Practice questions V answers, female genital tract

Practice questions V answers, female genital tract

Pathology of placenta

© Jun Wang, MD, PhD

1. A. This patient has clinical presentations of acute inflammation. With the physical examination finding of purulent vaginal discharge, and the opaque discolored fetal membrane, this is most likely acute chorioamnionitis. Eclampsia has hypertension, proteinuria, edematous changes and neurological abnormalities such as seizures and coma. Preeclampsia has hypertension, proteinuria, edematous changes without neurological abnormalities such as seizures and coma. Placenta accreta is implantation into myometrium, and is not commonly associated with acute inflammation. Succenturiate placenta is additional placental lobe, usually asymptomatic, although posting a risk for hemorrhage and thromboembolism. 

2. C. The characteristic feature of acute chorioamnionitis is neutrophilic infiltration of amnion or chorionic villi. Neutrophilic infiltration of umbilical cord is seen in acute funisitis, a condition sometimes seen with acute chorioamnionitis. 

3. B. Acute chorioamnionitis may be caused by ascending infection or blood spread of microorganisms, that may subsequently cause fetal infection. This patient has history of pneumonia prior to delivery, and haemophilus influenzae is not commonly associated with lower genital tract infection. Therefore the bacteria causing acute chorioamnionitis and infant infection is most likely originated from maternal pneumonia associated sepsis. 

4. C. Combination of hypertension, proteinuria and edema in a pregnant woman without previous history of hypertension or kidney disease is most supportive preeclampsia, if no specific neurological abnormality is present. Eclampsia has neurological abnormalities such as seizures and coma in a background of hypertension, proteinuria, edematous changes. Poststreptococcal glomerulonephritis has hematuria. Thrombotic thrombocytopenic purpura has microangiopathic hemolytic anemia, thrombocytopenic purpura, fever, abnormal renal function and neurological features, but hypertension is uncommon. Essential hypertension usually has elevated blood pressure before pregnancy. 

5. E. Preeclampsia is associated with vasoconstriction and subsequent ischemic changes of affected organ, including kidney. Autoimmune damage to glomeruli is seen in many nephritis. Bacterial toxin associated endothelial damage is seen in various clinical conditions, including

hemolytic-uremic syndrome. Loss of renal parenchyma due to scarring is a later stage feature of chronic renal inflammations. Microthrombi associated hemolysis can be seen in thrombotic thrombocytopenic purpura and hemolytic-uremic syndrome. 

6. E. Failure of endothelial replacement by cytotrophoblasts during placentation is believed to cause malfunctioning of placental vasculature in preeclampsia. Subsequent fetal ischemia causes release of various cytokines that result in maternal vasoconstriction. Abnormal activation of platelet due to ultra large von Willibrand factor is seen in thrombotic thrombocytopenic purpura. Autoantibody against glomerular basement membrane is seen Goodpasture syndrome. Autoantibody against platelet surface proteins is seen in immune thrombocytopenic purpura. Certain antibiotics may have renal toxicity and exaggerate hypertension, but usually has additional abnormalities, such as hematuria, skin rash etc.

7. C. Sudden neurological abnormalities such as seizures and coma in a background of hypertension, proteinuria, edematous changes in a pregnant woman are most supportive of eclampsia. Acute chorioamnionitis rarely presents with hypertension. Congestive heart failure usually has associated history. End stage renal disease usually has a long history of associated renal disease. Preeclampsia does not have coma or seizure. 

8. D. Early onset of presentations of preeclampsia, edematous chorionic villi, and presence of fetus are supportive of a partial mole. Acute chorioamnionitis has opaque discolored feral membrane, but not edematous villi. Choriocarcinoma is characterized by hemorrhage and necrosis, but not edematous villi. Complete mole does not have fetal component. Pure preeclampsia has small placenta, but no edematous villi. 

9. D. Both complete mole and partial mole have extra set of paternal chromosomes. Complete moles are most commonly diploid, with only paternal chromosomes. Partial mole are most commonly triploid, with both maternal and paternal chromosomes. Complex karyotypes are commonly seen high-grade malignancies. 9:22 translocation is seen in chronic myelogenous leukemia and B-cell acute lymphoblastic leukemia/lymphoma. 

10. B. Both complete mole and partial mole have extra set of paternal chromosomes. Complete moles are most commonly diploid, with only paternal chromosomes. Partial moles are most commonly triploid, with both maternal and paternal chromosomes. Ascending infection is seen in Acute chorioamnionitis. Failure of chromosome 21 separation during oogenesis causes Down syndrome. Failure of endothelial replacement by cytotrophoblasts during placentation causes malfunctioning of placental vasculature in preeclampsia and eclampsia. Loss of X chromosome during oogenesis causes Turner syndrome. 

11. B. Larger than normal uterus, abnormally high hCG, markedly edematous villi without fetal tissue are most likely complete mole. Choriocarcinoma is characterized by hemorrhage and necrosis, but not edematous villi. Partial moles have fetal tissue. Placental site nodule is usually asymptomatic without edematous villi. Pure preeclampsia has small placenta, but no edematous villi. 

12. B. See discussion in question 9.

13. B. All trophoblast cells are positive for hCG. Both complete mole and partial mole are positive for p53. P57 is only expressed in partial mole since it is a maternal gene, and complete mole has only paternal genes. 

14. C. Multiple tumor nodules in lung is highly suggestive of metastasis. Multinucleated tumor cells with positive reactivity to cytokeratin and hCG are most likely choriocarcinoma. Metastatic adenocarcinoma of lung is positive for TTF1. Anaplastic large-cell lymphoma is positive for CD45 and negative for cytokeratin and hCG. Large cell carcinoma of lung and mesothelioma metastasized to uterus are extremely rare, and should be negative for hCG. 

15. D. Trophoblast diseases, including complete mole, partial mole and choriocarcinoma usually has elevated hCG. AFP is elevated in yolk sac tumor and hepatocellular carcinoma. CA125 may be elevated in patients with ovarian serous adenocarcinoma. Elevated CEA may be associated with malignancies, such as ovarian mucinous adenocarcinoma. Elevated PLAP may be seen in dysgerminoma.

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