Successful laparoscopic management of acute abdominal pain due to spontaneous rupture of subserosal vessels overlying a uterine fibroid: a case report and surgical video.

BACKGROUND: Acute abdomen comprises several emergencies. Hemoperitoneum associated with uterine fibroids, which can present as acute abdominal pain, is rare and difficult to diagnose. Especially, spontaneous hemorrhage from the rupture of the superficial vessels overlying a uterine fibroid is extremely rare, and its diagnosis and management have not been established. CASE PRESENTATION: We report a case of a 55-year-old woman who presented at our hospital with acute abdomen. After performing a computed tomography scan, we conducted a laparoscopic examination and diagnosed hemoperitoneum of ambiguous origin. We treated the patient surgically, performing a laparoscopic myomectomy to remove the origin of the hemorrhage. The patient recovered well. CONCLUSIONS: We report a case of hemoperitoneum of ambiguous origin that was diagnosed laparoscopically and treated by laparoscopic myomectomy to remove the origin of the hemorrhage. Surgeons should rapidly diagnose and manage acute abdominal pain in women with a history of uterine fibroids to prevent severe morbidity or even mortality. Therefore, laparoscopic surgery is recommended in patients with stable hemodynamics.

Optimal duration of cardiotocography assessment using the iPREFACE score to predict fetal acidemia.

Cardiotocography (CTG) applicability to improve fetal outcomes remains controversial. This study aimed to determine the clinically optimal CTG assessment duration using the integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring (iPREFACE score). This single-center, retrospective observational study included 325 normal full-term singleton vaginal deliveries at the Toho University Omori Medical Center, from September 2018 to March 2019. The iPREFACE(10), iPREFACE(30), and iPREFACE(60) scores were calculated at 10, 30, and 60 min immediately before delivery. The primary outcome was fetal acidemia (umbilical artery blood pH < 7.2). The secondary outcome was the correlation between all iPREFACE scores and the umbilical artery blood pH, base excess (BE), and lactate values. Patients without accurate CTG findings or with failure of umbilical artery blood sampling immediately after birth were excluded, leaving 145 patients in the final analysis. Of these, 16, three, and two had umbilical artery blood pH of < 7.2, < 7.1, and < 7.0, respectively. All iPREFACE scores significantly correlated with umbilical artery blood pH, BE, and lactate values. iPREFACE(30) had the highest predictive capacity for fetal acidemia, suggesting that 30 min immediately before delivery may be a useful scoring time in clinical practice.

Porous diaphragm syndrome presenting as hemothorax secondary to hemoperitoneum after laparoscopic myomectomy: A case report and literature review.

Porous diaphragm syndrome includes all pleural cavity conditions, including pleural effusion, hemothorax, or pneumothorax, that occur secondary to peritoneal cavity disorders through defects in the diaphragm. In this report, we describe the first known case of porous diaphragm syndrome presenting as hemothorax after laparoscopic myomectomy. A 46-year-old nulliparous woman underwent laparoscopic myomectomy for multiple fibroids. Eight hours after surgery, the patient developed exertional dyspnea followed by hemoptysis. Radiological diagnosis revealed massive hemothorax in the right thoracic cavity. Thoracoscopic findings showed the presence of small fenestrae at the center of the right diaphragm, which were repaired thoracoscopically. Hence, quick postoperative diagnosis resulted in successful treatment. In this case, porous diaphragm syndrome is believed to be caused by retention of intraoperative bleed and saline from intra-abdominal lavage, in the abdominal cavity. Porous diaphragm syndrome is a potential life-threatening condition that gynecological surgeons should consider in this era of laparoscopic surgery.

Trocar-site hernia following laparoscopic salpingo-oophorectomy in a middle-aged Japanese woman: an initial case report after 40 years of experience at a single center and a brief literature review.

BACKGROUND: In gynecology, the number of laparoscopic surgeries performed has increased annually because laparoscopic surgery presents a greater number of advantages from a cosmetic perspective and allows for a less invasive approach than laparotomy. Trocar site hernia (TSH) is a unique complication that causes severe small bowel obstruction and requires emergency surgery. Its use has mainly been reported with respect to gastrointestinal laparoscopy, such as for cholecystectomy. Contrastingly, there have been few reports on gynecologic laparoscopy because common laparoscopic surgeries, such as laparoscopic salpingo-oophorectomy, are considered low risk due to shorter operative times. In this study, we report on a case of a woman who developed a TSH 5 days postoperatively following a minimally invasive laparoscopic surgery that was completed in 34 min. CASE PRESENTATION: A 41-year-old woman who had undergone laparoscopic salpingo-oophorectomy 5 days previously presented with the following features of intestinal obstruction: persistent abdominal pain, vomiting, and inability to pass stool or flatus. A computed tomography scan of her abdomen demonstrated a collapsed small bowel loop that was protruding through the lateral 12-mm port. Emergency surgery confirmed the diagnosis of TSH. The herniated bowel loop was gently replaced onto the pelvic floor and the patient did not require bowel resection. After the surgical procedure, the fascial defect at the lateral port site was closed using 2-0 Vicryl sutures. On the tenth postoperative day, the patient was discharged with no symptom recurrence. CONCLUSIONS: The TSH initially presented following laparoscopic salpingo-oophorectomy; however, the patient did not have common risk factors such as obesity, older age, wound infection, diabetes, and prolonged operative time. There was a possibility that the TSH was caused by excessive manipulation during the tissue removal through the lateral 12-mm port. Thereafter, the peritoneum around the lateral 12-mm port was closed to prevent the hernia, although a consensus around the approach to closure of the port site fascia had not yet been reached. This case demonstrated that significant attention should be paid to the possibility of patients developing TSH. This will ensure the prevention of severe problems through early detection and treatment.

Prenatal evaluation of functional pulmonary hypoplasia via fetal magnetic resonance imaging.

OBJECTIVE: The purpose of this study was to retrospectively examine the use of lung-to-liver signal intensity ratio (LLSIR) on T2-weighted images to predict functional pulmonary hypoplasia. METHODS: The subjects of this study were pregnant women who underwent magnetic resonance imaging (MRI). Patients who required nitric oxide inhalation and those who died from respiratory disorders were classified as having functional pulmonary hypoplasia (FPH). All other cases were presented as the control group. We retrospectively analyzed MRI and perinatal data. LLSIR was defined as the ratio of lung signal intensity to liver signal intensity. We examined the relationship between LLSIR and gestational age, compared the LLSIRs in the two groups, and calculated the best cut-off value of the LLSIR to predict FPH. RESULTS: One hundred and ninety-one patients were eligible for this study, and 12 cases were classified as having FPH. In the control group, LLSIR increased with age (r = 0.383, p < 0.001). We used the observed/expected LLSIR (o/e LLSIR), which was the ratio of obtained LLSIR to expected LLSIR calculated by the regression line to correct the effect of gestational age. In the FHP group, o/e LLSIR was significantly lower than in the control group (p < 0.001). A receiver operating characteristic curve analysis showed that cases with o/e LLSIR above 0.85 were less likely to cause FPH. CONCLUSIONS: Low o/e LLSIR might reflect the histological characteristics of hypoplastic lung structures. O/e LLSIR seems to be a useful MRI parameter for screening FPH.

Safety of uterine fundal pressure maneuver during second stage of labor in a tertiary perinatal medical center: A retrospective observational study.

OBJECTIVE: This study aimed to evaluate the conformity of the indications and implementation status of uterine fundal pressure maneuver (UPFM) and to examine its safety according to the Japan Society of Obstetrics and Gynecology (JSOG) guidelines. MATERIALS AND METHODS: We selected all the patients (n = 265) who were treated with UFPM between January 2015 and March 2017. We first evaluated the conformity of the indications and implementation status of UFPM concerning the guidelines for obstetrical practice in Japan, 2017. Second, we retrospectively examined maternal and fetal adverse events (AEs) to determine the safety of UFPM. RESULTS: In total, 265 patients underwent UFPM; of all the UFPM-assisted deliveries, 189 patients (72%) were evaluated for conformity. Of these 189 patients, 181 (95.7%) were confirmed to be compliant. Laceration of the birth canal was the most frequently occurring maternal AE, followed by cervical laceration. No cases of uterine rupture, severe AEs leading to an extended hospital stay, and maternal deaths were observed. Although fetal AEs requiring admission to neonatal intensive care unit (NICU) were recorded for 33 patients (12.5%), all newborns developed normally without sequela. CONCLUSION: The findings of this study may support the validity of the 2017 guidelines. Because it is difficult to find evidence of the safety of use of UFPM, it is essential to accumulate experiences and results learned in clinical practice to build a consensus in the future using the current 2017 guidelines as a standard as done in the current study.

Utility of fetal anteroposterior to transverse cerebellar diameter ratio to exclude cerebellar hypoplasia in trisomy 18.

AIM: This study was aimed to determine reference ranges for fetal cerebellar hemisphere biometry, including the transverse cerebellar diameter (TCD), anteroposterior cerebellar diameter (APCD) and APCD/TCD ratio in normal fetuses. In addition, we investigated which parameter would be useful for cerebellar hypoplasia in trisomy 18. METHODS: This retrospective study included 340 normal singleton pregnancies and 15 cases of trisomy 18, in all of which fetal cerebellar biometry was performed between 14 and 40 weeks of gestational age (GA). The TCD, APCD and APCD/TCD ratio were assessed ultrasonographically. RESULTS: In normal fetuses, the TCD (rs = 0.876, P < 0.001) and APCD (rs = 0.791, P < 0.001) were strongly correlated with GA. However, the APCD/TCD ratio was not correlated with GA (rs = 0.058, P = 0.289), with median values of 0.52. Low TCD, APCD and APCD/TCD ratio values were detected in 53%, 100% and 100% of trisomy 18 cases, respectively. The median APCD/TCD ratio for trisomy 18 was 0.39 (range, 0.30-0.43), which was significantly lower than that of normal fetuses (P < 0.001). A cut-off APCD/TCD ratio of 0.44 served as a good predictor for trisomy 18 (sensitivity 100%, specificity 95.3% and negative predictive value 100%). CONCLUSION: This study shows that TCD and APCD are correlated with GA, while the APCD/TCD ratio is a fixed value throughout gestation. Using the APCD/TCD ratio to assess cerebellar hypoplasia in trisomy 18 is useful because it does not require the individual evaluation of the TCD and APCD.

Diagnosis of umbilical cord entanglement in a monochorionic diamniotic twin pregnancy with spontaneous septostomy of the dividing membranes using dual-gate Doppler imaging.

Umbilical cord entanglement is the leading cause of fetal mortality in monoamniotic twin pregnancies and a pseudo monoamniotic environment. Published methods for detecting this complication include color Doppler and pulsed Doppler sonography; however, no method provides an absolute diagnosis. In this case, we report the diagnosis of umbilical cord entanglement using dual-gate Doppler imaging. A 35-year-old woman was referred to our hospital at 28 weeks of gestation for prenatal management because of diagnosis of a monochorionic diamniotic twin pregnancy with spontaneous septostomy of the dividing membranes. Each fetus displayed normal fetal growth without obvious discordance and anatomical abnormalities. However, the dividing membrane was not detected, and an entangled cord was suspected. Dual-gate Doppler examination was carried out. Two regions of interest were considered at different areas of the umbilical arteries, and when each Doppler image showed two different heart rates at the same time, we considered this to be evidence of umbilical cord entanglement. Cesarean section was performed at 32 weeks of gestation and twins were delivered. The delivered umbilical cords had sixfold entanglement. In this case, dual-gate Doppler seems to have been more accurate than conventional single-gate Doppler for the diagnosis of cord entanglement because we confirmed two different heart rates at the same time with dual-gate Doppler.

Quantitative evaluation of the influence of ovarian steroids on plasminogen activators and inhibitors in human endometrial cells and trophoblasts.

INTRODUCTION: Plasminogen activators and inhibitors were quantitated in cultured human endometrial and trophoblast cells under the influence of ovarian steroids in order to investigate the role of the fibrinolytic system for trophoblast invasion and anchorage. MATERIALS AND METHODS: Plasminogen activators (t-PA and u-PA) and their inhibitors (PAI-1 and PAI-2) secretions were assayed in cultures of epithelial, stromal, and trophoblast cells. These cells were also cultured on a fibrin substrate for microscopic examination of the fibrinolytic degradation. RESULTS: The u-PA from epithelial cells was predominant among PAs and PAI-1 in endometrial cells. Estradiol (E2) enhanced t-PA production in stromal cells and PAI-1 production in epithelial cells. Progesterone (P4) suppressed u-PA production in epithelial cells and enhanced PAI-1 production in both epithelial and stromal cells. Trophoblasts produced PAI-1, PAI-2, and small quantities of t-PA and u-PA, none of which were notably influenced by E2 or P4. The PAI-1 production in trophoblasts was more than four-fold greater than the u-PA production in epithelial cells. Epithelial and stromal cells initially grew on fibrin substrate but were gradually detached from the substrate with fibrinolytic degradation, with the exception of the stromal cells grown in the presence of P4 (or E2+P4). Trophoblasts grew well on fibrin substrate without fibrinolytic degradation both in the presence and absence of the steroids tested. CONCLUSIONS: Fibrinolytic balance seemed to be basically maintained between the endometrial PAs and the relative excess of trophoblasts-derived PAI-1. This balance might be regulated principally by P4 and focally by E2 in the endometrial tissue for placental implantation.