Excessive fibrinolysis detected with thromboelastography in a case of amniotic fluid embolism: fibrinolysis may precede coagulopathy.

Amniotic fluid embolism (AFE) is a catastrophic condition in the peripartum period and still remains as a leading cause of maternal death. Although over 80% of cases of AFE cases are accompanied by coagulopathy, the pathology of disseminated intravascular coagulation is not well understood not only because of its rarity but also because of the limited availability of laboratory testing in emergent clinical settings. We describe a case of AFE whose characteristic data for coagulation and fibrinolysis were timely depicted with sequential thromboelastography. We believe that the point-of-care, which provides information for both coagulopathy and fibrinolysis, may provide crucial data not only for the treatment of postpartum hemorrhage in daily clinical practice but also for the elucidation of AFE pathophysiology.

First trimester findings of decidual polyp: Caution to avoid polypectomy.

Obstetricians are sometimes faced with a dilemma in that polypectomy, which is a prerequisite for differentiating malignancy, may be associate with miscarriage or preterm delivery. We describe a case with a decidual polyp resulted in first trimester miscarriage after diagnostic polypectomy. Our experience with this patient provides us important information for clinical practice. That is, decidual polyp can be recognized as early as gestational week 5, the roots of cervical polyps should be meticulously observed, a polyp connected to the decidua is suggestive finding of decidual polyp, and suspected decidual polyp can be managed conservatively.

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

AIM: 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. METHODS: A single-center prospective cohort study was conducted. Twenty-eight patients with stage III-IV cystocele and uterine prolapse underwent reconstructive surgery. A combination of vaginal hysterectomy, McCall culdeplasty, and trocar-guided anterior vaginal mesh implantation was performed, and the patients' postoperative outcomes were analyzed. Patient satisfaction was investigated using the modified Short Form 12 version 2 (SF-12v2) questionnaire, and interviews regarding sexual behavior were conducted at 1 postoperative year. RESULTS: A bladder injury occurred during the dissection in one case (3.6%). Recurrent vaginal vault prolapse beyond the hymen was observed in one patient (cure rate: 96.4%), and further mesh augmentation was required in this case. Another patient developed mild cystocele (Ba = 0), but was simply observed because she did not complain of any symptoms caused by vaginal descent. We did not experience any other mesh-related complications, such as protrusion, chronic pain, or chronic inflammation, during the follow-up period. The patients' modified SF-12 scores at 12 months were significantly better than their preoperative scores in all eight domains. CONCLUSION: The satisfactory correction of pelvic organ prolapse was achieved using a combination of vaginal hysterectomy and uterosacral ligament colpopexy augmented by anterior vaginal mesh implantation. © 2016 Japan Society of Obstetrics and Gynecology.

Alterations in time intervals of ductus venosus and atrioventricular flow velocity waveforms in growth-restricted fetuses.

OBJECTIVE: To investigate time intervals of the ductus venosus (DV) flow velocity waveform (FVW) and those of the cardiac cycle that correspond with each DV-FVW component in fetuses with intrauterine growth restriction (IUGR) due to placental insufficiency. METHODS: Women with a pregnancy complicated by IUGR were recruited into the study, as was a normal control group. Time intervals for systolic (S) and diastolic (D) components were measured in DV-FVW as follows: S(DV), from the nadir of the a-wave during atrial contraction to the nadir between the S-wave and D-wave; D(DV), from the nadir between S-wave and D-wave to the nadir of the a-wave. Regarding cardiac cycles, the following variables were measured from ventricular inflow through the tricuspid valve (TV) and mitral valve (MV): S(TV) and S(MV), from the second peak of ventricular inflow caused by atrial contraction (A-wave) to the opening of the atrioventricular valve; D(TV) and D(MV), from the opening of the atrioventricular valve to the peak of the A-wave. In the IUGR group, only the last examination performed within 1 week of delivery was used for analysis. All variables were analyzed statistically using Z-scores. RESULTS: Data were obtained from 249 normal fetuses and 26 fetuses with IUGR. Compared to normal fetuses, S(DV) showed a significant decrease (P < 0.001), while D(DV) showed a significant increase (P < 0.001) in the IUGR group. Regarding cardiac cycles, S(TV) and S(MV) showed significant decreases (P = 0.014 and P < 0.001, respectively) and D(TV) and D(MV) showed significant increases (P = 0.008 and P = 0.002, respectively) in fetuses with IUGR. CONCLUSION: Time-interval alterations of DV-FVW in growth-restricted fetuses reflect the hemodynamic events caused by placental insufficiency.

Time-interval analysis of ductus venosus flow velocity waveforms in twin-to-twin transfusion syndrome treated with laser surgery.

OBJECTIVES: To investigate time-interval variables of ductus venosus (DV) flow velocity waveforms (FVWs) in twin-to-twin transfusion syndrome (TTTS), comparing the results with reference ranges from normal singleton fetuses. The impact of laser surgery and the effect of prognostic factors were also evaluated. METHODS: In 107 TTTS cases, DV-FVWs of both recipients and donors were recorded 1 day before and 2 days after laser therapy. Time intervals for systolic (S) and early diastolic (D) peaks were analyzed retrospectively with regard to acceleration time (acc-S and acc-D for S and D, respectively) and deceleration time (dec-S and dec-D for S and D, respectively). For each variable, Z-scores were calculated with respect to previously reported normal reference ranges. RESULTS: Z-scores for all variables showed statistically significant differences from those observed previously in normal fetuses, with the exception of dec-S of donors. The most striking differences were observed in longer dec-S of recipients (P < 0.001) and longer dec-D of donors (P < 0.001). Laser therapy showed significant impact on dec-S and acc-D in recipients and on all variables in donors. Regarding the short-term prognosis, acc-S and dec-S showed significant differences for the prediction of intrauterine fetal demise in donors (P = 0.009 and P = 0.011, respectively). CONCLUSION: This study demonstrates that time-interval variables of DV-FVWs may differentiate the characteristic hemodynamic changes caused by unbalanced blood volume between recipients and donors.

Stimulation of fetal granulopoiesis by intrauterine injection of recombinant human granulocyte colony- stimulating factor into rat fetuses.

The small neutrophil reserve and exaggerated release of stored neutrophils are factors which predispose neonates to neutrophil reserve exhaustion during bacterial sepsis. Our objective is to try to improve in utero the myelopoietic function of the fetus before delivery. In the first series, recombinant human (rh) granulocyte colony-stimulating factor (G-CSF) (rhG-CSF; 100 microg/kg) was injected subcutaneously into rat fetuses at the indicated times to assess drug absorption and fetal response. In the second series, rhG-CSF (100 microg/kg) or saline (control) was injected into the fetuses once every other day to investigate the effect of repeated injections of rhG-CSF on enhancing fetal myelopoiesis preceding birth. Delivery was performed by cesarean section on embryonic day 21. The plasma concentration of G-CSF was determined by ELISA. The effect of rhG-CSF injection on granulopoiesis was assessed by measurement of the neutrophil count in the fetal peripheral blood and by histological examination of the fetal bone marrow, spleen, and liver. Fetally administered rhG-CSF enhanced fetal myelopoiesis preceding birth.