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An abstract of the article "Longitudinal change in cardiac function of twin pregnant women," by K. Shimizu and colleagues is presented.

An abstract of the article "Maternal cardiac function in patients with severe pre-eclampsia" by K. Uno and colleagues is presented.

An abstract of the article "The efficiency of superb microvascular imaging in patients with endometrial cancer," by M. Ukai and colleagues is presented.

Objective: This study aimed to determine whether the number of resected pelvic lymph nodes (PLNs) affects the prognosis of endometrial cancer (EC) patients at post-operative risk of recurrence., Methods: JGOG2043 was a randomized controlled trial to assess the efficacy of three chemotherapeutic regimens as adjuvant therapy in EC patients with post-operative recurrent risk. A retrospective analysis was conducted on 250 patients who underwent pelvic lymphadenectomy alone in JGOG2043. The number of resected and positive nodes and other clinicopathologic risk factors for survival were retrieved., Results: There were 83 patients in the group with less than 20 PLNs removed (group A), while 167 patients had 20 or more PLNs removed (group B). There was no significant difference in patients' backgrounds between the two groups, and the rate of lymph node metastasis was not significantly different. There was a trend toward fewer pelvic recurrences in group B compared with group A (3.5% vs. 9.6%; p=0.050). Although Kaplan-Meier analysis showed no statistically significant difference in survival rates between the two groups (5-year overall survival [OS]=90.3% vs. 84.3%; p=0.199), multivariate analysis revealed that resection of 20 or more nodes is one of the independent prognostic factors (hazard ratio=0.49; 95% confidence interval=0.24-0.99; p=0.048), as well as surgical stage, high-risk histology, and advanced age for OS., Conclusion: Resection of 20 or more PLNs was associated with improved pelvic control and better survival outcomes in EC patients at risk of recurrence who underwent pelvic lymphadenectomy alone and were treated with adjuvant chemotherapy., Competing Interests: No potential conflict of interest relevant to this article was reported., (© 2025. Asian Society of Gynecologic Oncology, Korean Society of Gynecologic Oncology, and Japan Society of Gynecologic Oncology.)

The mechanisms leading to adrenal cortex development and steroid synthesis in humans remain poorly understood due to the paucity of model systems. Herein, we recapitulate human fetal adrenal cortex specification processes through stepwise induction of human-induced pluripotent stem cells through posterior intermediate mesoderm-like and adrenocortical progenitor-like states to ultimately generate fetal zone adrenal-cortex-like cells (FZLCs), as evidenced by histomorphological, ultrastructural, and transcriptome features and adrenocorticotropic hormone (ACTH)-independent Δ5 steroid biosynthesis. Furthermore, FZLC generation is promoted by SHH and inhibited by NOTCH, ACTIVIN, and WNT signaling, and steroid synthesis is amplified by ACTH/PKA signaling and blocked by inhibitors of Δ5 steroid synthesis enzymes. Finally, NR5A1 promotes FZLC survival and steroidogenesis. Together, these findings provide a framework for understanding and reconstituting human adrenocortical development in vitro, paving the way for cell-based therapies of adrenal insufficiency., Competing Interests: Declaration of interests Y. Seita is employed by Kishokai Medical Corporation., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The best thromboprophylaxis for pregnant women with congenital antithrombin deficiency (CAD) is controversial., Objective: To clarify the effectiveness of a protocol for venous thromboembolism (VTE) prevention in pregnant women with CAD., Methods: Women at high risk of VTE were administered antithrombin concentrate and heparin after conception, whereas those at low risk of VTE were administered heparin alone until delivery. All women received antithrombin concentrate at delivery except for one who was diagnosed with CAD., Results: Ten women had CAD, including one in the high-risk group and nine in the low-risk group. No women had VTE at delivery as per the protocol for VTE prevention. Almost all women had increased antithrombin activity before delivery followed by maintenance at ≥ 70% due to antithrombin concentrate administration. VTE prophylaxis during and after delivery was successful in all women with CAD. However, one woman in the low-risk group did not receive heparin and developed VTE induced by severe hyperemesis at 9 gestational weeks, before the diagnosis of CAD. Women in the high-risk group received antithrombin concentrate after delivery but had increased D-dimer levels at postpartum., Conclusions: Our protocol to prevent VTE in pregnant women with CAD is safe and effective., (© 2022. Japanese Society of Hematology.)

Aims/introduction: We investigated the association between gestational diabetes mellitus (GDM) and perinatal outcomes stratified by pre-pregnancy body mass index (BMI) and/or gestational weight gain (GWG)., Materials and Methods: Data from the national birth cohort in the Japan Environment and Children's Study from 2011 to 2014 (n = 85,228) were used. Japan uses the GDM guidelines of the International Association of Diabetes and Pregnancy Study Groups. The odds ratios (ORs) of perinatal outcomes were compared between women with and those without GDM., Results: The OR (95% confidence interval) of having a small for gestational age infant in the GDM group with a pre-pregnancy BMI of ≥25.0 kg/m 2 and insufficient GWG (<2.75 kg) was 1.78 (1.02-3.12). The OR of having a large for gestational age infant of the same BMI group with excessive GWG (>7.25 kg) was 2.04 (1.56-2.67). The OR of hypertensive disorders of pregnancy was higher in women with a BMI ≥18.5 kg/m 2 in the GDM group than in the non-GDM group., Conclusions: Large for gestational age and hypertensive disorders of pregnancy were associated with pre-pregnancy BMI and GWG in either normal weight or overweight/obese women, and the relationship was strengthened when GDM was present. Women with GDM and a BMI of ≥25.0 kg/m 2 are at risk of having small for gestational age and large for gestational age infants depending on GWG., (© 2021 The Authors. Journal of Diabetes Investigation published by Asian Association for the Study of Diabetes (AASD) and John Wiley & Sons Australia, Ltd.)

We aimed to investigate the association between nurses' electrocardiographic (ECG) monitoring education and their confidence and psychological stress regarding ECG monitoring. In 2019, a web-based cross-sectional study was conducted among Japanese nurses. A multivariable logistic regression analysis was performed to evaluate the effects of education on nurses' confidence and psychological stress regarding ECG monitoring. In total, 1652 nurses were included in the study. Factors significantly associated with nurses' confidence were post-graduate education experience (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.6), ≥11 post-graduate years (OR, 2.2; 95% CI, 1.5-3.1), male gender (OR, 4.4; 95% CI, 2.9-6.6), ≥5 helpful experiences with ECG monitoring (OR, 10.7; 95% CI, 6.0-19.1), work experience in an intensive care unit (OR, 2.3; 95% CI, 1.5-3.7), and work experience in a cardiology department (OR, 1.7; 95% CI, 1.2-2.4). Factors significantly associated with nurses' psychological stress were male gender (OR, 1.9; 95% CI, 1.2-2.9), ≥5 helpful experiences with ECG monitoring (OR, 1.9; 95% CI, 1.2-2.9), and work experience in an emergency room (OR, 2.4; 95% CI, 1.3-4.8). These results suggest that nurses' post-graduate ECG monitoring education enhanced their confidence, but did not reduce psychological stress regarding ECG monitoring.

Background: Lower limb lymphedema (LLL) is one of the most refractory and debilitating complications related to gynecological cancer treatment. We investigated factors associated with response to compression-based physical therapy (CPT) for secondary LLL after gynecologic cancer treatment., Methods: We performed a multicenter retrospective study using the records of seven medical institutions from 2002 and 2014. Patients who developed LLL after gynecological cancer treatment were included. Limb volumes were calculated from the lengths of the limb circumferences at four points. All participants underwent compression-based physical therapy for LLL. Factors, including MLD, indicative of circumference reductions in LLL were determined., Results: In total, 1,034 LLL met the required criteria of for the study. A multivariate linear regression analysis identified age; body mass index (BMI); endometrial cancer; radiotherapy; and initial limb circumference as significant independent prognostic factors related to improvement in LLL. In analysis of covariance for improvement in LLL adjusted by the initial limb circumference and stratified by BMI and radiotherapy, patients with BMI 28 kg/m 2 or higher and receiving radiation rarely responded to CPT., Conclusions: Improvements in the lower limb circumference correlated with clinical histories and physical characteristics, which may be used as independent prognostic factors for successful CPT for LLL after gynecological cancer treatment., (© 2021. The Author(s).)

Aim: To investigate the relationship between excessive gestational weight gain during the week prior to delivery (GWG) and severe morbidity and pregnancy termination among pregnant women with preeclampsia (hypertension with proteinuria)., Methods: We compared GWG, laboratory data, and complication(s) between 94 preeclamptic women (preeclampsia group) with singleton pregnancies who delivered at ≥22 gestational weeks and 188 healthy women (control group) with singleton pregnancies undergoing elective cesarean deliveries. The gestational weeks at delivery were matched in the preeclampsia and control groups., Results: Among 282 total participants, median of GWG was significantly higher in the preeclampsia group than in the control group (1.6 kg vs. 0.5 kg, p < 0.0001). Furthermore, the GWG cutoff value for the preeclampsia group was 1.6 kg. The odds ratio for morbidity of preeclampsia among the women with GWG ≥1.6 kg at delivery was 12.5 (95% confidence interval, 6.31-24.5). In the preeclampsia group, 47 women with GWG ≥1.6 kg had significantly higher risks of hypoproteinemia, proteinuria, and renal dysfunction than those of 47 women with GWG < 1.6 kg. While, multivariate analysis showed 1.5 kg was a GWG cutoff value for predicting maternal morbidity (p < 0.0001); preeclamptic women with GWG ≥1.5 kg had a significantly higher risk of pulmonary edema than preeclamptic women with GWG < 1.5 kg (odds ratio, 7.77; 95% confidence interval, 1.64-36.7)., Conclusion: Excessive GWG in women with preeclampsia might be a predictor for severe maternal life-threatening complications requiring pregnancy termination., (© 2021 Japan Society of Obstetrics and Gynecology.)

Aim: Obstetrics and gynecology (Ob/Gyn) training became compulsory for Japanese physician interns from April 2020 to improve medical competence in treating women's diseases. This study aims to understand the Ob/Gyn training needs of postgraduate year 1-2 physicians (interns) and thereby improve training efficiency., Methods: This study was administered to interns at Ob/Gyn training facilities from December 2019 to February 2020. An original questionnaire was used to evaluate their assessment of training needs. In analyses, interns were categorized according to whether they were willing to major in Ob/Gyn., Results: Of the 1154 participants, 163 (14.1%) would major in Ob/Gyn (Ob/Gyn applicants) and 967 (83.8%) would not (non-Ob/Gyn applicants). At the time of the survey, 634 (54.9%) had rotated in Ob/Gyn, 253 (21.9%) planned to rotate, and 267 (23.1%) chose not to rotate. The two most favorable training experiences were "experience in surgical procedures" (81/141, 57.4%) and "wide treatment areas covered by Ob/Gyn" (78/141, 55.3%) among the Ob/Gyn applicants, and "specificity of women's treatment" (308/488, 63.1%) among the non-Ob/Gyn applicants., Conclusions: Ob/Gyn applicants and non-Ob/Gyn applicants differed in their assessment of Ob/Gyn rotations. It is crucial to provide medical training based on interns' needs to improve their skills for treating female patients., (© 2021 Japan Society of Obstetrics and Gynecology.)

Aim: Perinatal telemedicine efforts have commenced worldwide in response to the COVID-19 pandemic. As there have been no prior studies on the acceptance of telemedicine by pregnant women, we conducted this survey to investigate the same., Methods: We conducted an anonymous questionnaire survey of pregnant women who underwent telemedicine check-ups from March 4 to June 30, 2020, using a mobile fetal heart rate monitor and video call system through the Hokkaido University Hospital., Results: Out of the 77 individuals who received prenatal telemedicine check-ups, 54 individuals (70%) had complications, and 64 individuals (83%) consented for the questionnaire survey. In the video call system, 18 individuals (28%) were found to be unwell and 17 individuals (27%) experienced difficulty using the mobile fetal heart rate monitoring device. Assuming scores for face-to-face consultations were five out of 10, the mean score for satisfaction was 4.2, but 19 (30%) women felt equal or greater satisfaction with face-to-face consultations. If not for the threat of COVID-19, only four individuals (6%) proactively expressed a desire for telemedicine, with a significantly less demand observed among primiparous women than multiparous women. The permissible additional financial burden enabling telemedicine was $10 or less for 80% of subjects., Conclusion: In this small preliminary study, 30% of the pregnant women felt equal or greater satisfaction with telemedicine than face-to-face consultations. A stronger demand for telemedicine was exhibited by multiparous women than primiparous women. Thus, a system that would be advantages by limiting subjects and enabling low-cost examinations is required for making perinatal telemedicine more popular., (© 2021 Japan Society of Obstetrics and Gynecology.)

Although gestational hypertension (GH) is a well-known disorder, gestational proteinuria (GP) has been far less emphasized. According to international criteria, hypertensive disorders of pregnancy include GH but not GP. Previous studies have not revealed the predictors of progression from GP to preeclampsia or those of progression from GH to preeclampsia. We aimed to determine both sets of predictors. A retrospective cohort study was conducted with singleton pregnant women who delivered at 22 gestational weeks or later. Preeclampsia was divided into three types: new onset of hypertension/proteinuria at 20 gestational weeks or later and additional new onset of other symptoms at < 7 days or at ≥ 7 days later. Of 94 women with preeclampsia, 20 exhibited proteinuria before preeclampsia, 14 experienced hypertension before preeclampsia, and 60 exhibited simultaneous new onset of both hypertension and proteinuria before preeclampsia; the outcomes of all types were similar. Of 34 women with presumptive GP, 58.8% developed preeclampsia; this proportion was significantly higher than that of 89 women with presumptive GH who developed preeclampsia (15.7%). According to multivariate logistic regression models, earlier onset of hypertension/proteinuria (before or at 34.7/33.9 gestational weeks) was a predicator for progression from presumptive GH/GP to preeclampsia (odds ratios: 1.21/1.21, P value: 0.0044/0.0477, respectively).

Aim: The Ministry of Health, Labour, and Welfare of Japan proposed a regulation of overtime work as a reform in work style. However, the regulation may deteriorate the quality of medical services due to the reduction in training time. Thus, the study aimed to reveal perceptions in terms of generation gaps in views on self-training and overtime work, among members of the Japan Society of Obstetrics and Gynecology (JSOG)., Methods: A web-based, self-administered questionnaire survey was conducted among members of the JSOG. In total, 1256 respondents were included in the analysis. Data were collected on age, sex, experience as a medical doctor, location of workplace, work style, the type of main workplace, and number of full-time doctors in the main workplace. The study examined the attitudes of the respondents toward overtime work and self-training. The respondents were categorized based on experience as a medical doctor., Results: According to years of experience, 112 (8.9%), 226 (18.0%), 383 (30.5%), 535 (42.6%) doctors have been working for ≤5, 6-10, 11-19, and ≥ 20 years, respectively. Although 54.5% of doctors with ≤5 years of experience expected the regulation on working hours to improve the quality of medical services, those with ≥20 years of experience expressed potential deterioration. After adjusting for covariates, more years of experience were significantly related with the expectation of deterioration in the quality of medical services., Conclusions: The study revealed a generation gap in the views about self-training and overtime work among obstetricians and gynecologists in Japan., (© 2021 Japan Society of Obstetrics and Gynecology.)

Aim: To clarify whether maternal characteristics or laboratory parameters could help predict the onset of recurrent gestational diabetes mellitus (GDM)., Methods: We enrolled 615 women with consecutive singleton deliveries at or after 28 GW from two perinatal medical centers between 2011 and 2019 and divided them into four groups according to whether they had GDM in the first and second pregnancies. The outcome of this study was to clarify the incidence and the predictors of recurrent GDM., Results: We found that among 72 women (11.7%) who had GDM during their first pregnancy, the rate of recurrent GDM was 47.2%. The 34 women (5.5%) with recurrent GDM gained significantly less weight in the first and second pregnancies and lost less weight between the first delivery and the second conception compared with those women without GDM in both pregnancies. Of women with GDM during the first pregnancy, 21 scored 2 or 3 (multiple) positive points on a 75-g oral glucose tolerance test (OGTT) during their first pregnancies; the GDM recurrence rate among these women (66.7%) was significantly higher than that among the 51 women who scored 1 positive point (39.2%; p = 0.0411). During the first pregnancy, insulin administration therapy was significantly more frequent in women with recurrent GDM than in women without recurrent GDM (23.5% vs. 5.3%, p = 0.0396, respectively)., Conclusion: A predictor of recurrent GDM onset was a score of 2 or 3 positive points on the OGTT during the first pregnancy., (© 2021 Japan Society of Obstetrics and Gynecology.)

Background: Although infection and inflammation within the genital tract during pregnancy is considered a major risk factor for spontaneous preterm birth (PTB), there are few studies on association between vaginal microorganisms in the early stage of pregnancy and PTB. The aim of this study was to investigate relationship between vaginal Group B streptococcus (GBS) colonization, a leading cause of infection during pregnancy, in the early stage of pregnancy and PTB., Methods: This single-center, retrospective cohort study utilized data from 2009 to 2017 obtained at TOYOTA Memorial Hospital. Women with singleton pregnancies who underwent vaginal culture around 14 weeks of gestation during their routine prenatal check-up were included. Vaginal sampling for Gram staining and culture was performed regardless of symptoms. GBS colonization was defined as positive for GBS latex agglutination assay. Statistical analysis was performed to determine the factors associated with PTB., Results: Overall 1079 singleton pregnancies were included. GBS (5.7%) and Candida albicans (5.5%) were the most frequently observed microorganisms. The incidence of PTB (before 34 and before 37 weeks of gestation) were significantly higher in the GBS-positive group than in the GBS-negative group (6.6% vs 0.5%, p = 0.001 and 9.8% vs 4.3%, p = 0.047). Our multivariable logistic regression analysis revealed that GBS colonization was a factor associated with PTB before 34 and before 37 weeks of gestation (Odds ratio [OR] 15.17; 95% confidence interval [CI] 3.73-61.74), and OR 2.42; 95%CI 1.01-5.91, respectively)., Conclusions: The present study found that vaginal GBS colonization in the early stage of pregnancy was associated with PTB. Our study indicates that patients at a high risk for PTB can be extracted by a simple method using conventional culture method.

Background: Currently, there is a disagreement between guidelines regarding platelet count cut-off values as a sign of maternal organ damage in pre-eclampsia; the American College of Obstetricians and Gynecologists guidelines state a cut-off value of < 100 × 10 9 /L; however, the International Society for the Study of Hypertension in Pregnancy guidelines specify a cut-off of < 150 × 10 9 /L. We evaluated the effect of mild thrombocytopenia: platelet count < 150 × 10 9 /L and ≥ 100 × 10 9 /L on clinical features of pre-eclampsia to examine whether mild thrombocytopenia reflects maternal organ damage in pre-eclampsia., Methods: A total of 264 women were enrolled in this study. Participants were divided into three groups based on platelet count levels at delivery: normal, ≥ 150 × 10 9 /L; mild thrombocytopenia, < 150 × 10 9 /L and ≥ 100 × 10 9 /L; and severe thrombocytopenia, < 100 × 10 9 /L. Risk of severe hypertension, utero-placental dysfunction, maternal organ damage, preterm delivery, and neonatal intensive care unit admission were analyzed based on platelet count levels. Estimated relative risk was calculated with a Poisson regression analysis with a robust error., Results: Platelet counts indicated normal levels in 189 patients, mild thrombocytopenia in 51 patients, and severe thrombocytopenia in 24 patients. The estimated relative risks of severe thrombocytopenia were 4.46 [95 % confidence interval, 2.59-7.68] for maternal organ damage except for thrombocytopenia, 1.61 [1.06-2.45] for preterm delivery < 34 gestational weeks, and 1.35 [1.06-1.73] for neonatal intensive care unit admission. On the other hand, the estimated relative risks of mild thrombocytopenia were 0.97 [0.41-2.26] for maternal organ damage except for thrombocytopenia, 0.91 [0.62-1.35] for preterm delivery < 34 gestational weeks, and 0.97 [0.76-1.24] for neonatal intensive care unit admission., Conclusions: Mild thrombocytopenia was not associated with severe features of pre-eclampsia and would not be suitable as a sign of maternal organ damage.

Aim: In Hokkaido, Japan, the number of people suffering from coronavirus disease 2019 (COVID-19) is rapidly increased, and by the end of February 2020, there were already 70 confirmed cases of the disease. We investigated the safety of urgently initiated maternal telemedicine in preventing the spread of the coronavirus infection., Methods: This retrospective, single-institution study examined maternal telemedicine at the department of obstetrics of the Hokkaido University Hospital from March 4 to April 2, 2020. The physicians remotely examined the pregnant women from their homes using a visual communication system which kept communication confidential, performed prenatal checkup and administered medical care according to their various blood pressures, weights and cardiotocograms., Results: Forty-four pregnant women received a total of 67 telemedicine interventions. Thirty-two pregnant women (73%) had complications, and 22 were primiparas (50%). Telemedicine interventions were provided 19 times at less than 26 weeks of gestation, 43 times between 26 and 36 weeks of gestation and 5 times after 37 weeks of gestation. There was one case with an abnormality diagnosed during the remote prenatal checkups, and the patient was hospitalized on the same day. However, there were no abnormal findings observed in mothers and children during the other 66 remote prenatal checkups and medical care., Conclusion: Maternal telemedicine can be safely conducted in pregnant women who are at risk of having an underlying disorder or fetal abnormality 1 month following the start of the attempt. It should be considered as a form of maternal medical care to prevent the spread of COVID-19., (© 2020 Japan Society of Obstetrics and Gynecology.)

Our previous research has focused on the development of a novel cancer therapy by using photohyperthermal therapy (PHT) with indocyanine green (ICG) as an optical sensitizer. ICG-Lipo is a liposomally formulated ICG derivative in which ICG is tagged with an octadeca-alkyl chain to incorporate into liposome bilayers, and contains antitumor drugs such as carboplatin and paclitaxel within the inner membrane space. The present study reported a case of feline nasal lymphoma that was treated with combination therapy of PHT with ICG-Lipo. An antitumour effect was observed, and the patient entered remission. Complications from the radiation treatment included skin burns and bleeding from the irradiated hard palate. Serious side effects related to the drugs were not observed. This report suggested that PHT using ICG-Lipo enabled efficient and safe treatment of lymphoma, and that treatment with a liposomal drug delivery system was enhanced by PHT., (Copyright © 2020, Spandidos Publications.)

Objective: This study compared the survival outcomes and the incidence of chemotherapy-related adverse events in endometrial cancer patients who received four and six cycles of adjuvant chemotherapy to examine the optimal number of adjuvant chemotherapy cycles., Methods: A total of 112 patients with endometrial cancer with a high risk of recurrence were retrospectively enrolled; 46 patients received four cycles and 66 received six cycles of adjuvant chemotherapy. Between-group differences of overall survival, disease-free survival, hematological and non-hematological toxicities were analyzed. Baseline patient's background differences were assessed with inverse probability of treatment weighting using propensity score., Results: Overall and disease-free survivals between the two groups were not significantly different. Paclitaxel + carboplatin, every 3-4 weeks was the most frequently used chemotherapy regimen in both groups. Patients in the six-cycle chemotherapy group developed neutropenia G4 or febrile neutropenia more frequently than those in the four-cycle group; odds ratio (95% confidence interval) is 4.07 (1.51-10.96). Peripheral sensory neuropathy was the most frequently observed non-hematological toxicity; the incidence of peripheral sensory neuropathy was not significantly different between four- and six-cycle chemotherapy group, P = 0.832. The result was same in the subgroup analysis in patients who received TC regimen, P = 0.455., Conclusion: This study implies a possible benefit of fewer cycles of adjuvant chemotherapy in endometrial cancer patients with a high risk of recurrence because of the lower incidence of hematological toxicities without impairing survival outcomes., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

Objectives: To investigate the relationship between serum total protein (TP) levels and maternal/neonatal outcomes among pregnant women with preeclampsia., Study Design: TP was measured at preeclampsia diagnosis and delivery in 94 women with singleton pregnancies and preeclampsia as hypertension with proteinuria who delivered at ≥ 22 gestational weeks (GWs). As a control group, measurements were also made in 188 women with singleton pregnancies without hypertension and/or proteinuria., Main Outcome Measures: The relationship between serum TP levels and maternal outcomes., Results: Serum TP levels showed a significantly negative relationship with urine protein-to-creatinine (P/C) ratio at preeclampsia diagnosis and delivery. Serum TP levels at delivery in the preeclampsia group (53 ± 7 g/L) were lower than in the control group (61 ± 4 g/L, P < 0.0001). In each group, there was no relationship between the daily decrease in TP and the daily increase maternal body weight. However, there was a positive relationship between the daily increase in P/C ratio and the daily increase in maternal body weight in the preeclampsia group (P = 0.0021). Severe hypoproteinemia at preeclampsia diagnosis was a predictor of abruptio placentae (TP < 49 g/L; odds ratio, 21.3) and peripartum cardiomyopathy (TP < 45 g/L; odds ratio, 43.5). Furthermore, women with severe hypoproteinemia at delivery had higher morbidity due to pulmonary edema (TP < 55 g/L; odds ratio, 26.4) and central serous chorioretinopathy (TP < 42 g/L; odds ratio, 264)., Conclusions: Serum TP levels and proteinuria severity at preeclampsia diagnosis and delivery showed a positive relationship and predicted poor maternal outcome., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)

Background: Cesarean delivery rates are increasing globally with almost half of them occurring due to a previous Cesarean delivery. A trial of labor after Cesarean (TOLAC) is considered a safe procedure, but most eligible women instead undergo Cesarean before 39 weeks of gestation. Lack of education about TOLAC is often associated with increased repeat Cesarean. To reveal the safety and feasibility of TOLAC, we conducted this observational, prospective study with women's independent decisions. We aimed to clarify the relationship between their chosen mode of delivery and the reason for their previous Cesarean. Additionally, we have tried to identify maternal and obstetric factors associated with failed TOLAC to improve its success rate., Methods: This was a prospective, observational study of 1086 pregnant women with at least one previous Cesarean delivery. Of these, 735 women met our TOLAC criteria (Table 1), and then, could choose TOLAC or repeat Cesarean after receiving detailed explanations regarding the risks and benefits of both procedures. The primary outcomes were the number of successful TOLAC procedures and 5-min Apgar scores < 7 for the trial of labor after Cesarean group and elective Cesarean group. We collected the maternal and neonatal data including the reasons of previous Cesarean., Results: In total, 64.1% of women chose TOLAC. The success rate was 91.3%. The uterine rupture rate was 0.6%. There were no significant differences in the rate of Apgar scores at 5 min < 7 between both groups. Histories of experience of labor in previous Cesarean delivery were observed in 30 and 50% of women who chose TOLAC and repeat Cesarean, respectively (p < 0.05). Factors related to failed TOLAC included ≥40 weeks of gestation (odds: 5.47, 95% CI: 2.55-11.70) and prelabor rupture of membranes (PROM) (odds: 4.47, 95% CI: 2.07-9.63)., Conclusions: TOLAC is a favorable delivery option for both mothers and neonates when women meet criteria and choose after receiving detailed explanations. Women who experience PROM or ≥ 40 weeks of gestation, their modes of delivery should be reconsulted.

Pregnant women with diabetes mellitus (DM) are at high risk for hypertensive disorder of pregnancy (HDP). Women with poor control DM sometimes have heavy-for-dates infants. However, women with HDP sometimes have light-for-dates infants. We aim to clarify the relationship between glycemic control and fetal growth in women with DM and/or subsequent HDP. Of 7893 women gave singleton birth at or after 22 gestational weeks, we enrolled 154 women with type 1 DM (T1DM) or type 2 DM (T2DM) whose infants did not have fetal abnormalities. Among women with T1DM or T2DM, characteristics of the three groups (with HDP, without HDP, and with chronic hypertension [CH]) were compared. No women with T1DM had CH, but 19 (17.4%) of 109 with T2DM did. HDP incidence was similar between women with T1DM (22.2%) and T2DM without CH (16.7%). Among women with T1DM, the incidences of fetal growth restriction (FGR) with and without HDP were similar. However, among women with T2DM without CH, this incidence was significantly higher among those with HDP (33.3%) than among those without HDP (5.3%), was significantly more common with HbA1c levels at first trimester ≥ 7.2% (33.3%) than with those < 7.2% (5.6%), and significantly more numerous without pre-pregnancy therapies for DM (23.3%) than with them (3.3%). Among women with T2DM and HDP, those with FGR had smaller placenta SDs and higher insulin dosages at delivery than those without light-for-dates. In multivariate analysis, the presence of diabetic nephropathy was a predictor of T1DM and HDP (P = 0.0105), whereas HbA1c levels ≥ 7.2% before pregnancy was a predictor of T2DM and HDP (P = 0.0009). Insulin dosage ≥ 50U/day at delivery (P = 0.0297) and the presence of HDP (P = 0.0116) independently predicted T2DM, HDP, and FGR development. Insufficient pre-pregnancy treatment of DM increased the risk of HDP., Competing Interests: The authors have declared that no competing interests exist.

Objectives: The present study aimed to determine the relationship between the severity of proteinuria and maternal/neonatal outcomes among women with preeclampsia., Study Design: Proteinuria severity was measured at preeclampsia diagnosis and at delivery in 94 women with preeclampsia (among 2904 women with singleton pregnancies, who delivered after 22 gestational weeks). Preeclampsia was defined as hypertension with proteinuria., Main Outcome Measures: Protein:creatinine (P/C) ratio to worse the maternal outcome was 4.8 among women with preeclampsia., Results: The frequencies of HELLP syndrome and maternal pulmonary edema in women with a P/C ratio ≥5.0 (35.5% and 35.5%, respectively) were significantly higher than those in women with a P/C ratio <5.0 (12.7%, P = 0.014 and 6.4%, P < 0.001, respectively). The best P/C ratio cutoff value to determine early-onset preeclampsia and early preterm birth (EPB) was 4.1 (P < 0.001 and P < 0.001, respectively). The best P/C ratio cutoff values to determine the interval between the preeclampsia diagnosis and delivery <7 days and the need to undergo cesarean section were 1.8 and 1.5, respectively. The best P/C ratio cutoff value to determine maternal pulmonary edema and central serous chorioretinopathy (CSC) was 4.8 (P = 0.020 and P = 0.014, respectively). Finally, the best P/C ratio cutoff values to determine EPB and maternal CSC in women with preeclampsia were 4.1 (odds ratio, 10.9; 95% confidence interval; 4.08 to 29.2, P < 0.0001) and 4.8 (odds ratio, 17.6; 95% confidence interval; 0.898 to 344, P = 0.0008), respectively, according to the multivariate analysis., Conclusions: A higher P/C ratio at delivery in women with preeclampsia might cause EPB and CSC., (Copyright © 2020 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)

Objectives: In Japan, the prevalence of irregular menstrual cycles and its association with the frequency of night shifts have scarcely assessed. The present study aimed to evaluate the relationship between irregular menstrual cycles and the frequency of night shifts in Japanese female nurses., Methods: We conducted a cross-sectional web-based self-administered questionnaire survey in 2019. An irregular menstrual cycle was defined as a cycle length of ≤21 days or ≥39 days at least a few times over the past year or amenorrhea for at least 3 months. We used Poison regression analysis with a robust error variance to calculate the prevalence ratios adjusted for age, body mass index, hospital size, and the department in which they worked., Results: A total of 1249 women were included, and 679 (54.4%) and 195 (15.6%) of them worked under two and three rotating shifts. The prevalence of irregular menstrual cycles was 24.8%, 37.4%, and 35.9% in the no night, two rotating, and three rotating shifts groups, respectively. While the frequency of night shifts had a dose-responsive relationship with irregular menstrual cycles in the two rotating shifts group, it was not observed in the three rotating shifts group. However, the risk of work getting affected by dysmenorrhea or premenstrual symptoms increased in the three rotating shifts group., Conclusions: Over 30% of Japanese female nurses working under night shifts had irregular menstrual cycles. The high frequency of night shifts increased the risk of irregular menstrual cycles and secondary amenorrhea in the two rotating shifts group., (© 2020 The Authors. Journal of Occupational Health published by John Wiley & Sons Australia, Ltd on behalf of The Japan Society for Occupational Health.)

Aim: This study aimed to examine how the number of patients diagnosed with pre-eclampsia increased according to the Japanese classification of hypertensive disorders of pregnancy (HDP) that was revised in 2018. The effect of new classification on perinatal outcomes was also analyzed., Methods: We enrolled 181 women with HDP who delivered at Hokkaido University Hospital between February 2011 and December 2017. All women were reclassified on the basis of the new classification, in which proteinuria was not required to diagnose pre-eclampsia in patients with maternal organ damage. The number and reasons of reclassification and the admission rate to the neonatal intensive care unit (NICU) and gestational age (GA) at the onset of HDP and at delivery were analyzed., Results: In this cohort, 17 (9.4%) of 181 women with HDP were reclassified. Low platelet count (41.2%) and uteroplacental dysfunction (41.2%) were the two main causes for reclassification. GA at the onset of HDP (33.6 [29.9-36.1] weeks vs 37.4 [35.7-38.4] weeks; P < 0.001) and at delivery (35.9 [32.4-37.3] weeks vs 38.1 [37.3-39.6] weeks; P < 0.001) were significantly earlier in women with reclassification than women without reclassification. The NICU admission rate was higher in women with reclassification than women without reclassification (70.6% vs 20.4%; P < 0.001)., Conclusion: Almost 10% of pregnant women were newly diagnosed with pre-eclampsia as per the new Japanese classification of HDP. Women with reclassification as pre-eclampsia had a greater risk of preterm delivery and NICU admission than those who were not reclassified., (© 2019 Japan Society of Obstetrics and Gynecology.)

Background: The normal range of plasma brain natriuretic peptide (BNP) in pregnant women is still unclear. Moreover, pregnant women experience dynamic body weight changes and suffer from anemia, but effects on maternal BNP have not been investigated. This study aimed to reveal the normal plasma BNP range and examine the effects of physiological changes on BNP among pregnant women., Methods and Results: Plasma BNP, hemoglobin, plasma creatinine and BMI were measured in 58 non-pregnant control women and in 773 normal pregnant women at late pregnancy, early postpartum and 1-month postpartum. Mean plasma BNP (in pg/mL) was 11.8 (95% confidence interval: 0-27.5) in non-pregnant women, 17.9 (0-44.7, p<0.001) at late pregnancy, 42.5 (0-112.6, p<0.001) early postpartum and 16.1 (0-43.9, p=0.001) 1-month postpartum. Multiple regression analysis revealed that pre-delivery BNP levels were negatively correlated with BMI (p<0.001) and hemoglobin (p=0.002) and positively correlated with creatinine (p<0.001). Post-delivery BNP was positively associated with body weight change during pregnancy (p=0.001) and post-delivery creatinine (p=0.010) but negatively associated with body weight loss at delivery (p<0.001) and post-delivery hemoglobin (p=0.004)., Conclusion: Even normal pregnancy affects plasma BNP, particularly in the early postpartum period, indicative of cardiac stress. Plasma BNP levels are affected by BMI, body weight changes, creatinine and hemoglobin levels; therefore, these factors should be considered when analysing cardiac function and the physiological implications of BNP levels in pregnant women., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Hepatic infarction is an extremely rare and fatal complication associated with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. It can develop into fulminant liver failure, which increases both maternal and neonatal mortality rates. A 34-year-old woman with no remarkable past medical history developed eclampsia after delivery at 40 weeks of gestation. Imaging indicated massive hepatic infarction and rupture followed by cardiac arrest and fulminant liver failure. Despite liver replacement therapy with plasma exchange and continuous hemodiafiltration, the patient gradually deteriorated with persistent bacterial infection until death at 98 days after delivery. The management of fulminant liver failure complicated with HELLP syndrome should be multidisciplinary. Liver transplantation, the only radical treatment for fulminant liver failure, is worth attempting, if applicable., (© 2016 Japan Society of Obstetrics and Gynecology.)

Background: Posterior reversible encephalopathy syndrome is observed frequently in patients with eclampsia; however, it has also been reported in some patients with preeclampsia., Objectives: The aim of this study was to determine the incidence of posterior reversible encephalopathy syndrome in patients with preeclampsia and eclampsia and to assess whether these 2 patient groups share similar pathophysiologic backgrounds by comparing clinical and radiologic characteristics., Study Design: This was a retrospective cohort study of 4849 pregnant patients. A total of 49 patients with eclampsia and preeclampsia and with neurologic symptoms underwent magnetic resonance imaging and magnetic resonance angiography; 10 patients were excluded from further analysis because of a history of epilepsy or dissociative disorder. The age, parity, blood pressure, and routine laboratory data at the onset of symptoms were also recorded., Results: Among 39 patients with neurologic symptoms, 12 of 13 patients with eclampsia (92.3%) and 5 of 26 patients with preeclampsia (19.2%) experienced the development of posterior reversible encephalopathy syndrome. Whereas age and blood pressure at onset were not significantly different between patients with and without encephalopathy, hematocrit, serum creatinine, aspartate transaminase, alanine transaminase, and lactate dehydrogenase values were significantly higher in patients with posterior reversible encephalopathy syndrome than in those without magnetic resonance imaging abnormalities. In contrast, patients with eclampsia with posterior reversible encephalopathy syndrome did not show any significant differences in clinical and laboratory data compared with patients with preeclampsia with posterior reversible encephalopathy syndrome. In addition to the parietooccipital regions, atypical regions (such as the frontal and temporal lobes), and basal ganglia were also involved in patients with eclampsia and patients with preeclampsia with posterior reversible encephalopathy syndrome. Finally, intraparenchymal hemorrhage was detected in 1 patient with eclampsia, and subarachnoid hemorrhage was observed in 1 patient with preeclampsia., Conclusions: Although the incidence of posterior reversible encephalopathy syndrome was high in patients with eclampsia, nearly 20% of the patients with preeclampsia with neurologic symptoms also experienced posterior reversible encephalopathy syndrome. The similarities in clinical and radiologic findings of posterior reversible encephalopathy syndrome between the 2 groups support the hypothesis that these 2 patient groups have a shared pathophysiologic background. Thus, magnetic resonance imaging studies should be considered for patients with the recent onset of neurologic symptoms, regardless of the development of eclampsia., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Pyometra is defined as an accumulation of purulent material in the uterine cavity. Spontaneous perforation is a very rare complication of pyometra. The clinical findings of perforated pyometra are similar to perforation of the gastrointestinal tract and other causes of acute abdomen., Case Report: We report a rare and difficult case of peritonitis in an elderly female that was caused by a spontaneous perforation of pyometra. A 90-year-old postmenopausal woman was referred to our hospital with complaints of vomiting, fever, and abdominal pain. Computed tomography revealed a large amount of ascites, cystic mass in the uterus, and intraperitoneal and intrauterine air. Transvaginal ultrasound demonstrated a thin area around the fundus. An emergency laparotomy was performed for the suspected gastrointestinal perforation or perforation of pyometra. At laparotomy, copious purulent fluid was present in the peritoneal cavity; however, no perforation of the gastrointestinal tract was observed. We identified a perforation site over the uterine fundus and purulent material exuding from the cavity. Subsequently, hysterectomy and bilateral salpingo-oophorectomy were performed. The patient was discharged on postoperative day 13 with no complications. Histopathologic studies revealed endometritis and myometritis with no evidence of malignancy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With diffuse peritonitis, ruptured pyometra should be considered, even in elderly female patients. This case illustrates the importance of clinical knowledge of acute gynecologic diseases. Here we also review the perforation of pyometra with no evidence of malignancy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

A sarcoid-like reaction is a development of non-caseating granuloma in patients with underlying malignancy and represents a false positive finding on positron emission tomography/computed tomography (PET/CT). A sarcoid-like reaction is a benign condition; therefore, differentiating a sarcoid-like reaction from cancer recurrence is necessary. Only uterine and ovarian cancer related cases have been reported in the gynecological field and to the best of our knowledge, this is the first case of a sarcoid-like reaction in vaginal cancer. A 59-year-old vaginal cancer patient received concurrent chemoradiotherapy and achieved complete remission. Recurrence of vaginal cancer was suspected because of the elevation of serum squamous cell carcinoma antigen level. PET/CT revealed abnormal uptake at the bilateral mediastinal and hilar lymph nodes. A non-caseating granuloma was detected from the biopsy of the swollen lymph nodes. No evidence of cancer recurrence was observed. A sarcoid-like reaction should be considered when evaluating PET/CT in cancer patients to prevent unnecessary treatments., (© 2015 Japan Society of Obstetrics and Gynecology.)

Introduction: Recombinant human soluble thrombomodulin (rhTM) is a novel anti-coagulant agent that regulates the imbalanced coagulation system by reducing the excessive activation of thrombin. rhTM potentially reduces the morbidity and mortality in patients with sepsis-induced disseminated intravascular coagulation (DIC). However, the efficacy of rhTM in obstetric DIC has not yet been established. We performed this study to examine whether the administration of rhTM was a potentially effective treatment for DIC induced by one or more underlying obstetric disorders., Methods: This is a single-center, retrospective cohort study conducted between January 2007 and February 2015 using the records of the Department of Obstetrics at the Perinatal Medical Center of TOYOTA Memorial Hospital, Aichi, Japan. The eligibility criteria were known or suspected obstetric DIC documented on the basis of clinical and laboratory data and association with one or more major underlying obstetric disorders. Baseline imbalance between patients with and without treatment of rhTM was adjusted using an inverse probability of treatment weighting using propensity scores composed of the following independent variables: severe postpartum hemorrhage, placental abruption, and preeclampsia/eclampsia, including hemolysis, elevated liver enzymes, and low platelet syndrome, initial platelet counts, D-dimer levels, fibrinogen levels, and prothrombin time-international normalized ratio (PT-INR). We evaluated laboratory changes and clinical outcomes in the early phase of obstetric DIC., Results: In total, 66 of 4627 patients admitted to our department during the study period fulfilled the required criteria; of these, 37 and 29 patients were included in the rhTM and control group, respectively. After adjustment, treatment with rhTM was associated with significant improvements in platelet counts, D-dimer levels, fibrinogen levels, and PT-INR compared with the control group. The platelet concentrate transfusion volume was significantly lower in the rhTM treatment group (3.02 vs 6.03 units, P = 0.016). None of the adjusted group differences were statistically significant for all types of organ damage and failure., Conclusion: rhTM administration was associated with clinical and laboratory improvement in patients with DIC caused by underlying obstetric conditions. Further clinical research is needed to clarify the optimal application of rhTM in each of the causative obstetric disorders.