DOCSLIB.ORG

Gestational Trophoblastic Disease

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Gestational Trophoblastic Disease Gestational Trophoblastic Disease What you need to know for the “once-every-10-years”patient Marisa Adelman, MD © UNIVERSITY OF UTAH HEALTH Definition • Gestational Trophoblastic Disease (GTD): Benign and malignant tumors of the uterus, arising from placental tissue. • Hydatidiform Moles (HM): benign, premalignant disease • Complete mole • Partial mole • Gestational Trophoblastic Neoplasia (GTN): malignant disease • Invasive mole • Choriocarcinoma • Intermediate trophoblastic tumors (ITT) • Placental site trophoblastic tumor (PSTT) • Epithelioid trophoblastic tumor (ETT) © UNIVERSITY OF UTAH HEALTH Classification GTD HM GTN 80% 20% Complete mole Partial mole Persistent mole Invasive mole Choriocarcinoma ITT (30% all GTD) (40% all GTD) (non-invasive) 15% PSTT ETT © UNIVERSITY OF UTAH HEALTH Epidemiology GTD subtype Incidence Overall 1.67 per 1,000 deliveries Hydatidiform mole 1.36 per 1,000 deliveries Complete hydatidiform mole 0.52 per 1,000 deliveries Partial hydatidiform mole 0.67 per 1,000 deliveries Choriocarcinoma 3 per 100,000 deliveries Placental site trophoblastic tumor 0.9 per 100,000 deliveries Epithelioid trophoblastic tumor 0.1 per 100,000 deliveries Trends in incidence for gestational trophoblastic disease over the last 20 years in a population-based study. Eybouts YK, et al. Gynecol Oncol 2016;140:70-5. © UNIVERSITY OF UTAH HEALTH Epidemiology • Age may play a role in the risk of molar pregnancy. • Increased relative risk of molar pregnancy at the extremes of maternal age (≥45 years old and ≤15 years old) • The risk is greatest for complete moles at the upper extreme of maternal age. • May be due to fertilization of an abnormal oocyte at the beginning and end of the female reproductive period. • May observe chromosomally deficient oocytes, allowing either dispermic fertilization, or monospermic nuclear duplication. • The majority of molar pregnancies, however, occur in the middle of the reproductive period. Trends in incidence for gestational trophoblastic disease over the last 20 years in a population-based study. Eybouts YK, et al. Gynecol Oncol 2016;140:70-5.; Risk of partial and complete hydatidiform molar pregnancy in relation to maternal age. Sebire NJ, et al. BJOG. 2002;109:99-102. © UNIVERSITY OF UTAH HEALTH Genetics • Complete mole • Result from abnormal fertilization of an ovum lacking nuclear DNA Duplication of a single sperm genome Dispermy • Partial mole • Results from abnormal fertilization of an ovum retaining its nuclear DNA Duplication of a single sperm genome (uncommon) Dispermy © UNIVERSITY OF UTAH HEALTH Genetics: complete mole Chromosome duplication 46 23 X 46 XX Diploid + XX Monospermic Empty ovum 46 23 X or Y 46 XX + XX Diploid Empty ovum Dispermic 23 X or Y 46 46 XY XX © UNIVERSITY OF UTAH HEALTH Genetics: partial mole 46 69 XXX XX 23 X or Y 46 + 23 X 69 XXY + XX Triploid Dispermic 23 X or Y Most common 46 69 XYY XX Rare © UNIVERSITY OF UTAH HEALTH Postmolar GTD Develops in 15-20% of complete moles Develops in 1-5% of partial moles • Invasive mole: • Arises from extension of villous trophoblast (from HM) into the myometrium via tissue or venous channels. • Choriocarcinoma • Arises from villous trophoblast following various types of pregnancy: • HM (50%) • Term or preterm pregnancy (25%) • Tubal pregnancy or abortion (25%) • Intermediate trophoblastic tumors • Arises from interstitial trophoblast at the placental implantation site following mostly non-molar pregnancies. • ETT is a rare variant of PSTT, resulting in neoplastic transformation of intermediate trophoblast years after a term delivery. • Has a greater propensity for lymphatic spread. • Metastases are noted in 30-50% of cases, most commonly to the lungs. © UNIVERSITY OF UTAH HEALTH Early placental development This occurs between the morula and blastocyst stage of development. Avagliano, L. (2016, August 12). Histology of the Human Placenta. Retrieved from https://www.semanticscholar.org © UNIVERSITY OF UTAH HEALTH Early placental development The syncytiotrophoblast penetrates the uterine wall The cytotrophoblast differentiates beneath the syncytiotrophoblast Avagliano, L. (2016, August 12). Histology of the Human Placenta. Retrieved from https://www.semanticscholar.org © UNIVERSITY OF UTAH HEALTH Early placental development The cytotrophoblast undergo rapid division, expanding the syncytiotrophoblast Avagliano, L. (2016, August 12). Histology of the Human Placenta. Retrieved from https://www.semanticscholar.org © UNIVERSITY OF UTAH HEALTH Early placental development Formation of cytotrophoblastic anchoring columns. Extravillous trophoblast invades the maternal decidua Avagliano, L. (2016, August 12). Histology of the Human Placenta. Retrieved from https://www.semanticscholar.org © UNIVERSITY OF UTAH HEALTH Correlation with GTN • Villous trophoblast • Cytotrophoblast invasive mole, choriocarcinoma • Syncytiotrophoblast invasive mole, choriocarcinoma • Extravillous trophoblast • Intermediate trophoblast PSTT and ETT © UNIVERSITY OF UTAH HEALTH Workup of HM • H&P • Pelvic ultrasound • Quantitative hCG • CBC • Liver, renal, and thyroid function tests • Blood type and screen • Chest x-ray Case courtesy of Dr Rengarajan R, Radiopaedia.org, rID: 23843; Case courtesy of Dr Avni K P Skandhan, Radiopaedia.org, rID: 25306 © UNIVERSITY OF UTAH HEALTH Treatment of HM • Suction D&C (preferably under ultrasound guidance) • Hysterectomy can be considered as an alternative if not desiring future fertility • Rho (D) administration where appropriate • Use of uterotonics during and following the procedure • Histopathologic review and possible genetic testing to confirm diagnosis • Flow cytometry to determine ploidy • Differentiate complete from partial moles • Biomarkers to identify the absence of paternally imprinted, but maternally expressed genes • Differentiate between complete moles and non-molar hydropic abortions Genest DR, Dorfman DM, Castrillon DH. Ploidy and imprinting in hydatidiform moles: complementary use of flow cytometry and immunohistochemistry of the imprinted gene product p57KIP2 to assist molar classification. J Reprod Med 2002;47:342-46. © UNIVERSITY OF UTAH HEALTH Prophylactic chemotherapy for HM • May reduce the incidence of postmolar GTN by 3-8% • May be considered in women with complete HM, at high risk for malignant transformation: • Age > 40 years old • hCG levels >100,000 mIU/mL • Excessive uterine enlargement • Theca lutein cysts > 6 cm. • NCCN Guidelines: prophylactic methotrexate or dactinomycin can be considered for patients deemed at high risk for post-molar GTN. Kim DS, Moon H, Kim KT, et al. Effects of prophylactic chemotherapy for persistent trophoblastic disease in patients with complete hydatidiform mole. Obstet Gynecol. 1986;67:690–94. Limpongsanurak S. Prophylactic actinomycin D for high-risk complete hydatidiform mole. J Reprod Med. 2001;46:110–16. Wang Q, Fu J, Hu L, et al. Prophylactic chemotherapy for hydatidiform mole to prevent gestational trophoblastic neoplasia. Cochrane Database of Systematics Reviews 2017;9. © UNIVERSITY OF UTAH HEALTH Prophylactic chemotherapy for HM • Although it may reduce the risk of progression to GTN in women who are at high-risk of malignant transformation, it also: • May increase drug resistance, • May delay treatment of GTN • Would expose women to toxic side effects • Cannot be routinely recommended, and: • Would only reduce the risk of needing full-scale chemotherapy • Would not eliminate the need for monitoring and follow-up Prophylactic chemotherapy for hydatidiform mole to prevent gestational trophoblastic neoplasia. Wang Q, et al. Cochrane Database of Syst Rev. 2017;9. © UNIVERSITY OF UTAH HEALTH Follow-up of HM • Quantitative hCG monitoring • hCG assay every 1-2 weeks until 3 consecutive normal levels. • hCG asses twice in 3 month intervals following initial normalization • Assay should be capable of detecting all forms of hCG (beta-hCG, core hCG, nicked-free beta, beta core, hypoglycosylated forms), as the molecules associated with HM tend to be more heterogenous and degraded. Cole LA. Human chorionic gonadotropin and associated molecules. Expert Rev Mol Diagn 2009;9:51-73. Muller CY, Cole LA. The quagmire of hCG and hCG testing in gynecologic oncology. Gynecol Oncol 2009;112:663-72. © UNIVERSITY OF UTAH HEALTH Recurrence, development of GTN • Risk of recurrence is <2% after a single molar pregnancy • Increased risk of CHM in woman with NLRP7 or KHDC3L gene mutations. • Reported incidence of GTN after molar pregnancy is 18-29% • 15-20% CM’s • 1-5% PHM’s • 2-3% of HM’s progress to choriocarcinoma • Once hCG level normalized, recurrent elevation occurs in <1%. Sebire NJ, Fisher, RA, Foskett M, et al. Risk of recurrent hydatidiform mole and subsequent pregnancy outcome following complete or partial hydatidiform molar pregnancy. Br J Obstet Gynaecol 2003;110:22-26. © UNIVERSITY OF UTAH HEALTH Risk of GTN after hCG normalization • The overall risk of developing GTN after normalization of hCG is approximately 0.3%. • 0-0.1% risk after a PHM • 0.3-0.6% risk after a CHM • 0-9.5% risk after a multiple pregnancy involving HM • Patients who required >56 days (8 weeks) to achieve a normal hcg level may have as much as a 10-fold increased risk of developing GTN. • May consider stopping surveillance: • At the time of normalization, following a PHM. • 6 months after normalization, following a CMH. • 12 months after normalization, following a multiple pregnancy involving HM Risk of gestational trophoblastic neoplasia after hCG normalization according to hydatidiform mole
Load more

Recommended publications
  • Placenta Increta at 14 Weeks with Subsequent Hysterectomy: a Case Report Abigail E Collett1*, Jean Payer1 and Xuezhi Jiang1,2
    ISSN: 2378-3656 Collett et al. Clin Med Rev Case Rep 2018, 5:225 DOI: 10.23937/2378-3656/1410225 Volume 5 | Issue 7 Clinical Medical Reviews Open Access and Case Reports CASE REPORT Placenta Increta at 14 Weeks with Subsequent Hysterectomy: A Case Report Abigail E Collett1*, Jean Payer1 and Xuezhi Jiang1,2 1Departments of OB/GYN, The Reading Hospital of Tower Health System, Reading, USA Check for updates 2Departments of OB/GYN, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, USA *Corresponding author: Abigail E Collett, DO., Department of OB/GYN-R1, The Reading Hospital of Tower Health, P.O. Box: 16052, Reading, Philadelphia, PA 19612-6052, USA, Tel: 484-628-8827, Fax: 484-628-9292, E-mail: Abigail.collett@ towerhealth.org Abstract transvaginal ultrasound which showed heterogeneous myo- metrium and a heterogeneous mass-like solid and cystic Background: Abnormal placental implantation (API) is an appearing area in the lower uterine segment. A total ab- uncommon obstetrical phenomenon that is associated with dominal hysterectomy, bilateral salpingectomy and cystos- significant maternal morbidity. Typically, the diagnosis of copy were performed. Intra-operative evaluation revealed a API is made at the time of delivery in the third trimester. firm protruding tissue mass in the left anterior lower uterine However there are reports of API presenting in the second segment that was found to be placenta increta or more on trimester, and rarely in the first trimester. Cesarean Scar final pathology. The patient recovered appropriately during Pregnancy (CSP) can be considered a subset of API. Early her hospital stay and was discharged in stable condition.
    [Show full text]
  • Gestational Trophoblastic Disease Early Detection, Diagnosis, and Staging Detection and Diagnosis
    cancer.org | 1.800.227.2345 Gestational Trophoblastic Disease Early Detection, Diagnosis, and Staging Detection and Diagnosis Catching cancer early often allows for more treatment options. Some early cancers may have signs and symptoms that can be noticed, but that is not always the case. ● Can Gestational Trophoblastic Disease Be Found Early? ● Signs and Symptoms of Gestational Trophoblastic Disease ● How Is Gestational Trophoblastic Disease Diagnosed? Staging After a cancer diagnosis, staging provides important information about the extent of cancer in the body and anticipated response to treatment. ● How Is Gestational Trophoblastic Disease Staged? Questions to Ask About Gestational Trophoblastic Disease Here are some questions you can ask your cancer care team to help you better understand your diagnosis and treatment options. ● What Should You Ask Your Doctor About Gestational Trophoblastic Disease? 1 ____________________________________________________________________________________American Cancer Society cancer.org | 1.800.227.2345 Can Gestational Trophoblastic Disease Be Found Early? Most cases of gestational trophoblastic disease (GTD) are found early during routine prenatal care. Usually, a woman has certain signs and symptoms, like vaginal bleeding, that suggest something may be wrong. (See Signs and Symptoms of Gestational Trophoblastic Disease.) These problems will prompt the doctor to look for the cause of the trouble. Often, moles or tumors cause swelling in the uterus that seems like a normal pregnancy. But a doctor can usually tell that this isn't a normal pregnancy during a routine ultrasound exam. A blood test for HCG (human chorionic gonadotropin can also show something abnormal. This substance is normally elevated in the blood of pregnant women, but it may be very high if there is GTD.
    [Show full text]
  • Placental Site Nodule (PSN): an Uncommon Diagnosis with a Common Presentation
    ISSN: 2377-9004 Sneha and Ramesh Kumar. Obstet Gynecol Cases Rev 2021, 8:199 DOI: 10.23937/2377-9004/1410199 Volume 8 | Issue 2 Obstetrics and Open Access Gynaecology Cases - Reviews CASE REPORT Placental Site Nodule (PSN): An Uncommon Diagnosis with a Common Presentation 1* 2 Check for Sneha GS and Ramesh Kumar R updates 1Assistant Professor, Department of Obstetrics and Gynaecology, SDM Medical College and Hospital, SDM University, Karnataka, India 2Professor, Department of Obstetrics and Gynaecology, SDM Medical College and Hospital, SDM University, Karnataka, India *Corresponding author: DR. Sneha GS, Assistant Professor, Department of Obstetrics and Gynaecology, SDM Medical College and Hospital, SDM University, 580009, Dharwad, Karnataka, India ferentiated from aggressive lesions of intermediate tro- Abstract phoblast like placental site trophoblastic tumor and epi- Placental site nodule is an uncommon, benign, generally thelioid trophoblastic tumor and from nontrophoblastic asymptomatic lesion of trophoblastic origin, which may of- ten be detected several months to years after the tenancy diseases like squamous cell carcinoma [1,4]. from which it resulted. PSN usually presents as menorrha- gia, intermenstrual bleeding or an abnormal pap smear. Case Report PSN is benign, but it is important to distinguish it from the A 29-yrs-old female patient para 3, living 3, abor- other benign and malignant lesions like decidua, placental polyp, exaggerated placental site and placental site tropho- tion 5, underwent laprotomy and tubectomy 2 yrs back blastic tumor and squamous cell carcinoma. Follow ups of presented with history of irregular menstrual cycles typical PSNs do not show recurrence or malignant potential. with menorrhagia since 6 months preceded by normal PSN is an uncommon condition which should be suspected cycles.
    [Show full text]
  • Partial Hydatidiform Molar Pregnancy
    DIAGNOSIS AT A GLANCE Marion-Vincent Mempin, MD, MSc; Poonam Desai, DO; Nadia Maria Shaukat, MD, RDMS, FACEP Partial Hydatidiform Molar Pregnancy Case partial molar pregnancy. A 26-year-old gravida 3, para 2-0-0-2, aborta 0 whose last An obstetric consultation was made and the patient menstrual period was 15 weeks 5 days, presented to the was taken to the operating room the following day for ED with complaints of mild vaginal spotting, which she a dilation and curettage (D&C) procedure. She was dis- first noted postcoitally the previous day. The patient de- charged home the next day without complications. The nied fatigue, lightheadedness, dyspnea, abdominal pain, products of conception were sent to pathology, and nausea, or vomiting. confirmed a triploid karyotype and p57 trophoblastic Physical examination revealed a well-appearing pa- immunopositivity, diagnostic of a partial hydatidiform tient with normal vital signs. The abdomen was soft and mole. nontender, and the fundus was palpable at the level of the umbilicus. A speculum examination was unremarkable, Discussion with normal external genitalia, a closed cervical os, no Hydatidiform moles are a subset of abnormal pregnan- adnexal masses or tenderness, and no blood in the vagi- cies termed gestational trophoblastic disease (GTD). nal vault. Laboratory studies were significant for a serum The two greatest risk factors for GTD are previous GTD beta human chorionic gonadotropin (beta-hCG) of 7,442 and extremis of maternal age.1 Patients often present mIU/mL (reference range for 15 weeks: 12,039-70,971 mIU/ mL). The patient was Rh posi- tive with a stable hematocrit.
    [Show full text]
  • Regulation of Placental Autophagy by the Bcl-2 Family Proteins Myeloid Cell Leukemia Factor 1 (Mcl-1) and Matador/Bcl-2 Related Ovarian Killer (Mtd/Bok)
    Regulation of Placental Autophagy by the Bcl-2 Family Proteins Myeloid Cell Leukemia Factor 1 (Mcl-1) and Matador/Bcl-2 Related Ovarian Killer (Mtd/Bok) by Manpreet Kalkat A thesis submitted in conformity with the requirements for the degree of Master of Science Department of Physiology University of Toronto © Copyright by Manpreet Kalkat, 2010 Regulation of Placental Autophagy by the Bcl-2 Family Proteins Myeloid Cell Leukemia Factor 1 (Mcl-1) and Matador/Bcl-2 Related Ovarian Killer (Mtd/Bok) Manpreet Kalkat Master of Science Department of Physiology University of Toronto 2010 Abstract The process of autophagy is defined as the degradation of cellular cytoplasmic constituents via a lysosomal pathway. Herein I sought to examine the regulation of autophagy in the placental pathologies preeclampsia (PE) and intrauterine growth restriction (IUGR). I hypothesized that the Bcl-2 family proteins Mcl-1L and MtdL regulate placental autophagy and contribute towards dysregulated autophagy in PE. My results demonstrate that Mcl-1L acts to repress autophagy via a Beclin 1 interaction, while MtdL induces autophagy when it interacts with Mcl-1L. My data indicate that while autophagy is elevated in PE, a pathology characterized by oxidative stress, it is decreased in IUGR, a hypoxic pathology. Treatment with sodium nitroprusside to mimic PE caused a decrease in Mcl-1L and an increase in MtdL levels in response to oxidative stress, thereby inducing autophagy. Overall, my data provide insight into the molecular mechanisms contributing to the pathogenesis of preeclampsia. ii Acknowledgments I would like to acknowledge the support my supervisor, Dr. Isabella Caniggia, who has provided me with many valuable lessons that have been instrumental in both my professional and personal growth in this early stage of my scientific career.
    [Show full text]
  • Gestational Trophoblastic Disease
    4/12/17njm Gestational trophoblastic disease Background Gestational trophoblastic disease (GTD) is a spectrum of tumors with a wide range of biologic behavior and potential for metastases. GTD refers to both the benign and malignant entities of the spectrum and include hydatidiform mole, invasive mole, choriocarcinoma, and placental site trophoblastic tumor. The last three are termed gestational trophoblastic tumors (GTT); all may metastasize and are potentially fatal if untreated. The incidence of hydatidiform mole varies in different regions of the world, but has been falling. In North America the incidence is approximately 0.6 to 1.1 per 1000 pregnancies; the rate is approximately three times higher in Asia. Choriocarcinoma in North America occurs in one of every 20,000 to 40,000 pregnancies. The risk of repeat molar pregnancy in a conception following one molar pregnancy (complete, partial, or persistent GTN) is approximately 1 percent, which is increased compared with the 1:1000 risk of molar gestation in the general population. Therefore, ultrasound should be obtained in the late first trimester of subsequent pregnancies to confirm normal fetal development. Additionally, an hCG level should be obtained six weeks after completion of subsequent pregnancies to rule out occult choriocarcinoma. (see Management of Subsequent Pregnancies, below) Routine pathologic evaluation of the placenta, while recommended in the past, is not necessary. However, products of conception should be evaluated by a pathologist following any spontaneous or
    [Show full text]
  • Implantation Site Intermediate Trophoblasts in Placenta Cretas
    Modern Pathology (2004) 17, 1483–1490 & 2004 USCAP, Inc All rights reserved 0893-3952/04 $30.00 www.modernpathology.org Implantation site intermediate trophoblasts in placenta cretas Kyu-Rae Kim1, Sun-Young Jun1, Ji-Young Kim2 and Jae Y Ro1 1Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea and 2Department of Pathology, Cha General Hospital, College of Medicine Pochun Cha University, Seoul, Korea Placenta cretas are defined as abnormal adherences or ingrowths of placental tissue, but their pathogenetic mechanism has not been fully explained. During histologic examination of postpartum uteri, we noticed that the number of implantation site intermediate trophoblasts was increased in the placental bed of placenta cretas. To validate our observation and to address the pathogenetic role of implantation site intermediate trophoblasts in placenta cretas, we examined postpartum uteri with placenta cretas (n ¼ 34) and noncretas (n ¼ 22), obtained from Cesarean or immediate postpartum hysterectomy specimens. Using antibody to CD146, a marker for implantation site intermediate trophoblasts, we found that placenta cretas had significantly thicker layer of implantation site intermediate trophoblasts (230071200 lm) than noncretas (150071200 lm, Po0.025). We also observed that the confluent distribution of cells was more frequent in placenta cretas (97%) than noncretas samples (45%, Po0.001), and that the total number of implantation site intermediate trophoblasts within the superficial myometrium of the placental bed was significantly higher in placenta cretas than noncretas. Using antibodies to Ki-67, Bcl-2 and cleaved caspase-3 to determine the proliferative index and apoptotic rates of implantation site intermediate trophoblasts, we found that they were close to zero in both groups and did not differ significantly.
    [Show full text]
  • Molar Pregnancy with Normal Viable Fetus Presenting with Severe Pre-Eclampsia: a Case Report Freddie Anak Atuk* and Juliana Binti Mohamad Basuni
    Atuk and Basuni Journal of Medical Case Reports (2018) 12:140 https://doi.org/10.1186/s13256-018-1689-9 CASE REPORT Open Access Molar pregnancy with normal viable fetus presenting with severe pre-eclampsia: a case report Freddie Anak Atuk* and Juliana Binti Mohamad Basuni Abstract Background: While gestational trophoblastic disease is not rare, hydatidiform mole with a coexistent live fetus is a very rare condition occurring in 0.005 to 0.01% of all pregnancies. As a result of the rarity of this condition, diagnosis, management, and monitoring will remain challenging especially in places with limited resources and expertise. The case we report is an interesting rare case which presented with well-described complications; only a few similar cases have been described to date. Case presentation: We report a case of a 21-year-old local Sarawakian woman with partial molar pregnancy who presented with severe pre-eclampsia in which the baby was morphologically normal, delivered prematurely, and there was a single large placenta showing molar changes. Conclusion: Even though the incidence of this condition is very rare, recognizing and diagnosing it is very important for patient care and it should be considered and looked for in patients presenting with pre-eclampsia. Keywords: Partial molar, Normal viable fetus, Pre-eclampsia Background Case presentation Molar pregnancy is significantly more common in A 21-year-old local Sarawakian primigravida woman was extremes of age [1]. Hydatidiform mole has been recog- diagnosed as having severe pre-eclampsia at 28 weeks and nized as a clinical entity since the time of Hippocrates and was admitted for blood pressure stabilization and moni- has always aroused interest because of its wide spectrum toring.
    [Show full text]
  • OBGYN-Study-Guide-1.Pdf
    OBSTETRICS PREGNANCY Physiology of Pregnancy: • CO input increases 30-50% (max 20-24 weeks) (mostly due to increase in stroke volume) • SVR anD arterial bp Decreases (likely due to increase in progesterone) o decrease in systolic blood pressure of 5 to 10 mm Hg and in diastolic blood pressure of 10 to 15 mm Hg that nadirs at week 24. • Increase tiDal volume 30-40% and total lung capacity decrease by 5% due to diaphragm • IncreaseD reD blooD cell mass • GI: nausea – due to elevations in estrogen, progesterone, hCG (resolve by 14-16 weeks) • Stomach – prolonged gastric emptying times and decreased GE sphincter tone à reflux • Kidneys increase in size anD ureters dilate during pregnancy à increaseD pyelonephritis • GFR increases by 50% in early pregnancy anD is maintaineD, RAAS increases = increase alDosterone, but no increaseD soDium bc GFR is also increaseD • RBC volume increases by 20-30%, plasma volume increases by 50% à decreased crit (dilutional anemia) • Labor can cause WBC to rise over 20 million • Pregnancy = hypercoagulable state (increase in fibrinogen anD factors VII-X); clotting and bleeding times do not change • Pregnancy = hyperestrogenic state • hCG double 48 hours during early pregnancy and reach peak at 10-12 weeks, decline to reach stead stage after week 15 • placenta produces hCG which maintains corpus luteum in early pregnancy • corpus luteum produces progesterone which maintains enDometrium • increaseD prolactin during pregnancy • elevation in T3 and T4, slight Decrease in TSH early on, but overall euthyroiD state • linea nigra, perineum, anD face skin (melasma) changes • increase carpal tunnel (median nerve compression) • increased caloric need 300cal/day during pregnancy and 500 during breastfeeding • shoulD gain 20-30 lb • increaseD caloric requirements: protein, iron, folate, calcium, other vitamins anD minerals Testing: In a patient with irregular menstrual cycles or unknown date of last menstruation, the last Date of intercourse shoulD be useD as the marker for repeating a urine pregnancy test.
    [Show full text]
  • From Trophoblast to Human Placenta
    From Trophoblast to Human Placenta (from The Encyclopedia of Reproduction) Harvey J. Kliman, M.D., Ph.D. Yale University School of Medicine I. Introduction II. Formation of the placenta III. Structure and function of the placenta IV. Complications of pregnancy related to trophoblasts and the placenta Glossary amnion the inner layer of the external membranes in direct contact with the amnionic fluid. chorion the outer layer of the external membranes composed of trophoblasts and extracellular matrix in direct contact with the uterus. chorionic plate the connective tissue that separates the amnionic fluid from the maternal blood on the fetal surface of the placenta. chorionic villous the final ramification of the fetal circulation within the placenta. cytotrophoblast a mononuclear cell which is the precursor cell of all other trophoblasts. decidua the transformed endometrium of pregnancy intervillous space the space in between the chorionic villi where the maternal blood circulates within the placenta invasive trophoblast the population of trophoblasts that leave the placenta, infiltrates the endo– and myometrium and penetrates the maternal spiral arteries, transforming them into low capacitance blood channels. Sunday, October 29, 2006 Page 1 of 19 From Trophoblasts to Human Placenta Harvey Kliman junctional trophoblast the specialized trophoblast that keep the placenta and external membranes attached to the uterus. spiral arteries the maternal arteries that travel through the myo– and endometrium which deliver blood to the placenta. syncytiotrophoblast the multinucleated trophoblast that forms the outer layer of the chorionic villi responsible for nutrient exchange and hormone production. I. Introduction The precursor cells of the human placenta—the trophoblasts—first appear four days after fertilization as the outer layer of cells of the blastocyst.
    [Show full text]
  • Table of Contents
    Problem-Based Clinical Cases Obstetrics and Gynecology Rotation Gyn Cases Updated December 2004 OB Cases Updated June 2005 By Dr. Manisha Patel Table of Contents Section I: General Gynecology Page 4. Breast Disorders..................................................................................................................................... 1 5. Contraception ......................................................................................................................................... 2 7. Dysmenorrhea........................................................................................................................................ 3 8. Dyspareunia ........................................................................................................................................... 5 9. Ectopic Pregnancy.................................................................................................................................. 8 10. Enlarged Uterus...................................................................................................................................... 9 19. Menorrhagia ......................................................................................................................................... 10 23. Pelvic Relaxation .................................................................................................................................. 12 25. Postmenopausal Bleeding...................................................................................................................
    [Show full text]
  • Ectopic Molar Tubal Pregnancy: an Important Histological Presentation
    CASE REPORT Ectopic Molar Tubal Pregnancy: An Important Histological Presentation Alexander Sabre∗,1, Ashley Molina∗, Manonmani Arul∗ and Malvina Elmadjian∗ ∗Lincoln Hospital and Mental Health Center 249 E 149th St. Bronx, N.Y. USA 10451. ABSTRACT BACKGROUND: Ectopic localization of molar pregnancy is rare from review of literature. To date, only 132 cases have been reported. The identification of molar pregnancies in this setting is critical given their malignant potential and post-surgical management. We present a case of tubal hydatiform molar pregnancy with features suggestive of partial mole, detailing the patient’s initial presentation, explorative surgical evaluation, and finally the revelation of diagnosis based upon pathological determination. It is essential for providers to not only be informed of an unusual pathology but of the importance and value of histological examination of tubal specimens post-surgery with the pertinence to diagnose cases of molar pregnancy for prompt and appropriate post-operative surveillance. KEYWORDS Ectopic pregmancy; Molar Pregnancy; Gynecology; Gynecological Malignancy; Laparoscopy need for further management. Other than genotypic analysis for definitive diagnosis, the molar pregnancy may be elucidated upon histological findings. These criteria include circumferential Introduction trophoblastic proliferation, hydropic scalloped villi, decidual- The incidence of ectopic pregnancy is approximately 20 in 1,000 ized tissue, myxomatous and karyorrhexis effects of stroma, and pregnancies [2]. Hydatidiform molar pregnancies are more rare, avascular cisternae [1]. Once diagnosed, close surveillance with occurring approximately 1 in 500 for partial moles and 1 in serial beta-human chorionic gonadotropic hormone (b-hCG) is 1,000 for complete molar pregnancies [2]. Molar pregnancy required to assess for malignant potential.
    [Show full text]