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Products of conception
From Libre Pathology

Products of conception, abbreviated POC, is stuff formed from the union of egg and sperm. This article covers
POC superficially.

There are separate articles for chorionic villi and gestational trophoblastic disease.

Contents
1 General
1.1 Clinical
1.1.1 Screening tests
1.1.1.1 First trimester screen
1.1.1.2 Maternal serum screen
1.1.1.3 Diagnostic tests
1.2 Microscopic
1.2.1 Images
2 Specific conditions
2.1 Arias-Stella reaction
2.1.1 General
2.1.2 Microscopic
2.1.2.1 Images
2.1.2.2 Subtypes
2.2 Ectopic pregnancy
2.2.1 General
2.2.2 Microscopic
2.2.2.1 Images
2.2.3 Sign out
2.2.3.1 Block letters
2.2.3.2 Micro
2.3 Retained products of conception
2.3.1 General
2.3.2 Microscopic
2.3.3 Sign out
2.3.3.1 Variants
2.3.3.2 No chorionic villi
2.3.3.3 Block letters
3 See also
4 References
5 External links

General
Clinical

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Therapeutic abortions - may be abbreviated "MVC" (manual vacuum aspiration).[1]

Diagnosis of pregnancy: beta-hCG > 10 mIU/mL.

Beta-hCG calculator: http://www.countdowntopregnancy.com/tools/beta_doubling_calculator.php.
If the beta-hCG is >1500 mIU/mL -- there is a good chance an ultrasound is diagnostic.[2]

Screening tests

First trimester screen

PAPP-A.
Nuchal translucency.
Beta-hCG.

Maternal serum screen

Alpha-fetoprotein.
Beta-hCG.
Estriol.

Diagnostic tests

Chorionic villus sampling (10-12 weeks???).

Amniocentesis (15-16 weeks+).

Microscopic
Features:

Chorionic villi are need to call POC - key feature.

Cytotrophoblast.
Centre of villi often have fetal red blood cells (which have nuclei) -- not required for diagnosis of
POC.
+/-Endometrium (intrauterine pregnancy):
Should have decidual changes -- mnemonic NEW:
Nucleus central.
Eosinophilic cytoplasm.
Well-defined cell borders.
+/-Uterine tube +/- decidualization (tubal pregnancy).
+/-Hyaline globules.[3]
+/-Embryo or fetus - a bonus.
Cartilage - common.
Primitive neuroepithelium.
Gastrointestinal epithelium.

Aside:

Embryo = conceptus before 8 weeks.

Fetus = conceptus 8th weeks 'til birth.

DDx:

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Partial hydatidiform mole.

Images

Chorionic villi - Chorionic villi and fetal

intermed. mag. (WC) parts - low mag. (WC)

Intermediate Intermediate
trophoblast reaction - trophoblast - high mag.
low mag. (WC) (WC)

www:

Tubal pregnancy - several images (gfmer.ch) (http://www.gfmer.ch/selected_images_v2/detail_list.php?cat1=

24&cat2=181&cat3=586&cat4=3&stype=n).

Specific conditions
Arias-Stella reaction
General

Benign atypical endometrial changes associated with chorionic tissue.[4]

May be seen in a normal pregnancy, hydatidiform moles, others.
Historically it was diagnosed as endometrial cancer.

Note:

To the novice... the nuclei look really scary, i.e. they look like cancer.

Microscopic
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Features:[4]

Epithelial component of endometrium with large nuclei - key feature.

+/-Nuclear hyperchromasia, i.e. dark nuclei.
+/-Irregular nuclear membrane.
+/-Nuclear clearing.[5]
+/-Nuclear pseudoinclusions.
NC ratio is preserved.[5]
Usually a focal change.
+/-Mitoses - uncommon.

Notes:

No decidual reaction in the stroma.

DDx:

Choriocarcinoma.
Herpetic endometritis.
Clear cell carcinoma.

Images

Arias-Stella reaction (odn.ne.jp) (http://www2.odn.ne.jp/g_nexus_6/images/Arias-Stella.jpg)[6]

Subtypes

There are five subtypes:[4]

1. Minimal atypia.
Usually early gestation.
2. Early secretory pattern.
Mimics secretory endometrium: cytoplasmic vacuoles, central nucleus, palisading architecture.
3. Secretory or hypersecretory pattern.
4. Regenerative, proliferative or nonsecretory pattern.
5. Monstrous cell pattern.

Ectopic pregnancy
General

Chorionic villi have to be identified (in some location, e.g. Fallopian tube) to Dx a pregnancy.
Endometrium: decidual reaction, as seen in any pregnancy.

Clinical:

Abdominal pain in woman of childbearing age.

Every woman of childbearing age should be assumed pregnant until proven otherwise![7]
Typical gestational age (GA) for a tubal pregnancy ~ 5-9 weeks.[8]
Beta-hCG elevated but may be relatively low (<100 IU/L) even in the context of (uterine tube)
rupture.[8]

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Microscopic

See Microscopic section above.

DDx:

Hydropic abortus.
Complete hydatidiform mole.
Partial hydatidiform mole.

Images

EP - low mag. (WC) EP - intermed. mag. EP - high mag. (WC) EP - intermed. mag.
(WC) (WC)

Sign out

Fallopian Tube, Right Salpingectomy:

- Fallopian tube with chorionic villi (tubal pregnancy).

Submitted as "Left Fallopian Tube and Ectopic Pregnancy", Excision:

- Tubal pregnancy; Fallopian tube with chorionic villi and fetal parts.

Block letters

FALLOPIAN TUBE, RIGHT, SALPINGECTOMY:

- FALLOPIAN TUBE WITH CHORIONIC VILLI (TUBAL PREGNANCY).

Micro

The sections show fallopian tube wall with chorionic villi.

Nucleated red blood cells are present. No other fetal components are identified.

The chorionic villi do not show a Norwegian fjord-like periphery. Central cisterns are not apparent. There is no
trophoblastic proliferation.

Retained products of conception

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General

May occur in a number of contexts, e.g. therapeutic abortion, sponatenous abortion.

Microscopic

See Microscopic section above.

DDx:

Complete hydatidiform mole.

Partial hydatidiform mole.
Choriocarcinoma.

Sign out

Submitted as "Products of Conception":

- Chorionic villi present with degenerative changes, NEGATIVE for
proliferation or significant atypia.
- Benign decidual tissue present.
- Necro-inflammatory debris and fibrin.

Variants

Submitted as "Products of Conception":

- Fetal tissue present.
- Benign decidual tissue present.
- Chorionic villi present, NEGATIVE for proliferation or significant atypia.

Submitted as "Products of Conception":

- Chorionic villi present with degenerative changes, negative for proliferation
or significant atypia.
- Benign decidual tissue present.
- Negative for fetal tissue.

Products of Conception, Curettage:

- Chorionic villi present without proliferation or significant atypia.
- Decidua present.
- Negative for malignancy.

No chorionic villi

Submitted as "Products of Conception", Curettage:

- Blood and fibrin.
- Scant benign squamous epithelium and scant benign endocervical epithelium.
- NEGATIVE for decidua.
- NEGATIVE for chorionic villi, see comment.

Comment:
The tissue was submitted in total. Clinical correlation is suggested.

The above was communicated to the on call gynecologist.

Notes:

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The above is considered a critical diagnosis.

It should be communicated to the on call gynecologist and this communication should be documented.

Block letters

ENDOMETRIUM, CURETTAGE:
- OUTLINES CONSISTENT WITH NON-VIABLE CHORIONIC VILLI WITH FIBRIN AND FOCAL
CALCIFICATIONS (COMPATIBLE WITH RETAINED PRODUCTS OF CONCEPTION).
- ENDOCERVICITIS, CHRONIC.
- NO DEFINITE ENDOMETRIUM.
- NO VIABLE CHORIONIC VILLI IDENTIFIED.
- NO EVIDENCE OF MALIGNANCY.

See also
Gynecologic pathology.
Chorionic villi.
Gestational trophoblastic disease.
Pregnancy luteoma.

References
1. Edelman A, Nichols MD, Jensen J (June 2001).
"Comparison of pain and time of procedures with two
first-trimester abortion techniques performed by
residents and faculty" (http://linkinghub.elsevier.com/re
trieve/pii/S0002937801372241). Am. J. Obstet.
Gynecol. 184 (7): 1564-7. PMID 11408881 (http://ww
w.ncbi.nlm.nih.gov/pubmed/11408881).
http://linkinghub.elsevier.com/retrieve/pii/S000293780
1372241.
2. Barnhart, KT.; Simhan, H.; Kamelle, SA. (Oct 1999).
"Diagnostic accuracy of ultrasound above and below
the beta-hCG discriminatory zone.". Obstet Gynecol 94
(4): 583-7. PMID 10511363 (http://www.ncbi.nlm.nih.
gov/pubmed/10511363).
3. Dharan M (September 2009). "Hyaline globules in
ectopic decidua in a pregnant woman with cervical
squamous cell carcinoma". Diagn. Cytopathol. 37 (9):
696–8. doi:10.1002/dc.21113 (http://dx.doi.org/10.100
2%2Fdc.21113). PMID 19526574 (http://www.ncbi.nl
m.nih.gov/pubmed/19526574).
4. Arias-Stella, J. (Jan 2002). "The Arias-Stella reaction:
facts and fancies four decades after.". Adv Anat Pathol
9 (1): 12-23. PMID 11756756 (http://www.ncbi.nlm.ni
h.gov/pubmed/11756756).
5. Tadrous, Paul.J. Diagnostic Criteria Handbook in
Histopathology: A Surgical Pathology Vade Mecum
(1st ed.). Wiley. pp. 236-7. ISBN 978-0470519035.
6. URL: http://pathblog.wordpress.com/2009/01/23/what-
is-arias-stella/. Accessed on: September 8, 2014.
7. Doust, J. (Oct 2012). "A is for aphorism - a woman is
pregnant until proven otherwise." (http://www.racgp.or
g.au/afp/2012/october/a-is-for-aphorism/). Aust Fam
Physician 41 (10): 827. PMID 23210111 (http://www.n
cbi.nlm.nih.gov/pubmed/23210111).
http://www.racgp.org.au/afp/2012/october/a-is-for-
aphorism/.
8. Saxon, D.; Falcone, T.; Mascha, EJ.; Marino, T.; Yao,
M.; Tulandi, T. (Jul 1997). "A study of ruptured tubal
ectopic pregnancy.". Obstet Gynecol 90 (1): 46-9.
doi:10.1016/S0029-7844(97)00180-4 (http://dx.doi.org/
10.1016%2FS0029-7844%2897%2900180-4).
PMID 9207811 (http://www.ncbi.nlm.nih.gov/pubmed/
9207811).

External links
Crown-rump length calculator (perinatology.com) (http://www.perinatology.com/calculators/Crown%20Rum
p%20and%20Nuchal%20Translucency.htm).

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