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'''Products of conception''', abbreviated '''POC''', is stuff formed from the union of egg and sperm. This article covers POC superficially.
'''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]]''.
There are separate articles for ''[[chorionic villi]]'' and ''[[gestational trophoblastic disease]]''.


==History==
=General=
===Clinical===
*Therapeutic abortions - may be abbreviated "MVC" (manual vacuum aspiration).<ref>{{cite journal |author=Edelman A, Nichols MD, Jensen J |title=Comparison of pain and time of procedures with two first-trimester abortion techniques performed by residents and faculty |journal=Am. J. Obstet. Gynecol. |volume=184 |issue=7 |pages=1564-7 |year=2001 |month=June |pmid=11408881 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002937801372241}}</ref>
*Therapeutic abortions - may be abbreviated "MVC" (manual vacuum aspiration).<ref>{{cite journal |author=Edelman A, Nichols MD, Jensen J |title=Comparison of pain and time of procedures with two first-trimester abortion techniques performed by residents and faculty |journal=Am. J. Obstet. Gynecol. |volume=184 |issue=7 |pages=1564-7 |year=2001 |month=June |pmid=11408881 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002937801372241}}</ref>
*Diagnosis of pregnancy: beta-hCG > 10 mIU/mL.
**Beta-hCG calculator: [http://www.countdowntopregnancy.com/tools/beta_doubling_calculator.php 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.<ref name=pmid10511363>{{Cite journal  | last1 = Barnhart | first1 = KT. | last2 = Simhan | first2 = H. | last3 = Kamelle | first3 = SA. | title = Diagnostic accuracy of ultrasound above and below the beta-hCG discriminatory zone. | journal = Obstet Gynecol | volume = 94 | issue = 4 | pages = 583-7 | month = Oct | year = 1999 | doi =  | PMID = 10511363 }}</ref>
====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+).
==Gross==
Fetal parts absent:
*Minimum of five cassettes.<ref>URL: [https://voices.uchicago.edu/grosspathology/peds-perinatal/products-of-conception/ https://voices.uchicago.edu/grosspathology/peds-perinatal/products-of-conception/]. Accessed on: 2023 April 3.</ref>


==Microscopic==
==Microscopic==
Line 11: Line 35:
**Cytotrophoblast.
**Cytotrophoblast.
**Centre of villi often have fetal red blood cells (which have nuclei) -- not required for diagnosis of POC.
**Centre of villi often have fetal red blood cells (which have nuclei) -- not required for diagnosis of POC.
*Should have decidual reaction of endometrium.
*+/-Endometrium (intrauterine pregnancy):
**Decidual changes -- mnemonic ''NEW'':
**Should have decidual changes -- mnemonic ''NEW'':
***Nucleus central.
***Nucleus central.
***Eosinophilic cytoplasm.
***Eosinophilic cytoplasm.
***Well-defined cell borders.
***Well-defined cell borders.
*Embryo or fetus - a bonus.
*+/-[[Uterine tube]] +/- decidualization (tubal pregnancy).
*+/-Hyaline globules.<ref name=pmid19526574 >{{cite journal |author=Dharan M |title=Hyaline globules in ectopic decidua in a pregnant woman with cervical squamous cell carcinoma |journal=Diagn. Cytopathol. |volume=37 |issue=9 |pages=696–8 |year=2009 |month=September |pmid=19526574 |doi=10.1002/dc.21113 |url=}}</ref>
*+/-[[Hyaline globules]].<ref name=pmid19526574 >{{cite journal |author=Dharan M |title=Hyaline globules in ectopic decidua in a pregnant woman with cervical squamous cell carcinoma |journal=Diagn. Cytopathol. |volume=37 |issue=9 |pages=696–8 |year=2009 |month=September |pmid=19526574 |doi=10.1002/dc.21113 |url=}}</ref>
 
*+/-Embryo or fetus - a bonus.
Image:
**Cartilage - common.
*[http://commons.wikimedia.org/wiki/File:Endometrium_ocp_use2.jpg Decidualization due to OCP - high mag. (WC)].
**Primitive neuroepithelium.
**Gastrointestinal epithelium.


Aside:
Aside:
Line 26: Line 51:
*Fetus = conceptus 8th weeks 'til birth.
*Fetus = conceptus 8th weeks 'til birth.


==Beta-hCG==
DDx:
Calculator: [http://www.countdowntopregnancy.com/tools/beta_doubling_calculator.php http://www.countdowntopregnancy.com/tools/beta_doubling_calculator.php]
*[[Partial hydatidiform mole]].
 
====Images====
<gallery>
Image:Chorionic_villi_-_intermed_mag.jpg | Chorionic villi - intermed. mag. (WC)
Image:Products_of_conception_-_low_mag.jpg | Chorionic villi and fetal parts - low mag. (WC)
</gallery>
<gallery>
Image:Intermediate_trophoblast_3_-_low_mag.jpg | Intermediate trophoblast reaction - low mag. (WC)
Image:Intermediate_trophoblast_3_-_high_mag.jpg | Intermediate trophoblast - high mag. (WC)
</gallery>
 
www:
*[http://www.gfmer.ch/selected_images_v2/detail_list.php?cat1=24&cat2=181&cat3=586&cat4=3&stype=n Tubal pregnancy - several images (gfmer.ch)].
 
=Specific conditions=
==Arias-Stella reaction==
===General===
*Benign atypical endometrial changes associated with chorionic tissue.<ref name=pmid11756756>{{Cite journal  | last1 = Arias-Stella | first1 = J. | title = The Arias-Stella reaction: facts and fancies four decades after. | journal = Adv Anat Pathol | volume = 9 | issue = 1 | pages = 12-23 | month = Jan | year = 2002 | doi =  | PMID = 11756756 }}</ref>
**May be seen in a normal pregnancy, [[hydatidiform mole]]s, others.
*Historically it was diagnosed as [[endometrial cancer]].
 
Note:
*To the novice... the nuclei look really scary, i.e. they look like cancer.
 
===Microscopic===
Features:<ref name=pmid11756756/>
*Epithelial component of endometrium with large nuclei - '''key feature'''.
**+/-Nuclear hyperchromasia, i.e. dark nuclei.
**+/-Irregular nuclear membrane.
**+/-Nuclear clearing.<ref name=Ref_DCHH236-7>{{Ref DCHH|236-7}}</ref>
**+/-[[Nuclear pseudoinclusions]].
*[[NC ratio]] is preserved.<ref name=Ref_DCHH236-7>{{Ref DCHH|236-7}}</ref>
*Usually a focal change.
*+/-Mitoses - uncommon.
 
Notes:
*No decidual reaction in the stroma.
 
DDx:
*[[Choriocarcinoma]].
*[[Herpes simplex virus|Herpetic]] [[endometritis]].
*[[Clear cell carcinoma]].
 
====Images====
*[http://www2.odn.ne.jp/g_nexus_6/images/Arias-Stella.jpg Arias-Stella reaction (odn.ne.jp)]<ref>URL: [http://pathblog.wordpress.com/2009/01/23/what-is-arias-stella/ http://pathblog.wordpress.com/2009/01/23/what-is-arias-stella/]. Accessed on: September 8, 2014.</ref>
 
====Subtypes====
There are five subtypes:<ref name=pmid11756756/>
#Minimal atypia.
#*Usually early gestation.
#Early secretory pattern.
#*Mimics secretory endometrium: cytoplasmic vacuoles, central nucleus, palisading architecture.
#Secretory or hypersecretory pattern.
#Regenerative, proliferative or nonsecretory pattern.
#Monstrous cell pattern.


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


==Arias-Stellas reaction==
Clinical:
*Large nuclei - to the novice... it looks really scary.
*Abdominal pain in woman of childbearing age.
*[[NC ratio]] is preserved.
**''Every woman of childbearing age should be assumed pregnant until proven otherwise!''<ref name=pmid23210111>{{Cite journal  | last1 = Doust | first1 = J. | title = A is for aphorism - a woman is pregnant until proven otherwise. | journal = Aust Fam Physician | volume = 41 | issue = 10 | pages = 827 | month = Oct | year = 2012 | doi =  | PMID = 23210111 |url = http://www.racgp.org.au/afp/2012/october/a-is-for-aphorism/ }}</ref>
*May see nuclear clearing.<ref name=Ref_DCHH236>{{Ref DCHH|236 (bottom)}}.</ref>
*Typical gestational age (GA) for a tubal pregnancy ~ 5-9 weeks.<ref name=pmid9207811/>
**Beta-hCG elevated but may be relatively low (<100 IU/L) even in the context of (uterine tube) rupture.<ref name=pmid9207811>{{Cite journal  | last1 = Saxon | first1 = D. | last2 = Falcone | first2 = T. | last3 = Mascha | first3 = EJ. | last4 = Marino | first4 = T. | last5 = Yao | first5 = M. | last6 = Tulandi | first6 = T. | title = A study of ruptured tubal ectopic pregnancy. | journal = Obstet Gynecol | volume = 90 | issue = 1 | pages = 46-9 | month = Jul | year = 1997 | doi = 10.1016/S0029-7844(97)00180-4 | PMID = 9207811 }}</ref>
 
===Microscopic===
:See ''Microscopic'' section above.
 
DDx:
*Hydropic abortus.
*[[Complete hydatidiform mole]].
*[[Partial hydatidiform mole]].


==Screening tests==
====Images====
===First trimester screen===
<gallery>
*PAPP-A.
Image:Ectopic pregnancy -- low mag.jpg | EP - low mag. (WC)
*Nuchal translucency.
Image:Ectopic pregnancy -- intermed mag.jpg | EP - intermed. mag. (WC)
*beta-hCG.
Image:Ectopic pregnancy -- high mag.jpg | EP - high mag. (WC)
Image:Ectopic pregnancy - decidua -- intermed mag.jpg | EP - intermed. mag. (WC)
</gallery>
 
===Sign out===
<pre>
Fallopian Tube, Right Salpingectomy:
    - Fallopian tube with chorionic villi (tubal pregnancy).
</pre>
 
<pre>
Submitted as "Left Fallopian Tube and Ectopic Pregnancy", Excision:
    - Tubal pregnancy; Fallopian tube with chorionic villi and fetal parts.
</pre>
 
====Block letters====
<pre>
FALLOPIAN TUBE, RIGHT, SALPINGECTOMY:
- FALLOPIAN TUBE WITH CHORIONIC VILLI (TUBAL PREGNANCY).
</pre>
 
====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==
===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===
<pre>
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.
</pre>
 
====Variants====
<pre>
Submitted as "Products of Conception":
- Fetal tissue present.
- Benign decidual tissue present.
- Chorionic villi present, NEGATIVE for proliferation or significant atypia.
</pre>
 
<pre>
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.
</pre>
 
<pre>
Products of Conception, Curettage:
- Chorionic villi present without proliferation or significant atypia.
- Decidua present.
- Negative for malignancy.
</pre>
 
====No chorionic villi====
<pre>
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.
</pre>
 
Notes:
*The above is considered a [[critical diagnosis]].  
*It should be communicated to the on call gynecologist and this communication should be documented.
 
<pre>
Submitted as "Products of Conception":
    - Decidualized endometrium with necro-inflammatory changes/degeneration,
      blood and fibrin.
    - NEGATIVE for chorionic villi, see comment.
 
Comment:
The tissue was submitted in total.
 
The ultrasound impression (intrauterine gestational sac present) is noted. The decrease in serum beta-hCG is noted.


===Maternal serum screen===
The lack of chorionic villi on pathology is a discordance with the clinical findings.
*Alpha-fetoprotein.
A non-exhaustive list of possible explanations includes: non-removal/retention and prior spontaneous passing. Clinical correlation is required.
*Beta-hCG.
</pre>
*Estriol.


==Diagnostic tests==
====Block letters====
*Chorionic villus sampling (10-12 weeks???).
<pre>
*Amniocentesis (15-16 weeks+).
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.
</pre>


==See also==
=See also=
*[[Gynecologic pathology]].
*[[Gynecologic pathology]].
*[[Chorionic villi]].
*[[Chorionic villi]].
*[[Gestational trophoblastic disease]].
*[[Gestational trophoblastic disease]].
*[[Pregnancy luteoma]].


==References==
=References=
{{reflist|2}}
{{reflist|2}}
=External links=
*[http://www.perinatology.com/calculators/Crown%20Rump%20and%20Nuchal%20Translucency.htm Crown-rump length calculator (perinatology.com)].


[[Category:Gynecologic pathology]]
[[Category:Gynecologic pathology]]
[[Category:Diagnosis]]
Michael
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