Miyuki Morishita

Delayed postpartum hemorrhage due to cesarean scar dehiscence

Case reportA 28-year-old woman presented with massive postpartum hemorrhage. Laparotomy revealed a cesarean scar dehiscence due to wound infection.Conclusion Although postpartum hemorrhage due to cesarean scar dehiscence is an unusual complication, practitioners should add dehiscence to their differential diagnoses.

Analgesic efficacy of controlled-release oxycodone in patients with uterine or ovarian cancer.

Treatment with opioid analgesics often causes adverse reactions that may make continuous use of such drugs difficult. We investigated the efficacy and safety of controlled-release oxycodone in the treatment of gynecologic cancer pain. The patients included 14 with cervical cancer, 6 with corpus cancer, and 17 with ovarian cancer. Treatment with controlled-release oxycodone was started at 5 mg/dose when pain control using nonsteroidal anti-inflammatory drugs became ineffective. The dose was titrated to the optimal level over a mean duration of 2.34 ± 1.13 days, and the initially optimal dose was 18.92 ± 5.23 mg/day. Although no patients experienced confusion, vomiting, or respiratory depression, 17 patients experienced adverse events, including constipation in 14 patients and nausea in 9 patients. The incidence of nausea was low in patients receiving oxycodone and prochlorperazine. In the present study, patients with moderate to severe pain caused by gynecologic cancer could successfully be treated with controlled-release oxycodone.

Successful delivery after transabdominal cerclage of uterine cervix for cervical incompetence after radical trachelectomy

Pregnancy after radical trachelectomy (RT) has a high risk of prematurity and complications such as preterm premature rupture of the membrane and chorioamnionitis. Placing a cervical cerclage at the time of RT plays an important role in preventing such obstetrical complications. In patients who have trouble with the cervical cerclage, miscarriage during the second trimester seems to be inevitable. We have therefore started preconception transabdominal cerclage (TAC) for these patients. A 36‐year‐old Japanese woman who had a history of miscarriage due to trouble with the nylon thread used for cerclage, successfully delivered after TAC. TAC is a useful treatment modality to prevent miscarriage for patients who have trouble with cerclage after RT.

Assisted reproductive technique increases the risk of placental polyp.

Abstract The purpose of this study was to clarify the risk factors and outcomes of placental polyp. This retrospective study was conducted on 1645 patients delivered or aborted in Sapporo Medical University from 2007 through 2011. Transvaginal color Doppler ultrasonography, hysteroscopy, contrast-enhanced MRI or 3D-CT angiography were performed. There were 1532 deliveries and 113 abortions. Seventy-one (4.3%) were ART-conceived and the remaining 1574 (95.7%) were non-ART pregnancies. Fifteen (0.91%) cases were confirmed as having placental polyp. Nine cases of placental polyp were identified among the 1574 (0.57%) as non-ART-related pregnancies, and 6 were identified among the 71 (8.5%) as ART-related pregnancies. Thus, pregnancies achieved through ART showed 20x greater incidence of complicating placental polyp than pregnancies achieved through without ART (p = 9.02 × 10−6; odds ratio, 19.59; 95% confidence interval, 5.27–72.84, logistic regression analysis). Evaluation of blood flow within the polyp showed that in five of seven patients with low blood flow, the polyps spontaneously dropped off 79–115 days postpartum. Thus, ART-related pregnancies may be a risk factor of placental polyp, and spontaneous drop-off of the polyp is often observed in cases with low blood flow within the mass.

Transabdominal cerclage (TAC) for patients with ultra-short uterine cervix after uterine cervix surgery and its impact on pregnancy

Patients with an ultra‐short uterine cervix as a result of large conization, repeated conization or radical trachelectomy (RT), are at high risk of preterm premature rupture of the membrane, which leads to preterm birth. We have commenced performing transabdominal cerclage (TAC) of the uterine cervix for these patients. In this study, we examined the safety of TAC and its impact on pregnancy.

Continuous follicle-stimulating hormone exposure from pituitary adenoma causes periodic follicle recruitment and atresia, which mimics ovarian hyperstimulation syndrome

Context Follicle-stimulating hormone (FSH)-secreting pituitary adenoma is usually a nonfunctioning tumor, but in rare cases it may develop into ovarian hyperstimulation. Several reports have revealed that serum FSH levels are normal to slightly high in patients with combined FSH-secreting pituitary adenoma with ovarian hyperstimulation. This finding is different from iatrogenic ovarian hyperstimulation syndrome (OHSS), which is associated with extremely high levels of FSH. Objective To describe the clinical course of two patients who developed OHSS from FSH-secreting pituitary adenoma. Results Endocrine studies of the two cases revealed that FSH levels were normal or slightly increased, but luteinizing hormone levels were low to undetectable. Their estradiol (E2) levels were intriguing: levels fluctuated drastically over 6 weeks in Case 1, but stayed flat in Case 2. Ultrasonographic examinations showed bilaterally enlarged multicystic ovaries, and magnetic resonance imaging indicated pituitary tumors. Transsephenoidal resection of the tumors ameliorated the symptoms and pathological diagnosis revealed FSH-secreting pituitary adenomas. Conclusion As is not the case in iatrogenic OHSS, even a small to moderate amount of FSH stimulation, which is continuously secreted by a pituitary adenoma, can cause ovarian hyperstimulation. Although FSH-secreting pituitary adenoma can cause ovarian hyperstimulation, an extremely high amount of E2 biosynthesis from granulosa cells seldom occurs.

Excessive Androgen Exposure as an Etiological Factor of Polycystic Ovary Syndrome

Abstract: Polycystic ovary syndrome (PCOS) is a heterogeneous group of disorders characterized by ovulation disorder, hyperandrogenism, and polycystic ovarian morphology (PCOM). Several diagnostic criteria suggest that hyperandrogenism is a core symptom of PCOS. Androgens are believed to cause preantral follicle growth and arrest the growth of antral follicles. This results in accumulation of small antral follicles in the ovaries, thus forming PCOM. Observational studies of patients with female-to-male transsexualism or congenital adrenal hyperplasia indicate that androgen administration to these patients does not produce typical PCOS-like features. However, endogenous androgen exposure in early life may lead to some traits of PCOS in adulthood. To reveal the association between the timing of excess androgen exposure and reproductive function, various animal models have been investigated using androgen administration. Rhesus monkeys exposed to excess androgen during the early fetal period show a PCOS-like phenotype, including metabolic and hypothalamic-pituitary characteristics. This finding implies that exposure to excess androgen during this critical period programs the hypothalamic-pituitary-ovary axis and metabolic organs. Although findings obtained in animal studies will not necessarily be replicated in humans, prenatal androgen excess is the dominant PCOS hypothesis.

Weight reduction and pioglitazone ameliorate polycystic ovary syndrome after removal of a Sertoli-stromal cell tumor

This report presents an unusual case of Sertoli-stromal cell tumor and polycystic ovary syndrome successfully treated with weight reduction and an insulin-sensitizing agent. A 22-year-old woman, gravida 0, para 0, visited our hospital for the first time with a 12-year history of secondary amenorrhea and hypertrichosis. Transvaginal ultrasonography revealed a solid tumor in the right ovary. Right salpingo-oophorectomy was performed and pathological examination confirmed a Sertoli-stromal cell tumor. The patient’s serum androgen levels declined postoperatively, but remained above normal. Pioglitazone treatment for 6 months also significantly reduced serum androgen levels, but they still remained above normal. However, after losing 12 kg of body weight, the patient’s serum androgen levels declined to normal, and spontaneous menstruation became regular. Weight reduction with pioglitazone is an effective means of treating hyperandrogenism.

A myotonic dystrophy 1 patient complicated with placental adherence after miscarriage of one dichorionic diamniotic twin following her tenth in vitro fertilization and embryo transfer

Placental adherence is one of the most common causes of emergency hysterectomy to save the mother’s life. Risk factors for placental adherence reportedly include a prior caesarean section, other previous uterine surgery, maternal age and multiparity. Recently, in vitro fertilization (IVF) pregnancy was also reported to be a risk factor [1]. Unfortunately, it appears likely that patients who seek help to have a baby are complicated with multiple risk factors. Physicians should be very careful when treating these patients. In the absence of serious symptoms, however, conservative therapy that preserves the patient’s fertility is preferable, so it has been proposed that conservative management should be attempted [2] unless the patient has massive bleeding [3] or signs of severe infection [4]. That said, there are few choices for conservative treatment. These include methotrexate (MTX) administration, uterine artery embolization (UAE) and uteruspreserving surgery [5, 6]. UAE is reported to be sometimes harmful to fertility [7], and it is usually difficult to continue MTX treatment when massive bleeding occurs during the therapy. As a backup treatment, uterus-preserving surgery [5] is thought to support the continuation of MTX treatment in these types of cases and should be tried if possible.