Clinical Practice Patterns of Hypertensive Disease in Pregnancy among Korean Obstetricians

Purpose@#The purpose of this study was to investigate the clinical practice patterns of Korean obstetricians and gynecologists the diagnosis and management of hypertensive disease in pregnant women. @*Methods@#From April 2015 to October 2015, questionnaire was distributed via email to obstetricians who were members of the Society for Maternal and Fetal Medicine. The survey consisted of 37 questions in 6 categories. Responses to the questions on the management of hypertensive disorders of pregnancy, from diagnosis to treatment, were evaluated. @*Results@#A total of 93 obstetricians and gynecologists responded to the survey. High blood pressure was allocated the highest priority as an index mainly used when deciding to hospitalize patients with hypertensive disease during pregnancy, followed by pregnancy symptoms, proteinuria, and blood test results. Calcium channel blocker (CCB) for oral administration and hydralazine for injection were preferred as antihypertensive drugs mainly used to control severe hypertension. Regarding the delivery method for hypertensive disease during pregnancy, in cases of preeclampsia, 63% of the respondents chose the delivery method according to the cervical status, and in cases of hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome and eclampsia, which increased in severity, 52% and 31% responded that the delivery method was determined according to the cervical status, respectively. In cases of mild preeclampsia, the 70% of respondents preferred 37–38 weeks of gestation for the delivery time. Regarding the use of aspirin in patient with hypertension during pregnancy, 52% of the respondents occasionally administered aspirin, and in patients with a history of hypertensive disease during pregnancy, only 43% were administered prophylactic aspirin. @*Conclusion@#Domestic obstetricians regarded blood pressure as the most meaningful factor when treating women with hypertension during pregnancy and considered blood pressure control as important. The preferred antihypertensive agents were oral CCB and hydralazine injections, and the choice of delivery method was determined according to the condition of the cervix and severity of the disease. Even in women with high risk factors for preeclampsia, prophylactic aspirin was administered in as low as 50%, of patients, possibly may due to the absence of domestic guidelines for aspirin use during pregnancy. Korean guidelines for prophylactic aspirin administration during pregnancy is needed based on additional research on the efficacy of aspirin for domestic women in the future.

Clinical Practice Patterns of Hypertensive Disease in Pregnancy among Korean Obstetricians

Purpose@#The purpose of this study was to investigate the clinical practice patterns of Korean obstetricians and gynecologists the diagnosis and management of hypertensive disease in pregnant women. @*Methods@#From April 2015 to October 2015, questionnaire was distributed via email to obstetricians who were members of the Society for Maternal and Fetal Medicine. The survey consisted of 37 questions in 6 categories. Responses to the questions on the management of hypertensive disorders of pregnancy, from diagnosis to treatment, were evaluated. @*Results@#A total of 93 obstetricians and gynecologists responded to the survey. High blood pressure was allocated the highest priority as an index mainly used when deciding to hospitalize patients with hypertensive disease during pregnancy, followed by pregnancy symptoms, proteinuria, and blood test results. Calcium channel blocker (CCB) for oral administration and hydralazine for injection were preferred as antihypertensive drugs mainly used to control severe hypertension. Regarding the delivery method for hypertensive disease during pregnancy, in cases of preeclampsia, 63% of the respondents chose the delivery method according to the cervical status, and in cases of hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome and eclampsia, which increased in severity, 52% and 31% responded that the delivery method was determined according to the cervical status, respectively. In cases of mild preeclampsia, the 70% of respondents preferred 37–38 weeks of gestation for the delivery time. Regarding the use of aspirin in patient with hypertension during pregnancy, 52% of the respondents occasionally administered aspirin, and in patients with a history of hypertensive disease during pregnancy, only 43% were administered prophylactic aspirin. @*Conclusion@#Domestic obstetricians regarded blood pressure as the most meaningful factor when treating women with hypertension during pregnancy and considered blood pressure control as important. The preferred antihypertensive agents were oral CCB and hydralazine injections, and the choice of delivery method was determined according to the condition of the cervix and severity of the disease. Even in women with high risk factors for preeclampsia, prophylactic aspirin was administered in as low as 50%, of patients, possibly may due to the absence of domestic guidelines for aspirin use during pregnancy. Korean guidelines for prophylactic aspirin administration during pregnancy is needed based on additional research on the efficacy of aspirin for domestic women in the future.

Survey Results on the Perception of Prostate-Specific Antigen and Prostate Cancer Screening Among the General Public

Purpose@#To assess awareness of prostate cancer and prostate cancer screening in high risk Korean men 40 years and older. @*Materials and Methods@#The Korean Urological Oncology Society implemented an online survey of 600 men aged 40 years or older from July 30 to August 6, 2019 to ask questions about prostate cancer and screening. @*Results@#Of the 600 respondents, 96.5% (579 of 600) were aware of prostate cancer and 49.8% (299 of 600) thought they were at risk. Men in their 60s, men with a family history and men with urological conditions were more concerned about prostate cancer. Most respondents (83.3%, 500 of 600) had never received prostate cancer screening. When asked why they had not, (multiple choices: first, second and third priority), the most common responses were: “They had no symptoms of prostate cancer”; “They were in good health”; “Cost burden of screening”; and “They thought screening was included in the National Health Examination Program.” Only 9.7% (58 of 600) were aware of prostate-specific antigen (PSA). After being informed about PSA, 97.7% (586 of 600) wanted it to be included in national cancer screening. @*Conclusions@#In this survey, 96.5% of respondents were aware of prostate cancer, and 44.2% recognized the need for early screening. However, only 16.7% had received screening. Awareness of prostate cancer risks tended to be high in elderly people, people with a family history and people with urological conditions. The results also indicate that there is support for national-level management and early screening programs for prostate cancer. (Korean J Urol Oncol 2020;18:40-46)

Practice patterns in the management of threatened preterm labor in Korea: A multicenter retrospective study

OBJECTIVE: This study aimed to examine clinical practice patterns in the management of pregnant women admitted with threatened preterm labor (TPL) in Korea. METHODS: Data from women admitted with a diagnosis of TPL were collected from 22 hospitals. TPL was defined as regular uterine contractions with or without other symptoms such as pelvic pressure, backache, increased vaginal discharge, menstrual-like cramps, bleeding/show and cervical changes. Data on general patient information, clinical characteristics at admission, use of tocolytics, antibiotics, and corticosteroids, and pregnancy outcomes were collected using an online data collections system. RESULTS: A total of 947 women with TPL were enrolled. First-line tocolysis was administered to 822 (86.8%) patients. As a first-line tocolysis, beta-agonists were used most frequently (510/822, 62.0%), followed by magnesium sulfate (183/822, 22.3%), calcium channel blockers (91/822, 11.1%), and atosiban (38/822, 4.6%). Of the 822 women with first-line tocolysis, second-line tocolysis were required in 364 (44.3%). Of 364 with second-line, 199 had third-line tocolysis (37.4%). Antibiotics were administered to 29.9% of patients (284/947) with single (215, 22.7%), dual (26, 2.7%), and triple combinations (43, 4.5%). Corticosteroids were administered to 420 (44.4%) patients. Betamethasone was administered to 298 patients (71.0%), and dexamethasone was administered to 122 patients (29.0%). CONCLUSION: Practice patterns in the management of TPL in Korea were quite various. It is needed to develop standardized practice guidelines for TPL management.

Laparoscopic transabdominal cervical cerclage: Case report of a woman without exocervix at 11 weeks gestation

Cervical incompetence is characterized by painless dilatation of the incompetent cervix and results in miscarriages and preterm delivery during second trimester. We report a 25-year-old patient, gravid 2, para 1, at 11 weeks' gestation with the diagnosis of cervical incompetence, in whom transvaginal cerclage was not technically possible and laparoscopic cervical cerclage was performed successfully. There were no operative or immediate postoperative complications. A healthy infant was delivered at 35 weeks by cesarean section. Laparoscopic cervical cerclage during pregnancy can be safe and effective treatment for well-selected patients with cervical incompetence and eliminates the need for open laparotomy.

The Assessment of Reliability of Cognitive Evoked Potential in Normal Person

OBJECTIVE: To evaluate intra-tester reliability of P300 more precisely, this study was designed. Event-related potential (ERP) is the result of endogenous brain response following cognitive stimulus. The P300 component of the human ERP is a positive wave with a latency of 300 ms or greater. Our purpose of this study was to estimate reliability of P300 latency and amplitude with 30 normal persons without head injury, as well as to set up them as the reference values in the event that they would be found to be highly reliable. METHODS: ERP was performed at three separate times on 30 normal adults in their 20s and 30s. We measured P300 latency and amplitude among ERP. RESULTS: P300 latency show excellent reliability with intraclass correlation coefficient (ICC) of 0.81. As to P300 amplitude, reliability was good to fair with ICC of 0.53. Average value of P300 latency was 311.3+/-37.0 ms, shorter than reference value of previous study in Korea. CONCLUSION: P300 latency revealed higher reliability than P300 amplitude, although reliability of P300 was confirmed in both component. After further study including precise mechanism, influence factor on measurement and method standardization, it is expected to be an objective indicator to assess the cognitive state and predict prognosis.

Treatment of Chronic Isolated Finger Flexor Tenosynovitis Through 50% Dehydrated Alcohol Installation

The isolated idiopathic finger flexor tenosynovitis is a rare condition, related to diversed etiologies. The traditional treatment of flexor tenosynovitis includes medications and injection of steroids. If the conservative treatment is not effective, surgical management is usually recommended. And alcohol installations have been rarely performed. We are reporting an extremely rare case of a 56-year-old man who had chronic idiopathic isolated finger flexor tenosynovitis which was treated through alcohol injections. The patient had not yet been treated despite of medication and serial injections of steroid. We performed 1 mL of 50% ethanol injection for the initial treatment and the second injection was done in the same way 10 months later due to the improvements of the patient's clinical symptoms and images of the follow-up ultrasonography. As a result, the authors suggest alcohol installation as an alternative non-surgical treatment for flexor tenosynovitis when other conservative managements are not effective enough.

Angular pregnancy complicated with preterm labor at 25 gestational weeks of pregnancy / 대한산부인과학회지

Angular pregnancy refers to implantation of the embryo just medial to uterotubal junction in the lateral angle of the uterine cavity. This is differentiated from interstitial pregnancy in which the gestational sac is located within intramural portion of the tube. Angular pregnancy is categorized as intrauterine pregnancy and the outcome is known favorable. However, there have been few reports about adverse perinatal complications such as abortion, retained placenta, placenta accreta, placenta percreta and uterine rupture. We report a case of angular pregnancy complicated with preterm labor at 25 gestational weeks, placenta accreta and postpartum endometritis. This case suggests that angular pregnancy should be differentiated from normal intrauterine pregnancy because of its potential risk of adverse outcome.

Perinatal outcome of pregnancy with hyperthyroidism / 대한산부인과학회지

OBJECTIVE: To evaluate the maternal and neonatal outcomes of pregnancies complicated with hyperthyroidism, according to the maternal treatment and thyroid function status during pregnancy. METHODS: This retrospective study was conducted on women complicated by hyperthyroidism who delivered between January 2000 and March 2010, at Catholic University Medical Center. The baseline characteristics as well as maternal and fetal outcomes were analyzed and compared according to maternal antithyroid medication and thyroid function status. RESULTS: Among 163 pregnant women complicated with hyperthyroidism, 103 women received antithyroid medication and 109 women showed euthyroid status during pregnancy. The mean gestational age and fetal birth weight at delivery were 38.2+/-2.9 weeks and 2.99+/-0.64 kg. There was no statistical difference in maternal complications between the medication group (n=103) and the non-medication group (n=59), while neonatal thyroid dysfunction including transient hypothyroidism was significantly higher in the medication group than the non-medication group (58% vs 24.5%, P<0.0001). The incidence of admission due to hyperemesis and neonatal thyroid dysfunction were significantly higher in the thyroid dysfunction group than the euthyroid group (21.7% vs 4.6%, P=0.0146; 66.7% vs 39.4%, P=0.0223, respectively). CONCLUSION: Maternal antithyroid medication as well as thyroid dysfunction during pregnancy could indicate the careful fetal thyroid monitoring to prevent neonatal thyroid dysfunction.

Perinatal Outcomes according to the Types of Fetal Acidosis in Term Newborns with Umbilical Artery Acidosis / 대한주산의학회잡지

PURPOSE:To investigate the significance of umbilical artery acidosis and compare perinatal outcomes according to the types of acidosis for a tertiary hospital population delivered at term. METHODS:We reviewed maternal and neonatal medical records of all term liveborn infants with an umbilical artery pH or =20 mEq/L) and high pCO2 (> or =20 mmHg) were significantly associated with low pH value, the perinatal outcomes were not significantly different according to the level of base deficit or pCO2. CONCLUSION:The mixed acidemia was more associated with pathologic fetal acidemia than pure respiratory or metabolic acidosis. The ability to predict not only metabolic but also respiratory component of fetal acidemia may help in safe management of delivery leading to reduce the fetal acidemia.

Perinatal outcome of term pregnancies with meconium-stained amniotic fluid / 대한주산의학회잡지

PURPOSE: The purpose of this study was to compare the obstetric and perinatal outcome between two groups with or without meconium staining of amniotic fluid (MSAF) at term birth in one-year consecutive population at our delivery unit. METHODS: Pregnancy complication including nonreassuring fetal heart rate pattern, intrauterine growth retardation, oligohydramnios, hydramnios and preeclampsia between the two groups were retrospectively documented by review of medical record. To evaluate the perinatal outcome, apgar score at 1min and 5min, and umbilical artery blood gas analysis were also analyzed. Student T test and chi square test were used for statistic analysis. RESULTS: The study population consisted of 687 full-term neonates with presence (n=89) and absence (n=598) of MSAF. Gestational age at delivery was significantly higher in the MSAF group (p12.0 mEq/L) was not increased. The incidence of non reassuring fetal heart rate pattern was also increased in the MSAF group (4.5% vs 1.0%, p=0.03). However there was no significant difference in 1 min and 5 min Apgar score. CONCLUSION: Although MSAF is associated with the risk of non reassuring fetal heart rate pattern and fetal acidemia, the metabolic acidemia and low apgar score at 5minutes was not significantly increased compared with clear amniotic fluid group. Delivery of pregnancy with MSAF should be managed under the careful fetal heart rate monitoring.

Effect of Repetitive Transcranial Magnetic Stimulation in Patients with Intractable Neuropathic Pain: Cases report

Drug resistant neuropathic pain can be relieved by non-invasive new therapy of repetitive transcranial magnetic stimulation (rTMS). Three patients who have been suffered from intractable neuropathic pain with diverse underlying causes were enrolled. The causes of their pain were the thalamic hemorrhage, the complex regional pain syndrome (CRPS) after resection of neurilemmoma, and the trigeminal schwanoma respectively. A thousand pulses of 10 Hz rTMS were delivered over the contralateral primary motor cortex at 80% of resting motor threshold for a period of 20 minutes per each treatment session. The intensity of pain was assessed using a visual analogue scale before and after rTMS session for 5 consecutive days. Immediate and dramatic analgesic effects were noticed as a result of rTMS in patients with thalamic hemorrhage and trigerminal schwanoma. Moderate analgesic effect was noticed in patient with CRPS. The duration of analgesic effect was variable.

Genomic gain and loss of cervical cancer using BAC Chip / 대한산부인과학회지

OBJECTIVE: Cervical cancer has long been linked to the sexually transmitted human papillomavirus (HPV), and the oncoproteins E6 and E7 disrupt the functions of tumour suppressor genes, resulting in genetic alteration. It was shown that loss of heterozygosity at 6p is a common genetic alteration in cervical cancer. However, the molecular genetics of cancer have only recently been understood, and for the development of cervical cancer additional genetic alterations in host cell genes are required. The present study has identified the differential changes of the cervical cancer-associated genetic alterations by a genome-wide array based comparative genomic hybridization (array-CGH). METHODS: We analyzed 15 cases of cervical cancer from St. Mary's hospital of The paraffin-fixed tissue samples were microdissected under microscope and DNA was extracted by the procedures of proteinase K digestion and chloroform extraction. Array-based CGH and genomic PCR were carried out with statistical analyses such as hierarchical clustering and Gene Ontology. The BAC array used in this study consisted of 1,440 human BACs, the space among the clones were approximately 2.08 megabase (Macrogen, Seoul, Korea). RESULTS: All of 15 cases of cervical cancer showed specific gains and losses. The analysis limit of average gains and losses was 53%. A significant positive correlation was found between 1p36.32, 3p14.2, 3q27.1, 7p21.1, 8q24.3 and 11q13.1 changes through the cervical carcinogenesis. The high-level of gain regions, BAC clones encoded GSDMDC1, RECQL4, TP73, ABCF3, ALG3, HDAC9, ESRRA and RPS6KA4 genes. Frequently gained BAC clones encoded genes were PRSS8, FUS, COL18A1, PCOLN3, MAFG and ASPSCR1. The genes encoded by frequently lost BAC clones were PTPRG, GRM7, ZDHHC3, EXOSC7, LRP1B and NR3C2. Also, hierarchical clustering of the expression data readily distinguished genomic alterations in cervical cancer. A subset of cellular processes from each gene was clustered by Gene Ontology database. CONCLUSION: Using Array-CGH, genomic alterations related to cervical cancer were identified to determine whether induction of chromosomal imbalances occurs prior to carcinogenesis. The high resolution of array-CGH combined with human genome database would give a chance to find out possible target genes present in the gained or lost clones.

Clusterin expression and paclitaxel resistance in cervical cancer cell lines / 대한산부인과학회지

OBJECTIVE: The purpose of this study was to evaluate whether clusterin expression is significantly correlated with paclitaxel resistance in cervical cancer cell lines. METHODS: The expressions of clusterin in cervical cancer cell lines were validated with western blotting. And subsequently, the correlation between clusterin expression levels and the IC50 of paclitaxel in several cervical cancer cell lines was evaluated. After transfection of clusterin siRNA into HeLaS3, which expressed high level of clusterin, their effect on chemo-resistance was evaluated by XTT assay. RESULTS: Clusterin expression levels were correlated with paclitaxel resistance in cervical cancer cell lines. And after transfection of clusterin siRNA into HeLa-S3 significantly decreased paclitaxel resistance (P<0.05). CONCLUSION: These findings suggest that clusterin expression may correlate with paclitaxel resistance.

Clusterin expression and paclitaxel resistance in cervical cancer cell lines / 대한산부인과학회지

OBJECTIVE: The purpose of this study was to evaluate whether clusterin expression is significantly correlated with paclitaxel resistance in cervical cancer cell lines. METHODS: The expressions of clusterin in cervical cancer cell lines were validated with western blotting. And subsequently, the correlation between clusterin expression levels and the IC50 of paclitaxel in several cervical cancer cell lines was evaluated. After transfection of clusterin siRNA into HeLaS3, which expressed high level of clusterin, their effect on chemo-resistance was evaluated by XTT assay. RESULTS: Clusterin expression levels were correlated with paclitaxel resistance in cervical cancer cell lines. And after transfection of clusterin siRNA into HeLa-S3 significantly decreased paclitaxel resistance (P<0.05). CONCLUSION: These findings suggest that clusterin expression may correlate with paclitaxel resistance.

The Success Rate of Posterior Approach Glenohumeral Injection in Patients with Adhesive Capsulitis

OBJECTIVE: Accuracy of injection in patient with adhesive capsulitis may significantly affect the clinical outcome. The purpose of this study was to evaluate the success rate of posterior approach glenohumeral injection in patients with adhesive capsulitis. METHOD: Twenty-two patients who were clinically diagnosed with adhesive capsulitis were enrolled. They had sustained pain and limitation of motion in shoulder in spite of medication and physical therapy for at least 2 months and no history of trauma. Patients were received by a posterior approach glenohumeral injection of 2 ml radiographic contrast. Radiograph of the shoulder joint was taken immediately after the injection to determine success of the intra-articular injection. RESULTS: 5 of the 22 procedures (22.7%) were judged to be accurately placed and in the others the contrast media was observed in the muscular and subcutaneous tissues. CONCLUSION: This study showed that posterior approach glenohumeral injection in adhesive capsulitis was a difficult procedure. The low success rate of posterior approach glenohumeral injection in adhesive capsulitis would lead to repetitive injection and side-effect of corticosteroid. We consider fluoroscopy-guided intra-articular injection in adhesive capsulitis rather than posterior approach glenohumeral injection to increase the accuracy of intra-articular injection.

A case of Antenatally diagnosed Changing Sonographic Findings of a Twisted Fetal Ovarian Cyst / 대한산부인과학회지

Ovarian cysts are common incidental findings in term infants and, if unusually large, may result in dystocia, torsion, or rupture. We report the case in which serial sonographic examination revealed changing pattern of cystic ovarian mass from hypoechogenic to well defined multiseptated echogenic during pregnancy. Postnatal T2-weighted MR images revealed a multilocular with high signal density. After delivery a laparotomy was performed, and a twisted ovary measuring 6.7x5x4.5 cm was removed. Ovarian torsion was left-sided and had been almost autoamputated. The resected specimens were nontense, thin walled cysts, filled with hemorrhage like fluid. Histological examination demonstrated the presence of lymphangioma with widespread hemorrhage and necrosis. The neonate did well after the procedure.

Effect of Dynamic Balance Training Using Visual Biofeedback of Center of Pressure in Patients with Stroke

OBJECTIVE: To investigate the effect of dynamic balance training with center of pressure (COP) games using visual biofeedback of COP movement in stroke patients. METHOD: Thirty-eight stroke patients were randomly as signed to the static or dynamic balance training group, or control group. Static group received weight-shift training with visual biofeedback of weight distribution bar. Dynamic group received dynamic balance training using COP games. Each training session lasted 30 minutes, 3 times in a week during 3 weeks. Control group received traditional rehabilitation only. The ability of balance control was assessed using posturography by total path distance, frequency of sway, and COP weight-spectrums during standing, and during presentation of virtual moving surround. Total patherror was also assessed during sine curve and dynamic circle trace test. RESULTS: In static group, there were significant improvement in the total path distance during comfortable standing and path error during sine curve tracing. In dynamic group, significant improvements were found in the path error during sine curve and dynamic circle tracing. CONCLUSION: Dynamic training group showed more improvement in dynamic balance ability, whereas static group showed more changes in the static balance ability. The visual biofeedback training is more specified for balance rehabilitation in stroke patients.

Tc-99m-ECD Brain Single Photon Emission Computed Tomography Findings in Cerebral Palsy: Comparison with Magnetic Resonance Imaging Findings

OBJECTIVE: To investigate the correlation between magnetic resonance imaging (MRI) findings and single photon emission computed tomograpy (SPECT) in cerebral palsy (CP). METHOD: Fourty-one patients with CP underwent MRI and SPECT of the brain. The patients were divided into 5 groups. Group 1 was for the cases with normal findings on MRI and SPECT, group 2 for abnormal on MRI but normal on SPECT, group 3 for normal on MRI but abnormal on SPECT, group 4 for abnormal findings on both MRI and SPECT with same abnormal lesion and group 5 for abnormal findings on both MRI and SPECT but with different abnormal lesion. RESULTS: In group 2, periventricular leukomalacia (PVL) and cortical atrophy were shown on MRI. In group 3, decreased blood flow at cerebellum was shown on SPECT. In group 4, brain atrophy on MRI and the decreased blood flow at the same site on SPECT were shown. In group 5, 15 of 22 cases with PVL on MRI and decreased blood flow at cerebellum, thalamus, basal ganglia and the cortical areas were shown. CONCLUSION: Brain SPECT was more sensitive in the detection of cerebellum, thalamus and cortical blood flow abnormality. MRI was more sensitive in demonstration of white matter lesion.

A Cadaver Study of Iliolumbar Ligament from a Viewpoint of Surface Anatomy

OBJECTIVE: To assess the anatomical relationship between spinous process of the lumbar vertebrae and iliolumbar ligament from a viewpoint of surface anatomy. METHOD: Fourteen iliolumbar ligaments of seven human cadavers were dissected and measured distance from the lumbar spinous process to the iliolumbar ligament and vertical depth of iliolumbar ligament from the skin surface. RESULTS: All 14 iliolumbar ligaments were originated at the L5 transverse process and inserted in anterior surface of the iliac crest. Direct distance from lumbar spinous process to the origin siteof the iliolumbar ligament was 7.67+/-0.39 cm(distance from the spinous process to presumed skin point of the termination site of the ligament, 6.71+/-0.4 cm). Vertical depth from skin surface was 3.94+/-0.57 cm to the origin site of the iliolumbar ligament, and 3.67+/-0.54 cm to the termination site of the iliolumbar ligament. CONCLUSION: The iliolumbar ligament was deep seated anatomical structure in the lumbosacral region. Superficial landmark of the lumbar spinous process may be useful in approach to iliolumbar ligament.