Rie Oyama

Changes in serum levels of heat shock protein 70 in preterm delivery and pre-eclampsia

Aim: The aim of this study was to investigate heat‐shock protein (Hsp)70 as a novel marker to evaluate the curative effects of treatment for preterm delivery high‐risk patients and pre‐eclampsia.

Tako-Tsubo Cardiomyopathy Caused Immediately following Cesarean Section Delivery of Triplets: A Case Report

The name ‘tako-tsubo’ cardiomyopathy was initially used to describe a unique ‘short-neck round-flask’-shaped form of left ventricular apical ballooning, resembling a Japanese tako-tsubo, a jar (tsubo) used for capturing octopus (tako). Tako-tsubo cardiomyopathy exhibits acute onset, transient left ventricular apical wall motion abnormalities with chest symptoms and minimal myocardial enzymatic release, mimicking acute myocardial infarction in patients without angiographic stenosis on coronary angiography. There have been few case reports on tako-tsubo cardiomyopathy, and this disorder is especially rare in pregnant women. A 30-year-old woman who was pregnant with triplets, and had been treated with ritodrine hydrochloride for 12 weeks for threatened premature delivery, underwent cesarean section with spinal anesthesia at 30 weeks’ gestation. Three hours later, she complained of acute chest pain, dyspnea and episodes of unconsciousness. She was transferred to the intensive care unit and intubated for ventilatory support. We diagnosed heart failure due to tako-tsubo cardiomyopathy based on heart ultrasonography, blood tests, chest X-ray, electrocardiogram and myocardial scintigraphy. She was extubated from the ventilator after 3 days of catecholamine, furosemide and carperitide administration. She was discharged from the hospital on day 53 without symptoms.

The Relationship between the Level of Expression of Intercellular Adhesion Molecule‐1 in Placenta and Onset of Preeclampsia

Objective: To investigate the differences in the expression of intercellular adhesion molecule‐1 (ICAM‐1) in the placenta and the concentration of soluble ICAM‐1 between early‐onset and late‐onset preeclampsia.

Towards improved ultrasound-based analysis and 3D visualization of the fetal brain using the 3D Slicer

Magnetic resonance imaging (MRI) provides useful three-dimensional (3D) information; however, there are some restrictions on its use during pregnancy due to safety concerns. In addition, fetal movements can create artifacts on MR images, as image quality depends on position of the fetus and placenta. In the past decade, 3D ultrasound imaging has been used in clinical practice to investigate the formation and volumetric size of critical anatomical structures of the fetus. However, current techniques rely mainly on analysis of sections of interest that do not integrate anatomical information concerning the shape of these structures. We provide a brief description of a workflow for semi-automated segmentation and 3D visualization of fetal ultrasound volumes in the second trimester using the 3D Slicer open source software1,2. Our workflow allowed quantitative image analysis of the choroid plexus and cerebrum from 3D ultrasound images. We acquired 3D ultrasound volumes from five healthy pregnant women at 12 (n=2), 14 (n=2) and 19 (n=1) weeks of gestation. Informed consent was obtained in each case. We used a Voluson E6 (GE Medical Systems, Zipf, Austria) ultrasound machine with a RAB4-8-D/OB D/4D 8-MHz transabdominal transducer. Our workflow consisted of four steps (Figure 1). Firstly, we imported DICOM (digital imaging and communications in medicine) ultrasound volumes into the 3D Slicer. We then used the ‘Grow Cut Segmentation’ algorithm3 of the interactive Editor module to extract critical structures from the ultrasound volumes. We reconstructed 3D surface models from segmented regions using the ‘Marching Cubes’ algorithm4, and finally computed the volume of 3D anatomical models using the ‘Label Statistics’ module of the software. Figure 1 Flowchart describing the 3D Slicer workflow used in this study. DICOM, digital imaging and communications in medicine. Figure 2 shows a 3D surface model of the choroid plexus and cerebrum reconstructed from the original 3D ultrasound volumes. The corresponding volumes of these structures at 12, 14 and 19 weeks’ gestation were, respectively: 431.1mm3, 698.9mm3 and 1203.3 mm3 for the choroid plexus and 183.6 mm3, 282.8 mm3 and 469.8 mm3 for the cerebrum. Figure 2 Result of ‘Grow Cut Segmentation’ of the fetal brain using the 3D Slicer. The blue structure represents the choroid plexus, and the yellow structure the cerebrum at 14 weeks of gestation (axial and coronal views). Using the 3D Slicer, we were able to obtain patient-specific quantitative information and 3D visualization of anatomical structures within the fetal brain. We anticipate being able to perform segmentation that accurately matches the anatomy using different methods. We believe this method, combined with ultrasound or MRI data, will be helpful in monitoring fetal development and detecting anomalies of the brain as well as other anatomical structures.

Monochorionic twin fetus with VACTERL association after intracytoplasmic sperm injection

We report a rare case of a monochorionic twin gestation after intracytoplasmic sperm injection (ICSI) in which one of the fetuses had VACTERL association. A 27‐year‐old woman became pregnant by ICSI and was found to have monochorionic twin fetuses. One fetus was noted to have the following anomalies: a multicystic, dysplastic left kidney with a hydroureter, and a dilated colon. A normal‐sized stomach and normal amount of amniotic fluid were observed during the prenatal period with no other anomalies. The postnatal examination revealed hypospadias, and anal, esophageal, and duodenal atresia; thus, a diagnosis of VACTERL association was established. Although the prenatal diagnosis of this disorder is a challenge, even in a singleton, some of the characteristic features observed during antepartum ultrasonography may be a clue to the diagnosis, especially in a twin pregnancy after ICSI.

Fetal goiter associated with preconception hysterosalpingography using an oil‐soluble iodinated contrast medium

Fetal goitrous hypothyroidism is rare in pregnancies of euthyroid women. It is reported to be caused by excessive maternal iodine exposure, such as from oral intake. There has however been one case that occurred after hysterosalpingography (HSG) with an oil-soluble iodinated contrast medium. Here we report our own experience of fetal goiter after preconception HSG using this contrast medium. A 27-year-old woman was referred to our hospital at 29 weeks’ gestation with polyhydramnios. Her history was negative for thyroid disease and her iodine intake was normal. She had undergone treatment for infertility and, on the 11th day of her last menstrual cycle, she had undergone HSG with an oil-soluble iodinated contrast medium. Basal body temperature indicated that she was pregnant 5 days after the procedure. Following detailed ultrasound examination, a large homogeneous goiter, measuring 35 × 19 mm, was identified in the anterior aspect of the fetal neck (Figure 1), which was also visualized with fetal magnetic resonance imaging (MRI) (Figure S1). Maternal thyroid function was low, confirmed by a high level of serum thyroid-stimulating hormone (TSH) and low levels of free thyroxine (T4) and free triiodothyronine (T3). At 35 week’s gestation, levels had returned to normal without medical treatment and the polyhydramnios

OP18.08: FGR fetuses have less facial expressions than AGA counterparts with the assessment by four-dimensional high-definition live (4D HDlive) ultrasound

only moderate decrease until 38 GW (108.2ml), but considerable variation of the absolute dimensions. The best fitting equation for SAS growth was a third-degree polynomial function (y = 433 – 59.6 * x + 2610 * x2 -33.36*x3; R2= 0.829). The relative SAS volume was high initially (40% in GW 16) and decreased until 23 GW (34%), peaked again at GW 27 (38%) and got reduced to 25% in GW 38. The best-fitting equation was a cubic function (y = 112-8.96*x+0.36*x2-0.00489*x3; R2 = 0.631). Conclusions: The SAS represents an important part of fetal intracranial anatomy, on average making up one third of the EV. Its reduction with advancing gestation may be considered a means to allow for further increase of brain volume until term, without concomitant increase in head size.

Progressive Fetal Subdural Hematoma Associated With Maternal Vitamin K Deficiency: Prenatal Diagnosis and Neurologically Favorable Prognosis

A 31-year-old woman, gravida 2, para 0, was referred to our hospital at 28 weeks’ gestation for an enlarged biparietal diameter in the fetus. Her first pregnancy had ended in artificial abortion at 11 weeks’ gestation for social reasons. She did not have any histories including anorexia or coagulation abnormality. She began to vomit frequently at 7 weeks’ gestation and was treated for hyperemesis gravidarum with infusion of nutrients. The nutritional solution contained multiple vitamins but not vitamin K. Because severe vomiting persisted, detailed examinations were performed. Upper gastrointestinal endoscopy at 25 weeks’ gestation revealed reflux esophagitis. She also had a diagnosis of mental disorders (attention deficit/hyperactivity disorder and anxiety disorder), and on-demand use of a major tranquilizer (risperidone) was started. At 28 weeks’ gestation, an enlarged biparietal diameter was noticed, and she was referred and admitted to our hospital. Fetal sonography revealed an enlarged biparietal diameter of 85.5 mm (14.0 standard deviation [SD]) caused by bilateral subdural hematoma (Figure 1A). As maternal serum protein induced by vitamin K absence or antagonist II (PIVKA-II) concentration, which was induced in the liver as a result of vitamin K absence, turned out to be 1.391 mAU/m (normal,< 40 mAU/mL), we highly suspected vitamin K deficiency and started its replacement therapy. There were not any other abnormal findings such as thrombopenia and coagulopathy (eg, low fibrinogen levels) in the maternal

Facial Expressions of Fetal Growth Restriction and Appropriate-for-Gestational Age Fetuses Assessed by Four-Dimensional High-Definition Live Ultrasound

Objective: To determine whether fetal growth restriction (FGR) fetuses have less facial expressions than appropriate-for-gestational age (AGA) counterparts with the assessment by four-dimensional high-definition live (4D HDlive) ultrasound. Methods: 4D HDlive ultrasound examinations of fetal facial expressions were performed on singleton pregnant women between 26 and 39 weeks of gestation. The duration of the 4D HDlive recordings was 15 minutes in all cases. The frequency of seven types of previously-reported facial expressions, or blinking, mouthing, yawning, tongue expulsion, sucking, smiling and scowling, were assessed. Two observers counted the frequencies, and inter-and intra-observer reproducibility was examined. Wilcoxon rank-sum test was used for comparison of FGR and AGA group. Kruskal-Wallis test was used for intra-group significance of frequencies of seven types of fetal facial expressions. P<0.05 was considered significant. Results: In this study, good intra- and inter-class correlation coefficients and intra- and inter-observer agreements were obtained. Thus, measurement values by only one examiner were used for further analysis. The facial expressions of 16 fetuses (FGR: n=8, AGA: n=8) were assessed. We noted a tendency for FGR fetuses to have less facial expressions than AGA counterparts. Although statistically significant inter-group difference was not detected in frequency of any facial expressions, this propensity is conspicuous in smiling (p=0.065) and mouthing (p=0.279). In AGA fetuses, the commonest facial expression was mouthing and was significantly more frequent than blinking (p=0.007), tongue expulsion (p=0.007) and sucking (p=0.002). We also noted a tendency that the frequency of facial expressions declines with fetal maturation. Although no statistically significant difference was shown, this propensity is prominent in mouthing of FGR (p=0.071). Conclusion: 4D HDlive ultrasound provides promising modalities in novel evaluative imaging of fetal various facial expressions, and may help to elucidate functional development of central nervous system (CNS) and facial expressions both in normal and compromised fetuses.

Successful ultrasound‐guided intraoperative external cephalic version of fetus in breech presentation immediately before ex‐utero intrapartum treatment (EXIT) procedure

A 32-year-old pregnant woman was referred to our hospital at 22 weeks of gestation because of fetal ascites. Ultrasound examination revealed massive ascites, enlarged hyperechogenic lungs with diaphragmatic inversion, dilated trachea and polyhydramnios, suggestive of congenital high airway obstruction syndrome (CHAOS) (Figure 1). The patient and her husband consented to undergo an ex-utero intrapartum treatment (EXIT) procedure, however the pregnancy had been complicated by a breech presentation throughout the whole gestational period (Figure 2). For a successful EXIT procedure, we planned to correct the fetal presentation by intraoperative external cephalic version (ECV). At 36 weeks of gestation, deep general anesthesia was achieved with desflurane and an abdominal midline incision was made. We performed an intraoperative ECV from the anterior wall of the uterus using sterile ultrasound guidance. We attempted first a forward roll of the fetus (counterclockwise rotation), which failed owing to the right-sided placental location preventing a forward roll of the fetal head (Figure 2). Therefore, we then attempted a backward roll of the fetus (clockwise rotation) and successfully moved the fetal head to the lower uterine segment. After the transverse incision was made at the lower uterine segment, the fetal head and neck were exposed. It was impossible to insert a tracheal tube through the larynx, thus a surgical airway was established by placement of an endotracheal tube via a tracheotomy. After delivery, congenital laryngeal atresia was confirmed by laryngoscopy (Figure S1). Fetuses with CHAOS cannot survive without appropriate perinatal management, owing to the lack of an airway for ventilation. An EXIT procedure, performed immediately prior to delivery, enables an airway to be secured by laryngoscopy, bronchoscopy or tracheostomy while being maintained on placental support1.