Tatsuya Arakaki

Prediction of early- and late-onset pregnancy-induced hypertension using placental volume on three-dimensional ultrasound and uterine artery Doppler

To determine whether uterine artery (UtA) Doppler findings and three‐dimensional (3D) ultrasound measurement of placental volume during the first trimester allowed prediction of early‐ and late‐onset pregnancy‐induced hypertension (early PIH and late PIH).

Management of vasa previa during pregnancy.

Abstract In order to prevent fetal mortality due to vasa previa, it is neceesary to obtain an antenatal diagnosis and perform elective cesarean section prior to membrane rupture. Under present circumstances, management strategies for vasa previa depend on each institutional policy. In our institution, patients are not routinely admitted, although precise outpatient management, including confirming the presence of uterine contractions and monitoring the cervical length, fetal growth and fetal heart rate, is provided for pregnant females with vasa previa. In the present report, we reviewed 21 cases of vasa previa managed at our hospital. Some 71% (15/21) of them were required inpatient management due to its complications, resulting in emergency delivery in about half of them. Therefore, our results suggest that only carefully selected asymptomatic patients may be successfully managed as outpatients.

Silent uterine rupture occluded by intestinal adhesions following laparoscopic myomectomy: A case report

We present a rare asymptomatic case in which intestinal adhesions covered and occluded a site of uterine rupture, which was found during cesarean section. The patient had undergone laparoscopic myomectomy 5 years previously. However, detailed antenatal ultrasound and magnetic resonance imaging examinations revealed no uterine or placental abnormalities. It is thought that uterine rupture was not detected due to intestinal adhesions, which had occurred following the previous surgery. The present case suggests that women who conceive after laparoscopic myomectomy may be at risk of silent uterine rupture. However, detection of the silent uterine rupture during pregnancy may be limited, even with detailed imaging.

Repeated Measurement of Crown-Rump Length at 9 and 11-13 Weeks' Gestation: Association with Adverse Pregnancy Outcome

Aims: To clarify whether ultrasonographic measurements of crown-rump length (CRL) at 11-13 weeks - based on the number of gestational days determined using the CRL at 9 weeks - can predict fetal prognosis. Methods: A prospective cohort study was conducted to evaluate the association between fetal growth in the first trimester and fetal prognosis. Fetal growth in the first trimester was evaluated measuring CRLs at 11-13 weeks determined using the CRL at 9 weeks. The subjects were divided into short CRL (s-CRL) and normal CRL (n-CRL). The prognoses were compared between the two groups. Results: A total of 126 patients in the s-CRL group and 1,130 patients in the n-CRL group were enrolled. Abortion occurred in 7.1% of s-CRL and 0.9% of n-CRL subjects (p < 0.001). Among the patients with chromosomal abnormalities, the incidence of trisomy 18 was significantly greater in s-CRL (4.8 vs. 0.1%, p < 0.001). Without abortion, placental weight, frequency of small for gestational age (SGA) and birth weight in s-CRL were significantly higher than those in the n-CRL group (12.8 vs. 3.6%, p < 0.001). Conclusions: Measuring CRL at 9 weeks is useful for determining gestational days prior to measuring CRL at 11-13 weeks. After reconfirming the gestational age at 9 weeks, measuring CRL at 11-13 weeks is useful for predicting the incidence of trisomy 18 as well as SGA later in pregnancy.

Antenatal ultrasound screening using check list before delivery for predicting a non-reassuring fetal status during labor.

Abstract Objective: To clarify the effectiveness of ultrasound screening at 36 weeks’ gestation for predicting a non-reassuring fetal status during labor (NRFS). Methods: A prospective cohort study was conducted between 2012 and 2013. Ultrasound evaluations of umbilical cord and placental abnormalities and fetal biometry were performed among pregnant females at 36 weeks’ gestation. Patients who underwent ultrasound screening were divided into three risk level groups according to their abnormalities. After delivery, NRFS and emergency Cesarean section (eCS) rate were compared between the risk groups. Results: A total of 790 subjects were analyzed. Elective Cesarean section was performed in 111 cases. Consequently, 34 cases in the high-risk group, 45 cases in the middle-risk group and 600 cases in the low-risk group were analyzed. NRFS was diagnosed in 17.6%* of the patients in the high-risk group, 11.1%* of the patients in the middle-risk group and 5.6% of the patient’s in the low-risk group. eCS was performed in 8.8%* of the high-risk subjects, 4.4%* of the middle-risk subjects and 0.8% of the low-risk subjects (*p < 0.05 compared to the low-risk group). Conclusions: The use of antenatal ultrasound screening and risk classification effectively identifies cases of NRFS during delivery.

Reference values of focused assessment with sonography for obstetrics (FASO) in low-risk population

Abstract Objective: Hemorrhagic shock is a relatively common occurrence in the postpartum period. In our hospital, we performed abdominal ultrasonography using the focused assessment with sonography for obstetrics (FASO) technique (a modified version of FAST). The aim of the present study was to determine the reference values for the ultrasonographic findings to establish the criteria for the diagnosis of a postpartum hemorrhage and severe shock using the FASO. Methods: The present prospective cohort study included all postpartum women who vaginally delivered singleton infants. Abdominal ultrasonography was performed after delivery. The observation points of ultrasonography were as follows: (1) the diameter of the intrauterine cavity, (2) the pouch of Douglas, (3) Morison’s pouch, (4) between the spleen and kidney, and (5) the diameter of the inferior vena cava. Results: One hundred and eighty-two postpartum women were included in this study. The mean uterine cavity was 9.8 ± 7.3 mm. An echo-free space in the pouch of Douglas was observed in three cases, in one case in Morison’s pouch, and not observed between the spleen and kidney. A negative correlation was found between the volume of bleeding and IVCi (p = 0.0008, r2= −0.061) and IVCe (p < 0.0001, r2= −0.106). Conclusions: The present study establishes criteria that can be used to diagnose a postpartum hemorrhage or severe shock using the FASO.

Causes of intrauterine fetal death are changing in recent years

Abstract Objective: To investigate, how causes of intrauterine fetal death (IUFD) have changed in recent years with the advancement of prenatal diagnosis at a single perinatal center in Japan. Methods: Medical records were retrospectively reviewed for all cases of IUFDs that occurred between 2001 and 2014. The most commonly associated causes of fetal deaths were compared between 2001–2007 and 2008–2014. Results: The number of IUFD after 20 weeks’ gestation/all deliveries in our center was 38/6878 cases (0.53%) in 2001–2007 and 35/7326 (0.48%) in 2008–2014. The leading cause of IUFD in 2001–2007 was fetal abnormalities (43.2%), the prevalence of which was only 8.6% in 2008–2014 (P<0.01). Meanwhile, the prevalence of umbilical cord abnormalities was relatively increased from 30.0% in 2001–2007 to 54.5% in 2008–2014 (P=0.06). In 2001–2007, chromosomal abnormalities were frequently observed (56% of IUFDs due to fetal abnormalities). Hyper-coiled cord (HCC) and umbilical ring constrictions were the most frequent cause of IUFD in both periods. The relatively decreased prevalence of IUFD due to velamentous cord insertion and umbilical cord entanglement, HCC and umbilical cord constriction was increased. Conclusions: The prevalence of IUFD due to fetal abnormalities was reduced, but IUFD associated with umbilical cord abnormalities tended to increase relatively.

Upside-Down and Inside-Out Signs in Uterine Inversion

Uterine inversion is a rare condition that is accompanied by massive hemorrhaging and shock, resulting in a maternal emergency. The diagnosis of uterine inversion is often difficult due to massive postpartum hemorrhaging. Ultrasonography is useful for the diagnosis in such conditions, but we do not often encounter typical ultrasonographic images in uterine inversion because it occurs rarely. In the present case report of uterine inversion, we demonstrate the typical ultrasonographic findings of uterine inversion.

Placenta previa with early opening of the uterine isthmus is associated with high risk of bleeding during pregnancy, and massive haemorrhage during caesarean delivery

OBJECTIVE To demonstrate the relationship between the timing of opening of the uterine isthmus and bleeding during pregnancy and caesarean section in patients with placenta previa. METHODS A prospective observational study was conducted at a single perinatal centre. All patients with placenta previa, diagnosed between 20 and 22 weeks of gestation, who were followed up at the study hospital and underwent caesarean section were enrolled. The condition of the uterine isthmus was examined every 2 weeks. The timing (in gestational weeks) of complete opening of the uterine isthmus was determined. Patients were divided into two groups: patients in whom the uterine isthmus opened before 25 weeks of gestation (EO-previa), and patients in whom the uterine isthmus opened after 25 weeks of gestation (LO-previa). The frequency of bleeding during pregnancy and the amount of intra-operative bleeding were compared between the two groups. RESULTS Forty-four cases of EO-previa and 55 cases of LO-previa were analysed. Complete placenta previa at delivery was observed more frequently in the EO-previa group than in the LO-previa group (88.6% vs 47.3%, p<0.001). An emergency caesarean section due to active bleeding was performed more frequently in the EO-previa group (48%) than in the LO-previa group (25%) (p=0.021). The frequency of massive haemorrage (>2500ml) during caesarean section was higher in the EO-previa group than in the LO-previa group (25% vs 9%, p=0.033). CONCLUSION Placenta previa was associated with a high risk of bleeding leading to emergency caesarean section during pregnancy, and massive haemorrhage during caesarean section in patients in whom the uterine isthmus opened before 25 weeks of gestation.

Vitamin C Induces the Reduction of Oxidative Stress and Paradoxically Stimulates the Apoptotic Gene Expression in Extravillous Trophoblasts Derived From First-Trimester Tissue

Aim: To investigate the effects of vitamin C on the expression of the genes related to apoptosis in extravillous trophoblasts (EVTs) in the first trimester. Methods: Extravillous trophoblasts were cultured under 2% O2 followed by 2% O2 or 8% O2 with or without vitamin C. The level of reactive oxygen species (ROS) in the cultured medium was estimated using electron spin resonance spectroscopy. The expression levels of the genes TP53, BCL2, and BAX were quantified using real-time quantitative polymerase chain reaction. Results: Reactive oxygen species were found to be decreased after adding vitamin C under increasing oxygen concentrations. In addition, the ratio of BAX/BCL2 also increased after adding vitamin C under conditions of 2% O2, while the gene expression level of BCL2 increased after adding vitamin C under increasing oxygen concentrations. In contrast, the gene expression level of TP53 and the ratio of BAX/BCL2 both decreased. Conclusion: We have revealed that vitamin C reduces ROS and may promote the apoptosis of EVTs under conditions of 2% O2 while paradoxically preventing apoptosis under increasing oxygen concentrations.