Placenta with Old, Diffuse Infarction that Was Difficult to Differentiate from a Placental Tumor.

Placental lesions, including placental infarction, are associated with fetal and neonatal mortality and morbidity. We present a case of fetal growth restriction associated with an old, diffuse placental infarction. Because the placenta had only a single viable cotyledon, the others being atrophic, the lesion appeared to be a placental tumor on prenatal ultrasonography. The patient did not have pregnancy-induced hypertension. At 31 weeks of gestation, a cesarean delivery was performed because of fetal growth arrest and breech presentation. A small-for-gestational age infant was delivered with Apgar scores of 8 at both 1 and 5 minutes, and the infant had cleft palate and cleft lips. Pathological examination of the placenta revealed an old, diffuse infarction without neoplastic change. In cases in which a placental tumor causing fetal growth restriction is strongly suspected, diffuse placental infarction should be considered as part of the differential diagnosis, because placental tumors are associated with poor maternal prognosis.

Association between fibrinogen levels and severity of postpartum hemorrhage in singleton vaginal deliveries at a Japanese perinatal center.

OBJECTIVE AND METHODS: We examined the relationship between low fibrinogen levels (<200 mg/dL) and the severity of postpartum hemorrhage in singleton vaginal deliveries after 22 weeks' gestation complicated by postpartum hemorrhage requiring transfusion at our hospital. RESULTS: During a 10-year period, 61 women (0.38%) received transfusions owing to postpartum hemorrhage within the first 24 hours after delivery. Of these women, 13 (21%) had low fibrinogen levels (mean, 123 ± 68 mg/dL) when postpartum hemorrhage was diagnosed, and the other 48 (79%) had normal fibrinogen levels (mean, 305 ± 50 mg/dL). Neither total blood loss nor the incidence of additional therapies, such as hysterectomy, differed between the 2 groups of women. Women with low fibrinogen levels started to receive transfusions significantly earlier (98 ± 58 minutes after delivery) than did women with normal fibrinogen levels (142 ± 75 minutes after delivery, p=0.03) and received more units of fresh-frozen plasma (p=0.03). CONCLUSION: The early transfusion of fresh-frozen plasma in women with postpartum hemorrhage and low fibrinogen levels might help prevent adverse outcomes.

Conservative management of hyperreactio luteinalis: a case report.

Hyperreactio luteinalis (HL) is characterized by bilaterally enlarged ovaries containing multiple self-limited theca lutein cysts and is usually associated with increased production of human chorionic gonadotropin in the presence of trophoblastic disease or multiple pregnancies. About 30 cases of HL have been reported in patients with normal singleton pregnancies, and most of these patients required surgical intervention during their first pregnancy because of ovarian torsion or to rule out of ovarian malignancy. However, the accurate diagnosis of HL by means of laboratory tests and magnetic resonance imaging and the exclusion of ovarian malignancy in asymptomatic pregnant woman may avoid unnecessary surgical intervention or termination of pregnancy. The present report describes case of HL in a woman with a normal singleton pregnancy in whom conservative management allowed the preservation of both ovaries.

Is a red umbilical cord a sign of umbilical venous congestion?: a case report.

Postnatal examination of fetal appendages is important because this information may help predict perinatal outcome. We present a case of a red streak along the entire umbilical vein after a cesarean section due to non-reassuring fetal status. The pathological findings revealed an umbilical cord with dilated vascular changes and mild funisitis. Because the dilated change was intense in the umbilical vein, the red streak of the umbilical cord was caused by venous congestion. Moreover, we considered that the umbilical venous congestion was due to increased resistance in the fetal intra-abdominal umbilical vein, which was associated with the non-reassuring fetal status.

Maternal risk factors for small-for-gestational age newborns in Japanese dichorionic twins.

AIM: To investigate the maternal risk factors for small-for-gestational age (SGA) newborns in Japanese dichorionic (DC) twins. METHODS: A retrospective study was conducted from 2003 to 2008 on 340 DC twin pregnancies resulting in two live births. Newborns were classified as SGA if their birth weight was below the 10th percentile according to Japanese singleton norms. Statistical differences were evaluated between pregnancies resulting in appropriate-for-gestational age (AGA) pairs and those resulting in at least one SGA neonate. RESULTS: The study population consisted of AGA/AGA (50.8%), AGA/SGA (37.0%) and SGA/SGA pairs (12.0%). Logistic regression analysis identified significant interrelations for SGA with maternal nulliparity (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.30-0.91), smoking (OR 3.25, 95% CI 1.09-9.66), assisted reproductive technology (OR 0.52, 95% CI 0.30-0.89), pregnancy-induced hypertension (OR 2.00, 95% CI 1.01-4.31), pregravid weight (kg) (unitary OR 0.94, 95% CI 0.91-0.97) and monthly weight gain (kg/month) (unitary OR 0.25, 95% CI 0.14-0.44). Bivariable receiver operating characteristic curves were generated for monthly weight gain (area under the curve [AUC] 0.626, cutoff 1.41 kg/month, P<0.001) and total weight gain (AUC 0.615, cutoff 14.0 kg, P<0.001). CONCLUSION: Cigarette smoking and weight gain control are relatively modifiable factors for which interventional management is necessary to avoid perinatal problems arising from SGA pregnancy. Further studies are needed to investigate optimal nutrition, health guidance and subsequent weight gain control that lead to concrete improvement in maternal and infant prognoses.

Effect of changes in renal circulation on serum uric acid levels in women with twin pregnancy.

OBJECTIVE: We examined the relationship between serum uric acid levels and changes in renal circulation in women with twin pregnancy compared with those in women with singleton pregnancy. METHODS: The Doppler waveforms of the bilateral maternal main renal arteries were obtained from 15 women at 37-38 weeks of nonpreeclamptic twin pregnancy and 16 healthy women at the same gestational age of singleton pregnancy. The resistance index (RI), pulsatility index (PI), and acceleration time were determined. RESULTS: The mean serum uric acid level in the twin pregnancy group was significantly higher than that in the singleton pregnancy group (5.0 ± 0.9 vs. 3.7 ± 0.6 mg/dl, P < 0.01). Although there were no significant differences in the RI or PI levels between the singleton and twin pregnancy groups, the acceleration time in the twin pregnancy group was significantly prolonged compared with that in the singleton pregnancy group (82.2 ± 29 vs. 59.9 ± 17 ms, P = 0.01). There was a significant correlation between serum uric acid levels and acceleration times (r(2) = 0.55, P < 0.01). CONCLUSION: The changes in renal circulation may be one of the possible mechanisms leading to hyperuricemia in women with twin pregnancies.

Hemodynamic changes in maternal renal arteries in twin pregnancy.

AIM: We examined whether the Doppler waveforms of the maternal renal main arteries are altered in women with twin pregnancy compared with those in singleton pregnancy. METHODS: The indices of vascular resistance and acceleration time of the maternal main renal arteries were obtained from 19 healthy women at 37-38 weeks of singleton gestation and 17 women at the same gestational age with non-preeclamptic twin gestation. RESULTS: There were no significant differences in the indices of vascular resistance between the singleton and twin groups. However, the acceleration time was significantly prolonged in the twin pregnancy group compared with that in the singleton pregnancy group (83.7 +/- 24 vs. 59.8 +/- 12 ms, p < 0.01). CONCLUSION: The current results imply that maternal renal arteries are more significantly affected by hemodynamic changes in twin pregnancy than in singleton pregnancy.

Abnormally shaped placentae in twin pregnancy.

OBJECTIVE: We examined the incidence of abnormally shaped placentae such as circumvallate placenta and succenturiate lobes of placenta and their complications in twin compared with singleton pregnancies. METHODS: A retrospective cohort study was performed with 592 (174 monochorionic and 418 dichorionic) twin and 11,311 singleton pregnancies managed at our hospital between 2000 and 2007. RESULTS: There was no measurable difference in the incidence of circumvallate placenta between twin and singleton pregnancies (1.2% vs. 1.9%), while the incidence of succenturiate lobes of placenta in twin pregnancies was significantly higher than that in singleton pregnancies (1.5% vs. 0.73%, P = 0.033). In singleton pregnancies, the incidences of placental complications such as placental abruption, vasa previa and retained placenta were observed to be associated with the presence of abnormally shaped placentae. In the twin pregnancies, however, there were no relation between the incidences of placental complications and the presence of abnormally shaped placentae. CONCLUSIONS: Succenturiate lobes of placenta were more common in twin pregnancies compared with singleton pregnancies. However, the presence of abnormally shaped placentae does not seem to affect perinatal outcomes in twin pregnancies.

Fetal heart rate patterns in monochorionic twins following acute twin-twin transfusion.

Background. We present here 2 cases of acute twin-twin transfusion occurred during vaginal labor in monochorionic-diamniotic twin pregnancies. Case. Fetal heart rate tracings showed tachycardia in the donor twin in the first case, while they showed reassuring patterns in both twins in the second case. Conclusion. These differences in changes of fetal heart rate in the donor twins following acute twin-twin transfusion may be resulted from the differences in amount of transfusion and elapsed time.

A case of monochorionic-diamniotic twin pregnancy with polyhydramnios-polyhydramnios sequence.

We present a case of monochorionic-diamniotic (MD) twin pregnancy with polyhydramnios-polyhydramnios sequence. A 20-year-old woman, gravida 1, para 0, was referred to our hospital at 31 weeks and 6 days' gestation for consultation about a high-risk pregnancy due to the presence of discordant fetal growth pattern (26% of fetal growth discordance) with polyhydramnios in MD twin pregnancy. Ultrasound examination at admission showed a maximal vertical pocket (MVP) of 11.4 cm in twin A and an MVP of 4.7 cm in twin B. At 33 weeks' gestation, the MVPs had increased to 22.2 cm and 10.2 cm, respectively. At 33 weeks and 2 days' gestation, Cesarean section was performed because of uncontrolled uterine contractions associated with polyhydramnios. Twin A was a female weighing 2,280 g, and twin B was a female weighing 1,782 g (22% growth discordance). The estimated amniotic fluid volumes of twins A and B were 5,000 and 1,000 mL, respectively.

Risk factors for preeclampsia in Japanese twin pregnancies: comparison with those in singleton pregnancies.

OBJECTIVE: To identify the factors associated with the increased risk of developing preeclampsia in twin pregnancies compared with those in singleton pregnancies. METHODS: We reviewed the obstetric records of all deliveries at > or =22 weeks' gestation managed at the Japanese Red Cross Katsushika Maternity Hospital between 2001 and 2007. RESULTS: The incidence of preeclampsia in the twin pregnancies (7.6%: 45 in 593) was significantly higher than that in the singleton pregnancies (1.7%: 196 in 11,311; P < 0.01). In singleton pregnancies, the developing preeclampsia was associated with maternal age at > or =35 years, primiparity, maternal BMI > or =25 before pregnancy, history of infertility therapies such as IVF and having a history of previous preeclampsia. In twin pregnancies, however, the developing preeclampsia was not associated with these variables. CONCLUSIONS: In Japanese women, the factors reported to be associated with the increased risk of preeclampsia in singleton pregnancies may not alter the increased risk of preeclampsia in twin pregnancies.

Ptyalism gravidarum.

CONTEXT: Ptyalism gravidarum is of unknown origin and is usually defined as an excessive secretion of saliva, common in women with nausea and vomiting who might have difficulty in swallowing their saliva. CASE REPORT: We present here 2 cases complicated by ptyalism gravidarum during all trimesters of pregnancy. In one case, ptyalism recovered spontaneously at 35-36 weeks' gestation, and in the other case, it recovered after delivery. CONCLUSION: Ptyalism gravidarum may not be a serious condition leading to adverse perinatal outcomes, however there may not be any satisfactory treatment.

Risk factors for transient tachypnea of the newborn in infants delivered vaginally at 37 weeks or later.

In this case-control study, we examined infants delivered vaginally at 37 weeks or later to identify factors associated with transient tachypnea of the newborn (TTN). We reviewed the obstetric records of all vaginal deliveries at the Japanese Red Cross Katsushika Maternity Hospital from 2005 through 2007. Demographic information and the characteristics of labor were extracted from patient charts. Multivariate analysis identified that the incidence of TTN was significantly associated with nulliparity; a history of infertility therapy, such as in vitro fertilization; augmentation of labor; nonreassuring fetal status; vacuum/forceps delivery; and low Apgar score (<7) at 1 and 5 minutes. In addition, a low Apgar score at 1 minute was the factor most strongly associated with the incidence of TTN (adjusted odds ratio, 20; 95% confidence intervals, 12-34; p<0.001). The present results indicate that the improvement of obstetric surveillance to diminish the frequency of low Apgar scores is important for preventing TTN in infants delivered vaginally at 37 weeks or later.

Elective cesarean as a risk factor for transfusion after delivery of twins.

We examined deliveries of twins to identify factors most strongly associated with an increased risk of transfusion. We reviewed the obstetric records of 511 twin deliveries at the Japanese Red Cross Katsushika Maternity Hospital from 2003 through 2007. After 18 (3.5%) of these deliveries, transfusions were required. Transfusion was significantly more likely after elective cesarean delivery at a gestational aged of 37 weeks or more (odds ratio, 4.85; 95% confidence interval, 1.87-12.61). Emergency cesarean delivery (at > or =37 weeks' gestation) was not associated with an increased risk of transfusion. The delivery mode of twins should be carefully considered because of the increased risk of transfusion after elective cesarean delivery at a gestational age of 37 weeks or more.

Clinical significance of pregnancies with succenturiate lobes of placenta.

OBJECTIVES: This study examined the clinical significance of patients complicated by succenturiate lobes of placenta in comparison with patients with normal placenta. METHODS: Data were collected from 47 patients complicated by succenturiate lobes of placenta and from 7,666 unaffected controls. RESULTS: The frequency of maternal age > or =35 years and history of using in vitro fertilization in patients complicated by succenturiate lobes of placenta were significantly higher than those in control patients (P < 0.01). In addition, the incidence of non-reassuring fetal status, vasa previa, postpartum hemorrhage and retained placenta in the study group were significantly higher than those in control (P < 0.01). CONCLUSION: These results support the adverse obstetric outcomes in pregnancies with succenturiate lobes of placenta and may suggest the pathogenesis of these placental shape aberrations associated with assisted reproductive technology.

Risk factors for postpartum hemorrhage after vaginal delivery of twins.

We examined vaginal deliveries of twins to identify factors most strongly associated with the increased risk of postpartum hemorrhage (estimated blood loss > or = 1,000 mL). We reviewed the obstetric records of all 171 twin vaginal deliveries at Japanese Red Cross Katsushika Maternity Hospital from January 2002 through August 2006. Of these deliveries, 41 (24%) were complicated by postopartum hemorrhage. Postpartum hemorrhage was significantly more likely in cases with gestational age > or = 39 weeks (odds ratio [OR], 3.47; 95% confidence interval [CI], 1.65-7.28), a combined birth weight of more than 5,500 g (OR, 2.53; 95% CI, 1.00-6.45), induction of labor (OR, 2.87; 95% CI, 1.38-5.98), oxytocin administration during labor (OR, 2.86; 95% CI, 1.27-6.48), or a duration of labor > or = 24 hours (OR, 2.55; 95% CI, 1.15-5.62). Postpartum hemorrhage is a frequent complication in twin pregnancies. Therefore, special attention should be given after birth to patients with induction of labor or intervened delivery especially at > or = 39 weeks gestation.