Tomohiro Oba

Administration of oral and vaginal prebiotic lactoferrin for a woman with a refractory vaginitis recurring preterm delivery: Appearance of lactobacillus in vaginal flora followed by term delivery

Lactoferrin (LF) is one of the prebiotics present in the human body. A 38‐year‐old multiparous woman with poor obstetrical histories, three consecutive preterm premature rupture of membrane at the 19th, 23rd and 25th week of pregnancy, was referred to our hospital. She was diagnosed as having refractory vaginitis. Although estriol vaginal tablets were used for 4 months, the vaginitis was not cured. We administrated vaginal tablets and oral agents of prebiotic LF, resulting in a Lactobacillus predominant vaginal flora. When she was pregnant, she continued to use the LF, and the Lactobacillus in the vaginal flora was continuously observed during pregnancy. An elective cesarean section was performed at the 38th week of pregnancy. When the administration of LF was discontinued after the delivery, Lactobacillus in the vaginal flora was disappeared.

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.

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.

Postpartum ultrasound: postpartum assessment using ultrasonography

Abstract Postpartum haemorrhage (PPH) is a potential cause of maternal mortality, and obstetricians must be prepared to rapidly diagnose and treat this condition. Optimal treatment is dependent upon the underlying cause of haemorrhage. Ultrasonography is the most helpful tool for prompt diagnosis of PPH aetiology and obstetricians must have a strong understanding of postpartum ultrasonography. In our previous report, we demonstrated the utility of ultrasonography using the focused assessment with sonography for obstetrics (FASO) technique (a modified version of FAST) as the primary postpartum obstetric survey. In the present article, we review the ultrasonographic findings of PPH, differentiated by the underlying cause of haemorrhage, including retained placenta, morbidly adherent placenta, uterine rupture, uterine inversion and uterine artery abnormalities.

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.

Decidual polyps are associated with preterm delivery in cases of attempted uterine cervical polypectomy during the first and second trimester

Abstract Objective: To clarify which types of cervical polyp removed during the first and second trimester are associated with the risk of spontaneous abortion and preterm delivery. Methods: Pregnant females who underwent attempted polypectomy of cervical polyps during pregnancy and delivered singleton infants between 2005 and 2011 were evaluated. The clinical courses and outcomes of preterm delivery after polypectomy stratified according to the pathologic diagnosis of the polyps were retrospectively reviewed. The removed polyps were classified into decidual polyps and endocervical polyps. Results: The pathological diagnoses included 41 decidual polyps and 42 endocervical polyps. No malignant polyps were found. The removal of decidual polyps during pregnancy carried a higher risk of spontaneous abortion (12.2% versus 0%, p = 0.026) and preterm delivery (34.2% versus 4.8%, p = 0.001) than that of endocervical polyps. According to the multivariate logistic regression analysis, risk factors for preterm delivery before 37 weeks’ gestation were the presence of decidual polyps and a history of preterm delivery. Conclusions: The risk of abortion and preterm delivery associated with polypectomy during pregnancy is greater in patients with decidual polyps. It might be safer not to remove cervical polyps during pregnancy, except in cases in which the polyps are suspected to be malignant.

The inferior vena cava diameter is a useful ultrasound finding for predicting postpartum blood loss

Abstract Purpose: To assess whether the ultrasonographic measurement of the inferior vena cava (IVC) diameter in postpartum women is a useful parameter in evaluating the actual blood loss during delivery due to massive postpartum hemorrhage. Materials and methods: In postpartum women with blood loss ≥500 g, abdominal ultrasonography was performed 1 hour after delivery. The IVC diameter was measured during inspiration (IVCi) and expiration (IVCe). The maternal heart rate, blood pressure, and shock index (heart rate/systolic blood pressure) were also measured. The predictive value of these parameters for severe anemia (hemoglobin <7.0 g/dL) a day after delivery was evaluated via receiver operating characteristic (ROC) analyses. Results: Seven patients with severe anemia and 77 controls were included in the analysis. The area under the curve (AUC) for IVCi (0.905) and IVCe (0.926) was higher than that for the shock index (0.890), heart rate (0.874), or systolic blood pressure (0.752). Among the examined parameters, the best sensitivity was achieved by IVCe and systolic blood pressure (71.4%). Conclusions: The ultrasonographic measurement of the IVC diameter was found to be the most useful parameter in evaluating the actual maternal blood loss after delivery.

First-trimester measurements of the three-dimensional ultrasound placental volume and uterine artery Doppler in early- and late-onset fetal growth restriction

Abstract Objectives: To clarify whether early-onset fetal growth restriction (EO-FGR) could be distinguished from late-onset (LO)-FGR using ultrasonographic evaluations of the uterine artery (UtA) Doppler indices and the three-dimensional (3D) ultrasound placental volume (PV) in the first trimester. Methods: Subjects with 1362 singleton pregnancies who underwent an ultrasound scan at 11–13 weeks were enrolled prospectively. The UtA Doppler and PV indices in cases with EO-FGR (<32 weeks at diagnosis) and LO-FGR (≥32 weeks at diagnosis) later in pregnancy were compared with the control group. Results: Twenty-eight EO-FGR, 73 LO-FGR, and 1261 control groups were analyzed. The crown-rump length (CRL) and PV were smaller in both EO and LO-FGR groups than in the control group. The UtA resistance index (RI) Z-score was significantly higher in the EO-FGR group than in the control group (0.723 versus 0.086, p < .001), but did not differ between LO-FGR and the control group. The area under the receiver operating characteristics curve for the prediction of EO-FGR by combining the uterine artery resistance index (UtA-RI) and CRL was 0.760 (95% CI: 0.654–0.865). The detection rate for EO-FGR was 45.8%, with a 10% false-positive rate. Conclusions: Both EO- and LO-FGR are associated with a small CRL in the first trimester. High UtA-RI is associated with EO-FGR, while a small maternal height and PV are associated with LO-FGR.