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The best thromboprophylaxis for pregnant women with congenital antithrombin deficiency (CAD) is controversial.To clarify the effectiveness of a protocol for venous thromboembolism (VTE) prevention in pregnant women with CAD.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.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.Our protocol to prevent VTE in pregnant women with CAD is safe and effective.

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 (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.

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

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.

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.

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.

To investigate the relationship between serum total protein (TP) levels and maternal/neonatal outcomes among pregnant women with preeclampsia.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.The relationship between serum TP levels and maternal outcomes.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).Serum TP levels and proteinuria severity at preeclampsia diagnosis and delivery showed a positive relationship and predicted poor maternal outcome.

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 present study aimed to determine the relationship between the severity of proteinuria and maternal/neonatal outcomes among women with preeclampsia.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.Protein:creatinine (P/C) ratio to worse the maternal outcome was 4.8 among women with preeclampsia.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 ratio5.0 (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 delivery7 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.A higher P/C ratio at delivery in women with preeclampsia might cause EPB and CSC.

BackgroundThrombocytopenia is considered a sign of maternal organ damage of preeclampsia. However, platelet count distribution during pregnancy shifts downward even in uncomplicated women, and platelet counts in some uncomplicated women falls below the cutoff value of thrombocytopenia. Thus, not only absolute platelet counts number but also platelet count reduction rate may relate with adverse outcomes of preeclampsia. This study aimed to evaluate whether the overall platelet count reduction rate was associated with adverse outcomes of preeclampsia. MethodsThis retrospective study included 240 singleton pregnant women with preeclampsia. Overall platelet count reduction ≥30.0% was used as a cut-off value because 10–20% platelet counts reduction can be observed in uncomplicated pregnancy. The association between the overall platelet count reduction from the first trimester ≥30.0% and adverse outcomes; severe hypertension, uteroplacental dysfunction, maternal organ damage except for thrombocytopenia, and preterm delivery ResultsA total of 95/240 (39.6%) of women had ≥30.0% of overall platelet count reduction from the first trimester. The incidences of maternal organ damage except for thrombocytopenia (12.4%, 22.1%; p = 0.047), and preterm delivery p = 0.005) were higher in women with ≥30.0% of overall platelet count reduction than those otherwise. Even in women without thrombocytopenia (platelet counts ≥150 × 109/L), severe hypertension (66.2%, 85.4%; p = 0.018), and preterm delivery p = 0.017) were more frequently observed in women with ≥30.0% of overall platelet count reduction than those otherwise.ConclusionsA ≥30.0% of overall platelet count reduction from the first trimester was associated with adverse outcomes of preeclampsia even in women without thrombocytopenia.

The mechanisms leading to adrenal cortex development and steroid synthesis in humans remain poorly understood due to the paucity of model systems. Herein, we faithfully recapitulate human fetal adrenal cortex specification processes through stepwise induction of human induced pluripotent stem cells through posterior intermediate mesoderm-like and adrenal 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 that 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.

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

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

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.

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 9/L; however, the International Society for the Study of Hypertension in Pregnancy guidelines specify a cut-off of 9/L. We evaluated the effect of mild thrombocytopenia: platelet count 9/L and ≥ 100 × 109/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 × 109/L; mild thrombocytopenia, 9/L and ≥ 100 × 109/L; and severe thrombocytopenia, 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 Conclusions Mild thrombocytopenia was not associated with severe features of pre-eclampsia and would not be suitable as a sign of maternal organ damage.

Additional file 1: Table S1. Nugent score. Table S2. Association between BV and GBS detection during the 3rd trimester.

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.

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.

BackgroundCurrently, 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 9/L; however, the International Society for the Study of Hypertension in Pregnancy guidelines specify a cut-off of 9/L. We evaluated the effect of mild thrombocytopenia: platelet count 9/L and ≥100 × 109/L on clinical features of pre-eclampsia to examine whether mild thrombocytopenia reflects maternal organ damage in pre-eclampsia. MethodsA total of 264 women were enrolled in this study. Participants were divided into three groups based on platelet count levels at delivery: normal, ≥150 × 109/L; mild thrombocytopenia, 9/L and ≥100 × 109/L; and severe thrombocytopenia, 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. Adjusted relative risk were calculated with a Poisson regression analysis with a robust error. ResultsPlatelet counts indicated normal levels in 189 patients, mild thrombocytopenia in 51 patients, and severe thrombocytopenia in 24 patients. The adjusted risk ratios of severe thrombocytopenia were 2.11 [95% confidence interval, 1.61–2.77] for maternal organ damage except thrombocytopenia, 1.24 [1.01–1.53] for preterm delivery ConclusionsMild thrombocytopenia was not related with severe features of pre-eclampsia and would not be suitable as a sign of maternal organ damage.

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.

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.

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.

BACKGROUND: Hemophagocytic lymphohistiocytosis is potentially fatal. Prompt diagnosis and initiation of treatment are critical for ensuring the best possible prognosis. CASE: We present a case of parvovirus B19 infection related to hemophagocytic lymphohistiocytosis during pregnancy. The patient experienced fever and pancytopenia. A bone marrow biopsy demonstrated hemophagocytosis and a giant proerythroblasts, which is characteristic of a parvovirus B19 infection. Viral serology for parvovirus B19 was positive. Prompt treatment was started because of the high level of certainty of viral-associated hemophagocytic lymphohistiocytosis, and the patient was successfully treated with prednisolone administration. She delivered a healthy newborn without any complications. CONCLUSION: Hemophagocytic lymphohistiocytosis should be considered when encountering unexplained cytopenia and fever. Prednisolone was an effective treatment.

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.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, p0.001) at late pregnancy, 42.5 (0-112.6, p0.001) 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 (p0.001) and hemoglobin (p=0.002) and positively correlated with creatinine (p0.001). 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 (p0.001) and post-delivery hemoglobin (p=0.004).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.

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.

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.

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.

Introduction Preeclampsia is one of the major causes of maternal and perinatal mortality and morbidities. Pregnancy is characterized by certain structural and functional changes in the cardiovascular systems. However, to date, few studies were conducted about the influence in severity of preeclampsia to maternal cardiac function and the structural changes. Objectives We examined maternal cardiac function in patients with preeclampsia during peripartum period and compared with normal pregnant women. Methods A total of 138 singleton patients with preeclampsia and 18 singleton pregnant women without preeclampsia were enrolled in this study. We defined severe preeclampsia as systolic blood pressure over 160 mmHg or diastolic blood pressure over 110 mmHg. Echocardiography was conducted three times during peripartum period; late stage of pregnancy, early postpartum and one-month postpartum. We did not perform echocardiography at one-month postpartum to the non-preeclamptic women. We measured intraventricular septal thickness (IVST), left ventricular end-diastolic diameter (LVIDd), left ventricular end-systolic diameter (LVIDs), left ventricular posterior wall thickness (LVPWT), left ventricular ejection fraction (EF), left atrium diameter (LAD) and early transmitral velocity/early diastolic velocity of the mitral annulus (E/e′). Statistical analysis of covariance with age were performed with the SPSS software package. Results There were 87 patients who had severe preeclampsia, 51 patients with mild preeclampsia and 18 normal pregnant women. In these groups, there were no differences in pre-pregnancy BMI. In late stage of pregnancy, whereas only IVST was significantly dilated between the normal pregnant and mild preeclampsia, some parameters were significantly decayed in the patients with severe preeclampsia. All parameters excluded LVIDs and EF were dilated between the normal and severe preeclampsia. IVST, LVIDd and LAD were significantly different between the mild and severe preeclampsia. In early postpartum, there were no differences between the normal and mild preeclampsia. LVIDs was significantly dilated in severe preeclampsia compared with normal pregnant women. LVIDd, LVIDs and LAD were significantly different in the mild and severe preeclampsia. In one-month postpartum, LVIDd and LVIDs were significantly different between the preeclampsia patients. Concerned about EF, there was no significantly difference in three groups through these periods. The table shows these detailed results. Conclusion Mild preeclampsia had influences on maternal cardiac functions and, after delivery, the changes recovered within a few days. However, severe preeclampsia patients got cardiac remodeling and these changes did not recover completely even one-month postpartum. Not only anatomical changes but also left ventricular diastolic function deteriorated in severe preeclampsia compared with mild preeclampsia patients and normal pregnant women. Therefore, the severity of preeclampsia should be considered when examining maternal cardiac function and the risk of future cardiovascular disease in patients with preeclampsia. Download : Download high-res image (265KB) Download : Download full-size image