Chizuko Isurugi

Changes in serum levels of heat shock protein 70 in preterm delivery and pre-eclampsia

Aim: The aim of this study was to investigate heat‐shock protein (Hsp)70 as a novel marker to evaluate the curative effects of treatment for preterm delivery high‐risk patients and pre‐eclampsia.

Monochorionic twin fetus with VACTERL association after intracytoplasmic sperm injection

We report a rare case of a monochorionic twin gestation after intracytoplasmic sperm injection (ICSI) in which one of the fetuses had VACTERL association. A 27‐year‐old woman became pregnant by ICSI and was found to have monochorionic twin fetuses. One fetus was noted to have the following anomalies: a multicystic, dysplastic left kidney with a hydroureter, and a dilated colon. A normal‐sized stomach and normal amount of amniotic fluid were observed during the prenatal period with no other anomalies. The postnatal examination revealed hypospadias, and anal, esophageal, and duodenal atresia; thus, a diagnosis of VACTERL association was established. Although the prenatal diagnosis of this disorder is a challenge, even in a singleton, some of the characteristic features observed during antepartum ultrasonography may be a clue to the diagnosis, especially in a twin pregnancy after ICSI.

Fetal goiter associated with preconception hysterosalpingography using an oil‐soluble iodinated contrast medium

Fetal goitrous hypothyroidism is rare in pregnancies of euthyroid women. It is reported to be caused by excessive maternal iodine exposure, such as from oral intake. There has however been one case that occurred after hysterosalpingography (HSG) with an oil-soluble iodinated contrast medium. Here we report our own experience of fetal goiter after preconception HSG using this contrast medium. A 27-year-old woman was referred to our hospital at 29 weeks’ gestation with polyhydramnios. Her history was negative for thyroid disease and her iodine intake was normal. She had undergone treatment for infertility and, on the 11th day of her last menstrual cycle, she had undergone HSG with an oil-soluble iodinated contrast medium. Basal body temperature indicated that she was pregnant 5 days after the procedure. Following detailed ultrasound examination, a large homogeneous goiter, measuring 35 × 19 mm, was identified in the anterior aspect of the fetal neck (Figure 1), which was also visualized with fetal magnetic resonance imaging (MRI) (Figure S1). Maternal thyroid function was low, confirmed by a high level of serum thyroid-stimulating hormone (TSH) and low levels of free thyroxine (T4) and free triiodothyronine (T3). At 35 week’s gestation, levels had returned to normal without medical treatment and the polyhydramnios

OP18.08: FGR fetuses have less facial expressions than AGA counterparts with the assessment by four-dimensional high-definition live (4D HDlive) ultrasound

only moderate decrease until 38 GW (108.2ml), but considerable variation of the absolute dimensions. The best fitting equation for SAS growth was a third-degree polynomial function (y = 433 – 59.6 * x + 2610 * x2 -33.36*x3; R2= 0.829). The relative SAS volume was high initially (40% in GW 16) and decreased until 23 GW (34%), peaked again at GW 27 (38%) and got reduced to 25% in GW 38. The best-fitting equation was a cubic function (y = 112-8.96*x+0.36*x2-0.00489*x3; R2 = 0.631). Conclusions: The SAS represents an important part of fetal intracranial anatomy, on average making up one third of the EV. Its reduction with advancing gestation may be considered a means to allow for further increase of brain volume until term, without concomitant increase in head size.

Progressive Fetal Subdural Hematoma Associated With Maternal Vitamin K Deficiency: Prenatal Diagnosis and Neurologically Favorable Prognosis

A 31-year-old woman, gravida 2, para 0, was referred to our hospital at 28 weeks’ gestation for an enlarged biparietal diameter in the fetus. Her first pregnancy had ended in artificial abortion at 11 weeks’ gestation for social reasons. She did not have any histories including anorexia or coagulation abnormality. She began to vomit frequently at 7 weeks’ gestation and was treated for hyperemesis gravidarum with infusion of nutrients. The nutritional solution contained multiple vitamins but not vitamin K. Because severe vomiting persisted, detailed examinations were performed. Upper gastrointestinal endoscopy at 25 weeks’ gestation revealed reflux esophagitis. She also had a diagnosis of mental disorders (attention deficit/hyperactivity disorder and anxiety disorder), and on-demand use of a major tranquilizer (risperidone) was started. At 28 weeks’ gestation, an enlarged biparietal diameter was noticed, and she was referred and admitted to our hospital. Fetal sonography revealed an enlarged biparietal diameter of 85.5 mm (14.0 standard deviation [SD]) caused by bilateral subdural hematoma (Figure 1A). As maternal serum protein induced by vitamin K absence or antagonist II (PIVKA-II) concentration, which was induced in the liver as a result of vitamin K absence, turned out to be 1.391 mAU/m (normal,< 40 mAU/mL), we highly suspected vitamin K deficiency and started its replacement therapy. There were not any other abnormal findings such as thrombopenia and coagulopathy (eg, low fibrinogen levels) in the maternal

Facial Expressions of Fetal Growth Restriction and Appropriate-for-Gestational Age Fetuses Assessed by Four-Dimensional High-Definition Live Ultrasound

Objective: To determine whether fetal growth restriction (FGR) fetuses have less facial expressions than appropriate-for-gestational age (AGA) counterparts with the assessment by four-dimensional high-definition live (4D HDlive) ultrasound. Methods: 4D HDlive ultrasound examinations of fetal facial expressions were performed on singleton pregnant women between 26 and 39 weeks of gestation. The duration of the 4D HDlive recordings was 15 minutes in all cases. The frequency of seven types of previously-reported facial expressions, or blinking, mouthing, yawning, tongue expulsion, sucking, smiling and scowling, were assessed. Two observers counted the frequencies, and inter-and intra-observer reproducibility was examined. Wilcoxon rank-sum test was used for comparison of FGR and AGA group. Kruskal-Wallis test was used for intra-group significance of frequencies of seven types of fetal facial expressions. P<0.05 was considered significant. Results: In this study, good intra- and inter-class correlation coefficients and intra- and inter-observer agreements were obtained. Thus, measurement values by only one examiner were used for further analysis. The facial expressions of 16 fetuses (FGR: n=8, AGA: n=8) were assessed. We noted a tendency for FGR fetuses to have less facial expressions than AGA counterparts. Although statistically significant inter-group difference was not detected in frequency of any facial expressions, this propensity is conspicuous in smiling (p=0.065) and mouthing (p=0.279). In AGA fetuses, the commonest facial expression was mouthing and was significantly more frequent than blinking (p=0.007), tongue expulsion (p=0.007) and sucking (p=0.002). We also noted a tendency that the frequency of facial expressions declines with fetal maturation. Although no statistically significant difference was shown, this propensity is prominent in mouthing of FGR (p=0.071). Conclusion: 4D HDlive ultrasound provides promising modalities in novel evaluative imaging of fetal various facial expressions, and may help to elucidate functional development of central nervous system (CNS) and facial expressions both in normal and compromised fetuses.

Successful ultrasound‐guided intraoperative external cephalic version of fetus in breech presentation immediately before ex‐utero intrapartum treatment (EXIT) procedure

A 32-year-old pregnant woman was referred to our hospital at 22 weeks of gestation because of fetal ascites. Ultrasound examination revealed massive ascites, enlarged hyperechogenic lungs with diaphragmatic inversion, dilated trachea and polyhydramnios, suggestive of congenital high airway obstruction syndrome (CHAOS) (Figure 1). The patient and her husband consented to undergo an ex-utero intrapartum treatment (EXIT) procedure, however the pregnancy had been complicated by a breech presentation throughout the whole gestational period (Figure 2). For a successful EXIT procedure, we planned to correct the fetal presentation by intraoperative external cephalic version (ECV). At 36 weeks of gestation, deep general anesthesia was achieved with desflurane and an abdominal midline incision was made. We performed an intraoperative ECV from the anterior wall of the uterus using sterile ultrasound guidance. We attempted first a forward roll of the fetus (counterclockwise rotation), which failed owing to the right-sided placental location preventing a forward roll of the fetal head (Figure 2). Therefore, we then attempted a backward roll of the fetus (clockwise rotation) and successfully moved the fetal head to the lower uterine segment. After the transverse incision was made at the lower uterine segment, the fetal head and neck were exposed. It was impossible to insert a tracheal tube through the larynx, thus a surgical airway was established by placement of an endotracheal tube via a tracheotomy. After delivery, congenital laryngeal atresia was confirmed by laryngoscopy (Figure S1). Fetuses with CHAOS cannot survive without appropriate perinatal management, owing to the lack of an airway for ventilation. An EXIT procedure, performed immediately prior to delivery, enables an airway to be secured by laryngoscopy, bronchoscopy or tracheostomy while being maintained on placental support1.

Intramural Pregnancy Implanted Into a Myometrial Defect Caused by Curettage: Diagnosis With Transvaginal Sonography and Preconception and Postconception Magnetic Resonance Imaging.

A 31-year-old woman, gravida 0, para 0, was referred to our hospital for suspected ectopic pregnancy at 7 weeks’ gestation. She had undergone conization of the uterine cervix for adenocarcinoma in situ 2 years previously. Transvaginal sonography revealed a gestational sac with a live fetus at the fundus of the uterus (Figure 1A), and color Doppler sonography showed marked hypervascularity around the gestational sac, which was located within the fundic uterine wall. Because this sonographic appearance strongly suggested intramural pregnancy at the fundic uterine wall, we asked the patient whether she had previously undergone surgery of the uterine corpus. She then told us that an artificial abortion had been performed by dilation and curettage for social reasons 10 years previously (gravida 1). We therefore reexamined the magnetic resonance imaging (MRI) obtained 2 years previously. It had clearly indicated a thin myometrium at the fundus of the uterus (Figure 1B). Magnetic resonance imaging performed at 7 weeks’ gestation showed a gestational sac growing inside the fundic uterine wall and confirmed the diagnosis of intramural pregnancy implanted into the myometrial defect (Figure 1C). Uterine artery embolization was chosen for initial treatment at 7 weeks’ gestation. A pelvic angiogram verified that the gestational sac was fed by bilateral uterine arteries, and uterine artery embolization was performed. Laparotomy was performed 3 days after embolization. The gestational sac, covered somehow by the markedly thinned fundic uterine myometrium with abundant vessels on its surface, was protruding (Figure 1D). The lesion was resected, and the histologic examination confirmed the tissue with chorionic villi and decidua. The patient had an uneventful postoperative course. Here we report a case of intramural pregnancy implanted into the myometrial defect after dilation and curettage. We find this case quite unique for 2 reasons. One is the fact that the gestational sac observed clearly inside the fundic uterine wall on transvaginal sonography, apart from the endometrium (Figure 1A), led us to a strong suspicion that the patient must have undergone some kind of surgery of the uterine corpus. The other is the fact that MRI obtained 2 years previously showing an extremely thin myometrium at the fundus of the uterus along with MRI at 7 weeks’ gestation during this pregnancy led us to a definitive preoperative diagnosis of the current intramural pregnancy implanted into the myometrial defect caused by an artificial abortion by dilation and curettage 10 years previously.

Vesico-amniotic shunting for lower urinary tract obstruction in a fetus with VACTERL association†

Newborn cases of VACTERL association with lower urinary tract obstruction (LUTO) are rare and there have been no reports on those patients undergoing fetal therapy in English literature. We successfully performed vesico‐amniotic shunting in a fetus having LUTO caused by abnormality of the external genitalia at 16 weeks’ gestation. Although fetal karyotype was normal 46XY, follow‐up fetal ultrasound examinations revealed ventriculomegaly in the brain, a small stomach and a right multicystic dysplastic kidney. MRI at 31 weeks’ gestation suggested lobar type holoprosencephaly. Diagnosis of VACTERL association was confirmed postnatally. We consider that vesico‐amniotic shunting is indicated for a fetus of VACTERL association with LUTO if the parents wish the procedure after genetic counseling and explanations about the fetal conditions.

Successful intraoperative external cephalic version of a fetus in the breech presentation using ultrasonography immediately before Ex utero intrapartum treatment (EXIT) procedure

A 32-year-old pregnant woman was referred to our hospital at 22 weeks of gestation because of fetal ascites. Ultrasound examination revealed massive ascites, enlarged hyperechogenic lungs with diaphragmatic inversion, dilated trachea and polyhydramnios, suggestive of congenital high airway obstruction syndrome (CHAOS) (Figure 1). The patient and her husband consented to undergo an ex-utero intrapartum treatment (EXIT) procedure, however the pregnancy had been complicated by a breech presentation throughout the whole gestational period (Figure 2). For a successful EXIT procedure, we planned to correct the fetal presentation by intraoperative external cephalic version (ECV). At 36 weeks of gestation, deep general anesthesia was achieved with desflurane and an abdominal midline incision was made. We performed an intraoperative ECV from the anterior wall of the uterus using sterile ultrasound guidance. We attempted first a forward roll of the fetus (counterclockwise rotation), which failed owing to the right-sided placental location preventing a forward roll of the fetal head (Figure 2). Therefore, we then attempted a backward roll of the fetus (clockwise rotation) and successfully moved the fetal head to the lower uterine segment. After the transverse incision was made at the lower uterine segment, the fetal head and neck were exposed. It was impossible to insert a tracheal tube through the larynx, thus a surgical airway was established by placement of an endotracheal tube via a tracheotomy. After delivery, congenital laryngeal atresia was confirmed by laryngoscopy (Figure S1). Fetuses with CHAOS cannot survive without appropriate perinatal management, owing to the lack of an airway for ventilation. An EXIT procedure, performed immediately prior to delivery, enables an airway to be secured by laryngoscopy, bronchoscopy or tracheostomy while being maintained on placental support1.