Shunichiro Tsuji

MRI Evaluation of the Uterine Structure after Myomectomy

Myomectomy is a good indication for women with uterine leiomyoma who desire to preserve their child-bearing potential. However, there are still no reports about how long it takes the uterus to reach a stable state after myomectomy. We evaluated the changes in uterine structure during the recovery process after myomectomy by MR images. MR images were used to analyze the time-dependant changes in the length of the uterine cavity, the volume of the uterus, recovery of the junctional zone, prevalence of modification of the endometrium, and uterine structure in the region of the enucleated myoma. The cavity length and the volume of the uterus, and the myometrium were stabilized at six weeks after the myomectomy. With regard to the endometrium, 12 weeks were required for it to achieve a stable state after myomectomy. However, even at 12 weeks postoperatively, 14.2% of the cases showed an unusual view near the uterine incision on MR images. We concluded that the recovery process is complete at 12 weeks after the operation if there are no clear findings of hematoma or edema formation in the myometrium on MR images.

Recommendations for preventing stillbirth: a regional population-based study in Japan during 2007-2011.

The perinatal mortality rate in Japan has recently been at the lowest level in the world. However, the perinatal mortality rate of Shiga prefecture has been continuously higher than the Japanese average. The reason for this has not yet been explained. The perinatal mortality rate comprises both stillbirths and neonatal deaths. As stillbirths were almost double neonatal deaths, we focused on the stillbirths to determine how they might be prevented. All of the stillbirth certificates in Shiga Prefecture during 2007-2011 were inspected. On the basis of that information, we designed the original questionnaire and sent it to each obstetrician submitting a death certificate to obtain further information associated with the stillbirth. Reviewing retrospectively returned questionnaires by a peer-review team, we evaluated the possibility of preventing stillbirth along with recommendations for prevention. There were 252 stillbirths among 66,682 deliveries in Shiga during this period. We were able to analyze 188 stillbirths (75%). The audit conference judged that 47 cases of them (25%) were determined to have had some possibility of prevention with seven cases (4%) having strong possibility. We identified major causes of preventable stillbirths, including substandard obstetrical management, delayed referral of high-risk women from primary obstetrical clinics to higher perinatal centers, and delayed visits of pregnant women with decreased fetal movements to clinics or hospitals. Based on the results of this study, we conclude that education for pregnant women is required as well as the necessity of improving obstetric care to prevent stillbirths.

Suppressive regulatory T cells and latent transforming growth factor-β-expressing macrophages are altered in the peritoneal fluid of patients with endometriosis

BackgroundEndometriosis is a known cause of infertility. Differences in immune tolerance caused by regulatory T cells (Tregs) and transforming growth factor-β (TGF-β) are thought to be involved in the pathology of endometriosis. Evidence has indicated that Tregs can be separated into three functionally and phenotypically distinct subpopulations and that activated TGF-β is released from latency-associated peptide (LAP) on the surfaces of specific cells. The aim of this study was to examine differences in Treg subpopulations and LAP in the peripheral blood (PB) and peritoneal fluid (PF) of patients with and without endometriosis.MethodsPB and PF were collected from 28 women with laparoscopically and histopathologically diagnosed endometriosis and 20 disease-free women who were subjected to laparoscopic surgery. Three subpopulations of CD4+ T lymphocytes (CD45RA+FoxP3low resting Tregs, CD45RA−FoxP3high effector Tregs, and CD45RA−FoxP3low non-Tregs) and CD11b+ mononuclear cells expressing LAP were analyzed by flow cytometry using specific monoclonal antibodies.ResultsProportions of suppressive Tregs (resting and effector Tregs) were significantly higher in the PF samples of patients with endometriosis than in those of control women (P = 0.02 and P < 0.01, respectively) but did not differ between the PB samples of patients and controls. The percentage of CD11b+LAP+ macrophages was significantly lower in PF samples of patients with endometriosis than in those of controls (P < 0.01) but was not altered in the PB samples.ConclusionProportions of suppressive Tregs and LAP+ macrophages are altered locally in the PF of endometriosis patients.

Excessively delayed maternal reaction after their perception of decreased fetal movements in stillbirths: Population-based study in Japan

BACKGROUND Fetal movement is the most common method to evaluate fetal well-being. Furthermore, maternal perception of decreased fetal movements is associated with perinatal demise. Previously, we showed that perception of decreased fetal movements was the most common reason for mothers visiting the outpatient department among those who had stillbirths in our region. Further investigation of stillbirths with decreased fetal movements is essential to find a possible way of preventing stillbirth. AIM To investigate maternal reaction time after their perceiving decreased fetal movements among stillbirths in our region of Japan. METHODS This is a population-based study of stillbirths in Shiga Prefecture, Japan conducted from 2007 to 2011. We sent a questionnaire to each obstetrician who had submitted the stillbirth certificate. We reviewed and evaluated the questionnaires returned from the obstetricians. FINDINGS There were 66 cases (35%) with decreased fetal movements among 188 stillbirths in Shiga during the study period. The number of maternal visits to outpatient department after perception of decreased fetal movements within 24h was only seven (11%) among 64 stillbirths diagnosed at outpatient department. CONCLUSION We conclude that delayed maternal visit after perceiving decreased fetal movements is frequently observed in stillbirths. Promoting more thorough maternal education on fetal movements, including emphasizing earlier visitation after perceiving decreased fetal movements, may prevent stillbirths.

Possible Prevention of Neonatal Death: A Regional Population-Based Study in Japan

Purpose The neonatal mortality rate in Japan has currently been at the lowest level in the world. However, it is unclear whether there are still some potentially preventable neonatal deaths. We, therefore, aimed to examine the backgrounds of neonatal death and the possibilities of prevention in a region of Japan. Materials and Methods This is a population-based study of neonatal death in Shiga Prefecture of Japan. Results The 103 neonatal deaths in our prefecture between 2007 and 2011 were included. After reviewing by a peer-review team, we classified the backgrounds of these neonatal deaths and analyzed end-of-life care approaches associated with prenatal diagnosis. Furthermore, we evaluated the possibilities of preventable neonatal death, suggesting specific recommendations for its prevention. We analyzed 102 (99%) of the neonatal deaths. Congenital malformations and extreme prematurity were the first and the second most common causes of death, respectively. More than half of the congenital abnormalities (59%) including malformations and chromosome abnormality had been diagnosed before births. We had 22 neonates with non-intensive care including eighteen cases with congenital abnormality and four with extreme prematurity. Twenty three cases were judged to have had some possibility of prevention with one having had a strong possibility of prevention. Among specific recommendations of preventable neonatal death, more than half of them were for obstetricians. Conclusion There is room to reduce neonatal deaths in Japan. Prevention of neonatal death requires grater prenatal care by obstetricians before birth rather than improved neonatal care by neonatologists after birth.

Management of secondary infertility following cesarean section: Report from the Subcommittee of the Reproductive Endocrinology Committee of the Japan Society of Obstetrics and Gynecology

The aim of this study was to examine the current status and management of secondary infertility following cesarean section in Japan.

Effects of β-estradiol on cold-sensitive receptor channel TRPM8 in ovariectomized rats

Transient receptor potential cation channel subfamily M member 8 (TRPM8) is associated with sensitivity to cold sensation in mammals. A previous study demonstrated that TRPM8 was overexpressed in the skin of ovariectomized (OVX) rats due to the loss of estrogen. In the present study, we investigated whether estrogen replacement restricts overexpression of the TRPM8 channel in the skin of OVX rats. We divided 15 Sprague Dawley rats into three groups: a non-operated group (NON-OPE), an ovariectomy group (OVX), and a group subjected to estrogen replacement during 4 weeks beginning 7 days after ovariectomy (OVX + E2). Five weeks later, TRPM8 channel mRNA and protein in lumbar skin were quantified by real-time RT-PCR, protein ELISA, and immunohistochemistry. The OVX + E2 group exhibited a trend for decreased expression of the TRPM8 channel in the lumbar skin in comparison with the OVX group, whereas ELISA data and immunohistochemistry data and immunohistochemistry graphs relating to TRPM8 protein did not show any obvious differences between the OVX group and the OVX + E2 group. Estrogen replacement may restrict the overexpression of TRPM8 in the dermis of OVX rats.

Subchondral Insufficiency Fracture of the Femoral Head in a Pregnant Woman with Pre-existing Anorexia Nervosa

Subchondral insufficiency fracture (SIF) is a fragility fracture secondary to osteoporosis that leads to collapse of the femoral head with no evidence of osteonecrosis. SIF of the femoral head has been reported in adults of varying ages and both sexes, but it has never been reported to occur in pregnant women. Herein, we describe a 40-year-old primiparous patient with pre-existing anorexia nervosa who developed SIF of the femoral head in the third trimester. At 29 weeks of gestation, the patient complained of sudden pain on walking in both hips. Despite the bed rest, her hip pain increased; consequently, cesarean section was performed at 36 weeks. After delivery, plain radiographs showed that the left femoral head was collapsed. Dual-energy X-ray absorptiometry indicated that the patient was osteoporotic. The magnetic resonance imaging (MRI) of her hips showed the findings that were compatible with SIF. Her left hip pain worsened during follow-up, and a radiograph showed progressive collapse of the left femoral head. The patient then underwent left bipolar hip arthroplasty 18 months after delivery, and she was diagnosed with SIF histopathologically. This is the first report of SIF in a pregnant woman that may reflect pregnancy-associated osteoporosis. SIF in pregnancy might be overlooked or misdiagnosed because the MRI findings have several overlaps with those of other hip disorders. Precise diagnosis of SIF in pregnancy may contribute to a better outcome by avoiding early arthroplasty in young women and appropriate evaluation of the osteopenic status of the patient.

Molecular Pathogenesis of Uterine Fibroids

Researchers investigated aberrant gene expression in uterine fibroids to elucidate their molecular pathogenesis. Complex networks of multiple factors such as growth factors and WNT/β-catenin signaling have been shown to be involved in the pathogenesis of uterine fibroids. This chapter will focus on the current knowledge of molecular mechanism that are involved in the generation or development of uterine leiomyomas.

Impact of hysteroscopic surgery for isthmocele associated with cesarean scar syndrome

Cesarean scar syndrome (CSS) is characterized by increased risk of postmenstrual abnormal uterine bleeding, dysmenorrhea, and infertility, due to a post‐cesarean scar defect known as an isthmocele. This study aimed to assess the impact of hysteroscopic surgery on isthmocele associated with CSS.