Kazuaki Yoshimura

Effect of Stimulation and Antagonism of Interleukin-1 Signaling on Preterm Delivery in Mice

Objective: Transgenic mice that overexpress the interleukin-1 receptor antagonist (IL-1ra), an endogenous competitive inhibitor of interleukin-1 (IL-1) signaling, were used to test whether blockade of IL-1 can prevent bacterially induced preterm delivery in a validated murine model. These IL-1ra transgenic mice have been shown previously to be protected from lethal endotoxin shock. Methods: In a series of four separate experiments, 201 female wild-type and transgenic mice on day 14.5 of a 19-20 day gestation underwent intrauterine injection with either 0.5-20 μg of recombinant human IL-1β (rhIL-1β) or 105-108 heat-killed Escherichia coli organisms. Fetuses were either all wild-type, all transgenic, or of mixed genotype (see below). Preterm delivery and maternal survival rates were recorded. IL-1ra protein levels were determined by enzyme-linked immunosorbent assay (ELISA). Results: Intrauterine administration of IL-1β induced preterm delivery in a dose-dependent manner and did not cause other adverse maternal effects. In bacterially inoculated mice, neither maternal nor fetal carriage of the IL-1ra overrexpression transgene affected preterm delivery rates. Fetal carriage of the IL-1ra transgene did not up-regulate IL-1ra protein levels in maternal or fetal tissues. Conclusion: Although intrauterine IL-1 exposure is sufficient for induction of preterm delivery, it was not possible to prevent bacterially induced preterm birth using the IL-1ra transgene. This may be either because the timing or magnitude of IL-1ra up-regulation in transgenic mice was insufficient to block IL-1s interaction with its receptor, or because bacterially induced laboar in this model does not depend on IL-1 signaling alone.

Intravaginal microbial flora by the 16S rRNA gene sequencing

OBJECTIVE Conventional diagnosis of bacterial vaginosis contains some controversial points. To understand accurately the relationship between clinical stages and the microbiotas, the intravaginal microbial flora was analyzed by the clone library method. STUDY DESIGN Vaginal fluid samples from 31 patients were examined. Lactobacillary grade, Nugent score, culture-based method, and clone library analysis using the 16SrRNA gene sequencing were performed and were compared with each other. RESULTS Patients were categorized by Lactobacillary grade as I (normal) (n = 6), II (intermediate) (n = 11), and III (bacterial vaginosis) (n = 14). The clone library analysis detected 36 bacterial genera and 60 species from all 31 samples. A principal component analysis of the microbial proportions revealed a novel classification, which suggested the significance of the relative ratio of Lactobacillus iners, Atopobium vaginae and anaerobes in bacterial vaginosis. CONCLUSION Clone library analysis in combination with the conventional method provides substantial information for diagnosis of bacterial vaginosis.

Cervical varix accompanied by placenta previa in twin pregnancy

Background:  Uterine cervical varix is a rare complication in pregnant women and can be the cause of obstetric hemorrhage in the vagina resulting in adverse events for both the mother and fetus.

Guidelines for office gynecology in Japan: Japan Society of Obstetrics and Gynecology and Japan Association of Obstetricians and Gynecologists 2011 edition

Gynecology in the office setting is developing worldwide. Clinical guidelines for office gynecology were first published by the Japan Society of Obstetrics and Gynecology and the Japan Association of Obstetricians and Gynecologists in 2011. These guidelines include a total of 72 clinical questions covering four areas (Infectious disease, Malignancies and benign tumors, Endocrinology and infertility, and Healthcare for women). These clinical questions were followed by several answers, backgrounds, explanations and references covering common problems and questions encountered in office gynecology. Each answer with a recommendation level of A, B or C has been prepared based principally on evidence or consensus among Japanese gynecologists.These guidelines would promote a better understanding of the current standard care practices for gynecologic outpatients in Japan.

Prenatal spontaneous disruption of the dividing membrane in monochorionic diamniotic twins detected at the time of fetoscopic laser photocoagulation

Spontaneous antepartum rupture of the dividing membrane occurring in monochorionic diamniotic twins (MD twin) is an extremely rare complication and difficult to diagnose prenatally. We present a case of pseudo‐monoamniotic twins derived from an MD twin gestation, which was suspected by ultrasound and was confirmed by antepartum fetoscopy. A 28‐year‐old woman, gravida 1, para 1 at 24 weeks of gestation was referred because of suspected polyhydroamnios in an MD twin. Ultrasound suggested twin–twin transfusion syndrome stage III, spontaneous rupture of the dividing membranes and cord entanglement. Fetoscopic laser photocoagulation (FLP) was performed using the Nd:YAG laser on 12 placental vascular connections. Fetoscopy revealed the spontaneous rupture of the dividing membrane and cord entanglement. The remainder of the pregnancy was managed as a monoamniotic twin gestation. Elective cesarean section was performed at 32 weeks of gestation following antenatal steroids and concordantly grown healthy male infants were delivered.

Effects of pelvic organ prolapse ring pessary therapy on intravaginal microbial flora

Introduction and hypothesisThe purpose of this paper is to report our evaluation of changes in intravaginal microbial flora after ring pessary therapy for pelvic organ prolapse (POP) using conventional and our clone library method.MethodsThirteen patients with POP who were fitted with a ring pessary participated in this longitudinal study that incorporates data from before and 1 month after beginning ring pessary therapy. Changes in intravaginal microbial flora were evaluated by conventional methods, i.e., vaginal pH, lactobacillary grade (LAC grade), Nugent score, and culture-based bacterial detection methods. In addition, we performed our clone library method using 16S ribosomal RNA (rRNA) sequencing of vaginal fluid.ResultsConventional methods revealed that most patients had abnormal intravaginal microbial flora. Mean numbers of detected bacterial species by the culture-based and our clone library method were 3.1 (1–6) and 11.8 (1–25), respectively. Our clone library method showed that Lactobacillus spp. increased in four and decreased in two cases after ring pessary therapy but reappeared after therapy in two cases; no Lactobacillus spp. were detected in five cases.ConclusionsOur study showed that ring pessary therapy did not always disturb intravaginal microbial flora, especially for patients with Lactobacillus spp. prior to ring pessary insertion. Anaerobic circumstances in the vagina after therapy seem to have induced the growth of anaerobic bacteria.

Retrospective study of tension‐free vaginal mesh operation outcomes for prognosis improvement

The aim of this study is to look at the weak points of tension‐free vaginal mesh (TVM) operation for pelvic organ prolapse by reviewing recurrent cases.

Laparoscopic fixation of the vaginal cuff to the uterosacral ligaments at the time of hysterectomy.

Introduction and HypothesisTransvaginal ipsilateral uterosacral ligament colpopexy for pelvic organ prolapse (POP), which was reported by Shull et al. (Shulls colpopexy) in 2000, is one of the most frequently performed non-mesh pelvic floor reconstructive surgical procedures. Despite its excellent anatomical outcomes, ureteral injury and difficulty in uterosacral ligament detection (especially in patients with severe POP) are typical issues with this procedure.MethodThis video demonstrates the procedure in a 58-year-old woman, gravida 2 para 2, with POP-Q stage II uterine prolapse and stage I cystocele. At the beginning of the operation, the bilateral uterosacral ligaments were confirmed and separated from the ureters after entering the retroperitoneal space. The inferior hypogastric nerve and pelvic nerve plexus were also separated from the uterosacral ligament. After total laparoscopic hysterectomy, three ipsilateral delayed absorbable monofilament sutures were placed between the uterosacral ligament and the vaginal cuff. Retroperitonealization was then performed using a continuous suture with closure of the Douglas pouch.ConclusionLaparoscopic Shull’s colpopexy for POP is a secure procedure with the advantages of laparoscopy (magnification and sharing the operative field). This may become one of the most useful operations for apical support as native tissue repair.

Novel technique for adhesion barrier insertion by using cut‐off surgical glove fingers in laparoscopic surgery

Laparoscopic surgery causes fewer postoperative adhesions than laparotomy and adhesion barriers are used to lessen the chance of adhesion. Sodium hyaluronate and carboxymethylcellulose (SH‐CMC), a bioresorbable membrane, is effective in preventing adhesions. However, its properties make it difficult to insert the film into the abdominal cavity and to place it into the target area during laparoscopic surgeries. Here we report a novel technique for applying SH‐CMC during laparoscopic surgeries by using cut‐off surgical glove fingers.

How to reduce the operative time of laparoscopic sacrocolpopexy

Objective: Laparoscopic sacrocolpopexy (LSC) has been reported to achieve lower recurrence rates, shorter recovery time, and less dyspareunia. However, as a pelvic organ prolapse (POP) surgery, LSC is problematic because it requires specific techniques and it takes a comparatively longer operative time. In this study, we present our surgical techniques of LSC and their effectiveness for shortening operative times and raising safety. Methods: Thirty-four women with stage 2 or greater POP who underwent LSC in our hospital between September 2014 and October 2015 were enrolled in this study. The notable points of our operative procedures are as follows: (1) fixing the sigmoid colon to the left lateral abdominal wall for a clearer visualization of the sacral promontory, (2) making a retroperitoneal tunnel (not opening the peritoneum) from the sacral promontory to the Douglas pouch, (3) dissection of the vaginal wall after transvaginal hydrodissection, (4) fixation of mesh to the vaginal wall by using absorbable tacks, and (5) limiting usage of posterior mesh for the patients with posterior vaginal wall descent. Results: The median operative time was 140 (range, 90–255) minutes, and blood loss was 50 (range, 10–1600) mL. The operative time decreased as the surgical techniques improved through experience. No major intra- or postoperative complications occurred. The mean follow-up period was 4 (range, 1 –14) months, and only one patient presented a recurrent grade 2 cystocele. Conclusion: Our unique procedures will help shorten operative times and reduce complications of LSC.