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Mesonephric‐like adenocarcinoma (MLA) is a rare tumor that occurs in the uterine endometrium and ovary. It morphologically and immunohistochemically resembles cervical mesonephric adenocarcinoma (MA). Here, we present a case of MLA of the ovary along with a literature review. An asymptomatic 84‐year‐old woman presented with a pelvic mass, detected by computerized tomography. Magnetic resonance imaging demonstrated a polycystic mass with a solid component in the left adnexal region. The solid component showed low signal intensity on T2‐weighted imaging and high signal intensity on diffusion‐weighted imaging. We strongly suspected an ovarian malignant tumor; therefore, surgical resection of the uterus and adnexa was performed. Macroscopically, the tumor was predominantly solid with yellowish‐tan cut surface. Microscopically, it showed a tubular pattern with intraluminal colloid‐like material resembling MA. The tumor cells were negative for estrogen receptor, calretinin, and CD10 and positive for PAX8 and TTF‐1. These findings are consistent with those of MLA. [ABSTRACT FROM AUTHOR]

Lymphoepithelioma‐like carcinoma of the uterine cervix is a rare variant of squamous cell carcinoma. Herein, we describe three cases of lymphoepithelioma‐like carcinoma of the uterine cervix and review relevant literature. All three patients initially presented with postmenopausal bleeding. Gross appearances were endophytic with ulcerated mucosa in case 1, exophytic with polypoid morphology in case 2, and unremarkable even using colposcopy and hysteroscopy in case 3. Magnetic resonance imaging demonstrated well‐demarcated cervical masses with high‐intermediate intensity on T2‐weighted images and high intensity on diffusion‐weighted images in all three cases. In case 3, biopsy referring to local information from magnetic resonance images was required for preoperative diagnosis. We reviewed the literature of 59 lymphoepithelioma‐like carcinoma cases in 19 papers published between 2001 and 2020. Preoperative diagnosis of lymphoepithelioma‐like carcinoma is sometimes challenging, although magnetic resonance imaging findings may help determine the location of the tumor and obtain a successful biopsy. [ABSTRACT FROM AUTHOR]

Aim: Whether young cervical cancer patients have poorer prognosis compared to older ones has remained controversial over the past half century. The last three decades have seen a rise in morbidity and mortality among young Japanese women with cervical cancer. This reflects the fact that the importance of prevention has not been fully recognized due to limited clinical studies. We examined the relationship between age and prognosis in cervical cancer. Methods: We retrospectively examined medical records of consecutive patients with International Federation of Gynecology and Obstetrics stage IB and IIB cervical cancer at a hospital in Japan. Patients were divided into two age groups: less than or equal to 39 years (adolescent and young adult [AYA] group) and greater than or equal to 40 years (older adult group). We compared prognosis and clinical factors associated with prognosis between AYA and older adult patients. Results: Data from 182 patients (AYA n = 71; older adults n = 111) treated between 2004 and 2011 were analyzed. The proportion of loss to follow‐up was 6.0%. Significant differences were observed in stage and lymph node metastasis between the two groups at baseline. However, despite the older adult group having a higher proportion of advanced cancer patients, the overall survival rate of stage IIB patients in the AYA group at the 3‐year follow‐up was significantly lower (AYA 53.6%, older adults 86.3%, P < 0.05). Multivariate analysis adjusted for clinical factors revealed that AYA patients had a 3.7–3.9 times greater mortality risk compared to older adults. Conclusion: AYA patients with stage IB and IIB cervical cancer may have a prognostic disadvantage. [ABSTRACT FROM AUTHOR]

Abstract: Condylomatous, or warty squamous cell carcinoma (SCC) of the uterine cervix, is a rare variant of invasive SCC. Here, we describe a case of aggressive condylomatous SCC of the uterine cervix. A 43‐year‐old woman was monitored for 3 years for suspected low‐grade squamous intraepithelial lesion. A whitish papillary mass occupied the cervix, and the colposcopic diagnosis was condyloma acuminatum. A cervical biopsy revealed papillary proliferating thick squamous epithelium, which consisted of koilocytes and atypical cells with enlarged nuclei. Hysterectomy specimens showed a thick layer of atypical squamous epithelium with koilocytosis invading the stroma. Immunohistochemistry revealed negative p16 expression. Hysterectomy specimens tested positive for low‐risk human papillomavirus type 6, but negative for other high‐risk human papillomavirus types. The bilateral pelvic and para‐aortic lymph nodes were positive for metastases. In spite of adjuvant chemotherapy, the case relapsed with multiple lymph nodes and lung metastases shortly after the operation. [ABSTRACT FROM AUTHOR]

Aim The aim of this study was to elucidate the feasibility and safety of vaginal delivery (VD) when placental abruption causes fetal demise. Methods We conducted a retrospective study of women who were managed for placental abruption with intrauterine fetal death at Kyoto University Hospital during the period from 1995 to 2015. Results Sixteen cases were identified during the study period. VD was attempted in 15 cases and was accomplished in 14 (93.3%) cases. The median gestational age was 36 (24-39) weeks, and there were eight primiparas. The median Bishop score on admission was 2.5 (1-9). Eight pregnancies were complicated with pregnancy-induced hypertension. The median duration of labor was 5 h and 18 min (30 min-12 h 43 min), and the median amount of hemorrhage was 2503 (445-6808) mL. Fresh frozen plasma (≥ 20 U) and red cell concentrate (≥ 10 U) were administered in 10 (71%) and 9 (64%) cases, respectively. Two cases required uterine artery embolization for post-partum hemorrhage, while there was no case of maternal death or hysterectomy. Patients with Bishop score > 3 ( n = 6) experienced shorter-duration deliveries ( P = 0.020) and had significantly larger blood loss volume ( P = 0.020) compared to patients with Bishop score ≤ 3. The duration of labor was negatively correlated with the amount of blood loss ( R 2 = −0.56, P = 0.039). Conclusion After placental abruption with intrauterine fetal death, VD is feasible and safe regardless of gestational age, parity, cervical maturity, and duration of labor when intensive medical resources are available. [ABSTRACT FROM AUTHOR]

Aim Thioredoxin binding protein-2 (TBP-2), which is identical to thioredoxin interacting protein (Txnip), controls cellular proliferation and differentiation. The aim of the present study was to compare TBP-2 protein and mRNA expression in human placenta during the three trimesters of pregnancy and to investigate the role of hypoxia in the change of these expressions in placental tissue. A secondary objective was to determine the gene expression of peroxisome proliferator-activated receptors (PPARs) in TBP-2 deficient placenta using TBP-2 gene disrupted mice (TBP-2−/−). Methods Protein and mRNA expression of TBP-2 in human placenta from each trimester were analyzed by immunohistochemistry, Western blots, and by quantitative reverse-transcriptase-polymerase chain reaction. The effect of hypoxia on TBP-2 expression was tested using an explant culture of human placenta. In TBP-2−/− mouse placenta, we detected PPAR mRNA expression. Results TBP-2 was located in syncytiotrophoblasts and cytotrophoblasts, and also in the endothelium in human placenta. Its expression in the placenta was low in the first trimester, and increased in the second and third trimesters. Hypoxia decreased TBP-2 mRNA and protein expression in human placental explant culture. In TBP-2−/− mice, placental mRNA levels of PPARα and γ were significantly suppressed compared with those in wild-type mice. Conclusion Hypoxia suppresses TBP-2 gene expression, which may ultimately alter placental development. [ABSTRACT FROM AUTHOR]

Aim There are an increasing number of reports of pregnancy following liver transplantation, but many questions remain regarding preconception counseling and management of the pregnancy. The aim of this study was to report pregnancy outcomes in women who had undergone liver transplants and to gain insight into these issues. Methods We conducted a retrospective review of liver transplant recipients who had received prenatal care at Kyoto University Hospital between January 2001 and December 2015. Results Twenty-six consecutive pregnancies in 17 liver transplant recipients were identified during the period. The most common indication for liver transplantation was biliary atresia (65%). The median age at transplantation was 19 years (range, 2-38). The median age at conception was 28 years (range, 20-41) with a median time between transplantation and conception of 8 years (range, 0-22). A tacrolimus-based immunosuppressive regimen ( n = 21, 81%) was the most common at the time of conception. There were 13 live births (50%), four spontaneous miscarriages (15%), and nine induced abortions (35%). Median gestational age at delivery was 38 weeks (range, 32-42), and the median birthweight was 2858 g (range, 1815-3864 g). Pregnancy and maternal complications included preterm deliveries (23%), intrauterine growth restriction (23%), pre-eclampsia (8%), cesarean delivery (23%), bacterial infection (15%), and biopsy-proven acute cellular rejection (15%). Two infants had congenital anomalies (tetralogy of Fallot and hydronephrosis). Conclusion Pregnancy after liver transplantation can achieve relatively favorable outcomes. Obstetricians should be involved in the contraceptive and fertility counseling of female transplant recipients to prevent unintended pregnancies. [ABSTRACT FROM AUTHOR]

Campylobacter fetus often causes systemic infection in immunocompromised or older patients, and prenatal infection, but Campylobacter has rarely been reported as a cause of adnexitis in healthy young women. Here we report two cases of endometriotic cysts infected by C. fetus for the first time. In case 1, a 28-year-old woman with a left adnexal cyst was hospitalized for left tubo-ovarian abscess and underwent left salpingo-oophorectomy. In case 2, a 22-year-old woman with a right adnexal cyst was hospitalized for a bilateral tubo-ovarian abscess and underwent right salpingo-oophorectomy and left salpingectomy. In both cases, C. fetus was detected on culture, and histopathology indicated a purulent endometriotic cyst. The present findings suggest that endometriotic cyst can be a focus of C. fetus infection. [ABSTRACT FROM AUTHOR]

A Wolffian tumor is a rare tumor arising from the remnants of the mesonephric duct. Herein, we report two cases. A 61-year-old woman presented with swollen left adnexa. On T2 weighted magnetic resonance imaging (MRI), a 4.4 cm solid pelvic mass showed slightly high signal intensity, with a low-signal-intensity rim. Microscopically, cuboidal cells with bland nuclei were arranged in a dense tubular form. A 40-year-old woman complained of lower abdominal pain. On T2 weighted MRI, a 6.0 cm solid mass with a low-signal-intensity rim was found. The pathology of the resected tumor was similar to that of case 1. Both cases were diagnosed as Wolffian tumor. The rims of the tumors in both cases were composed of eosinophilic spindle-shaped cells immunoreactive to alpha-smooth muscle actin and desmin, identical to the smooth muscle cells surrounding the mesonephric duct remnants. MRI findings reflecting smooth muscle rims might contribute to an accurate preoperative diagnosis of this rare tumor. [ABSTRACT FROM AUTHOR]

A partial molar pregnancy almost always ends in miscarriage due to a triploid fetus. We describe a rare case of a singleton, partial molar pregnancy with a seemingly huge placenta, which continued to delivery of a live-born diploid baby. A 27-year-old primigravida suffered from severe pre-eclampsia and progressive anemia. The uterus was enormously enlarged for the gestational age. A cesarean section was performed because of deterioration of maternal status at 25 weeks' gestation, when more than 3000 mL blood spouted concurrently with the delivery of the placenta. The histological examination showed congestion in the decidua, which indicated disturbance of maternal venous return from the intervillous space. The chromosome complement of the placenta and the neonate were 69,XXX and 46,XX, respectively. We also reviewed all published cases of a singleton, partial molar pregnancy. A literature search yielded 18 cases of a singleton, diploid fetus with partial molar pregnancy. The mean gestational age at delivery was 24.5 ± 6.2 weeks, and fetuses survived outside the uterus in only four cases (22.2%). Intriguingly, previous reports numbered 10 cases with diploid placenta as well as five cases with no karyotyping of the placenta, indicating that they may have included a complete mole in a twin pregnancy or placental mesenchymal dysplasia. In conclusion, this was the first case of placentomegaly that presented manifestations of excessive abdominal distension and maternal severe anemia, and the second case of a singleton, partial molar pregnancy confirmed by chromosome analysis resulting in a diploid living baby. [ABSTRACT FROM AUTHOR]

Aim Nuclear factor erythroid 2-related factor 2 (Nrf2) is a key transcriptional regulator against oxidative stress through the induction of antioxidant and cytoprotective genes, such as heme oxygenase 1 (HO-1), glutamyl cysteine ligase catalytic (GCLC), and glutamyl cysteine ligase modulatory (GCLM). Nrf2 signaling is disrupted in pre-eclamptic placentas, although increased oxidative stress is implicated in pre-eclampsia. The aims of the study were: (i) to investigate the mechanism that underlies the impaired Nrf2 signaling in pre-eclamptic placentas, and (ii) to examine the potential therapeutic role of statin for pre-eclampsia. Material and Methods Human choriocarcinoma JAR cells were cultured under normoxia (20% O2) or hypoxia (1% O2). Small-interfering ribonucleic acids were used to knockdown Nrf2. Real-time quantitative reverse transcriptase polymerase chain reaction and Western blotting were used to evaluate the influence of oxidative stress (H2O2 100 μM) and simvastatin (50 μM) on Nrf2 and its target genes. Reactive oxygen species levels were analyzed by flow cytometry in immortalized human trophoblast TCL1 cells treated with or without H2O2 (100 μM) ± simvastatin (50 μM). Results Nuclear factor erythroid 2-related factor 2 activation was significantly suppressed under hypoxic conditions. Nrf2 knockdown resulted in insufficient enhancement of HO-1, GCLC and GCLM expression under oxidative stress. In contrast, Nrf2 signaling was augmented by simvastatin, which suppressed the induction of oxidative stress in trophoblasts. Conclusion Hypoxia is one of the important negative regulators of Nrf2 activation, and simvastatin inhibits oxidative stress through the activation of Nrf2 signaling in trophoblasts, indicating the potential therapeutic role of statin for pre-eclampsia. [ABSTRACT FROM AUTHOR]

Aim The aim of this study was to clarify the magnetic resonance (MR) imaging findings, including diffusion-weighted imaging (DWI), of hemorrhagic infarction of ovarian torsion. Material and Methods Twelve patients presenting surgically confirmed ovarian masses with torsion were independently evaluated by two radiologists about the following MR findings: presence of ascites, uterine deviation, wall thickening on T2 weighted image (WI), recognition of twisted pedicle on T1/T2WI, and presence of wall enhancement of ovarian lesions on Gd-T1WI. The signal intensities on T1WI and DWI were compared with those of the iliopsoas muscle and the nerve root, respectively. These MR findings were statistically compared between cases of ovarian torsion with histopathologically proven hemorrhagic infarction and those without. Results Pathologically, hemorrhagic infarction of the wall was confirmed in six of twelve cases. Ascites, uterine deviation and twisted pedicle were detected in most cases whether with or without hemorrhagic infarction. The complete absence of wall enhancement was observed in only one case with necrosis. A higher signal intensity of the wall compared to controls was observed in 4/6 and 5/6 cases with infarction on T1WI/DWI, respectively. This was not observed in any cases without infarction. Three out of five cystic lesions with hemorrhagic infarction showed irregular wall thickening on T2WI, and no cystic lesion without hemorrhagic infarction did. Smooth wall thickening was observed in 2/6 cases without hemorrhagic infarction. Conclusion Pathological hemorrhagic infarction of ovarian torsion was associated with several MR imaging findings, including high signal intensity on T1WI/DWI, and irregular wall thickening on T2WI. [ABSTRACT FROM AUTHOR]

We report two cases of clinically suspected placental hypocirculation, as per evidenced by specific half-Fourier acquisition single-shot turbo spin-echo ( HASTE) magnetic resonance findings of the whole placenta. Patient 1 was a case of fetal growth restriction caused by pregnancy-induced hypertension, while patient 2 experienced a discordant dichorionic diamniotic twin pregnancy with fetal growth restriction complication with a velamentous insertion of the umbilical cord in the smaller twin. In both cases, HASTE images showed noticeably decreased signal intensity with high-intensity signal spots present in the central region of the placenta. In the twin pregnancy case, the low-intensity signal area in the placenta of the smaller twin was much lower compared to that of the larger twin. Pathological findings failed to support or explain these observations. HASTE images might reflect compensatory alternation of the distribution of maternal blood and villus caused by hypocirculation. In conclusion, our results suggest that HASTE imaging might be a useful approach for the visualization of placental hypocirculation. [ABSTRACT FROM AUTHOR]

Extensively distended and tortuous vessels on both sides of the uterus are rare incidental findings on transvaginal sonography in early pregnancy. A 31-year-old woman with a history of surgical repair for congenital intestinal stenosis was noted to have utero-ovarian varices on a transvaginal ultrasound examination during her first prenatal visit at 6 weeks' gestation. Magnetic resonance imaging revealed dilated ovarian veins along with infrarenal absence of inferior vena cava as well as the absence of external and common iliac veins. Despite concerns regarding spontaneous utero-ovarian vessels rupture, her antenatal course was uneventful. A vaginal delivery was successfully achieved without any postpartum complication. We also demonstrated an intraoperative view of the utero-ovarian vessels during cesarean section in her subsequent pregnancy. Absence of inferior vena cava and pelvic varices can occur in women with a history of neonatal surgery. Although the risk of utero-ovarian varices rupture remains unclear, vaginal delivery may be safely achieved. [ABSTRACT FROM AUTHOR]

Aim To assess the use of magnetic resonance imaging ( MRI) for prenatal differentiation between complete hydatidiform mole with a twin live fetus ( CHMTF) and placental mesenchymal dysplasia ( PMD). Methods Three CHMTF cases and three PMD cases, from two institutions over a 6-year period, were retrospectively included in this study. Clinical findings including age, pregnancy history, serum h CG level, ultrasonography findings, complications of the mother, outcome of the fetus, and results of chromosomal study of fetus, amniotic fluid and lesion, if possible, were noted. MRI findings were evaluated by two radiologists with respect to the location of the disease (intra- or extra-fetal sac), the presence of multicystic component, and presence of intra- or extra-lesional hemorrhage. Results In all six cases, the diseases were recognized as multicystic lesions by ultrasonography and MRI. In two of three CHMTF cases, patients continued with the pregnancy, which resulted in spontaneous abortion. In one case of CHMTF, the patient underwent artificial abortion, after which the mole progressed into an invasive mole with lung metastases. All three PMD patients had live births, and two of the three babies had fetal growth restriction. By MRI, CHMTF was located within an extra-fetal sac accompanied by intra- and/or extra-lesional hemorrhage, while PMD was located within the placenta in the fetal sac without hemorrhage. Conclusion MRI could provide important information about the prenatal differential diagnosis of CHMTF and PMD, based on the pathophysiology and characteristics of the diseases. [ABSTRACT FROM AUTHOR]

We report two cases of endometrial carcinoma in which peritumoral enhancement ( PTE) was detected on dynamic contrast-enhanced ( DCE) images and was compared with the pathologic findings. In the first case, DCE images showed subendometrial enhancement ( SEE) disrupted by focally irregular PTE, reflecting the increased vascularity at the tumor attachment site. In the second case, DCE images revealed the presence of PTE as an irregular, thin-layered early enhancement, reflecting the increased vascularity at the tumor front. In similar cases, the presence of PTE should be recognized in order to avoid a possible misinterpretation as SEE. [ABSTRACT FROM AUTHOR]

Chronic abruption-oligohydramnios sequence ( CAOS), characterized by chronic vaginal bleeding and oligohydramnios, is associated with adverse pregnancy outcomes, including preterm delivery and lung problems in the infant. Fetal lung damage may be induced by not only oligohydramnios but also iron-induced oxidative stress through chronic aspiration of bloody substances in amniotic fluid. We describe a pregnancy complicated with CAOS that was managed with repeated amnioinfusions. This is the first report showing that amnioinfusions succeeded in a significant reduction in high concentrations of iron, lactose dehydrogenase, and 8-hydroxy-2′-deoxyguanosine, a marker of oxidative DNA damage, in the amniotic fluid complicated by CAOS. The baby, born at 26 weeks' gestation via cesarean, was discharged home without supplemental oxygen 116 days after birth. [ABSTRACT FROM AUTHOR]

Aim Post-partum hemorrhage ( PPH) is the leading cause of maternal mortality. Identification of the precise bleeding site is generally important to control hemorrhage, but such an approach has not been fully established in the context of PPH. We postulated that visualization of bleeding sites could aid treatment decisions in the management of PPH. Methods We conducted a prospective review of 26 patients who underwent dynamic computed tomography ( CT) for PPH. Results A total of 17 cases presented with uterine bleeding, eight with vaginal hematomas, and one with hemoperitoneum. Overall, dynamic CT identified contrast media extravasation in the arterial phase in 12 of 26 (46.2%) cases: the upper ( n = 4) and the lower uterine segment including the cervix ( n = 2), subfascial space ( n = 1) and vagina ( n = 5). Identification of precise arterial bleeding sites using CT provided informative guidance about where to place balloons for intractable uterine bleeding, and how to manage hemoperitoneum and vaginal hematomas. In addition, dynamic CT revealed the existence of a subtype of uterine atony, which is characterized by focal active arterial bleeding in the upper uterine segment. Furthermore, negative contrast extravasation extracted cases of PPH that were well controlled without the need for surgical or radiological intervention. No patient required emergency hysterectomy to control PPH. Conclusion Dynamic CT has potential clinical utility in treatment decision-making for PPH. [ABSTRACT FROM AUTHOR]

Humoral hypercalcemia of malignancy ( HHM) is a paraneoplastic syndrome primarily caused by a tumor-producing parathyroid hormone-related protein ( PTH- rP). We describe the first reported case of a uterine carcinosarcoma causing HHM. A 70-year-old patient was transferred to our hospital for a uterine tumor accompanied by impaired consciousness. The laboratory tests indicated anemia, malnutrition, elevated serum calcium and elevated PTH- rP. Emergency surgery, including abdominal hysterectomy and bilateral salpingo-oophorectomy, was performed due to uncontrollable uterine bleeding. The pathological diagnosis was carcinosarcoma consisting of pure squamous cell carcinoma in its epithelial component. Postoperatively, chemotherapy with paclitaxel and carboplatin was performed. The patient had recurrent tumors at the para-aortic lymph nodes 11 months after the initial surgery and underwent a pelvic and para-aortic lymphadenectomy, which removed all of the recurrent tumors. [ABSTRACT FROM AUTHOR]

An intrauterine balloon tamponade is a simple but highly effective method for the management of postpartum hemorrhage. However, treatment failure can occur due to prolapse of an intrauterine balloon into the vagina. We present two cases with a successful maneuver in maintaining the intrauterine placement of the balloon by clamping the cervix with two ring forceps in the management of postpartum hemorrhage. Although the balloon was initially expelled through a dilated cervix, a cervical clamp using ring forceps prevented displacement of the balloon, and the hemorrhage ceased. Clamping the cervix with two ring forceps to retain the balloon can be a simple and readily available approach to consider when an intrauterine balloon tamponade does not work due to its expulsion. [ABSTRACT FROM AUTHOR]

Pyomyoma (suppurative leiomyoma) is a rare but serious complication of uterine leiomyomas. Although the management of leiomyomas during pregnancy is usually expectant, prompt surgical intervention is mandatory for pyomyoma. We present a case of pyomyoma with peritonitis that necessitated myomectomy at 21 weeks of gestation in a 28-year-old nullipara in which the pregnancy continued to successful delivery at 37 weeks of gestation. Perinatal and neonatal outcomes in pregnancies complicated with pyomyoma may be improved by prompt surgical intervention even in the early second trimester. A brief review of the literature regarding pyomyoma associated with pregnancy is also described. [ABSTRACT FROM AUTHOR]

Whether to manage placenta previa percreta surgically or conservatively has been a controversial issue. A 30-year-old woman with placenta percreta with bladder involvement was treated conservatively. A planned cesarean section was performed at 33 weeks' gestation. A 1768-g female infant was delivered through a transverse fundal uterine incision with the placenta left inside the uterus. The following morning, a massive postpartum hemorrhage occurred, and was successfully treated with transarterial embolization. The placenta was never expelled and spontaneously disappeared 4 months after surgery. We demonstrate serial magnetic resonance imaging of the placenta percreta during pregnancy and the postpartum period. [ABSTRACT FROM AUTHOR]

Solitary fibrous tumor (SFT), which was first described as a pleural lesion by Klemperer and Rabin in 1931, is a rare, slow-growing neoplasm characterized by the proliferation of fibroblast-like spindle cells arranged in a patternless manner with few nuclear atypia. Extrathoracic SFT have increasingly been recognized, but those in the genital tract are extremely rare. Gynecological SFT behave as tumors with low malignant potential to recur, metastasize, or affect nearby organs resulting in infertility. We report a case of vulvar SFT slowly growing for 10 years, and propose a strategy for the diagnosis and treatment of gynecological SFT. [ABSTRACT FROM AUTHOR]

Although yolk sac tumors (YSTs) are the second most common malignant germ cell tumor of the ovary, those arising from the omentum or pelvic peritoneum are extremely rare and have no established treatment guidelines. We report a case of a primary YST disseminated throughout the abdomen and associated with a high serum alpha-fetoprotein (AFP) elevation (441 611 ng/ml). Optimal cytoreduction was not achieved in order to preserve the patient's fertility and avoid adjacent organ injury. Residual tumor responded to adjuvant chemotherapy with a sharp decline in AFP levels, and confirmed remission was documented by serial 18F-fluorodexyglucose-positoron emission tomography and computerized tomography (FDG-PET/CT). In cases of advanced YST with unresectable residual disease, AFP levels combined with FDG-PET/CT scans may be a helpful way to monitor treatment response and assist in treatment planning for a disease that primarily affects young women who may desire to preserve fertility. [ABSTRACT FROM AUTHOR]

We here report a case of a 33-year-old woman who experienced secondary postpartum hemorrhage (PPH) due to uterine artery pseudoaneurysm rupture. She had intrauterine balloon tamponade for unexplained primary PPH after spontaneous vaginal delivery, and subsequent angiography showed no abnormal contrast extravasation. However, profuse vaginal bleeding occurred 22 days postpartum. Color Doppler ultrasonography demonstrated an anechoic mass with turbulent flow in the lower uterine segment, corresponding to uterine artery pseudoaneurysm. She was successfully treated with selective uterine arterial embolization. Decreased levels of von Willebrand factor and factor VIII led to the diagnosis of von Willebrand disease. When it is determined that a patient has unexplained PPH or uterine artery pseudoaneurysm, a high index of suspicion and further investigation for underlying bleeding disorders is warranted. [ABSTRACT FROM AUTHOR]

We present a rare case of alpha-fetoprotein (AFP) producing ovarian clear cell carcinoma. This is the first report of a clear cell ovarian carcinoma with hepatoid carcinoma arising from endometriosis. A 54-year-old menopausal woman had a primary ovarian carcinoma of International Federation of Gynecology and Obstetrics stage IIIc. Serum level of AFP was 4195 ng/mL. Histological examination revealed clear cell adenocarcinoma arising from endometriosis with hepatoid carcinoma. Metastatic liver and lymph node tumors were found after 25 months from the first surgery. However, the patient's serum AFP was within normal limits. The recurrent and metastatic tumors disappeared in response to combined liposomal doxorubicin and carboplatin chemotherapy. She has had a disease-free survival of 4 years. In conclusion, the patient had a clear cell ovarian carcinoma with hepatoid carcinoma arising clearly from endometriosis. The recurrent tumors did not show a component of hepatoid carcinoma. Therefore, it is possible to expect better survival with good sensitivity to chemotherapy. [ABSTRACT FROM AUTHOR]

Glassy cell carcinoma of the uterine cervix (GCC) is a rare form of cervical carcinoma that is characterized by aggressiveness and poor prognosis. We reviewed a variety of clinicopathological features, treatment strategies, and outcomes in three women with GCC. The three patients were successfully treated by radical hysterectomy with pelvic/para-aortic lymphadenectomy. The patients had stage Ib1, stage IIa, and stage Ib2 tumors without lymph node metastases. A 44-year-old woman with stage Ib1 tumor did not undergo adjuvant chemotherapy or radiation therapy. She had recurrent pelvic tumors 12 months after surgery, and died 6 months after the recurrent disease. The histological findings of her cervix, which were different from the other two patients, did not show the marked infiltration of eosinophils. The other two patients with stage Ib2 and IIa tumors underwent adjuvant chemotherapy with paclitaxel and carboplatin, and had disease-free survival for 4.5 and 9 years. We think that all patients with GCC of stage Ib1 or more should undergo adjuvant chemotherapy of paclitaxel and carboplatin or other adjuvant therapies. [ABSTRACT FROM AUTHOR]

Clinical guidelines for obstetrical practice were first published by the Japan Society of Obstetrics and Gynecology (JSOG) and the Japan Association of Obstetricians and Gynecologists (JAOG) in 2008, and a revised version was published in 2011. The aims of this publication include the determination of current standard care practices for pregnant women in Japan, the widespread use of standard care practices, the enhancement of safety in obstetrical practice, the reduction in burdens associated with medico-legal and medico-economical problems, and a better understanding between pregnant women and maternity-service providers. These guidelines include a total of 87 Clinical Questions followed by several Answers (CQ&A), a Discussion, a List of References, and some Tables and Figures covering common problems and questions encountered in obstetrical practice. Each answer with a recommendation level of A, B or C has been prepared based principally on 'evidence' or a consensus among Japanese obstetricians in situations where 'evidence' is weak or lacking. Answers with a recommendation level of A or B represent current standard care practices in Japan. All 87 CQ&A are presented herein to promote a better understanding of the current standard care practices for pregnant women in Japan. [ABSTRACT FROM AUTHOR]

Primary squamous cell carcinoma arising from the fallopian tube (SCCFT) is extremely rare with only six reported cases. We report a case of primary SCCFT accompanied by multifocal pyloric glandular metaplasia in the genital tract. An accompanying review of the literature describes the characteristics of this rare histological subtype invading into the muscular layer of the fallopian tube to involve adjacent pelvic organs, while the most common serous type tends to spread into the abdominal cavity through tubal ducts. Due to the low response rate of adjuvant therapies, the 5-year survival rate of patients bearing primary SCCFT at stage II-IV is very poor, only accounting for 25%. All patients were alive without disease where optimal resection had been successfully achieved. These findings imply that radical tumor resection is mandatory for satisfactory treatment of primary SCCFT. [ABSTRACT FROM AUTHOR]

Amniotic fluid embolisms (AFE) are one of the most fatal complications of pregnancy. We describe a case of AFE that occurred 2 h after vaginal delivery at 41 weeks of gestation. The diagnosis of AFE was made by symptoms of dyspnea, coagulopathy, and severe hypotension. ZnCP-1, the characteristic component of meconium, was elevated in the serum. Cardiac compressions after repeated cardiac arrests were required during the initial 2 h of resuscitation. Primary resuscitation was performed with airway management and aggressive fluid management, including infusion of 33 units of red cell concentrates and 57 units of fresh frozen plasma. The patient recovered without any aftereffects. This case report warrants that AFE should be considered when coagulopathy and dyspnea are observed during the postpartum period. [ABSTRACT FROM AUTHOR]

Cases of retained products of conception (RPOC) with marked vascularity present a clinical challenge because simple dilation and curettage (D&C) can lead to life-threatening hemorrhage. We describe here two cases of hypervascular RPOC that were successfully managed with two different approaches. Case 1: A 26-year-old woman with history of 3 D&Cs was transported to the emergency room for heavy vaginal bleeding 45 days after a spontaneous abortion. Diagnosis of RPOC with aneurysm-like structure was considered and uterine artery embolization was performed. Four days after the uterine artery embolization, reduction of the vascularity of RPOC was confirmed on color Doppler ultrasonography and D&C was successfully carried out. Case 2: A 37-year-old woman with history of one cesarean section became pregnant after the regular menses. She underwent D&C for missed abortion at 8 weeks' gestation. Seven days after the D&C, sonographically heterogenous mass emerged in the vicinity of the previous cesarean scar. Thereafter, the mass gradually grew larger and diagnosis of hypervascular placental polyp was considered. As the amount of vaginal bleeding was small, expectant management was instituted. Sixty-one days after the first D&C, reduction of the vascularity of RPOC was confirmed on color Doppler ultrasonography and D&C was successfully completed. [ABSTRACT FROM AUTHOR]

Several reports have documented adenocarcinoma arising from endometriotic implants within cesarean section (C-S) scars on the serosal surface of the uterus; however, endometrial cancer invading the C-S scar from the uterine cavity has not been described. We report a case of a grade 1 endometrioid adenocarcinoma 'drop' lesion invading a previous C-S scar with resultant cervical stromal invasion. Using both MR images and a thorough review of the pathology, the tumor at the C-S scar was determined to be an implant derived from a primary lesion at the uterine fundus. With increases in the incidence of both endometrial cancer and births by C-S, it is likely we will encounter more cases of iatrogenic implants of endometrial cancers in C-S scars. [ABSTRACT FROM AUTHOR]

Middle cerebral artery-peak systolic velocity (MCA-PSV) has been reported to predict fetal anemia with similar accuracy as amniotic ΔOD450 assay. Alloimmunized dizygotic twin pregnancy allows us to compare anemic and non-anemic twins in the same intrauterine environment. We herein present a case of Rh (E)-incompatible dizygotic twin pregnancy, where MCA-PSV could precisely detect the anemia in one of the twins. A 36-year-old woman, whose previous child required exchange transfusion due to hemolytic anemia of newborn (HFDN), conceived twins after in vitro fertilization-embryo transfer. At 24 weeks' gestation, MCA-PSV of twin A and twin B were 23.9 cm/s (0.8 multiples of median; MoM) and 30.7 cm/s (1.0 MoM), respectively. At 31 weeks' gestation, MCA-PSV values of both twins were sharply elevated to nearly 1.4 MoM. Thereafter, MCA-PSV of twin A fell to 1.0 MoM, whereas MCA-PSV of twin B exceeded 1.5 MoM at 34 weeks' gestation. Development of fetal anemia was suspected and emergency cesarean section was performed. Twin B showed moderate anemia with positive direct Coombs' test and was diagnosed as HFDN due to anti-E alloimmunization. Twin B required phototherapy and red cell transfusion, but exchange transfusion was safely obviated. [ABSTRACT FROM AUTHOR]

Aim: Prolongation of pregnancy in cases of fetal membrane prolapse into the vagina during the second trimester is difficult using conservative therapy. After pushing the membranes back into the cervix, emergency cervical cerclage may be advantageous in improving the neonatal outcome. We have been managing membrane repositioning and emergency cervical cerclage with a technique using a rubber balloon device (known as a ‘ mini metreu’ in Japan), and we examined the efficacy of this technique in five cases. Methods: Our management was as follows: Initially, the full bladder technique was attempted under general anesthesia. If this was not effective, amnioreduction was performed by transabdominal amniocentesis. After the membrane repositioning using a mini metreu, double suture cervical cerclage (McDonald method + Shirodkar method) was performed. Results: The diameter of the bulging prolapsed membranes ranged from 30–84 mm, with a mean of 52 mm. Cerclage was successfully performed in all of the five cases. Prolongation of the pregnancy period was from 22–107 days (average; 77.6 ± 28.9 days). In cases 1–4, healthy newborns were delivered, but in case 5 sudden intrauterine fetal death due to umbilical cord complications occurred at 24 weeks of gestation. Conclusion: It appears that long-term prolongation of pregnancy is possible, when performing membrane repositioning using the mini metreu and emergency cervical cerclage for fetal membrane prolapse into the vagina. [ABSTRACT FROM AUTHOR]

Ovarian leiomyoma is a rare tumor. Ovarian leiomyoma accompanied with Meigs’ syndrome is extremely rare. We report a case of ovarian leiomyoma presenting with Meigs’ syndrome, which was first noted as dyspnea in a 79-year-old woman. A whole-body examination revealed a solid mass of the ovary, accumulation of ascites and pleural effusion, and elevated serum carbohydrate antigen 125. Abdominal hysterectomy and salpingo-oophorectomy were carried out. After the surgery, ascites and pleural effusion disappeared. The pathological diagnosis of the removed tumor was leiomyoma of the left ovary. The patient has been healthy for 24 months after the surgery, with no signs of recurrence. We also review the literature on this disease and the clinicopathologic characteristics of the current case are discussed. [ABSTRACT FROM AUTHOR]

There have been no previous reports of human placentas mimicking the cotyledonary placenta of ruminants. We report a case of cotyledonary-like placenta associated with severe intrauterine growth restriction. A woman pregnant for the first time was referred to our hospital at 27 weeks’ gestation because of severe intrauterine growth restriction. Characteristics of the placenta in the patient were examined by ultrasonographical and histopathological techniques. Ultrasonography revealed that a hypo-echoic area intermingled with small segmented tissues in the placenta. The hypo-echoic area changed in size and shape according to uterine contractions. At 31 weeks’ gestation, a caesarean section was performed because of non-reassuring fetal status. A female baby weighing 814 g was delivered. The placenta, which weighed 260 g, contained several long stem villi running over a distance of 6 to 7 cm without branching into intermediate or terminal villi. Small villous tissues had developed only at the tips of these stem villi. The present case shows an extraordinarily abnormal development of the villous trees in the placenta, which may have caused fetal IUGR and non-reassuring fetal status. [ABSTRACT FROM AUTHOR]

We report a rare case of a complete hydatidiform mole with two or more coexisting fetuses where both infants survived without complications. A male infant weighing 1258 g and a female infant weighing 880 g were delivered without complications and discharged 95 days after the birth. The analysis of DNA microsatellite polymorphisms indicated that the mole was of paternal origin and probably homozygous. The mother suffered from multiple pulmonary metastasis of the hydatidiform mole which was detected 3 days after the surgery and was successfully treated with methotrexate. A complete hydatidiform mole with two or more coexisting fetuses produces a dilemma between immediate termination and pregnancy continuation. Although the present case resulted in a favorable outcome, a review of the 14 reported cases suggests that the high fetal loss rate (90%) must be a consideration in the decision regarding management of such a pregnancy. [ABSTRACT FROM AUTHOR]

Soluble fms-like tyrosine kinase-1 (sFlt1), a circulating vascular endothelial growth factor receptor 1 antagonist, is associated with the pathogenesis of pre-eclampsia. Extracorporeal removal of sFlt1 (sFlt1 apheresis) is emerging as a treatment for pre-eclampsia. We performed sFlt1 apheresis for a patient with very early onset pre-eclampsia, beginning at 15 weeks' gestation. She underwent sFlt1 apheresis 13 times from 19 to 23 weeks' gestation. The series of treatments lowered circulating sFlt1, stabilized blood pressure, reduced urinary protein, and preserved renal function, which contributed to a successful prolongation of pregnancy for 4 weeks and a live birth at 23+3 weeks' gestation. Further studies are necessary for clinical application of sFlt1 apheresis as sFlt1 might have a protective function for the placenta and fetus in pre-eclampsia. [ABSTRACT FROM AUTHOR]

Remarkable leukocytosis with obscure abdominal pain during pregnancy is clinically challenging for obstetricians. A 31-year-old pregnant woman developed persistently elevated white blood cell (approximately 30 000/µL) and C-reactive protein (3.0 mg/dL) with occasional moderate abdominal pain. At 29 gestational weeks, she underwent emergency cesarean section due to suspected abruptio placentae. Hemoperitoneum was observed with extensive hemorrhagic nodules on the peritoneal and omental surfaces. White blood cells rose 87 200/µL, and C-reactive protein peaked at 44.9 mg/dL after surgery. Pathologically, biopsies showed deciduosis, and decidual cells on the omental surface showed immunohistochemical staining for granulocyte colony-stimulating factor (G-CSF). Serum G-CSF concentration was 339 pg/mL at 28 weeks, and that of ascites was 312 000 pg/mL at cesarean section. G-CSF-producing deciduosis can induce leukocytosis as well as abdominal pain during pregnancy and postpartum. [ABSTRACT FROM AUTHOR]

A response by Yukiyasu Sato, Hiroshi Fujiwara, and Ikuo Konishi to a letter to the editor regarding their article "Management of retained products of conception with marked vascularity," in the 2011 issue is presented.