Hypertension, resulting from reduced endothelial production of the vasodilators prostacyclin and prostaglandin E2 and from increased production of the vasoconstrictor thromboxane A2
Hypercoagulability, due to endothelial dysfunction and release of tissue factor from the placenta
End-organ failure, most notably of the kidney and the liver, which occurs in patients with full-blown eclampsia. Approximately 10% of the patients with severe preeclampsia develop the so-called “HELLP syndrome”, characterized by elevated liver enzymes, microangiopathic hemolytic anemia, thrombocytopenia due to platelet consumption, and sometimes fullblown disseminated intravascular coagulation (DIC).
disorder.Placentalabnormalitiesinclude
Infarcts,whichcanbeafeatureofnormalpregnancy,butaremuchmorenumerouswithseverepreeclampsiaoreclampsia
Prematurematurationofplacentalvilliassociatedwithvillousedema,hypovascularity,andincreasedproductionofsyncytialepithelialknots
Preeclampsia presents insidiously during weeks 24 to 25 of gestation with edema, proteinuria, and rising blood pressure. Should the condition evolve into eclampsia, renal function is impaired, blood pressure rises further, and convulsions may occur. Prompt therapy early in the course aborts the associated organ changes, with all abnormalities resolving promptly after delivery or after cesarean section.
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Three important features distinguish the breast from other organs. First, rather than being essential for survival, the major function is the nutritional support of another individual, the infant. Second, the structure of the organ undergoes marked changes throughout life: expansion of the lobular system after menarche, periodic remodeling during adulthood, especially during and after pregnancy, and ultimately involution and regression of lobules. Finally, breasts are visible and as a result have a social, cultural, and personal significance not shared by other organs. All of these features play a role when considering the origins, presentations, and treatment of breast disease.
The functional unit of the breast is the lobule, which is supported by a specialized intralobular stroma. The inner luminal epithelial cells produce milk during lactation. The basally located myoepithelial cells have contractile function to aid in milk ejection and also help support the basement membrane. The ducts are conduits for milk to reach the nipple. The size of the breast is determined primarily by interlobular stroma, which increases during puberty and involutes with age. Each normal constituent is a source of both benign and malignant lesions (
Fig. 19.22
The predominant symptoms and signs of diseases of the breast are pain, inflammatory changes, nipple discharge, “lumpiness,” or a palpable mass (Fig. 19.23A ). However, few symptoms are so severe as to require treatment, and the primary reason for investigating their cause is to evaluate the possibility of malignancy. Most symptomatic breast lesions (>90%) are benign. Of women with cancer, about 45% have symptoms, whereas the remainder come to attention through screening tests (
Fig. 19.23B
Pain (mastalgia or mastodynia) is a common symptom often related to menses, possibly due to cyclic edema and swelling. Pain localized in a specific area is usually caused by a ruptured cyst or trauma to adipose tissue (fat necrosis). Almost all painful masses are benign, but for unknown reasons a small fraction of cancers (about 10%) cause pain.
Inflammation causes an edematous and erythematous breast. It is rare and is most often caused by infections, which only occur with any frequency during lactation and breastfeeding. An important mimic of