Practice questions V, female genital tract

Practice questions V, female genital tract

Pathology of placenta

© Jun Wang, MD, PhD

1. Use this case for the next two questions. A 21-year-old G4P0A3 woman at gestation 35 weeks presents with painless vaginal fluid leaking for 3 hours. She has a history of cervical herpes 4 years ago but no abnormality is noted through current prenatal examinations. She denies any history of alcohol or cigarette usage. Physical examination reveals a cervical dilation of 2 cm. Laboratory tests are within normal range. Group B strep prophylaxis was initiated but the patient declined induction. A week later she experiences contraction. Physical examination reveals a temperature of 39.5 degree Celsius and copious foul smelling yellow greenish vaginal discharge. Laboratory tests reveals a leukocytosis with left shift. Since fetal monitoring indicates tachycardia and late decelerations, a cesarean section for delivery was performed. The male neonatal has an Apgar score of 3 and 9 at a and 5 min. The placenta has one oval plate and the cotyledons are complete. The fetal membrane is opaque with a yellow greenish color. The umbilical cord is unremarkable. What is the most likely diagnosis?

A. Chorioamnionitis

B. Eclampsia

C. Placenta accreta

D. Preeclampsia

E. Succenturiate placenta

2. A 21-year-old G4P0A3 woman at gestation 35 weeks presents with painless vaginal fluid leaking for 3 hours. She has a history of cervical herpes 4 years ago but no abnormality is noted through current prenatal examinations. She denies any history of alcohol or cigarette usage. Physical examination reveals a cervical dilation of 2 cm. Laboratory tests are within normal range. Group B strep prophylaxis was initiated but the patient declined induction. A week later she experiences contraction. Physical examination reveals a temperature of 39.5 degree Celsius and copious foul smelling yellow greenish vaginal discharge. Laboratory tests reveals a leukocytosis with left shift. Since fetal monitoring indicates tachycardia and late decelerations, a cesarean section for delivery was performed. The male neonatal has an Apgar score of 3 and 9 at a and 5 min. The placenta has one oval plate and the cotyledons are complete. The fetal membrane is opaque with a yellow greenish hue. The umbilical cord is unremarkable. What is the most likely finding in placenta?

A. Eosinophilic infiltration in amnion

B. Lymphocytic infiltration in amnion

C. Neutrophilic infiltration in amnion

D. Neutrophilic infiltration in umbilical cord

E. Plasma cells in decidua

3. A 32-year-old G2P1 woman at 36 weeks of gestation presents with cough and fever for two days. She has a history of type I diabetes and candidal vaginitis. The prenatal course is unremarkable except asymptomatic bacterial vaginosis. Physical examination reveals a temperature of 38.5 degree Celsius, heart rate at 110 bmp, and uterine tenderness and cervical dilation of 3 cm. Laboratory tests reveals a white cell count at 14.5 (normal 4.7-10.5) with left shift. Chest X-ray reveals patchy infiltrate at the lower lobe of her right lung. Fetal monitoring reveals tachycardia. 2 hours later spontaneous rupture of membranes occurred with foul-smelling amniotic fluid. The infant as an Apgar score of 1, 5 and 7 at 1, 5, and 10 minutes. The infant was intubated and transferred to NICU. Subsequent blood culture of the infant reveals growth of haemophilus influenzae. What is the most likely cause of the positive culture results of infant blood?

A. Acute chorioamnionitis ascending spreading of vaginal bacteria

B. Acute chorioamnionitis associated with maternal sepsis

C. Acute chorioamnionitis associated with rupture of membrane

D. Acute respiratory infection during delivery

E. Acute respiratory infection after delivery

4. Use this case for the next three questions. A 22-year-old G1P0 woman at 32 weeks gestation presents with headache and blurred vision for 2 days. She describes the headache as throbbing and grades it as 8/10. She took Tylenol but it is not relieved. She denies vaginal bleeding, urinary symptoms, fever or other symptoms. She has acute tonsillitis 1 week earlier, and was treated with antibiotics. Her past medical history and prenatal courses are unremarkable. Her vital signs include a blood pressure of 185/120 mmHg. Physical examination reveals pitted edema of bilateral legs. Urine dip reveals 3+ protein. CBC reveals platelet count at 95,000/microliter (normal 150-450,000) and creatinine at 3.5 mg/dL (normal 0.5-1.2 mg/dL). Peripheral blood smear reveals a few fragmented red cells. No other abnormality is noted. What is the most likely diagnosis?

A. Eclampsia

B. Essential hypertension

C. Preeclampsia

D. Poststreptococcal glomerulonephritis

E. Thrombotic thrombocytopenic purpura

5. A 22-year-old G1P0 woman at 32 weeks gestation presents with headache and blurred vision for 2 days. She describes the headache as throbbing and grades it as 8/10. She took Tylenol but it is not relieved. She denies vaginal bleeding, urinary symptoms, fever or other symptoms. She has acute tonsillitis 1 week earlier, and was treated with antibiotics. Her past medical history and prenatal courses are unremarkable. Her vital signs include a blood pressure of 185/120 mmHg. Physical examination reveals pitted edema of bilateral legs. Urine dip reveals 3+ protein. CBC reveals platelet count at 95,000/microliter (normal 150-450,000) and creatinine at 3.5 mg/dL (normal 0.5-1.2 mg/dL). Peripheral blood smear reveals a few fragmented red cells. No other abnormality is noted. What is the most likely cause of her elevated creatinine?

A. Autoimmune damage to glomeruli

B. Bacterial toxin associated endothelial damage

C. Loss of renal parenchyma due to scarring

D. Microthrombi associated hemolysis

E. Poor renal perfusion due to vasoconstriction

6. A 22-year-old G1P0 woman at 32 weeks gestation presents with headache and blurred vision for 2 days. She describes the headache as throbbing and grades it as 8/10. She took Tylenol but it is not relieved. She denies vaginal bleeding, urinary symptoms, fever or other symptoms. She has acute tonsillitis 1 week earlier, and was treated with antibiotics. Her past medical history and prenatal courses are unremarkable. Her vital signs include a blood pressure of 185/120 mmHg. Physical examination reveals pitted edema of bilateral legs. Urine dip reveals 3+ protein. CBC reveals platelet count at 95,000/microliter (normal 150-450,000) and creatinine at 3.5 mg/dL (normal 0.5-1.2 mg/dL). Peripheral blood smear reveals a few fragmented red cells. No red cells are seen in urine. No other abnormality is noted. What is the most important underlying abnormality associated with her presentations?

A. Abnormal activation of platelet due to ultra large von Willebrand factor

B. Autoantibody against glomerular basement membrane

C. Autoantibody against platelet GPIIb/IIIa or GPIb/IX

D. Drug toxicity by antibiotics

E. Failure of endothelial replacement by cytotrophoblasts

7. A 26-year-old G1P0 woman at 36 week of pregnancy was brought to emergency department due to sudden loss of consciousness and a few episodes of seizure. Per her family members, she has experienced headache and blurred vision in the last week. She has a history of type I diabetes since age 15 and is currently treated with insulin. She denies history of seizure, dizziness or other neurological disorders. She did not have any prenatal visiting. Physical examination reveals a blood pressure of 180/120 mmHg and marked edema of both legs. Laboratory test results include a white blood cell count at 25,000/microliter (normal 4,500-10,500/microliter), platelet at 120,000/microliter (normal 150,000-450,000/microliter), creatinine at 9.5 mg/dL (normal 0.4-1.2 mg/dL), AST at 95 U/L (normal 10-40 U/L) and urine protein at 8,500 mg/dl (normal 0-20 mg/dL). What is the diagnosis?

A. Acute chorioamnionitis

B. Congestive heart failure

C. Eclampsia

D. End stage renal disease

E. Preeclampsia

8. Use this case for the next three questions. A 22-year-old G1P0 woman at 18th week of pregnancy presents with cramping lower abdominal pain and vaginal bleeding for 1 day. Her past medical history is unremarkable. She has a blood pressure of 170/110 mmHg. Physical examination reveals diffuse marked edema. No other abnormality is seen. Bimanual examination reveals a uterus with a size compatible with 14th week of gestation. Sonographic examination reveals a small fetus without heartbeat. Induction was performed and a non-viable fetus was delivered. The placenta is larger than normal. The cotyledons are complete but have many edematous villi. No abnormalities are seen in umbilical cord and fetal membranes. What is the most likely diagnosis?

A. Acute chorioamnionitis

B. Choriocarcinoma

C. Complete hydatidiform mole

D. Incomplete hydatidiform mole

E. Preeclampsia

9. A 22-year-old G1P0 woman at 18th week of pregnancy presents with cramping lower abdominal pain and vaginal bleeding for 1 day. Her past medical history is unremarkable. She has a blood pressure of 170/110 mmHg. Physical examination reveals diffuse marked edema. No other abnormality is seen. Bimanual examination reveals a uterus with a size compatible with 14th week of gestation. Sonographic examination reveals a small fetus without heartbeat. Induction was performed and a non-viable fetus was delivered. The placenta is larger than normal. The cotyledons are complete but have many edematous villi. No abnormalities are seen in umbilical cord and fetal membranes. What is the most likely genetic abnormality of the placenta?

A. Complex karyotype

B. Diploid karyotype

C. Translocation of chromosome 9 and 22

D. Triploid karyotype

E. Trisomy 21

10. A 22-year-old G1P0 woman at 18th week of pregnancy presents with cramping lower abdominal pain and vaginal bleeding for 1 day. Her past medical history is unremarkable. She has a blood pressure of 170/110 mmHg. Physical examination reveals diffuse marked edema. No other abnormality is seen. Bimanual examination reveals a uterus with a size compatible with 14th week of gestation. Sonographic examination reveals a small fetus without heartbeat. Induction was performed and a non-viable fetus was delivered. The placenta is larger than normal. The cotyledons are complete but have many edematous villi. No abnormalities are seen in umbilical cord and fetal membranes. What is the most likely cause of her presentations?

A. Ascending bacterial infection from vaginal

B. Extra paternal chromosome in fertilized egg

C. Failure of chromosome 21 separation during oogenesis

D. Failure of endothelial replacement by cytotrophoblasts

E. Loss of X chromosome during oogenesis

11. Use this case for the next three questions. An 18-year-old G1P0 woman at 9th week of pregnancy presents with cramping abdominal pain and pronounced nausea and vomiting. She does not have fever, diarrhea and vaginal bleeding/discharge. She has a history of genital herpes 2 months ago. Physical examination reveals a uterus in the size of 18 weeks. No other abnormality is seen. Urine hCG test is positive. Serum hCG is 1,545,534 mIU/ml (normal 25,700 to 288,000 mIU/ml). Sonographic examination reveal a dilated uterine cavity with complex echogenic tissue containing numerous hypoechoic cystic spaces. No fetus is identified. Uterus evacuation reveal many markedly edematous villi. No hemorrhage or necrosis is seen. Microscopically, these villi have cystically dilated spaces. Trophoblast proliferation is diffuse. No significant cytological atypia is seen. What is the most likely diagnosis?

A. Choriocarcinoma

B. Complete hydatidiform mole

C. Incomplete hydatidiform mole

D. Placental site nodule

E. Preeclampsia

12. An 18-year-old G1P0 woman at 9th week of pregnancy presents with cramping abdominal pain and pronounced nausea and vomiting. She does not have fever, diarrhea and vaginal bleeding/discharge. She has a history of genital herpes 2 months ago. Physical examination reveals a uterus in the size of 18 weeks. No other abnormality is seen. Urine hCG test is positive. Serum hCG is 1,545,534 mIU/ml (normal 25,700 to 288,000 mIU/ml). Sonographic examination reveal a dilated uterine cavity with complex echogenic tissue containing numerous hypoechoic cystic spaces. No fetus is identified. Uterus evacuation reveal many markedly edematous villi. No hemorrhage or necrosis is seen. Microscopically, these villi have cystically dilated spaces. Trophoblast proliferation is diffuse. No significant cytological atypia is seen. What is the most likely karyotype?

A. Diploid, with both maternal and paternal genomes

B. Diploid, with only paternal genomes

C. Triploid, with both maternal and paternal genomes

D. Triploid, with maternal genomes only

E. Tetraploid, with both maternal and paternal genomes

13. An 18-year-old G1P0 woman at 9th week of pregnancy presents with cramping abdominal pain and pronounced nausea and vomiting. She does not have fever, diarrhea and vaginal bleeding/discharge. She has a history of genital herpes 2 months ago. Physical examination reveals a uterus in the size of 18 weeks. No other abnormality is seen. Urine hCG test is positive. Serum hCG is 1,545,534 mIU/ml (normal 25,700 to 288,000 mIU/ml). Sonographic examination reveal a dilated uterine cavity with complex echogenic tissue containing numerous hypoechoic cystic spaces. No fetus is identified. Uterus evacuation reveal many markedly edematous villi. No hemorrhage or necrosis is seen. Microscopically, these villi have cystically dilated spaces. Trophoblast proliferation is diffuse. No significant cytological atypia is seen. What is the most likely immunohistochemistry profile?

A. Positive for hCG, negative for p53 and p57

B. Positive for hCG and p53, negative for p57

C. Postive for hCG, p53 and p57

D. Positive for p53 and p57, negative for hCG

E. Positive for p57, negative for hCG and p53

14. Use this case for the next two questions. A 22-year-old woman presents with progressive dry cough for 1 week. She has a history of spontaneous abortion 6 months earlier. Her past medical history is otherwise unremarkable. She smokes cigarette 1 and half pack per day for 6 years. She denies alcohol or illicit drug use. Physical examination reveals a slightly enlarged uterus. Chest CT reveal multiple nodules at the peripheral area of the lower lobe of her left lung. Biopsy of these nodules reveals markedly atypical large multinucleated cells with hyperchromic nuclei and prominent nucleoli. Necrosis, hemorrhage and brisk mitosis are seen. Per immunohistochemistry, these cells are positive for cytokeratin, but negative for TTF1, CD45 and calretinin. Endometrial biopsy reveals lesions with same morphology. What is the diagnosis?

A. Adenocarcinoma of lung with endometrial metastasis

B. Anaplastic large cell lymphoma involving lung and uterus

C. Choriocarcinoma of uterus with lung metastasis

D. Large cell carcinoma of lung with endometrial metastasis

E. Mesothelioma with endometrial metastasis

15. A 22-year-old woman presents with progressive dry cough for 1 week. She has a history of spontaneous abortion 6 months earlier. Her past medical history is otherwise unremarkable. She smokes cigarette 1 and half pack per day for 6 years. She denies alcohol or illicit drug use. Physical examination reveals a slightly enlarged uterus. Chest CT reveal multiple nodules at the peripheral area of the lower lobe of her left lung. Biopsy of these nodules reveals markedly atypical large multinucleated cells with hyperchromic nuclei and prominent nucleoli. Necrosis, hemorrhage and brisk mitosis are seen. Per immunohistochemistry, these cells are positive for cytokeratin, but negative for TTF1, CD45 and calretinin. Endometrial biopsy reveals lesions with same morphology. What marker is likely to be elevated in serum?

A. AFP

B. CA125

C. CEA

D. hCG

E. PLAP

Answers

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