Search

In the case of placenta previa‐accreta when the placenta covers the entire anterior uterine wall, it is difficult to avoid transecting the placenta by traditional low‐transverse cesarean section (CS), resulting in catastrophic hemorrhage and fetal anemia. To prevent this critical risk, we developed the CS with transverse uterine fundal incision (TUFI) and this technique has been widely used as a beneficial surgical method in clinical practice owing to its safety advantages for the mother and neonate since our first report. However, the risk of uterine rupture during a subsequent pregnancy remains unclear. Based on our 17 years of experience, patients who require TUFI do not need to avoid this beneficial operative method simply because of their desire to conceive again, as long as certain conditions can be met. To approve a post‐TUFI pregnancy, an appropriate suture method, delay in conception for at least 12 months with evaluation of the TUFI scar, and cautious postoperative management are at a minimum essential. In this article, we showed our recommendation for operative procedure and discuss the current status of the management of post‐TUFI pregnancies based on the evaluation of the TUFI wound scar and experience with postoperative pregnancies. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Pelvic inflammatory disease associated with cytomegalovirus infection in immunocompetent adults might be difficult to diagnose because of the rarity and relatively inconspicuous symptoms of infectious mononucleosis. Even if the main complaint is lower abdominal pain, careful search for symptoms latent outside the abdomen could lead to the diagnosis. [ABSTRACT FROM AUTHOR]

Aim: We have established a novel extraperitoneal cesarean section technique by supravesical approach. An advantage of this technique over the conventional paravesical approach is that the lower uterine segment is broadly exposed and that all operative procedures can be performed under direct vision. We present the details of this novel technique. Methods: The bladder and the peritoneum are exposed by removing the transversalis and extraperitoneal fasciae. Subsequently, a triangular area between the median umbilical ligament, the peritoneum, and the bladder is exposed. The median umbilical ligament is dissected at this site. Bladder dissection from the peritoneum is also initiated from this area and proceeds toward the lower uterine segment. Results: Operative times for pelvic fascia dissection and bladder removal from the peritoneal surface are currently around 15–25 min. During the process of development of this technique, there have been no bladder injuries in 501 patients that caused urine leakage. Discussion: The supravesical approach has been considered difficult due to the strong adhesion between the perivesical fascia and the peritoneum at the bladder fundus. In this paper, we show how to safely remove the bladder fundus from the peritoneum. The bladder can then be easily lowered down toward the lower uterine segment. Although this technique allows the lower uterine segment to be broadly exposed and all operative procedures can be performed under direct vision, a disadvantage is the comparatively long time currently required to perform it. Conclusions: This technique could be a valuable option for extraperitoneal cesarean section, but disadvantages must also be considered. [ABSTRACT FROM AUTHOR]

Aim: Transverse uterine fundal incision (TUFI) was developed to avoid catastrophic hemorrhage associated with cesarean section of the placenta previa–accreta. Abdominal incisions extend as far as the upper abdomen in patients in the third trimester of pregnancy and require general anesthesia. Instead, we tried to aspirate amniotic fluid (AF) to reduce the uterine size. Methods: TUFI was performed in 19 of our patients in the third trimester in whom placenta previa accreta could not be ruled out between June 2012 and August 2016. After the lower abdominal vertical incision, we attempted to exteriorize the uterine fundus. If this was impossible, we inserted an 18‐gauge spinal needle into the amniotic space. We aspirated AF until the uterine fundus could be exteriorized. Results: We exteriorized the uterine fundus without extending the incision to the upper abdomen by aspirating 250–670 mL of AF in 12 patients who were between the 33rd and 37th week of pregnancy, and TUFI was performed under spinal anesthesia. AF aspiration was not required in four patients who were in the 30th or 31st week of pregnancy and in two patients with oligohydramnios in the 35th week of pregnancy. In one case, the trial was canceled due to hemorrhagic AF aspiration. No serious complications were observed in mothers or neonates. Conclusion: TUFI could be made by abdominal incision to the left of the umbilicus under spinal anesthesia without anesthesia by reducing the uterine size through AF aspiration, even for patients in the third trimester of pregnancy. [ABSTRACT FROM AUTHOR]

Cesarean section en caul could cause neonatal anemia, but the mechanism remains unknown. We demonstrate an association between neonatal anemia and velamentous insertion of the umbilical cord in cesarean section en caul, and suggest a way to make this procedure safer. We performed cesarean section en caul, but the placenta and the membrane sac were delivered separately. The neonate was severely anemic. The umbilical cord was attached to the membrane and the blood vessel connecting the umbilical cord and placenta was torn. The amniotic membrane covering the placental surface had peeled away. Velamentous insertion of the umbilical cord could be a cause of neonatal anemia associated with cesarean section en caul. [ABSTRACT FROM AUTHOR]

Objective: Key considerations for managing an umbilical artery aneurysm (UAA) are a timely termination and the prevention of rupture of the UAA during delivery. Herein, we propose a treatment strategy based on our experience of UAA complicated by a fetal cardiac anomaly.Case: A case of UAA was referred to our hospital at 23 weeks of gestation. The UAA increased its size to 6 cm. The blood reservoir within the UAA was presumed to be equivalent to the circulating blood volume of the fetus. At 28 weeks, small echogenic components suspected to be hematomas appeared in the umbilical vein, and the umbilical interstitial substance became edematous. An improvement in the fetus' condition could not be expected unless the UAA size was smaller. Thus, a cesarean delivery was performed at 30 weeks during which the UAA ruptured. The baby was anemic, disseminated intravascular coagulation (DIC) and later died.Conclusion: We present an assessment of a large blood reservoir within an UAA that may indicate the likelihood of high-output cardiac failure of the fetus. Either a classical cesarean section or a transverse uterine fundal incision should be performed when the UAA size is greater than 5 cm to prevent rupture of the UAA. [ABSTRACT FROM AUTHOR]

Endometriosis is a complex trait, which means that multiple susceptibility genes interact with one another and the environment to produce the phenotype. One of the genes previously implicated in the disease is CYP17; this encodes the enzyme P450c17a, which plays a vital role in steroid biosynthesis in the ovary. The presence of a single nucleotide polymorphism (T?C) in the 5'-promoter region of the gene creates a new recognition site for the restriction enzyme MspA1 producing a mutant allele (A2), which affects circulating estrogen levels. In this study, we compared the frequency of the CYP17 MspA1 polymorphism in two different ethnic populations. DNA was obtained from (1) 94 women with revised American Fertility Society (rAFS) stage III–IV endometriosis and 97 male blood donors in the UK, and (2) 130 women with rAFS stage III–IV endometriosis and 179 female newborn infants in Japan. No significant differences in allele or genotype frequencies were seen in either population. The genotype distribution in the UK population was 33/94 [35.1%] (cases) and 39/97 [40.2%] (controls) for A1A1 (homozygous wild-type); 43/94 [45.7%] (cases) and 44/97 [45.4%] (controls) for A1A2; and 18/94 [19.1%] (cases) and 14/97 [14.4%] (controls) for A2A2. The genotype distribution in the Japanese population was 31/130 [23.9%] (cases) and 57/179 [31.8%] (controls) for A1A1; 73/130 [56.2%] (cases) and 89/179 [49.7%] (controls) for A1A2; and 26/130 [20.0%] (cases) and 33/179 [18.4%] (controls) for A2A2. The CYP17 MspA1 polymorphism is probably not associated with endometriosis in either the UK or the Japanese population. [ABSTRACT FROM AUTHOR]

Background: Several studies show that 17beta-estradiol (E2) has protective effects on atherosclerosis in the arterial wall in postmenopausal women. Little information is, however, available regarding the effect of estriol (E3) on atherosclerosis. This study was conducted to investigate the effects of E3 alone and combined E3/pravastatin therapy on intima-media thickness (IMT) of common carotid artery in postmenopausal women. Methods: Thirty-three postmenopausal women were allocated to four groups: daily treatment with E3 (2 mg) alone (E3 group, n = 10), pravastatin (10 mg) alone (pravastatin group, n = 6), combined treatment with E3 (2 mg) and pravastatin (10 mg; E3/pravastatin group, n = 7) and untreated control group (n = 10). All women attended the Kobe University Hospital once a year for routine gynecological and ultrasonographic examinations for the evaluation of atherosclerosis. Results: A significant decrease in IMT was noted in the E3/pravastatin group compared with that in the untreated control group (p < 0.05), whereas there was no significant difference in the reduction rate of IMT in the pravastatin group, E3 group and untreated control group. Conclusions: The combined E3/pravastatin therapy appeared to retard the progression of atherosclerosis in postmenopausal women. [ABSTRACT FROM AUTHOR]

Background: Tumor necrosis factor-alpha (TNF-alpha) is a multifunctional proinflammatory cytokine, associated with various inflammatory and autoimmune diseases. Elevated TNF-alpha levels in peritoneal fluid have been reported in women with endometriosis, suggesting that TNF-alpha may be involved in the development of endometriosis. In this study, we investigated the possible association between endometriosis and the TNF-alpha gene promoter polymorphisms -238G/A, -308G/A, -857C/T, -863C/A and -1031T/C in a Japanese population., Methods: We compared the distribution of the -238G/A, -308G/A, -857C/T, -863C/A and -1031T/C polymorphisms in the promoter region of TNF-alpha in 130 endometriosis cases and 185 controls using PCR-RFLP analysis., Results: The allele frequencies of -238A, -308A, -857T, -863A and -1031C in controls were 2.0%, 1.3%, 19.4%, 17.0% and 18.6%, and in the cases 1.1%, 0.3%, 19.6%, 18.6% and 13.6%, respectively. No significant differences in frequencies were found between the crude endometriosis cases and controls. However, when the endometriosis group was divided into a subgroup of women with stage IV disease only, the frequency of the -1031C allele was significantly lower in this subgroup than controls., Conclusions: The variability of the -1031T/C polymorphism of the TNF-alpha gene may be associated with susceptibility to (AUTHOR: as meant?) endometriosis.

Objective: Betacellulin (BTC), purified and cloned from mouse beta cell tumor (BTC-JC10), is regarded as a new member of the epidermal growth factor family. The present study was conducted to clarify the expression of BTC and its receptors, ErbB-1 and ErbB-4, in the trophoblasts in the human placenta over the course of pregnancy., Design and Methods: Human placental tissues were obtained from 4 pregnant women at the 4th to 5th week of pregnancy (very early placentas), 10 women at the 6th to 12th week (early placentas), 5 women at the 18th to 21st week (mid placentas) and 8 women at the 38th and 40th week (term placentas). The mRNA expressions of BTC, erbB-1 and erbB-4 were evaluated by quantitative RT-PCR with Southern blotting and the expression of the soluble form of BTC was determined by western immunoblot with a specific antibody to BTC protein. Immunohistochemical staining of BTC, ErbB-1 and ErbB-4 was also performed., Results: The levels of BTC mRNA expression in early and mid placentas were significantly higher than those in term placentas. The soluble form of BTC protein with an estimated molecular mass of 9.5 kDa was expressed in early and mid placentas, whereas the soluble form was not detected in term placentas. BTC from very early placentas until mid placentas was immunolocalized in syncytiotrophoblasts (S-cells), and was most abundant in early placentas. In contrast, BTC was immunolocalized in extravillous trophoblasts (EVTs), but not in villous trophoblasts in term placentas. The levels of erbB-1 mRNA in the early and mid placentas were significantly higher than those in term placentas, whereas the levels of erbB-4 mRNA in early placentas were significantly lower than those in mid and term placentas. ErbB-1 was immunolocalized in cytotrophoblasts in very early placentas, whereas it was immunolocalized in S-cells from early until term placentas. ErbB-4 from very early placentas until mid placentas was immunolocalized in S-cells, whereas ErbB-4 in the term placentas was detected in EVTs, but not in villous trophoblasts., Conclusions: These findings provide evidence for changes in expression and cytological localization of BTC and its receptors in the trophoblasts in human placenta over the course of pregnancy. BTC may play a pivotal role as a local growth factor in promoting the differentiated villous trophoblastic function via ErbB-1 in early placentas and in contributing to placental growth through the maintenance of EVT cell function via ErbB-4 in term placentas.

p53 protein, a tumor suppressor gene product, has been reported to play a crucial role in suppressing the growth of a variety of cancer cells. However, little information is currently available regarding the content of p53 protein in human leiomyomas. The present study was conducted to elucidate the p53 protein content in human leiomyomas and its regulation by sex steroid hormones. The content of p53 protein in leiomyomas was examined by immunohistochemical staining and Western blot analysis in comparison with that in the adjacent normal myometrium or leiomyoma specimens from GnRH agonist-treated patients. In addition, isolated human leiomyoma cells were subcultured in phenol red-free DMEM supplemented with 10% FBS for 120 h and then stepped down to serum-free conditions for an additional 72 h in the absence or presence of 17 beta-estradiol (E2; 10 ng/ml), progesterone (P4; 100 ng/ml), or E2 (10 ng/ml) plus P4 (100 ng/ml). The effects of sex steroids on p53 protein content in cultured leiomyoma cells were also assessed by Western immunoblot analysis. Immunohistochemical staining and Western blot analysis revealed that p53 protein content was highest in leiomyomas treated with GnRH agonist for 16 wk, lower in leiomyomas in the secretory, P4-dominated phase, and lowest in leiomyomas in the proliferative, E2-dominated phase of the menstrual cycle. There was no difference in p53 content between leiomyomas and the adjacent normal myometrium. Western blot analysis of cultured leiomyoma cell extracts revealed that E2 treatment significantly decreased p53 protein content compared with the control cultures, whereas either P4 treatment or combined treatment with E2 and P4 did not affect p53 protein content in cultured leiomyoma cells. The concentrations of sex steroid hormones used were within the physiological tissue concentrations in leiomyomas and myometrium described earlier. The present study suggests that E2 down-regulates p53 protein content, whereas P4 is ineffective in those cells. The E2-induced decrease in p53 protein content in leiomyoma cells leads us to propose that E2 may regulate human leiomyoma growth in part by down-regulating p53 tumor suppressor protein content in those cells.

Objective: To evaluate the role of transarterial embolization followed by hysteroscopic removal of a placental polyp with preservation of reproductive capacity., Study Design: Three patients with placental polyps with abundant blood flow, suspected on ultrasonography with color Doppler imaging and on magnetic resonance imaging, were studied. They underwent transarterial embolization followed by hysteroscopic removal of the polyp. Transarterial embolization of the bilateral uterine arteries was carried out using an absorbable gelatin sponge. Selective removal via hysteroscopy was performed on the following day using a cutting loop without electrical stimulation. The polyp was gradually resected to the level of the surrounding endometrium., Results: Complete removal of the placental polyp was achieved in all patients. The presence of a placental polyp was confirmed by pathologic examination. The operative time was ranged from 26 to 53 minutes. In all cases, no complications were noted, and bleeding was minimal during and immediately after the procedure. Postoperative ultrasonography demonstrated a uterine cavity free of residual mass in each case., Conclusion: Transarterial embolization of the uterine arteries followed by selective hysteroscopic removal is a safe and effective method of minimizing bleeding and preserves fertility in the treatment of placental polyps with an abundant blood flow.