Fetal therapies as standard prenatal care in Japan

With recent advances in fetal medicine, various attempts have been made to save fetuses facing perinatal death or devastating consequences despite optimal management after birth. The concept of the fetus as a patient has been established through the application of in utero treatments. This paper reviews fetal therapies in order to highlight the role of perinatal medicine as standard prenatal care. Fetal therapies consist of medical therapy, percutaneous ultrasound-guided surgery, fetoscopic surgery, and open fetal surgery. In the 1980s, with advances in ultrasound imaging, percutaneous ultrasound-guided surgeries such as vesicoamniotic shunting for lower urinary tract obstruction and thoracoamniotic shunting (TAS) for fetal hydrothorax (FHT) were started. In the 1990s, fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) was introduced, and later, a fetoscopic approach for congenital diaphragmatic hernia was also established. The revival of open fetal surgery, introduced in the 1980s by pediatric surgeons, began in the 2010s after a successful clinical study for myelomeningocele. Although many fetal therapies are still considered experimental, some have proven effective, such as FLS for TTTS, TAS for primary FHT, and radiofrequency ablation (RFA) for twin reversed arterial perfusion (TRAP) sequence. These three fetal therapies have been approved for coverage by Japan National Health Insurance as a result of clinical studies performed in Japan. FLS for TTTS, TAS for primary FHT, and RFA for TRAP sequence have become standard prenatal care approaches in Japan. These three minimally invasive fetal therapies will help improve the perinatal outcomes of fetuses with these disorders.

Prediction of Labor in Term Pregnancy Ising Fetal Fibronectin and Transvaginal Ultrasonography / 대한주산의학회잡지

OBJECTIVE: We performed the transvaginal ultrasonographic evaluation of uterine cervix and fetal fibronectin in cervicovaginal secretions in women after 37 complete weeks of gestation to predict the onset of labor. METHODS: Total 80 primiparous or multiparous women were divided into two groups on the duration between evaluation and onset of labor. The biometric analysis of uterine cervix(cervical index, endocervical length, funneling, funnel length and width) was done by transvaginal ultrasonography. The cervicovaginal fetal fibronectin was measured by fetal fibronectin immunoassay (ELISA kit, Adeza Biochemical, USA). The efficacy of these method was analyzed with Pearson chi-square test, receiver-operator characteristic curves, and multiple logistic regression test. RESULTS: 1) There were no significant differences in clinical characteristics between two groups. 2) Group 1(onset of labor within 7 days after evaluation) showed significantly shorter endocervical length(Group 1: 2.33+/-0.75cm,Group 2: 2.93+/- 0.42cm, p=0.013), higher value of cervical index(Group 1: 1.27+/-0.67, Group 2: 0.62+/-0.34, p=0.008) and higher level of fetal fibronectin(Group 1: 98.65+/-11.34ng/ml, Group 2: 13.37+/- 2.7ng/ml, p=0.004). 3) The ROC curve analysis showed that a level of endocervical length 0.7, fetal fibronectin> 60ng/ml had the diagnostic performance in predicting group 1. Fetal fibronectin level in cervicovaginal secretion> 60ng/ml showed the highest diagnostic index in predicting the onset of labor within 7 days(p<0,001, odds ratio=21.3). CONCLUSION: Cervicovaginal fetal fibronectin predicts delivery within 7 days more accurately than cervical index, endocervical length. Combine use of these tests improve the diagnostic efficiency and allowed prediction of onset of labor, identifying a subgroup of patients who may require aggressive treatment.

Periprostatic Pelvic Arteriovenous Malformation with Postejaculatory Hematuria / 대한비뇨기과학회지

Congenital arteriovenous malformations in the true pelvis are extremely rare : only 8 cases have been described in male patient. In most cases, the diagnosis may be obscure and the management is difficult due to frequent recurrence, so appropriate angiographic study is decisive in establishing the diagnosis and directing the mode of treatment. We report on 53 year old male patient who was treated with embolization due to congenital pelvic arteriovenous malformation with painless gross hematuria after erection or sexual intercourse. Diagnosis was established as periprostatic pelvic arteriovenous malformation by means of transrectal color Doppler ultrasonography and confirmed by angiography. Our attempt at management by embolization is described. A literature review and discussion of congenital arteriovenous malformation and worth of color Doppler ultrasonography are presented.