Kana Yoshida

Placenta previa increta/percreta in Japan: A retrospective study of ultrasound findings, management and clinical course

Aim:  Placenta accreta is an abnormally firm attachment of placental villi to the uterine wall, which may cause postpartum hemorrhage resulting in maternal morbidity and mortality. The purpose of the present study was to clarify the incidence, clinical background and prognosis of placenta previa increta/percreta treated with different modalities in Japan.

Validation of the Prediction Model for Success of Vaginal Birth after Cesarean Delivery in Japanese Women

Aim: To validate a previously developed prediction model for vaginal birth after cesarean (VBAC) using a Japanese cohort. Methods: We performed a cohort study of all term pregnant women with a vertex position, singleton gestation, and one prior low transverse cesarean delivery attempting a trial of labor between April 1985 and March 2010. Variables necessary for the prediction of successful VBAC were maternal age, pre-pregnancy body mass index, ethnicity, prior vaginal delivery, prior VBAC, and indication for prior cesarean delivery. They were extracted from medical records and put into the formula that calculates an individual womans predicted VBAC success rate. The predicted rates were then partitioned into deciles and compared with the actual VBAC rates. The predictive ability of the model was assessed with a receiver operating characteristic and the area under the curve (AUC) was determined. Results: Seven hundred and twenty-five women who met the inclusion criteria had complete data available, of which 664 (91.6%) had VBAC. The predicted probability of VBAC, as calculated by the regression equation, was significantly higher in those who had a successful trial of labor (median 80.1%, interquartile range 71.5-88.7) than those who did not (median 69.4%, interquartile range 59.9-78.9, P<0.001). The predictive model had AUC of 0.80, which was comparative to the originally described one. When the predicted rates were each deciles of over 70%, the actual success rates were more than 90%. Conclusion: The previously published prediction model for VBAC developed in the USA is also available to Japanese women.

Impact of subclinical chorioamnionitis on maternal and neonatal outcomes

Background. Chorioamnionitis is considered to be one of the main causes of preterm labor and has been associated with an adverse perinatal outcome in preterm infants. The controversy about the benefits/risks of delaying labor is a critical issue concerning the management of chorioamnionitis. Methods. The database between July 2001 and March 2006 was reviewed for women with singleton pregnancies between 22 and 28 weeks of gestation and with chorioamnionitis diagnosed on admission by amniotic fluid neutrophil elastase level. Women were classified according to the severity of chorioamnionitis (group A, amniotic fluid neutrophil elastase level of 0.15–1 µg/ml; B, 1–10 µg/ml; and C, ≥10 µg/ml). During expectant management, serum C‐reactive protein levels monitored the remission and aggravation of chorioamnionitis. Following deliveries, placentas were examined for histologic chorioamnionitis. Results. One hundred women were enrolled (group A, 38; B, 34; C, 28). The latency period until delivery was significantly longer in group A than in groups B and C. C‐reactive protein levels just before delivery were higher than those on admission in 61% of the overall cases. Histologic chorioamnionitis and funisitis were manifested in 90.4% and 65.5%, respectively. Intrauterine fetal demise (4 cases) and neonatal and postneonatal deaths during admission (10 cases) were observed. Bronchopulmonary dysplasia was the most common major morbidity noted in groups B and C. Conclusion. Chorioamnionitis could be controlled but is hard to cure. Higher levels of amniotic fluid neutrophil elastase are associated with a shorter interval from admission to delivery in women with subclinical chorioamnionitis.

Aggressive intervention of previable preterm premature rupture of membranes.

Objective. To assess the neonatal and maternal outcomes of pregnancy complicated by previable preterm premature rupture of membranes (PPROM). Design. Retrospective study. Setting. Tertiary referral hospital. Sample. Forty‐five women having aggressive intervention with antibiotics, amnioinfusion, cerclage and tocolysis. Methods. The hospital database between July 2001 and December 2009 was reviewed for women with singleton fetuses and PPROM before 23+0 weeks of gestation. We analysed maternal and neonatal characteristics. Main outcome measures. Neonatal survival without major morbidity. Results. Thirty‐eight infants were delivered alive and seven were stillborn. Ten infants died in the neonatal intensive care unit and one in the labor ward. Twenty‐seven live‐born infants survived to discharge from hospital. The survival rate of pregnancies with aggressive management was 60% (27 of 45); that of live‐born infants was 71.1% (27 of 38). The median gestational age at PPROM and at delivery were significantly lower in the non‐surviving group than the surviving group. Thirty‐seven women (82.2%) had an amniotic neutrophil elastase level >0.15 μg/mL. Only four women (8.9%) developed clinical chorioamnionitis. Overall, 90.7% of the women showed histological evidence of chorioamnionitis. Eighty‐three per cent of the surviving children had bronchopulmonary dysplasia. Nine infants had serious sequelae at a corrected age of one and a half years. Maternal complications were uncommon. Conclusions. An aggressive treatment protocol for women with previable PPROM resulted in a high neonatal survival rate. Neonatal survival was associated with higher gestational age at delivery and with more frequent use of antenatal corticosteroids. The prognosis is still bad in PPROM before 22+0 weeks of gestation.

Fetal Intraventricular Bleeding Possibly due to Maternal Vitamin K Deficiency

We report a rare case of fetal intraventricular bleeding possibly due to maternal vitamin K deficiency. A 20-year-old woman was admitted to our hospital due to impending premature delivery and loss of dietary intake at 28 weeks of gestation. Her blood examination showed metabolic alkalosis, prolonged prothrombin time, and extremely high level of plasma des-gamma-carboxyprothrombin (protein induced by vitamin K absence, PIVKA-II). Intraventricular hemorrhage was demonstrated by ultrasonography 6 days after admission. She delivered a 2,288-gram girl infant at 40 weeks of gestation. Cranial computerized tomography and magnetic resonance images obtained postnatally demonstrated a reduced cerebral parenchyma adjacent to the interior side of the right lateral ventricle and the deficit of left cerebellum. The infant’s head control was insufficient and central impaired hearing was noted at 6 months of life.

Observation on validity of the five-tier system for fetal heart rate pattern interpretation proposed by Japan Society of Obstetricians and Gynecologists

Objective: To evaluate the five-tier classification of fetal heart rate (FHR) tracings recently proposed by Japan Society of Obstetricians and Gynecologists (JSOG). Methods: The database between January and June 2009 was reviewed for women in active labor at ≥36 + 0 gestational weeks, with singleton fetuses in cephalic presentation and with umbilical artery blood gas analyses. Continuous FHR tracings were assessed according to the five-tier classification proposed by JSOG, where level 1 is normal, level 2 is subnormal and levels 3–5 are abnormal patterns. Results: A total of 341 parturient women were eligible for this study protocol. The median (range) of the levels in the first and the second stage of labor were 1 (1–4) and 2 (1–4), respectively (p < 0.001). Both pH and base excess of umbilical artery decreased with higher levels of FHR tracings interpretation (p < 0.01). Interventions resulting in delivery were more necessary in the first stage of labor than in the second stage of labor in cases of levels 3 and more. Conclusions: Five-tier system for FHR tracing interpretation proposed by JSOG intercorrelates with the fetal acid-base balance well. Categorization of FHR tracings by uniform diagnostic criteria will be useful to standardize therapeutic strategy by sharing common perception among obstetrical staff.

Umbilical cord hematoma: association with chorioamnionitis and funisitis

1. Milard FE, Hunter CS, Anderson M, Edelman MJ, Kosty MP, Luiken GA. Clinical manifestations of essential thrombocythemia in young adults. Am J Heamatol. 1990;/33:/27 31. 2. Randi ML, Barbone E, Rossi C, Girolami A. Essential thrombocythemia and pregnancy: a report of six normal pregnancies in five untreated patients. Obstet Gynecol. 1994;/83:/915 6. 3. Solal-Celigny P, Fernandez H, Tertian G. Grossesse chez les malades atteintes de thromboctemie essentielle [Pregnancy in patients with essential thrombocythemia] (in French with English abstract). Presse Med. 1992;/21:/2085 8. 4. Katz VL, Watson WJ. Essential thrombocytemia during pregnancy. J Matern Fetal Med. 1993;/2:/34 7. 5. Perez-Encinas M, Bello JL, Perez-Crespo S, De Miquel R, Tome S. Familial myeloproliferative syndrome. Am J Heamatol. 1994;/46:/225 9. 6. Delage R, Demers C, Cantin G, Roy J. Treatment of essential thrombocythemia during pregnancy interferon-a. Obstet Gynecol. 1996;/87:/814 7.

Life-threatening septic shock in a pregnant woman with ileus

Septic shock during pregnancy is very rare but has high mortality. We report a case of septic shock in a pregnant woman with ileus, showing that severe ileus in a pregnant woman could be attributed to life-threatening septic shock and that we should give special attention to a nosocomial infection.

Maternal excessive vomiting: Association with periventricular leukomalacia

Periventricular leukomalacia (PVL) is an important cause of cerebral palsy in preterm infants [1]. Although obstetric risk factors for PVL include maternal infection, meconium-stained amniotic fluid, fetal hypoxia, and antepartum hemorrhage [2,3], maternal excessive vomiting is less well mentioned. A 36-year-old woman, gravida 3, para 1, whose body weight was 39 kg before pregnancy, was repeatedly admitted to hospital with anorexia, nausea, and vomiting. She had no past history of bulimia. At 30 weeks of gestation, she was hospitalized again because of severe vomiting and loss of dietary intake. Her body weight on admission was 35 kg. Intravenous hyperalimentation was started and her appetite was increased gradually. Because she stubbornly refused hospitalization and the non-stress test was reactive, she was discharged from hospital at 32 weeks and 6 days of gestation. At discharge, the blood chemistry study showed moderate hypokalemia (2.9 mEq/L) and hypochloremia (95 mEq/L) but not dehydration. At 33 weeks and 3 days of gestation, she was admitted to the hospital again with a complaint of staining and abdominal pain. She gave a history of having had excessive vomiting during her stay at home. In fact she had had a meal with her family but vomited by stealth. Ultrasonography demonstrated oligohydramnios. Loss of variability and variable and late decelerations were observed on fetal heart rate monitoring. Thus, an emergency cesarean section was performed and she was delivered of a 1322 g girl infant with an Apgar score of 6 (5-minute). Although respiratory management was necessary, blood pressure (67/45 mmHg) was within normal limits. Placental pathology demonstrated chorioamnionitis (grade 1) but not funisitis. Blood chemistry data and umbilical blood gas values are shown in Table I. The blood gas analyses of umbilical cord clearly demonstrated fetal metabolic alkalosis. Although maternal blood gas analysis was unfortunately not done, hypokalemia and hypochloremia induced by vomiting strongly suggests maternal alkalosis. The infant’s electroencephalogram (EEG) on day 1 revealed absent continuous pattern and disorganized pattern, indicating acute and chronic stage abnormalities, respectively [4]. Such abnormal EEG patterns on day 1 imply that the timing of injury was some time before birth [5]. Furthermore, that cranial ultrasonography had already shown periventricular hyperechodensity and cystic change on day 0 and 2 (Figure 1, A–C) supports prenatal insult of the brain. Ultrasonography on day 18 (Figure 1, D) and magnetic resonance imaging subsequently demonstrated typical multi-cystic PVL. The association between alkalosis and PVL has been reported in premature infants who demonstrated hypocarbia due to mechanical ventilation after birth [6–8]. Our case is unusual in that the newborn had already shown alkalosis at birth. One possible cause of fetal alkalosis is maternal metabolic alkalosis. Although we did not study the maternal arterial blood gases, which illustrate pH, PO2, PCO2, HCO3, and base excess, the venous levels of electrolytes were compatible with maternal alkalosis. Excessive vomiting is also an indirect evidence for maternal alkalosis. There arises a question as to whether changes in fetal acid–base occur secondary to maternal alterations in pH. It has been clarified that, in contrast to the rapid transplacental diffusion The Journal of Maternal-Fetal and Neonatal Medicine, October 2006; 19(10): 675–677

Would omitting the assessment of heart rate be harmful to initial neonatal care

Objective. To test the hypothesis that counting heart rate is dispensable and other components of the Apgar score are satisfactory to evaluate the physical condition of infants shortly after birth in routine deliveries. Methods. The database of the Japanese Red Cross Nagoya First Hospital was reviewed for newborn infants whose Apgar scores were marked by trained neonatologists attending delivery. Results. The scores of respiratory effort, muscle tone, and reflex irritability increased parallel to Apgar scores. Heart rate gained higher marks even in lower Apgar scores, whereas color demonstrated lower marks even in higher Apgar scores. Correlation coefficients were higher among respiratory effort, muscle tone, and reflex irritability. In contrast, both heart rate and color exhibited lower correlation coefficients against other components and total Apgar scores. High correlation coefficients were shown between the sum of the four components other than heart rate and the total score. Conclusions. Heart rate and color play more independent roles in the Apgar score. Heart rate seems to be dispensable and the other components of the Apgar score are satisfactory to evaluate the physical condition of infants shortly after birth, and hence, counting heart rate may be omitted in routine deliveries when a newborn infant is apparently well.