INSTRUCTORS ONLY

Repro Path Lab 3

GESTATIONAL LAB:
Fallopian Tube, Trophoblastic Diseases,
and Endometriosis

Fallopian Tube

Laparoscopic Photo of Abnormal Fallopian Tube
Abnormal Histology [WebScope] [ImageScope]
Normal Histology for Comparison [WebScope] [ImageScope]

Case History:
23-year-old sexually active G0 presents with an acute abdomen. Birth Control – none reported. Symptoms began in the week following her menses and have gradually worsened. She is febrile and guards on examination of her lower abdomen. Pelvic exam demonstrates a mucopurulent discharge from her cervical os and positive cervical motion tenderness.

1. What is the differential diagnosis based upon the history provided?

2. Assuming this histologic slide resulted from an emergent surgical procedure on the patient noted above, what is your diagnosis?

3. Which organisms might be implicated in the cause of this condition?

4. What are the long term complications of the histopathologic effects seen in the slide on the fallopian tube and surrounding anatomy (assuming that surgical removal, usually a last resort, is not performed)?

Fallopian Tube

Laparoscopic Photo of Abnormal Fallopian Tube
Abnormal Histology [WebScope] [ImageScope]
Normal Histology for Comparison [WebScope] [ImageScope]

Case History:
Same patient as in the first case of this lab. Following medical treatment of her condition, her symptoms resolve. Time passes and she conceives. She presents to her obstetrician at around 8 weeks gestational age with right lower quadrant pain and vaginal bleeding. On exam, her cervical os is closed with a small amount of blood noted. Her uterus is “6-8 weeks size” and she has some right lower quadrant “fullness.”

1. What clinical approaches might her obstetrician take to help make a diagnosis?

2. Review the gross photograph along with the microscopic sections. What is your diagnosis?

3. If not recognized, what potential complication might you expect?

Uterine Contents

Gross Photo of Uterine Contents
Abnormal Histology of Endometrial Curettings [WebScope] [ImageScope]

Case History:
30-year-old G2P1 initially presents to her obstetrician at around 8 weeks gestational age with vaginal bleeding. On exam, her cervical os is closed with a small amount of blood noted. Her uterus is “12 weeks size.” Ultrasound shows intrauterine contents without obvious evidence of a fetus. Serum ß-hCG is 170,000 IU/ml. A suction curettage is performed. Weeks pass.

1. What is the differential diagnosis?

2. What if the serum ß-hCG was 4,000IU/ml?

3. Describe the findings in the curettings.

4. What are the histogenetic theories of hydatidiform moles (molar pregnancy)?

Endometrial Curettings

Abnormal Histology of Curettings [WebScope] [ImageScope]
Abnormal Histology of Hysterectomy [WebScope] [ImageScope]
Gross Photo of Hysterectomy

Case History:
Our patient in the previous case is followed carefully by her Ob/Gyn physician with serial serum ß-hCG tests. After a steady decline in her serum titers, the patient is lost to follow-up. She returns a year later with abnormal uterine bleeding and elevated ß-hCG. Ultrasound shows intrauterine echoes and bilateral ovarian "cysts." A curettage is performed.

1. What are the diagnostic possibilities based upon history alone?

2. Describe the findings in the curettings. What is your diagnosis?

Follow-up information: Subsequent chest x-ray shows multiple ill-defined lung masses. A hysterectomy is performed. See Gross Photo of Hysterectomy and Histology [WebScope] [ImageScope].

3. What is the relationship between molar gestation (complete vs. partial) and gestational choriocarcinoma?

4. What is the most likely condition that would explain enlargement of both ovaries?

Ovary

Laparoscopic Photo of Ovarian Findings (left panel) and
     Cross-Section of Resected Ovary (right panel)
Abnormal Histology [WebScope] [ImageScope]

Case History:
A 34-year-old nulligravida presents to the Reproductive Endocrinologist because she has been unable to conceive during the four years she has been married. She has no history of STD, but does relate severe dysmenorrhea and dyspareunia. On pelvic examination, a tender left adnexal mass is noted (~10cm) along with uterosacral nodularity.

1. Review the gross photos and histologic sections of the ovarian mass. What is your diagnosis?

2. What other anatomic locations can be affected by the process that resulted in this patient’s ovarian mass?

3. What are the theories of histogenesis of this process?

The answers to the path lab questions will be posted approximately 48-72 hours after the lab sessions. These are abbreviated answers, not a full discussion of the topics. You can find them in the M2 CTools site resources. In the folder for each sequence the will be a folder called 'Path Lab Resources'