Does maternal oxygen administration during non-reassuring fetal status affect the umbilical artery gas measures and neonatal outcomes?

PURPOSE: To clarify whether maternal oxygen administration during vaginal delivery improves umbilical artery (UA) gas measurements and neonatal outcomes. METHODS: Singleton pregnancies requiring operative vaginal delivery or emergency cesarean section (CS) due to non-reassuring fetal status (NRFS) during vaginal delivery at our hospital from 2018 to 2021 were retrospectively investigated. Intrapartum fetal wellbeing was evaluated based on the 5-tier fetal heart rate (FHR) pattern which is a delivery management method widely used in Japan. Operative vaginal deliveries or emergency CS was performed under integrated judgment in NRFS. Patients were divided into the oxygen group to whom oxygen (10 L/min) was supplied by a facemask and the room air group. The UA gas measurements and neonatal outcomes were compared. The oxygen administration was classified by conditions before and after the coronavirus disease 2019 pandemic. As a secondary evaluation, stratification of FHR pattern levels and factors associated with UA pH < 7.15 were examined. RESULTS: A total of 250 patients required obstetric surgical delivery due to NRFS, including 140 (56%) and 110 (44%) in the oxygen and room air groups, respectively. No differences in maternal background factors were found between both groups, except for maternal age. UA gas measurements and neonatal outcomes also showed no significant differences. No significant factors were extracted in the multivariate analysis for UA pH < 7.15. CONCLUSIONS: Trans-maternal oxygen administration for intrapartum NRFS did not affect neonatal cord blood gasses or neonatal outcomes. Thus, routine oxygen administration for intrapartum NRFS may not always be necessary.

High maternal mortality rate associated with advanced maternal age in Japan.

This study aimed to clarify the relationship between maternal mortality and advanced maternal age in Japan and to provide useful information for future perinatal management. Maternal death rates by age group were investigated for all maternal deaths in Japan for an 11-year period, from 2010 to 2021. Maternal deaths among those aged ≥ 40 years were examined in detail to determine the cause, and the number of deaths by cause was calculated. The causes of onset of the most common causes of death were also investigated. The maternal mortality rates were 0.8 (95% confidence interval [CI] 0.3-4.7) for < 20 years, 2.6 (95% CI 1.7-3.8) for 20-24 years, 2.9 (95% CI 2.3-3.6) for 25-29 years, 3.9 (95% CI 3.3-4.5) for 30-34 years, 6.8 (95% CI 5.9-7.9) for 35-39 years, and 11.2 (95% CI 8.8-14.3) for ≥ 40 years of age. Patients who were ≥ 40 years of age had a significantly higher mortality rate compared to that in other age groups. Hemorrhagic stroke was the most common cause of death in patients aged ≥ 40 years (15/65 [23%]), and preeclampsia (8/15 [54%]) was the most common cause of hemorrhagic stroke. Maternal mortality is significantly higher in older than in younger pregnant women in Japan, with hemorrhagic stroke being the most common cause of maternal death among women > 40 years of age. More than half of hemorrhagic strokes are associated with hypertension disorder of pregnancy. These facts should be considered by women who become pregnant at an advanced age and by healthcare providers involved in their perinatal care.

COVID-19 mRNA vaccination status and concerns among pregnant women in Japan: a multicenter questionnaire survey.

BACKGROUND: mRNA vaccination is an effective, safe, and widespread strategy for protecting pregnant women against infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. However, information on factors such as perinatal outcomes, safety, and coverage of mRNA vaccinations among pregnant women is limited in Japan. Therefore, this study aimed to investigate the perinatal outcomes, coverage, adverse effects, and short-term safety of mRNA vaccination as well as vaccine hesitancy among pregnant women. METHODS: We conducted a multicenter online survey of postpartum women who delivered their offspring at 15 institutions around Tokyo from October 2021 to March 2022. Postpartum women were divided into vaccinated and unvaccinated groups. Perinatal outcomes, COVID-19 prevalence, and disease severity were compared between the two groups. Adverse reactions in the vaccinated group and the reasons for being unvaccinated were also investigated retrospectively. RESULTS: A total of 1,051 eligible postpartum women were included. Of these, 834 (79.4%) had received an mRNA vaccine, while 217 (20.6%) had not, mainly due to concerns about the effect of vaccination on the fetus. Vaccination did not increase the incidence of adverse perinatal outcomes, including fetal morphological abnormalities. The vaccinated group demonstrated low COVID-19 morbidity and severity. In the vaccinated group, the preterm birth rate, cesarean section rate, and COVID-19 incidence were 7.2%, 33.2%, and 3.3%, respectively, compared with the 13.7%, 42.2%, and 7.8% in the unvaccinated group, respectively. Almost no serious adverse reactions were associated with vaccination. CONCLUSIONS: mRNA vaccines did not demonstrate any adverse effects pertaining to short-term perinatal outcomes and might have prevented SARS-CoV-2 infection or reduced COVID-19 severity. Concerns regarding the safety of the vaccine in relation to the fetus and the mother were the main reasons that prevented pregnant women from being vaccinated. To resolve concerns, it is necessary to conduct further research to confirm not only the short-term safety but also the long-term safety of mRNA vaccines.

Are There Maternal Deaths Related to Hemorrhagic Stroke Due to Hypertensive Disorder of Pregnancy That Could Be Potentially Preventable by Tight Hypertension Management in Antepartum? A Retrospective Study from the Maternal Death Exploratory Committee in Japan.

BACKGROUND: Unlike Europe and the United States, Japan has seen numerous maternal deaths from hemorrhagic strokes related to hypertensive disorders of pregnancy (HDP). This study retrospectively analyzed deaths associated with HDP-related hemorrhagic stroke in Japan to determine the number of deaths that may have been prevented with blood pressure control during pregnancy. METHODS: This study included maternal deaths related to hemorrhagic stroke cases. The proportion of patients without proteinuria whose blood pressure exceeded 140/90 mmHg between 14+0 and 33+6 weeks of gestation were determined. Lastly, the application of tight antihypertensive management was evaluated. RESULTS: Among 34 HDP-related maternal deaths, 4 cases involved patients without proteinuria whose blood pressures exceeded 140/90 mmHg between 14+0 and 33+6 weeks of gestation. These included two chronic hypertension and two gestational hypertension cases. None of the patients received antihypertensive agents, and their blood pressures were managed leniently. CONCLUSION: Among HDP-related hemorrhagic stroke deaths in Japan, only a few cases of maternal death could have been prevented with tight blood pressure management, as described in the CHIPS randomized controlled trial. Therefore, to prevent HDP-related hemorrhagic stroke in Japan, new preventive strategies during pregnancy should be established.

Pregnancy-related maternal deaths due to cardiovascular diseases in Japan from 2010 to 2019: an analysis of maternal death exploratory committee data.

OBJECTIVE: Cardiovascular disease (CVD) is the leading cause of maternal deaths in high-income countries. This study aimed to assess the characteristics of maternal deaths due to CVDs and the quality of care provided to patients, and to identify elements to improve maternal care in Japan. METHODS: This descriptive study used the maternal death registration data of the Maternal Deaths Exploratory Committee of Japan between 2010 and 2019. RESULTS: Of 445 eligible pregnancy-related maternal deaths, 44 (9.9%) were attributed to CVD. The most frequent cause was aortic dissection (18 patients, 40.9%), followed by peripartum cardiomyopathy (8 patients, 18.2%), and pulmonary hypertension (5 patients, 11.4%). In 31.8% of cases, cardiopulmonary arrest occurred within 30 min after initial symptoms. Frequent symptoms included pain (27.3%) and respiratory symptoms (27.3%), with 61.4% having initial symptoms during the prenatal period. 63.6% of the patients had known risk factors, with age ≥35 years (38.6％), hypertensive disorder (15.9%), and obesity (15.9%) being the most common. Quality of care was assessed as suboptimal in 16 (36.4%) patients. Cardiac risk assessment was insufficient in three patients with preexisting cardiac disease, while 13 patients had symptoms and risk factors warranting intensive monitoring and evaluation. CONCLUSION: Aortic dissection was the leading cause of maternal death due to CVDs. Obstetrics care providers need to be familiar with cardiac risk factors and clinical warning signs that may lead to impending fatal cardiac events. Timely risk assessment, patient awareness, and a multidisciplinary team approach are key to improving maternal care in Japan.

Risk factors for severe disease and impact of severity on pregnant women with COVID-19: a case-control study based on data from a nationwide survey of maternity services in Japan.

OBJECTIVE: To identify independent risk factors for severe COVID-19 in pregnant women and to evaluate the impact of disease severity on preterm birth. DESIGN: A case-control study based on data from a nationwide questionnaire-based survey of maternity services in Japan. SETTING: A questionnaire was mailed to all 2135 delivery institutions in Japan between July and August 2021. A total of 1288 institutions responded (60% of all delivery institutions in Japan). 566 facilities reported having cared for pregnant women with COVID-19, and 722 facilities reported having had no such patients. PARTICIPANTS: One thousand and forty-three hospitalised and non-hospitalised pregnant women diagnosed with COVID-19 between July 2020 and 30 June 2021. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was progression to severe COVID-19. The secondary outcome was preterm birth due to COVID-19 infection. RESULTS: 56 cases (5.4%) were severe, and 987 (94.6%) were non-severe. Multivariable logistic regression analysis showed that gestational age≥24 weeks (adjusted OR (aOR) 6.68, 95% CI 2.8 to 16.0) and maternal age≥32 years (aOR 2.40, 95% CI 1.3 to 4.3) were independently associated with severe cases. Using the Kaplan-Meier method, the probability of continued pregnancy at 14 days after diagnosis for severe cases was 0.57 between 24 and 31 weeks' gestation and 0.27 between 32 and 36 weeks' gestation. The probability for non-severe cases was 1.0 between 24 and 31 weeks' gestation and 0.8 between 32 and 36 weeks' gestation. Among the patients with COVID-19 in the preterm period, preterm birth due to infection was significantly more common in severe than non-severe cases (48% vs 6%, p< 0.0001). CONCLUSIONS: Severe COVID-19 in pregnant women was associated with gestational age≥24 weeks and maternal age≥32. The rate of preterm delivery due to the infection was significantly higher in severe COVID-19 cases.

Long-term outcome of cases of fetal pleural effusion: A study at a single perinatal center in Japan.

PURPOSE: To analyze the long-term prognosis of primary and secondary fetal pleural effusion (FPE). METHODS: We investigated all cases of FPE in a single University hospital (2005-2020). Cases were classified as primary (cases with only pleural effusion) and secondary (cases with other abnormalities such as chromosomal abnormalities or fetal cardiac failure). We retrospectively reviewed the medical records from the time of diagnosis, to assess medical procedures performed, chromosomal test results, and clinical outcomes. RESULTS: Among 18 027 deliveries, 17 FPEs were identified (primary FPE: 8, secondary FPE: 9). Most primary FPEs were diagnosed in the second trimester of pregnancy, while all secondary FPEs were diagnosed in the third trimester. Secondary FPE was often associated with chromosomal abnormalities, including trisomy 21. The prognosis of pleural effusion caused by trisomy 21 was relatively good, except for cases with TAM. Cases of secondary FPE without trisomy 21 were of cardiac origin, and the neonatal prognosis was poor. The short-term prognosis was better in the primary FPE group, but long-term follow-up identified conditions such as acute encephalitis with refractory, repetitive partial seizures, developmental delay and attention deficit hyperactivity disorder. CONCLUSION: Fetal pleural effusion without the presence of chromosomal abnormalities or morphologies has a good short-term prognosis, but the long-term prognosis is poor. Thus, long-term follow-up is necessary for all cases of fetal pleural effusion.

Medical Professional Enhancement Using Explainable Artificial Intelligence in Fetal Cardiac Ultrasound Screening.

Diagnostic support tools based on artificial intelligence (AI) have exhibited high performance in various medical fields. However, their clinical application remains challenging because of the lack of explanatory power in AI decisions (black box problem), making it difficult to build trust with medical professionals. Nevertheless, visualizing the internal representation of deep neural networks will increase explanatory power and improve the confidence of medical professionals in AI decisions. We propose a novel deep learning-based explainable representation "graph chart diagram" to support fetal cardiac ultrasound screening, which has low detection rates of congenital heart diseases due to the difficulty in mastering the technique. Screening performance improves using this representation from 0.966 to 0.975 for experts, 0.829 to 0.890 for fellows, and 0.616 to 0.748 for residents in the arithmetic mean of area under the curve of a receiver operating characteristic curve. This is the first demonstration wherein examiners used deep learning-based explainable representation to improve the performance of fetal cardiac ultrasound screening, highlighting the potential of explainable AI to augment examiner capabilities.

Timing of birth and adverse pregnancy outcomes in cases of prenatally diagnosed vasa previa: a systematic review and meta-analysis.

OBJECTIVE: The ideal time for birth in pregnancies diagnosed with vasa previa remains unclear. We conducted a systematic review aiming to identify the gestational age at delivery that best balances the risks for prematurity with that of pregnancy prolongation in cases with prenatally diagnosed vasa previa. DATA SOURCES: Ovid MEDLINE, PubMed, CINAHL, Embase, Scopus, and Web of Science were searched from inception to January 2022. STUDY ELIGIBILITY CRITERIA: The intervention analyzed was delivery at various gestational ages in pregnancies prenatally diagnosed with vasa previa. Cohort studies, case series, and case reports were included in the qualitative synthesis. When summary figures could not be obtained directly from the studies for the quantitative synthesis, authors were contacted and asked to provide a breakdown of perinatal outcomes by gestational age at birth. METHODS: Study appraisal was completed using the National Institutes of Health quality assessment tool for the respective study types. Statistical analysis was performed using a random-effects meta-analysis of proportions. RESULTS: The search identified 3435 studies of which 1264 were duplicates. After screening 2171 titles and abstracts, 140 studies proceeded to the full-text screen. A total of 37 studies were included for analysis, 14 of which were included in a quantitative synthesis. Among 490 neonates, there were 2 perinatal deaths (0.4%), both of which were neonatal deaths before 32 weeks' gestation. In general, the rate of neonatal complications decreased steadily from <32 weeks' gestation (4.6% rate of perinatal death, 91.2% respiratory distress, 11.4% 5-minute Apgar score <7, 23.3% neonatal blood transfusion, 100% neonatal intensive care unit admission, and 100% low birthweight) to 36 weeks' gestation (0% perinatal death, 5.3% respiratory distress, 0% 5-minute Apgar score <7, 2.9% neonatal blood transfusion, 29.2% neonatal intensive care unit admission, and 30.9% low birthweight). Complications then increased slightly at 37 weeks' gestation before decreasing again at 38 weeks' gestation. CONCLUSION: Prolonging pregnancies until 36 weeks' gestation seems to be safe and beneficial in otherwise uncomplicated pregnancies with antenatally diagnosed vasa previa.

Perinatal outcomes of cases with umbilical hypocoiled cord: a study at a single perinatal center.

OBJECTIVES: To evaluate the perinatal outcomes of hypocoiled cord. METHODS: This retrospective study was carried out in the Department of Obstetrics and Gynecology at Showa University Hospital between 2011 and 2017. Umbilical cord index (UCI) was calculated by dividing the total number of coils by the total length of umbilical cord. All umbilical cords were measured and calculated coiling index by obstetrician after delivery. Perinatal outcomes like non-reassuring fetal status (NRFS), emergency cesarean sections, and other perinatal complications were compared. RESULTS: From January 2011 to December 2017, a total of 4047 fetuses were born at our hospital after 28 weeks' gestation. After excluding 100 fetuses of hypercoiled cord, a total of 3947 fetuses were included in this study, of which 71 fetuses were hypocoiled cord and 3876 fetuses were normal coiled cord. There were no association between maternal background and both UCI group. NRFS during labor was significantly associated with hypocoiled cord compared with normal cord (p = .02). Additionally, the rates of emergency cesarean section were raised in cases of hypocoiled cord (p = .02). CONCLUSION: In this study, it was found that hypocoiled cord is related to NRFS and emergency cesarean section. In addition, hypocoiled cord was not associated with any maternal factors. However, in previous studies, no opinion has been reported on the timing of diagnosis of hypocoiled cord during pregnancy. It is difficult to evaluate hypocoiled cord correctly in third trimester. It is a task to find the hypocoiled cord correctly before birth.

The role of first-trimester ultrasound screening for women with positive noninvasive prenatal testing results.

AIM: This study aimed to assess the utility of ultrasound screening for pregnancies with positive noninvasive prenatal testing results for trisomy 21, trisomy 18, and trisomy 13. METHODS: We performed a retrospective analysis of positive noninvasive prenatal testing results and first-trimester ultrasound screening at our department between 2013 and 2019. Invasive genetic testing was performed if the patient had positive noninvasive prenatal testing results. Fetal ultrasound and cytogenetic data were collected. Noninvasive prenatal testing was performed in the women for advanced maternal age, nuchal translucency thickness, or history of abnormality in the previous child or relative. RESULTS: Forty-one pregnant women had positive noninvasive prenatal testing results for trisomy 21, trisomy 18, and trisomy 13. Twenty-three women had positive results for trisomy 21, 13 had positive results for trisomy 18, and 5 had positive results for trisomy 13 at 11 to 14 weeks of gestation. The positive predictive value of noninvasive prenatal testing was 100% for trisomy 21, 84.6% for trisomy 18, and 100% for trisomy 13. The positive predictive value of positive noninvasive prenatal testing results and fetal morphological abnormalities was 100% for trisomy 21, trisomy 18, and trisomy 13. CONCLUSION: Combining an ultrasound examination with noninvasive prenatal testing resulted in a higher positive predictive value for trisomy 18. Normal ultrasound examination results can help alleviate stress caused by false-positive noninvasive prenatal testing results. In contrast, the positive predictive value and negative predictive value for trisomy 21 were not altered by adding an ultrasound examination to noninvasive prenatal testing.

Clinical characteristics of pregnant women with COVID-19 in Japan: a nationwide questionnaire survey.

BACKGROUND: Few reports have presented an overall view of pregnant women with coronavirus disease 2019 (COVID-19) across an entire country and throughout the entire gestation period. Furthermore, no such reports are available for Japan. We examined the clinical characteristics and outcomes of pregnant women with COVID­19 on a national scale in Japan. METHODS: A nationwide questionnaire-based survey for all 2,185 maternity services in Japan was conducted between July and August 2020. Information regarding maternal characteristics and epidemiological, clinical, treatment, and perinatal outcomes of pregnant women diagnosed with COVID-19 between 16 January and 30 June 2020 were collected. Main outcome measures were incidence of pregnant women with COVID-19 and infant infection, positive rate of the universal screening test for asymptomatic pregnant women, identification of infection route and rates of maternal death, and severe cases. RESULTS: Responses from 1,418 institutions were assessed (65% of all delivery institutions in Japan). Seventy-two pregnant women were reported to have been diagnosed with COVID-19. The positive rate of the universal screening test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among asymptomatic pregnant women was 0.03% (2/7428). The most common route of infection was familial (57%). Fifty-eight pregnant women with COVID-19 were symptomatic, of whom five (8.6%) had a severe infection and one died (a tourist). Severe respiratory symptoms, oxygen administration, and pneumonia were frequently reported in the third trimester and postpartum period compared with in early pregnancy (22.2% vs 2.5% [P = 0.03], 38.9% vs 7.5% [P = 0.01], and 50.0% vs 7.5% [P < 0.001], respectively). All pregnant women with COVID-19 underwent caesarean sections, regardless of symptoms. There were no SARS-CoV-2 transmissions to newborns. CONCLUSIONS: In Japan, the number of cases of COVID-19 infection in pregnant women is very low. Compared with early pregnancy, late pregnancy may be a risk factor for exacerbation of symptoms and familial transmission is the most common route of infection. The importance of infection prevention should be emphasised, especially in women in late pregnancy, their families, and any cohabitants.

Current status of community-acquired infection of COVID-19 in delivery facilities in Japan.

A nationwide questionnaire survey about community-acquired infection of coronavirus disease 2019 (COVID-19) was conducted in July 2020 to identify the characteristics of and measures taken by Japanese medical facilities providing maternity services. A case-control study was conducted by including medical facilities with (Cases) and without (Control) community-acquired infection of COVID-19. Responses from 711 hospitals and 707 private clinics were assessed (72% of all hospital and 59% all private clinics provided maternity service in Japan). Seventy-five COVID-19-positive pregnant women were treated in 52 facilities. Community-acquired infection was reported in 4.1% of the facilities. Of these, 95% occurred in the hospital. Nine patients developed a community-acquired infection in the maternity ward or obstetric department. Variables that associated with community-acquired infection of COVID-19 (adjusted odds ratio [95% confidence interval]) were found to be state of emergency prefecture (4.93 [2.17-11.16]), PCR test for SARS-CoV-2 on admission (2.88 [1.59-5.24]), and facility that cannot treat COVID-19 positive patients (0.34 [0.14-0.82]). In conclusion, community-acquired infection is likely to occur in large hospitals that treat a higher number of patients than private clinics do, regardless of the preventive measures used.

The routine use of prophylactic Bakri balloon tamponade contributes to blood loss control in major placenta previa.

OBJECTIVE: To verify the blood loss control effect of routine prophylactic Bakri balloon tamponade on major and minor placenta previa (PP). METHODS: We conducted a retrospective cohort study of all singleton pregnancies that involved cesarean section (CS) for PP at our hospital. All participants were divided into Bakri balloon (underwent routine prophylactic use just after placenta removal) and non-balloon groups, and into major and minor PP groups. Clinical outcomes in major and minor PP were compared between balloon and non-balloon groups. RESULTS: The balloon and non-balloon groups contained 74 and 89 patients, respectively. There were 41 and 33 (balloon group) and 48 and 41 (non-balloon group) major and minor PP cases, respectively. Intraoperative and perioperative blood losses of major PP were significantly lower in the balloon group than the non-balloon group (1045 ml versus 1553 ml, P = 0.016; and 1189 ml versus 1810 ml, P = 0.006, respectively). The frequency of massive postpartum hemorrhage (>500 ml) with major PP was lower in the balloon group than in the non-balloon group (2.4% versus 16.7%, P = 0.027), but with no significant difference with minor PP. CONCLUSION: Routine prophylactic use of Bakri balloon tamponade during and after CS is effective in controlling blood loss in major PP.

Model-Agnostic Method for Thoracic Wall Segmentation in Fetal Ultrasound Videos.

The application of segmentation methods to medical imaging has the potential to create novel diagnostic support models. With respect to fetal ultrasound, the thoracic wall is a key structure on the assessment of the chest region for examiners to recognize the relative orientation and size of structures inside the thorax, which are critical components in neonatal prognosis. In this study, to improve the segmentation performance of the thoracic wall in fetal ultrasound videos, we proposed a novel model-agnostic method using deep learning techniques: the Multi-Frame + Cylinder method (MFCY). The Multi-frame method (MF) uses time-series information of ultrasound videos, and the Cylinder method (CY) utilizes the shape of the thoracic wall. To evaluate the achieved improvement, we performed segmentation using five-fold cross-validation on 538 ultrasound frames in the four-chamber view (4CV) of 256 normal cases using U-net and DeepLabv3+. MFCY increased the mean values of the intersection over union (IoU) of thoracic wall segmentation from 0.448 to 0.493 for U-net and from 0.417 to 0.470 for DeepLabv3+. These results demonstrated that MFCY improved the segmentation performance of the thoracic wall in fetal ultrasound videos without altering the network structure. MFCY is expected to facilitate the development of diagnostic support models in fetal ultrasound by providing further accurate segmentation of the thoracic wall.

Image Segmentation of the Ventricular Septum in Fetal Cardiac Ultrasound Videos Based on Deep Learning Using Time-Series Information.

Image segmentation is the pixel-by-pixel detection of objects, which is the most challenging but informative in the fundamental tasks of machine learning including image classification and object detection. Pixel-by-pixel segmentation is required to apply machine learning to support fetal cardiac ultrasound screening; we have to detect cardiac substructures precisely which are small and change shapes dynamically with fetal heartbeats, such as the ventricular septum. This task is difficult for general segmentation methods such as DeepLab v3+, and U-net. Hence, here we proposed a novel segmentation method named Cropping-Segmentation-Calibration (CSC) that is specific to the ventricular septum in ultrasound videos in this study. CSC employs the time-series information of videos and specific section information to calibrate the output of U-net. The actual sections of the ventricular septum were annotated in 615 frames from 421 normal fetal cardiac ultrasound videos of 211 pregnant women who were screened. The dataset was assigned a ratio of 2:1, which corresponded to a ratio of the training to test data, and three-fold cross-validation was conducted. The segmentation results of DeepLab v3+, U-net, and CSC were evaluated using the values of the mean intersection over union (mIoU), which were 0.0224, 0.1519, and 0.5543, respectively. The results reveal the superior performance of CSC.

Declined use of cervical ripening balloon did not reduce the incidence of umbilical cord prolapse in Japan.

AIM: To clarify whether the incidence of umbilical cord prolapse (UCP) at delivery is related to the cervical ripening balloon (CRB). METHODS: A postal questionnaire study was conducted in 2018 in institutions providing maternity services across Japan. Questions on the number of deliveries, labor inductions, used CRB and cases of UCP in 2017 were included. Because a similar questionnaire survey was conducted in 2012, the incidence of UCP and frequency of the use of CRB were compared. RESULTS: A total of 1354 answers were assessed (57% of all delivery institutions). The total number of deliveries was 490 279. Of these, 78% were transvaginal; 74 cases of UCP were reported (0.015%), while 13 cases were reported from obstetric facilities never using CRB (0.008%). The incidence of UCP (odds ratio [95% confidence interval]) was 0.036% in the intracervical type (4.3 [1.6-11.3]), 0.091% in the disk-type (11.0 [4.2-29.0]) and 0.067% in the ball-type (8.1 [2.8-22.8]). Frequencies of the use of CRB were 7.3% and 6.6% in the 2012 and 2018 surveys, respectively. The use of the intracervical type increased from 2.8% in the 2012 survey to 3.5% in the 2018 survey, while that of the disk-type and ball-type declined. However, the incidence of UCP was not different between the two surveys regardless of the use of cervical ripening balloons (0.014% vs 0.015% with CRB, 0.005% vs 0.008% without CRB). CONCLUSION: Although the frequency of CRB use significantly declined, the incidence of UCP did not significantly reduce in the last 5 years.

Decline number of uterine fundal pressure maneuver in Japan recent 5 years.

AIM: To clarify whether the incidence of uterine fundal pressure (UFP) maneuver at delivery and consequent uterine rupture were declined. METHODS: Population-based postal questionnaire study was conducted. A questionnaire was sent to obstetric institutions across Japan. Questions were included the total number of deliveries, UFP and uterine ruptures associated with UFP in 2012 and 2017. As the primary outcome, frequencies of the UFP and uterine rupture were compared between 2012 and 2017. The secondary outcomes were included improved managements of delivery regarding UFP. RESULTS: A number of vaginal deliveries were significantly declined from 80.4% in 2012 to 78.1% in 2017 (P < 0.001). Frequencies of UFP per vaginal deliveries were also significantly declined 11.2% (38 973/347771) in 2012 to 9.5% (35 205/404444) in 2017 (<0.001). Number of uterine ruptures were 6 cases in 2012 (1:6496) and 11 cases in 2017 (1:3473) (P = 0.210). Compared to situation in 2012, informed consent was more frequently obtained for UFP in 2017. Written informed consent for UFP became to be obtained in 12% of institutions in 2017 from only 3% in 2012. More than 80% of institutions are performing UFP within 3 times. Regarding to uterine rupture, try of labor after the cesarean section, UFP and augmentation were improved in more than 10% of institutions. Most impact vehicle changing behavior was OBGY clinical guideline. CONCLUSION: Although significant declined incidence of uterine rupture after UFP could not be demonstrated, frequency of UFP was decreased recent 5 years. This is due to improvement of obstetric management by obstetric caregivers throughout Japan.

First-trimester measurements of the three-dimensional ultrasound placental volume and uterine artery Doppler in early- and late-onset fetal growth restriction.

Objectives: To clarify whether early-onset fetal growth restriction (EO-FGR) could be distinguished from late-onset (LO)-FGR using ultrasonographic evaluations of the uterine artery (UtA) Doppler indices and the three-dimensional (3D) ultrasound placental volume (PV) in the first trimester.Methods: Subjects with 1362 singleton pregnancies who underwent an ultrasound scan at 11-13 weeks were enrolled prospectively. The UtA Doppler and PV indices in cases with EO-FGR (<32 weeks at diagnosis) and LO-FGR (≥32 weeks at diagnosis) later in pregnancy were compared with the control group.Results: Twenty-eight EO-FGR, 73 LO-FGR, and 1261 control groups were analyzed. The crown-rump length (CRL) and PV were smaller in both EO and LO-FGR groups than in the control group. The UtA resistance index (RI) Z-score was significantly higher in the EO-FGR group than in the control group (0.723 versus 0.086, p < .001), but did not differ between LO-FGR and the control group. The area under the receiver operating characteristics curve for the prediction of EO-FGR by combining the uterine artery resistance index (UtA-RI) and CRL was 0.760 (95% CI: 0.654-0.865). The detection rate for EO-FGR was 45.8%, with a 10% false-positive rate.Conclusions: Both EO- and LO-FGR are associated with a small CRL in the first trimester. High UtA-RI is associated with EO-FGR, while a small maternal height and PV are associated with LO-FGR.

Usefulness of color Doppler mode for fetal cardiac ultrasound screening in the second trimester: a study at a single perinatal center.

Objectives: To evaluate the usefulness of color Doppler in fetal cardiac ultrasound screening in the second trimester.Methods: Fetuses who underwent ultrasound screening at 18-20 weeks' gestation at Showa University Hospital between 2011 and 2016 were evaluated. After delivery, neonatal congenital heart abnormalities were reviewed and compared with the antenatal ultrasound findings. Since 2014, we have added color Doppler to the routine B mode evaluation of the fetal heart. Congenital heart diseases (CHDs) found antenatally and postnatally were compared before and after protocol alternation. Medical records of all fetuses who underwent ultrasound screening at 18-20 weeks' gestation at Showa University Hospital between 2011 and 2016 were retrospectively reviewed.Results: There were 47 cases of CHDs confirmed postnatally. The detection rates of CHDs were 45.0% (9/20) in 2011-2013 and 55.6% (15/27) in 2014-2016. In 2011-2013, cases with antenatal diagnosis showed obvious abnormal findings of three-vessel view and four-chamber view with the B mode. In 2014-2016, the detection rate of isolated ventricular septal defect (VSD) was elevated from 10 to 42.9% using color Doppler.Conclusions: In this study, color Doppler improved the detection rate of CHDs. Color Doppler could give us additional information on blood flow although the canal or vessel is too small to detect morphological changes in the second trimester. It might be a useful tool for screening of CHDs with stenosis, regurgitation, and shunt that are difficult to detect by only the B mode in the second trimester.