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.

A Case of Fetal Cardiac Rhabdomyoma with Tuberous Sclerosis / 대한주산의학회잡지

Fetal cardiac tumors are a rare condition and are histologically benign. Cardiac rabdomyoma is the most common cardiac tumor and may be associated with tuberous sclerosis. Clinical follow-up including monitoring of fetal well-being is warranted as long as the fetus remains asymptomatic and there is no evidence for hydrops fetalis. If obstruction to blood flow and/or early fetal compromise is noted, then the decision of whether to deliver early must be made. We report a case of fetal cardiac tumor diagnosed by antenatal ultrasonography and diagnosed as tuberous sclerosis with brain MRI scanning after birth.

Clinical significance of oligohydramnios in intrauterine growth restriction / 대한산부인과학회지

OBJECTIVE: This study was performed to prove the significance of the oligohydramnios in the intrauterine growth restriction. METHODS: Eighty two patients were identified to have intrauterine growth restriction with oligohydramnios (Group of IUGR+Oligihydramnios) and fifty six patients were identified to have intrauterine growth restriction without oligohydramnios (Group of IUGR) on ultrasound examination from January 1st, 2005 to December 31st, 2007 at St. Vincent Hospital of Catholic University of Korea. Perinatal outcomes were compared between two groups. RESULTS: Statistically significant differences were not shown between two groups in the maternal characteristics and fetal clinical features except amniotic fluid index and the duration between diagnosis and delivery. The incidence of hyperbilirubinemia and complications in the urogenital system were significantly increased in the group of IUGR+ Oligihydramnios. The other complications were not shown significant difference between two groups. CONCLUSION: Oligohydramnios may not seem to be significant predictor of adverse neonatal outcome of IUGR except the development of hyperbilirubinemia and urogenital complications.

A case of unicornuate uterus with noncommunicating rudimentary horn with ipsilateral renal agenesis / 대한산부인과학회지

Rudimentary uterus with ipsilateral renal agenesis is a very rare mullerian duct malformation. The unicornuate uterus is a rare type of the anomalous uteri, which is caused by failure of development of one of the mullerian ducts. The most common clinical presentation is pelvic pain and dysmenorrhea shortly after menarche, in associated with the finding of a vaginal or pelvic mass. An appropriate and prompt diagnosis and treatment will prevent unnecessary procedures and offer relief of symptoms. We presented a rare case of a unicornuate uterus with a noncommunicating horn, and ipsilateral renal agenesis with a brief review of concerned literatures.

Severe preeclampsia at 16 weeks' gestation associated with a partial hydatidiform mole and bilateral theca-lutein cysts / 대한산부인과학회지

We present an unusual case in which a patient was diagnosed with the preeclampsia associated with a partial hydatidiform mole and bilateral theca-lutein cysts. The patient newly developed proteinuric hypertension at 16 weeks' gestation. Ultrasound findings showed small multiple cystic spaces in the placenta and a live singleton fetus. Triploid 69, XXX was confirmed at karyotype analysis. Intrauterine fetal death was found at 18 weeks' gestation and termination of pregnancy was performed, and a partial hydatidiform mole was confirmed at pathologic examination. Torsion of bilateral theca-lutein cysts was developed at postpartum one week. Detorsion and aspiration of the bilateral theca-lutein cysts were performed under the laparoscopy.

Clinical Effects of Continuous Transabdominal Amnioinfusion in Preterm Premature Rupture of Membranes : Retrospective Study / 대한주산의학회잡지

OBJECTIVE : To assess the clinical role of continuous transabdominal amnioinfusion in pregnancies with preterm premature rupture of membranes (PPROM) less than 34 weeks of gestation. METHODS : In this retrospective study between January 1999 and December 2003, 76 singleton pregnancies complicated with PPROM less than 34+0 weeks of gestation, were included. Thirty-eight patients consented to undergo the continuous transabdominal amnioinfusion. The control group, matched with the amnioinfusion group by parity and gestational age at rupture of membranes, was managed expectantly. RESULTS : The median intervals from PPROM and delivery (latency period) (8.0+/-7.3 days vs. 1.7+/-2.5 days, p<0.001), the gestational age at delivery (223+/-17.8 days vs. 211+/-18.0 days, p=0.003) and the birth weight (1,853+/-465 g vs. 1,556+/-459 g, p=0.006) were significantly increased in the amnioinfusion group compared to the control group, respectively. In maternal complications, the amnioinfusion group showed higher rate of placental abruption (5.2% vs. 2.6%, p=0.556) than the control group, but were comparable in the rates of cesarean section (44.7% vs. 42.1%, p=0.817) and clinical chorioamnionitis (18.4% vs. 18.4%). The rate of neonatal ventilator care of positive pressure ventilation was significantly decreased in the amnioinfusion group, compared to the control group (15.8% vs. 50.0%, p=0.002). In neonatal morbidity, respiratory distress syndrome was more frequent in the control group compared to the amnioinfusion group, although it did not show statistical significance (34.2% vs. 15.8%, p=0.06). There were no significant differences in rates of Intraventricular hemorrhage (IVH) grade III, IV, neonatal sepsis and neonatal mortality between two groups. CONCLUSION : Our results suggest that, in pregnancies complicated with preterm premature rupture of membranes less than 34 weeks of gestation, the continuous transabdominal amnioinfusion might have improved the neonatal outcome without increasing the perinatal infection rate.

The risk factors of emergency cesarean hysterectomy for placenta previa / 대한산부인과학회지

OBJECTIVES: The purpose of this study is to investigate the clinical risk factors of emergency cesarean hysterectomy in patients with pregnancies complicated by placenta previa and whether the third trimester transvaginal ultrasonographic findings of placenta previa would predict emergency cesarean hysterectomy. MATERIALS AND METHODS: Between January 1995 and March 2005, we retrospectively reviewed the records and compared between patients with pregnancies complicated by placenta previa who underwent cesarean hysterectomy and patients with pregnancies complicated by placenta previa who did not undergo cesarean hysterectomy. RESULTS: There were 314 had placenta previa and 34 patients were performed cesarean hysterectomy (10.83%). There were significant differences on the basis of maternal age (31.53+/-4.41 vs 34.06+/-4.12, p<0.05), parity (0.81+/-0.70 vs 1.29+/-0.63, p<0.05) , the number of cesarean section (0.36+/-0.56 vs 0.91+/-0.75, p<0.05), previous history of placenta previa and presence of placenta accreta, but not on the basis of gestational age, the number of antenatal vaginal bleeding, the number of abortions and emergency operation between two groups. On the basis of third trimester transvaginal ultrasonographic findings, significant differences were found on the distances from the internal os of cervix (1.18+/-3.66 vs 2.67+/-2.94, p<0.05) and thickness of lower placental edge. However, the presence of lacuna in the lower placenta was not associated with emergency hysterectomy. CONCLUSIONS: Patients with placenta previa are at a higher risk of undergoing cesarean hysterectomy when they are associated with placenta accreta, thick lower placenta edge, and positively longer distance to the internal os of cervix. The other clinical factors such as maternal age, parity, the number of cesarean section and previous history of placenta previa might be associated the risk of cesarean hysterectomy.

Maternal-neonatal outcome in HELLP syndrome and severe preeclampsia / 대한산부인과학회지

OBJECTIVE: To assess the clinical characteristics, laboratory findings, the maternal and neonatal complications between HELLP syndrome and severe preeclampsia. METHODS: We reviewed the material and neonatal charts of 34 pregnancies complicated by HELLP syndrome and 40 pregnancies complicated by severe preeclampsia managed at our hospital between January, 2001 and December, 2005. We compared the clinical characteristics, laboratory findings, the maternal and neonatal complications between two groups. Results were compared by student T test, chi-square test. RESULTS: Our study showed that in HELLP syndrome patients had the less gestational age at admission, gestational age at delivery, the lower platelet counts, the higher AST, ALT, LDH, and the longer hospitalization period than in severe preeclampsia. Steroid (dexamethasone) use, cesarean delivery rate and MgSO4 use were more frequent in HELLP syndrome than severe preeclampsia. Neonatal birth weight was lower with HELLP syndrome. There was no significant difference in maternal and neonatal complications. CONCLUSION: HELLP syndrome need to be recognized a unique form of severe preeclampsia. It was associated with serious maternal and fetal mortality, the appropriate management would be done by early diagnosis using laboratory tests.

A case of transverse vaginal septum with modified Garcia technique / 대한산부인과학회지

The incidence of all transverse vaginal septum is 1:2,100 - 1:72,000. The transverse vaginal septum is a developmental defect of vagina which may be fused incompletely between the Mullerian duct component and the urogenital sinus component of vagina. Serious complications may be hematocolpos, hematometra and hematosalpinx. Simple surgical excision or simple incision have been developed to treat congenital transverse vaginal septa, but also caused common complications such as secondary tissue contracture. Garcia technique using eight vaginal mucosa flaps was developed to avoid common complication of secondary vaginal stenosis. Here, we present a case of contracted transverse vaginal septum who has been performed a simple incision 13 years ago, successfully performed the modified Garcia technique without serious postoperative complication.

Pregnancy Outcome in Renal Transplant Recipients: A Retrospective Study / 대한주산의학회잡지

OBJECTIVE: The aim of our study was to identify graft, obstetric and maternal outcomes of pregnancies in renal transplant recipients at our center. METHODS: A 14-year retrospective study between January 1990 and December 2003, 224 women 15 to 45 years of age had transplantation and were analyzed the outcomes of pregnancies, obstetric complications and graft function. RESULTS: Thirty-four pregnancies occurred in 21 of 224 patients. The mean age at the time of conception was 29.5 years (21 to 36 years) with a mean interval of 61.9 months (one to 162 months). In the pregnancy outcome, there were the 23 live births (67.6%) included 13 preterm and 10 term deliveries, 3 spontaneous abortions (8.8%), 7 artificial abortions (20.5%) and one case of ectopic pregnancy (2.9%). Obstetric complications were; preeclampsia (39.1%), preterm labor (43.4%), urinary tract infections (38.2%) and gestational diabetes (8.6%). Nine pregnancies within 2 years of transplantation had the permissible obstetric outcomes comparing with the others after 2 years (spontaneous abortion: p=0.77, artificial abortion: p=0.88, live birth: p=0.36). In twelve pregnancies appearing renal dysfunction associated with pregnancy, the abortion rate was increased comparing the others with stable renal function (p=0.006). Pre-pregnancy serum creatinine > or =1.4 mg/dl was associated with increased preterm delivery, but not significant (50.0% vs 28.5%, p=0.30). In graft function, serum creatinine 3~6 postpartum was significantly increased comparing pre-pregnancy levels (p=0.04). Five cases of 7 patients with acute rejection episode associated with pregnancy conceived after 4 years of transplantation. Two-year graft survival after delivery was 95.2% (20/21) and chronic rejection and graft failure was diagnosed in one case at postpartum 14 months. CONCLUSION: These findings suggest that, if the graft function is stable, pregnancy within 2 years after renal transplantation might be safe. Pregnancy does not appear to have adverse effects on long term graft survival.

Two Cases of Acute Interstitial Pneumonia During the Second Trimester of Pregnancy / 대한주산의학회잡지

We present two cases of acute interstitial pneumonia (AIP) during the second trimester of pregnancy managed by mechanical ventilation, high dose corticosteroids. We described clinical course, laboratory data and imaging studies. Case 1) A 29-year-old woman, G1P1, was referred for aggravated continuous coughing, sputum and dyspnea, pleuritic chest pain and mild fever for 3 weeks at 24(+3) weeks of gestation. There were coarse breathing sounds with crackles on the both lung field. Her chest X-ray showed diffuse haziness in both lungs with suspicious nodular opacities and suggested pneumonia. HRCT showed diffuse ground glass opacities with interstitial thickening and suspicious fine nodular infiltration in both lungs suggesting acute interstitial pneumonia combined with ARDS. Because her symptoms were more aggravated, she was performed mechanical ventilation treatment. After that, she was performed cesarean hysterotomy and delivered a dead male 850grams. After her symptoms were much more improved. All antibiotics were stopped and reduced the doses of steroids, she was discharged with t-tube capped state. Case 2) A 33-year-old woman, G1P1, was referred for continuous coughing, sputum and dyspnea for 3 months and low abdominal discomfort at 24(+4) weeks of gestation. There were coarse breathing sounds with rales on the both lung field. Her chest X-ray showed diffuse haziness in both lungs with suspicious nodular opacities and suggested interstitial pneumonia. HRCT showed diffuse ground glass opacities with some intralobular and interlobular interstitial thickening and suspicious fine nodular infiltration in both lungs suggesting acute interstitial pneumonia or miliary TBc combined with ARDS. She was treated with antibiotics, oxygen, high dose corticosteroids, and tocolytics. There was no evidence of TBc in the bronchoscopy. She showed decreased mentality and decreased O2 saturation below 90% in spite of mechanical ventilation, high dose steroids and IVGV therapy. She delivered a boy of 870 g (Apgar score 1/5). After delivery, she was expired due to combined aggravating DIC. Her baby was expired at the next day, too. The outcome of AIP is fatal, reporting 59~100% mortality rate. The clinical course, laboratory data and treatment are not well established due to rarity of this disease entity. Chest X-ray and HRCT may be helpful in diagnosis and high dose steroid and immunosuppressive agents usually used but the efficacy is not guaranteed.

Two cases of adnexal torsion during the third trimester of pregnant women / 대한산부인과학회지

Adnexal torsion during pregnancy is rare condition that is infrequently diagnosed preoperatively. Its incidence is 1 in 5000 during pregnancy, and adnexal torsion in the third trimester is rare. We present two cases of an adnexal torsion during the third trimester. The one had not been previously diagnosed by ultrasound and was associated with fetal distress and the other had been diagnosed having an ovary cyst by ultrasound in the first trimester. Both of patients were sent to our emergency room for sudden onset of severe low abdominal pain. Treatment was maintenance of adequate circulating intravascular volume and rapid surgical intervention.

Two cases of adnexal torsion during the third trimester of pregnant women / 대한산부인과학회지

Adnexal torsion during pregnancy is rare condition that is infrequently diagnosed preoperatively. Its incidence is 1 in 5000 during pregnancy, and adnexal torsion in the third trimester is rare. We present two cases of an adnexal torsion during the third trimester. The one had not been previously diagnosed by ultrasound and was associated with fetal distress and the other had been diagnosed having an ovary cyst by ultrasound in the first trimester. Both of patients were sent to our emergency room for sudden onset of severe low abdominal pain. Treatment was maintenance of adequate circulating intravascular volume and rapid surgical intervention.

Analysis of Gene Expression in the Human Chorion of Preterm Labor Using cDNA Microarray / 대한주산의학회잡지

OBJECTIVE: We used a genome-wide approach to identify differentially expressed genes in patients with preterm delivery caused by preterm labor to improve the understanding of underlying molecular mechanism. METHODS: RNA was isolated from the chorions of patients with preterm delivery caused by preterm labor with intact membranes and term vaginal delivery. cDNA microarray experiments were used to identify differentially expressed genes, and reverse transcriptase-polymerase chain reaction was used in follow-up experiment. RESULTS: cDNA microarray experiments identified significantly increased expression of 104 genes and decreased expression of 102 genes in the preterm cases. 18 genes showed more than 1.5-fold increased expressions in the chorions of patients with preterm delivery by preterm labor than those with term vaginal delivery. In preterm delivery, up-regulated genes were associated with cell adhesion, cell cycle regulation, development, transport, morphogenesis, muscle contraction, signal transduction, and transcription. 15 genes showed more than 1.5-fold decreased expressions in chorions of patients delivered preterm by preterm labor than delivered term by labor. In preterm delivery, down-regulated genes were associated with cell differentiation, development, metabolism, morphogenesis, RNA processing, signal transduction, transcription, and transport. CONCLUSION: This study suggests cDNA microarray technique might provide insights into the molecular basis of preterm delivery caused by preterm labor.

A case of ovarian pregnancy with focal adenomyosis mimicking cornual pregnancy that managed by laparoscopy / 대한산부인과학회지

Ovarian pregnancy is rare form of ectopic pregnancy occurring in 0.5-1% of all ectopic pregnancies. But the presenting symptom is very similar and difficult to distinguish with other forms of ectopic pregnancy. We report a case of ovarian pregnancy mimicking cornual pregnancy managed with laparoscopy. Early detection is important role in preserving fertility to avoid the ablation of functional ovarian tissue. The diagnostic criteria, etiology, and management are discussed.

Search for Differentially Expressed Genes in Preterm Human Placentae and Their Membranes by Annealing Control Primer System / 대한주산의학회잡지

OBJECTIVE: The aim of this study was to investigate the gene expression profiles using GeneFishingTM kit in human placentae and their membranes delivered at preterm caused by preterm labor. METHODS: Specimens were obtained from placenta, chorion, and amnion delivered at preterm and term, respectively. Total RNAs were isolated from each specimen. Thereafter, the profiles of expression genes between preterm and term specimens were compared using a new and accurate reverse transcription-polymerase chain reaction (RT-PCR) that involves annealing control primers (ACPs) to identify the genes expressed differentially and screened by basic local alignment search tool (BLAST) search. RESULTS: Using 20 ACPs, 13 differentially expressed genes (DEGs) were identified and sequenced. 7 of them were expressed up-regulation, while 6 were expressed down-regulation in preterm deliveries. A BLAST searches revealed that 11 were known genes and 2 were unknown genes. Among known genes, up-regulated genes were insulin-like growth factor II associated protein, vigilin, acyl-Coenzyme A dehydrogenase, tissue inhibitor of metalloproteinase 1 (TIMP1), ribosomal protein S26 (RPS26), follistatin-like 1 (FSTL1) and down-regulated genes were two mitochondrial DNAs, ribosomal protein S28 (RPS28), transglutaminase 2 (TGM2), heparin sulfate proteoglycan (HSPG, perlecan). CONCLUSION: This study shows that the ACP system is a good method for the identification of preterm-related genes. Furthermore, this study suggests that further analysis of the differentially expressed genes in preterm we have identified should provide insights into the molecular basis of preterm delivery caused by preterm labor.

Expression of Fas, Fas-ligand, Bcl-2 and Bad with Maturation of Human Ovarian Follicle / 대한산부인과학회잡지

Human ovarian follicles reduce rapidly in number throughout fetal and adult life. Throughout the menstrual cycles, primordial follicles grow into mature follicles and then ovulate to form corpus luteum. Apoptosis has been implicated in several events that occur during the process of follicular growth, atresia and the regression of the corpus luteum. By the use of immunohistochemistry, we clarified the involvement of apoptosis in the human ovary during follicular growth, regression and atresia by investigating the expression of Fas, Fas-ligand, Bcl-2 and Bad in primordial follicles, primary follicles and mature follicles. Fas immunostaining was present in primordial oocytes, both oocytes and granulosa cells of primary follicles, preantral follicles and all follicular cells of mature follicles. Fas-ligand and Bad immunostaining patterns were similar to those of Fas except for theca cells. Bcl-2 immunostaining was present in both oocytes and granulosa cells of primary, preantral and mature follicles. In corpus luteum, Fas, Fas-ligand, Bcl-2 and Bad immunostaining were observed and decreased in the regressing corpus luteum. In postmenopausal ovary, Fas, Fas-ligand, Bcl-2 and Bad immunostaining were entirely negative. Bad immunostaining was observed but Bcl-2 was not in atretic follicle. These results suggest that Fas, Fas-ligand, Bcl-2 and Bad may play important roles in human ovary during follicular growth, regression and atresia simultaneously. Further studies should be required to elucidate the underlying mechanism and apoptosis of the disease associated with normal and abnormal ovarian aging.

Assessment of Pelvic Floor Muscle Exercise using Vaginal Cone in Stress Urinary Incontinence of Korea Women / 대한산부인과학회잡지

Defective or inadequate pelvic floor function is important etiologic factor for urinary stress incontinence and uterine prolapse. Pelvic floor muscle exercise is the mainstream of the nonoperative treatment for female stress urinary incontinence. Especially Vaginal cones have been known as a simple and practical means of improving both pelvic floor muscle strength and genuine stress incontinence using biofeedback mechanism. Forty adult women suffering from mild and moderate stress incontincnce were instructed to exercise their pelvic muscles using vaginal cones. They retained cones of increasing weight in the vagina by contracting pelvic floor muscles for 15 minutes twice a day for 4 weeks. The comparison of pelvic floor muscle function before and after the exercise were assessed by the frequency of incontinence, vaginal digital palpation, vaginal pressure measurement and speculm lift test. The results were as follows; 1. The frequency of incontinence was significantly reduced after the exercise using vaginal cone (P<0.001). 2. Vaginal digital palpation score (strength of vaginal levator muscle) was significantly increased after the exercise using vaginal cone (P<0.001). 3. The vaginal pressure by perineometer was significantly increased after the exercise using vaginal cones (P<0.001). 4. The vaginal lumen during contraction was significantly narrower after the exercise using vaginal cones (P<0.001). 5. The maximal cone weight which patients could hold over 1 minute was significantly increased after the exercise using vaginal cones (P<0.001).

A Case of Hypogonadotrophic Hypogonadism due to Intrasellar Arachnoid Cyst / 대한산부인과학회잡지

Primary amenorrhea due to intrasella arachnoid cyst is a very rare disease and require careful and frequent evaluation because may produce intracranial hemorrhage, elevated intracranial pressure and rapid expansion. Surgical intervention is needed only when visual disturbance, hypopituitarism or enlarging lesion is shown. Thus, we present a case of primary amenorrhea due to intrasella arachnoid cyst which was resected through the transsphenoidal approach.

A Case of Pulmonary Embolism After Cesarean Delivery / 대한산부인과학회잡지

Pulmonary Embolism, one of the causes of maternal death, is a life threatening disease that needs early and accurate diagnosis. We have exprerienced a case of a fatal pulmonary embolism which was diagnosed by lung perfusion scan on the postoperative 1 day after cesarean delivery and was managed with heparin therapy. We present this case with a brief review of literatures.