Myeloid cell thrombus and fetal vascular malperfusion in placentas with transient abnormal myelopoiesis.

Transient abnormal myelopoiesis (TAM), also known as transient myeloproliferative disorder or transient leukemia, is a self-regressing neoplasia that afflicts infants with trisomy 21. A recent review article documented "myeloid cell thrombus (MCT)" and "fetal vascular malperfusion (FVM)" in placentas with TAM, although the characteristic TAM placental findings have not been clarified. Here, we compared the clinical and pathological placental findings between trisomy 21 patients with or without TAM. In 13 cases of trisomy 21, we identified six placentas with TAM and seven placentas without TAM. The six placentas with TAM included two stillborn cases. Microscopically, MCT was noted in all the cases, and a high incidence of FVM (50%) was observed in TAM cases. Immunohistochemically, MCT was found to be a platelet-rich thrombus. The placentas were grouped according to the presence or absence of TAM and subsequently compared. Clinically, the incidences of abnormal fetal heart rate pattern and fetal or neonatal death were significantly higher in TAM cases. Pathologically, placenta in TAM cases weighted more than those in cases without TAM, and the incidence of MCT was significantly higher in placentas with TAM. Moreover, the incidence of FVM was higher in placentas with TAM, but this difference was not statistically significant. We propose that MCT is a diagnostic feature of placentas with TAM and may be associated with poor fetal outcomes.

Feasibility of a mobile cardiotocogram device for fetal heart rate self-monitoring in low-risk singleton pregnant women.

AIM: This study aimed to clarify the feasibility of a mobile cardiotocogram (CTG) device for self-monitoring fetal heart rate (FHR) in low-risk singleton pregnant women. METHODS: This study was conducted at six university hospitals and seven maternity clinics in Japan. Using a mobile cardiotocogram device (iCTG, Melody International Ltd., Kagawa, Japan), participants of more than 34 gestational weeks measured the FHR by themselves at least once a week until hospitalization for delivery. We evaluated the acquisition rate of evaluable FHR recordings and the frequency of abnormal FHR patterns according to the CTG classification system of the Japan Society of Obstetrics and Gynecology (JSOG). The participants also underwent a questionnaire survey after delivery to evaluate their satisfaction level of self-monitoring FHR using the mobile CTG device. RESULTS: A total of 1278 FHR recordings from 101 women were analyzed. Among them, 1276 (99.8%) were readable for more than 10 min continuously, and the median percentage of the total readable period in each recording was 98.9% (range, 51.4-100). According to the JSOG classification system, 1245 (97.6%), 9 (0.7%), 18 (1.4%), and four (0.3%) FHR patterns were classified as levels 1, 2, 3, and 4, respectively. The questionnaire survey revealed high participant satisfaction with FHR self-monitoring using the iCTG. CONCLUSION: The mobile CTG device is a feasible tool for self-monitoring FHR, with a high participant satisfaction level.

Characteristics and influence of Mycoplasma/Ureaplasma cultures in amniotic fluid on perinatal outcomes.

AIM: To investigate the effects of Mycoplasma/Ureaplasma cultured in amniotic fluid on perinatal characteristics in preterm delivery between 22 and 33 weeks of gestation. METHODS: The study was conducted in a tertiary perinatal center and involved 38 pregnant women who had undergone amniocentesis to evaluate intrauterine infection due to preterm labor or premature rupture of membranes. The subjects were divided into three groups based on the culture results: negative (Negative Group, n = 24), positive for Mycoplasma/Ureaplasma (M/U Group, n = 6), and positive for other pathogens (Other Pathogens Group, n = 8). One-way analysis of variance was used to compare the three groups. RESULTS: The incidence of histological chorioamnionitis and neonatal sepsis was significantly different among the three groups (the Negative Group and the Other Pathogens Group, P < 0.01; the M/U Group and the Other Pathogens Group, P = 0.03). In the M/U Group, no infants had sepsis, severe intraventricular hemorrhage, cystic periventricular leukomalacia, or poor neurological outcomes, but one infant developed bronchopulmonary dysplasia and needed home oxygen treatment. Although one died of gastrorrhexis, the remaining five patients had normal brain magnetic resonance imaging findings and developed normally. CONCLUSION: The presence of Mycoplasma/Ureaplasma isolated from amniotic fluid did not cause neonatal sepsis or poor prognosis. In some infants, there was no histological chorioamnionitis in the placenta. These pathogens thus seem to be less invasive than any other microbes with respect to perinatal outcomes.

Manual removal of placenta in women having unpredictable adherent placenta.

AIM: Our aim is to provide expected outcomes for undergoing manual removal of placenta (MROP) following vaginal delivery in women having an unpredictable adherent placenta (AP). METHODS: The data were obtained from four hospitals in Miyazaki Prefecture, Japan. We used propensity score-matched (1:1) analysis to match women who underwent MROP with women who did not undergo MROP (control). Total blood loss and hemorrhagic rate used as a ratio of women who reached a certain amount of blood loss were compared. Subgroup analysis was undertaken and was dependent on the presence of AP. We found the cut-off value of blood loss for detecting AP. RESULTS: Thirty-seven MROP cases were identified. Total blood loss and hemorrhagic rate differed significantly between MROP cases and controls; 95% of controls had blood loss of 1000 mL or less, whereas for the MROP cases, it was 14%. Fourteen MROP cases were diagnosed with AP. The hemorrhagic rate differed significantly between MROP cases with and without AP (n = 19); 79% of MROP cases without AP had blood loss of 2000 mL or less, whereas for the MROP cases with AP, it was 7%. There were seven incidents of hysterectomy and two of arterial embolization in MROP cases with AP. Through receiver operating characteristic curve analysis, 2035 mL of blood loss was determined to be the optimal cut-off value for detecting AP. CONCLUSION: The incidence of unpredictable AP in MROP cases was as high as 38%. The morbidity of MROP cases with unpredictable AP was severe. MROP should be prohibited in the absence of appropriate hemostatic preparations.

Maternal Morbidity in Women with Placenta Previa Managed with Prediction of Morbidly Adherent Placenta by Ultrasonography.

Objective. To determine maternal morbidity in women with placenta previa managed with prediction of morbidly adherent placenta (MAP) by ultrasonography. Methods. A retrospective cohort study was undertaken comprising forty-one women who had placenta previa with or without risk factors for MAP. Women who had all three findings (bladder line interruption, placental lacunae, and absence of the retroplacental clear zone) were regarded as high suspicion for MAP and underwent cesarean section followed by hysterectomy. We attempted placental removal for women having two findings or less. Results. Among 28 women with risk, nine with high suspicion underwent hysterectomy and were diagnosed with MAP. Three of 19 women with two findings or less eventually underwent hysterectomy and were diagnosed with MAP. The sensitivity and positive predictive value for the detection of MAP were 64% and 100%. The pathological severity of MAP was significantly correlated with the cumulative number of findings. There were no cases of MAP among 13 women without risk. There was no difference of blood loss between women with high suspicion and those without risk (2186 ± 1438 ml versus 1656 ± 848 ml, resp.; p = 0.34). Conclusion. Management with prediction of MAP by ultrasonography is useful for obtaining permissible morbidity.

The effect of placental abruption on the outcome of extremely premature infants.

OBJECTIVE: To determine the effect of placental abruption on the outcome of infants born between 22 and 26 weeks of gestation. METHODS: A retrospective study involving 32 cases of placental abruption. Controls were matched to cases according to gestational age and birth weight. Medical records were reviewed to confirm maternal background and neonatal outcome. We compared characteristics of maternal background and neonatal outcome between the two groups. RESULTS: There were no significant differences in the incidence of pregnancy-induced hypertension, low maternal fibrinogen (<200 mg/dl), premature rupture of membrane, intrauterine infection, ischemic changes of the placenta, or funisitis between the groups. Non-reassuring fetal heart rate patterns (NRFHRs) during intrapartum were frequently seen in the placental abruption group compared to controls (75% versus 51%, p = 0.02). However, no differences were found for the incidence of low umbilical artery pH (<7.1), cerebral palsy, or neonatal death. The incidence of chronic lung disease (CLD, 66% versus 43%, p = 0.04) and hemosiderin deposition on the placenta (16% versus 0%, p < 0.01) was higher in abruptions compared to controls. CONCLUSION: Placental abruption has a risk for the development of NRFHRs and CLD in infants born between 22 and 26 weeks of gestation, but shows no effect on neonatal mortality.

Perinatal death and neurological damage as a sequential chain of poor outcome.

OBJECTIVE: We investigated the risk factors of perinatal death and neurological damage. METHODS: Perinatal death and neurological damage were retrospectively investigated using a population-based study of 108 024 deliveries from 1998 to 2007. Main factors studied were asphyxia, growth restriction and preterm delivery < 34 weeks of gestation, since these three factors were most often associated with poor prognosis. The impact of each factor was identified by multiple regression analyses. RESULTS: There were 459 perinatal deaths (4.3/1000) and 220 neurological damages (2.0/1000). Preterm delivery accounted for 50% of perinatal deaths and neurological damage, whereas it constituted 2.6% of total births. Multiple regression analyses showed that prematurity < 34 weeks (10-fold), asphyxia (10-fold) and growth restriction (2-fold) were independent and significant risk factors associated with poor outcomes, and that the magnitude was similar throughout the three consecutive critical events of fetal death, neonatal death and neurological damage. CONCLUSIONS: Prematurity < 34 weeks, asphyxia and growth restriction are independent and persistent risk factors from perinatal death to neurological damage.