Yukiko Mikami

Pre‐delivery fibrinogen predicts adverse maternal or neonatal outcomes in patients with placental abruption

Placental abruption is a severe obstetric complication of pregnancy that can cause disseminated intravascular coagulation and progress to massive post‐partum hemorrhage. Coagulation disorder due to extreme consumption of fibrinogen is considered the main pathogenesis of disseminated intravascular coagulation in patients with placental abruption. The present study sought to determine if the pre‐delivery fibrinogen level could predict adverse maternal or neonatal outcomes in patients with placental abruption.

Provisional criteria for the diagnosis of hypertension in pregnancy using home blood pressure measurements

Most guidelines for the management of hypertension define it as a home blood pressure (HBP) value >135/85 mm Hg. However, there is no reference HBP value to diagnose hypertension in pregnant women. Therefore, in this study, we analyzed HBP measurements of pregnant women to determine whether it is appropriate to use the criteria for non-pregnant subjects for pregnant women. The participants of this study were 100 singleton pregnant women who visited our hospital between September 2013 and September 2016. We lent sphygmomanometers to the patients so they could measure their BP at home twice daily, and we measured their clinical BP when they visited the hospital. Six patients developed hypertensive disorders in pregnancy, whereas there were 63 women without hypertension or other complications that may affect BP. In the normotensive pregnant women, HBP values significantly correlated with the clinical BP values. HBP values equivalent to a clinical BP of 140/90 mm Hg, determined using the standard major axis method, were 120.8/83.5 mm Hg, 126.0/85.2 mm Hg and 136.3/89.3 mm Hg in the first, second and third trimesters, respectively. In normotensive pregnant women, HBP levels that indicate a risk of hypertensive disorder in pregnancy may be lower than 135/85 mm Hg before 28 weeks of gestation.

Can biparietal diameter-to-femur length ratio be a useful sonographic marker for screening thanatophoric dysplasia since the first trimester? A literature review of case reports and a retrospective study based on 10,293 routine fetal biometry measurements

OBJECTIVE The aim of the study was to determine whether the biparietal diameter/femur length (BPD/FL) ratio can be used to detect thanatophoric dysplasia in the first trimester of pregnancy. MATERIALS AND METHODS Twenty-four reported cases of thanatophoric dysplasia diagnosed based on ultrasonographic results with molecular or radiographic diagnosis were included. All sonographic measurement records were extracted and reviewed, and the BPD/FL ratio was calculated for each gestational week. In addition, 10,293 routine fetal biometry measurements from 1395 cases of patients without skeletal dysplasia were compared. RESULTS The BPD/FL ratio in the control group decreased to less than 3 prior to gestational week 13, and to less than 2 prior to week 18. Of the 27 BPD/FL ratios obtained from 24 cases of thanatophoric dysplasia, none was in the control range. CONCLUSION The BPD/FL ratio may be used to detect lethal skeletal dysplasias such as thanatophoric dysplasia since the first trimester.

Methotrexate and actinomycin D chemotherapy in a patient with porphyria: a case report

BackgroundDespite their broadly recommended use as chemotherapeutic agents, the porphyrogenicity of methotrexate and actinomycin D have not been confirmed. Accordingly, it is not known whether these agents are safe for use in patients with porphyria.Case presentationIn this report, we present a case of an invasive mole with lung metastasis in a 49-year-old Japanese woman who had previously been diagnosed with acute intermittent porphyria at 27 years of age but had no recent history of acute intermittent porphyria attacks. Her serum human chorionic gonadotropin level was elevated 1 month after hysterectomy, and she was referred to our center for chemotherapy. After she received 100 mg of methotrexate, drug eruptions were observed starting on day 3 and grew progressively worse. Erythema and mucosal erosion spread throughout her body, whereupon she was administered prednisolone. In addition, our patient experienced febrile neutropenia and required granulocyte colony- stimulating factor treatment. No changes in our patient’s urinary coproporphyrin or uroporphyrin levels were detected during this entire episode. Methotrexate was replaced by actinomycin D (0.5 mg/body intravenously on days 1–5 every 2 weeks). After five uneventful cycles of actinomycin D, our patient achieved and maintained a normal serum human chorionic gonadotropin level for 3 years.ConclusionsMethotrexate and actinomycin D did not induce acute porphyric attacks in this patient with acute intermittent porphyria; however, severe adverse effects were noted with methotrexate. Although further investigation is required, our data suggest that these agents are nonporphyrinogenic and can therefore be used to treat patients with comorbid porphyria.

The Progression of Serum Prorenin Concentration during Pregnancy

Objective: An association between the renin-angiotensin system and the pathogenesis of pregnancy-induced hypertension has been reported. The prorenin receptor was discovered in 2002, and Wanatabe et al. reported that women with plasma soluble prorenin receptor concentrations above the 75th percentile at delivery had a significantly increased risk of preeclampsia. We evaluated serum prorenin concentrations during pregnancy, and we assessed the incidence of pregnancy-induced hypertension. Methods: We measured serum prorenin concentrations in 430 pregnant women (565 samples). Regression analysis was performed to determine the associations between the serum prorenin level and maternal/neonatal complications. Results: The serum prorenin concentration and gestational age had a positive correlation in non-pregnancyinduced hypertension in women with singleton pregnancies (Spearman rank-correlation coefficient, -0.215: p<0.0001). The serum prorenin concentration in women with multiple pregnancies was significantly higher than that in women with singleton pregnancies (multiple linear regression analysis, p<0.0001). Low prorenin levels in the third trimester (≤20.1 percentile) were significantly associated with pregnancy-induced hypertension (adjusted odds ratio, 18.16: 95% confidential interval, 1.95-412.41: p=0.0107). Conclusion: The serum prorenin levels during pregnancy may be adversely correlated with the prorenin receptor, and low prorenin levels during late pregnancy were significantly associated with pregnancy-induced hypertension.

Differences in home blood pressure and pulse rates between singleton and twin pregnancies

Objectives To evaluate home blood pressure (HBP) measurements during pregnancy and postpartum and investigate differences between singleton and twin pregnancies. Methods This prospective study involved normotensive, pregnant women who were planning to give birth at Saitama Medical Centre, Saitama, Japan between September 2013 and March 2017. HBP and pulse rate were measured twice daily and clinical blood pressure values were determined from patient records. Results HBP values were available from 101 participants; 69 women with singleton and 32 women with twin pregnancies. Systolic BP was statistically significantly higher in twin pregnancies from 23 weeks of gestation until 8 weeks after delivery compared with singleton pregnancies. Pulse rate was also statistically significantly higher between 11 and 30 weeks gestation in women with twin pregnancies compared with those with singleton pregnancies. Conclusions BP monitoring is important in the management of twin pregnancies, especially during the later gestational weeks and postpartum period and HBP would facilitate this monitoring.

Associations between the levels of soluble (pro)renin receptor in maternal and umbilical cord blood and hypertensive disorder of pregnancy

INTRODUCTION The prorenin (PR) receptor [(P)RR] contributes to the regulation of the tissue renin-angiotensin system (RAS) and Wnt signaling, which is involved in embryogenesis and the pathological progression of malignant tumors and diabetes mellitus. Placental (P)RR is significantly upregulated in placental tissues from preeclamptic women. However, because it cannot be examined during pregnancy, the chronological relationship between the acceleration of tissue RAS and the disease state of hypertensive disorder of pregnancy (HDP) has not been reported. In this study, we examined whether chronological changes in placental tissue RAS can be assessed by measuring soluble (P)RR [s(P)RR]. METHODS We obtained maternal and umbilical cord blood samples from 517 pregnant women (441 singleton and 76 twin pregnancies). The concentrations of s(P)RR and prorenin (PR) were measured using enzyme-linked immunosorbent assays. RESULTS Multivariate analysis showed that maternal serum s(P)RR levels were significantly higher in patients with HDP or fetal growth restriction (FGR) and were positively correlated with serum PR levels. Furthermore, the maternal s(P)RR level was significantly higher in HDP with severe hypertension and after the onset of HDP. However, maternal s(P)RR levels were not affected by the severity of proteinuria. Serum s(P)RR levels in umbilical cord blood of singleton pregnancies were significantly correlated with gestational week at delivery and PR level. DISCUSSION Maternal serum s(P)RR concentrations may reflect acceleration of tissue RAS in the placenta and blood pressure severity; however, the umbilical serum s(P)RR concentration was not affected by maternal HDP.