Kyousuke Takeuchi

Comparison of Magnetic Resonance Imaging and Ultrasonography in the Prenatal Diagnosis of Congenital Thoracic Abnormalities

Objectives: To evaluate prenatal MRI in the diagnosis of fetal thoracic abnormalities and to determine whether MRI provides useful information in addition to that of ultrasonography (US). Methods: Ultrafast MR scanning was performed in 7 pregnant women in whom US was suspicious of fetal congenital anomalies of the thorax [3 cases of congenital diaphragmatic hernia (CDH), 3 cases of chylothorax and 1 case of congenital cystic adenomatoid malformation (CCAM) type III]. The presence, position, size and characteristics of the congenital lesions were determined and compared with postnatal diagnoses. Results: The MRI diagnoses were 3 cases of CDH, 2 of chylothorax and one each of esophageal atresia and CCAM type III. The results of MRI were in agreement with those of US in 6 cases and in disagreement in 1 case of esophageal atresia. Final diagnoses were confirmed at surgery or autopsy in all fetuses. Combined use of MR and US imaging enabled a correct diagnosis in 5 cases and led to an error in the diagnosis of 1 fetus with bronchial stenosis, which had been diagnosed as CCAM type III by US and MRI. MRI led to a correct diagnosis in 1 fetus with esophageal atresia, in whom US had been equivocal in the prenatal diagnosis. Conclusion: MRI helped further characterize the fetal thoracic lesions and confirmed or changed the prenatal diagnosis based on US. MRI seems to be powerful in the prenatal diagnosis of thoracic lesions that are atypical or complicated by multiple abnormalities.

Successful medical treatment with danazol after failed embolization of uterine arteriovenous malformation

BACKGROUND Transcatheter arterial embolization has been the therapy of choice for uterine arteriovenous malformations, whereas medical therapy has not been popular because of patient propensity to bleed. CASE A 29-year-old woman, gravida 3, para 0, was diagnosed with uterine arteriovenous malformation. Because initial treatment with uterine artery embolization was unsuccessful, she was ultimately treated with danazol. Resolution of the lesion after 2 weeks of danazol therapy was observed. As of follow-up at 16 months, she has remained free from further abnormal bleeding episodes and recurrence of the lesion. CONCLUSION Danazol has the potential for medical management of uterine arteriovenous malformations in hemodynamically stable patients who do not respond to embolization.

Transient postpartum diabetes insipidus in twin pregnancy associated with HELLP syndrome

Abstract Diabetes insipidus during pregnancy is an uncommon medical problem, and its cause is not entirely clear. We present a woman with twin pregnancy associated with HELLP syndrome, who developed diabetes insipidus during postpartum period. A hypertonic saline infusion study with measurement of plasma arginine vasopressin concentrations confirmed the diagnosis. She had mild response to 1-desamino-8-d-arginine-vasopressin (dDAVP) during the immediate postpartum period. On the 3rd postpartum day two doses of 100μl of dDAVP were administered, and her urinary volume gradually decreased. We could stop dDAVP on the 30th postpartum day. This exacerbation may result from increased vasopressinase activity caused by the excessive production in the placenta due to twin pregnancy, together with the insufficient degradation in the liver due to HELLP syndrome.

Bioelectrical impedance analysis in the clinical management of preeclamptic women with edema

Abstract Objective: The aim of this study was to correlate bioelectrical impedance analysis (BIA) with the clinical course of preeclampsia with edema. Design: 440 pregnant women with apparently normal, single pregnancy participated in this longitudinal study. Anthropometric measurements and BIA were performed during pregnancy and postpartum period. Results: All of the measurements were completed in 333 of the women; 279 of the women had a normal pregnancy (control group). The remaining 54 women developed edema during the third trimester of pregnancy. Of these, 40 women had only edema, and 14 women had edema followed by hypertension and/or proteinuria (preeclampsia group). The BIA index (the height squared divided by resistance) in the control group increased significantly towards late pregnancy, compared to that in early pregnancy. The indexes in the edema group were significantly higher during the third trimester compared to those of the control group at the same gestational week. The index in the preeclampsia group was higher relative to that in the control group. Moreover, a substantial increase in the index preceded the development of edema in the cases in which pregnancy was terminated due to deterioration of preeclampsia. Conclusions: Our results show that BIA is a useful method for monitoring longitudinal changes in total body water in pregnant women, and that BIA may be a powerful predictor of deterioration of preeclampsia preceded by edema.

Prenatal Evaluation of Bidirectional Epignathus: Comparison of Ultrasonography and Magnetic Resonance Imaging

Epignathus is an unusual, benign, congenital teratoma of the hard palate. Most of these teratomas are unidirectional and protrude through the mouth. Hence, the prognosis depends on the size of the tumor and degree of face distortion and airway obstruction. Occasionally, intracranial extension of the tumor is present, involving and destroying the brain tissue, resulting in a poor prognosis. The authors describe 2 cases of bidirectional epignathus, showing the different findings on ultrasonography and magnetic resonance imaging.

Dysfibrinogenemia during pregnancy treated successfully with fibrinogen

There are three types of congenital abnormalities associated with fibrinogen: afibrinogenemia, hypofibrinogenemia and dysfibrinogenemia. Of these, dysfibrinogenemia is usually clinically silent or is associated with mild to moderate bleeding tendency or defective wound healing. The obstetric complications of dysfibrinogenemia include first-trimester abortion, hemorrhage and placental abruption during pregnancy, and thrombophlebitis (1). We report a case of a dysfibrinogenemic patient with a history of recurrent fetal loss due to placental abruption, which was successfully treated with fibrinogen prophylaxis.

Laparoscopic varicocele ligation for pelvic congestion syndrome

Over the years many investigators have suggested that dilatation of the pelvic veins with venous congestion is the commonest finding in women with no obvious cause for chronic pelvic pain. Recently, laparoscopic varicocele ligation has been used successfully to treat testicular varicoceles in men [l]. It has been suggested that ovarian vein varicoceles in women are analogous to varicoceles of the testicular veins in men, so it seems logical that this treatment can be applied to the analogous condition in women. We report our initial clinical experience with this technique. We treated two women with chronic pelvic pain, who had symptoms consistent with the pelvic congestion syndrome. The patients then underwent pelvic transvaginal ultrasonography. Dilated pelvic veins were identified using the criteria of hypoechoic areas with well defined walls and Doppler signals. Laparoscopic varicocele ligation was performed under general anesthesia. While grasp-

Prenatal Imaging of Congenital Cerebral Primitive Neuroectodermal Tumor

A case of fetal brain tumor, which appeared after 32 weeks’ gestation, is presented. Prenatal ultrasonography and magnetic resonance imaging demonstrated a large heterogeneous mass in the right supratentorial region and left enlarged ventricle. A male fetus weighing 2,616 g was delivered at 34 weeks’ gestation by cesarean section and died on the 37th day of life due to rapid growth of the tumor. Following autopsy, the pathohistological examination revealed primitive neuroectodermal tumor. Magnetic resonance imaging in the prenatal management of the congenital brain tumor is efficient in evaluating the expansion and margin of the tumor and intratumoral bleeding, which are not demonstrated by ultrasonography.

Pregnancy outcome of uterine arterial embolization followed by selective hysteroscopic removal of a placental polyp

Objective. To evaluate the pregnancy outcome of uterine arterial embolization followed by selective hysteroscopic removal of a placental polyp. Methods. Thirteen patients of placental polyp with abundant blood flow, which was diagnosed by ultrasound with color Doppler imaging, were studied. They underwent uterine arterial embolization followed by selective hysteroscopic removal of the polyp. Uterine arterial embolization was carried out using an absorbable gelatin sponge. Selective removal via hysteroscopy was performed on the following day, using the cutting loop with or without electrical stimulation. The polyp was gradually resected to the level of the surrounding endometrium. Results. Complete removal of the placental polyp was achieved in all patients. The presence of placental polyp was confirmed by pathologic examination. The operative time ranged from 20 to 53 min. In all cases, no complications were noted and the bleeding was minimal during and immediately after the procedure. Postoperative ultrasound demonstrated a uterine cavity free of residual mass in each case. The seven patients with complete gestation gave birth to health babies. No recurrence of placental polyp was observed. Conclusions. Selective removal directed via hysteroscopy after reduction of blood supply by uterine arterial embolization provides a safe and effective method to minimize bleeding, and can preserve future fertility and successful uneventful pregnancies in the treatment of placental polyp with abundant blood flow.

Prevention of postpartum hemorrhage by uterotonic agents: comparison of oxytocin and methylergometrine in the management of the third stage of labor

Objectives. To determine the efficacy of intravenous oxytocin administration compared with intravenous methylergometrine administration for the prevention of postpartum hemorrhage (PPH), and the significance of administration at the end of the second stage of labor compared with that after the third stage. Methods. A prospective study was undertaken: two major groups (oxytocin group and methylergometrine group) of 438 women with singleton pregnancy and vaginal delivery were studied during a 15‐month period. These two groups were subdivided into three subgroups: 1. intravenous injection (two minutes) group immediately after the delivery of the fetal anterior shoulder, 2. intravenous injection (two minutes) group immediately after the delivery of the placenta, and 3. drip infusion (20 min) group immediately after the delivery of the fetal head. In each group, quantitative postpartum blood loss, frequencies of blood loss >500 ml, and need of additional uterotonic treatment were evaluated. Results. As compared with methylergometrine, oxytocin administration was associated with a significant reduction in postpartum blood loss and in frequency of blood loss >500 ml. The risk of PPH was significantly reduced with intravenous injection of oxytocin after delivery of the fetal anterior shoulder, compared with intravenous injection of oxytocin after expulsion of the placenta (OR 0.33, 95%CI 0.11–0.98) and intravenous injection of methylergometrine after delivery of the fetal anterior shoulder (OR 0.31, 95%CI 0.11–0.85). Conclusions. Intravenous injection of 5 IU oxytocin immediately after delivery of fetal anterior shoulder is the treatment of choice for prevention of PPH in patients with natural course of labor.