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This retrospective study aims to compare the early manual removal of placenta (MROP) and conservative management of retained products of conception (RPOC) after 34 weeks of gestation. Nineteen cases underwent MROP within 24 h of delivery, of which nine patients had no symptoms requiring emergent treatment. These 9 patients (group M) were compared with 22 patients who were treated conservatively (group C). Massive bleeding was observed in 5 (56%) patients in group M and 11 (50%) patients in group C, with no significant difference in frequency. However, the lowest hemoglobin level within 72 h after massive bleeding was lower in group M (median: 6.7 vs. 7.7 g/dL, p = 0.029), suggesting that massive bleeding occurred in a short period of time. On the other hand, a retained placenta was observed in four patients in group M after the MROP; however, the placenta disappeared more quickly than in group C (median; 1.0 vs. 99.0 days, p = 0.009). In group C, all bleeding and infection occurred within 60 days of delivery, including heavy bleeding in six cases during the placental-extraction trial. Human chorionic gonadotropin in group C fell below the measurable threshold at a median of 67 days postpartum. In conclusion, for RPOC without urgent symptoms, early MROP and conservative treatment have their advantages and disadvantages. Randomized controlled trials are needed to determine which of those treatments is superior. [ABSTRACT FROM AUTHOR]

Aim: In postpartum women, retained placenta is diagnosed in the absence of signs of placental separation and expulsion, and requires manual removal of the placenta (MROP). MROP may lead to massive hemorrhage, hemodynamic instability, and the need for emergency interventions including blood transfusion, interventional radiology, and hysterectomy. In this study, we aimed to identify the risk factors for retained placenta requiring MROP after vaginal delivery and postpartum hemorrhage (PPH) following MROP. Methods: A multicenter retrospective study was performed using data from women who delivered at term between 2010 and 2018 at 13 facilities in Japan. Of 36 454 eligible women, 112 women who required MROP were identified. Multivariate logistic regression analyses were conducted to evaluate the risk factors for retained placenta and PPH following MROP. Results: A history of abortion, assisted reproductive technology (ART), instrumental delivery, and delivery of small‐for‐gestational‐age infant were independent risk factors for MROP (adjusted odds ratios [95% confidence intervals]: 1.93 [1.28–2.92], 8.41 [5.43–13.05], 1.80 [1.14–2.82], and 4.32 [1.97–9.48], respectively). ART was identified as an independent risk factor for PPH (adjusted odds ratio [95% confidence interval]: 6.67 [2.42–18.36]) in patients who underwent MROP. Conclusion: ART pregnancies significantly increased the risk of retained placenta requiring MROP and PPH. Our results suggest that clinicians need consider patient transfer to a higher‐level facility and preparation of sufficient blood products before initiating MROP in cases of ART pregnancies. Our study may assist in identifying high‐risk women for PPH before MROP and in guiding treatment decisions, especially in facilities without a blood bank. [ABSTRACT FROM AUTHOR]

Bacterial placentitis in horses commonly results in abortion, premature birth or compromised neonatal foal health. Although mycobacterial infections are generally uncommon in horses, 10 equine abortion cases caused by Mycobacterium avium subsp. hominissuis (MAH) infections occurred between 2018 and 2019 in Japan. They occurred on seven Thoroughbred horse farms in the Hidaka district of Hokkaido, but direct contact among the mares on different farms was not recorded. Most cases were characterized by extensive pathological lesions of the placenta, which are not typical in cases of common pathogenic bacteria such as Streptococcus zooepidemicus and Escherichia coli. All abortions featured white–yellow exudates on the surface of the placenta. Mycobacterial granuloma formations were histologically found in the placenta and fetal organs, and acid‐fast bacteria were isolated from the placenta, fetal samples (heart, lung, liver, kidney, spleen and stomach contents) or uterine lavage fluid. The greatest number of bacteria was isolated from necrotic lesions on the placenta, which could be an important site for bacterial isolation in mycobacterial equine abortions. The isolates were identified as MAH based on internal genome sequences. In variable number tandem repeat analysis, all patterns of the strains were identical. Single nucleotide polymorphism analysis of the core genome grouped all strains in the II‐a/SC3 subcluster. Both results reveal that these strains share the same genetic background, suggesting that the horses had been infected by the same unknown contagious source. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to evaluate the clinical features and pregnancy outcomes of placental mesenchymal dysplasia (PMD) in Japan. Methods: We requested detailed clinical information and placental tissue of PMD cases in 2000–2018 from Japanese facilities with departments of obstetrics and gynecology and analyzed the pregnancy course and neonatal outcomes. Results: We collected 49 cases of PMD. Of 18 patients with measured maternal serum alpha‐fetoprotein (MSAFP) levels, 15 (83.3%) had elevated levels. Maternal serum human chorionic gonadotropin (MShCG) levels were transiently elevated in five (17.8%) of 28 patients. Forty‐seven patients continued their pregnancies. All pregnancies were singleton and 40 (85.1%) were associated with adverse events including fetal growth restriction (FGR), threatened premature delivery, fetal demise, and hypertensive disorder of pregnancy in 34 (72.3%), 14 (29.8%), eight (17.0%), and six (12.8%) patients, respectively. Of 47 infants, there were eight stillbirths. There were 40 (85.1%) female infants, and eight (17.0%) had Beckwith–Wiedemann syndrome. Of 39 live births, 23 (59.0%) were associated with premature induction of labor or cesarean section for obstetric indications related to FGR. Eighteen (46.2%) neonates had complications. PMD‐affected placentas were pathologically heterogeneous in both grossly PMD‐affected and non‐affected areas. Conclusions: Our study included the largest number of PMD cases with detailed clinical information. PMD is a high‐risk condition for both the mother and the child. Elevated MSAFP levels with normal MShCG levels indicate PMD. Conventional perinatal management of FGR in Japan might be effective in reducing the fetal mortality rate. [ABSTRACT FROM AUTHOR]

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

Objective: To investigate maternal outcomes after leaving the placenta in situ for placenta accreta spectrum (PAS) disorders in patients with placenta previa on a cesarean delivery scar.Methods: The present retrospective study reviewed medical records from women with placenta previa on a cesarean scar underwent perinatal care at secondary- or tertiary-level perinatal centers in Japan between January 1, 2010, and December 31, 2014. Perinatal management was conducted based on each leading obstetrician's discretion. The primary outcome was success of the leaving the placenta in situ approach for PAS disorders (defined as preserving the uterus without hysterectomy).Results: Of 178 eligible centers, 126 (71%) participated in this study; data from 613 patients were included. Of these, 41 had the placenta left in situ owing to PAS disorders and follow-up data were available for 36 women. Leaving the placenta in situ was successful in 25 (69%) patients, with placental resorption occurring postpartum (median 89 days; range 6-510). Hysterectomy was performed for 11 patients, primarily owing to hemorrhage and/or infection (median 30 days; range 0-95 days, postpartum).Conclusion: Leaving the placenta in situ, with close postpartum follow-up for at least several months, could be a uterus-preserving option for patient with PAS disorders. [ABSTRACT FROM AUTHOR]

Background: Although adult height is inversely related with the risk of chronic disease, the association between maternal height and ischaemic placental disease remains unclear.Methods: We used the national, multicentre Japan Society of Obstetrics and Gynecology perinatal database to assess the risk of preeclampsia, placental abruption, and small for gestational age (SGA) births (birthweight < 10th percentile), which together constitute the syndrome 'ischaemic placental disease', in relation to self-reported height in 218 412 women with no underlying diseases before pregnancy, who delivered singletons in 2005-11. Height was categorised into quartiles as well as considered in linear terms, and its effect on each outcome was estimated using multivariable log binomial regression adjusted for the maternal characteristics.Results: The risk of preeclampsia, placental abruption, and SGA birth was inversely related to maternal height. In the adjusted model, mothers in the lowest quartile for height (<155 cm) were at higher risk of preeclampsia (relative risk (RR) 1.35, 95% confidence interval (CI) 1.25, 1.45), placental abruption (RR 1.20, 95% CI 1.07, 1.34), and SGA (RR 1.96, 95% CI 1.90, 2.03) compared with mothers in the highest quartile (>162 cm). When the association between height and outcomes was considered in linear terms, each 5 cm decrement in height was associated with an increased risk of preeclampsia (RR 1.11, 95% CI 1.09, 1.14), placental abruption (RR 1.04, 95% CI 1.01, 1.09), and SGA birth (RR 1.30, 95% CI 1.28, 1.31).Conclusion: Shorter height was associated with an increased risk of preeclampsia, placental abruption, and SGA birth. [ABSTRACT FROM AUTHOR]

Aim To examine clinical and surgical performances of cases with placental polyps in which uterine preservation surgery was conducted. Methods During the period September 2002 to April 2009, we examined eight cases (hysteroscopic resection, six cases; laparotomy, one case; dilatation and curettage, one case) diagnosed with placental polyp that had been treated with polyp extraction surgery. Imaging evaluation was done using magnetic resonance imaging and 2- D ultrasound. Results Three of the eight cases (37.5%) had been first-time pregnancies. Most of our cases experienced minimal surgical manipulation after medical abortion. Among them, six cases (75%) were mid-term medical abortions, one case (12.5%) received no treatment after spontaneous abortion, and one case (12.5%) had postsurgical abortion (dilatation and curettage). All cases showed variable amount of blood flow in the internal mass and myometrium by color Doppler ultrasound. Magnetic resonance imaging angiography showed contrast effects in the intrauterine cavity and myometrium in selected cases. The average duration from diagnosis to surgery was 32 days (range, 11-105). Color Doppler revealed a reduction in blood flow in five cases during the waiting period until surgery with an average blood loss of 10 g (range, 0-20) during surgery. Conclusion Use of color Doppler ultrasound may be useful in diagnosing placental polyp. Although hysteroscopic resection of placental polyp is effective in patients hoping for uterine preservation, delaying timing of surgery may reduce blood loss during operative procedure. [ABSTRACT FROM AUTHOR]

Aim: To assess the usefulness of a new method for cesarean section (CS) that is comprised of a transverse incision into the uterine fundus, developed for women with placentas covering the entire anterior uterine wall, and introduced in September 2006. Material and Methods: Review of medical records of 12 and 29 women who underwent CS by the new and conventional methods, respectively, for placenta previa, placenta accreta (accreta, increta and percreta) or placenta widely covering the entire anterior uterine wall in which placenta accreta cannot be excluded, between June 2003 and March 2011. Results: Placenta accreta (67% [8/12] vs 10% [3/29], P = 0.0006) and cesarean hysterectomy (67% vs 10%) were significantly more frequent in the group with the new compared with the conventional method. There were no significant differences between groups with the new and conventional methods in amount of blood loss (1732 ± 1067 vs 1847 ± 1279 g, respectively), prevalence of blood loss >3000 g (8.3% vs 17%, respectively) or blood transfusion (92% vs 72%, respectively), time required for cesarean hysterectomy (210 ± 58 vs 195 ± 41 min), or neonatal conditions at birth. The amount of blood loss for cesarean hysterectomy was significantly less for the new than conventional method (1959 ± 1025 g vs 4450 ± 1145 g, P = 0.041). Conclusion: The new method was superior to the conventional method with respect to reduction of blood loss during cesarean hysterectomy. However, careful observations are mandatory in women with preserved uterus with respect to a possible increased risk of uterine rupture in future pregnancies. [ABSTRACT FROM AUTHOR]

Aim: To assess the usefulness for predicting vasa previa by detecting a cord insertion site in the lower third of the uterus between 9 and 13 weeks' gestation. Methods: The positional relationship between the uterine cavity and the cord insertion site was examined in consecutive subjects prospectively using ultrasonography at 9-13 weeks' gestation. The distance between the internal os and the fundus was divided equally into three parts. Cord insertions in the lower third were defined as cases; other insertions were defined as controls. Placental and umbilical cord abnormalities at the time of the delivery were analyzed between the two groups. Results: The cord insertion sites were identified as 139 (10.6%) cases with low cord insertion and 1172 control cases. The case subjects frequently had an abnormal placental form (6.5% vs 2.1%, RR 3.2, 95% CI 1.5-7.0) or placenta previa (4.7% vs 1.3%, RR 3.5, 95% CI 1.3-9.1). The frequencies of velamentous cord insertion were 7.2% in cases and 0.9% in controls (RR 8.1, 95% CI 3.4-19.6). Three cases (2.2%) of vasa previa were observed in the cases, but none were observed in the controls ( P = 0.001). Placental abruption occurred in 4.3% of the cases and 0.9% of the controls (RR 4.7, 95% CI 1.7-13.1). Conclusion: Screening sonography in the late first or early second trimesters and following up at the second trimester in cases with low cord insertion is a useful way to detect vasa previa. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to demonstrate the differences in risk factors for obstetrical complications between Japan and Western countries. Material and Methods: Using the Perinatal Database of the Japan Society for Obstetrics and Gynecology, we studied singleton deliveries after 22 weeks of gestation ( n = 242 715) at 125 centers of the perinatal network in Japan from 2001 through 2005 as a base cohort. In total, 3749 births (1.5% of the base cohort) were randomly selected as a subcohort. We compared the rate of risk factors in the cases with ten obstetrical complications with that in the subcohort (case-cohort study). Results: Almost all of the evaluated risk factors were common between Western countries and Japan. Older age at pregnancy was a common risk factor for pregnancy-induced hypertension, placental abruption, placenta previa, and placenta accreta/increta/percreta. On the other hand, younger age at pregnancy was a common risk factor for eclampsia and preterm delivery. Smoking during pregnancy was a common risk factor for pregnancy-induced hypertension, preterm premature rupture of the membranes, preterm delivery, cervical insufficiency, chorioamnionitis, and placental abruption. In vitro fertilization and embryo transfer was a common risk factor for cervical insufficiency, placenta previa, and placenta accreta/increta/percreta. Conclusion: This case-cohort study in Japan clarified the common risk factors between Western countries and Japan as well as the risk factors indigenous to Japanese women. To identify the risk factors for a disease in a specific country, we should use data derived from its population. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which highlights the misinterpretation on the classification of placental abruption.