Kenjiro Takagi

Uterine leiomyoma confounding a noninvasive prenatal test result

Sequenom Laboratories, San Diego, CA, USA Department of Obstetrics and Gynecology, Saitama Medical University Hospital, Saitama, Japan Perinatal Medical Center, Saitama Medical Center, Jichi Medical University, Saitama, Japan GeneTech Inc., Tokyo, Japan Sequenom Laboratories, Grand Rapids, MI, USA Department of Obstetrics, Gynecology and Reproductive Medicine, Michigan State University, East Lansing, MI, USA *Correspondence to: Nilesh G. Dharajiya. E-mail: ndharajiya@sequenom.com These authors contributed equally to this article.

Use of intra-arterial nitroglycerin during uterine artery embolization for severe postpartum hemorrhage with uterine artery vasospasm.

OBJECTIVE Uterine artery embolization (UAE) is a standard method for treating postpartum hemorrhage (PPH), although uterine artery vasospasm during UAE may lead to failure of hemostasis. Here, we report our experience with a case of PPH in which the bleeding was successfully controlled by intra-arterial administration of nitroglycerin during the second UAE. CASE REPORT A 30-year-old woman experienced PPH following a successful cesarean section, and a UAE was performed. However, 6 hours later, vaginal bleeding restarted; the reason for unsuccessful embolization during the first UAE was vasoconstriction due to hypovolemic shock. We performed a second UAE, but uterine bleeding continued. After intra-arterial administration of nitroglycerin, hemostasis was confirmed, and there was no reperfusion of the uterine artery. After these two UAE procedures, no recurrence of bleeding was observed. CONCLUSION Thus, use of intra-arterial nitroglycerin was effective for controlling uterine artery vasospasm during UAE. However, larger studies are required to confirm these findings.

Can biparietal diameter-to-femur length ratio be a useful sonographic marker for screening thanatophoric dysplasia since the first trimester? A literature review of case reports and a retrospective study based on 10,293 routine fetal biometry measurements

OBJECTIVE The aim of the study was to determine whether the biparietal diameter/femur length (BPD/FL) ratio can be used to detect thanatophoric dysplasia in the first trimester of pregnancy. MATERIALS AND METHODS Twenty-four reported cases of thanatophoric dysplasia diagnosed based on ultrasonographic results with molecular or radiographic diagnosis were included. All sonographic measurement records were extracted and reviewed, and the BPD/FL ratio was calculated for each gestational week. In addition, 10,293 routine fetal biometry measurements from 1395 cases of patients without skeletal dysplasia were compared. RESULTS The BPD/FL ratio in the control group decreased to less than 3 prior to gestational week 13, and to less than 2 prior to week 18. Of the 27 BPD/FL ratios obtained from 24 cases of thanatophoric dysplasia, none was in the control range. CONCLUSION The BPD/FL ratio may be used to detect lethal skeletal dysplasias such as thanatophoric dysplasia since the first trimester.

A pregnancy-associated nonfamilial case of PAPA (pyogenic sterile arthritis, pyoderma gangrenosum, acne) syndrome

Little is known about the influence of pregnancy on pyogenic sterile arthritis, pyoderma gangrenosum, acne (PAPA) syndrome. We experienced a rare case of pregnancy complicated with PAPA syndrome. The patient had various histories of skin and joint disorders and experienced subarachnoid hemorrhage during pregnancy; however, her skin lesion was unaffected.

Letter to ‘Removal of retained products of conception showing marked vascularity without uterine artery embolization: Two case reports’: Intrauterine vascular lesions

Dear Editor, We read with interest the report by Usui et al. on the use of laminaria for manually removing the retained products of conception showing marked vascularity. As a pretreatment for cervical dilation, they used maximum laminaria tents on two para 1 women, successfully terminating abnormal vascularity and enabling the removal of the retained products of conception without uterine artery embolization (UAE), which can potentially cause infertility. We congratulate them on their success. We agree that treatments less invasive than UAE should be considered in women desiring pregnancy with a similar diagnosis. However, to prevent unfavorable outcomes, alternative procedures with insufficient evidence for safety should be discussed more carefully with a detailed plan. We have some suggestions for the maximum laminaria procedure. First, the intravenous anesthesia should be given ‘after’, not ‘before’ removal of the laminaria tents and ultrasound confirmation of the absence of blood flow. We noted that Usui et al. did not describe whether an ultrasonographic assessment was performed before ketamine administration. Thus, the risk of the laminaria tents failing to stop the abnormal blood flow remains. In such a situation, if anesthesia has not been administered, the consent to undergo UAE, if needed, can be obtained from the patient, who can then be quickly transferred to the intravascular radiology room for the procedure. Second, a second-line treatment, such as intrauterine balloon compression, which is useful in controlling bleeding in similar situations, should be prepared for the procedure. When bleeding occurs during the removal of the intrauterine contents, balloon tamponade can temporarily stop the bleeding, delay the need for UAE, or even achieve hemostasis, as reported by Takeda et al. Third, the preprocedure assessment of feeding vessels by contrast-enhanced or three-dimensional computed tomography is needed. Lesions that originate from a single-feeding, doublefeeding or triple-feeding vessel may show different results; lesions that originate from the ovarian artery may specifically require embolization of the ovarian artery. Careful preparation can help avoid tragic accidents.

Rupture of hidden abnormal myometrial vessels during cesarean delivery of a patient with subserosal leiomyoma: A possible pathogenesis of sudden-onset disseminated intravascular coagulation

We report a case of sudden‐onset disseminated intravascular coagulation during cesarean delivery for a patient with a subserosal leiomyoma. Rupture of hidden anastomotic vessels resulted in a significant decrease in fibrinogen levels and uncontrolled bleeding. Uterine venous flow disturbance caused by subserosal leiomyoma compression can possibly cause such a situation.

Open fan sign: An ultrasound finding suggesting postpartum intrauterine forgotten gauze

Gauze counting is regarded as the most essential way to prevent forgotten gauze inside the body during any surgery. However, incident may still occur due to artificial mistake. An open fan sign on ultrasonography may indicate a gauze left in the intrauterine cavity.

Preoperative administration of eculizumab to prevent surgery-triggered hemolysis during cesarean section with paroxysmal nocturnal hemoglobinuria

Eculizumab in pregnancy has been reported to be effective in improving outcomes in patients with paroxysmal nocturnal hemoglobinuria. However, a cesarean section may result in surgery‐triggered hemolysis. An additional dose of eculizumab just prior to delivery is an appropriate choice to prevent postoperative hemolysis.

A Case of Pregnancy Complicated with Type 1 Hereditary Angioedema(HAE 1)

Hereditary angioedema (HAE) is an inherited autosomal dominant trait and symptoms of HAE include sudden onset of edema in various organs, such as subcutaneous edema, laryngeal edema and gastrointestinal tracts mucosa. We have experienced a case of a pregnant woman diagnosed with HAE and successfully managed her pregnancy. The patient was 37 years old, gravida 1, primiparous. She had experienced two attacks of angioedema during pregnancy but her delivery course was not affected by her HAE. The frequency of attacks during pregnancy had decreased compared with before and after pregnancy. Treatment using human C1-inactivator concentrate was as effective for attack suppression during pregnancy as it had been in her non-pregnant state.

Managing vulvovaginal hematoma by arterial embolization as first-line hemostatic therapy

OBJECTIVE A puerperal vulvovaginal hematoma may continue to grow after a surgical procedure and may require blood transfusion. Thus, we selected arterial embolization for hemostasis as the first-line management in two cases of large vulvovaginal hematoma. MATERIALS AND METHODS Case 1 was a 32-year-old pregnant woman. After delivery, a 10-cm vulvar hematoma developed. An enhanced computed tomography (CT) scan revealed active bleeding. Arterial embolization was performed and complete hemostasis was obtained. Case 2 was a 34-year-old woman with a recurring hematoma after delivery. An enhanced CT scan revealed extravasation in the hematoma. Gelatin sponges were applied and complete hemostasis was obtained. In both cases, arterial embolization was successful without requiring blood transfusions. RESULTS AND CONCLUSION We successfully managed two cases of puerperal vulvovaginal hematoma by arterial embolization based on the evaluation of an enhanced CT scan. In conclusion, we suggest arterial embolization to be a viable option for first-line treatment in the management of vulvovaginal hematomas.