GROUP DISCUSSION ON
SPECIMENS
DR. MB BELLAD
DR. SHIVANI
DR. VOMICA
DR. ARITRI
CONTENTS
1. Anencephaly
2. Vesicular Mole / Gestational trophoblastic disease
3. Fibroid Uterus
4. Retained Placenta
5. Carcinoma Cervix
ANENCEPHALY
IDENTIFICATION OF SPECIMEN:
• Absence of major portion of the brain, skull and scalp, but
with normal face.
Anencephaly
• Incidence- 1 in 1000 births
• Neural Tube Defect
• Deficient development of the skull vault and brain tissue
whereas the facial profile remains Normal
Williams Obstetrics – 25Th Edition
Q ) What is Neurulation?
When does Caudal Pore and Neural pore Closes ?
• The neural plate (NP) is a portion of the dorsal ectoderm
that is specified to become the neural ectoderm.
• Neurulation – formation of neural tube
Stages-
1. Formation of neural plate
2. Shaping of neural plate
3. Bending of neural plate
4. Closure of neural groove
Larsen’s Human Embryology – 5Th Edition
• Cytoskeletal , Extracellular Matrix / Cell Adhesion / Cell Cycle , Cell Death
genes result In Neural Tube Defects
• Closure of neural groove begins on D22 and eventually Cranial and
Caudal Neuropores close at D24 and D26.
Open NTDs a/k/a dysraphism or craniorachischisis
Total dysraphism in brain , with normal formation of spinal cord leads to
Cranioschisis or anencephaly
Larsen’s Human Embryology – 5Th Edition
Features
• Acrania with absence of telencephalic structures
• Absent or hypoplastic Pituitary Gland
• Absent or hypoplastic Adrenal Gland
• Incidence : Females > Males
Diagnosed in Late I st and II nd Trimester of
pregnancy
Most Common Cause for suspicion – inability to
view BPD
DC Dutta Book Of Obstetrics – 25Th Edition
Q ) How to do Early Diagnosis of Neural Tube Defects ?
Screening Tests which help in Early Diagnosis and Treatment of
NTDs?
Biochemical Tests Results
Maternal Serum Alpha Feto Protein Increased
Estriol Decreased
HCG (Human Chorionic Gonadotropin) Normal
Williams Obstetrics – 25Th Edition
What Sonographic
Findings are seen in
Anencephaly ?
Acrania
Frog Eye / Mickey Mouse
Appearance may be seen (Due to absence of
cranial bone/brain and bulging orbits)
Williams Obstetrics – 25Th Edition
DC Dutta Book Of Obstetrics – 25Th Edition
Q ) What is Lemon and Banana sign and is
Associated with which Congenital Anomaly ?
Lemon sign
Frontal bone scalloping
Lemon Sign
Banana Sign
Obliteration of the Cisterna Magna
Absent cerebellum or Abnormal Anterior Curvature
of the Cerebellar Hemispheres
Williams Obstetrics – 25Th Edition
DC Dutta Book Of Obstetrics – 25Th Edition Banana Sign
Q ) Other Congenital Anomalies associated with
Anencephaly
1. Polyhydraminos
2. Abdominal wall defects – Omphalocele
3. Hydronephrosis
4. Cardiac Anomalies
5. Cleft Palate
Williams Obstetrics – 25Th Edition
Q ) Complications associated with Neural Tube Defects ?
• Hydraminos (70%)
• Malpresentations-face or breech
• Premature labour
• Tendency of post maturity
• Shoulder dystocia
• Obstructed labour
Williams Obstetrics – 25Th Edition
Q )List all the Neural Tube Defects ?
1. Craniorachischisis
2. Encephalocele
3. Iniencephaly
4. Spina bifida Occulta
5. Closed spinal dysraphism
6. Meningocele
7. Myelomeningocele
Williams Obstetrics – 25Th Edition
Lakshmi Seshadri Essentials of Obstetrics – 25Th Edition
Q) How will you Manage such a case ?
• Termination of pregnancy
Q ) How Will You Counsel This Woman If She Has History Of Congenital
Anomalies In The Previous Pregnancies ?
If This Woman Comes In The Preconceptional Period What Counseling Should Be
Done?
• Pre-pregnancy counseling
• Folic acid supplementation (4 mg daily) begining 1 month before conception
to about 12 weeks of pregnancy
Williams Obstetrics – 25Th Edition
Q ) What are the high risk factors which predispose to neural tube defect in
fetus?
GENETIC HISTORY MATERNAL CAUSES – EXPOSURE TO FOLL
Multifactorial Inheritance Zinc deficiency DRUGS
MTHFR Mutation Folate Deficiency Valproate
Syndromes with Autosomal Gestational Diabetes Mellitus
Inheritance Thalidomjde
Abnormal Placentation
Meckel Grubler
Placental Insufficiency
Carbamezipine
Joubert Syndrome
Obesity Radiation exposure
Trisomy 13
Trisomy 18
Maternal Age >35 yrs Pesticide Exposure
k/c/o Epilepsy Fungal Toxins
Q ) What is the risk of recurrence in subsequent pregnancy if there is a
history of neural tube defect in fetus in previous pregnancy ?
2 % is the risk of recurrence in the subsequent pregnancy if there is previous history of
neural tube defects ?
Q ) What is the Difference between Omphalocele and Gastrochisis
Gastroschisis Omphalocele
Right paraumbilical Center
Content not covered by membranes Presence of peritoneum- amniotic membrane
No Umbilical Cord Umbilical cord inserted in caudal end of hernial
sac
Content – Intestine , Colon , Gonads( rare ) Intestine , Colon , Spleen , Liver
Not Associated With Other Congenital Anomalies Associated With Other Congenital Anomalies
What are the Causes of Increased and Decreased MSAFP?
Increased MSAFP Decreased MSAFP
Open Neural Tube Defects Obesity
Urinal Atresia. Diabetes
Fetal Urinary Tract Obstructions Gestational Trophoblastic Disease
Sacrococcygeal Teratoma Intrauterine Fetal Demise
Omphalocele And Overestimated Gestational Age.
Gastroschisis Chromosomal Trisomies,
Anencephaly Iniencephaly
Deficient development of the There is failure of formation of
skull vault and brain tissue cervical and upper thoracic
whereas the facial profile vertebrae and base of the skull
remains Normal with abnormally formed brain
tissue.
GESTATIONAL TROPHOBLASTIC DISEASE
Identification of specimen
• Mass filling the uterus with MULTIPLE
grape like vesicles
• Partial mole- fetus or at least amniotic sac
present
• Complete mole-no trace of embryo or
amniotic sac
Williams Obstetrics – 25Th Edition
Lakshmi Seshadri Essentials of Obstetrics – 25Th Edition
CLASSIFICATION (HISTOLOGICAL )
• Hydatidiform mole
• Invasive mole
• Choriocarcinoma
• Placental site trophoblastic tumor (PSTT)
HYDATIDIFORM MOLE
Define Hydatiform Mole ?
• It is an abnormal condition of the placenta where there are
partly degenerative and partly proliferative changes in the
young chorionic villi.
• Benign neoplasm of the chorion with malignant potential.
• Incidence-1 in 400 in india
Williams Obstetrics – 25Th Edition
Lakshmi Seshadri Essentials of Obstetrics – 25Th Edition
What Are The Risk Factors causing Molar Pregnancy ?
• Prevalence :Highest in teenage pregnancies
Women over 35 years of age
• H/o prior Hydatidiform mole increases the chances of recurrence.
• Faulty nutrition-Inadequate protein ,animal fat and carotene.
• Immunodeficient status
• Increased Maternal Gamma Globulin in absence of Hepatic disease
Williams Obstetrics – 25Th Edition
CYTOGENIC ABNORMALITIES
85 % - 46xx-the molar chromosome
will be
derived entirely from father
Maternal : Paternal chromosome ratio
is high
1. In Complete Mole 2:0
2. In Partial Mole 2:1
Williams Obstetrics – 25Th Edition
How Will Patient With Hydatiform Mole Present ?
1. White Current In Red Current Juice – PV Bleeding (blood + gelatinous fluid)
2. Expulsion of grape like vesicles Per Vaginum
3. Lower abdominal pain
4. Increased Constitutional symptoms –
• Hyperemesis Gravidarum
• Tachycardia
• Breathlessness
Williams Obstetrics – 25Th Edition
Lakshmi Seshadri Essentials of Obstetrics – 25Th Edition
What Will Examination Findings In Hydatiform Mole ?
Pallor +
Per Abdomen - Uterine size not corresponding to Gestational Age
Uterus Doughy and Elastic
Fetal parts not felt
No fetal movements
FHS Absent
Per Vaginum - Internal Ballotment not Elicitated
Palpable U/L or B/L theca luteal cyst
Grape like vesicle +
Williams Obstetrics – 25Th Edition
At What Hcg Level Can Intrauterine Pregnancy Be
Demonstrated On TVUS ?
What Is Doubling Time Of Serum Bhcg ?
DISCRIMINATORY ZONE of Serum HCG Level –
1500-2000 mIU/ml , an intrauterine Pregnancy should be
demonstrated using TVUS
• If Serum HCG Level is lower than 1500mIU/ml , test is
repeated in 48 Hrs ,HCG Level will double In 48 hrs .
What Investigations Will You Do For Hydatiform Mole ?
1. Biochemical Tests-
Quantitative measurement of beta HCG
High Titer in Urine Diluted upto 1 in 200 - 1 in 500 Beyond
100 Days Gestation
Rapidly increasing Serum HCG
COMPLETE MOLE >1,00,000 miu/ml
PARTIAL MOLE < 1,00,000 miu/ml
2. Trans Abdominal Sonography -snowstorm appearance
Williams Obstetrics – 25Th Edition
What Are The Causes Of Increased B HCG ?
• Hyperemesis Gravidarum
• Multiple Pregnancy
• Gestational Trophoblastic Disease
What Are The complications Of Hydatiform Mole ?
• Sepsis
• Hemorrhage and shock
• Perforation of uterus
• Preeclampsia
• Acute pulmonary insufficiency
• Coagulation failure
• Choriocarcinoma
Williams Obstetrics – 25Th Edition
Lakshmi Seshadri Essentials of Obstetrics – 25Th Edition
What are the risk factors associated with malignant
change ?
• Patient’s age ( >40 or < 20 years irrespective of parity)
• Parity >3 Age is more important than the parity
• Serum hCG > 100,000 mIU/m The development of
choriocarcinoma
• Uterine size > 20 weeks following Hydatidiform
Mole ranges between
• Previous history of molar pregnancy 2–10%
• Theca lutein cysts: Large
Williams Obstetrics – 25Th Edition
How will you manage a patient with H mole ?
• Suction and Evacuation - Till 20 weeks
HYSTERECTOMY
Indications
• Hysterotomy 1. Age > 35
2. Family Completed
• Hysterectomy 3. Uncontrolled hemorrhage
or perforation during
• Prophylactic Therapy surgical evacuation.
Hysterectomy reduces the
risk of GTN by fivefold.
Williams Obstetrics – 25Th Edition
Normal and Problem Pregnancies – Gabbe 7th Edition
Q ) What is prophylactic chemotherapy?
What are the different regimens that can be used ?
what are the indications ?
Methotrexate Regimen -
Methotrexate - 1 mg/kg/day IV/IM
(Days 1, 3, 5 and 7)
INDICATIONS
1. HCG level fails to regularize (10–12
Folinic acid - 0.1 mg/kg IM weeks)
(Days 2, 4, 6 & 8) 2. Any Evidence of metastases
3. In cases of high risk for malignant
sequelae
Actinomycin Regimen -
Actinomycin D 12 mg/kg body weight/day IV x 5 days
Williams Obstetrics – 25Th Edition
Normal and Problem Pregnancies – Gabbe 7th Edition
What are side effects of MTX therapy ?
• Nausea And Vomiting
• Stomatitis
• Conjunctivitis
• Gastritis
• Enteritis
• Dermatitis
• Pneumonitis
• Alopecia
• Elevated Liver Enzymes
• Bone Marrow Suppression
How will you follow-up the patient ?
Routine follow-up - At least 1 year
hCG levels following evacuation should regress to normal within 3
months time.
Follow Up Intervals
1. Initially, once/week till the serum hCG Levels become Negative
2. Once negative within 9 weeks, the patient is followed up at
once/month x 6 Months
Williams Obstetrics – 25Th Edition
Normal and Problem Pregnancies – Gabbe 7th Edition
What Are The Tests To Be Done During A Routine
Follow Up?
1. Any relevant symptoms like Irregular Vaginal Bleeding, Persistent Cough,
Breathlessness or Hemoptysis
2. Abdomino-vaginal examination to note: (i) involution of the uterus, (ii) ovarian
size
3. Investigations: (i) Detection of hCG in urine or serum
(ii) Chest X-ray – To check for any signs of metastasis
Williams Obstetrics – 25Th Edition
Normal and Problem Pregnancies – Gabbe 7th Edition
Q) If a patient presents with cough and breathlessness ? What will you
suspect ?
• With large molar pregnancies, the volume of tissue may be sufficient to produce
clinically apparent respiratory insufficiency, pulmonary edema, or even embolism.
Their chest x-ray manifestations clear rapidly without specific treatment.
• Choriocarcinoma is most common type of trophoblastic neoplasm to follow a term
pregnancy or a miscarriage, molar gestation.
It is composed of cells reminiscent of early cytotrophoblast and syncytiotrophoblast,
however, it contains no villi.
Metastases are generally blood-borne and the most common sites are the lungs and
vagina.
Features Complete Mole Partial Mole
Embryo/ Fetus Absent Present
Hydropic degeneration of villi Pronounced/Diffuse Variable and Focal
Trophoblast Hyperplasia Diffuse Focal
Uterine Size >POG <POG
Theca Lutein Cysts Common Uncommon
Karyotype 46, XX Triploid
Beta-hCG High >1,00,000 Slight Elevation <1,00,000
Classic c/f Common Rare
Risk of persistent GTN 20% <5%
Immunostaining (p57 KIP-2) Negative Positive
DC Dutta Book Of Obstetrics – 25Th Edition
CARCINOMA CERVIX
QUESTIONS
1. What is the recommended management of a woman with CIN 1?
2. What are the situations in which cone biopsy is indicated?
3. What is the differential diagnosis of a granulomatous growth on
cervix? From where should biopsy be taken in such a case?
4. . What are the treatment options for stage IB 2 and IIA?
5. For which patients should colposcopy f/b Pap Smear be done ?
QUESTIONS
6. How do you grade PAP smear?
7. How do you process PAP smear-method, stain used?
8. Which other technique is used for grading of cancer pathologies?
9. Comment on HBV DNA testing.
10. Which high risk HPV Viruses cause squamous cell carcinoma?
11. Management of patient if she is HPV- DNA positive?
HPV
Central role in development of cervical carcinoma.
High risk – 16, 18, 45, 31
Once epithelium is acutely infected with HPV one of the 3 clinical scenarios ensues:
1) Asymptomatic latent infection
2) Active infection but no genome integration
3) Neoplastic transformation following integration of oncogenic HPV DNA into
human genome.
Time interval between infection and development of invasive cancer is 10-20 years
RISK FACTORS
•Young age at first intercourse
•Multiple sexual partners
•Tobacco smoking
•Multi parity
•Lower socioeconomic status
•Chronic immune suppression (HIV and HPV infection- increases the risk 46 times)
•Long term use of contraceptive pills(estrogen prevents apoptosis of cells)
•Race- Black women, Hispanic women, American, Indian women
Berek and Novak Gynecology 16th edition
TRANSFORMATION ZONE
SYMPTOMS
1. Abnormal P/V bleeding in the form of
• Blood stained leucorrheal discharge
• Intermenstrual bleeding
• Frequent leucorrhea which is usually serosanguinous, purulent, odorous and non pruritic
• Post coital bleeding
2. Pelvic pain often unilateral, radiates to hip/thigh (advanced case)
3. Involuntary loss of feces and urine through vagina(sign of fistula)
4. Generalized weakness, anemia, weight loss
General physical examination
• Cachexia
• Pallor
• Pedal oedema
• Supraclavicular and inguinal nodes
Systemic examination
• Pulmonary metastasis
Abdominal examination
• Enlarged uterus, tenderness
• Ascites
• Hepatomegaly
METHODS OF SCREENING
1. Pap smear
• Conventional
• Liquid based
• Automated image guided slide
2. Visual inspection
• After acetic acid
• After acetic acid with magnification
• After lugol’s iodine
3. HPV DNA
New Recommendations – American Cancer Society
Population ACS 2020 ACS 2012
Aged <25 years No screening Cytology alone every 3 years starting at age 21
years
Aged 25-65 years Starting at age 25 years, primary HPV test alone Cytology alone every 3 years until age 29 years
every 5 years (preferred) Aged 30-65 years, switch to co-testing (preferred)
cytology alone every 3 years (acceptable)
Use an FDA-approved HPV test for primary
screening Screening by primary HPV testing alone not
recommended for most clinical settings
Co-testing every 5 years or cytology alone every
3 years are acceptable options
Co-testing or cytology testing alone are
acceptable where access to primary HPV testing
is limited or not available; as the United States
makes the transition to primary HPV testing, the
use of co-testing or cytology alone for cervical
cancer screening will not be included in future
guidelines
Population ACS 2020 ACS 2012
Aged >65 years Discontinue screening if adequate negative prior No screening after adequate negative
screening prior screening
Individuals aged >65 years without documentation of
prior screening should continue screening until criteria
for cessation are met
Adequate negative prior screening is currently defined as
2 consecutive, negative
primary HPV tests, or 2 negative co-tests, or 3 negative
cytology tests within the past
10 years, with the most recent test occurring within the
past 3-5 years, depending on the test
used
Population ACS 2020 ACS 2012
After Individuals without a cervix and without a history of CIN2 No screening after hysterectomy (with
hysterectomy or a more severe diagnosis in removal of the cervix) for reasons not
the past 25 y or cervical cancer ever should not be screened related to cervical
cancer and no history of cervical
cancer or serious precancer
HPV vaccinated Follow age-specific screening recommendations (same as Follow age-specific screening
unvaccinated individuals) recommendations
1. Unaided visual inspection of the cervix, referred to as "Downstaging"
by WHO.
2. Unaided visual inspection of the acetic acid
3. Aided visual inspection of the acetic acid treated cervix:
4. Speculoscopy
5. Cervicography
VISUAL INSPECTION OF ACETOWHITE AREAS
(VIA)
Abnormal areas are detected by applying 5% acetic acid (down staging)
Acetic acid dehydrates the abnormal areas containing increased nuclear material
and protein which turn acetowhite.
The Normal cells containing Glycogen remain Normal.
VIA CATEGORY CLINICAL FINDINGS
Negative No acetowhite lesions
Polyp, cervicitis, inflammation, Nabothian cysts.
Positive Sharp, distinct, well-defined, dense (opaque/dull or oyster white)
acetowhite areas with or without raised margins touching the
squamocolumnar junction (SCJ)
Leukoplakia and warts
Suspicious for Malignancy Clinically visible ulcerative, cauliflower-like growth or ulcer; oozing
and/or bleeding on touch.
NEGATIVE POSITIVE SUSPICIOUS OF
MALIGNANCY
BETHESDA SYSTEM OF CYTOLOGY
REPORTING
Satisfactory cytology—endocervical cells seen
Unsatisfactory
1. Squamous cell abnormalities
• Atypical squamous cells (ASC)
• Ascus—atypical cells of undetermined significance
• ASC- H—cannot rule out high-grade lesion
• Low-grade squamous intra epithelial lesion (LSIL)— includes CIN I
• High grade squamous intraepithelial lesion (HSIL)— includes CIN II, III
• Squamous cell carcinoma
2. Glandular abnormalities
• Atypical glandular cells
• Adenocarcinoma in situ
• Adenocarcinoma
3. Other malignant neoplasms
Revised FIGO Clinical staging, 2018
STAGE I
STAGE II
Revised FIGO Staging, 2018
STAGE III
STAGE IV
Normal cytology
Colposcopy
Cone Biopsy
Stage IA cervical Cancer
Stage A Stage A2
Younger Younger
Older women Older women
women women
Completed Completed
Desires Desires
Family Family
Fertility Fertility
Therapeutic
Simple Hysterectomy
Conization Modifiied radical Radical
Hysterectomy Trachelectomy
Pelvic Pelvic
Lymphadenopathy Lymphadenopathy
Management of Stage IB-IV
STAGE TREATMENT
Stage IB1 Radical Hysterectomy with Pelvic Lymphadenopathy / Chemoradiation
Stage IB2 Chemoradiation
Stage IIA1 Radical Hysterectomy with Pelvic Lymphadenopathy / Chemoradiation
Stage IIA2 Chemoradiation
Stage III Chemoradiation
Stage IVA Chemoradiation
Stage IVB Palliative Radiation or
Palliative Chemotherapy
