Hitoshi Masamoto

Elective Use of Aortic Balloon Occlusion in Cesarean Hysterectomy for Placenta Previa Percreta

Background: Only few reports are available on the use of aortic balloon catheter for cesarean hysterectomy in placenta previa percreta. Case: A 32-year-old woman with placenta previa percreta underwent cesarean hysterectomy at 34 weeks of gestation. Before starting the surgery, an aortic occlusion balloon catheter (30 mm balloon, 5 Fr) was inserted. For total hysterectomy, the aortic balloon catheter was inflated and there was a sudden and dramatic reduction in blood loss, and the surgery was completed safely. An aortic occlusion was sustained for 80 min, with blood loss estimated at 3,200 ml. The postoperative course was uneventful. At 3 months after the operation, the mother and baby remained healthy. Conclusion: An aortic balloon is rapidly and easily inserted, and is an option for major hemorrhage in placenta previa percreta.

Endometriosis and pregnancy outcome: are pregnancies complicated by endometriosis a high-risk group?

OBJECTIVES Increased incidence of preterm birth, pregnancy-induced hypertension (PIH) and small-for-gestational-age (SGA) babies have been reported in women with endometriosis, but the study populations included women in whom a definitive diagnosis was not attainable, and women who conceived via in vitro fertilization/embryo transfer (IVF/ET), which, in itself, is a risk factor for adverse pregnancy outcome. Thus there is a lack of consensus on the effects of endometriosis on pregnancy outcome. This study compared the pregnancy outcomes of women with or without a definitive diagnosis of endometriosis on laparoscopy. STUDY DESIGN Retrospective comparison of pregnancy outcomes of 108 women who underwent managed delivery of pregnancies established after laparoscopic investigation of infertility. Women with factors known to affect pregnancy outcome, such as age ≥41 years, conception via IVF/ET and multiple births, were excluded. Forty-nine of the study participants had endometriosis (En+ group) and 59 participants did not have endometriosis (En- group). RESULTS There were no significant differences in mean (±standard deviation) age (33±3.8 vs 33.6±4.1 years), history of miscarriage, history of preterm birth and history of PIH between the two groups. Ovulation induction was used for infertility treatment in 26.5% of the En+ group and 30.5% of the En- group, and artificial insemination was used in 30.6% of the En+ group and 32.2% of the En- group. Regarding pregnancy outcomes, no significant differences in miscarriage (18.4% vs 18.6%), subchorionic haematoma (5.0% vs 2.1%), preterm birth (7.5% vs 8.3%), PIH (15.0% vs 12.5%), caesarean section (32.5% vs 22.9%), gestational age at delivery (38.9±1.5 vs 38.8±1.7 weeks), birth weight (3013.3±480 vs 2934.5±639.5g) and SGA babies (2.5% vs 2.1%) were found between the En+ and En- groups. Placental abruption did not occur in either group. One neonate had trisomy 21 in the En+ group, and one woman had gestational diabetes in the En- group. CONCLUSION Endometriosis may not affect pregnancy outcome, but there is a need for a large prospective study.

Twin pregnancy in each half of a uterus didelphys with a delivery interval of 66 days

A 29-year-old woman complained of secondary infertility. Her first pregnancy resulted in a spontaneous miscarriage three years previously. A uterus didelphys was diagnosed by hysterosalpingography (Fig. 1) and laparoscopy. Intravenous pyelography showed that she had no renal or urinary collecting system abnormalities. The longitudinal vaginal septum separating two small cervices was removed surgically. Her present pregnancy developed following induction of ovulation by clomiphene citrate and human menopausal gonadotrophin, combined with transcervical insemination into each uterine cavity. Ultrasound examinations revealed a gestational sac containing an embryo in each uterine cavity at the eighth gestational week. She had preterm rupture of the membranes at the 25th gestational week. Clear amniotic fluid flowed from the left horn of the uterus, with a decreasing amniotic fluid index. Her temperature increased to 38.5jC with elevation of her white blood count and C-reactive protein. Spontaneous regular contractions occurred in the left horn, accompanied by severe variable decelerations of the fetal heart rate. The right horn of the uterus rarely contracted, and the fetus had no abnormal heart rate patterns. An emergency caesarean section was performed under epidural analgesia. Uterus bicornis bicollis was found. The fetus in the left horn was delivered through a transverse incision of the lower uterine segment of the left horn. A little boy weighing 764 g with Apgar scores of 3 and 4 at 1 and 5 minutes, respectively, was resuscitated immediately and transferred to the neonatal intensive care unit. The placenta weighed 180 g with no findings of chorioamnionitis. Prophylactic intravenous ritodrine chloride was given post-operatively for a few days. No significant regular contractions were noted in the right horn during and after surgery. Her post-operative course was uneventful with no signs of infection. Serial obstetric ultrasound examinations indicated no abnormal findings in the fetus in the right horn of the uterus. At the 35th gestational week, 66 days after delivery of the first twin, spontaneous labour started in the right horn, and the second twin was born spontaneously, a little boy weighing 2360 g with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. The placenta weighed 520 g with no abnormal findings. The first and second babies were discharged without complication on the 108th day after birth, weighing 2090 g, and on the 18th day weighing 2456 g, respectively.

Warfarin-associated fetal intracranial hemorrhage in woman with mitral valve replacements: a case report.

Warfarin-associated fetal hemorrhage is a fatal event. We report the case of a 39-year-old woman who had been taking warfarin for 23 years since undergoing mitral valve replacement. Thereafter, when she was found to be pregnant, the medication was switched to heparin from 6 to 21 weeks of gestation. Following this, she was prescribed oral warfarin again (3.5 mg per day), with a strict control of prothrombin time/international normalized ratio (PT/INR). At 23 weeks of gestation, fetal intracranial hemorrhage occurred because of maternal exposure to warfarin. Maternal PT/INR does not correlate well with the activity of warfarin in the fetus and currently, there is no direct way to prevent fetal intracranial hemorrhage. Hence, further research on the optimal coagulation therapy in pregnant women with valve replacement should be encouraged.

Outcome of pregnancy after laser conization: Implications for infection as a causal link with preterm birth

Objective:  To investigate a causal link between infection and preterm birth in women with a shortened cervix induced by prior laser conization.

Clearance of Antiphospholipid antibodies in pregnancies treated with heparin

Objective To describe the natural history of serum antiphospholipid antibodies (lupus anticoagulant and anticardiolipin antibodies) in pregnant women treated with heparin, and to identify a possible association between changes in antibody status and outcomes of subsequent pregnancies. Methods Thirty-six women with antiphospholipid antibodies who had three or more repeated miscarriages were enrolled. Intravenous heparin was used for each of the first pregnancies after referral. Changes in antibody status were investigated with relation to outcomes of the index and subsequent pregnancies. Results Eighteen of 23 pregnancies in 36 antibody-positive women treated with heparin resulted in term or preterm deliveries with live-born infants, and five ended in abortions. Antibodies cleared in ten of 12 term pregnancies, in five of six preterm pregnancies, and in one of five abortions. There was a statistically significant difference between the term pregnancy and abortion groups (P < .05). Eleven second and third pregnancies in nine women in whom antibodies cleared resulted in term or preterm deliveries of live-born infants, without heparin therapy. The second and third pregnancies in one woman whose antibodies persisted ended in miscarriages despite repeated heparin administration. Conclusion Antiphospholipid antibodies cleared spontaneously in some pregnant women treated with heparin. Subsequent pregnancies among women in whom antibodies cleared were managed successfully without medication, whereas pregnancies in women with persistent antibodies required treatment.

Thyroid function after hysterosalpingography using an oil-soluble iodinated contrast medium

Background. The objective of the present study was to evaluate the effect of an oil-soluble iodinated contrast medium (lipiodol) for hysterosalpingography (HSG) on thyroid function. Methods. In 214 of 528 women with infertility examined by HSG using lipiodol between 1996 and 2006 at our institution, serum free thyroxine (FT4) and thyrotropin-stimulating hormone (TSH) were measured before and several months after HSG. Results. The average age of the women was 34.5 ± 4.6 years and their average infertility period was 2.9 ± 2.5 years (mean±standard deviation). The 214 patients were divided into three groups based on the results of thyroid function before HSG: 180 in euthyroid, 28 in subclinical hypothyroidism and 13 in subclinical hyperthyroidism. The number of patients in the subclinical hypothyroidism group who developed hypothyroidism after HSG (ten of 28) was significantly higher than that of the euthyroid group (four of 180). Thyroid hormone replacement was required in three patients from the subclinical hypothyroidism group 1, 2 and 5 months after HSG. Conclusions. We conclude that thyroid function should be monitored closely after HSG using lipiodol to detect the development of hypothyroidism, particularly in patients with subclinical hypothyroidism, and TSH and FT4 measurements should be performed before HSG to identify patients at risk for hypothyroidism.

Post-partum maternity ‘blues’ as a reflection of newborn nursing care in Japan

Objectives: To investigate the prevalence of post‐partum ‘blues’ in mothers whose babies are cared for in a newborn nursery, compared with mothers providing rooming‐in care. Methods: Japanese normal primiparous women were prospectively studied from 1998 to 1999. The newborns of these mothers were managed in the newborn nursery or by rooming‐in care. To diagnose maternity ‘blues’ and ‘depression’, the Steins Questionnaire and the Edinburgh Postnatal Depression Scale were used. Results: Ninety‐seven and 93 women were managed by newborn nursery care and by rooming‐in care, respectively. Of these women, a total of 181 women were considered for analysis. ‘Blues’ was noted in 31 of 92 mothers (33.7%) receiving newborn nursery care and in 18 of 89 (20.2%) receiving rooming‐in care with a significant difference (P<0.05), and in 49 of 181 (27.1%) as a whole. The daily Steins scores changed significantly during the 10 days post‐partum in each group (P<0.0001). Post‐partum ‘depression’ was observed in three mothers (3.4%) in the newborn nursery care group and in four (4.8%) of the rooming‐in care group, not a significant difference, and in seven (4.1%) as a whole. Conclusion: Maternity ‘blues’ is experienced by 25% or more of Japanese primiparous women delivering healthy babies via uncomplicated delivery. The system of newborn nursery infant care may be a potential causal factor for maternity ‘blues’, although it should be confirmed by a prospective randomized trial.

Hysteroscopic tubal catheterization under laparoscopy for proximal tubal obstruction.

PurposeThe purpose of this study was to investigate the fertility outcomes of infertile patients having proximal tubal obstruction treated with hysteroscopic tubal catheterization (HCT) for recanalization under diagnostic laparoscopy.MethodsFrom January 2000 to December 2008, diagnostic laparoscopy was used to assess the tubal status of 61 patients with unilateral or bilateral proximal tubal obstruction, as confirmed by hysterosalpingography. Among them, 35 patients with tubal obstruction confirmed by chromopertubation under laparoscopy subsequently underwent HCT. The pregnancy outcomes and success rates of recanalization were investigated.ResultsIn the 35 patients with confirmed tubal obstruction, HCT was performed in 54 fallopian tubes. The success rate of recanalization was 25.9% (14/54) per tube and 37.1% (13/35) per patient. Of the patients in whom tubal patency was restored, 4 achieved pregnancy, including 1 tubal pregnancy and 1 miscarriage. Among the 61 patients, excluding 14 who underwent in vitro fertilization–embryo transfer (IVF–ET) after laparoscopy, 13 were pregnant (27.7%), 9 gave live births, 1 had tubal pregnancy, and 3 had miscarriages.ConclusionsHCT under laparoscopy is an option for couples with tubal infertility who do not prefer IVF–ET.

Subchorionic hematoma occurs more frequently in in vitro fertilization pregnancy.

OBJECTIVE Obstetric complications occur more frequently in pregnancies after in vitro fertilization (IVF). We attempted to determine the correlation between subchorionic hematoma and IVF pregnancies. STUDY DESIGN We analyzed 194 pregnancies achieved by infertility treatment between January 2008 and February 2012 at our hospital. Among these, 67 were achieved by IVF and 127 by non-IVF approaches. We compared the frequency of subchorionic hematoma between the groups and examined the risk factors for subchorionic hematoma in the IVF group. RESULTS No significant differences regarding age and the number of uterine surgery were observed between the groups. The duration of infertility was longer, parity and the rate of luteal support were higher in the IVF group compared with that in the non-IVF group. The frequency of subchorionic hematoma was significantly higher in the IVF group (22.4%) than that in the non-IVF group (11%) (P=0.035). Univariate analysis in the IVF group demonstrated that frozen-thawed embryo transfer (OR, 6.18; 95% CI, 1.7-22.4), parity≥1 (OR, 3.67; 95% CI, 1.0-13.2) and blastocyst transfer (OR, 3.75; 95% CI, 1.1-13.3) were risk factors for the subchorionic hematoma. CONCLUSION The frequency of subchorionic hematoma is high in IVF pregnancies, and frozen-thawed embryo transfer, parity≥1, and blastocyst transfer may contribute to subchorionic hematoma onset.