The Effect of Sexual Intercourse during Pregnancy on Preterm Birth: Prospective Single-Center Cohort Study in Japan.

Several studies in Europe and the United States have shown that sexual intercourse (SI) during pregnancy is not associated with preterm birth. However, it is unclear whether these findings apply to pregnant Japanese women. The aim of this prospective cohort study was to elucidate the influence of SI during pregnancy on preterm birth in Japan. A total of 182 women who underwent antenatal care and delivery were included in this study. The frequency of SI was assessed using a questionnaire, and its association with preterm birth was analyzed. The results showed that SI during pregnancy was associated with a significantly higher cumulative preterm birth rate (p = 0.018), which was more pronounced for SI more than once a week (p < 0.0001). Multivariate analysis showed that SI, bacterial vaginosis in the second trimester, previous preterm birth, and smoking during pregnancy were independent risk factors for preterm birth. The combination of SI and second trimester bacterial vaginosis was associated with a 60% preterm birth rate, whereas either factor alone was associated with a lower rate, suggesting a synergistic effect (p < 0.0001). Future studies are needed to investigate the effect of prohibiting SI in pregnant women with bacterial vaginosis on preterm birth.

Conservative Management for Retained Products of Conception in Late Pregnancy.

This retrospective study aims to compare the early manual removal of placenta (MROP) and conservative management of retained products of conception (RPOC) after 34 weeks of gestation. Nineteen cases underwent MROP within 24 h of delivery, of which nine patients had no symptoms requiring emergent treatment. These 9 patients (group M) were compared with 22 patients who were treated conservatively (group C). Massive bleeding was observed in 5 (56%) patients in group M and 11 (50%) patients in group C, with no significant difference in frequency. However, the lowest hemoglobin level within 72 h after massive bleeding was lower in group M (median: 6.7 vs. 7.7 g/dL, p = 0.029), suggesting that massive bleeding occurred in a short period of time. On the other hand, a retained placenta was observed in four patients in group M after the MROP; however, the placenta disappeared more quickly than in group C (median; 1.0 vs. 99.0 days, p = 0.009). In group C, all bleeding and infection occurred within 60 days of delivery, including heavy bleeding in six cases during the placental-extraction trial. Human chorionic gonadotropin in group C fell below the measurable threshold at a median of 67 days postpartum. In conclusion, for RPOC without urgent symptoms, early MROP and conservative treatment have their advantages and disadvantages. Randomized controlled trials are needed to determine which of those treatments is superior.

Candida glabrata infection of the amniotic fluid with chorioamnionitis and maternal candidemia and a negative 1,3-ß-D-glucan test: A case report.

A case is reported of Candida glabrata microbial invasion of the amniotic cavity and maternal candidemia with a negative 1,3-ß-D-glucan test. A 28-year-old singleton pregnant woman (gravida 1, para 0) presented at 18 weeks and 3 days of gestation following in vitro fertilization and embryo transfer. She had suddenly experienced uterine contraction and genital bleeding with watery discharge and. After diagnosing preterm rupture of the membrane with clinical chorioamnionitis, Candida glabrata was detected both in the amniotic fluid and in the vaginal discharge; however, a test for 1,3-ß-D-glucan in the maternal serum was negative. At 18 weeks and 5 days of gestation, the pregnancy was terminated after intensive counseling. On the eighth day of admission, Candida glabrata was detected in maternal blood culture. When a culture of amniotic fluid is positive for Candida glabrata, even if the 1,3-ß-D-glucan test is negative, maternal candidemia should be suspected in the presence of features of clinical chorioamnionitis.

Plasma Antithrombin Activity during Long-Term Magnesium Sulfate Administration for Preeclampsia without Severe Hypertension.

In preeclampsia, plasma antithrombin activity is decreased, which leads to exacerbation of the disorder. We previously showed that long-term magnesium sulfate (MgSO4) administration prolonged the pregnancy period and may be able to improve pregnancy outcomes for patients with severe preeclampsia. The present study aimed to investigate the changes in plasma antithrombin activity during long-term MgSO4 administration for patients without severe hypertension. This multicenter retrospective study included patients with preeclampsia and superimposed preeclampsia without severe hypertension at diagnosis. The participants were divided into two groups: MgSO4 nontreatment group (three institutions) and MgSO4 treatment group (one institution). Antithrombin activity from time of diagnosis to delivery were compared between the two groups. In the MgSO4 nontreatment group (n = 16), antithrombin activity prior to delivery was significantly lower than at time of diagnosis (p = 0.015). In three cases, antithrombin activity was less than 60%. On the other hand, in the MgSO4 treatment group (n = 34), antithrombin activity did not change until just before delivery (p = 0.74). There were no cases in which antithrombin activity was decreased below 60%. Long-term MgSO4 administration for preeclampsia without severe hypertension may prevent a decrease in antithrombin activity and improve the disease state of preeclampsia.

Re-evaluation of the predictive value of Quintero staging of twin-twin transfusion syndrome for fetal death after fetoscopic laser photocoagulation.

OBJECTIVE: To elucidate the significance of sonographic indices, including Doppler waveforms, that constitute the Quintero classification for predicting death of the recipient or donor after fetoscopic laser photocoagulation (FLP) for twin-twin transfusion syndrome (TTTS). METHODS: Prospectively collected data of twins who underwent FLP for TTTS were reviewed. Among the abnormal indices of ultrasound performed just before FLP, factors that were significantly associated with fetal and neonatal deaths in the log-rank test, including fetal demise of co-twins and preterm birth before 28 weeks of gestation, were introduced into the Cox proportional-hazards model to calculate risk ratio (RR). RESULTS: We included 235 cases with a prevalence of recipient and donor deaths of 7% and 14%, respectively. In the proportional-hazards model, absent or reversed umbilical artery end-diastolic velocity (UA AREDV) of recipients (n = 7) was independently associated with recipient death (RR = 6.97). In recipients without UA AREDV, reversed ductus venosus (DV) a-wave of recipients (RR = 3.55) was independently associated with recipient death. In donors, UA AREDV with a visible bladder (stage III atypical donor) was independently associated with donor death (RR = 4.24). CONCLUSION: Some individual components of the Quintero stage are associated with death of either recipient or donor twins following FLP.

Factors contributing to favourable neonatal outcomes in early-onset severe preeclampsia.

We collected data from all the women with singleton pregnancies complicated by early-onset severe preeclampsia between 2008 and 2018 to identify the factor(s) that contributed to favourable neonatal outcome. Thirty women delivered the neonates with favourable outcome and the remaining 21 women delivered those with unfavourable outcome. Univariate logistic regression analysis revealed that gestational age at diagnosis ≥28 weeks (crude odds ratio [OR], 6.00), protocol-based management (crude OR 5.83), use of magnesium sulphate (crude OR, 6.00), gestational age at delivery ≥32 weeks (crude OR, 31.90), and birthweight ≥1000 g (crude OR, 10.36) were significantly associated with favourable neonatal outcome. Among these five factors, multivariate logistic regression analysis extracted gestational age at delivery ≥32 weeks (adjusted OR, 17.62) as an only independent factor contributing to favourable neonatal outcome. These data suggest that prolongation of pregnancy up to 32 weeks of gestation is a key factor to improve neonatal outcome in the expectant management of early-onset severe preeclampsia.This study was approved by the ethics committee of Otsu Red Cross Hospital (reference number: 363, date of approval: April 28th, 2016).Impact statementWhat is already known on this subject? It has been demonstrated that expectant management for the women with early-onset severe preeclampsia is associated with decreased neonatal morbidity as compared to the aggressive management, suggesting that prolongation of the pregnancy period contributes to improved neonatal outcomes.What do the results of this study add? Among multiple elements composing expectant management for the women with early-onset severe preeclampsia, 'gestational age at delivery ≥32 weeks' was extracted as an only independent factor that significantly contributes to favourable neonatal outcomes. Importantly, small for gestational age was not significantly associated with poor neonatal outcomes.What are the implications of these findings for clinical practice and/or further research? The obstetrician should aim to prolong the pregnancies complicated by early-onset severe preeclampsia up to 32 gestational weeks even in the presence of foetal growth restriction, as far as maternal conditions allow. Such management policy could contribute to improvement of the neonatal outcomes.

Mechanisms of thrombin-Induced myometrial contractions: Potential targets of progesterone.

Intrauterine bleeding during pregnancy is a major risk factor for preterm birth. Thrombin, the most abundant coagulation factor in blood, is associated with uterine myometrial contraction. Here, we investigated the molecular mechanism and signaling of thrombin-induced myometrial contraction. First, histologic studies of placental abruption, as a representative intrauterine bleeding, revealed that thrombin was expressed within the infiltrating hemorrhage and that thrombin receptor (protease-activated receptor 1, PAR1) was highly expressed in myometrial cells surrounding the hemorrhage. Treatment of human myometrial cells with thrombin resulted in augmented contraction via PAR1. Thrombin-induced signaling to myosin was then mediated by activation of myosin light chain kinase- and Rho-induced phosphorylation of myosin light chain-2. In addition, thrombin increased prostaglandin-endoperoxidase synthase-2 (PTGS2 or COX2) mRNA and prostaglandin E2 and F2α synthesis in human myometrial cells. Thrombin significantly increased the mRNA level of interleukine-1ß, whereas it decreased the expressions of prostaglandin EP3 and F2α receptors. Progesterone partially blocked thrombin-induced myometrial contractions, which was accompanied by suppression of the thrombin-induced increase of PTGS2 and IL1B mRNA expressions as well as suppression of PAR1 expression. Collectively, thrombin induces myometrial contractions by two mechanisms, including direct activation of myosin and indirect increases in prostaglandin synthesis. The results suggest a therapeutic potential of progesterone for preterm labor complicated by intrauterine bleeding.

Enoxaparin administration within 24 hours of caesarean section: a 6-year single-centre experience and patient outcomes.

A caesarean section (CS) is a major risk factor for a venous thromboembolism, and enoxaparin, a low-molecular-weight heparin, has been widely used for thromboprophylaxis. However, it remains unclear whether an enoxaparin thromboprophylaxis has an acceptable safety profile when given early after CS compared to delayed administration, especially in the presence of an epidural catheter. This study aimed to survey cases in which enoxaparin administration was performed within 24 hours of CS and to evaluate patient outcomes with or without epidural anaesthesia. The number of eligible cases were 578: 328 patients received an epidural anaesthesia (epidural group), and 250 did not (non-epidural group). In both groups, no patient developed a spinal epidural haematoma. A wound or a subcutaneous bleeding occurred in 22 (6.7%) and 20 (8.0%) cases in the epidural and non-epidural groups, respectively. One patient developed a mild pulmonary embolism, and one case of asymptomatic deep vein thrombosis was detected. An enoxaparin administration within 24 hours of CS appears to be reasonable, regardless of an epidural anaesthesia. Impact statement What is already known on this subject? A venous thromboembolism (VTE) after a caesarean section (CS) remains a significant cause of maternal morbidity and mortality. Therefore, a thromboprophylaxis using enoxaparin, a low-molecular-weight heparin, has been widely recommended and accepted. However, there is no consensus regarding the optimal timing to initiate an enoxaparin administration after CS in the presence of an epidural catheter. What do the results of this study add? This is the largest study that has collected cases receiving enoxaparin within 24 hours of a CS. Irrespective of the presence of an epidural catheter, no patient developed a spinal epidural haematoma after an early administration of enoxaparin. Furthermore, the incidence of haemorrhagic complications did not increase. What are the implications of these findings for clinical practice and/or further research? Given the significant incidence of VTE after CS and the extremely low frequency of spinal epidural haematomas, it can be justified to initiate thromboprophylaxis with enoxaparin soon after CS. However, appropriately designed, large clinical trials are necessary to examine the safety and efficacy of an early enoxaparin administration after CS. Based on such studies, the starting time of thromboprophylaxis after a CS should be decided.

Power morcellation-induced dissemination of sarcomatous component arising in leiomyoma.

In 2014, the US Food and Drug Administration issued a safety communication warning against the use of power morcellators during laparoscopic hysterectomy or myomectomy. We report a case of peritoneal leiomyosarcomatosis attributable to power morcellation. A 49-year-old nulligravid woman presented with a huge uterine tumor measuring 15 × 8 cm that was diagnosed as benign leiomyoma on magnetic resonance imaging. The uterine tumor had shrunk to 13 × 7 cm after five treatment courses with a gonadotropin-releasing hormone agonist. She underwent laparoscopic hysterectomy using power morcellation; postoperative pathological diagnosis was benign leiomyoma. After 6 months, urinary ascites developed because of right ureteral rupture. She underwent laparotomy and was diagnosed with peritoneal leiomyosarcomatosis. Meticulous and thorough reevaluation of the morcellated specimens revealed a small component of leiomyosarcoma. Use of power morcellation should be minimized until the advent of novel methods that can perfectly differentiate benign from malignant uterine tumors preoperatively.