Feasibility of a mobile cardiotocogram device for fetal heart rate self-monitoring in low-risk singleton pregnant women.

AIM: This study aimed to clarify the feasibility of a mobile cardiotocogram (CTG) device for self-monitoring fetal heart rate (FHR) in low-risk singleton pregnant women. METHODS: This study was conducted at six university hospitals and seven maternity clinics in Japan. Using a mobile cardiotocogram device (iCTG, Melody International Ltd., Kagawa, Japan), participants of more than 34 gestational weeks measured the FHR by themselves at least once a week until hospitalization for delivery. We evaluated the acquisition rate of evaluable FHR recordings and the frequency of abnormal FHR patterns according to the CTG classification system of the Japan Society of Obstetrics and Gynecology (JSOG). The participants also underwent a questionnaire survey after delivery to evaluate their satisfaction level of self-monitoring FHR using the mobile CTG device. RESULTS: A total of 1278 FHR recordings from 101 women were analyzed. Among them, 1276 (99.8%) were readable for more than 10 min continuously, and the median percentage of the total readable period in each recording was 98.9% (range, 51.4-100). According to the JSOG classification system, 1245 (97.6%), 9 (0.7%), 18 (1.4%), and four (0.3%) FHR patterns were classified as levels 1, 2, 3, and 4, respectively. The questionnaire survey revealed high participant satisfaction with FHR self-monitoring using the iCTG. CONCLUSION: The mobile CTG device is a feasible tool for self-monitoring FHR, with a high participant satisfaction level.

Clinical characteristics of pregnant women with COVID-19 in Japan: a nationwide questionnaire survey.

BACKGROUND: Few reports have presented an overall view of pregnant women with coronavirus disease 2019 (COVID-19) across an entire country and throughout the entire gestation period. Furthermore, no such reports are available for Japan. We examined the clinical characteristics and outcomes of pregnant women with COVID­19 on a national scale in Japan. METHODS: A nationwide questionnaire-based survey for all 2,185 maternity services in Japan was conducted between July and August 2020. Information regarding maternal characteristics and epidemiological, clinical, treatment, and perinatal outcomes of pregnant women diagnosed with COVID-19 between 16 January and 30 June 2020 were collected. Main outcome measures were incidence of pregnant women with COVID-19 and infant infection, positive rate of the universal screening test for asymptomatic pregnant women, identification of infection route and rates of maternal death, and severe cases. RESULTS: Responses from 1,418 institutions were assessed (65% of all delivery institutions in Japan). Seventy-two pregnant women were reported to have been diagnosed with COVID-19. The positive rate of the universal screening test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among asymptomatic pregnant women was 0.03% (2/7428). The most common route of infection was familial (57%). Fifty-eight pregnant women with COVID-19 were symptomatic, of whom five (8.6%) had a severe infection and one died (a tourist). Severe respiratory symptoms, oxygen administration, and pneumonia were frequently reported in the third trimester and postpartum period compared with in early pregnancy (22.2% vs 2.5% [P = 0.03], 38.9% vs 7.5% [P = 0.01], and 50.0% vs 7.5% [P < 0.001], respectively). All pregnant women with COVID-19 underwent caesarean sections, regardless of symptoms. There were no SARS-CoV-2 transmissions to newborns. CONCLUSIONS: In Japan, the number of cases of COVID-19 infection in pregnant women is very low. Compared with early pregnancy, late pregnancy may be a risk factor for exacerbation of symptoms and familial transmission is the most common route of infection. The importance of infection prevention should be emphasised, especially in women in late pregnancy, their families, and any cohabitants.

Declined use of cervical ripening balloon did not reduce the incidence of umbilical cord prolapse in Japan.

AIM: To clarify whether the incidence of umbilical cord prolapse (UCP) at delivery is related to the cervical ripening balloon (CRB). METHODS: A postal questionnaire study was conducted in 2018 in institutions providing maternity services across Japan. Questions on the number of deliveries, labor inductions, used CRB and cases of UCP in 2017 were included. Because a similar questionnaire survey was conducted in 2012, the incidence of UCP and frequency of the use of CRB were compared. RESULTS: A total of 1354 answers were assessed (57% of all delivery institutions). The total number of deliveries was 490 279. Of these, 78% were transvaginal; 74 cases of UCP were reported (0.015%), while 13 cases were reported from obstetric facilities never using CRB (0.008%). The incidence of UCP (odds ratio [95% confidence interval]) was 0.036% in the intracervical type (4.3 [1.6-11.3]), 0.091% in the disk-type (11.0 [4.2-29.0]) and 0.067% in the ball-type (8.1 [2.8-22.8]). Frequencies of the use of CRB were 7.3% and 6.6% in the 2012 and 2018 surveys, respectively. The use of the intracervical type increased from 2.8% in the 2012 survey to 3.5% in the 2018 survey, while that of the disk-type and ball-type declined. However, the incidence of UCP was not different between the two surveys regardless of the use of cervical ripening balloons (0.014% vs 0.015% with CRB, 0.005% vs 0.008% without CRB). CONCLUSION: Although the frequency of CRB use significantly declined, the incidence of UCP did not significantly reduce in the last 5 years.

Decline number of uterine fundal pressure maneuver in Japan recent 5 years.

AIM: To clarify whether the incidence of uterine fundal pressure (UFP) maneuver at delivery and consequent uterine rupture were declined. METHODS: Population-based postal questionnaire study was conducted. A questionnaire was sent to obstetric institutions across Japan. Questions were included the total number of deliveries, UFP and uterine ruptures associated with UFP in 2012 and 2017. As the primary outcome, frequencies of the UFP and uterine rupture were compared between 2012 and 2017. The secondary outcomes were included improved managements of delivery regarding UFP. RESULTS: A number of vaginal deliveries were significantly declined from 80.4% in 2012 to 78.1% in 2017 (P < 0.001). Frequencies of UFP per vaginal deliveries were also significantly declined 11.2% (38 973/347771) in 2012 to 9.5% (35 205/404444) in 2017 (<0.001). Number of uterine ruptures were 6 cases in 2012 (1:6496) and 11 cases in 2017 (1:3473) (P = 0.210). Compared to situation in 2012, informed consent was more frequently obtained for UFP in 2017. Written informed consent for UFP became to be obtained in 12% of institutions in 2017 from only 3% in 2012. More than 80% of institutions are performing UFP within 3 times. Regarding to uterine rupture, try of labor after the cesarean section, UFP and augmentation were improved in more than 10% of institutions. Most impact vehicle changing behavior was OBGY clinical guideline. CONCLUSION: Although significant declined incidence of uterine rupture after UFP could not be demonstrated, frequency of UFP was decreased recent 5 years. This is due to improvement of obstetric management by obstetric caregivers throughout Japan.

Obstetric risk factors for umbilical cord prolapse: a nationwide population-based study in Japan.

OBJECTIVES: To demonstrate the clinical course and the obstetric risk factors for umbilical cord prolapse. METHODS: The clinical course of reported cases of umbilical cord prolapse that occurred in Japan between 2007 and 2011 was retrospectively analyzed. The obstetric risk factors for umbilical cord prolapse were investigated by a nationwide population-based case-cohort study. RESULTS: Three hundred and sixty-nine cases (0.018 %) of fore-lying/prolapsed umbilical cord in 2,037,460 deliveries were analyzed. Most cases of fore-lying umbilical cord were diagnosed by an ultrasound scan (78 %), whereas umbilical cord prolapse was most frequently diagnosed by an internal examination (63 %). Umbilical cord prolapse was found to be significantly associated with the following factors: multiple pregnancy [odds ratio (OR) 3.57; 95 % confidence interval (CI) 2.60, 4.90], non-vertex presentation (OR 4.67; 95 %CI 3.73, 5.86), preterm labor (OR 2.28; 95 %CI 1.83, 2.83), premature rupture of membranes (OR 3.84; 95 %CI 3.10, 4.77), prolapsed amniotic bag (OR 12.31; 95 %CI 9.00, 16.85), polyhydramnios (OR 2.89; 95 %CI 1.49, 5.61), and a birth weight of <2500 g (OR 2.26; 95 %CI 1.84, 2.79). CONCLUSION: The current study is the largest in Japan to demonstrate the obstetric clinical course and risk factors associated with umbilical cord prolapse. Prolapsed amniotic bag, labor and rupture of membrane during premature period, and fetal abnormal presentation induced by multiple pregnancy, and polyhydramnios were high risk situation for umbilical cord prolapse.

Maternal Death Due to Stroke Associated With Pregnancy-Induced Hypertension.

BACKGROUND: The aim of this study was to clarify the clinical features of maternal death due to stroke associated with pregnancy-induced hypertension (PIH) in Japan. METHODS AND RESULTS: Reported maternal deaths occurring between 2010 and 2012 throughout Japan were analyzed by the Maternal Death Exploratory Committee. Among a total of 154 reports of maternal death, those due to stroke with (n=12) or without (n=13) PIH were compared. Cerebral stroke occurred more frequently in the third trimester and during the second stage of labor in deaths with PIH, whereas it occurred at any time point in deaths not involving PIH. Although 83% of patients with PIH who died had experienced initial symptoms in a hospital, more than half of them required maternal transport due to lack of medical resources. Among the patients without PIH, some vascular abnormalities were identified, but no evidence was found among the patients with PIH. In addition, 58% of PIH cases resulting in stroke were complicated by hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome. CONCLUSIONS: Appropriate management of PIH during pregnancy and labor, including anti-hypertensive therapy and early maternal transport to tertiary hospital, may reduce the maternal death rate.

The use of balloons for uterine cervical ripening is associated with an increased risk of umbilical cord prolapse: population based questionnaire survey in Japan.

BACKGROUND: To clarify whether the use of balloons for cervical ripening is associated with the incidence of umbilical cord prolapse. METHODS: A postal questionnaire survey was distributed in Japan. Cases of umbilical cord prolapse occurring during labor in association with the use of balloons for cervical ripening between 2007 and 2011 in Japan were analyzed. RESULTS: Answers from 942 institutions were obtained. The subjects included 369 patients with fore-lying or prolapse of the umbilical cord among a total of 2,037,460 deliveries. Among the singleton vertex cases, fore-lying or prolapse of the umbilical cord during labor were observed in 88 (0.005%) of 1,891,189 deliveries not associated with the use of balloons for cervical ripening and in 93 (0.064%) of 146,271 deliveries associated with the use of balloons for cervical ripening (Odds ratio 13.67, 95% confidence interval 10.21, 18.30). All types of balloons were significantly associated with the occurrence of fore-lying or prolapse of the umbilical cord. A total of 39% of cases of umbilical cord prolapse occurred during manual or spontaneous balloon removal, while 53% of cases occurred after a while not directly associated with balloon removal. CONCLUSION: The risk of umbilical cord prolapse was significantly increased during the use of balloons for cervical ripening, especially in cases involving the use of disk-type and ball-type balloons filled with large amounts of water.

Uterine rupture after the uterine fundal pressure maneuver.

OBJECTIVE: To clarify the incidence of uterine fundal pressure at delivery and its effect on uterine rupture. STUDY DESIGN: A questionnaire was sent to 2518 institutions in Japan. We received a response from 1430. RESULTS: Of reporting institutions, 89.4% used fundal pressure in at least some of their deliveries. Among the 347,771 women who delivered vaginally in this study, 38,973 (11.2%) were delivered with the assistance of fundal pressure. There were six cases of uterine rupture associated with uterine fundal pressure, with one case resulting in maternal death secondary to amniotic fluid embolism. CONCLUSION: Since uterine fundal pressure may potentially cause serious injury to either the mother and/or neonates, the indications for application need to be clearly elucidated, and obstetric care providers also need comprehensive education and training.

Antimicrobial Resistance for Chlamydia Trachomatis Genital Infection during Pregnancy in Japan.

The current study examined the antimicrobial resistance of Chlamydia trachomatis (CT) genital infection during pregnancy in Japan. We requested 2,146 obstetrical facilities that are members of Japan Association of Obstetricians and Gynecologists to provide information of CT screening tests and antimicrobial resistance in pregnant women between April 2020 and March 2021. The prevalence of CT genital infection in Japan was 2.1%. The antimicrobial resistance was recognized in 2.0 and 2.4% of the cases using azithromycin and clarithromycin, respectively. There were no significant differences in the antimicrobial resistance rate between the 2 analogues (P = 0.28). In Japan, azithromycin and clarithromycin have effectively treated genital CT infections during pregnancy.

Risk factors for severe disease and impact of severity on pregnant women with COVID-19: a case-control study based on data from a nationwide survey of maternity services in Japan.

OBJECTIVE: To identify independent risk factors for severe COVID-19 in pregnant women and to evaluate the impact of disease severity on preterm birth. DESIGN: A case-control study based on data from a nationwide questionnaire-based survey of maternity services in Japan. SETTING: A questionnaire was mailed to all 2135 delivery institutions in Japan between July and August 2021. A total of 1288 institutions responded (60% of all delivery institutions in Japan). 566 facilities reported having cared for pregnant women with COVID-19, and 722 facilities reported having had no such patients. PARTICIPANTS: One thousand and forty-three hospitalised and non-hospitalised pregnant women diagnosed with COVID-19 between July 2020 and 30 June 2021. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was progression to severe COVID-19. The secondary outcome was preterm birth due to COVID-19 infection. RESULTS: 56 cases (5.4%) were severe, and 987 (94.6%) were non-severe. Multivariable logistic regression analysis showed that gestational age≥24 weeks (adjusted OR (aOR) 6.68, 95% CI 2.8 to 16.0) and maternal age≥32 years (aOR 2.40, 95% CI 1.3 to 4.3) were independently associated with severe cases. Using the Kaplan-Meier method, the probability of continued pregnancy at 14 days after diagnosis for severe cases was 0.57 between 24 and 31 weeks' gestation and 0.27 between 32 and 36 weeks' gestation. The probability for non-severe cases was 1.0 between 24 and 31 weeks' gestation and 0.8 between 32 and 36 weeks' gestation. Among the patients with COVID-19 in the preterm period, preterm birth due to infection was significantly more common in severe than non-severe cases (48% vs 6%, p< 0.0001). CONCLUSIONS: Severe COVID-19 in pregnant women was associated with gestational age≥24 weeks and maternal age≥32. The rate of preterm delivery due to the infection was significantly higher in severe COVID-19 cases.

NKG2A inhibits invariant NKT cell activation in hepatic injury.

Activation of invariant NKT (iNKT) cells in the liver is generally regarded as the critical step for Con A-induced hepatitis, and the role of NK cell receptors for iNKT cell activation is still controversial. In this study we show that blockade of the NKG2A-mediated inhibitory signal with antagonistic anti-NKG2A/C/E mAb (20d5) aggravated Con A-induced hepatitis in wild-type, Fas ligand (FasL)-mutant gld, and IL-4-deficient mice even with NK cell and CD8 T cell depletion, but not in perforin-, IFN-gamma-, or IFN-gamma- and perforin-deficient mice. Consistently, 20d5 pretreatment augmented serum IFN-gamma levels and perforin-dependent cytotoxicity of liver mononuclear cells following Con A injection, but not their FasL/Fas-dependent cytotoxicity. However, blockade of NKG2A-mediated signals during the cytotoxicity effector phase did not augment cytotoxic activity. Activated iNKT cells promptly disappeared after Con A injection, whereas NK1(-) iNKT cells, which preferentially expressed CD94/NKG2A, predominantly remained in the liver. Pretreatment with 20d5 appeared to facilitate disappearance of iNKT cells, particularly NK1(-) iNKT cells. Moreover, Con A-induced and alpha-galactosylceramide-induced hepatic injury was very severe in CD94/NKG2A-deficient DBA/2J mice compared with CD94/NKG2A-intact DBA/2JJcl mice. Overall, these results indicated that a NKG2A-mediated signal negatively regulates iNKT cell activation and hepatic injury.

Vascular, renal and placental effects on pregnant offspring of protein-restricted rat dams.

AIM: Our previous study showed that a maternal low-protein diet induced hypertension and vascular dysfunction in rat offspring after day 175. In the present study, we hypothesized that these female offspring would develop hypertension in their own pregnancies even at ages less than 175 days because potential vascular dysfunction is exacerbated by the circulatory demands of pregnancy. MATERIAL AND METHODS: Wistar rats were fed an isocaloric diet containing either 18% (control group) or 9% (low-protein group) casein throughout pregnancy. The female offspring were fed standard chow and mated between days 70 and 125. At the end of pregnancy, blood pressure was measured, and the uterine arteries were dissected and investigated with a wire myograph. RESULTS: Placental weights were significantly lower in offspring of the low-protein group versus control. There were no significant differences in blood pressure. Renal expression of AT1 receptor mRNA was greater, and of AT2 receptor was less, in the low-protein group versus control. Vasoconstriction of uterine arteries to phenylephrine and U46619 was increased in the low-protein group, and vasodilatation to sodium nitroprusside was also increased. CONCLUSION: Low-protein diet induces vascular effects on female offspring in their pregnancy, in terms of increased uterine artery vasoconstriction. This may be compensated for by increased sensitivity to nitric oxide (NO), maintaining blood pressure normal in the face of the demands of pregnancy. Such renal and vascular effects, combined with placental size, may transmit risk of vascular dysfunction to subsequent generations.

Recent Prevalence of Human T-cell Leukemia Virus Type 1 Carrier Associated with Horizontal Transmission in Pregnant Japanese Women.

The current study was conducted to examine the number of human T-cell leukemia virus type 1 (HTLV-1) carriers and how horizontal transmission affected the prevalence of HTLV-1 carriers among pregnant Japanese women in 2019. We requested 2,214 obstetrical facilities to provide information on HTLV-1 tests for pregnant women who delivered in 2019. The estimated number of HTLV-1 carriers among pregnant Japanese women was 952. At least 10% or more of the carriers acquired HTLV-1 through horizontal transmission.

Current status of community-acquired infection of COVID-19 in delivery facilities in Japan.

A nationwide questionnaire survey about community-acquired infection of coronavirus disease 2019 (COVID-19) was conducted in July 2020 to identify the characteristics of and measures taken by Japanese medical facilities providing maternity services. A case-control study was conducted by including medical facilities with (Cases) and without (Control) community-acquired infection of COVID-19. Responses from 711 hospitals and 707 private clinics were assessed (72% of all hospital and 59% all private clinics provided maternity service in Japan). Seventy-five COVID-19-positive pregnant women were treated in 52 facilities. Community-acquired infection was reported in 4.1% of the facilities. Of these, 95% occurred in the hospital. Nine patients developed a community-acquired infection in the maternity ward or obstetric department. Variables that associated with community-acquired infection of COVID-19 (adjusted odds ratio [95% confidence interval]) were found to be state of emergency prefecture (4.93 [2.17-11.16]), PCR test for SARS-CoV-2 on admission (2.88 [1.59-5.24]), and facility that cannot treat COVID-19 positive patients (0.34 [0.14-0.82]). In conclusion, community-acquired infection is likely to occur in large hospitals that treat a higher number of patients than private clinics do, regardless of the preventive measures used.

Current status of cervical cytology during pregnancy in Japan.

In Japan, uterine cancer screening during pregnancy is subsidized by public funds. We examined the current status of the results of cervical cytology conducted during pregnancy in Japan. We requested 2,293 obstetrical facilities to provide information on cervical cytology in pregnant women who delivered between October 2018 and March 2019. A total of 1,292 obstetrical facilities responded, with valid information on a total of 238,743 women. The implementation rate of cervical cytology during pregnancy was 86.8% in Japan. The prevalence of abnormal cervical cytology during pregnancy was 3.3% in total and 4.9% using a spatula/brush with liquid-based cytology (LBC). The prevalence of positive high-risk human papillomavirus (HPV) in teenagers with atypical squamous cells of undetermined significance (ASC-US) was significantly higher than women of other ages (p < 0.01). Because HPV vaccine coverage has dropped to less than 1% in Japan, a further study with various conditions will be needed to improve the accuracy of cervical cancer screening during pregnancy.

Effectiveness of human papillomavirus vaccination in young Japanese women: a retrospective multi-municipality study.

In Japan, government support for human papillomavirus (HPV) vaccination began in November 2010. However, the mass media repeatedly reported on severe adverse events. The Japanese Ministry of Health, Labor and Welfare suspended proactive recommendations for HPV vaccines in June 2013. Japan's HPV vaccination rate dropped from 70% to less than 1% in 2017.We examined cervical cancer screening results in terms of abnormal cytology, histology, and HPV vaccination status among 11,903 women aged 20 to 25 y in the fiscal year 2015. The overall rate of HPV vaccination was 26.1% (3,112/11,903). Regarding cytology, the rate of atypical squamous cells of undetermined significance (ASC-US) or worse was 3.3% (103/3,112) in women who received HPV vaccination (vaccine (+) women) and 5.6% (496/8,791) in women who did not (vaccine (-) women). The rate of high-grade squamous intraepithelial lesion (HSIL) or worse was 0.26% (8/3,112) in vaccine (+) women and 0.81% (72/8,791) in vaccine (-) women. Regarding histology, the rate of cervical intraepithelial neoplasia 1 or worse (CIN1+) was 1.4% (42/3,112) in vaccine (+) women and 2.1% (178/8,791) in vaccine (-) women. The rates of CIN2+ and CIN3+ were similar regardless of vaccination. We found a significantly lower incidence of CIN in vaccine (+) women. These results suggest that the resumption of recommending HPV vaccination as primary prevention for cervical cancer is needed in Japan.

Induction of senescence by progesterone receptor-B activation in response to cAMP in ovarian cancer cells.

OBJECTIVE: Progesterone receptor (PR) expression is a favorable prognostic marker in ovarian cancer. We previously demonstrated that the induction of PR-B by treatment with cAMP was associated with G0/G1 arrest of the cell cycle and growth inhibition in NIH 3T3 cells. In this study, we examined the effect of cAMP treatment on cell growth in Ras-transformed NIH3T3 cells and ovarian cancer cells. METHODS: 1) The levels of PR-B and cell cycle associated proteins (p21, p27 and Rb) following treatment with cAMP in the Ras-transformed NIH3T3 cells (K12V) and ovarian cancer cell lines (SKOV cells) were investigated by Western blots. 2) The effects of PR overexpression following treatment with cAMP or after infection of an adenovirus expressing PR-B on cell growth and tumorigenicity in a soft agar culture were examined. RESULTS: 1) Treatment with cAMP increased PR-B and p27 levels in K12V cells and inhibited cell growth by inducing premature senescence. Induction of senescence was specific to the transformed cells. 2) In SKOV cells, treatment with cAMP induced PR-B, p27 and p21 expression, reduced the level of phosphorylated Rb, caused accumulation of cells in the G0/G1 fraction of the cell cycle, and induced senescence. 3) Both anchorage-dependent and -independent SKOV cell growths were inhibited by cAMP treatment. 4) Induction of both the expression and transcriptional activity of PR-B is critical for the induction of senescence and suppression of tumorigenicity. CONCLUSION: Treatment of cAMP, through activation of PR-B, induced senescence and suppressed tumorigenicity in ovarian cancer cells.

Current status of Neisseria gonorrhoeae cervicitis in pregnant women in Japan.

We evaluated the current prevalence of gonococcal cervicitis among pregnant women in institutes that either do or do not routinely screen for gonococcal infection in Japan. We requested 2,330 obstetrical facilities to provide information on Neisseria gonorrhoeae cervicitis in pregnant women. A total of 1,876 (80.5%) of them responded. The universal screening test for gonococcal cervicitis, involving nucleic acid amplification for all pregnant women, was performed in 281 institutes (13.9% of institutes across Japan). The total rate of pregnant women with gonococcal cervicitis was 1.3% in the institutes performing the screening test during pregnancy, while it was only 0.2% (p < 0.01) in those not performing it. This suggests that 84% of infected women may have been missed in the institutes that do not routinely perform the screening test for gonococcal cervicitis. It may be time to examine the cost-effectiveness of providing gonococcal screening for all pregnant women in Japan.

Decline in maternal death due to obstetric haemorrhage between 2010 and 2017 in Japan.

This descriptive study was based on the maternal death registration system established by the Japan Association of Obstetricians and Gynecologists and the Maternal Death Exploratory Committee (JMDEC). 361 women died during pregnancy or within 42 days after delivery between January 2010 and June 2017 throughout Japan were analysed, in order to investigate the trend in maternal deaths related to obstetric medical practice. Reports of maternal death were consistent, ranging from 45 cases in 2010 to 44 cases in 2017. Among all maternal deaths, the frequency of deaths due to obstetric haemorrhage ranged from 29% (2010) to 7% (2017) (p < 0.001). The causes of obstetric haemorrhage have progressively reduced, especially maternal deaths due to uterine inversion and laceration have not occurred since 2014. The remaining causes of obstetric haemorrhage-related maternal deaths were placenta accreta spectrum, placental abruption, and severe forms of uterine focused amniotic fluid embolism. We believe the activities of the JMDEC including annual recommendations and simulation programs are improving the medical practices of obstetric care providers in Japan, resulting in a reduction of maternal deaths due to obstetric haemorrhage.