Rie Usui

Risk of Complications and Uterine Malignancies in Women Undergoing Hysterectomy for Presumed Benign Leiomyomas

Objectives: To determine the incidences of complications and uterine malignancies among women undergoing hysterectomies for presumed benign leiomyomas. Methods: We retrospectively reviewed the medical records of 923 women who underwent total hysterectomies between January 1983 and December 1997 at our hospital due to presumed benign leiomyomas. Results: The mean age (SD) of the patients was 44.5 ± 5.2 years, 105 ± 35 minutes was required for the procedure, and 405 ± 312 ml of blood was lost during the procedure. Forty-one (4.4%) women demonstrated complications of intraoperative hemorrhages and required transfused blood. Urinary tract and bowel injuries occurred in 10 (1.1%) and 2 (0.2%) women, respectively. One woman (0.1%) died from pulmonary embolism that occurred on postoperative day 1. One woman (0.1%) required relaparotomy to control intraabdominal hemorrhage. Uterine malignancies were discovered postoperatively in 4 (0.4%) women, including 2 endometrial carcinoma, 1 leiomyosarcoma, and 1 endometrial stromal sarcoma. Conclusions: The incidences of complications and unrecognized uterine malignancies were similar to the results of previous studies. Of patients undergoing hysterectomy for presumed benign leiomyomas, the risk of major complications was 6.0% (55/923) and the risk of preoperatively undiagnosed uterine malignancies was 0.4%.

Effect of maternal age on blood loss during parturition: a retrospective multivariate analysis of 10,053 cases.

Abstract Objective: An extensive study as to whether maternal age itself is a risk factor for blood loss during parturition. Method: A total of 10,053 consecutive women who delivered a singleton infant were studied.The excess blood loss was defined separately for women with vaginal and cesarean deliveries as ≥= 90th centile value for each delivery mode. The effects of 13 potential risk factors on blood loss were analyzed using multivariate analysis. Results: The 90th centile value of blood loss was 615 ml and 1,531 ml for women with vaginal and cesarean deliveries, respectively. A low lying placenta (odds ratio[OR] , 4.4), previous cesarean (3.1), operative delivery (2.6), leiomyoma (1.9), primiparity (1.6), and maternal age ≥= 35 years (1.5) were significant independent risk factors for excess blood loss in women with vaginal delivery. Placenta previa (6.3), leiomyoma (3.6), low lying placenta (3.3), and maternal age ≥= 35 years (1.8) were significant independent risk factors for excess blood loss in women with cesarean sections. Conclusion: A maternal age of ≥= 35 years was an independent risk factor for excess blood loss irrespective of the mode of delivery, even after adjusting for agerelated complications such as leiomyoma, placenta previa, and low lying placenta.

Uterine compression sutures for postpartum hemorrhage: an overview

In 1997, B‐Lynch pioneered the use of uterine compression sutures for postpartum hemorrhage. Since then, some researchers, including ourselves, have devised various uterine compression sutures. High‐level evidence has not been demonstrated as to whether compression sutures achieve better and safer hemostasis for postpartum hemorrhage than other methods, and, if they do, whether one suture is more efficient and safer than another. However, generally speaking, uterine compression sutures have achieved hemostasis while preserving fertility in many women and thus their efficacy and safety have been time‐tested. Each suture has both merits and drawbacks: obstetricians must be aware of the fundamental characteristics of various sutures. In this review, we summarize the technical procedures, efficacy, safety and complications of various uterine compression sutures. We add our own experiences and opinions where necessary.

Important surgical measures and techniques at cesarean hysterectomy for placenta previa accreta

For cesarean hysterectomy with placenta previa accreta, “universally achievable” measures are required. We propose eight measures: (i) placement of intra‐iliac arterial occlusion balloon catheters; (ii) placement of ureter stents; (iii) “holding the cervix” to identify the site to be transected; (iv) uterine fundal incision; (v) avoidance of uterotonics; (vi) “M cross double ligation” for ligating the ovarian ligament; (vii) “filling the bladder” to identify the bladder separation site and “opening the bladder” for placenta previa accreta with bladder invasion; and (viii) to continue to clamp the medial side of the parametrium or the cervix or employment of the “double edge pick‐up” to ligate it. These eight measures are simple, easy, effective, and thus “universally achievable”.

A Retrospective Survey of Clinical, Pathologic, and Prognostic Features of Adnexal Masses Operated on during Pregnancy

Objectives: To evaluate retrospective data concerning patients with adnexal masses that were managed surgically during pregnancy and their effect on fetal outcome.

Normal and High-Normal Blood Pressures, but Not Body Mass Index, Are Risk Factors for the Subsequent Occurrence of Both Preeclampsia and Gestational Hypertension: A Retrospective Cohort Study

Blood pressure (BP) levels and body mass index (BMI) are known as risk factors for preeclampsia and gestational hypertension. However, there have been few investigations regarding the effects of BP and BMI levels on preeclampsia and gestational hypertension in the same cohort. In the present study, we conducted a retrospective cohort study using multiple logistic regression analysis. The cohort included 1,518 patients without nephritis. The unadjusted odds ratios (ORs) of preeclampsia and gestational hypertension were increased in pregnant women with normal BP (120–129 mmHg systolic or 80–84 mmHg diastolic), high-normal BP and hypertension in the second trimester compared to those with optimal BP. The unadjusted ORs of preeclampsia and gestational hypertension were also increased in obese women in the pre-pregnancy period compared to women with normal range BMI. When adjustment was made for both the BP levels and pre-pregnancy BMI levels, the ORs (95% confidence intervals) of normal BP, high-normal BP, hypertension and obesity for the subsequent occurrence of preeclampsia were 5.1 (2.2–12), 8.3 (3.1–22), 16 (5.0–50) and 2.0 (0.67–5.9), and those for the subsequent occurrence of gestational hypertension were 7.0 (2.6–19), 7.4 (2.1–25), 22 (6.1–83) and 1.3 (0.33–4.8), respectively. For the subsequent occurrence of preeclampsia or gestational hypertension, normal BP, high-normal BP and hypertension in the second trimester may be independent risk factors. Obesity in the pre-pregnancy period, however, may not be an independent risk factor.

Vaginal lactobacilli and preterm birth

Abstract Objective: To assess the relationship between the absence of vaginal lactobacilli and preterm birth at < 33 weeks of gestation. Methods: A prospective study of the vaginal flora in the second trimester was undertaken in 1958 women with singleton pregnancies. The contribution of various microorganisms to preterm delivery was analyzed using a multivariate-logistic regression model. Results: Lactobacillus species were not cultured from 28% of 118 women who delivered at < 33 weeks, 10% of 224 women who delivered between 33 and 36 weeks, and 5% of 1616 women who delivered at > 37 weeks of gestation. Lactobacilli (odds ratio and 95% confidence interval: 0.15 [0.09 to 0.24]), Mycoplasma hominis (2.3 [1.0 to 5.4]), and glucose non-fermentative gram-negative rods (2.1 [1.0 to 4.2]) were identified as independent risk factors for preterm delivery at < 33 weeks of gestation. Absence of lactobacilli (sensitivity and positive predictive value: 28% and 25%) was a better predictor of preterm delivery at < 33 weeks of gestation than the presence of Mycoplasma hominis (7% and 13%, respectively) or glucose non-fermentative rods (9% and 11%). Conclusions: Although this was not a cohort study, results suggest that tests for determining the presence of vaginal lactobacilli may be clinically useful tools for identifying women at an increased risk of preterm delivery at < 33weeks of gestation.

Alteration of serum soluble endoglin levels after the onset of preeclampsia is more pronounced in women with early-onset.

It has been established that serum soluble endoglin (sEng) increases in women with preeclampsia. However, sEng levels have not been evaluated using a normal reference value specific to each gestational age. First, we established the normal reference value for sEng using 85 pregnant controls without preeclampsia, from whom serum samples were collected three times at 20–23, 27–30, and 36–38 weeks of gestation. Second, we evaluated the serum sEng levels after the onset of preeclampsia in 56 preeclamptic patients. In three women (3.5%) with normal pregnancies, sustained high sEng levels (>15 ng/mL) were observed. We calculated the reference value for sEng using the remaining 82 normal controls. The log10sEng was almost normally distributed at each gestational week during 20–38 weeks, and the mean log10sEng was represented as a quadratic curve of gestational week. The SD of log10sEng was represented as a linear equation of gestational week. The mean log10sEng significantly and gradually increased from 20–23 weeks to 27–30 weeks of gestation and then rapidly increased at 36–38 weeks of gestation. Ninety-three percent of preeclamptic women showed sEng≥95th percentile of the reference value. The log10sEng levels and the SD score (SDS) of log10sEng in women with early-onset preeclampsia (onset<32 weeks of gestation) were significantly higher than those in women with late-onset preeclampsia (onset≥32 weeks of gestation) (1.97±0.23 vs. 1.78±0.28, 9.94±2.61 vs. 4.47±2.06, respectively). In conclusion, alteration of serum sEng levels after the onset of preeclampsia was more pronounced in women with early-onset preeclampsia compared to those with late onset.

Uterine artery pseudoaneurysm: not a rare condition occurring after non-traumatic delivery or non-traumatic abortion

PurposeUterine artery pseudoaneurysm (UAP) is considered a rare disorder after traumatic delivery or traumatic pregnancy termination such as cesarean section or dilatation and curettage, initially manifesting as genital hemorrhage. Our clinical impression contradicts these three assumptions; after traumatic delivery/termination, hemorrhage, and its rarity. Thus, we attempted to clarify these three issues.MethodsWe retrospectively analyzed 22 UAP cases treated at our institute over a 6-year period.ResultsUterine artery pseudoaneurysm occurred in 2–3/1,000 deliveries. Of 22 cases, half occurred after non-traumatic deliveries or non-traumatic pregnancy termination. Fifty-five percent (12/22) showed no hemorrhage; ultrasound or color Doppler revealed UAP. Thus, half of UAP occurred after non-traumatic deliveries or non-traumatic pregnancy termination and showed no hemorrhage at the time of their diagnoses. All patients received transarterial embolization, which stopped blood flow into UAP or achieved hemostasis.ConclusionWe must be aware that UAP may not be so rare and it may be present in patients after non-traumatic deliveries/pregnancy termination and without postpartum or postabortal hemorrhage.

Opening the bladder for cesarean hysterectomy for placenta previa percreta with bladder invasion

Cesarean hysterectomy for placenta previa percreta with bladder invasion often induces not only massive hemorrhage but also severe bladder/ureter injuries. A 37‐year‐old woman with previous cesarean delivery suffered placenta previa percreta with bladder invasion. At the 34th week, we performed cesarean hysterectomy. Without separating the bladder from the uterus/cervix, we incised the bladder lateral wall using an automatic stapling/cutting device, leaving the bladder posterior wall adhering to the uterus and resecting it with the uterus. The bladder was easily repaired without urological sequelae. We suggest a new, simple and safe technique for cesarean hysterectomy for this disease.