Transverse uterine fundal incision for placenta praevia with accreta, involving the entire anterior uterine wall: a case series.

OBJECTIVE: To determine the feasibility and safety of transverse fundal incision with manual placental removal in women with placenta praevia and possible placenta accreta. DESIGN: Case series. SETTING: Four level-three Japanese obstetric centres. POPULATION: Thirty-four women with prior caesarean section and placenta praevia that widely covers the anterior uterine wall, in whom placenta accreta cannot be ruled out. METHODS: A transverse fundal incision was performed at the time of caesarean section and manual placental removal was attempted under direct observation. MAIN OUTCOME MEASURE: Operative fluid loss. RESULTS: The total volume of fluid lost during our operative procedure compares favourably with the volume lost during our routine transverse lower-segment caesarean sections performed in patients without placenta praevia or accreta. The average fluid loss was 1370 g. No patients required transfer to intensive care, and there were no cases of fetal anaemia. CONCLUSIONS: This procedure has the potential to reduce the heavy bleeding that arises from caesarean deliveries in women with placenta praevia and placenta accreta.

[Pyogenic sacroiliitis in pregnancy].

Pyogenic sacroiliitis is an extremely rare disease in the field of obstetrics and gynecology, and especially for the cases discovered and treated during pregnancy, only five cases can be found in literature. We experienced one case of the disease in which the patient needed urgent hospitalization due to dysbasia caused by fever and pain at the left hip at the 27th week of her pregnancy. The patient was a 31-year-old primipara presenting typical clinical symptoms of pyogenic sacroiliitis along with evidence of severe infection as represented by fever of 39.7 degrees C and CRP of 12.6 mg/dl. She showed a good response to meropenem (MEPM) at 1 g twice a day for 8 days and then at 0.5 g twice a day for 2 days, followed by faropenem (FRPM) at 200 mg three times a day for 12 days, which successfully improved her subjective and objective findings as well as her laboratory test values, resulting in a complete cure. The definitive diagnosis of the disease in the patient was made on the basis of MRI findings, but no pathogen was identified. The patient was found to have marginal placenta previa as a complication, but she had an uneventful trans-vaginal delivery at the 37th week of her pregnancy and left hospital after both she and her baby showed favorable post-delivery progress. The case reported here is the first case of pyogenic sacroiliitis that has ever been discovered and treated during pregnancy in Japan.

Developmental retardation of XO mouse embryos at mid-gestation.

It is not known why XO mouse embryos, which develop more slowly than XX embryos until early mid-gestation, reach the same stage in their growth and development as their XX littermates at the mid-gestation stage. It is hypothesized that there is an effect of 'litter size' that causes an acceleration of the development of XO embryos at mid-gestation. The present study was performed to determine whether the development of XO embryos is retarded compared with that of their XX litermates at early mid-gestation (day 8 of gestation), before reduction of litter size. The percentage of pre-somite stage XO embryos was greater than the percentage of pre-somite stage XX embryos, and the mean number of somites was greater in XX embryos than it was in XO embryos. These findings indicate that the development of XO embryos was retarded when compared with that of their XX litermates at early mid-gestation. This result is discussed with respect to the compensatory development of XO embryos at mid-gestation and the reduction of litter size shortly after early mid-gestation.

Development and sexual difference in embryonic heart rates in pregnancies resulting from in vitro fertilization.

The purpose of this study was to investigate the gestational change of embryonic heart rates (EHRs) and to estimate the influence of embryonic sex on the EHR in pregnancies resulting from in vitro fertilization in the early first trimester. With transvaginal ultrasonography, we performed 92 and 105 examinations, on 27 male and 30 female embryos, respectively. The EHR increased gradually from 87 beats per min at 38 days of gestation to 189 beats per min at 62 days of gestation. The relationship between gestational age and EHR was explored by regression analysis: male EHR (beats per min) = 3.78 x gestational age (days) - 51.30 (r = 0.95), female EHR = 3.65 x gestational age - 44.56 (r = 0.95). These regression lines were mutually included in the 95% confidence intervals for each other. Our results indicate both a close positive correlation between the EHR and gestational age and no statistically significant difference in the EHR between male and female embryos. These findings suggest that the EHR measurement is a novel method for very early ultrasound dating with the identical EHR criterion without regard to embryonic sex.

Sexual difference in early fetal crown-rump length versus gestational age in pregnancies arising from in vitro fertilization.

The purpose of this study was to investigate the influence of fetal sex on the crown-rump length (CRL) derived from pregnancies resulting from in vitro fertilization without the uncertain conception dating in the first trimester. With ultrasonography, we performed 334 and 353 examinations, on 88 male and 102 female fetuses, respectively. The relationship between gestational age and fetal CRL was explored with regression analysis: male CRL (mm) = 1.13 x gestational age (days) - 47.39 (r = 0.97), female CRL = 1.11 x gestational age - 46.44 (r = 0.97). These regression lines were mutually included in the 95% confidence intervals for each other. Our results indicate no statistically significant difference in the CRL between the two sexes, being supportive of using the identical fetal CRL criterion regardless of fetal sex for gestational age assessment with ultrasonography in the first trimester of pregnancy.

Placental transfer of lidocaine hydrochloride after prolonged continuous maternal intravenous administration.

We treated a patient with arrhythmia during pregnancy with prolonged intravenous administration of lidocaine hydrochloride. This was a case of twin-to-twin transfusion syndrome and the arrhythmia was caused by ritodrine therapy. In total, 14.1 g lidocaine (50 mg.hr-1 for 282 hr) were used. Since there are no descriptions of human placental transfer of lidocaine after such a prolonged continuous intravenous administration, we measured lidocaine concentrations in maternal and fetal serum, and in the amniotic fluid (AF) at delivery. Fetal serum lidocaine concentrations (donor: 0.83 microgram.ml-1; recipient: 0.82 microgram.ml-1) were lower than in the maternal serum (1.6 micrograms.ml-1), while the AF lidocaine concentrations (donor: 1.05 micrograms.ml-1; recipient: 1.04 micrograms.ml-1) were higher than those of the fetal sera. The fetal/maternal concentration ratios of lidocaine were 0.52 for the donor and 0.51 for the recipient, which were similar to those described previously after administration of lidocaine in labour.

Viability, development and incidence of chromosome anomalies of preimplantation embryos from XO mice.

We examined the viability and developmental status of XO embryos at preimplantation stage (day 3 of gestation) by assessing blastocyst formation and counting cell number using our XO mouse colony. We also examined the incidence of chromosome anomalies. Embryos from XO mice (XY, XX and XO) developed more slowly (in cell numbers and blastocoele formation) than those from XX mice (XY and XX). XO embryos also tended to develop more slowly than XX embryos in the XO group. Although litter size at the preimplantation stage of gestation was almost twice as large (12.7) as those at mid-gestation (7.6) and near-term (7.2) in this colony, the adjusted XY:XX:XO ratio (2.8:2.0:1.0) did not differ greatly. This indicates that almost half of the embryos must have been eliminated during the first half of gestation in the XO group, probably regardless of sex chromosome complements. Thus, we consider that maternal XO sex chromosome constitution is disadvantageous for the intrauterine development of the embryo during the early period of gestation. This may be related to precocious aging of XO mice. Further, we confirmed that a high incidence of abnormal karyotypes occurs in embryos from our XO mouse colony.

[Clinical evaluation of combined use of miconazole and G-CSF on deep-seated mycoses in patients with gynecological cancers].

A combined therapy using miconazole (MCZ) and G-CSF was evaluated in clinical patients who developed deep-seated mycoses and fever of unknown etiology following chemotherapy for malignant gyneco-obstetrical tumors. 1. Combined administration of 100 to 250 micrograms/day of G-CSF, 400 to 800 mg/day of MCZ, and various antibiotics (Group I) was evaluated in 7 patients with mycoses (fungemia and fungal infections of the digestive and respiratory systems). The efficacy of the treatment was found to be 3/3. When 200 to 1,200 mg/day of MCZ was combined with various antibiotics (Group III), the therapy was found to be slightly effective (2/4). The rate of fungal eradication was 3/5. 2. The efficacy of combined administration of 400 to 800 mg/day of MCZ, 100 to 250 micrograms/day of G-CSF, and various antibiotics (Group II) in patients with fever of unknown etiology (n = 8) was 4/4. The efficacy of combined administration of 400 to 800 mg/day of MCZ and various antibiotics (Group III) was 3/4. 3. Leukocyte counts were recorded in the 7 patients who had received G-CSF (Groups I and II). The counts rose from < 1,000/microliters before the chemotherapy to > 5,000/microliters in 6 patients (6/7) in 5 to 8 days following drug administration. The favorable clinical efficacy was recorded in all who received MCZ and antibiotics. 4. The objective or subjective adverse effects of this therapeutic modality were limited to mild nausea in a single case. No deviations from norm were noted in clinical or other tests.

[Clinical studies on imipenem/cilastatin sodium in the field of obstetrics and gynecology].

The efficacy and safety of imipenem/cilastatin sodium (IPM/CS) were studied in patients with obstetric and gynecologic infections and in those given the drug as prophylaxis against postoperative infections. The following results were obtained: 1. Efficacy rates were 96.0% (48/50) in patients with obstetric and gynecologic infections and 100% (28/28) in those with urinary tract or other infections. The overall efficacy rate was 97.4% (76/78). Bacteriologically, 30 organisms were isolated from 28 patients. The eradication rate was 95.2% (20/21) and the efficacy rate was 96.4% (27/28). 2. Changes in blood elastase before and after treatment were compared with those in CRP, WBC, and ESR in the patients with obstetric and gynecologic infections. The changes in elastase were similar to those in CRP. 3. The efficacy rate was 98.0% (48/49) in the patients given prophylaxis against postoperative obstetric and gynecologic infections. 4. An adverse reaction was observed in only one patient (diarrhea), and abnormal laboratory findings were noted in 2 patients (elevation of GOT and GPT). These results indicate that IPM/CS is very useful for the treatment of obstetric and gynecologic infections.

[Clinical study of intramuscular imipenem/cilastatin sodium in the field of obstetrics and gynecology].

We evaluated the clinical efficacy and safety of intramuscular (as a new route of administration) imipenem/cilastatin sodium (IPM/CS) in patients with intrauterine infections which are typical in the field of obstetrics and gynecology. The obtained results are summarized as follows. 1. Twenty-seven patients were treated with IPM/CS, 250 mg/250 mg b.i.d. (3 patients), 500 mg/500 mg b.i.d. (22) and other dosages (a change in dosing regimen, 2). The duration of treatment ranged from 3 to 11 days and the total dosage during an entire course of treatment varied from 1.5 to 9.0 g. The drug was suspended in a lidocaine solution and administered in the gluteal muscle of the patients. 2. Clinical efficacies were excellent in 7 patients (26%), good in 19 (70%) and poor in 1 (4%) and the overall efficacy rate was 96.3%. All of the 8 patients who had not previously showed improvements with treatment by other antibiotics responded well to this drug. 3. Bacteriologically, the clinical efficacy rate was 95.8% (23/24) and the eradication rate was 76.2% (16/21). 4. No adverse effects due to the drug were observed. As abnormal laboratory test results, transient elevations of GOT and GPT were noted in one patient.

[Prophylactic effects of a combined use of a cephem antibiotic, latamoxef, and tobramycin on postoperative infection in obstetrics and gynecology].

To prevent postoperative infection in obstetric gynecology, latamoxef (LMOX) and tobramycin (TOB) were intravenously administered to 81 patients at daily doses of 2 g and 120 mg, respectively, for 5 postoperative days, and the preventive effect of the combined drugs on postoperative infection were evaluated in terms of the clinical effects and safety. 1. The fever index was low as a whole; 3.38 +/- 2.30 degree hours in patients receiving simple panhysterectomy (n = 61), 3.21 +/- 3.84 degree hours in those given cesarean section (n = 12), and 3.53 +/- 2.78 degree hours in those given other surgical procedures (n = 8). 2. There were no abnormalities in hematological findings or liver and kidney functions 14 days after the surgery. PIVKA-II was observed in 3 of 32 patients 14 days after the operation, at a rate of 9.4%. 3. Except mild diarrhea which was observed in 7 of the 81 patients (8.6%) in 4 to 6 days after the operation, no subjective or objective side effects or postoperative complications were observed. The combined use of LMOX and TOB seems useful for preventing postoperative infection in obstetrics and gynecology in terms of its efficacy and safety.