Reversible cerebral vasoconstriction syndrome shows different clinical pictures at different times during the perinatal period: Two case reports.

OBJECTIVE: With the development of diagnostic imaging, a new clinical entity called reversible cerebral vasoconstriction syndrome (RCVS), which is considered to be a cause of secondary headache, has emerged. We herein present two cases of RCVS with different patterns of clinical progression. CASE REPORT: Case 1 occurred during labor, whereas case 2 occurred after delivery. Neither case presnted thunderclap headache at the onset of symptoms. Hypertensive disorders of pregnancy did not occur during the pregnancy or the puerperium in either case. Neurological symptoms following mild headache (Case 1: coma; Case 2: paralysis of the right extremities) were observed. CONCLUSION: Even when a patient has no risk factors for RCVS and had no severe headache, it is important not to miss any of the neurological symptoms. Magnetic resonance imaging (MRI) strongly supports the diagnosis, even during pregnancy. In addition, the diagnosis should always be reviewed while excluding eclampsia.

Nationwide status of progestogen treatment to prevent spontaneous preterm birth: A questionnaire survey for childbirth healthcare facilities in Japan.

AIM: This study aimed to investigate the current status of progestogen treatment for pregnant women at a high risk for preterm birth (PTB) in childbirth healthcare facilities in Japan. METHODS: A web-based nationwide questionnaire survey regarding progestogen use for prevention of PTB was conducted among childbirth healthcare facilities from 2019 to 2021. RESULTS: Valid responses were obtained from 528 facilities (25.2% of those surveyed), including 155 tertiary perinatal facilities (making up 92.3% of all tertiary perinatal care facilities). In the survey period, progestogen treatment was implemented in 207 facilities (39.2%) for PTB prevention. Regarding types of progestogens, 17α-hydroxyprogesterone caproate was used in 170 facilities (82.1%), with a low dose (125 mg/week) administered in 62.9% of the facilities to comply with the regulations of the national health insurance system, although 250 mg/week is considered the best dose. Vaginal progesterone was used in 36 facilities (17.4%), although the cost of vaginal progesterone was not covered by health insurance. Of the facilities not administering progestogen treatment, approximately 40% expressed that vaginal progesterone would be their first choice for PTB prevention in daily practice if it would be covered by health insurance in the future. CONCLUSIONS: Due to the current regulations of the Japanese health insurance system, 17α-hydroxyprogesterone caproate, rather than vaginal progesterone, was mainly used for PTB prevention. Despite global evidence supporting vaginal progesterone as the approach with the highest efficacy, only a limited number of facilities have utilized it due to the current drug use regulations in Japan.

Effectiveness of treating menorrhagia using microwave endometrial ablation at a frequency of 2.45 GHz.

BACKGROUND: Microwave endometrial ablation (MEA) is a minimally invasive treatment for menorrhagia. It has been covered by the national insurance in Japan since April 2012, and its demand has been increasing as the importance of women's health has advanced in society. AIM: To examine the efficacy of MEA as a treatment option for menorrhagia. METHODS: In this study, we retrospectively analyzed 76 patients who underwent MEA between January 2016 and March 2020 in our department. MEA was performed in the lithotomy position, under general anesthesia, and with transabdominal ultrasound guidance, including the entire endometrial circumference while confirming endometrial coagulation. The Microtaze AFM-712 and the Sounding Applicator CSA-40CBL-1006200C were used for MEA, and the endometrium was ablated using a Microtaze output of 70 W and coagulation energization time of 50 s per cycle. The visual analog scale (VAS) was used to evaluate menorrhagia, menstrual pain, and treatment satisfaction. Additionally, the hemoglobin (Hb) levels before and after MEA and associated complications were investigated. RESULTS: The average age of the patients was 44.8 ± 4.0 years. While 14 patients had functional menorrhagia, 62 had organic menorrhagia, of whom 14 had endometrial polyps, 40 had uterine fibroids, and 8 had adenomyosis. The VAS score before MEA and 3 and 6 mo after the procedure were 10, 1.3 ± 1.3, and 1.3 ± 1.3, respectively, for menorrhagia and 10, 1.3 ± 1.8, and 1.3 ± 1.8, respectively, for menstrual pain, both showing improvements (P < 0.001). The MEA Hb level significantly improved from 9.2 ± 4.2 g/dL before MEA to 13.4 ± 1.2 g/dL after MEA (P = 0.003). Treatment satisfaction was high, with a VAS score of 9.6 ± 0.7. Endometritis was observed in one patient after surgery and was treated with antibiotics. CONCLUSION: MEA is a safe and effective treatment for menorrhagia.

Efficacy of transvaginal ultrasound-guided local injections of absolute ethanol for ectopic pregnancies with intrauterine implantation sites.

BACKGROUND: Cervical pregnancies, interstitial tubal pregnancies, and cesarean scar pregnancies, which are ectopic pregnancies with intrauterine implantation sites exhibit increasing trends with the recent widespread use of assisted reproductive technologies and increased rate of cesarean deliveries. The development of high-sensitivity human chorionic gonadotropin testing reagents and the increased precision of transvaginal ultrasonic tomography have made early diagnosis possible and have enabled treatment. Removal of ectopic pregnancies using methotrexate therapy and/or uterine artery embolization has been reported. However, delayed resumption of infertility treatments after methotrexate therapy is indicated, and negative effects on the next pregnancy after uterine artery embolization have been reported. AIM: To examine the efficacy and safety of ultrasound-guided topical absolute ethanol injection in ectopic pregnancies with an intrauterine implantation site. METHODS: In this study, we retrospectively examined the medical records of 21 patients who were diagnosed with an ectopic pregnancy with an intrauterine implantation site at our hospital, between April 2010 and December 2018, and underwent transvaginal ultrasound-guided local injections of absolute ethanol to determine the treatment outcomes. We evaluated the treatment methods, treatment outcomes, presence of bleeding requiring hemostasis measures and blood transfusion, complications, and treatment periods. Successful treatment was defined as the completion of treatment using transvaginal ultrasound-guided local injections of absolute ethanol alone. RESULTS: There were 21 total cases comprising 10 cervical pregnancies, 10 interstitial tubal pregnancies, and 1 cesarean scar pregnancy. All patients completed treatment with this method. No massive hemorrhaging or serious adverse reactions were observed during treatment. The mean gestation ages at the time of diagnosis were 5.9 wk (SD, ± 0.9 wk) for cervical and 6.9 wk (SD, ± 2.1 wk) for interstitial tubal pregnancies. The total ethanol doses were 4.8 mL (SD, ± 2.2 mL) for cervical pregnancies and 3.3 mL (SD, ± 2.2 mL) for interstitial pregnancies. The treatment period was 28.5 days (SD, ± 11.7 d) for cervical pregnancies and 30.0 ± 8.1 d for interstitial pregnancies. Positive correlations were observed between the blood ß- human chorionic gonadotropin level at the beginning of treatment and the total ethanol dose (r = 0.75; P = 0.00008), as well as between the total ethanol dose and treatment period (r = 0.48; P = 0.026). CONCLUSION: Transvaginal ultrasound-guided local injections of absolute ethanol could become a new option for intrauterine ectopic pregnancies when fertility preservation is desired.

Uterine contraction may not be an independent risk factor for spontaneous preterm birth before 35 weeks in women with cervical shortening.

OBJECTIVE: To compare the risk of spontaneous preterm birth (SPTB) before 35 weeks in symptomatic and asymptomatic women with cervical shortening at 16-34 weeks under mid-trimester universal screening of cervical length (CL). METHOD: Multicenter retrospective cohort study involving six secondary/tertiary perinatal centers was planned in 2016. Primary outcomes were SPTB before 35 weeks. In all, 407 women were analyzed using multivariable logistic regression analysis for predicting SPTB before 35 weeks while adjusting for presence/absence of uterine contraction, gestational weeks, vaginal bleeding, and CL classification (1-9, 10-14, 15-19, and 20-24 mm) at admission, the execution of cervical cerclage, and the presence/absence of past history of preterm delivery. RESULTS: SPTB before 35 weeks of pregnancy occurred in 14.5%. Presence of uterine contraction was not an independent risk factor for SPTB before 35 weeks (adjusted odds ratio [aOR] 1.22, 95% confidence interval [CI] 0.67-2.20). CL of 1-9 mm, CL of 10-14 mm, and vaginal bleeding at admission were independent risk factors for SPTB before 35 weeks (aOR 5.35, 95% CI 2.11-13.6; aOR 2.79, 95% CI 1.12-6.98; and aOR 2.37, 95% CI 1.12-5.10, respectively). CONCLUSION: In women with a cervical shortening at 16-34 weeks, presence of uterine contractions at admission may not be an independent risk factor for the occurrence of SPTB before 35 weeks.

Successful live birth following hysteroscopic adhesiolysis under laparoscopic observation for Asherman's syndrome: A case report.

BACKGROUND: Asherman's syndrome is characterized by reduced menstrual volume and adhesions within the uterine cavity and cervix, resulting in inability to carry a pregnancy to term, placental malformation, or infertility. We present the case of a 40-year-old woman diagnosed with Asherman's syndrome who successfully gave birth to a live full-term neonate after hysteroscopic adhesiolysis under laparoscopic observation, intrauterine device insertion, and Kaufmann therapy. CASE SUMMARY: A 40-year-old woman (Gravida 3, Para 0) arrived at our hospital for specialist care to carry her pregnancy to term. She had previously undergone six sessions of dilation and curettage owing to a hydatidiform mole and persistent trophoblastic disease, followed by chemotherapy. She subsequently became pregnant twice, but both pregnancies resulted in spontaneous miscarriages during the first trimester. Her menstrual periods were very light and of short duration. Hysteroscopic adhesiolysis with concurrent laparoscopy was performed, and Asherman's syndrome was diagnosed. The uterine adhesions covered the area from the internal cervical os to the uterine fundus. Postoperative Kaufmann therapy was administered, and endometrial regeneration was confirmed using hysteroscopy. She became pregnant 9 mo postoperatively and delivered through elective cesarean section at 37 wk of gestation. The postpartum course was uneventful, and she was discharged on postoperative day 7. CONCLUSION: Hysteroscopic adhesiolysis with concurrent laparoscopy enables identification and resection of the affected area and safe and accurate surgery, without complications.

Ultrasound-guided local ethanol injection for fertility-preserving cervical pregnancy accompanied by fetal heartbeat: Two case reports.

BACKGROUND: The incidence of cervical pregnancy is increasing due to the recent widespread application of assisted reproductive technology. Although hysterectomy has been a treatment option, high-sensitivity human chorionic gonadotropin testing and improved accuracy of transvaginal ultrasound imaging have increased possibility of uterine preservation. Dilation and curettage with methotrexate therapy and uterine artery embolization have been reported as treatments with fertility preservation; however, certain disadvantages limit their use. CASE SUMMARY: In our two reported cases, we avoided massive bleeding and immediately resumed infertility treatment using ultrasound-guided local ethanol injection for cervical pregnancies with fetal heartbeats. CONCLUSION: This treatment may be a new fertility-preserving option for cervical pregnancy.

Safety and efficacy of manual vacuum aspiration under local anesthesia compared to general anesthesia in the surgical management of miscarriage: a retrospective cohort study.

BACKGROUND: In Japan, dilatation & curettage (D&C) has been performed under general anesthesia as a surgery for an early pregnancy miscarriage for a long time. In 2016, manual vacuum aspiration (MVA) under general anesthesia was introduced at our hospital and has been used as a surgical treatment for first-trimester pregnancy miscarriage, with its utility to date being reported here. In July 2018, our hospital introduced the MVA procedure under local anesthesia. In this study, we evaluated the efficacy and safety of MVA under general and local anesthesia in first-trimester pregnancy miscarriage surgery in Japanese women. METHODS: In this retrospective observational cohort study, we enrolled 322 pregnant women at less than 12 weeks of gestation, who underwent MVA surgery under local anesthesia (n = 166) or conventional general anesthesia (n = 156). The duration of surgery, blood loss volume, quantity of anesthesia, presence or absence of retained products of conception, and clinical complications were evaluated. In addition, the intraoperative pain and treatment satisfaction were assessed using the visual analog scale (VAS). RESULTS: The duration of surgery was significantly shorter in the local anesthesia group. No significant differences were observed between both groups in terms of the blood loss volume and incidence of retained products of conception. In addition, no serious complications were observed in either group. No significant differences were noted between the two groups in the VAS scores for pain and treatment satisfaction. CONCLUSIONS: In this retrospective study, the use of MVA under local anesthesia for early pregnancy miscarriage surgery was found to be equally safe and effective when performed under conventional general anesthesia. This technique allowed the achievement of appropriate pain control with excellent patient satisfaction.

Developing an obstetric care screening tool to improve social support access for pregnant women: A prospective cohort study.

Background: This study aimed to develop an efficient interview sheet during pregnancy and screening tool to identify pregnant women needing social support at obstetric institutions. Moreover, we investigate the perinatal factors associated with the Edinburgh postnatal depression scale (EPDS). Methods: This prospective cohort study was conducted at three medical institutions that commonly encounter cases with social issues. Pregnant women were assessed using an interview sheet at the first visit (n = 678), at approximately 28 weeks gestation (n = 495), 36 weeks gestation (n = 296), and the postpartum period (n = 822). We investigated the important items identified on the new screening questionnaire (NEW interview sheets) for women needing social support. The items on the interview sheet were scored by multiple linear regression analysis, and the cutoff values were calculated using the receiver operating characteristic curve. The association between perinatal factors and EPDS was assessed using multiple logistic regression analyses. Results: The study included 166 cases for which all NEW interview sheets for all periods were available. NEW interview sheets and stepwise screening tools during the first and second trimester were developed in which 2.5% of pregnant women were identified as requiring social support, respectively. The factors associated with EPDS ≧ 9 were "Women who felt confused/troubled or did not feel anything to be pregnant" (adjusted odds ratio [aOR]: 6.51, 95% confidence interval [CI]: 1.62-26.15), "Maternal mental disorder" (aOR 4.38; CI 1.06-18.10), "Consultation request at first visit" (aOR 3.22; CI 1.09-9.45), and "Women who have difficulty or anxiety about pregnancy during the second trimester" (aOR 3.14; CI 1.29-7.67). Conclusions: We created the NEW interview sheets and screening tools during the first and the second trimester. Future studies are needed to validate these screening tools.

Vaginal pessary sharpens uterocervical angle in uterine prolapse during pregnancy. A case report.

A 37-year-old multiparous woman complained of uterine prolapse at 14 weeks of gestation. A silicone ring-shaped middle-size vaginal pessary (# 62 mm) was placed into the vagina to reduce prolapsed uterus. Because the cervical length became shortened at 25 weeks of gestation, we decided to start intramuscular administration of progesterone (250 mg) weekly. At 33 weeks of gestation, she complained of the vaginal pessary spontaneous falling out, so we inserted a vaginal pessary of the same size again. The uterocervical angle became acute, going from 100° to 60° after placing the vaginal pessary into the vagina. We took the vaginal pessary out at 37 weeks of gestation. The patient gave birth at 39 weeks by spontaneous vaginal delivery to a healthy baby. A vaginal pessary may help continue a pregnancy via the same mechanism as a cervical pessary, which sharpens the uterocervical angle.

Effects of prophylactic vaginal progesterone administration on mild cervical shortening (TROPICAL study): a multicenter, double-blind, randomized trial.

Vaginal progesterone reduces the preterm birth frequency among high-risk women with a cervical length ≤25 mm at midtrimester. However, the strategy may promote no substantial reduction in overall preterm birth rates, because such high-risk women are only approximately 2% of all pregnant women, which restrict the number of participants. Our purpose was to determine whether prophylactic vaginal progesterone administration can preserve cervical length and reduce preterm birth rates among women with mild cervical shortening.This multicenter, parallel-arm, double-blind, randomized, placebo-controlled trial involved vaginal progesterone administration (200 mg daily from 16 to 33 weeks of gestation) among asymptomatic women with a singleton pregnancy and a sonographic cervical length of 25 to <30 mm between 16 and 23 weeks of gestation. The primary and secondary endpoints were cervical shortening rates at 34 weeks of gestation and preterm birth rates, respectively. The trial was registered at the University Hospital Medical Information Network (UMIN000013518) in Japan.Between April 2014 and March 2018, 119 women were randomly assigned to the progesterone group (n = 59) and the placebo group (n = 60). No significant differences in the frequency of women with a cervical length ≥20 mm at 34 weeks of gestation were observed between both groups. All preterm births occurred after 34 weeks of gestation, except for one patient in the placebo group. The progesterone group had a lower rate of preterm birth before 37 weeks than the placebo group (3.4% vs. 15.0%, respectively; p < .05).Despite having no effect on preserving cervical length, prophylactic vaginal progesterone administration reduced preterm birth frequency among women with mild cervical shortening. Our results are suggesting that women with mild cervical shortening are at risk for late preterm birth and the need for expanding progesterone treatment indications to include not only high-risk but also low-risk populations.

Effectiveness of microwave endometrial ablation combined with hysteroscopic transcervical resection in treating submucous uterine myomas.

BACKGROUND: Hypermenorrhea is characterized by excessive menstrual bleeding that causes severe anemia and interferes with everyday life. This condition can restrict women's social activities and decrease their quality of life. Microwave endometrial ablation (MEA) using a 2.45-GHz energy source is a minimally invasive alternative to conventional hysterectomy for treating hypermenorrhea that is resistant to conservative treatment, triggered by systemic disease or medications, or caused by uterine myomas and fibrosis. The popularity of MEA has increased worldwide. Although MEA can safely and effectively treat submucous myomas, some patients may still experience recurrent hypermenorrhea postoperatively and may require additional treatment. AIM: To investigate the efficacy of MEA combined with transcervical resection (TCR). METHODS: Participants underwent cervical and endometrial evaluations. Magnetic resonance imaging and hysteroscopy were performed to evaluate the size and location of the myomas. TCR was performed before MEA using a hystero-resectoscope. MEA was performed using transabdominal ultrasound. The variables included operation time, number of ablation cycles, length of hospital stay, and visual analog scale cores for hypermenorrhea, dysmenorrhea, and treatment satisfaction at 3 and 6 mo postoperatively. The postoperative incidence of amenorrhea, changes in hemoglobin concentrations, and MEA-related complications were evaluated. RESULTS: A total of 34 women underwent a combination of MEA and TCR during the study period. Two patients were excluded from the study as their histopathological tests identified uterine malignancies (uterine sarcoma and endometrial cancer). The 32 eligible women (6 nulliparous, 26 multiparous) had a mean age of 45.2 ± 4.3 years (range: 36-52 years). Patients reported very severe hypermenorrhea (10/10 points on the visual analog scale) before the procedure. However, after the procedure, the hypermenorrhea scores decreased to 1.2 ± 1.3 and 0.9 ± 1.3 at 3 and 6 mo, respectively (P < 0.001). The mean follow-up duration was 33.8 ± 16.8 mo. Although 10 women (31.3%) developed amenorrhea during this period, none experienced a recurrence of hypermenorrhea. No surgical complications were observed. CONCLUSION: Reducing the size of uterine myomas by combining MEA and TCR can safely and effectively treat hypermenorrhea in patients with submucous myomas.

Successful Conservative Treatment of Cesarean Scar Ectopic Pregnancy with Local Injections of Absolute Ethanol.

Cesarean scar ectopic pregnancy (CSEP) is becoming more common worldwide. Here, we report a case of cesarean scar pregnancy successfully treated using transvaginal ethanol injection. A 31-year-old female (gravida 3, para 2) with two prior cesarean sections presented at 9 weeks and 3 days of pregnancy. Her serum human chorionic gonadotropin level was 91,798 mIU/mL. CSEP was confirmed by transvaginal ultrasonography, pelvic magnetic resonance imaging, and color Doppler ultrasonography. Transvaginal absolute ethanol local injection under transvaginal ultrasound guidance was performed. She was discharged 7 days after treatment with no complications and resumed normal menses 1 month after treatment. We describe a safe and successful treatment option for CSEP.

Low placental growth factor levels and high soluble endoglin levels at 26-31 weeks of gestation precede light placenta with and without relatively heavy infant, respectively: A retrospective cohort study.

AIM: Our aim was to examine whether serum levels of placental growth factor (PlGF) and soluble endoglin (sEng) at 19-25 and 26-31 weeks of gestation were associated with the occurrence of the 9-block categorization of placenta weight (PW) and fetal/placenta ratio (F/P ratio). METHODS: We performed a retrospective cohort study in 1391 women with singleton pregnancy. Serum levels of PlGF and sEng were measured by enzyme immunosorbent assay. A light placenta was defined as PW ZS < -1.28 SD. Based on the PW (light, normal, and heavy) and F/P ratio (relatively heavy, balanced growth, and relatively small), 9-block categorization were performed. Multivariable logistic regression analyses were performed. RESULTS: Low PlGF at 26-31 weeks was an independent risk factor for the birth of infants belonging to Block A (light placenta and relatively heavy infant), after adjusting for prepregnancy body mass index and serum levels of sEng. High sEng at 26-31 weeks was an independent risk factor for the birth of infants belonging to Block D (light placenta and balanced growth of infant), after adjusting for past history of either preeclampsia or gestational hypertension, high pulsatility index of uterine artery flow velocity waveforms in the second trimester, and serum level of PlGF. CONCLUSIONS: Low PlGF levels at 26-31 weeks of gestation may precede a light placenta and relatively heavy infant (Block A), and high sEng levels at 26-31 weeks of gestation may precede a light placenta and balanced growth of infant (Block D).

Safety and efficacy of manual vacuum suction compared with conventional dilatation and sharp curettage and electric vacuum aspiration in surgical treatment of miscarriage: a randomized controlled trial.

BACKGROUND: The World Health Organization does not recommend dilatation and sharp curettage (D&C) for the surgical treatment of miscarriage during the first trimester because this may cause Asherman's syndrome due to endometrial damage; therefore, suction remains the primary treatment option. While manual vacuum aspiration (MVA) has been widely used since the 1990s outside Japan, the use of an MVA device (Women's MVA system) was approved in Japan in October 2015. Here, we examined the efficacy of the MVA kit in women surgically treated for miscarriage. METHODS: This retrospective cohort study was conducted between 2014 and 2018 at the International University of Health and Welfare Hospital in Japan. Women who underwent surgical treatment for miscarriage within 12 weeks of pregnancy were identified and enrolled in the study. A total of 404 women were included who underwent the following procedures: 121 D&C, 123 electric vacuum aspiration (EVA), and 160 MVA. For each participant, the duration of surgery, amount of bleeding, amount of anesthetic used, incomplete abortion requiring repeat procedures, and intraoperative/postoperative complications were evaluated. RESULTS: The duration of surgery was 13.7 ± 7.2, 11.2 ± 4.2, and 6.9 ± 4.3 min in the D&C, EVA, and MVA groups, respectively (p = 1.00). The amount of anesthetic used was not significantly different among all groups. Bleeding of ≥ 100 mL was confirmed in three (2.4%), one (0.8%), and one (0.6%) patient(s) in the D&C, EVA, and MVA groups, respectively (p = 0.50). Incomplete abortion was identified in three (2.4%), two (1.6%), and one (0.6%) patient(s) in the D&C, EVA, and MVA groups, respectively (p = 0.61). However, severe intraoperative/postoperative complications were not observed in any group. CONCLUSIONS: Surgical treatment for miscarriage performed using the MVA kit has safety and efficacy similar to those of conventional methods, such as D&C and EVA.

Difference in Z scores of placental weight and fetal/placental weight ratio by mode of delivery.

AIM: The difference of placental weight (PW) and fetal/placental weight ratio (F/P) Z scores by mode of delivery is unclear. To investigate such differences and the actual conditions underlying the imbalance between fetal and placental growth. METHODS: The data from Japanese database 2013 were assessed. Light-for-dates (LFD, n = 12 884), appropriate-for-dates (n = 114 464) and heavy-for-dates (n = 13 164) from 140 512 placentas/infants of mothers delivered a singleton infant. Using Z scores of PW and F/P based on the standard curves of a sex-, parity- and gestational-age-specific PW and F/P, the rate of inappropriately heavy placenta according to the mode of delivery (vaginal [VD] vs cesarean [CS]) was investigated. RESULTS: (i) The PW and F/P were heavier and bigger in VD than in CS, in each subgroup. In the LFD groups, the PW Z score in VD was higher than that in CS, whereas the F/P Z score was lower than in VD than that in CS. (ii) Data of single regression analyses between the PW Z score and F/P Z score in VD groups were different from those in CS, especially in LFD infants. (iii) In the LFD subgroups, the rates of inappropriately heavy placenta in VD (n = 7781) and CS (n = 5103) were 0.54% and 0.86%, respectively. CONCLUSION: Difference in the mode of delivery influenced the PW and F/P, and the rate of inappropriately heavy placenta is associated with mode of delivery among LFD infants. This methodology might give us a clue to search a useful way for identifying the high-risk groups requiring postnatal counseling.

Intrauterine Fetal and Neonatal Death between Small for Date and Non-Small for Date in Small for Gestational Age Infants.

Objective: To demonstrate the differences in intrauterine fetal deaths and neonatal deaths between small for date (SFD) and Non-SFD neonates by applying a novel classification from both Z scores of placental weight (PW) and fetal/placental weight ratio (F/P) to small for gestational age (SGA) neonates. Methods: From 93,034 placentas/infants of mothers who vaginally delivered a singleton infant (Japan Perinatal Registry Network database 2013), SGA (n=7,780) was chosen according to the reference to Japanese neonatal growth chart. They were divided into two subgroups: SFD (body weight and height less than the 10th percentile, n=3,379) and Non-SFD (only body weight less than the 10th percentile, n=4,401). Z scores of PW and F/P based on the standard curves for sex-, parity-, and gestational-age-specific PW and F/P were calculated. The population was classified into 9 groups according to the combination of 'low vs. middle vs. high' i) PW Z score and ii) F/P Z score. In both i) and ii), ± 1.28 standard deviations in the Z scores were used for classifying low vs. middle vs. high, with 3×3 making 9 groups. From top-left to bottom-right, we labeled the groups as Group A to Group I. Results: SFD and Non-SFD neonates distributed in the same 6 groups (A, D, E, G, H, I). In group E, which was considered to be balanced placental and infant growth, the incidence of intrauterine fetal death was significantly higher in Non-SFD neonates than in SFD neonates. In group D, which was considered to be small placenta and balanced infant growth, the incidence of neonatal death was significantly higher in SFD neonates than in Non-SFD neonates. Conclusion: Assessment of SGA neonates by dividing them into SFD and Non-SFD neonates and application of a 9-group classification by PW and F/P Z scores were informative to understand the pathophysiological involvement of an imbalance between placental and fetal sizes.

Randomized trial of the efficacy of intravaginal ulinastatin administration for the prevention of preterm birth in women with a singleton pregnancy and both cervical shortening and inflammation of lower genital tract.

AIM: To assess the preventive effect on preterm birth of intravaginal ulinastatin (urinary trypsin inhibitor; UTI) administration during the mid-trimester in women with singleton pregnancy and both cervical shortening and lower genital infections. METHODS: Pregnant women with a short cervical length < 25 mm between 16 and 26 weeks of gestation and who had been diagnosed with a lower genital infection were randomly assigned for intravaginal UTI administration or placebo. All of the women were screened for infection or inflammation of the lower genital tract, and women with negative results were excluded. RESULTS: Of the 92 patients with a short cervical length who were assessed for eligibility for this study, 86 singleton patients were enrolled. All patients were randomized to one of two treatment groups: patients administered UTI (n = 35) and placebo (n = 35). There were no differences between the two groups in the incidence of preterm delivery before 28, 30, 32, 34 and 37 weeks of gestation and in perinatal outcomes. CONCLUSION: For women diagnosed with a short cervical length < 25 mm) between 16 and 26 weeks of gestation and lower genital infection, who were at risk of preterm birth, administration of transvaginal UTI with vaginal irrigation showed no apparent benefit. Future research on the efficacy of UTI should evaluate modified modes of UTI application.

Impact of placental weight and fetal/placental weight ratio Z score on fetal growth and the perinatal outcome.

Objective: To classify the infants into 9 blocks based on the deviation of both placental weight (PW) and fetal/placental weight ratio (F/P) Z score and compared the incident rate of perinatal death in each of the small for date (SFD) vs. appropriate for date (AFD) vs. heavy for date (HFD) groups. Methods: The study population consisted of 93,034 placentas/infants from women who vaginally delivered a singleton infant. They were classified into 3 groups according to infants' weight: SFD (n=3,379), AFD (n=81,143) and HFD (n=8,512). The population was classified into 9 blocks according to the combination of i) low vs. middle vs. high placental weight (PW: a sex-, parity- and gestational-age-specific placental weight) and ii) low vs. middle vs. high F/P. In both i) and ii), ± 1.28 standard deviations in the in the Z scores was used for classifying low vs. middle vs. high, with 3x3 making 9 blocks. We then determined whether or not the perinatal death in each block differed among the three groups (SFD vs. AFD vs. HFD). Results: (1) The proportions of 'balanced growth of placenta and infant' (appropriate PW and F/P based on Z-score) were 37.6% in the SFD group, 78.8% in the AFD group, and 51.2% in HFD group. (2) The proportion of 'inappropriately heavy placenta' in the SFD group and that of 'inappropriately light placenta' in the HFD group were 0.3 and 0.4%, respectively, a very rare phenomenon. The proportions of 'inappropriately heavy placenta' and 'inappropriately light placenta' accounted for 4.1 and 5.5% in AFD group, respectively. (3) The rates of perinatal death in those with 'balanced growth of placenta and infant' were lowest in the SFD and AFD groups. Conclusion: By showing the fact that perinatal death was lowest in cases with balanced fetal/ placental growth, we conclude that 9-block categorization of PW and F/P based on deviation in the Z-score may be a candidate factor employable for understanding fetal and placental growth and perinatal deaths.

Annual Report of the Perinatology Committee, Japan Society of Obstetrics and Gynecology, 2016: Overall report on a comprehensive retrospective study of obstetric management of preterm labor and preterm premature rupture of the membranes.

We conducted a questionnaire survey on the current obstetric management of preterm labor (PL) and preterm premature rupture of the membranes (pPROM). The questionnaire covered approximately a third of all preterm deliveries and nearly half of the preterm deliveries before 32 gestational weeks. The diagnostic criterion for PL was either painful uterine contractions or cervical dilatation. Tocolytic agents were primarily used as long-term maintenance therapy. Intrauterine infection was clinically diagnosed at most responding institutions. Amniocentesis was performed for PL or pPROM at only a small number (10%) of institutions. Prenatal steroids were administered for PL or pPROM, if indicated, at approximately 40-60% of responding institutions. Prophylactic antibiotics to maintain pregnancy were administered for pPROM at approximately 90% and for PL at approximately 20% of institutions. Maintenance therapy with a tocolytic agent was used for pPROM at approximately 90% of institutions.