!

GESTATIONAL*TROPHOBLASTIC*DISEASES,*
ABNORMALITIES*OF*THE*PLACENTA,*FETAL**
MEMBRANES*&*UMBILICAL*CORD*
Vincent*Lohengrin*A.*Fortun,*MD,*FPOGS,*FPSSTD*
June%18,%2014;%8:00.10:00%AM%
Obstetrics!and!Gynecology!II%

*
OUTLINE*(OBJECTIVES)% * “And!if!you’re!lucky,!if!you’re!the!luckiest!person!on!
• Gestational%Trophoblastic%Diseases% this!entire!planet,!the!person!you!love!decides!to!love!
*
• Abnormalities%of% you!back."!–!One%Tree%Hill%(space%filler%lang%hehe)!
*
! Placenta% %
! Fetal%membranes%% COMPLETE*MOLE*
!
! Umbilical%cord% • Results%from%fertilization%of%an%inactivated%egg%
% and*a*single*23X*sperm*which%then%duplicates%to%
form%the%46XX*karyotype%(diploid%.%85%)%
GESTATIONAL*TROPHOBLASTIC*DISEASE* • In%15%%of%cases,%complete%hydatidiform%mole%also%
• A%general%term%for%proliferative%abnormalities%of% results%from%the%fertilization%of%an%egg%by%2%sperms,%
the%trophoblast% resulting%in%either%46XX%or%46XY%chromosomes%
• Once%the%trophoblast%behaves%abnormally,%it% • Chromosomal%%composition%%is%%usually%%diploid%
becomes%a%disease%% and%of*paternal*origin%
• Encompasses%%both%%benign%%and%%malignant% • Characteristics:%
conditions% ! More*common%than%the%partial%H.mole%
% ! High%risk%for%malignant*degeneration%
CLINICAL**CLASSIFICATION**OF**GESTATIONAL* ! Uterus%is%usually%larger*for*the*AOG%
TROPHOBLASTIC*DISEASES* ! Toxemia,%hypertension,%preeclampsia,%
• Hydatidiform%mole%(Benign)% albuminuria%in%the%patient%occurs%early%
• Gestational%%%Trophoblastic%%%Neoplasias,%%%also% ! High*serum*hCG*titer*
called%%%malignant%%%gestational%trophoblastic% ! No*evidence*of*the*fetus%by%
disease%(Malignant)% ultrasonography%or%histology%
! Histology:*
%
" All%placental%villi%are%cystically*dilated*
HYDATIDIFORM*MOLE*
and*avascular*
• Grossly:*“sagoLlike”/”tapiocaLlike”*
# Responsible%for%the%gross%sago.like%
• Very%common%among%Filipinos%
appearance%
• Incidence%is%1%in%145%pregnancies,%this%is%a%very%big%
# Placental!villi!appear!like!tiny!
number%compared%to%that%in%North%America%or%
islands;!in!HDmole,!napupuno!ng!
Europe%
tubig!admixed!with!blood!clots!and!
• Classified%into:%
placental!tissue!‘yung!villi!
! Complete%Mole%
" Marked%cytotrophoblast%proliferation%
! Partial%(Incomplete)%Mole%
" No*gestational*sac*or*fetus*present*
Complete!HDmole!gross!picture!composed!of!cystic!vesicles!or!sagoD
!
like!materials.%
* If!the!patient!asked!you,!“Doc,!saan!ko!po!ba!nakuha!itong!
! hydatidiform!mole!na!ito?!Sino!ba!ho!sa!aming!magDasawa!
! ang!may!diperensya?”!You!will!answer!them!as!follows...!
! “Kayong!2!po!ang!nagkaroon!ng!diperensya!dito!sa!
! pagbubuntis!na!ito.!Iyon!pong!punla!na!ibinigay!ng!asawa!
! ninyo!ay!may!depekto.!Ganun!din!po!‘yung!punla!na!ibinigay!
! ninyo!dito!sa!pagbubuntis!na!ito.!Dapat!kung!inactivated!
! ‘yung!itlog!ninyo!or!bugok!‘yung!itlog!ninyo,!kapag!‘yan!ay!
! nagsanib!pwersa!sa!semilya!ng!asawa!ninyo,!wala!dapat!
When!you!take!away!the!blood,!it!would!look!like!this:! buhay!na!mabubuo.!Pero!hindi!eh,!after!magfuse!nung!
% semilya!ng!asawa!ninyo!doon!sa!bugok!na!itlog,!‘yung!
% semilya!ng!asawa!ninyo!nagbuhay!pa!uli!para!makumpleto!
* ‘yung!HDmole!na!normally!hindi!nangyayari!in!nature.”!
* !
* Why!does!it!happen!in!a!case!of!hydatidiform!mole?!It’s!only!
* God!who!can!answer!that.!
!

Transcriber/s:!Ynoli!Diosomito,!Karl!Nievera!,!Anonymous!Third!Wheel!
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3
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%
% DIPLOID!
% TRIPLOID!
%
%
%
%
%
%
!
Normally,!placental!villi!appear!like!tiny!islands.!In!HDmole,!
the3“islands”3are3filled3with3fluid.!Normally,!villi!are!lined!
by!a!single!layer!of!trophoblasts.!These!facilitate!transport!
by!active!and!passive!means.!In!HDmole,!merong3several3
layers3ng3trophoblast.3This!is!called!cytotrophoblastic!
proliferation!wherein!kumakapal!‘yung!layers!sa!HDmole.!
!
PARTIAL*(INCOMPLETE)*MOLE*
• Karyotype%is%triploid%(85%)%.%usually%69XXX,%
69XXY,%each%are%composed%of%one*maternal*and*
two*paternal*haploid%sets%of%chromosome% *
• Characteristics:* SIGNS*AND*SYMPTOMS*OF*HLMOLE*
! Lower*risk*for*malignant*degeneration*
• Bleeding*.%most%common%
! Fetus*may*be*present%on%pelvic%
• Amenorrhea%
sonography%%
• Disparity%in%the%size%of%the%uterus%and%the%age%of%
! Fetus%%has%%multiple**congenital**defects,%%is%
gestation%(in%50%%of%cases,%the%uterus%can%be%larger%
stunted%(bansot),%and%usually%does%not%
than%the%computed%AOG,%%25%%.%the%uterus%can%be%
survive%%
smaller%in%size%compared%to%the%computed%AOG,%
! Histology:*
25%%.%%the%size%of%the%uterus%and%the%AOG%may%be%
" Villi%are%NOT*all*cystic%
similar)%
# May%sago.like%appearance%pa%rin%but%
• Full%or%boggy%lower%uterine%segment%upon%IE%
there%is%more%of%the%placenta%like%
• No%fetal%heart%tones%may%be%heard%(complete%H.
tissue%in%the%mix%of%the%specimen% mole)%%
submitted%to%the%laboratory%
• Signs*of*pregnancy*are*exaggerated%as%a%result%
" Villi%%%contain%%%blood%%%vessels%%%with% of%%the%%elevation%%of%%serum%%hCG;%%nausea,%
nucleated%red%blood%cells% vomiting%and%other%signs%of%pregnancy%appear%at%
" Minimal%to%variable%trophoblastic% an%early%age%of%gestation%(maaga%naglilihi)%
proliferation% %
" Presence*of*fetal*membranes* DIAGNOSIS*OF*HLMOLE*
* • Clinical%signs%and%symptoms%
* • Ultrasonography%(“snowstorm”*appearance)%.%
* easiest%test%to%diagnose%the%condition:%UTZ%of%
* pelvis%
% • β.hCG%%is%%higher%%compared%%to%%a%%normal%
% singleton%pregnancy%
%
% At!10!wks!AOG,!the!usual!HCG!titer!of!a!normal!singleton!
% pregnancy!approaches!100,!000!mIU/mL.!If!you’re!dealing!
% however!with!an!HDmole,!it!may!get!values!of!up!to!500,!000!to!
Still! have! those! giant! islands! of! individual! placental! villi! 600,!000!mIU/mL.!Bakit?!Because!HDmole!is!a!tumor.!The!
but!more!of!the!familiar!normal!looking!villi3 number!of!trophoblasts,!specifically!the!syncytiotrophoblasts!
that!are!responsible!for!secreting!your!hCG!molecule,!is!a!lot!
*
higher.!Therefore,!mas!madaming!trophoblast!na!!nagrerelease!
% ng!hCG!=!mas!mataas!level!ng!hCG!sa!HDmole.!
%
% %
% !
% %
%
%
%
%
%
% %
% %
Partial!HDmole!with!a!baby!who!grew!up!to!34!weeks,!but! %
died!due!to!multiple!congenital!defects!

Transcriber/s:!Ynoli!Diosomito,!Karl!Nievera!,!Anonymous!Third!Wheel!
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• Hysterectomy*
! For**older,**multiparous**patients**who**no*
longer*want*to*bear*children*
! For%patients%with%uterine%rupture%due%to%the%
presence%of%the%mole%
! For%%hypovolemic%%patients%%with%%profuse%
vaginal%bleeding%
%
FOLLOWLUP*OF*HLMOLE*PATIENTS*
• Follow%up%for%a%minimum%of%18%months%
• Serial%monitoring%of%β.hCG%%titers%
• Complete%physical%examination%per%visit%(‘wag%lang%
puro%vital%signs!)%
Sonogram3of3a3molar3pregnancy3
• Prescribe%contraception%for%at%least%18%months%
Absence!of!fetus/gestational!sac;!no!baby!present!
!Alternating!hyperD!and!hypoechoic!materials!D!sagoDlike!
materials! So!hindi!sila!pwedeng!magbuntis!for!at!least!183months!
after!you!evacuate!the!mole.!Kapag!nabuntis!ang!
Large!island!ng!dark!areas!D!clots!
patient,!the!risk!of!persistent!disease!is!greater!as!
Grayish!D!placenta!like!tissue% opposed!to!getting!pregnant!after!the!first!18!months!
* postDevacuation!of!the!mole.!!
DIFFERENTIAL*DIAGNOSIS*OF*HLMOLE* %
• Multiple%pregnancy% PROPHYLACTIC*CHEMOTHERAPY*FOR*HLMOLE*
!
• Polyhydramnios% • The%administration%of%a%single%course%of%single%
• Placenta%previa% agent%%chemotherapy%%within%%one%%month%%of%
• Abruptio%placenta% evacuation%of%an%H.mole%(usually%used:%
• Threatened%abortion% methotrexate%or%actinomycin)%
• Pregnancy%%with%%a%%concomitant%%uterine%%or%
adnexal%tumor% It!is!expensive!and!harmful!sa!patient!so!hindi!lahat!
* binibgyan.!This!is!to!decrease!the!probability!of!a!
TREATMENT*OF*HLMOLE* complete!HDmole!degenerating!into!a!cancer.!Again,!the!
• Replacement%of%blood%loss% risk!will!go!down!from!25%!to!2%!
! 2%units%of%blood%to%prepare,%bloody%tumor%
kasi%ang%H.mole% REFER*HLmole*cases*to*a*SPECIALIST!*(like*Doc*F*$%)%
• Termination%of%pregnancy%% %
• Prophylactic%chemotherapy%(if%warranted,%give%1% %
course%of%single%agent%chemotherapy%within%1% %
month%after%evacuating%the%mole)%–% %
! to%decrease%the%probability%of%the%H.mole% %
degenerating%into%a%cancer% %
• Follow.up%for%at*least*18*months%for%signs%of% %
persistent%%disease%%and%%degeneration%%to%%a% %
malignancy%
%
%
If!you!don’t!know!how!to!!manage!!this!!trophoblastic!!cancer!
%
once!it!appears,!your!patient!has!less!than!6!months!to!live.!
%
That’s!why!you!need!to!have!a!high!index!of!suspicion!for!it.!
%
! %
For!every!molar!pregnancy,!there!is!a!25%!probability!that!a! %
malignancy!or!a!gestational!trophoblastic!neoplasia!is!going!to! %
follow!the!termination!of!that!pregnancy.!If!you!give! %
prophylactic!chemotherapy,!the!25%!probability!can!be! MALIGNANT*TROPHOBLASTIC*DISEASES*
decreased!down!to!a!risk!of!only!2%.!It!doesn’t!go!down!all!the! • May%%develop%%following%%an%%h.mole%(50%),%%a%
way!to!0%!kaya!‘pag!nagprophylactic!chemotherapy!for!HD • Normal%pregnancy%(25%),%and%an%abortion/ectopic%
mole,!you!!still!have!to!followDup!the!patient!for!at!least!18! pregnancy%(25%)%
months!to!check!for!signs!of!persistent!disease.! • Irregular%%%vaginal%%%bleeding%%%with%%%uterine%
• SubinvolutionL*most*common*clinical*finding**
TERMINATION*OF*PREGNANCY*IN*HLMOLE* • Can%kill%patients%in%less%than%6%months%%
• Suction*curettage* • Trophoblast.%%most%%invasive%%cell%%in%%human%
! Makes%use%of%suction%machine%and%a%special% physiology%
curette%%to%%facilitate%%evacuation%%of%%molar% • Histologically%these%tumors%include:%
products% ! Invasive%mole%
! Reduces%operating%time% ! Gestational%choriocarcinoma%
! Lessens%blood%loss% ! Placental%Site%Trophoblastic%Tumor%
! For*patients*who*are*young*or*are* ! Epithelioid%Trophoblastic%Tumor%
desirous*of*further*child*bearing* %

Transcriber/s:!Ynoli!Diosomito,!Karl!Nievera!,!Anonymous!Third!Wheel!
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CRITERIA*FOR*THE*DIAGNOSIS*OF*GTN*(FIGO,*2002)%% molar%evacuation%
• Plateau%of%serum%beta.hCG%>%10%%for%4%weekly% • Failure%of%uterine%involution%
consecutive%measurements% • Plateauing%or%increasing%hCG%titers%
• Rise%of%serum%beta.hCG%%>%%10%%for%%3%weekly%
consecutive%measurements% Invasive3mole33
• Serum%beta.hCG%level%remains%detectable%for%6% D!ang!mole!ay!nagpepenetrate!sa!myometrium,!not!confined!sa!
months%or%more% uterus.!Bumabaon!sya!sa!muscle!layer!ng!matres!!
• Histological%criteria%for%Choriocarcinoma% D!Propensity!to!spread!to!other!parts!of!the!body.!
%
GTN*CLINICAL*STAGING% DIAGNOSIS*OF*INVASIVE*MOLE*
• Thorough%pelvic%assessment,%hemogram,%renal% • Demonstrating%%%the%%%pathology%%%itself%%%via%
and%liver%function%studies,%chest%x.ray,%pelvic% hysterectomy*
sonogram,%CT%scan%help%determine%the%extent% • Ultrasonography%
of%metastases%
• Doppler%scanning%
• Clinical%staging%is%similar%to%that%of%the%ovarian% • Curettings%(rarely)%
cancer,%except%that%Stage%III%includes%pulmonary%
metastases%
Sasabihin!ng!patho!D!may!abnormal!trophoblast!invading!the!
%
myometrium.!So!hindi!H!mole,!invasive!mole!na!siya!(cancer)!
Stage%I:%Tumor%confined%to%the%uterus%
Stage%II:%Tumor%confined%to%the%pelvis%
%
Stage%III:%Pulmonary%metastases%
%
Stage%IV:%Distant*metastases%
%
Trophoblastic!ca!D!you!die!in!less!than!6!months!so!magpatingin! %
na!agad!sa!specialist.!You!need!to!refer!also!as!an!OB!GYN.! %
%
WHO*RISK*SCORING*SYSTEM* %
• Determines%the%risk%assessment%and%type%of% %
chemotherapy%to%be%used% %
• Low%Risk%Neoplasia:%%0%to%6% Invasive3mole3grossly3
• High%Risk%Neoplasia:%%7%or%higher% %
• Scores%of%0%to%4%are%given%to%each%category%(age,% %
type%of%antecedent%pregnancy%and%the%interval% %
from%it,%serum%beta.hCG%concentration,%size%of% %
the%tumor,%its%site,%number%of%metastases%and% %
previous%chemotherapy)% %
% %
TREATMENT*OF*GTN* %
• IMPORTANT:*Referral*to*a*trophoblastic* %
diseases*expert* %
• Chemotherapy%(principal%mode%of%treatment.%Eto% Dark3areasE3hemorrhage3
muna%bago%surgery.)% Kung!h!mole!dapat!nsa!uternine!cavity!lang!pero!eto!nasa!
! Following%successful%treatment,%fertility%is% labas!na!and!it!is!penetrating!the!muscularis!layer.!
not%%%impaired%%%and%%%pregnancy% %
outcomes%are%normal% %
• Hysterectomy%(adjunctive)% %
• Surgery%and%radiotherapy%(adjunctive)% %
• βhCG%monitoring%for%a%minimum%of%18%months%k%%% %
Contraception% %
• Surveillance%%for%%recurrence%%of%%disease%%after% %
chemotherapy%is%done%for%18%months% %
• Contraception%(mandatory!)% %
• Treatment%for%%GTN%%is%%the%opposite%of%%what% %
gynecologic%%%oncologists%%%do%%%for%%%cervical% %
endometrial,%uterine,%ovarian,%vulvar% Pink3areas3E3uterine3musculature.!large!sago!like!cystically!
cancer:%surgery%first%then%chemotherapy%+% dilated!placental!villi!invading!the!musclaris!
radiotherapy;%for*GTN*chemotherapy*first* %
followed*by*surgery*and*radiotherapy!!*%
CHORIOCARCINOMA*
%
• May%%be%%considered%%a%%carcinoma**of**the*
INVASIVE*MOLE* chorionic*epithelium*
• Excessive*trophoblastic*overgrowth*and*deep* • May%%arise%%from%%or%%accompany%%any%%type%%of%
penetration*by*trophoblastic*elements*into*the* pregnancy%
myometrium*and*adjacent*structures*
• Usual*antecedent*pregnancy*is*HLmole*
• Hemorrhage%
• Grossly%%appears%%as%%a%%rapidly%%growing%%mass%
• Metastases% invading%both%myometrium%and%blood%vessels,%
• Persistent%or%%irregular%%vaginal%%bleeding%%after% causing%hemorrhage%and%necrosis%

Transcriber/s:!Ynoli!Diosomito,!Karl!Nievera!,!Anonymous!Third!Wheel!
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• Microscopically,%there%is%exuberant%trophoblastic% Globular!spherical!white!masses!D!canon3ball3lesions!
growth,%appear%as%column%and% pero!nowadays,!it!mimics!chest!findings!ng!early!
sheets%of%trophoblast%with%no*villous*pattern% pneumonia!and!pulmonary!TB.!But,!mahuhuli!sa!
• Propensity%to%invasive%growth%and%necrosis%of%blood% location:!sa!tb!D!mahilig!sa!o2!so!nasa!bandang!taas!
vessels%
yung!haziness.!yung!pulmonya!D!may!pus!secretions!so!
• Irregular***vaginal*bleeding%%%is%%%the%%%most%%% by!gravity!nasa!bandang!baba!nagsisimula.!ang!
common%
choriocarcinoma!usually!nasa!middle!lung!fields.!
presentation%
kala!mo!haziness!but!check!for!+!preg!test!&!blood!
• May%present%as%an%isolated%finding%of%distant%
stained!sputum.!
metastases%
!
• Signs%and%symptoms%may%be%seen%immediately%
after%or%years%after%the%antecedent%pregnancy% PLACENTAL*SITE*TROPHOBLASTIC*TUMOR**
• Rare%%trophoblastic%%tumor%%arises%%from%%the%
Sa!invasive!mole!D!may!sago!sago,!sa!chorio,!wala!nang!sago!
neoplastic*transformation*of*the*intermediate*
sago.!sheaths!of!abnormal!cells!lang.!it!is!a!cancer!D!prone!siya!
trophoblastic***cells,%%%many%%%of%%%which%%%are%
na!mag!invade!and!metastasize! prolactin.producing%
DIAGNOSIS*OF*CHORIOCARCINOMA* • May%complicate%or%follow%any%gestation%%
• High%index%of%suspicion% • Diagnosis%is%made%by%D%&%C,%hysterectomy%%
• All**cases**of**hLmole**should**be**considered* • Serum%beta.hCG%levels%are%low,%compared%to%
potential*cases*of*choriocarcinoma* tumor%mass%
• Should%%always%%be%%considered%%when%%uterine% • Secretes%%human%%placental%%lactogen%(hPL)%.%
involution%does%not%occur%or%is%delayed% tumor%marker%
• Signs%of%unexplained%distant%metastases% • Symptoms%appear%immediately%or%even%years%
• hCG%assays% after%%pregnancy%%in%%the%%form%%of%%irregular%bleeding%
% and%amenorrhea%
METASTASIS*IN*CHORIOCARCINOMA* • Bleeding*L*main*presenting*symptom**
• Hematogenous*route* • Tumor*growth*is*infiltrative*
• May%exhibit%distant%metastasis%without%a%trace% • WHO%Prognostic%Score%is%of%little%help%hence%
of%residual%disease%in%the%uterus% chemotherapy%has%little%effect%on%this%tumor%%
• Occurs%early% • Hysterectomy*is*the*best*treatment*
• Most%common%site:*lungs**(>75%)*and*vagina* ! Hysterectomy!will!only!buy!you!enough!time.!
(50%)* Palliative!lang.!

Very!sneaky!tumor!haha.!walang!bukol!sa!matres!pag!ka! Remember:33PSTT3E33hPL,3HEmole3E3hCG3
ultrasound!pero!pwede!sa!brain!pag!nag!CT!scan!ka.!Can!also!be! In!choriocarcinoma,!!you!can!still!determine!the!syncitio!and!
in!the!lungs.! cytotroph.!In!pstt,!hindi!na.!It!all!looks!hyperchromatic.!nucleus!
! has!many!nucleoli!
% !
% Placental!site!trophoblastic!tumor:!mas!galing!sa!poorly!diff!
% trophoblasts!D!intermediate!trophoblast!ang!tawag.!
%
No!treatment!for!this,!goodbye!kana!daw.!Haha!huhu!
% !
%
% EPITHELIOID*TROPHOBLASTIC*TUMOR*
% • New%kind%of%trophoblastic%tumor%
% • Arise%%%from%%%mononuclear% (chorionic.type)%
% intermediate%trophoblasts%
% • Microscopically%similar%to%PSTT,%but%the%cells%
% are%%%%smaller%%%%and%%%%show%%%%less%%%%nuclear%
% pleomorphism%
Dark!areasD!hemorrhage!and!necrosis! • Tumor%growth%is%nodular%
% • Hysterectomy%is%the%best%treatment;%does%not%
% respond%very%well%to%chemotherapy%
%
% (Nice!to!know!pang!specialist!level!daw!‘to)!
% PROPHYLACTIC3CHEMOTHERAPY3CRITERIA:3
% # hCg!above!100k!untis/ml!
% # Callutein(?)!cysts!6cm!above!
% # If!pt!comes!from!a!far!flung!area!and!risk!for!no!follow!
% up!is!great!
% # Gravida!5!or!more!
% # If!pt!has!had!a!previous!!H!mole!in!a!prev.!pregnancy!
% Drugs!D!Methotrexate!or!Actinomycin.!But!Methotrexate!kasi!
cheaper!and!side!effects!less!uncomfortable!sa!patient.!
%
Not!for!young!patients.!35!y/o!and!above!only.!
!
Transcriber/s:!Ynoli!Diosomito,!Karl!Nievera!,!Anonymous!Third!Wheel!
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ABNORMALITIES*OF*THE*PLACENTA* • The%umbilical%cord%and%portion%of%placenta%will%
1.%%Abnormal%shape%or%implantation% lacerate%%%portion%of%placenta%will%be%left%behind%%%
2.%%Circulatory%disturbances% Bleed%
3.%%Placental%calcification% %
4.%%Hypertrophic%villous%lesions%% %
5.%%Placental%tumors%% %
% %
ABNORMAL*SHAPE*OR*IMPLANTATION* %
1.%%Multiple%Placentae%with%single%fetus% %
2.%%Succenturiate%Lobe% %
3.%%Placental%Membranacea% %
4.%%Ring%Shaped%Placenta% %
5.%%Placental%Fenestrata%
6.%%Extrachordial%Placentation% Ang!placental!villi!nasa!main!placental!mass!dapat.!Here,!may!
7.%%Placenta%Accreta,%Increta,%Percreta% villi!even!on!the!membranes!covering!the!placenta!itself.!
% !

MULTIPLE*PLACENTAE*WITH*SINGLE*FETUS* RING*SHAPED*PLACENTA*
• Uncommonly,%the%placenta%forms%as%separate,% • Placenta%is%annular*in*shape.%More%commonly,%it%
nearly%equal%sized%disks.% is!shaped!like!a!horseshoe!due!to!atrophy!of!a!
• Bipartite*Placenta%.%the%umbilical%cord%inserts% portion%of%the%supposed%ring.%
between%2%placental%lobes% • The%placental%mass%forms%a%ring%and%the%center%of%
% it%is%just%a%membrane%
% %
% %
% %
% %
% %
% %
% %
• Multiple/Multilobate*Placenta%.%the%umbilical% %
cord%inserts%in%three%or%more%placental%lobes% %
% PLACENTAL*FENESTRATA*
SUCCENTURIATE*LOBE* • The%central**portion*of*a*discoid*placenta*is*
• Succenturiate%refers%to%one*or*more*accessory* missing.%
lobe%%that%%develops%%in%%membranes%%that%%are% %
usually%at%a%distance%from%the%main%placenta.% EXTRATRACHORIAL*PLACENTATION*
• These%%%%accessory%%%%lobes%%%%have%%%%vascular% • When%the%chorionic%plate,%which%is%on%the%fetal%
connections%of%fetal%origin.% side%of%placenta,%is%smaller%than%the%placental%
% fetal%%plate(located%%at%%the%%maternal%%side)%
% • Uncovered*placental*periphery*
% %
% CIRCUMVALLATE*PLACENTA*
% • The%fetal%surface%of%the%placenta%has*a*central*
% depression**surrounded**by**a**thickened,*
greyish*white*ring.%
%
• Within%%the%%ring,%%the%%large%%vessel%%of%%the%
%
placenta%%disappears%%abruptly%%at%%the%%ring%
% edge.%
% • The%umbilical%cord%inserts%at%the%center%and%the%
• Basically,%you%already%have%a%main%placenta%and% placenta%is%surrounded%by%a%ring%
then%you%also%have%a%separate%accessory%lobe%
%
• The%complication%with%this%is%that%the%placenta*is*
delivered*but*the*succenturiate*lobe*is*not.% %
• Because%of%this,%patients%are%prone%to%have% %
postpartum**hemorrhage%%since%%the%% %
succenturiate%lobe%is%not%delivered.% %
% %
PLACENTAL*MEMBRANACEA* %
• All%or%a%large%part%of%the%fetal%membranes%are% %
covered*by*functioning*villi%
%
• Problem%%%%also%%%%involves%%%%post%%%%partum%
hemorrhage:%% %
%

Transcriber/s:!Ynoli!Diosomito,!Karl!Nievera!,!Anonymous!Third!Wheel!
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CIRCUMMARGINATE*PLACENTA* • Syncytiotrophoblast%%is%%important%%in%%fetal%
• The%ring%does*not*have*a*central*depression* restriction.%If%they%die,%then%the%baby%will%go%
where*the*umbilicus*inserts.*(walang!lubog.!Lubog! through%restriction%or%death.%
not!libog!ok.)%
% PLACENTAL*HEMATOMA*
%
% %
%
%
%
% %
%
%
%
%
PLACENTA*ACCRETA,*INCRETA,*PERCRETA** • Retroplacental%.%%Collection%%of%%blood%%is%
• Trophoblastic*tissue*invades*the*myometrium* between%the%placenta%and%adjacent%decidua%
to*varying*depths.** • Marginal%.%Collection%of%blood%is%between%the%%
• This%%is%%more%%likely%%with%%placenta%%previa%%or% chorion%%and%%decidua;%%This%%is%%also%referred%to%as%
implantation%over%previous%uterine%incision.% subchorionic%hemorrhage%
%
During!the!first!part!of!pregnancy,!the!placenta!is!absent! %
from!the!decidua.!With!Placenta!accreta,!increta!and! %
percreta,!it!is!attached!and!hindi!matanggal.!And!as!a! %
result,!the!patient!will!have!post!partum!hemorrhage! %
!
%
PLACENTAL*CIRCULATORY*DISTURBANCES*
%
1.%%Maternal%Blood%Flow%Disruption% %
2.%%Fetal%Blood%Flow%Disruption%
%
%
• Subchorial**Thrombosis*(Breus**Mole)*L*
MATERNAL*BLOOD*FLOW*DISRUPTION* Collection%of%blood%along%the%roof%of%the%
MATERNAL*FLOOR*INFARCTION* intervillous%space%and%beneath%the%chorionic%plate%
• A%dense,*fibrinoid*layer%is%deposited%on%the% • Subamniotic%.%%Collection%%%of%%%blood%%is%
placental%%basal%%plate%%and%%this%%acts%%as%%a% between%the%placenta%and%the%amnion%
blockade%to%normal%maternal%blood%flow% %
• Associated%%with%%fetal%%growth%%restriction,%
PLACENTAL*INFARCTION*
abortion,%preterm%and%stillbirth%
• Seen*in*hypertensive*patients*
• Grossly,%appears%as%a%whitish*material*(whitish!
• Hypertensive%%%%conditions%%%%diminish%%%%or%obstruct%
material!daw!oh…..!kasi!infarcted.!Hehe!ano!naisip!
the%maternal%circulation%through%the%
mo!ha?)%
uteroplacental%%vessels%%%uteroplacental*
%
insufficiency%
%
% %
% %
% %
% %
% %
% %
%
%
%
The!Fibrinoid!material!is!a!waste!product!and!practically!a!dead!
%
material.!If!fibrinoid!material!!is!!deposited!!on!!placenta!!
FETAL*BLOOD*FLOW*DISRUPTION*
basal!plate,!blood!is!unable!to!pass!through!the!placenta!!
properly.!!Because!!of!!this!!the!uteroplacental!perfusion!is! FETAL*THROMBOTIC*VASCULOPATHY*
affected.!This!could!lead!to!Fetal!growth!restriction.! • Distal%%to%%the%%point%%of%%obstruction,%%the%
affected*villi*are*rendered*nonLfunctional%
Whitish!areas!are!infarcted!areas!of!the!placenta.!if!you!have!
infarcts!there!is!disruption!of!maternal!blood!flow!and!can!lead!
to!complications! Basically,!!The!!vessels!!thrombose!!!blocked!!vessel!!!no!!
! blood!!can!!pass!through!!!Villi!!!are!!!rendered!!!nonD
PERIVILLOUS*FIBRINOID*DEPOSITION* functional!
• Small*nodules*form%within%the%placenta%when% !
%
normal%maternal%blood%flow%around%a%villus%slows%
HEMATOMA*
%%Blood*stasis*and*fibrin*deposition%%%
Diminished%oxygenation%%%Syncytiotrophoblast% • Subamniotic*.%%%The%%%hematoma%%%occurs%
necrosis%%%Fetal*growth*restriction*or*demise% between%%the%%placenta%%and%%amnion.%%This%
rd
usually%occurs%during%the%3 %stage%of%labor%when%

Transcriber/s:!Ynoli!Diosomito,!Karl!Nievera!,!Anonymous!Third!Wheel!
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cord%traction%ruptures%a%vessel%near%the%cord% CHORIOAMNIONITIS*
insertion% • Infection*of*Fetal*membrane*
% • Begins%with%entry%of%vaginal%bacteria%into%the%upper%
PLACENTAL*CALCIFICATION% reproductive%tract%%%Infection%of%the%chorion%and%%
• Placental%%%calcification%%%is%%%associated%%%with% adjacent%%decidua%%overlying%%the%internal%cervical%os%
nulliparity,%%higher%%socioeconomic%%status%%and% %%full%thickness%involvement%of%the%membranes.%
greater%maternal%serum%calcium%levels.% • Chorion%and%amnion%are%already%affect6ed%and%as%a%
• Seen%through%sonography% result%there%is%clouding*of*membranes*and*the*
• Of*no*clinical*significance* presence*of*foul*odor.%
% • May%result%from:%
1. Hematogenous%routes%
HYPERTROPHIC*VILLOUS*LESIONS*
2. Aspiration%
• Enlargement%of%the%chorionic%villi.%This%is%usually%
3. Fetal%Swallowing%
associated%%with%%severe**Erythroblastosis**and*
4. %Direct%contact%with%contaminated%
fetal*hydrops.*
amniotic%fluid%
%
%
PLACENTAL*TUMORS* Fetal!Membranes!appear!clouded!and!when!insinuated!in!
GESTATIONAL*TROPHOBLASTIC*DISEASE* between!membranes!and!placental!cotyledon!it!appears!
• Gestational%trophoblastic%diseases%are%pregnancy. white!and!fingers!are!not!transilluminating!!
related%%trophoblastic%%proliferative%abnormalities% !
% Normal:!Glistening!white!with!fingers!seen!when!
CHORANGIOMA* insinuated!in!between!the!membranes!and!the!placental!
• Choriangiomas%are%wellLcircumscribed,*rounded,*** cotyledon.!
hypoechoic***lesions***near***the*chorionic**surface** %
which**protrude**into**the*amniotic*cavity.% • Treatment:*
• Basically,!your!placenta!has!a!bukol.!! ! Giving%%antibiotics%%for%%gram%(.)%%and%
In!!large!!growth,!!there!!is!!significant!!arterioDvenous! anaerobic%bacteria%
shunting!within!the!placenta!à!fetal!anemia!and! ! Expedient*delivery*of*the*fetus*
hydrops! " If%patient%is%already%8.10%cm%dilated%and%
• Other%complications! baby%has%good%fetal%heart%tone,%you%can%
still%give%normal%delivery.%%But%you%will%
! Antepartum!hemorrhage!
need%oxytocin%and%forceps%to%aid%in%
! Preterm!delivery!
delivery.%
! Amniotic!fluid!abnormalities!
" o%%%If%only%2%cm%dilated%but%already%shows%%
! Fetal!growth%restriction%
anaerobic%%symptoms,%even%if%the%baby%
• Treatment%
has%good%fetal%heart%%tones,%you%don’t%
! Vessel%occlusion%or%aberration%in%order%to% do%expedient%delivery%%%Emergency%CS%
reduce%the%blood%flow%to%the%tumor% instead%
" Infection%can%kill%both%the%mother%and%the%
TUMOR*METASTATIC*TO*THE*PLACENTA%% baby%
• Tumor*cells*are*usually*confined*to*intervillous* !
space* OTHER*ABNORMALITIES*
• Tumors% like% Melanomas,% Leukemias,% AMNION*NODOSUM*
Lymphoma,%Breast%Cancer%metastasize%to%the% • Consists%of%several%small,*light*tan*nodules%on%the%
placenta% amnion%that%overlies%the%placenta%
%
• Hallmark*of*prolonged*and*severe*
ABNORMALITIES*OF*THE*FETAL*MEMBRANES* Oligohydramnios*
*
1.%%Meconium%staining%
AMNIONIC*BANDS*
2.%%Chorioamnionitis%
• Bands%or%strings%that%entrap%the%fetus%as%a%
3.%%Others% result%of%disruption%of%the%amnion%%%impaired%
%
growth%and%development%of%involved%structure%
MECONIUM*STAINING* %
• Seen%in%post.term%fetus% ABNORMALITIES*OF*THE*UMBILICAL*CORD*
• Vagal%%stimulation%%due%%to%%cord%%or%%head% 1.%%Measurements%
compression% 2.%%Coiling%
• Fetal%acidosis,%non.reassuring%fetal%heart%rate% 3.%%Vessel%number%
patterns%and%low%APGAR%score%%%Fetal%hypoxia%% 4.%%Insertion%
%%%Fetal%hypoxia%(initial%insult)%%%Anal%sphincter% 5.%%Abnormalities%that%impede%blood%flow%
relaxation%%and%%fetal%%gasping%%%%In%%utero% %
aberration%of%meconium% ABNORMALITIES*OF*CORD*LENGTH*
% • Fetal%cords%usually%measure%50.60%cm%
Meconium!stained!placenta!(greenish)!
% • Short%cords%may%be%associated%with%adverse%
Meconium!Aspiration!Syndrome! perinatal%outcomes%such%as:%
%
Obstruction!of!airways!!!Severe!fetal!hypoxia!à!!Inflammation!and!
% ! Fetal!growth!restriction!
Infection!
% ! Congenital!malformation!
MeconiumDladen!!!amniotic!!!fluid!!!embolism!increases!maternal!mortality! ! Intrapartum!distress!
rates!from!cardioDrespiratory!failure!and!consumptive!coagulopathy!!!!Poop!
Transcriber/s:!Ynoli!Diosomito,!Karl!Nievera!,!Anonymous!Third!Wheel!
can!also!embolize!
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Risk!of!Peuperal!Metritis!also!increases!
Editor/s:!Aibhen!Naguna!&!Chacha!Mercado!
!
!
! Increased%risk%of%fetal%death% %
% FURCATE*INSERTION*
• Long%cords%may%be%associated%with:% • The%cord%insertion%site%is%normal,%but%the%vessels%
! Cord!prolapse!or!entanglement! lose*their*protective*Wharton*jelly*shortly*
! Fetal!anomalies! before*insertion%%%Prone%to%compression,%
! Fetal!distress! twisting,%thrombosis%of%the%umbilical%cord%
! Fetal!demise!
• Lean%cords%are%associated%with%poor%fetal% The!Wharton’s!jelly!is!lacking!or!lost!right!before!inserting!into!
Growth%(makipot%=%bansot)% the!placenta.!Could!rupture!and!cause!placental!hematoma!and!
! Usually!lacerate!and!break! intraplacental!perfusion!may!be!impaired.!
! Not!!able!!to!!deliver!!the!!placenta! !

immediately! VELAMENTOUS*INSERTION*
! May!need!to!do!manual!extraction!of!the! • The%umbilical%vessels%spread%within%the%membranes%
placenta! at%a%distance%from%the%placental%margin%which%they%
• Large%diameter%cords%are%associated%with%fetal% reach%surrounded%only%by%a%fold%of%amnion%%%
Macrosomia%(makapal%=%malaki)% vulnerable%to%compression%%fetal%anoxia%
* • Common%in%placenta%previa%and%multifetal%
CORD*COILING* gestation!
• Hypocoiling%%%Fetal%demise% • Vessels!tend!to!spread!even!before!the!umbilical!cord!
• Hypercoiling%(too%many%coils)%%%Fetal%growth% inserts!into!the!placenta.!Vessels!can!rupture.!Still!has!
restriction,%intrapartum%fetal%acidosis,%asphyxia% their!membranes!but!because!of!their!superficial!
% location,!they!rupture.!
ABNORMALITIES*OF*CORD*VESSEL*NUMBER* %
1.%%Single%Umbilical%Artery% VASA*PREVIA*
2.%%Hyrtl%Anastomosis% • Placental*vessels*overlie*the*cervix,%lie%between%
3.%%Four.Vessel%Cord% the%cervix%and%the%presenting%fetal%part%and%are%
4.%%Fused%Umbilical%Artery% supported%only%by%membranes%%%Compression%
% and%laceration%
SINGLE*UMBILICAL*ARTERY* • Sometimes%present%earlier%than%the%head%%%can%
• Due%%to%%secondary*atrophy*of*a*previously* rupture%%%baby%will%bleed%%%fetal%distress%
normal*umbilical*artery% %
• %Increased%risk%of%presence%of%aneuploidy%% RISK*FACTORS:*
• Increased%%frequency%%of%%associated%%anomalies% • Bilobate%or%succenturiate%placenta%
(renal%%agenesis,%%imperforate%%anus,%%vertebral% • Second%trimester%placenta%previa,%with%or%without%
defects)% later%migration%
% • Pregnancies%conceived%by%in%vitro%fertilization%
HYRTL*ANASTOMOSIS* %
• A%%connection**between**the**two**umbilical* ANTEPARTUM*DIAGNOSIS*
arteries% • Palpation%%or%%direct%%visualization%%of%%a%vessel%in%the%
• Present%in%most%placenta% membrane%overlying%the%fetal%part%
• Act%as%a%pressure.equalizing%system%between%the%%% • Endovaginal%sonography%
two%%%umbilical%%%arteries%%%Improves%placental% • Color%Doppler%
perfusion%during%uterine%contraction%
• An%abnormality%that%helps%the%baby%during%labor% Ito!ay!ung!umbilical!cord,!malayo!pa!sya!sa!placental!
% insertion,!ayun!naghiwalay!na!ang!blood!vessels!ang!
FOURLVESSEL*CORD* problema,mahaharang!ngayon!sila!sa!internal!os,!so!kapag!
ang!baby!na!ito!ay!gumalaw!or!naglabor!to,!itinulak!ng!fundus!
• Presence%of%an%umbilical%vein%remnant%
yung!baby!papunta!ditto!matatamaan!nya!itong!mga!vessels!
• Usually,!there!is!only!1!umbilical!vein.!If!there!is!a! na!ito.!So!pwedeng!magrupture,!macompress!yan.!The!baby!
remnant,!there!will!be!4!cords!upon!the!inspection! becomes!anoxic!and!the!baby!can!die!due!to!Fetal!distress.!
of!the!umbilicus! !

% %
FUSED*UMBILICAL*ARTERY* ABNORMALITIES*THAT*IMPEDE*BLOOD*FLOW*
• During%early%embryological%development,%the% 1.%%Knots%
umbilical%artery%fails%to%split%%%fused%shared%lumen% 2.%%Loops%
• Higher%rates%of%velamental%or%marginal%cord% 3.%%Funic%Presentation%
insertions% 4.%%Stricture%
CORD%INSERTIONS% 5.%%Hematoma%
ABNORMAL*CORD*INSERTIONS* 6.%%Cysts%
1. Marginal% 7.%%Thrombosis%
2. Furcate% 8.%%Vessel%Dilatation%
3. Velamentous% %
* UMBILICAL*CORD*KNOTS*
MARGINAL*CORD*INSERTION* FALSE*KNOTS*
• Cord%is%inserted%at%the%placental%margin% • Appear%as%knobs%protruding%from%the%cord%surface%
• Battledore%Placenta% • are%focal%redundancies%of%a%vessel%or%of%Wharton’s%
• Is%of%little%clinical%significance% Jelly%
• No%clinical%significance%

Transcriber/s:!Ynoli!Diosomito,!Karl!Nievera!,!Anonymous!Third!Wheel!
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% %
TRUE*KNOTS* UMBILICAL*CORD*CYST*
• Caused%by%active*fetal*movement% TRUE*CYST*
• Common%%%in%%%monoamniotic%%%twin%pregnancies% • Epithelium.lined%remnants%of%the%allantois%
• Increased%risk%for%stillbirth%
• Impedes!blood!flow!the!baby!could!die! PSEUDOCYSTS*
• From%local%degeneration%of%Wharton’s%jelly%
%
UMBILICAL*CORD*LOOPS* • More%common%
• More%likely%with%long*cords% • Associated%with%fetal%structural%and%
• Nuchal%cord% chromosomal%defects%if%they%persist%beyond%the%
! Cord%that%is%looped%around%the%fetal%neck% first%trimester%%
• Uterine%contractions%may%compress%the%cord% %
vessels%%%Fetal%heart%rate%decelerations% UMBILICAL*CORD*THROMBOSIS**
• Usually%involves%%umbilical%vein%thrombosis;%have%
%
FUNIC*PRESENTATION* lower%perinatal%morbidity%and%mortality%rates%%
• Umbilical*cord*is*the*presenting*part*in*labor** • Umbilical%%artery%%thrombosis%%are%%associated%%
• Often%%associated%%with%%fetal%%malpresentation,% with%fetal%growth%restriction%and%demise%%
cord%prolapse%and%fetal%heart%rate% • There!is!a!blood!clot!within!umbilical!cord!!!
abnormalities% Umbilical!vessel!is!obstructed!!
• Identified%antenatally%by%sonography%and%color% %
flow%Doppler% UMBILICAL*CORD*VESSEL*DILATATION**
• Here,!the!umbilical!cord!is!“nauuna!sa!birth! UMBILICAL*VEIN*VARIX*
canal”!and!this!leads!to!fetal!distress.!Because!of! • A%marked*focal*dilatation%that%may%develop%
this,!a!CS!is!usually!performed! within%the%intraamniotic%part%of%the%umbilical%
% vein%or%within%its%fetal%intraabdominal%portion%%
UMBILICAL*CORD*STRICTURE* • The%varix%can%be%within%the%stomach%of%the%baby%
• A%focal%narrowing%of%the%umbilical%cord%in%the% or%part%of%umbilicus%outside%the%stomach%of%the%
area%of%fetal%umbilical%insertion% baby%%
! Caused%by%absence%of%Wharton’s%jelly%and%% %
stenosis%%or%%obliteration%%of%%cord%vessels%at% COMPLICATIONS**
the%narrow%segment% • Rupture%%
• Most%fetuses%are%stillborn%because%no%oxygen,% • Thrombosis%%
blood%and%nutrients%can%penetrate%or%pass% • Compression%of%the%umbilical%artery%%
through.% • Fetal%cardiac%failure%due%to%increased%preload%%
% %
UMBILICAL*CORD*HEMATOMA* UMBILICAL*ARTERY*ANEURYSM*
• Results%from%a%varix*rupture,%usually%the% • Rare,*congenital*thinning*of*the*vessel*wall*
umbilical%vein,%with%effusion%of%blood%into%cord%% with*diminished*support*from*Wharton’s*jelly**
• Associated%with%short%cords,%trauma%and%fetal% • Associated%with%%the%%presence%%of%%a%%single%
entanglement% umbilical%%artery,%%Trisomy%18,%%fetal%%growth%
% restriction%and%stillbirth%due%to%umbilical%vein%
% compression%%
% %
LENDL*
TRANSCRIPTION*DETAILS*
Handout;%Lecture;%
Anonymous%Gwapo%
BASIS% Pictures%of%slides;%HB% RECORDINGS% +% NOTES% ++% DEVIATIONS% 9%% CREDITS%
Transcriber%
Notes%
No%Powerpoint%provided.%%
REMARKS%
Pussykip%Dolls%#1%Fan%–AnnaBerthaLudwig.%Inaalay%ko%ang%tranx%na%ito%sa%inyo.%Hail%Row%E.B,%COFC!%:D
EBATCH320163Transcribers’3Guild3Transcriptions.3Version31.0.0.0.03Build33106E3
%
!

* **
* !
Pussykip Dolls
!
!

Transcriber/s:!Ynoli!Diosomito,!Karl!Nievera!,!Anonymous!Third!Wheel!
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