Mitsuru Matsushita

Perinatal Outcome of Monochorionic Twins with Selective Intrauterine Growth Restriction and Different Types of Umbilical Artery Doppler under Expectant Management

Objectives: To evaluate the prognosis of monochorionic twins with selective intrauterine growth restriction (sIUGR), classified according to the type of umbilical artery Doppler, under expectant management. Methods: The outcome of 81 cases with isolated sIUGR was evaluated according to a classification based on umbilical artery (UA) Doppler diastolic flow in the IUGR twin (I: present, II: constantly absent/reverse, III: intermittently absent/reverse). Selective feticide was not considered due to legal constraints. Perinatal outcomes included perinatal death and neurological outcome at 6 months of age. Results: From 81 cases with the diagnosis of sIUGR, twin-twin transfusion was diagnosed in 18 cases. This left 63 cases, of which 23 were classified as type I (36.5%), 27 as type II (42.9%) and 13 as type III (20.6%). Intrauterine death occurred in 4.3% (1), 29.6% (8) and 15.4% (2) among IUGR twins, and 4.3% (1), 22.2% (6) and 0.0% (0) among larger twins. Neonatal death occurred in 0.0% (0), 18.5% (5) and 0.0% (0) among IUGR twins, and 0.0% (0), 11.1% (3) and 23.0% (3) among larger twins. Neurological abnormalities at 6 months were found in 4.3% (1), 14.8% (4) and 23.1% (3) in smaller twins and 0.0% (0), 11.1% (3) and 38.5% (5) in larger twins, respectively. Intact survival at 6 months was recorded in 91% (21), 37% (10) and 61% (8) in smaller twins and 95% (22), 55% (15) and 38% (5) in larger twins, respectively. Conclusion: The outcome in monochorionic twins with sIUGR and abnormal umbilical artery Doppler is poor under expectant management. Normal Doppler seems to be associated with a good prognosis.

Stage Ia1 cervical squamous cell carcinoma: conservative management after laser conization with positive margins

OBJECTIVE Cone margin status has been reported to be the most important predictor of recurrent disease in patients with cervical intraepithelial neoplasia (CIN) undergoing cervical conization. Our purpose was to evaluate the conservative management of selected patients with microinvasive (FIGO stage Ia1) squamous cell carcinoma who have been treated by cervical conization with positive margins. METHODS Twenty-seven patients underwent KTP laser conization and vaporization for stage Ia1 squamous cell carcinoma followed by careful observation. Involved margins were diagnosed if CIN III or more was present at the ectocervical or endocervical margin and 7 patients formed the basis of the present study. Follow-up consisted of cytology, histology, and pelvic examination. Disease recurrence was defined as a histology diagnosis of CIN III or more on colposcopically directed biopsy or endocervical curettage. RESULTS The endocervical margins were involved by carcinoma in situ in seven (26%) patients. No ectocervical margin involvement was detected. No lymph-vascular space involvement (LVSI) and confluent invasion were seen. All seven patients were free of recurrent disease during median follow-up of 4.0 (range 2.3-7.6) years. CONCLUSION These results suggest that laser conization and vaporization may be a reasonable treatment option in patients with microinvasive (FIGO Stage Ia1) squamous cell carcinoma despite positive cone margins without invasive disease when LVSI is not demonstrated.

Perinatal magnetic resonance fetal lung volumetry and fetal lung‐to‐liver signal intensity ratio for predicting short outcome in isolated congenital diaphragmatic hernia and cystic adenomatoid malformation of the lung

Aim:  To evaluate the usefulness of magnetic resonance imaging (MRI) in predicting the risk of lethal pulmonary hypoplasia in fetuses.

Incidence of spontaneous twin anemia-polycythemia sequence in monochorionic-diamniotic twin pregnancies: Single-center prospective study.

The purpose of this study was to prospectively estimate the incidence of spontaneous twin anemia–polycythemia sequence (TAPS) in monochorionic–diamniotic twin pregnancies.

Transitory increase in middle cerebral artery peak systolic velocity of recipient twins after fetoscopic laser photocoagulation for twin-twin transfusion syndrome.

Objective: It was the aim of this study to elucidate the clinical features of recipient twins with increased middle cerebral artery peak systolic velocity (MCA-PSV) after fetoscopic laser photocoagulation (FLP) for twin-twin transfusion syndrome. Methods: Serial Doppler velocimetry of the MCA was performed in 30 recipient twins before and after FLP. Clinical data and perinatal outcome were compared between cases with and without increased MCA-PSV. Results: Increased MCA-PSV was observed in 7 recipients (23.3%) within 14 days after FLP. MCA-PSV gradually decreased to <1.5 multiples of median in 6 recipients; however, 1 patient resulted in fetal demise subsequent to the demise of the co-twin. The incidences of fetal and neonatal demise and neurological morbidity were similar. No recipient was diagnosed as anemic at birth. Conclusions: The increase in MCA-PSV in recipients following FLP appeared to be generally transitory; this differs from twin anemia-polycythemia sequence.

Fetoscopic Laser Photocoagulation for the Treatment of Twin-Twin Transfusion Syndrome in Monochorionic Twin Pregnancies

Fetoscopic laser surgery for severe twin-twin transfusion syndrome (TTTS) has become the optimal treatment choice since the release of the Eurofetus randomized clinical trial. These techniques have been adopted throughout the globe, and many institutions have instituted or will soon institute fetoscopic laser surgery procedures; however, laser sur- gery has a steep learning curve because of the following: challenging placental location, complex and unexpected com- municating anastomoses, residual anastomoses after surgery, or discolored amniotic fluid. We have been performing laser surgery since 2002 in Japan; to date, we have compiled a series of 170 cases. Our data indicates a 78% of overall survival with 5% neonatal morbidity, 63% of survival of both twins, and 93% survival of at least one twin. The recurrent TTTS rate was 1% and the residual vessel rate was 3%. To improve the learning curve of laser surgery, the employment of various techniques is recommended to achieve a suc- cessful surgical outcome: (1) Mapping: before laser ablation, a very thorough mapping of vascular anastomoses should be done, and should be repeated after ablation; (2) Sequential order: obliteration of arterio-venous anastomoses from donor to recipient should be done first to avoid donor hypotension and/or anemia; (3) Trocar (cannula) assisted technique: Trocar assisted technique: Using gentle indent the trocar to the placenta by withdrawing the scope shortly, then anastomoses could be ablated easily; (4) Line method: to avoid residual anastomoses, the laser should draw a virtual line at the hemo- dynamic equator; The operator must be careful not to miss small anastomoses. These techniques can help achieve a successful outcome for fetoscopic laser surgery and improve the outcome for cases of severe TTTS.

Roles of venovenous anastomosis and umbilical cord insertion abnormalities in birthweight discordance in monochorionic–diamniotic twin pregnancies without twin–twin transfusion syndrome

We evaluated risk factors for birthweight discordance in monochorionic diamniotic (MCDA) twin pregnancies without twin–twin transfusion syndrome (TTTS).

Embryo transfer is a risk factor for severe postpartum hemorrhage and blood transfusion requirement

Abstract Purpose: This study aimed to investigate the risk factors for severe postpartum hemorrhage (PPH) and blood transfusion requirement that are recognizable during any period of pregnancy. Materials and methods: We retrospectively reviewed the medical data of 4829 pregnant women who received care and delivered at our institution between July 2010 and March 2015. The cohort was divided into patients with and without severe PPH. Multivariate logistic regression analysis was performed to assess risk factors associated with severe PPH. The same analysis was repeated for blood transfusion requirement. Results: A total of 127 (2.7%) patients had severe PPH and 43 (0.87%) required blood transfusion. The multivariate logistic regression analysis demonstrated that embryo transfer (odds ratio [OR] 2.6; p < .001), uterine myoma (OR 2.0; p < .01), prior uterine surgery (OR 1.9; p = .03), prior cesarean section (OR 1.8; p = .01), and maternal age (OR 1.5; p = .03) were independent risk factors for severe PPH. Embryo transfer was an independent risk factor for blood transfusion requirement (OR 3.1, p < .001). Conclusions: Embryo transfer is a risk factor for both severe postpartum hemorrhage and blood transfusion requirement.