Retrospective details of false-positive and false-negative results in non-invasive prenatal testing for fetal trisomies 21, 18 and 13.

OBJECTIVE: Maternal characteristics and neonatal outcomes associated with cell-free DNA (cfDNA) results were analysed retrospectively to assess the details of false-positive and false-negative results after initial blood sampling in non-invasive prenatal testing (NIPT). STUDY DESIGN: A multicentre retrospective study was performed for women undergoing NIPT who received discordant cfDNA results between April 2013 and March 2018. The NIPT data obtained using massive parallel sequencing were studied in terms of maternal background, fetal fraction, z-scores, invasive procedure results and neonatal outcomes after birth. RESULTS: Of the 56,545 women who participated in this study, 54 false-positive (0.095 %) and three false-negative (0.006 %) cases were found. Seven of the 54 false-positive cases (13.0 %) had vanishing twin on ultrasonography. Among the 18 false-positive cases of trisomy 18, confined placental mosaicism (CPM) was confirmed in three cases (16.7 %), while CPM was present in one of the three false-negative cases of trisomy 21. CONCLUSION: These data suggest that the incidence of women with false-positive or false-negative results is relatively low, that such false results can often be explained, and that vanishing twin and CPM are potential causes of NIPT failure. Genetic counselling with regard to false results is important for clients prior to undergoing NIPT.

Effectiveness on high-grade cervical abnormalities and long-term safety of the quadrivalent human papillomavirus vaccine in Japanese women.

This study for the first time assessed quadrivalent human papillomavirus (qHPV) vaccine effectiveness against HPV6/11/16/18-related high-grade cervical disease in Japanese women (16-26 years old), as previously demonstrated in overseas trials, and vaccine safety in a longer term (48-month) open-label study (NCT01544478). Participants received three doses of qHPV vaccine (Day 1, Month 2, Month 6). Effectiveness endpoints, assessed in the per-protocol population, included incidence of HPV6/11/16/18-related cervical intraepithelial neoplasia (CIN) Grade 2 or worse (CIN Grade 2 and 3, adenocarcinoma in situ, and/or cervical cancer) as primary endpoint and incidence of external genital lesions (EGLs). Disease related to other high-risk HPV types was also assessed. Adverse events (AEs) and serious AEs (SAEs) were collected from Days 1-15 after any vaccination; vaccine-related SAEs, deaths, and new medical conditions were collected throughout the study. A total of 1030 women received at least one vaccination. No cases of CIN2 or worse or EGLs were reported in the per-protocol population. Injection site-related AEs were reported in 14.5% of participants; most were mild and resolved within 15 days. Vaccine-related systemic AEs occurred in 8.6% of participants, most commonly headache (2.3%), malaise (1.7%), and pyrexia (1.3%). There were no vaccine-related SAEs; one participant discontinued due to a vaccine-related AE of mild uticaria. Overall, qHPV vaccine effectiveness against HPV6/11/16/18-related high-grade cervical disease and EGLs was indicated in Japanese women. The vaccine was well-tolerated, without new safety signals throughout the 48-month study period. Findings are consistent with overseas qHPV vaccine pivotal trials. CLINICAL TRIAL REGISTRY: clinicaltrials.gov; NCT01544478.

[Complication with paraaortic lymphadenectomy in gynecological cancer patients].

Although paraaortic lymphadenectomy is one of the standard treatments for gynecological cancer in Japan, it is very invasive so one must examine its safety for patients. Paraaortic lymphadenectomy was performed in 215. Two hundred and fifteen gynecologic cancer patients at our hospital between January 1991 and August 2005. We evaluated operation time, estimated blood loss and the incidence of operative injury, wound complication, and postoperative ileus. It was revealed that the mean operation time was 364 minutes and the estimated blood loss was increased at the operation around the vena cava or renal vein. After we adopted Kocher's technique, the mean blood loss was decreased. The incidence of postoperative ileus was 13.3%, but almost all of the patients were cured within seven days without surgical treatment. The incidence of wound complication was within 10%.

Would omitting the assessment of heart rate be harmful to initial neonatal care?

OBJECTIVE: To test the hypothesis that counting heart rate is dispensable and other components of the Apgar score are satisfactory to evaluate the physical condition of infants shortly after birth in routine deliveries. METHODS: The database of the Japanese Red Cross Nagoya First Hospital was reviewed for newborn infants whose Apgar scores were marked by trained neonatologists attending delivery. RESULTS: The scores of respiratory effort, muscle tone, and reflex irritability increased parallel to Apgar scores. Heart rate gained higher marks even in lower Apgar scores, whereas color demonstrated lower marks even in higher Apgar scores. Correlation coefficients were higher among respiratory effort, muscle tone, and reflex irritability. In contrast, both heart rate and color exhibited lower correlation coefficients against other components and total Apgar scores. High correlation coefficients were shown between the sum of the four components other than heart rate and the total score. CONCLUSIONS: Heart rate and color play more independent roles in the Apgar score. Heart rate seems to be dispensable and the other components of the Apgar score are satisfactory to evaluate the physical condition of infants shortly after birth, and hence, counting heart rate may be omitted in routine deliveries when a newborn infant is apparently well.

Life-threatening septic shock in a pregnant woman with ileus.

Septic shock during pregnancy is very rare but has high mortality. We report a case of septic shock in a pregnant woman with ileus, showing that severe ileus in a pregnant woman could be attributed to life-threatening septic shock and that we should give special attention to a nosocomial infection.

Impact of subclinical chorioamnionitis on maternal and neonatal outcomes.

BACKGROUND: Chorioamnionitis is considered to be one of the main causes of preterm labor and has been associated with an adverse perinatal outcome in preterm infants. The controversy about the benefits/risks of delaying labor is a critical issue concerning the management of chorioamnionitis. METHODS: The database between July 2001 and March 2006 was reviewed for women with singleton pregnancies between 22 and 28 weeks of gestation and with chorioamnionitis diagnosed on admission by amniotic fluid neutrophil elastase level. Women were classified according to the severity of chorioamnionitis (group A, amniotic fluid neutrophil elastase level of 0.15-1 microg/ml; B, 1-10 microg/ml; and C, > or = 10 microg/ml). During expectant management, serum C-reactive protein levels monitored the remission and aggravation of chorioamnionitis. Following deliveries, placentas were examined for histologic chorioamnionitis. RESULTS: One hundred women were enrolled (group A, 38; B, 34; C, 28). The latency period until delivery was significantly longer in group A than in groups B and C. C-reactive protein levels just before delivery were higher than those on admission in 61% of the overall cases. Histologic chorioamnionitis and funisitis were manifested in 90.4% and 65.5%, respectively. Intrauterine fetal demise (4 cases) and neonatal and postneonatal deaths during admission (10 cases) were observed. Bronchopulmonary dysplasia was the most common major morbidity noted in groups B and C. CONCLUSION: Chorioamnionitis could be controlled but is hard to cure. Higher levels of amniotic fluid neutrophil elastase are associated with a shorter interval from admission to delivery in women with subclinical chorioamnionitis.

Amniotic fluid neutrophil elastase and lactate dehydrogenase: association with histologic chorioamnionitis.

BACKGROUND: Chorioamnionitis (CAM) is considered to be one of the main causes of preterm labor and has been associated with an adverse perinatal outcome in preterm infants. The diagnosis of acute histologic CAM requires delivery and examination of the placenta. Although numbers of markers have been reported to predict histologic CAM before birth, it is unknown whether the levels of neutrophil elastase and lactate dehydrogenase (LDH) in amniotic fluid are associated with histologic CAM. METHODS: Sixty women at gestational age of 16-35 weeks underwent transabdominal amniocentesis within 48 hr before delivery. Amniotic fluid was analyzed for white blood cell count, glucose level, LDH level, and neutrophil elastase level. The levels of neutrophil elastase were measured by latex immunoassay. Following delivery, tissue samples were obtained from umbilical cord, chorionic plate, and placental membranes. Histologic CAM was diagnosed based on Blanc's criteria. RESULTS: Receiver-operator characteristic curve analysis showed that the amniotic fluid neutrophil elastase had the best screening efficiency in predicting histologic CAM. Using amniotic fluid cut-off levels of 0.15 microg/ml for neutrophil elastase and 250 IU/l for LDH, the sensitivity, specificity, and positive and negative predictive values for predicting histologic CAM were 88.9% versus 84.1%, 73.3% versus 66.7%, 90.9% versus 88.1%, and 68.8% versus 58.8%, respectively. CONCLUSION: Amniotic neutrophil elastase and LDH are useful markers in predicting histologic CAM.

[Neoadjuvant chemotherapy with intra-arterial infusion in the treatment of advanced cervical cancer].

Neoadjuvant chemotherapy (NAC) with intra-arterial infusion was performed in the treatment for 53 patients with advanced cervical squamous cell carcinoma. After NAC with intra-arterial infusion of the anticancer agents including cisplatin via internal iliac artery or uterine artery, 42 patients received radical hysterectomy. The response to therapy was observed in 45 of all patients (84.9%) clinically, and 36 of 42 patients (85.7%) pathologically. Cancer cells disappeared in 11.9% of patients with cervical invasion, 69.2% with vaginal wall invasion and 39.4% with parametrium invasion after NAG. Five-year survival rates were 100% in stage I, 71.5% in stage II, 52.2% in stage II and 0% in stage IV. The group of patients without cancer in the parametrium after NAC showed a significantly better 5-year survival rate than the group with residual cancer in the parametrium. According to the results, the elimination of cancer invasion to the parametrium by NAC is thought to be important for improvement of the prognosis in advanced cervical cancer.

Mature ovarian cystic teratoma with a highly differentiated homunculus: a case report.

BACKGROUND: Mature ovarian cystic teratomas, which are commonly observed benign ovarian tumors, consist of ectodermal, mesodermal, and endodermal components that are generally disorganized. In this report, we document a case in which the solid portion of an ovarian teratoma demonstrated considerable differentiation, forming a doll-like structure. CASE: A 25-year-old virginal Japanese woman underwent surgery for an ovarian tumor that was diagnosed as a mature teratoma. A solid mass within the tumor was found to have a head, trunk, and extremities. Consequently, this mass was diagnosed as a mature fetiform teratoma (homunculus). Brain, eye, spinal nerve, ear, teeth, thyroid gland, bone, bone marrow, gut, trachea, blood vessels, and phallic cavernous tissue were confirmed microscopically. Distinctive features were the clear anterior-posterior, ventral-dorsal, and left-right axes, with a spatially well-organized arrangement of the organs. An eye was located on the front of the head, a spinal nerve lay dorsal to the spinal bones, the thyroid gland was anterior to the trachea, and the gut was deep inside the trunk. CONCLUSIONS: These findings indicate that the information necessary for organization of the body plan may be conserved and transmitted, even with parthenogenesis. Mature cystic teratomas of the ovary are mostly benign and do not always attract detailed attention. However, precise analyses of such tumors may significantly enhance our understanding of both parthenogenetic and normal human development.

Tissue distribution of placental leucine aminopeptidase/oxytocinase during mouse pregnancy.

Placental leucine aminopeptidase (P-LAP), also called oxytocinase, is an enzyme responsible for hydrolyzing oxytocin. This enzyme is identical to cystine aminopeptidase. We examined the tissue distribution of P-LAP in normal adult mice and also in mothers and fetuses during mouse pregnancy using immunohistochemical (IHC) analysis. P-LAP-immunoreactive protein was expressed in various organs in a cell- and gestational stage-dependent manner. In the kidney, P-LAP was located in distal and collecting tubules but not in proximal tubules. The islet of Langerhans in the maternal pancreas stained positively for P-LAP in the periphery in early gestation. This staining pattern changed so that both the periphery and inner cells were positive during mid-gestation and finally only inner cells were positive in late gestation. Among the hematopoietic cells in the fetal liver, only megakaryocytes showed strong expression of P-LAP. The staining intensity increased with gestation on the apical surface of trophoblasts in the placental labyrinth. These data demonstrate that P-LAP is present in a variety of tissues, and its presence is affected by pregnancy and fetal development. Therefore, P-LAP may play a significant role in various physiological processes in non-pregnant, pregnant, and fetal mice.

Hypertension and angiotensin II hypersensitivity in aminopeptidase A-deficient mice.

Local concentrations of the vasopressor peptide, angiotensin II (AngII), depend upon the balance between synthesis and degradation. Previous studies of blood pressure (BP) regulation have focused primarily on the generation of AngII and its receptors, and less attention has been devoted to angiotensin degradation. Aminopeptidase A (APA, EC 3.4.11.7) is responsible for the N-terminal cleavage of AngII, a hydrolytic event that serves as a rate-limiting step in angiotensin degradation. To evaluate the physiological role of APA, we examined BP homeostasis in APA-deficient mice. We measured basal BP and BP with continuous infusion of AngII in APA mutant mice by tail-cuff method. We also evaluated the development and histology of AngII-targeted organs as well as urine excretion in these mice. Homozygous APA mutant mice were found to have elevated basal systolic BP when compared with heterozygous mutant and wild-type littermate mice. Infusion of AngII led to an enhanced systolic BP response in the APA-deficient mice. Despite the sustained elevation of BP in APA knockout mice, neither their renal and cardiac sizes nor their histological appearances were not different from control mice. Moreover, the volume, osmolality, and electrolyte content of the urine were normal in APA-deficient mice. APA deficiency increased baseline BP and enhanced the hypertensive response to increased levels of AngII. These findings indicate a physiological role for APA in lowering BP and offer novel insight into the mechanisms for developing hypertension.

Proliferation and stratification of keratinocyte on cultured amniotic epithelial cells for tissue engineering.

Human amniotic epithelial cells (HAECs) are formed from amnioblasts, separated from the epiblast at about the 8th day after fertilization. Recent studies suggest that HAECs can produce various biologically active substances. In this study, the effects of cultured HAECs on keratinocytes were investigated. First of all, the effect of the medium conditioned by cultured HAECs on the proliferation of keratinocytes was examined. The conditioned medium significantly enhanced the proliferation (P<0.05). Next, the effect of co-culture with HAECs was also examined. The keratinocytes formed a stratified epithelium on day 7 after the start of co-culture. The cultured epithelium formed by the co-culture was five to six layers thick, could be detached by dispase treatment, and had sufficient strength as a sheet. These results suggest that HAECs will be a novel supplemental material for the tissue engineering of skin.

Possible involvement of aminopeptidase A in hypertension in spontaneously hypertensive rats (SHRs) and change of refractoriness in response to angiotensin II in pregnant SHRs.

BACKGROUND: Hypertension complicated with pregnancy is a major cause of maternal and fetal mortality, but its pathophysiology is unclear. OBJECTIVE: To investigate the pressor response to angiotensin II (Ang II) and the involvement of the Ang II degrading protease, aminopeptidase A, in spontaneously hypertensive rats (SHRs). DESIGN: Pregnant SHRs and Wistar-Kyoto (WKY) rats were studied. Angiotensin II (200 ng/kg per min) or saline was infused by osmotic pump from day of 15 gestation, and caesarean section was performed at day 20 of gestation. Blood pressure during pregnancy, weight of placentas and pups at caesarean section, and aminopeptidase A activity in placenta and renal cortex were measured. RESULTS: Ang II treatment induced increases in blood pressure that were greater in non-pregnant WKY rats than those in pregnant WKY rats, pregnant SHRs, and non-pregnant SHRs. Renal aminopeptidase A activity in SHRs was significantly lower than that in WKY rats. Renal aminopeptidase A activity in pregnant SHRs was significantly greater than that in non-pregnant SHRs, but there was no significant increase in pregnant WKY rats. Placental aminopeptidase A activity in SHRs was greater than that in WKY rats. Placental aminopeptidase A activity in WKY rats was increased by Ang II, but was not increased in SHRs. Weights of placentas and pups were significantly lower in SHRs than in WKY rats. CONCLUSIONS: Renal aminopeptidase A may be involved in the development of hypertension and the regulation of blood pressure in SHRs. Placental aminopeptidase A may be upregulated in response to fetal stress in pregnant SHRs.