Chihiro Hirai

Isolated gestational proteinuria preceding the diagnosis of preeclampsia – an observational study

Some pregnant women develop significant proteinuria in the absence of hypertension. However, clinical significance of isolated gestational proteinuria (IGP) is not well understood. This study aimed to determine the prevalence of IGP in singleton pregnancies and the proportion of women with IGP who subsequently developed preeclampsia (IGP‐PE) among all PE cases.

Uterine balloon tamponade as a test to assess further treatment

Sir We read with interest the letter “Drainage failure of Bakri balloon: no drainage does not indicate no bleeding” by Matsubara et al. (1) following the letter entitled “Practical consideration of inserting intrauterine balloon during cesarean section for placenta previa” (2). Currently, uterine balloons, including the Bakri balloon, have been accepted for controlling postpartum hemorrhage as the author described. At our institution, uterine balloon tamponade has been in use since 2009 with 89 cases of obstetric hemorrhage. Although we have used the metreurynter (Fuji-Metro ; Fuji Latex Co. Ltd., Tochigi, Japan), which does not have a drainage channel, we have never experienced such massive bleeding as described (1) after insertion of a balloon. During the tamponade we administer uterotonics and serially monitor the vital signs, including shock indexes. Furthermore, we carefully check for additional uterine bleeding escaping the balloon. We believe that frequent confirmation of possibly trapped bleeding in the uterine corpus is necessary after balloon insertion (3). We have, however, two unclarified issues with the letter (1): (i) How did the woman’s vital signs and shock indexes change before the hysterectomy? (ii) Was the concealed bleeding in the uterus or possible intraperitoneal blood collection as a counterflow through the Fallopian tubes evaluated before the surgery? We think that these points are important for the management of balloon tamponade. Serial monitoring of the vital signs and of the hemorrhage may lead to earlier intervention and a better outcome. Obstetricians should keep in mind that balloon tamponade is a beneficial option for hemostasis but simultaneously it has to be used as a test to assess the necessity for further treatment. Shintaro Makino*, Jun Takeda, Chihiro Hirai, Atsuo Itakura and Satoru Takeda Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan

Chymotrypsin Enhances Soluble Fms-Like Tyrosine Kinase 1 Production Through Protease-Activated Receptor 2 in Placenta-Derived Immortalized Human Trophoblast Cells.

The production of soluble fms-like tyrosine kinase 1 (sFLT1) by exogenous chymotrypsin in trophoblast cells through protease-activated receptor (PAR) 2 was investigated to identify the role of a chymotrypsin-like serine protease in preeclampsia (PE) pathogenesis. We evaluated the expression of chymotrypsin, FLT1, and sFLT1 in monolayers of immortalized human trophoblast cells derived from placenta (TCL-1 cells). To investigate whether chymotrypsin enhances the production and release of sFLT1 through PAR-2, we examined changes in sFLT1 protein levels in conditioned medium by enzyme-linked immunosorbent assay and sFLT1 messenger RNA (mRNA) levels by real-time polymerase chain reaction in TCL-1 cells treated with exogenous chymotrypsin in the presence or absence of a PAR-2 antagonist or a chymotrypsin inhibitor (TPCK). We also examined changes in PAR-2 expression in TCL-1 cells treated with tumor necrosis factor (TNF) α in the presence or absence of a polyclonal anti-TNF-α antibody. Western blot analysis showed that TCL-1 trophoblast cells expressed chymotrypsin, FLT1, and sFLT1. Compared with the control cells, the sFLT1 level in the conditioned medium and sFLT1 mRNA level in cells were both significantly enhanced when treated with a PAR-2 agonist or chymotrypsin for 6 hours. In contrast, the sFLT1 level in the medium and sFLT1 mRNA level in cells treated with a PAR-2 agonist or chymotrypsin were suppressed in the presence of a PAR-2 antagonist or a chymotrypsin inhibitor. The PAR-2 expression was upregulated by TNF-α, which was suppressed in the presence of TNF-α antibodies. These results indicate that chymotrypsin-like serine protease enhances sFLT1 production through PAR-2 in trophoblast cells and thus plays an important additional role in PE pathogenesis.

Incidence and risk factors of severe lacerations during forceps delivery in a single teaching hospital where simulation training is held annually

This study was conducted to evaluate the incidence of severe lacerations during forceps delivery and the risk factors associated with such delivery in a hospital where simulation training is held annually.

Predictive markers and prenatal management of isolated fetal complete atrioventricular block: A retrospective review at a single institution

The study was conducted to determine an effective method for identifying patients at high risk of developing isolated complete atrioventricular block (CAVB) and to review the efficacy of prenatal anti‐inflammatory treatment.