Search

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

Not all obstetric care facilities offer sufficient genetic counseling in Japan. When necessary, patients are referred to tertiary perinatal care centers for genetic counseling and further testing. Because each facility typically has an exclusive contract with a laboratory, the additional testing required may be performed at a different laboratory. With no reporting standards for normal chromosomal variants, differences between laboratories impede result interpretation, and clinical errors may occur. We present a case of a patient diagnosed with 46,XX,?dup (4)(p12p12) variant over two pregnancies. During the first pregnancy, the variant was determined to be a de novo, leading the parents to terminate the pregnancy. During the second pregnancy, further analysis revealed no 4p duplication, and we diagnosed as a normal variant, 4cenh+, inherited from the mother. Differences in reporting standards for a normal variant made evaluation of this patient difficult. Medical staff should be aware of this issue, and reporting standards should be standardized. [ABSTRACT FROM AUTHOR]

Aim: Perinatal group A streptococcal infection is a rare but life‐threatening condition. Few reports have focused on its clinical characteristics and how to prevent deterioration. We report our experience with two antenatal fatal cases and reviewed 96 cases in the literature to assess the clinical characteristics of group A streptococcal infection. Methods: English‐language clinical reports of antenatal and postnatal group A streptococcal infection in 1974–2019 were retrieved and examined. Relationships between clinical characteristics and maternal outcomes were assessed. Results: Univariate analysis revealed that antenatal group A streptococcal infection was significantly associated with an age of ≤19 or ≥ 35 years, cesarean section, sore throat as an initial symptom, positive throat culture, maternal death and fetal death. Multivariate analysis revealed that antenatal onset (odds ratio = 7.922, 95% confidence interval = 1.297–48.374; P = 0.025) and a quick sepsis‐related organ‐failure assessment score (qSOFA; low blood pressure, high respiratory rate or altered mental status) of ≥2 (odds ratio = 6.166, 95% confidence interval = 1.066–35.670; P = 0.042) were significantly related to maternal death. Conclusion: Per our findings, antenatal group A streptococcal infection was significantly associated with maternal and fetal death. Further, the antenatal infection was revealed as a more critical risk factor. We suggest that the presence of any sign related to the qSOFA is a potential clue suspecting perinatal group A streptococcal infection in primary obstetric facilities. [ABSTRACT FROM AUTHOR]

Aim: The high rate of stored preoperative autologous blood wastage is concerning. This study analyzed patients who provided preoperative autologous blood donations (PABDs) for massive bleeding during surgery for placenta previas and low‐lying placentas, and investigated the optimal PABD storage volume required to avoid allogeneic transfusion. Methods: Of 386 patients who provided PABDs at our hospital from 2008 to 2013, 269 patients with placenta previas or low‐lying placentas were retrospectively analyzed. The PABD storage volumes were stratified into four groups based on the amounts stored, and the allogeneic transfusion usage frequencies were compared. Results: A total of 124 patients (46.1%) received PABDs and 12 patients (4.5%) received allogeneic transfusions. The average PABD volume wasted was 23 940 mL/year. The allogeneic transfusion utilization rate was significantly higher in the 1‐ to 300‐mL group (17.2%) than in the 301‐ to 600‐mL (1.69%), 601‐ to 900‐mL (3.82%), and 901‐ to 1200‐mL (0%) groups (P < 0.05). The PABD cut‐off volume for avoiding allogeneic blood transfusion was 300 mL, and the odds ratio for ≤300‐mL PABD in a multivariate analysis was 14.3 (95% confidence interval 1.3–149.3; P = 0.03). The maximum surgical blood order schedule was 2.16 units (432 mL), and the surgical blood order equation was 2.15 units (430 mL). Conclusion: The allogeneic transfusion utilization rate did not differ between the 600‐mL group and the groups with higher PABD storage volumes; hence, storing 600 mL of PABD was appropriate for surgery for placenta previas and low‐lying placentas. [ABSTRACT FROM AUTHOR]

Aim: In cases of critical obstetric hemorrhage leading to extreme hypofibrinogenemia, fibrinogen is the marker that indicates the critical severity, and early fibrinogen supplementation centering on hemostatic resuscitation is a vital treatment to stabilize a catastrophic condition. In this review, we investigated the effect of fibrinogen level on hemostasis and what we can do to treat hypofibrinogenemia efficiently and improve patients' outcome. Methods: We reviewed numerous articles related to hypofibrinogenemia in critical obstetric hemorrhage. Especially, we performed a systematic review on target value of fibrinogen for hemostasis and effectiveness of fibrinogen concentrate. We also reviewed the articles about the methods for early normalization of fibrinogen level such as tranexamic acid, massive transfusion protocol, and point‐of‐care testing. Results: The target value of fibrinogen calculated by needs for massive transfusion was 200 mg/dL or 10 mm of A5FIBTEM. Although fibrinogen concentrate worked poorly on fibrinogen levels within the normal range, it improved the blood fibrinogen levels rapidly when it was administered to critical obstetric hemorrhage patients with serious hypofibrinogenemia. Hence, the volume of FFP transfused could be reduced along with a reduction in the frequency of pulmonary edema due to volume overload. Conclusion: The patient group for which fibrinogen concentrate works most effectively is cases with severe hypofibrinogenemia. Further research is required in the light of evidence. The essence of the transfusion algorithm in critical obstetric hemorrhage is to approach the target value for obtaining hemostasis, ensure an accurate and prompt grasp of the severity using point‐of‐care testing, introduce a massive transfusion protocol and use tranexamic acid. [ABSTRACT FROM AUTHOR]

Abstract: Aim: To examine the rates of medical malpractice and cerebral palsy after vacuum delivery in comparison with forceps delivery and establish approaches for enabling safe vacuum delivery from the perspective of forceps delivery. Methods: This study reviewed the Japan Obstetric Compensation System report data, which contains data from studies involving 188 cases through May 2013, including cases of emergency delivery. These cases included 118 cases of cesarean section (62.8%) and 70 cases of vaginal delivery (37.2%). Of the 188 patients, 145 required emergency delivery (77.1%), of which cesarean sections were performed in 117 patients (80.7%), vacuum delivery in 24 patients (16.6%) and forceps delivery in 4 patients (2.8%). Results: In evaluating the contents of the report with a focus on vacuum delivery, it was found that vacuum delivery was attempted in 35 patients, and delivery was successful in 24 of these patients (68.6%); however, in 11 patients (31.4%), delivery was unsuccessful and cesarean section was required. Thus, vacuum delivery was unsuccessful in approximately one third of the cases. Conclusion: For delivery to be completed as successfully and quickly as possible, it is essential for obstetricians to have a good understanding of the process of vacuum delivery, and to have expertise in the relevant techniques. However, it is also necessary to modify the indications under which vacuum delivery is considered safe to perform, from fetal station ±0, that is, engagement of the fetal head, to station +2, or descent of the fetal head. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Umbilical cord ulceration (UCU) is a disease in which an ulcer forms in the umbilical cord in the pregnant uterus and is accompanied by hemorrhaging from the same site. UCU occurs in fetuses with congenital upper‐intestinal atresia (CUIA); however, its onset mechanism remains unclear. Here, we report our investigation of cases of UCU in our hospital. Methods: Among the 9825 deliveries performed between 2007 and 2016 at this hospital, 20 fetuses were diagnosed with CUIA, 4 (20%) of which had UCU. There was no difference in the backgrounds of the fetuses with UCU (UCU group: 4 fetuses) and those without (non‐UCU group: 16 fetuses). Results: There was no intergroup difference in gestational age at delivery. Four cases in the UCU group had maternal age 35 weeks (26–39), weeks of delivery 35 weeks (35–36) and weight 2178.5 g (1600–2640); three out of four fetuses were female; and the location of gastrointestinal obstruction was in the duodenum in one case and in the jejunum in three cases. Death occurred in three of four fetuses in the UCU group versus none in the non‐UCU group. Conclusion: We performed a retrospective statistical investigation on the risk of UCU onset in cases from this hospital; however, we could not identify any prognostic factors for its onset. We investigated a total of 27 past reported UCU cases and the 4 cases in this study. Mean gestational age at onset was 33.3 ± 2.7 for all 27 cases. Various methods for the early discovery of UCU have been reported in the past; however, there is currently no gold standard. Based on this report and a review of past papers, for CUIA, it is desirable to perform in‐hospital management from gestational week 30 onward and decide proper delivery timing on a case‐by‐case basis. [ABSTRACT FROM AUTHOR]

Abstract: Aims: We investigated whether common iliac artery balloon occlusion (CIABO) was effective for decreasing blood loss during cesarean hysterectomy (CH) in patients with placenta previa with accreta and was safe for mothers and fetuses. Methods: Of the 67 patients who underwent CH for placenta previa with accreta at our facility from 1985 to 2014, 57 patients were eligible for the study. The amount of intraoperative bleeding during CH was compared between three groups: surgery without blood flow occlusion (13 patients), internal iliac artery ligation (15 patients) and CIABO (29 patients). Additionally, multivariate analysis was performed to assess risk factors for massive bleeding during CH. Results: The mean blood loss in the CIABO group (2027 ± 1638 mL) was significantly lower than in the other two groups (3787 ± 2936 mL in the no occlusion, 4175 ± 1921 mL in the internal iliac artery ligation group; P < 0.05). Multivariate analysis showed that spontaneous placental detachment during surgery (odds ratio [OR] 49.174, 95% confidence interval [CI] 4.98–1763.67), a history of ≥ 2 cesarean sections (OR 9.226, 95% CI 1.07–231.15) and no use of CIABO (OR 26.403, 95% CI 3.20–645.17) were significantly related to massive bleeding during surgery. There was no case of necrosis resulting from ischemia. The mean radiation dose during balloon placement never exceeded the threshold value for fetal exposure. Conclusion: Bleeding during CH for placenta previa with accreta can be decreased by CIABO. This study also confirmed the safety of CIABO in regard to maternal lower limb ischemia and fetal radiation exposure during balloon placement. [ABSTRACT FROM AUTHOR]

Abstract: Edwardsiella tarda (E. tarda) is a rare pathogen in humans, especially during the peripartum period. Only a few cases of fatal neonatal infection with E. tarda have been reported. Herein, we describe a case of maternal septicemia caused by E. tarda following peripartum chorioamnionitis. The mother developed septic shock, disseminated intravascular coagulation and a post‐cesarean wound hematoma with abscess. Her condition improved with multidisciplinary therapy including blood transfusion, antimicrobial agents, recombinant thrombomodulin and surgical debridement. E. tarda was isolated from the maternal blood, cesarean wound and neonatal skin, pharynx and gastric fluid. This case demonstrates that peripartum infection with E. tarda is a rare but life‐threatening condition, not only for the neonate but also for the mother. [ABSTRACT FROM AUTHOR]

Aim Appropriate screening and plasma glucose control is important during pregnancy, but an international consensus has not been reached regarding the recommended method of screening and diagnosis of gestational diabetes mellitus (GDM). We investigated glucose intolerance in pregnant women diagnosed with GDM, applying stricter screening criteria. Methods The study involved 452 women with singleton pregnancies, who underwent a 2 h 75 g oral glucose tolerance test between January 2006 and December 2010. They had previously been screened for GDM using Japan Society of Obstetrics and Gynecology (JSOG) criteria. We retrospectively re-evaluated their status using International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria. The major differences between JSOG and IADPSG criteria are the number of applicable threshold values, and the threshold value for fasting glucose measured by the glucose tolerance test. The insulinogenic index and insulin resistance according to the homeostasis model assessment were compared among groups in the presence or absence of obesity. Results GDM was diagnosed in 56 (1.07%) and 133 (2.54%) women based on the JSOG and IADPSG criteria, respectively. Compared to non-GDM, non-obese women, those diagnosed with GDM according to IADPSG criteria had significantly higher insulin resistance, while those diagnosed with GDM exceeding two or more threshold values had significantly lower insulinogenic indexes. Conclusion Adopting stricter diagnostic criteria increased the prevalence of GDM 2.37-fold, as women previously diagnosed with milder abnormalities in glucose levels were then diagnosed as having GDM. [ABSTRACT FROM AUTHOR]

Aim Placental abruption is a severe obstetric complication of pregnancy that can cause disseminated intravascular coagulation and progress to massive post-partum hemorrhage. Coagulation disorder due to extreme consumption of fibrinogen is considered the main pathogenesis of disseminated intravascular coagulation in patients with placental abruption. The present study sought to determine if the pre-delivery fibrinogen level could predict adverse maternal or neonatal outcomes in patients with placental abruption. Methods This retrospective medical chart review was conducted in a center for maternal, fetal, and neonatal medicine in Japan with 61 patients with placental abruption. Fibrinogen levels prior to delivery were collected and evaluated for the prediction of maternal and neonatal outcomes. The main outcome measures for maternal outcomes were disseminated intravascular coagulation and hemorrhage, and the main outcome measures for neonatal outcomes were Apgar score at 5 min, umbilical artery pH, and stillbirth. Results The receiver-operator curve and multivariate logistic regression analyses indicated that fibrinogen significantly predicted overt disseminated intravascular coagulation and the requirement of ≥6 red blood cell units, ≥10 fresh frozen plasma units, and ≥20 fresh frozen plasma units for transfusion. Moderate hemorrhage occurred in 71.5% of patients with a decrease in fibrinogen levels to 155 mg/dL. Fibrinogen could also predict neonatal outcomes. Umbilical artery pH < 7.00 occurred in 77.1% of patients with a decrease in fibrinogen levels to ≤ 250 mg/dL. Conclusion Pre-delivery fibrinogen can predict adverse maternal as well as neonatal outcomes with placental abruption. © 2016 Japan Society of Obstetrics and Gynecology [ABSTRACT FROM AUTHOR]

Aim The aim of this study was to evaluate the efficacy and safety of cell-free concentrated ascites reinfusion therapy (CART) on a large amount of ascites. Material and Methods Fifty-eight CART procedures were performed in nine patients with ovarian, endometrial, or cervical cancer from February 2013 to September 2014. The medical records were retrospectively reviewed for the amount of collected ascites, vital signs, and laboratory results before and after CART. Results No obvious change in the plasma protein and plasma albumin concentration was found after CART for < 5 L of ascites; however, obvious increases in both were observed in CART for ≥ 5 L of ascites ( P < 0.001). The optimum cut-off value for obtaining a positive variant of plasma protein and plasma albumin after CART was 7.9 L. CART for ≥ 5 L of ascites did not increase the risk of transient water retention in the body (odds ratio = 2.2; 95% confidence interval: 0.35-13.83; P = 0.38); however, CART for ≥ 7.9 L of ascites increased the risk of water retention (odds ratio = 8.4; 95% confidence interval: 1.91-44.09; P = 0.004). The optimal cut-off value of ascites for predicting water retention due to CART was 9.2 L. Conclusion Massive ascites collection in CART < 9.2 L appears to be a safe and effective treatment for improving general condition, plasma protein, and electrolytes in gynecologic cancer patients. [ABSTRACT FROM AUTHOR]

Aim Massive obstetric hemorrhage ( MOH) requires prompt transfusion of red blood cells and coagulation factors. Because MOH has a diverse pathogenesis, the shock index ( SI) alone may be insufficient for determining blood transfusion. Here, we retrospectively analyzed patients with MOH to determine usefulness of the indicators of shock including the SI in evaluating the need for blood transfusion. Methods We reviewed records of 80 emergency referral patients who had received blood transfusions at our department between 1 January 2009 and 31 July 2011. The shock indicators for blood transfusion are estimated blood loss, fibrinogen level, hemoglobin concentration, the Japan Society of Obstetrics and Gynecology disseminated intravascular coagulation ( JSOG DIC) score and the SI. The strength of the correlation of each shock indicator with the transfusion volume was ranked using Spearman's rank correlation coefficient-ρ and multivariate analysis. Results Although the SI showed significant positive correlation with blood transfusion volume for red blood cell concentrate ( RCC) and fresh frozen plasma ( FFP) in patients with dilutional coagulopathy, a stronger correlation was seen with the fibrinogen level and JSOG DIC score. In patients with consumptive coagulopathy, the strongest correlation was seen between RCC transfusion volume and fibrinogen level, and between FFP transfusion volume and JSOG DIC score followed by fibrinogen level. In multivariate analysis, only fibrinogen level was significantly associated with both RCC and FFP massive transfusion. Conclusion Because MOH has a diverse pathogenesis, various indicators should be evaluated. Among shock indicators, fibrinogen level was the best indicator of the need for blood transfusion following MOH. [ABSTRACT FROM AUTHOR]

Aim We examined the post-partum recovery course in patients with pre-eclampsia ( PE) and gestational hypertension ( GH) and evaluated the associated factors. Methods In a retrospective review of 145 patients with GH or PE who gave birth between 1 January 2008 and 30 October 2011 at our institution, there were 125 PE and 20 GH cases. Data collected included the gestational age at initial examination and delivery, delivery mode, time for normalization of blood pressure ( BP), and time until resolution of proteinuria in PE patients. Comparisons were made between singleton and multiple pregnancies, onset (early, <32 weeks; late, ≥32 weeks) and fetal growth restriction in singleton pregnancies. Results The mean interval for normalization of BP was 41.8 ± 29.4 days (median, 31.5). The mean interval for resolution of proteinuria was 30.0 ± 39.6 days (median, 27.0). Ninety percent of patients required 77 and 60 days to recover from hypertension and proteinuria, respectively. The time for BP normalization was longer in the early-onset group. The time for resolution of proteinuria was not affected by any factor examined. Conclusion A post-partum observation period of 12 weeks is acceptable for differentiating PE and GH from chronic hypertension or renal disease. GH severity did not affect the recovery period, but proteinuria severity did. Onset time was a factor influencing the recovery from PE and GH. [ABSTRACT FROM AUTHOR]

Aim We investigated the neonatal outcome in chronically hypertensive patients with controlled hypertension, uncontrollable hypertension, or superimposed pre-eclampsia. Material and Methods The study included 120 patients who had chronic hypertension and were divided into three groups for which the perinatal and neonatal outcomes were retrospectively compared: pre-eclampsia superimposed on chronic hypertension ( SP: n = 28), chronic hypertension with severe hypertension uncontrolled in spite of intravenous or multiple oral antihypertensive medications in the latter half of pregnancy ( uCH: n = 44), and chronic hypertension with controlled to mild hypertension with or without medication ( cCH: n = 48). Results Preterm birth rate incidence was significantly higher in the SP and uCH groups than in the cCH group ( P < 0.05 for both). The incidence rates of low birthweight, very low birthweight, and extremely low birthweight for the groups were as follows: SP > uCH > cCH. Admission to the neonatal intensive care unit was significantly higher in the uCH and SP groups than in the cCH group ( P < 0.05 for both). Conclusion Like superimposed pre-eclampsia, uncontrolled chronic severe hypertension during late pregnancy results in a poorer neonatal outcome than controlled chronic mild hypertension. We conclude that absolute blood pressure can be used as a predictor of clinical outcome in pregnant chronic hypertension patients. [ABSTRACT FROM AUTHOR]

Aim: Our purpose was to evaluate the effect of internal iliac ligation as a bleeding control during cesarean hysterectomy for placenta accreta. Methods: We retrospectively reviewed the cases of placenta accreta receiving cesarean hysterectomy during the period of 1987–2006 in the Saitama Medical Center. The clinical outcomes of these patients either receiving or not receiving internal iliac artery ligation were compared in terms of bleeding amount, and length of hospitalization. The bleeding amounts in the variants of placenta accreta managed with internal iliac artery ligation were also analyzed to determine whether the different pathological findings would affect blood loss during cesarean hysterectomy. Results: Among 23 cases, the mean blood loss during the operation and the length of hospitalization after the operation, with or without internal iliac artery ligation (IIAL) were not significantly different. There was no significant difference between the mean blood loss and the pathological findings of cases managed with IIAL. Conclusion: In cases of placenta previa accreta, ligation of the internal iliac artery did not significantly contribute to hemostasis during cesarean hysterectomy. [ABSTRACT FROM AUTHOR]

Objective: In pre-eclampsia, fetal growth restriction is frequently observed, and the possible involvement of inhibitory substances on trophoblast cell proliferation and differentiation has been suggested. The objective of this study was to investigate the effects humoral factors, such as cytokines, produced in immune cells on proliferation of an immortalized trophoblastic cell line (TCL) that we established. Methods: Serum and lymphocyte layers were isolated from the blood of normal pregnant and preeclamptic women. The lymphocyte layer was further fractionated into different immune cell populations by the Stem Sep method. Immortalized trophoblastic cells were cultured with the sera diluted. The cytokine concentrations in the supernatants of lymphocyte cultures were compared between normal pregnancy and pre-eclampsia. The number, DNA content and induced apoptosis were examined on the immortalized trophoblastic cells at the end of culture. Results: The sera from preeclamptic women significantly inhibited the immortalized trophoblastic cell proliferation in comparison with those from normal pregnancy. Among the lymphocyte fractions, monocytes significantly inhibited the immortalized trophoblastic cell proliferation. The monocytes from preeclamptic women were found to produce higher levels of tumor necrosis factor-α (TNF-α) in the culture supernatant than those from normal pregnant women. The coculture with the monocytes from preeclamptic women increased the frequency of TUNEL-positive TCL cells. TNF-α inhibited immortalized trophoblastic cell proliferation in a dose-dependent manner and induced apoptosis. Conclusion: The present results suggest that monocytes are activated and that cytokines, such as TNF-α, which is produced by monocytes, induce apoptosis and inhibit proliferation of trophoblast cells in pre-eclampsia. [ABSTRACT FROM AUTHOR]

The article offers information on the Obstetrical hemorrhage which is more likely to produce exacerbation of systemic conditions than hemorrhage in general surgery and is often being complicated by obstetrical disseminated intravascular coagulation (DIC). It mentions that treatment with fluid and a red blood cell transfusion leads to a dilutional decrease in coagulation factors and exacerbates hemorrhagic diathesis associated with DIC. It states that need for focusing on abnormal vital signs.