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This study aimed to clarify the appropriate management of gravid uterus incarceration through a retrospective analysis of 10 women with an incarcerated gravid uterus who delivered at our hospital between 2000 and 2019. The incidence of an incarcerated gravid uterus was one in 2000 cases. Nine cases were diagnosed during pregnancy (15-30 gestational weeks) and one during caesarean section (performed at 37 gestational weeks on suspicion of placenta previa). Two women underwent manual reduction at 19 and 20 gestational weeks, respectively; the procedure failed in one case, and intrauterine foetal death occurred after the procedure. Among the remaining eight cases, spontaneous reduction was observed in three women at 31, 33 and 34 gestational weeks, respectively. The prevalence of incarcerated gravid uteri may be higher than that previously reported, cases may more likely recover spontaneously, and spontaneous reduction could occur in the third trimester.Impact Statement

This study investigated the implementation status, attitudes, and practices regarding maternal pertussis vaccination in delivery facilities in Kanagawa, Japan. We conducted a questionnaire survey of pertussis vaccination during pregnancy at 125 delivery service facilities, excluding midwifery clinics, in Kanagawa Prefecture from June 18 to July 20, 2020. The questionnaire comprised multiple-choice items, with single or multiple answers depending on the question. Of the 125 facilities surveyed, valid responses were obtained from 72 facilities (58%). There were 41 primary clinics with birthing facilities (57%), 16 general hospitals (not designated perinatal centers) (22%), 10 regional perinatal centers (14%), and five tertiary perinatal centers (7%). None of the facilities administered pertussis vaccination during pregnancy. Forty facilities (56%) reported knowledge of the severity of neonatal and infant pertussis infections. Twenty-three facilities (32%) reported knowledge of the prevention of pertussis infection by vaccination during pregnancy. All facilities reported willingness to consider vaccination if included in the Japanese guidelines. In Japan, the pertussis vaccination during pregnancy is not highly practiced by obstetricians; thus, it is not as popular as in other countries. Further studies are needed to promote strategies to prevent pertussis infection in the neonatal and infant periods.

Aim The aim of this study was to clarify the physical and mental burden of the COIVD‐19 pandemic on obstetricians and gynecologists in Japan and to identify factors that increase the burden of their psychological stress. Methods A web‐based questionnaire was sent to obstetricians and gynecologists in Japan via email and social media to collect voluntary responses. This survey was conducted from September 1 to 30, 2020. Results A total of 852 valid responses were included in the analysis; 76% (644) of the physicians felt that the COVID‐19 pandemic caused them physical and mental stress equal to or greater than the most severe disaster they had ever experienced. Physicians who reported high mental and physical stress were more likely to be in areas with high numbers of infected patients (odds ratio (OR) 1.571, p = 0.012). Physicians experienced great stress to the point of wearing heavy personal protective equipment during routine vaginal deliveries by mothers with no COVID‐19 symptoms. This trend was markedly pronounced for physicians working in regions with fewer cases of COVID‐19 infection. Conclusions Obstetricians and gynecologists who reported high mental and physical stress were more likely to be in areas with high numbers of infected patients. One potential reason for this may be that they were required to wear more personal protective equipment than necessary. Infection control methods that ensure the safety of obstetricians and gynecologists while not causing unnecessary physical or psychological stress are needed.

Aim To evaluate psychological stress among pregnant and puerperal women in Japan during the coronavirus disease 2019 (COVID‐19) pandemic. Methods In this cross‐sectional study, we recruited pregnant women and puerperal women who delivered between January and September 2020 in Japan, using an online questionnaire. Participants were divided into low, middle, and high groups according to the degree of the epidemic in their region of residence. Related factors were analyzed using the chi‐squared test. The relationship between COVID‐19 epidemic regions and depression risks and anxiety using the Edinburgh Postnatal Depression Scale (EPDS) and Kessler 6 scale (K6) was evaluated using a univariate and multivariable logistic regression model. Results Overall, 7775 cases, including 4798 pregnant and 2977 puerperal women, were analyzed. The prevalence of high EPDS and K6 scores was significantly increased in pregnant women in the high than those in the low epidemic regions (EPDS: adjusted odds ratio [aOR] 1.453, 95% confidence interval [CI] 1.205–1.753; K6: aOR 1.601, 95% CI 1.338–1.918). There was no difference in EPDS score, but the prevalence of high K6 scores was significantly increased in puerperal women in the high than those in the low epidemic regions (aOR 1.342, 95% CI 1.066–1.690). Further, restriction on going to their hometown for delivery increased the prevalence of high EPDS scores among pregnant (aOR 1.663, 95% CI 1.296–2.133) and puerperal women (aOR 1.604, 95% CI 1.006–2.557). Conclusions Decreased support due to the COVID‐19 pandemic affected the psychological status of pregnant and puerperal women; hence, investing medical resources in their healthcare essential.

Aim This study aimed to clarify how the COVID‐19 pandemic impacts psychological stress levels in postpartum women in Yokohama, Japan. Methods We retrospectively compared the rates of positive screening tests for postpartum depression (Edinburgh Postnatal Depression Scale score of 9 or more or self‐injury factors) and liaison/psychiatric intervention rates between pre‐pandemic and pandemic groups of postpartum women who delivered a live birth at our tertiary perinatal center in Yokohama, Japan between January 2019 and May 2020. Those whose postpartum health screening was performed in 2019 (March–June 2019) were considered the pre‐pandemic group, and those whose screening was performed between March and June 2020 were considered the pandemic group. Adjustments were made for maternal background, pregnancy, and delivery outcomes, including a history of psychiatric disorders, complications, preterm delivery, NICU admission, and maternal postpartum complications, and the data were analyzed using a logistic regression analysis. Results Postpartum health screenings were performed on 339 women before the pandemic and 279 women during the pandemic. Positive screening rates for postpartum depression did not change before and during the pandemic (adjusted odds ratio 1.48, 95% confidence interval 0.885–2.46). Conclusions There was no apparent increase in maternal psychological stress due to the COVID‐19 pandemic in Yokohama, Japan. Postpartum women responded differently in settings with varied levels of disease severity and social restrictions.

According to the 2004 Japanese definition, early-onset (EO) preeclampsia (PE) is defined as PE occurring at32 weeks of gestation. This was based on the presence of "dual peaks" (30-31 and 34-35 weeks) in the prevalence of severe forms of hypertension. In contrast, the international definition adopted a cutoff of 34 weeks based on the consensus. Our aim was to investigate whether there were "dual peaks" in the gestational-age-specific incidence or prevalence of PE onset in pregnant women who underwent maternal check-ups at20 weeks of gestation in a multicenter retrospective cohort study. Diagnoses of PE and superimposed preeclampsia (SPE) were based on the new Japanese definition. A total of 26,567 pregnant women with singleton pregnancy were investigated. The best fitting equations for the distribution of the onset of gestational-age-specific incidence (hazard) rates of PE/SPE, PE, and PE with severe hypertension (a systolic blood pressure ≥160 and/or a diastolic blood pressure ≥110 mmHg) were investigated using the curve estimation function in SPSS. PE/SPE occurred in 1.83% of the patients. EO-PE/SPE with onset at32 and34 weeks of gestation and preterm PE/SPE occurred in 0.38, 0.56, and 1.07% of the patients, respectively. Gestational-age-specific incidence rates of PE/SPE, PE, and PE with severe hypertension showed exponential increases, with very high R

Lobular endocervical glandular hyperplasia (LEGH) is characterized by clinically profuse and watery vaginal discharge. In pregnancy with LEGH, with watery fluid leakage persisting throughout pregnancy, it is often difficult to visually diagnose PROM. Adding to this difficulty, auxiliary diagnostic tests might also show positive results, complicating treatment and management.

Because the anterior lower uterine segment is stretched, the incarcerated gravid uterus case with a history of cesarean section is a good candidate for manual reduction.

Aim Reports on pregnancy and delivery in women with Turner syndrome (TS) in Japan are limited to case reports, and the current situation remains unclear. Therefore, this study aimed to clarify the current situation of pregnancy and delivery in women with TS in Japan. Methods Our study comprised primary and secondary surveys and we included perinatal centers approved by the Ministry of Health, Labor and Welfare. Results A total of 24 cases from 19 facilities were reported, and we obtained individual information for 20 cases from 16 facilities. Of these 20 patients, 13 (65%) had become pregnant via oocyte donation. Three of these patients had received oocyte donation in Japan, while the other 10 had received donations in foreign countries. The other seven patients became pregnant with their own oocyte, with spontaneous menarche. Live babies were delivered by 18 patients, while an induced abortion was required at 18 weeks of gestation in one patient and an intrauterine fetal death from an unknown cause was detected at 38 weeks of gestation in another patient. Cesarean section was performed in 14 patients, with the most frequent indication being cephalopelvic disproportion. The rate of implementation of screening for complications related to TS was low, suggesting insufficient cooperation between facilities responsible for TS treatment, infertility and pregnancy and delivery management. Conclusion To improve pregnancy outcomes in women with TS, improved cooperation between facilities and laws regarding oocyte donation in Japan are needed.

The aim of this study was to clarify the risk factors for chlamydial infection and determine whether infection during pregnancy is associated with preterm birth in Japanese women. The subjects were women who underwent Chlamydia trachomatis polymerase chain reaction testing during a singleton pregnancy and delivered after the 22nd week of gestation at a tertiary care center between January 1, 2000 and December 31, 2016. We compared Chlamydia-positive (n = 259) and Chlamydianegative (n = 1,974) groups and evaluated the pregnancy outcomes. The Chlamydia-positive group had a higher rate of public assistance coverage, smoking during pregnancy, nulliparity, lack of a partner, presence of other sexually transmitted infections, high-risk social status, and younger age (P < 0.01). The incidence of preterm births was not different between the groups, with an odds ratio of 0.95 (95% confidence interval: 0.62-1.46). The incidences of low birth weight deliveries, premature rupture of membranes, and preterm premature rupture of membranes prior to the 37th week were also comparable between the groups. Chlamydial infection during pregnancy had no effect on preterm birth, even after adjustment for confounding factors.

To investigate how an extremely prolonged second stage of labor of 12 h or more affects maternal and neonatal outcomes.This retrospective cohort study included nulliparous, pregnant women with 37 + 0 to 41 + 6 weeks of gestation whom vaginal delivery was attempted at the Yokohama City University Medical Center between 2014 and 2018.In 446 cases of the prolonged second stage of labor, there were 296 women (66%) in the 2- to 6-h second stage of labor group, 112 women (25%) in the 6- to 12-h group, and 38 women (8.5%) in the 12-h or longer group. The longer the second stage of labor, the more significant was the increase in the rates of augmentation of the delivery, emergency cesarean delivery, and operative vaginal delivery. Even in the 12 h or longer group, 82% were able to have vaginal delivery. The 6- to 12-h group had a significant increase in third- or fourth-degree perineal lacerations compared to the 2- to 6-h group (aOR 8.12 [95% CI 1.55-42.6]). Clinical chorioamnionitis was significantly increased in the 12 h or longer group (aOR 4.88 [95% CI 1.62-14.8]). In terms of neonatal outcomes, comparison between the three groups showed no significant difference.With an extremely prolonged second stage of labor, maternal complications involved a significant increase in severe perineal lacerations and chorioamnionitis; however, there was no increase in adverse outcomes for neonates. It was not possible to conclusively determine if the duration of the second stage is acceptable.

Vasa previa can occur even in cases without placental malposition and the precise diagnosis of vasa previa, and the course of the cord vessels contributes to a safe delivery. The color Doppler is a useful and easy‐to‐use device to confirm the presence of vasa previa.

Aims The Japanese Society for the Study of Hypertension in Pregnancy revised the diagnostic criteria for pre-eclampsia (PE) to conform to those of the International Society for the Study of Hypertension in Pregnancy (ISSHP) in 2018. This study aimed to investigate whether pregnancy outcomes differ based on the presence of proteinuria and validate the adoption of the ISSHP criteria in Japan. Methods This is a retrospective study involving 308 women diagnosed with hypertensive disorders of pregnancy at a tertiary center. They were divided into the following groups: PE with proteinuria (n = 218), PE without proteinuria (n = 45) and gestational hypertension (n = 45) according to the ISSHP criteria for comparison of pregnancy outcomes. Results Applying the ISSHP criteria increased the number of pregnant women diagnosed as having PE by 14.6% (45 women). The difference in the rate of composite maternal complications between the two groups was unremarkable, with 33 cases (15.1%) in the PE with proteinuria group and 9 cases (20%) in the PE without proteinuria group. Moreover, composite neonatal complications occurred in 37 cases (17%) of PE with proteinuria group and 6 cases (13.3%) of PE without proteinuria group, showing remarkably similar incidence rate in the two groups. Women with PE with and without proteinuria had significantly earlier deliveries and lower neonatal birth weight than those with gestational hypertension. Conclusion Pregnancy outcomes of PE with and without proteinuria were almost similar although their incidence increased, confirming its validity for adaptation of the ISSHP criteria in Japan.

A 30-year-old woman with a bicorporeal uterus complained of abdominal pain and vaginal hemorrhage at 28 weeks and 5 days of gestation. There were no signs of placenta previa with echography in the second trimester; however, the echography showed a highly echoic area (91 × 85 mm), indicating placenta previa. Thereafter, abdominal pain and vaginal bleeding increased. Thus, we suspected placental abruption and performed cesarean section. After cesarean section, discharge of placenta-like tissue into the vagina was confirmed and pathological examination of the tissue showed only the decidua. In cases of uterine malformations, in which the uterine cavity is divided into pregnant and nonpregnant sides, the decidua on the nonpregnant side can be discharged before the onset of delivery. In addition, at the time of decidual discharge, echography findings are similar to those of placenta previa and the clinical symptoms are similar to those of placental abruption.

Aims To investigate whether the Institute of Medicine (IOM) guidelines for optimal gestational weight gain (GWG) in twin pregnancies are applicable to Japanese women. Methods This was a retrospective study involving women who delivered full-term twins at our tertiary center diagnosed with a normal prepregnancy body mass index. The women were divided into two groups, according to the optimal GWG recommended by the IOM (16.8-24.5 kg): the adequate GWG (AGWG) group with GWG meeting the guidelines and the low GWG (LGWG) group with GWG below the guidelines. Next, the women were divided into two groups according to birthweight: a group with both twins born appropriate for gestational age (AGA group) and a group with one or both twins born small for gestational age (SGA group). Their GWG as well as their pregnancy outcomes were compared. Results A total of 265 women were included. The AGWG group had a significantly higher proportion of hypertensive disorders of pregnancy than the LGWG group. There was no significant difference in the proportion of women with both twins born AGA or the rate of admission to the neonatal intensive care unit. Meanwhile, the median GWG in the AGA group was 13.6 kg, which was significantly higher than 12.0 kg in the SGA group. And even the median GWG in the AGA group was below the lower limit of the IOM guidelines. Conclusion The optimal GWG for Japanese women with twin pregnancies may be below the IOM guidelines.

A 35-year-old primiparous woman was diagnosed with Turner syndrome at the age of 12 yr due to short stature. Her karyotype showed a mosaic pattern [45, X(19)/46, XX(11)]. She had been followed up by the pediatric service. GH was not prescribed because, although she was of relatively short stature, her growth trajectory was reasonable. She was started on estrogen replacement therapy at 15 yr of age and switched to Kaufmann therapy after 1 yr. After transitioning her care to the gynecology service at 20 yr of age, she was screened for complications and Kaufmann therapy was continued. No abnormalities were detected in the pre-pregnancy screening. She conceived by in vitro fertilization and embryo transplantation with oocyte donation. No severe complications occurred during gestation, and she gave birth to a female neonate vaginally at 41 wk and 6 d of gestation. The neonate’s birthweight was 3166 g, and her Apgar scores were 8 and 9 at 1 and 5 min, respectively. No severe complications occurred during the postpartum period. Comprehensive medical treatment and appropriate transition from pediatric to adult services may improve the pregnancy outcomes of women with Turner syndrome.

Objectives To investigate the effect of chronic hypertension on expectant management for preeclampsia (PE). Study design Pregnant women who were diagnosed with severe PE before 34 weeks of gestation between 2005 and 2016 and managed at a tertiary center were the subjects of the study. Mothers were classified into two groups: a severe superimposed PE (SSP) group and a severe PE (SP) group. We compared the groups in terms of perinatal outcomes. Main outcome measures Pregnancy prolongation from the diagnosis of severe PE to delivery. Results The SSP group included 30 women whereas the SP group included 79 women. Expectant management could be performed in 24 subjects (80.0%) in the SSP group and 49 (62.0%) in the SP group (P = 0.110). Gestational age at diagnosis of PE (P = 0.016) and gestational age at delivery (P = 0.031) were significantly lower in the SSP group than in the SP group. There were no significant differences between the groups in terms of pregnancy prolongation (SSP, 8.5 days versus SP, 6.0 days; P = 0.25) or maternal and neonatal complications. Conclusions Compared to severe PE, severe PE superimposed on chronic hypertension does not increase the prevalence of maternal complications, and an equivalent pregnancy prolongation was obtained. Expectant management was possible in severe superimposed PE on chronic hypertension, as it was in severe PE.

Key Clinical Message As labor may mask a symptom of the rupture of ovarian cyst and delivery is a risk factor of its rupture, the possibility of rupture of ovarian cyst should always be considered during delivery.

The objective of this study is to examine the effect of low-glucose value on the 1-h 50-g glucose challenge test (GCT) on neonatal body weight in low-risk Asian singleton pregnant women.We retrospectively analyzed women who delivered a singleton neonate at term at a tertiary center and underwent GCT at 24-28 weeks of gestation between June 2001 and June 2015. The low GCT group was defined as75 mg/dL and 75-139 mg/dL were control. We compared these two groups of maternal characteristics, small for gestational age neonate (SGA), large for gestational age neonate (LGA), low-birth weight, and macrosomia. The χThere were 313 low GCT groups and 4611 control. The low GCT group were younger, had lower prepregnancy body weight, higher stature, and lower prepregnancy body mass index (BMI). After adjusting these variables, the low GCT group had a lower rate of LGA and a higher rate of SGA. Neonatal body weight is more influenced by maternal physique than by low GCT result (standardized coefficient (β); GCT 0.071, height 0.188, prepregnancy BMI 0.143).Neonatal body weight was only slightly influenced by low GCT result, but markedly influenced by maternal physique, such as height and prepregnancy BMI.

Objectives Currently, no unified set of criteria to classify preeclampsia (PE) exists. Further, no consensus has been reached whether fetal growth restriction (FGR) should be included in diagnostic criteria for PE. We examined the adequacy of including FGR in diagnostic criteria for PE. Study design Singleton pregnancy patients who developed PE before 34 weeks of gestation managed at a tertiary center between 2010 and 2016 were included. Patients were divided into two groups according to cause for PE diagnosis. In addition, those diagnosed with PE because of gestational hypertension (GH) and FGR were divided into two groups according to presence of proteinuria or organ dysfunction during the expectant management. Main outcome measures Pregnancy prolongation from PE diagnosis. Results Of 69 PE patients, 18 (28.1%) were diagnosed as PE with GH and only FGR (F group). Pregnancy prolongation between PE diagnosis to delivery was longer in the F group than in PE cases with primary organ dysfunction (P group) (21 vs 10 days, P = 0.049). Of 18 patients in the F group, 12 (66.7%) subsequently had proteinuria or organ dysfunction (S group). The remaining 6 patients (33.3%) had no subsequent proteinuria or organ dysfunction (N group). There were no significant differences in prolongation of pregnancy from organ dysfunction onset to delivery between the S and P groups (10 vs 10 days, P = 0.36). Conclusions Organ dysfunction onset may reflect PE progression more accurately than FGR onset. Further investigations on whether to include FGR into the diagnostic criteria for PE are needed.

Genital ulcer is one of the main clinical symptoms of Behçet disease; ulcers mostly occur in the vulva and are usually quite painful. We present an unusual case of Behçet disease wherein a painless genital ulcer was localized in the vagina. Our case is of a 43-year-old woman diagnosed with Behçet disease that was controlled with prednisolone. She became pregnant and developed fever, oral ulcers, and arthralgia at 16 weeks of gestation. Although a relapse of Behçet disease was suspected, ulceration and pain of the vulva were not observed. At 18 and 28 weeks of gestation, a vaginal ulcer was observed during regular prenatal examination, but the patient had no pain or other symptoms in the vulva. The vaginal ulcer healed at 29 weeks of gestation. No recurrence of the vaginal ulcer and other symptoms of Behçet disease were seen on subsequent follow-up examination at 1 month after delivery. Although genital ulcers of Behçet disease are common in the vulva and are generally painful, if they are located in the vagina, they can be painless. If Behçet disease is suspected based on other symptoms, a vaginal examination should be conducted as necessary for accurate evaluation of Behçet disease.

IntroductionThis study aimed to assess the validity of applying the International Association of Diabetes and Pregnancy Study Group (IADPSG) criteria for the diagnosis of gestational diabetes mellitus (GDM) at any time during pregnancy.Research design and methodsThis multicenter cohort study was conducted at five Japanese facilities from January 2018 to April 2019. The study cohort included women at a high risk of GDM who met one or more of the following IADPSG criteria during early pregnancy: fasting plasma glucose (FPG) ≥92 mg/dL and 75 g oral glucose tolerance test (OGTT) value of ≥180 mg/dL at 1 hour, or ≥153 mg/dL at 2 hour (hereafter early-onset GDM). Women diagnosed with early-onset GDM were followed up without therapeutic intervention and underwent the 75 g OGTT again during 24–28 weeks of gestation. Those exhibiting the GDM patterns on the second 75 g OGTT were diagnosed with true GDM and treated, whereas those exhibiting the normal patterns were diagnosed with false positive early GDM and received no therapeutic intervention.ResultsOf the 146 women diagnosed with early-onset GDM, 69 (47%) had normal 75 g OGTT values at 24–28 weeks of gestation, indicating a false-positive result. FPG levels were significantly higher in the first 75 g-OGTT test than in the second 75 g-OGTT test (93 mg/dL and 87.5 mg/dL, respectively; pConclusionsAlthough women with early-onset GDM were followed up without treatment, the results of repeated 75 g OGTT during mid-pregnancy were normal in about 50%. Our data did not support the adoption of IADPSG thresholds for the diagnosis of GDM prior to 20 weeks of gestation.

Although it is widely accepted that uterine artery embolization (UAE) is an effective therapeutic strategy for postpartum hemorrhage (PPH), no consensus has been reached regarding the efficacy of UAE in patients with PPH with disseminated intravascular coagulation (DIC). This single-center retrospective cohort study included patients treated with UAE using NBCA for PPH between 2010 and 2015. The patients were divided into DIC and non-DIC groups, according to the obstetrical DIC score and the overt DIC diagnostic criteria issued by the International Society of Thrombosis and Haemostasis (ISTH), and their clinical outcomes were compared. There were 28 patients treated with UAE using NBCA. Complete hemostasis was achieved by UAE in 19 of 28 patients. In eight of nine patients with unsuccessful hemostasis, surgical hemostatic interventions were performed after UAE, and hemostasis was achieved in seven patients. UAE using NBCA showed no significant intergroup differences in complete hemostasis according to the presence or absence of DIC based on obstetrical DIC score (70% versus 62.5%, P=1.000) or ISTH DIC score (54.5% versus 76.5%, P=0.409). UAE using NBCA may be a useful first-choice treatment for PPH with DIC.