The Effect of Vanishing Twin on Firstand Second-Trimester Maternal Serum Markers and Nuchal Translucency: A Multicenter Prospective Cohort Study

Background@#The purpose of this study was to evaluate the effect of vanishing twin (VT) on maternal serum marker concentrations and nuchal translucency (NT). @*Methods@#This is a secondary analysis of a multicenter prospective cohort study in 12 institutions. Serum concentrations of pregnancy-associated plasma protein-A in the first trimester and alpha-fetoprotein (AFP), total human chorionic gonadotrophin, unconjugated estriol, and inhibin A in the second trimester were measured, and NT was measured between 10 and 14 weeks of gestation. @*Results@#Among 6,793 pregnant women, 5,381 women were measured for serum markers in the first or second trimester, including 65 cases in the VT group and 5,316 cases in the normal singleton group. The cases in the VT group had a higher median multiple of the median value of AFP and inhibin A than the normal singleton group. The values of other serum markers and NT were not different between the two groups. After the permutation test with adjustment,AFP and inhibin A remained significant differences. The frequency of abnormally increased AFP was also higher in the VT group than in the normal singleton group. @*Conclusion@#VT can be considered as an adjustment factor for risk assessment in the secondtrimester serum screening test.

Ultrasonographic ovarian mass scoring system for predicting malignancy in pregnant women with ovarian mass

During routine antenatal ultrasound examinations, an ovarian mass can be found incidentally. In clinical practice, the differential diagnosis between benign and malignant ovarian masses is essential for planning further management. Ultrasound imaging has become the most popular diagnostic tool during pregnancy, with the recent development of ultrasonography. In non-pregnant women, several methods have been used to predict malignant ovarian masses before surgery. The International Ovarian Tumor Analysis (IOTA) group reported several scoring systems, such as the IOTA simple rules, IOTA logistic regression models, and IOTA assessment of different NEoplasias in the adneXa. Other researchers have also evaluated the malignancy of ovarian masses before surgery using scoring systems such as the Sassone score, pelvic mass score, DePriest score, Lerner score, and Ovarian-Adnexal Reporting and Data System. These researchers suggested specific features of ovarian masses that can be used for differential diagnosis, including size, proportion of solid tissue, papillary projections, inner wall structure, locules, wall thickness, septa, echogenicity, acoustic shadows, and presence of ascites. Although these factors can also be measured in pregnant women using ultrasound, only a few studies have applied ovarian scoring systems in pregnant women. In this article, we reviewed various scoring systems for predicting malignant tumors of the ovary and determined whether they can be applied to pregnant women.

Worsening of Migraine Associated with Hyperprolactinemia

A 45-year-old woman presented with worsening of migraine without aura. Laboratory test revealed hyperprolactinemia, but brain magnetic resonance imaging was normal. She had no known etiologies of hyperprolactinemia. Headache improved together with normalization of serum prolactin level after administration of bromocriptine. However, withdrawal of bromocriptine caused elevation of serum prolactin level and worsening of migraine headache. She repeated similar pattern of improvement and aggravation two times more. We suggest that hyperprolactinemia may cause aggravation of migraine headache.

Current Status of the Delivery Rate within the Jurisdiction of Local Government in Korea

Purpose@#This study aimed to analyze the rate of delivery within the jurisdiction of local governments in Korea. @*Methods@#Information regarding the population, number of women of childbearing age, and number of births was extracted from the Korean Statistics Information Service, National Health Insurance Service, and health map of the National Medical Center. We defined the rate of delivery within the jurisdiction of the local government as the ratio of the number of deliveries delivered by maternity facilities in the region to the total number of deliveries of pregnant women living in the region. @*Results@#The average nationwide delivery rate in the jurisdiction of local governments was 48.0%. The Si area was the highest at 54.9%, and the Gun area was the lowest at 22.1%. Compared to 2014, the national average delivery rate in the jurisdiction decreased by 4.3%; however, the gun area increased by 4.9%. The geographic maternity service area was 122 in 2014; however, this number decreased to 104 in 2020. @*Conclusion@#The national average rate of delivery in the jurisdiction of local governments was 48.0%, and the rate decreased between 2014 and 2020.

After 20 years of low fertility, where are the obstetrician-gynecologists?

Korea has entered a stage of low fertility, with a total fertility rate of 1.178 in 2002 and 0.92 in 2019. The low birth rate has led to the closure of obstetric hospitals and clinics from 1,371 maternity health facilities in 2003 to 541 in 2019, which is 39.5% compared to 2003. Since 2011, the Ministry of Health and Welfare has been operating an “Obstetrically Underserved Areas Support Project,” however, a shortage of obstetrician-gynecologists (OB/GYNs) who can participate in labor and delivery is a major problem. In 2019, there were 5,800 OB/GYNs practicing. Of these, 4,225 (72.8%) were working in obstetrics-gynecology hospitals, each responsible for 2,855 fertile women. Their average age was 51.8 years. A total of 2,659 (45.9%) worked in clinics and 3,110 (73.6%) were working in metropolitan districts. Only 124 OB/GYNs (2.9%) worked in vulnerable rural areas. OB/GYNs working in obstetric hospitals were responsible for 113.8 newborns in 2019. Their average age was 50.1 years. Of them, 67.4% were working in hospitals, 74.1% in urban areas, and only 60 specialists (2.3%) were working in rural areas. To establish a safe childbirth environment during an era of low fertility, it is important to have obstetricians in charge of childbirth. The government should establish a comprehensive long-term plan to resolve the shortage of OB/GYNs.

Serum Ferritin Concentration in the Early Third Trimester of Pregnancy and Risk of Preterm Birth and Low Birth Weight Based on Gestational Age

Objective@#Although serum ferritin is considered the best measure of total body iron, with low levels indicating iron deficiency, recent studies have shown that high levels are associated with gestational diabetes, premature birth, and low birth weight. This study aimed to analyze the association between serum ferritin levels in the third trimester of pregnancy and low birth weight and preterm birth. @*Methods@#This study included pregnant women who delivered a single fetus at Kangwon National University Hospital between January 2009 and December 2013 and in whom serum ferritin levels were measured between 28 and 34 weeks of gestation. The association between serum ferritin levels measured in the early third trimester of pregnancy and preterm birth and low birth weight infants was analyzed. @*Results@#A total of 1,079 women fulfilled the study criteria and had their serum ferritin level measured during the third trimester (28–33.9 weeks of gestation) and later delivered at Kangwon National University Hospital. Comparison of the group with serum ferritin levels above the 75th percentile and those below the 25th percentile at the beginning of the third trimester revealed that the incidence of preterm births (<34 weeks of gestation, <37 weeks of gestation) and low birth weight were significantly higher in the group with serum ferritin levels above the 75th percentile than those below the 25th percentile (p<0.05). When variable factors were controlled through multiple regression analysis, the group whose serum ferritin levels were above the 75th percentile at 30–31.9 weeks of gestation had the highest risk of preterm birth before 34 weeks of gestation (adjusted odds ratio [OR], 7.85; 95% confidence interval [CI], 1.32–29.9) and low birth weight (adjusted OR, 6.49; 95% CI, 2.10–20.0). @*Conclusion@#In this study, when serum ferritin was high in the third trimester of pregnancy, it was significantly increased with preterm birth (<34 and 37 weeks) and low birth weight. In particular, when serum ferritin levels were high at 30–31.9 weeks of gestation, the risk of premature birth before 34 weeks and low birth weight was statistically highest.

Spontaneous Rupture of Ovarian Artery Aneurysm in a Postmenopausal Woman: A Case Report and Literature Review

Spontaneous rupture of an ovarian artery aneurysm is an extremely rare, life-threatening disease and has been reported to be most highly associated with pregnancy. The current study presents a case of intraperitoneal and retroperitoneal hematoma caused by spontaneous rupture of a right ovarian artery aneurysm in a 56-year-old woman. A 56-year-old woman visited the emergency room with right lower quadrant abdominal pain. Contrast-enhanced computed tomography showed a large retroperitoneal and intraperitoneal hematoma and active extravasation of contrast medium in the right retroperitoneum. Consequently, transcatheter arterial embolization was successfully performed. Spontaneous rupture of an ovarian artery aneurysm should be suspected in multiparous women with abdominal or flank pain even if it is unrelated to pregnancy. Suspicion of this entity is needed for earlier diagnosis and management.

After 20 years of low fertility, where are the obstetrician-gynecologists?

Korea has entered a stage of low fertility, with a total fertility rate of 1.178 in 2002 and 0.92 in 2019. The low birth rate has led to the closure of obstetric hospitals and clinics from 1,371 maternity health facilities in 2003 to 541 in 2019, which is 39.5% compared to 2003. Since 2011, the Ministry of Health and Welfare has been operating an “Obstetrically Underserved Areas Support Project,” however, a shortage of obstetrician-gynecologists (OB/GYNs) who can participate in labor and delivery is a major problem. In 2019, there were 5,800 OB/GYNs practicing. Of these, 4,225 (72.8%) were working in obstetrics-gynecology hospitals, each responsible for 2,855 fertile women. Their average age was 51.8 years. A total of 2,659 (45.9%) worked in clinics and 3,110 (73.6%) were working in metropolitan districts. Only 124 OB/GYNs (2.9%) worked in vulnerable rural areas. OB/GYNs working in obstetric hospitals were responsible for 113.8 newborns in 2019. Their average age was 50.1 years. Of them, 67.4% were working in hospitals, 74.1% in urban areas, and only 60 specialists (2.3%) were working in rural areas. To establish a safe childbirth environment during an era of low fertility, it is important to have obstetricians in charge of childbirth. The government should establish a comprehensive long-term plan to resolve the shortage of OB/GYNs.

Spontaneous Rupture of Ovarian Artery Aneurysm in a Postmenopausal Woman: A Case Report and Literature Review

Spontaneous rupture of an ovarian artery aneurysm is an extremely rare, life-threatening disease and has been reported to be most highly associated with pregnancy. The current study presents a case of intraperitoneal and retroperitoneal hematoma caused by spontaneous rupture of a right ovarian artery aneurysm in a 56-year-old woman. A 56-year-old woman visited the emergency room with right lower quadrant abdominal pain. Contrast-enhanced computed tomography showed a large retroperitoneal and intraperitoneal hematoma and active extravasation of contrast medium in the right retroperitoneum. Consequently, transcatheter arterial embolization was successfully performed. Spontaneous rupture of an ovarian artery aneurysm should be suspected in multiparous women with abdominal or flank pain even if it is unrelated to pregnancy. Suspicion of this entity is needed for earlier diagnosis and management.

Effect of Cervical Cerclage on the Risk of Recurrent Preterm Birth after a Twin Spontaneous Preterm Birth

BACKGROUND@#This study aimed to evaluate the effect of cervical cerclage on the recurrence risk for preterm birth in singleton pregnant women after a twin spontaneous preterm birth (sPTB).@*METHODS@#This multicenter retrospective cohort study included women who had a singleton pregnancy from January 2009 to December 2018 at 10 referral hospitals and a twin sPTB before the current pregnancy. We compared the cervical lengths during pregnancy and pregnancy outcomes, according to the placement of prophylactic or emergency cerclage. We evaluated the independent risk factors for sPTB (< 37 weeks of gestation) in a subsequent singleton pregnancy.@*RESULTS@#For the index singleton pregnancy, preterm birth occurred in seven (11.1%) of 63 women. There was no significant difference in the cervical lengths during pregnancy in women with and without cerclage. In a multivariate logistic regression analysis, the placement of emergency cerclage was an independent risk factor for subsequent singleton preterm birth (odds ratio [OR], 93.188; 95% confidence interval [CI], 1.633–5,316.628; P = 0.027); however, the placement of prophylactic cerclage (OR, 19.264; 95% CI, 0.915–405.786; P = 0.057) was not a factor. None of the women who received prophylactic cerclage delivered before 35 weeks' gestation in the index singleton pregnancy.@*CONCLUSION@#Cerclage did not lower the risk of preterm birth in a subsequent singleton pregnancy after a twin sPTB. However, emergency cerclage was an independent risk factor for preterm birth and there was no preterm birth before 35 weeks' gestation in the prophylactic cerclage group. Therefore, close monitoring of the cervical length and prophylactic cerclage might be considered in women who have experienced a twin sPTB at extreme gestation.

The Identification of Immune-Related Plasma Proteins Associated with Spontaneous Preterm Delivery and Intra-Amniotic Infection in Women with Premature Cervical Dilation or an Asymptomatic Short Cervix

BACKGROUND@#We aimed to investigate whether various immune-related plasma proteins, alone or in combination with conventional clinical risk factors, can predict spontaneous preterm delivery (SPTD) and intra-amniotic infection in women with premature cervical dilation or a short cervix (≤ 25 mm).@*METHODS@#This retrospective study included 80 asymptomatic women with premature cervical dilation (n = 50) or a short cervix (n = 30), who underwent amniocentesis at 17–29 weeks. Amniotic fluid (AF) was cultured, and maternal plasma was assayed for interleukin (IL)-6, matrix metalloproteinase (MMP)-9, tissue inhibitor of metalloproteinases (TIMP)-1, and complements C3a and C5a, using enzyme-linked immunosorbent assay (ELISA) kits. The primary outcome measures were SPTD at < 32 weeks and positive AF cultures.@*RESULTS@#The plasma levels of IL-6, C3a, and C5a, but not of MMP-9 and TIMP-1, were significantly higher in women with SPTD at < 32 weeks than in those who delivered at ≥ 32 weeks. The women who delivered at < 32 weeks had more advanced cervical dilatation, and higher rates of antibiotic and tocolytic administration and were less likely to be given vaginal progesterone than those who delivered at ≥ 32 weeks. Using a stepwise regression analysis, a combined prediction model was developed, which included the plasma IL-6 and C3a levels, and cervical dilatation (area under the curve [AUC], 0.901). The AUC for this model was significantly greater than that for any single variable included in the predictive model. In the univariate analysis, plasma IL-6 level was the only significant predictor of intra-amniotic infection.@*CONCLUSION@#In women with premature cervical dilation or a short cervix, maternal plasma IL-6, C3a, and C5a levels could be useful non-invasive predictors of SPTD at < 32 weeks. A combination of these biomarkers and conventional clinical factors may clearly improve the predictability for SPTD, as compared with the biomarkers alone. An increased plasma level of IL-6 predicted intra-amniotic infection.

Effect of Cervical Cerclage on the Risk of Recurrent Preterm Birth after a Twin Spontaneous Preterm Birth

BACKGROUND@#This study aimed to evaluate the effect of cervical cerclage on the recurrence risk for preterm birth in singleton pregnant women after a twin spontaneous preterm birth (sPTB).@*METHODS@#This multicenter retrospective cohort study included women who had a singleton pregnancy from January 2009 to December 2018 at 10 referral hospitals and a twin sPTB before the current pregnancy. We compared the cervical lengths during pregnancy and pregnancy outcomes, according to the placement of prophylactic or emergency cerclage. We evaluated the independent risk factors for sPTB (< 37 weeks of gestation) in a subsequent singleton pregnancy.@*RESULTS@#For the index singleton pregnancy, preterm birth occurred in seven (11.1%) of 63 women. There was no significant difference in the cervical lengths during pregnancy in women with and without cerclage. In a multivariate logistic regression analysis, the placement of emergency cerclage was an independent risk factor for subsequent singleton preterm birth (odds ratio [OR], 93.188; 95% confidence interval [CI], 1.633–5,316.628; P = 0.027); however, the placement of prophylactic cerclage (OR, 19.264; 95% CI, 0.915–405.786; P = 0.057) was not a factor. None of the women who received prophylactic cerclage delivered before 35 weeks' gestation in the index singleton pregnancy.@*CONCLUSION@#Cerclage did not lower the risk of preterm birth in a subsequent singleton pregnancy after a twin sPTB. However, emergency cerclage was an independent risk factor for preterm birth and there was no preterm birth before 35 weeks' gestation in the prophylactic cerclage group. Therefore, close monitoring of the cervical length and prophylactic cerclage might be considered in women who have experienced a twin sPTB at extreme gestation.

The Identification of Immune-Related Plasma Proteins Associated with Spontaneous Preterm Delivery and Intra-Amniotic Infection in Women with Premature Cervical Dilation or an Asymptomatic Short Cervix

BACKGROUND@#We aimed to investigate whether various immune-related plasma proteins, alone or in combination with conventional clinical risk factors, can predict spontaneous preterm delivery (SPTD) and intra-amniotic infection in women with premature cervical dilation or a short cervix (≤ 25 mm).@*METHODS@#This retrospective study included 80 asymptomatic women with premature cervical dilation (n = 50) or a short cervix (n = 30), who underwent amniocentesis at 17–29 weeks. Amniotic fluid (AF) was cultured, and maternal plasma was assayed for interleukin (IL)-6, matrix metalloproteinase (MMP)-9, tissue inhibitor of metalloproteinases (TIMP)-1, and complements C3a and C5a, using enzyme-linked immunosorbent assay (ELISA) kits. The primary outcome measures were SPTD at < 32 weeks and positive AF cultures.@*RESULTS@#The plasma levels of IL-6, C3a, and C5a, but not of MMP-9 and TIMP-1, were significantly higher in women with SPTD at < 32 weeks than in those who delivered at ≥ 32 weeks. The women who delivered at < 32 weeks had more advanced cervical dilatation, and higher rates of antibiotic and tocolytic administration and were less likely to be given vaginal progesterone than those who delivered at ≥ 32 weeks. Using a stepwise regression analysis, a combined prediction model was developed, which included the plasma IL-6 and C3a levels, and cervical dilatation (area under the curve [AUC], 0.901). The AUC for this model was significantly greater than that for any single variable included in the predictive model. In the univariate analysis, plasma IL-6 level was the only significant predictor of intra-amniotic infection.@*CONCLUSION@#In women with premature cervical dilation or a short cervix, maternal plasma IL-6, C3a, and C5a levels could be useful non-invasive predictors of SPTD at < 32 weeks. A combination of these biomarkers and conventional clinical factors may clearly improve the predictability for SPTD, as compared with the biomarkers alone. An increased plasma level of IL-6 predicted intra-amniotic infection.

The Identification of Immune-Related Plasma Proteins Associated with Spontaneous Preterm Delivery and Intra-Amniotic Infection in Women with Premature Cervical Dilation or an Asymptomatic Short Cervix

BACKGROUND: We aimed to investigate whether various immune-related plasma proteins, alone or in combination with conventional clinical risk factors, can predict spontaneous preterm delivery (SPTD) and intra-amniotic infection in women with premature cervical dilation or a short cervix (≤ 25 mm).METHODS: This retrospective study included 80 asymptomatic women with premature cervical dilation (n = 50) or a short cervix (n = 30), who underwent amniocentesis at 17–29 weeks. Amniotic fluid (AF) was cultured, and maternal plasma was assayed for interleukin (IL)-6, matrix metalloproteinase (MMP)-9, tissue inhibitor of metalloproteinases (TIMP)-1, and complements C3a and C5a, using enzyme-linked immunosorbent assay (ELISA) kits. The primary outcome measures were SPTD at < 32 weeks and positive AF cultures.RESULTS: The plasma levels of IL-6, C3a, and C5a, but not of MMP-9 and TIMP-1, were significantly higher in women with SPTD at < 32 weeks than in those who delivered at ≥ 32 weeks. The women who delivered at < 32 weeks had more advanced cervical dilatation, and higher rates of antibiotic and tocolytic administration and were less likely to be given vaginal progesterone than those who delivered at ≥ 32 weeks. Using a stepwise regression analysis, a combined prediction model was developed, which included the plasma IL-6 and C3a levels, and cervical dilatation (area under the curve [AUC], 0.901). The AUC for this model was significantly greater than that for any single variable included in the predictive model. In the univariate analysis, plasma IL-6 level was the only significant predictor of intra-amniotic infection.CONCLUSION: In women with premature cervical dilation or a short cervix, maternal plasma IL-6, C3a, and C5a levels could be useful non-invasive predictors of SPTD at < 32 weeks. A combination of these biomarkers and conventional clinical factors may clearly improve the predictability for SPTD, as compared with the biomarkers alone. An increased plasma level of IL-6 predicted intra-amniotic infection.

Effect of Cervical Cerclage on the Risk of Recurrent Preterm Birth after a Twin Spontaneous Preterm Birth

BACKGROUND: This study aimed to evaluate the effect of cervical cerclage on the recurrence risk for preterm birth in singleton pregnant women after a twin spontaneous preterm birth (sPTB).METHODS: This multicenter retrospective cohort study included women who had a singleton pregnancy from January 2009 to December 2018 at 10 referral hospitals and a twin sPTB before the current pregnancy. We compared the cervical lengths during pregnancy and pregnancy outcomes, according to the placement of prophylactic or emergency cerclage. We evaluated the independent risk factors for sPTB (< 37 weeks of gestation) in a subsequent singleton pregnancy.RESULTS: For the index singleton pregnancy, preterm birth occurred in seven (11.1%) of 63 women. There was no significant difference in the cervical lengths during pregnancy in women with and without cerclage. In a multivariate logistic regression analysis, the placement of emergency cerclage was an independent risk factor for subsequent singleton preterm birth (odds ratio [OR], 93.188; 95% confidence interval [CI], 1.633–5,316.628; P = 0.027); however, the placement of prophylactic cerclage (OR, 19.264; 95% CI, 0.915–405.786; P = 0.057) was not a factor. None of the women who received prophylactic cerclage delivered before 35 weeks' gestation in the index singleton pregnancy.CONCLUSION: Cerclage did not lower the risk of preterm birth in a subsequent singleton pregnancy after a twin sPTB. However, emergency cerclage was an independent risk factor for preterm birth and there was no preterm birth before 35 weeks' gestation in the prophylactic cerclage group. Therefore, close monitoring of the cervical length and prophylactic cerclage might be considered in women who have experienced a twin sPTB at extreme gestation.

Recent Advances in Uterine Myoma and Pregnancy

Uterine myomas (fibroids) are the most common benign tumors in women and occur in 20%–40% of women of reproductive age. Myomas are benign monoclonal tumors that develop from the smooth muscle cells of the myometrium. Most pregnant women with myomas do not have complications during pregnancy, but complications can occur. Among the complications, pain is the most common, and the risks of miscarriage, preterm labor and delivery, abnormal positioning of the fetus, and placental abruption increase slightly. There are also concerns about the potential effects of uterine myomas on infertility and reproductive function. Therefore, there are frequent clinical concerns about the presence of myomas during pregnancy;however, the treatments are unclear. In this study, we summarize the latest trends in uterine myomas and pregnancy and consider the treatments.

Negative myoclonus associated with tramadol use / 영남의대학술지

Negative myoclonus (NM) is a shock-like jerky involuntary movement caused by a sudden, brief interruption of tonic muscle contraction. NM is observed in patients diagnosed with epilepsy, metabolic encephalopathy, and drug toxicity and in patients with brain lesions. A 55-year-old man presented with NM in both his arms and neck. He has taken medications containing tramadol at a dose of 80–140 mg/day for 5 days due to common cold. He had no history of seizures. Acute lesions were not observed during magnetic resonance imaging, and abnormal findings in his laboratory tests were not noted. His NM resolved completely after the discontinuation of tramadol and the oral administration of clonazepam. Our case report suggests that tramadol can cause NM in patients without seizure history or metabolic disorders, even within its therapeutic dose.

Isolated hemorrhage in the cerebellar vermis with vertigo and body lateropulsion to the contralesional side / 영남의대학술지

There have been several reports of patients with isolated lesions of the cerebellar vermis presenting with clinical features similar to those of peripheral vestibulopathy. We report a case of small, isolated hematoma in the cerebellar vermis in a patient who presented with vertigo, ipsilesional nystagmus, and body lateropulsion to the contralesional side without the usual signs or symptoms of cerebellar dysfunction. Although they present with symptoms that mimic those of peripheral vestibulopathy, and brain computed tomography shows no abnormality, as there may be a small, isolated hematoma or infarction in the cerebellar vermis. Thus, brain magnetic resonance imaging should be performed in elderly patients with vascular risk factors.

Neurosyphilis Mimicking Limbic Encephalitis and Creutzfeldt-Jakob Disease

No abstract available.

Multiple Cerebral Infarction after Injection of N-Butyl-2-Cyanoacrylate for Gastric Variceal Bleeding

Endoscopic obliteration with N-butyl-2-cyanoacrylate is the first-line treatment for gastric variceal bleeding. Although N-butyl-2-cyanoacrylate has higher success rate, there is some fatal complications such as systemic embolization. We report a case of 54-year-old male who developed myocardial and multiple cerebral infarction after endoscopic obliteration of gastric variceal bleeding with N-butyl-2-cyanoacrylate.