Takuya Misugi

Insulin-Lowering Agents Inhibit Synthesis of Testosterone in Ovaries of DHEA-Induced PCOS Rats

Background: Insulin-lowering agents are reported to be useful in treating polycystic ovary syndrome (PCOS) anovulation. It has been suggested that lower insulin levels secondarily affect ovarian tissue, although the direct mechanism of action has not yet been verified. Here we investigated if these agents directly affect the ovary. Methods: Thirty female Wister rats were studied. Six control rats were injected subcutaneously with 0.2 ml sesame oil, while 24 rats used as PCOS models were injected subcutaneously with dehydroepiandrosterone (DHEA) and divided into four groups. Six rats were injected with only DHEA, while the remaining 18 rats received metformin, pioglitazone or troglitazone. The ovaries were immunohistochemically stained with anti- testosterone and anti-17β-HSD antibodies, and then evaluated for morphological changes. Results: In the DHEA administration group, the number of atretic follicles significantly increased compared to that of control rats. The insulin-lowering agents did not improve the multicystic appearance. Serum testosterone concentrations significantly increased with DHEA administration, but the increase was inhibited by oral administration of insulin-lowering agents. Testosterone deposits in ovarian tissue were also reduced by feeding rats insulin-lowering agents. Conclusion: Insulin-lowering agents affected ovarian tissue by inhibiting testosterone biosynthesis in vivo.

Combined reconstructive surgery involving uterosacral colpopexy and anterior vaginal mesh implantation for pelvic organ prolapse.

The optimal treatment for pelvic organ prolapse has been the subject of much discussion. The aim of this study was to assess the utility of a combination of uterosacral colpopexy and anterior vaginal mesh implantation.

On-site hemostatic suturing technique for uterine bleeding from placenta previa and subsequent pregnancy.

We have found that our operative technique of hemostasis in cases with massive bleeding from the placental removal site was useful during cesarean delivery. In addition, subsequent pregnancy occurred in 7 cases with uncomplicated outcomes. We describe our surgical technique and the patients’ outcomes. The data of patients who had undergone cesarean section at our institute from April 2010 to December 2014 were retrospectively analyzed. Cesarean sections were performed for 67 pregnant women with placenta previa; 2 cases with placenta increta and 1 case that did not need any hemostatic technique were excluded from this study. Table 1 shows the summary of the patients and operation outcomes. The uterine incision was made on the lower segment in all cases. If the placenta was located anteriorly, we partially separated the placenta towards the closest edge to rupture the membrane and deliver the infant [1]. After placental removal, figure-of-eight suturing with PDS Plus (ETHICON, US) into the myometrium but not to the uterine serosa on-site at the uterine bleeding point was used in 64 cases (Fig. 1). Multiple square suturing was added if the bleeding sites were located on the anterior wall of the lower uterine segment [2]. All of the cases that underwent figure-of-eight suturing had relatively little uterine bleeding after the operation, and none of them required additional treatments, such as uterine arterial embolization, B-Lynch compression suturing, or hysterectomy, or a stay in the intensive care unit. Due to the precise control of hemostasis, more than 93 % of the cases were able to take anticoagulant therapy after surgery. Regarding subsequent pregnancy, 9 pregnancies of 8 women were confirmed at our institute, and 7 of them had uneventful pregnancies without placenta percreta/increta and were successfully delivered by cesarean section. Two cases are still pregnant awaiting delivery. Placenta previa is associated with serious maternal outcomes, including antenatal and post-partum hemorrhage, placenta increta and percreta, and peripartum hysterectomy. Various hemostatic techniques have been reported to achieve hemostasis, although some methods are reported to be related to complications such as uterine necrosis or subsequent sterility [3–5]. In addition, there is an increased risk of placenta previa in pregnancies following use of assisted reproduction technology (ART) [6– 8], where in some cases, peritoneal and/or pelvic adhesions may be increased, and compression sutures and cesarean hysterectomy would be very difficult. On the other hand, our method of applying figure-of-eight suturing for on-site bleeding points is very simple and can be performed even in cases with broad rectal or intestinal adhesions to the posterior wall of the uterus, which are sometimes seen in cesarean section following ART. Although the assistant needs to evacuate the blood to show the bleeding points to perform precise on-site suturing (Fig. 1), and we performed relatively many sutures (up to 17 times) during the operations, no additional treatment or transfusions due to further bleeding were needed. In addition to fertility conservation, we believe that our simple method may be helpful in many emergent cases, even outside of tertiary centers. & Daisuke Tachibana dtachibana@med.osaka-cu.ac.jp

EP03.05: Sequential ultrasoundgraphic findings and perinatal outcomes of decidual polyps treated with cervical cerclage: Electronic Poster Abstracts

Objectives: Decidual polyps (DPs) are highly associated with spontaneous abortion and preterm birth, although the management still remains to be established. We aimed to meticulously observe the sequential ultrasoundgraphic findings of DPs which were treated with cervical cerclage (CC) because of the shortening of cervical length (CL) and evaluate their clinical outcome. Methods: The patients who presented DPs which had more than 8 mm stalks in its diameter protruding out of the external os from upper side of the internal os were retrospectively reviewed. Polypectomy was not performed in any cases. CC was performed using McDonald method for the patients whose CL was less than 25mm before 25 weeks of gestation. Results: Fifteen patients were diagnosed with DPs between 2016 to 2018. Migration of DPs into placental parenchyma and the shortening of cervical length were observed simultaneously in eight cases and CC was performed. Median values and ranges were as following at the time of surgery: gestational age (GA), 18+6 (11+5-22+3) weeks / WBC, 10700 (7300 13000)/μl; CRP, 0.18 (0.02 0.79) mg/dl; CL, 14.5 (0-21.6) mm. Median GA of delivery was 36+5 (35+0-38+5) weeks and all the mothers and neonates discharged uneventfully. Conclusions: CC was successfully performed even in the cases with internal migration of DPs. Clinical obstetricians should keep in mind that CC might be effective in the patients who suffer from threatened abortion or preterm delivery because of DPs. EP03.06 Assisted reproductive technology and the risk of preterm birth

EP04.06: Systolic and diastolic time interval ratios of the ductus venosus flow velocity waveform in fetal growth restriction: Electronic Poster Abstracts

Methods: Cases with umbilical venous thrombosis diagnosis during Jan, 2018 to Feb, 2018 were reviewed for history, fetal heart monitor pattern during labour, ultrasound report, and laboratory reports. Results: A total of three cases with umbilical venous thrombosis were recruited for the study. The indications of admission were preterm labour, unsatisfied fetal monitor pattern with gestational diabetes mellitus, and onset of labour at term respectively. All cases delivered by emergent Caesarean section for persistent abnormal fetal hear monitor pattern, and all the babies were good except the preterm one at 32 weeks of gestation who was transferred to NICU immediately for respiratory acidosis and pneumonia. Their birthweights were compatible with gestational ages. The pathology examination of placentas all revealed as chorioamnionitis. All the ultrasound examination during pregnancy and at the time of admission of these three cases were reported normal. Except for the preterm mother whose WBC rose to 25.61,*09/L, the CBC of other two pregnant women at time of delivery were all normal. Conclusions: Cases with persistent abnormal fetal heart monitoring may be a reliable sign for umbilical venous thrombosis and should be handle with great care. Umbilical venous thrombosis is related to clinical and subclinical chorioamnionitis.

Time-interval changes of cardiac cycles in fetal growth restriction.

OBJECTIVE The aims of this study were to investigate the time intervals of each component of cardiac flow velocity waveforms (FVWs) in fetuses with fetal growth restriction (FGR) and to compare these with those of normal fetuses using reference ranges. METHODS The durations of atrioventricular (AV) valve opening (AVVO), AV valve closure (AVVC), total E- (total-E) and A- (total-A) waves, total ejection time (total-ET), acceleration time (acc-E for E-wave, acc-A for A-wave, and acc-ET for ejection time), and deceleration time (dec-E for E-wave, dec-A for A-wave, and dec-ET for ejection time) were measured in fetuses with FGR. All variables were analyzed using z-scores. RESULTS Measurements of 17 growth-restricted fetuses were obtained. The time intervals between the last Doppler examination and delivery ranged from 0 to 6 days, with a median of 1 day. Significant increases were observed in AVVO, total-E, dec-E, and acc-A of the left heart. acc-E, acc-ET and AVVC of the left heart were significantly decreased. In the right heart, AVVO, total-E and dec-E were significantly increased. CONCLUSION A prolonged time interval between early ventricular inflow and atrial contraction, as well as increased duration of AV valve opening, may reflect hemodynamic alterations in FGR fetuses.

Serum Biopterin and Neopterin Levels as Predictors of Empty Follicles

OBJECTIVE This study measured serum and follicular fluid (FF) levels of biopterin, neopterin, vascular endothelial growth factor (VEGF), and macrophage colony-stimulating factor (M-CSF) in patients receiving mild ovarian stimulation for oocyte retrieval. PATIENTS AND METHODS Infertile patients who underwent ovarian stimulation were divided into the following: Group 1, no oocyte retrieval (n = 12), and Group 2, retrieval of more than four oocytes (n = 13). Median total gonadotropin dose in both groups was 150 IU. Biopterin and neopterin levels were measured using high-performance liquid chromatography. VEGF and M-CSF levels were measured by enzyme-linked immunosorbent assay. RESULTS Compared to Group 2, serum and FF levels of neopterin and VEGF and serum levels of M-CSF were significantly increased, and serum and FF levels of biopterin were significantly decreased in Group 1 (P < 0.05 each). CONCLUSION Biopterin and neopterin levels showed similar differences in FF and serum of patients with empty follicles. Decreased biopterin and increased neopterin in serum could predict poor oocyte retrieval.

Sustained Decrease of Early-Phase Insulin Secretion in Japanese Women with Gestational Diabetes Mellitus Who Developed Impaired Glucose Tolerance and Impaired Fasting Glucose Postpartum

OBJECTIVE The aim of this study was to compare glucose intolerance in the antenatal and the postpartum periods using a 75-g oral glucose tolerance test (OGTT) in the Japanese women with gestational diabetes mellitus (GDM) using a retrospective design. PATIENTS AND METHODS Data were obtained from 85 Japanese women with GDM who delivered from April 2011 through April 2015 and who underwent an OGTT 6–14 weeks postpartum. The women were divided into two groups based on the results of the postpartum OGTT: one group with normal glucose tolerance (NGT) and the other with impaired glucose tolerance (IGT) as well as impaired fasting glucose (IFG). We analyzed the associations between postpartum IGT–IFG and various factors. RESULTS Antenatally, a significant difference was observed between the groups only in the 1-hour plasma glucose level of the 75-g OGTT. Postpartum results of plasma glucose level were significantly higher at 0.5, 1, and 2 hours in the IGT–IFG group than those in the NGT group. Moreover, a significant decrease in the levels of 0.5-hour immunoreactive insulin and insulinogenic index was observed in the IGT–IFG group compared to those in the NGT group. Homeostasis model assessment-insulin resistance and homeostasis model assessment β-cell function of both groups were found to significantly decrease in the postpartum period; however, there was no significant change in the insulinogenic index of either group. CONCLUSIONS Our study clearly showed that the postpartum IGT and IFG levels of Japanese women with GDM are affected by impaired early-phase insulin secretion; however, insulin resistance promptly improves.