosis good or bad?

Back 13

Front 14

What is shown here? What are the two arrows pointing at?

Back 14

Front 15

What is the definition of spontaneous abortion?

Occurs in what percent of clinically unrecognized pregnancies? Sensitive gonadotropin assays show that what percent of more pregnancies abort spontaneously? Most in what trimester?

How much does the rate increase between 20 year olds and 4o year olds?

Back 15

Front 16

What is the most common cause of pregnancy loss in each?

First trimester? 1/2 with what abnormalities?

Second trimester? What disease?

Third trimester?

Back 16

Front 17

What are the common causes of recurrent spontaneous abortion? What are recurrent stillbirths associated with (what states)?

Back 17

Front 18

What is implantation in the LOWER UTERUS or CERVIS, sometimes covering internal cervical os?

What does it often result in?

How do you diagnose it? What is the treatment?

Back 18

Front 19

What is defective decidua, with adherence of villous tissue to myometrium?

Back 19

Placenta accreta

Front 20

What is defective decidua, with penetration of villous tissue into myometrium?

Back 20

Placenta increta

Front 21

What is defective decidua, with penetration of villous tissue through entire uterine wall?

Back 21

Placenta percreta

Front 22

What are the relative percents of placenta accreta, increta, and percreta?

They can cause persistent what?

What are the two three treatment options?

Back 22

Front 23

What are abnormal gestations due to two sperm fertilizing one egg or one or two sperm fertilizing an "empty egg" with absent or nonfunctional DNA?

Are they rare in the US?

In what part of the world are they the least rare?

Tend to occur in what ages of women?

Back 23

Front 24

Complete moles are_______

Partial moles are ______.

Back 24

Front 25

What makes hydatidiform moles resemble grapes?

What hyperplasia is more prominent in complete moles (usually all the way around villi)?

Back 25

Front 26

What is this?

Back 26

Hydatiform mole

Front 27

What is this?

Back 27

Hydatiform mole

Front 28

What is this?

Back 28

PARTIAL hydatidiform mole

Front 29

What is this?

Back 29

Partial hydatidiform mole

Front 30

What is this?

Back 30

Complete hydatidiform mole filling and distending uterus

Front 31

What is this? Any hyperplasia?

Back 31

Complete hydatidiform mole:

Circumferential trophoblast hyperplasia

Front 32

When are hydatidiform moles often diagnosed? Why? Ultrasound showle abnormally rapid and high elevation of what?

How do you treat it? What do you monitor to make sure it is all the way out?

Back 32

Front 33

What are the four types of twin placentas? Draw each.

Back 33

Front 34

69% of twin placentas are what type? 80% of this type of placenta are "__zygotic."

Back 34

Front 35

What type of placenta?

30% of twin placentas are what type?

All twins with this type of placenta are what?

Back 35

Front 36

What is twin-twin transfusion syndrome? What type of placenta?

Back 36

Front 37

Twin-twin transfusion:

Death of the deprived “donor” twin can send necrotic ______ material into the ______ threatening the life of the other twin and then the ______.

Back 37

Front 38

What is this?

Back 38

Front 39

What is the acronym for hematogenous infections?

What does each stand for?

What infection ascends from the vagina?

Back 39

Front 40

Transplacental infections:

Hematogenous:

What does T stand for? Where does it come from? What can it cause?

What does the O stand for? Are they all rare in the US with prenatal care?

Back 40

Front 41

What does R stand for? What can it cause?

Back 41

Front 42

What does the C stand for? What does it cause?

Back 42

Front 43

What does the H stand for? What are some things that it can cause? In neonates it is preventable with what?

Back 43

Front 44

Acute chorioamnionitis:

Is it common or uncommon? Rupture of membranes at what weeks? (percentages)

What are the stages? (draw the pathway)

Inflammation is procoagulant (true or false)

Back 44

Front 45

How will the placenta appear when it is infected?

Back 45

Front 46

What is the condition? What is shown in B?

What is shown in C?

Back 46

Front 47

What is the condition? Labels each arrow (placental septum, chorionic villi, subchorionic fibrin with entrapped villi, wavefront of ploys starting to infiltrate, amnion).

Back 47

Front 48

What is the condition? What stage? What features tell you that it is this stage? What are 95% of the blue dots?

Back 48

Front 49

What is the condition? What has happened where the arrow is pointing? In what two locations do you see many inflammatory cells?

Back 49

Front 50

What is the condition? What two things is it complicated by? If this thrombosis occludes the umbilical cord blood, what is the result? Remember, inflammation is ______________________.

Back 50

Front 51

What is shown here?

Back 51

Normal fetal membrane roll

Front 52

What is the condition?

What do you notice occurring at the top arrow? Bottom arrow?

Remember, inflammation is ____________.

Back 52

Front 53

Acute chorioamionitis:

Infection ascends from __________ and _________.

Inflammatory response: mainly maternal _________ (so starts in the ____________ space).

Causes premature rupture of ____________ (acronym PRO__) and premature labor and delivery due to ______________ .

Back 53

Front 54

Placental Infections: Acute Chorioamnionitis

Infection is usually __________, with
multiple ______ flora bacteria

Syndrome: fever, _______ (fetal and
maternal), uterine ________, foul
smelling amniotic fluid and _______

Diagnosis: clinical

Treatment: ______ and delivery

Prognosis: usually good, but can cause
fetal ______, cerebral palsy, ________

Back 54

Front 55

PRE-ECLAMPSIA: Pathogenesis

Normally, trophoblast cells invade _______ spiral arteries going to the placenta, destroy the _________ cells in their walls and convert them from small caliber ______ vessels to large caliber capacitance vessels that accommodate vastly _______ blood flow later in gestation.

Pre-eclamptic trophoblast fail to thus convert _____ arteries, resulting in placental ______.

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Front 56

Back 56

Front 57

Pathogenesis of Pre-eclampsia

Ischemic placenta releases ______substances:
(1) _________, a truncated form of VEGF receptor that acts as a decoy
(2) soluble _____, a form of ______ receptor that acts as a decoy

This blocks _____ and ______ mediated production of nitric oxide and _______, causing maternal hypertension, proteinuria and _______.

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Front 58

Pathogenesis of Pre-eclampsia

Ischemic placenta also releases proinflammatory cytokines like _______.

Pre-eclampsia is a _______ state partly due to blockage of __________ production.

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Front 59

Back 59

Front 60

Pre-eclampsia has numerous _______ effects in the placenta and on the fetus and the mother, including fetal intrauterine growth restriction (IUGR), maternal ________, maternal HELLP syndrome. What are the components of HELLP?

Pre-eclampsia and eclampsia are associated with visible changes in placental _______ very similar to atherosclerosis (a universal disease of arterial endothelial injury in all permanent organs).

Back 60

Front 61

What is shown? What are the two arrows pointing to?

What looks like necrosis can be just _____ of plasma.

Back 61

Front 62

What is shown?

Back 62

Pre-eclampsia

Front 63

The initial effect of ischemia on the development of chorionic villi is accelerated
______ that makes them more efficient at _______, nutrient import, and ________, but when ischemia becomes more severe, it results in villous _________.

Back 63

Front 64

Sluggish blood flow in the _________ space and the ________ state of pre-eclampsia can lead to ______ clot formation in the intervillous space, which can lead to _____ of villi, “choked off” by the ______ around them.

Back 64

Front 65

What are the there components of HELLP syndrome? It is a complication of pre-eclampsia in what percent of patients with pre-eclampsia?

What is the pathogenesis of HELLP syndrome? (draw the pathway).

Back 65

Front 66

In HELLP syndrome, liver injury can progress to _______, hemorrhage, even liver ________.

20% of patients with HELLP syndrome get _________; some get hepato-renal failure, some pulmonary edema and acute respiratory distress syndrome (ARDS), and ______ die of it.

Back 66

Front 67

Placental Ischemia and Infarction:

______ is the overwhelmingly most common cause, but hyper-coagulable states, autoimmune vasculitis and ______ are also causes of it.

The fetus can tolerate infarction of more than ______ of the placenta, but extensive infarction causes ___________, neurologic injury and fetal demise.

Back 67

Front 68

What is shown here? How do you know?

Back 68

Front 69

What is shown here? What are the arrows pointing to? What is the tan area? Light red area?

Back 69

Front 70

Invasive Mole and Choriocarcinoma:

Basically, there is a spectrum from non-invasive moles through invasive moles to _______.

7% of partial moles persist after
______ and ______ become carcinoma.

______ of complete moles persist after
initial therapy and _____ become
choriocarcinomas.

Invasive moles look like well differentiated ________, but do not ______ (?just have not).

Back 70

Front 71

What is shown in each? Is there invasion?

Back 71

Front 72

What type of mole is this?

Edematous _____-like chorionic villi

Back 72

Front 73

What type of mole? What type of hyperplasia?

Back 73

Front 74

What is shown? Are they rare?

Back 74

Front 75

What are some common sites of metastatic choriocarcinoma?

Back 75

Front 76

How does choriocarcinoma spread? So where does it go first? What is the most common first symptom? What is the treatment? What is the prognosis if mets?

Back 76

Front 77

Oligohydramnios

Deficiency of _________

Causes a sequence of compressive injuries to the _______, but also pulmonary _______ because the fetus needs to “breathe” for normal ________ development, and absence of fetal “_______” in amniotic fluid due to fetal _______ disease causes pulmonary ________ incompatible with life after birth.

Back 77

Front 78

What is the condition?What is contracted?What would a more severe deformation show?

What is the facies?

Back 78

Front 79

What are amniotic bands?

Back 79

Front 80

What is this called?

Back 80

Front 81

Umbilical cord true knots occur in ______% of pregnancies and can cause ______ demise, especially in the ______ trimester when fetal movement can pull on it.

Back 81

Front 82

Umbilical cords are normally _____ and _____coiling can create what looks like a ____knot, but is not, a _____ knot.

Are both hyper and hypo coiling of the cord are associated with poor obstetrical outcomes (true or false)?

Back 82

Front 83

Placental Abruption: bleeding at the ______ interface causing placental ______ before delivery of the fetus.

The detachment can be _____ or total.

It complicates ______ of pregnancies and the incidence is ______.

Back 83

Front 84

_____ of placental abruptions cause fetal ______ and ______ causes 8% of perinatal mortality.

The immediate cause of abruption is rupture of _______ blood vessels.

This results in a _______ hematoma in 2/3 of cases, but 1/3 of hematomas are without associated _______.

Back 84

Front 85

Complete the chart.

Back 85

Front 86

What is this?

Back 86

Front 87

Pulmonary thromboembolism

The risk is _______ up to 50-fold with pregnancy and up to 1 in 500 pregnancies is complicated by pulmonary ________.

The risk is greater ______ & after delivery than before because that releases compression of the _______. The vast majority come from _______ in left leg.

Back 87

Front 88

Amniotic fluid embolism

Life-threatening obstetric emergency due to acute ________ failure from pulmonary
vasospasm, _______ and right heart ______ triggering pulmonary diffuse ______damage, sometimes with a second phase of ______ and
hemorrhage.

Back 88

Front 89

Amniotic fluid embolism

Rare, but true incidence hard to pin down (between 1 in _____ and 1 in ______ deliveries)

Thought to be due to ______ and amniotic elements entering maternal veins as _____detaches and embolizing to ______, which react with vasospasm, etc.

Back 89

Front 90

Amniotic fluid embolism

Commonly fatal to the ______, but true fatality rate hard to pin down (between ______ and 80%)

Thought to account for _____ of maternal deaths in the US. Less commonly fatal to the ______, but about ______ die after their mothers develop the syndrome.

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Front 91

What is this condition? What does the arrow point to? What is under the arrow? There are called what and where do they come from?

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Front 92

Peripartum Cardiomyopathy

A ________ (possibly _______ mediated) which resolves spontaneously (in 1/3) or leads to _______ cardiomyopathy (in 2/3).

Rare (1:______ to 1:15,000 pregnancies),

Most common in multiparous _________ (race).

Back 92

Front 93

How do you diagnose peripartum cardiomyopathy?

What is the treatment if it fails to resolve spontaneously?

Back 93

Front 94

What is the differential for acute onset dyspnea during labor and delivery?

P, P, P, A, A, M

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Front 95

Maternal deaths in the US

The rate of maternal death in the US has been _______ for over 20 years. The mortality rate in postpartum hospitalizations increased _______ between 1999 and 2009. The maternal death rate is 3X higher for ______ women. The five leading causes of maternal death are _______.

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