A Retrospective Multicenter Study on the Usefulness of 50 g Glucose Challenge Test in Gestational Diabetes Mellitus Screening.

INTRODUCTION: To clarify the usefulness of glucose challenge test (GCT), the rate of gestational diabetes mellitus (GDM) detection and perinatal outcomes were compared between the groups of random blood glucose level (RBG) and 50 g GCT in this study. METHODS: The first survey was conducted at 255 institutions registered by the Kanto Society of Obstetrics and Gynecology and clinical training institutions in the Kanto Area, followed by a second survey. The included women were broadly classified into the RBG and GCT groups, according to the mid-trimester blood glucose screening method, and the perinatal outcomes of the two groups were retrospectively compared. The primary outcomes were the proportion of infants weighing 3,500 g or more and birth weight ≥90th-percentile infants. RESULTS: The rate of GDM diagnosis was significantly higher in the GCT group (7.6%) than that in the RBG group (4.8%). However, no significant differences were observed in perinatal outcomes, i.e., the proportion of infants weighing 3,500 g or more or birth weight ≥90th percentile. CONCLUSIONS: GCT is not superior for predicting infants weighing 3,500 g or more and birth weight ≥90th percentile, as compared with RBG.

Characteristics of labor-onset hypertension persist after neuraxial labor analgesia.

AIM: This study aimed to investigate the rate of labor-onset hypertension (LOH) under neuraxial labor analgesia and the effect of neuraxial labor analgesia on LOH. METHODS: A retrospective study was conducted in a tertiary university hospital from 2015 to 2016. Patients who were admitted to the hospital for vaginal delivery under combined spinal and epidural anesthesia were selected. LOH was defined as the elevation of systolic blood pressure (BP) to ≥140 mmHg or diastolic BP to ≥90 mmHg for the first time after the onset of labor. Cases of LOH that persisted after neuraxial labor analgesia (prolonged LOH) were further analyzed to determine the hypertension severity and therapeutic intervention rate. RESULTS: Among 775 patients, 213 (28.4%) developed LOH. Prolonged LOH was observed in 30 patients (3.9%). LOH severity and the likelihood of prolonged LOH were positively correlated. Therapeutic intervention was administered only to the patients with prolonged LOH, that is, to 100% of those with emergent hypertension, to 21.1% of those with severe hypertension during labor, and to 36.8% of those with severe hypertension, to 55.6% of those with mild hypertension in the post-partum period. CONCLUSION: The rate of LOH was reduced significantly after neuraxial labor analgesia. Patients with prolonged LOH should be carefully followed up during labor and in the post-partum period because such patients often require antihypertensive therapy.

Assessment of extravasation on ruptured uterine artery pseudoaneurysm using contrast-enhanced ultrasonography during uterine balloon tamponade.

OBJECTIVE: Contrast-enhanced ultrasonography (CEU) has been used in critical trauma situations to visualize extravasation; however, its use is limited in the field of obstetrics. Cases of ruptured uterine artery pseudoaneurysm (UAP) were analyzed to clarify the efficacy to CEU during uterine balloon tamponade. METHODS: Cases of ruptured UAP diagnosed at a teaching university hospital from January 2015 to December 2017 were retrospectively analyzed. UAP was diagnosed using color Doppler ultrasonography. Extravasation was identified using computed tomography and double checked using CEU with an intravenously administered contrast agent (Sonazoid; Daiichi Sankyo Company, Ltd., Tokyo, Japan) and an ultrasound instrument (HI VISION Preirus; Hitachi Aloka Medical, Ltd., Tokyo, Japan). A balloon was then inserted into the uterine cavity and inflated at the point of bleeding until extravasation ceased. RESULTS: Three patients exhibited ruptured UAP during the study period. Bleeding points were successfully identified using CEU in all cases, and hemostasis was achieved using uterine balloon tamponade. Obliteration of UAP was confirmed using magnetic resonance imaging, and no patients developed recurrent UAP or any complications. CONCLUSION: CEU can be used at the bedside to promptly diagnose ruptured UAP. Moreover, it precisely facilitates balloon compression at the point of bleeding.

Long-term uterine balloon tamponade for treatment and obliteration of ruptured uterine pseudoaneurysm.

OBJECTIVE: Rupture of uterine artery pseudoaneurysm (UAP) is a life-threatening event after childbirth. Hysterectomy or uterine arterial embolization was often needed for hemostasis. However, such procedures may cause severe morbidities for these women. To estimate the efficacy of uterine balloon tamponade (UBT) for controlling ruptured UAP bleeding, a retrospective analysis in a single teaching hospital was performed. MATERIALS AND METHODS: We reviewed the medical record of Juntendo University Hospital in 2015. All the women diagnosed with UAP were recruited to this study and management for UAP was investigated. RESULTS: Three women were treated with UBT for ruptured UAP. All cases achieved hemostasis. One case had recurrent UAP after 24 h of UBT, and was retreated with UBT for a longer duration. The UAP was obliterated after more than 2 days of UBT in all cases. CONCLUSION: UBT has potential as a therapeutic technique not only for treatment of a ruptured UAP but also for obliteration of a UAP.

Incidence and risk factors of severe lacerations during forceps delivery in a single teaching hospital where simulation training is held annually.

AIM: This study was conducted to evaluate the incidence of severe lacerations during forceps delivery and the risk factors associated with such delivery in a hospital where simulation training is held annually. METHODS: The medical records of 857 women who underwent forceps delivery at term with singleton cephalic presentation from 2010 to 2015 were reviewed. The relationship between clinical characteristics and birth canal trauma was analyzed. Birth canal trauma included third and fourth degree perineal lacerations. Univariable and multivariable models of logistic regression were employed to estimate the raw odds ratio and were adjusted for cofactors with 95% confidence intervals. Statistical significance was defined as P < 0.05. RESULTS: The incidence of severe lacerations was 10.1%. Birth weight, fetal head station, the rate of malrotation and the number of extractions were higher in women with severe lacerations (P < 0.01), whereas the use of obstetric anesthesia was lower in women with such lacerations (P < 0.01). Neither the indication for forceps delivery nor the qualifications of the operator had any influence on the incidence of severe lacerations. CONCLUSION: The incidence of severe lacerations was relatively low. Risk factors for severe lacerations with forceps delivery were identified as birth weight, fetal head station, malrotation and the number of extractions. Obstetric anesthesia may protect against severe lacerations.

Predictive markers and prenatal management of isolated fetal complete atrioventricular block: A retrospective review at a single institution.

AIM: The study was conducted to determine an effective method for identifying patients at high risk of developing isolated complete atrioventricular block (CAVB) and to review the efficacy of prenatal anti-inflammatory treatment. METHODS: Fourteen CAVB cases and 76 anti-Ro-positive cases without CAVB were included in the study. Anti-Ro/La titers by double immunodiffusion and the prevalence of anti-52 kDa/60 kDa-Ro/48 kDa-La by Western blotting were compared between anti-Ro-positive women with and without CAVB. Outcomes of anti-Ro-positive CAVB cases were compared based on active prenatal anti-inflammatory treatment (plasma exchange or transplacental betamethasone). We evaluated the outcomes of five pregnancies from three women who had an affected child and underwent prophylactic plasma exchange (PEX) during subsequent pregnancy. RESULTS: Ten out of 14 patients with CAVB were positive for anti-Ro. Anti-Ro titers were significantly higher in patients with CAVB (CAVB median 64; without CAVB median 16; P < 0.01). All cases with CAVB showed high titers of anti-Ro (≥ 32×), whereas only 42% of cases without CAVB showed high titers (≥ 32×) (P < 0.001). The survival rate at one year was 80% in anti-Ro-positive CAVB cases with active prenatal anti-inflammatory treatment, but only 40% in cases that did not receive treatment. Recurrence was not observed in cases treated with prophylactic PEX. CONCLUSIONS: An anti-Ro level of 32× could be the threshold value for CAVB development. Prenatal anti-inflammatory treatment in patients with CAVB and prophylactic PEX in patients who had an affected child may have the potential to improve pregnancy outcomes.

Relationship between fetal heart rate patterns and a time course for evaluation of fetal well-being: "the 30 minutes rule" for decision of mechanical delivery.

OBJECTIVE: To predict acidosis in fetus showing deceleration associated with non-reassuring fetal status during delivery, we examined the relationship between duration of the deceleration and umbilical arterial pH. MATERIALS AND METHODS: A total of 19,907 deliveries in eight facilities of the Juntendo Perinatal Care Group, 895 cases of vaginal deliveries with level 3 decelerations were selected for the subjects of this study. The cut-off point of time when the umbilical arterial pH fell below 7.20 in all cases of level 3 and for each deceleration type were examined. The explanatory variables were the pH and pO2 of umbilical arterial gas and the time from onset of the level 3 pattern to delivery. From receiver operating characteristic (ROC) analysis using these variables, the critical point indicating low Apgar score was set at an umbilical arterial pH < 7.20. RESULTS: The cut-off point of time when the umbilical arterial pH fell below 7.2 was 33.5 min for all cases of level 3, and 604 cases of severe variable decelerations with normal baseline variability and normal baseline heart rates, the cut-off point was 33.5 min as well. For 108 cases of late decelerations, there was no significant cut-off point for either the mild or severe cases. Mild prolonged deceleration showed the cut-off point of 34.5 min. CONCLUSIONS: We confirmed the time indices for predicting and preventing acidosis in fetuses showing decelerations. To prevent fetal acidosis, the decision related to proper timing for performing assisted delivery by considering the time course is important.

Chymotrypsin Enhances Soluble Fms-Like Tyrosine Kinase 1 Production Through Protease-Activated Receptor 2 in Placenta-Derived Immortalized Human Trophoblast Cells.

The production of soluble fms-like tyrosine kinase 1 (sFLT1) by exogenous chymotrypsin in trophoblast cells through protease-activated receptor (PAR) 2 was investigated to identify the role of a chymotrypsin-like serine protease in preeclampsia (PE) pathogenesis. We evaluated the expression of chymotrypsin, FLT1, and sFLT1 in monolayers of immortalized human trophoblast cells derived from placenta (TCL-1 cells). To investigate whether chymotrypsin enhances the production and release of sFLT1 through PAR-2, we examined changes in sFLT1 protein levels in conditioned medium by enzyme-linked immunosorbent assay and sFLT1 messenger RNA (mRNA) levels by real-time polymerase chain reaction in TCL-1 cells treated with exogenous chymotrypsin in the presence or absence of a PAR-2 antagonist or a chymotrypsin inhibitor (TPCK). We also examined changes in PAR-2 expression in TCL-1 cells treated with tumor necrosis factor (TNF) α in the presence or absence of a polyclonal anti-TNF-α antibody. Western blot analysis showed that TCL-1 trophoblast cells expressed chymotrypsin, FLT1, and sFLT1. Compared with the control cells, the sFLT1 level in the conditioned medium and sFLT1 mRNA level in cells were both significantly enhanced when treated with a PAR-2 agonist or chymotrypsin for 6 hours. In contrast, the sFLT1 level in the medium and sFLT1 mRNA level in cells treated with a PAR-2 agonist or chymotrypsin were suppressed in the presence of a PAR-2 antagonist or a chymotrypsin inhibitor. The PAR-2 expression was upregulated by TNF-α, which was suppressed in the presence of TNF-α antibodies. These results indicate that chymotrypsin-like serine protease enhances sFLT1 production through PAR-2 in trophoblast cells and thus plays an important additional role in PE pathogenesis.

Isolated gestational proteinuria preceding the diagnosis of preeclampsia - an observational study.

INTRODUCTION: Some pregnant women develop significant proteinuria in the absence of hypertension. However, clinical significance of isolated gestational proteinuria (IGP) is not well understood. This study aimed to determine the prevalence of IGP in singleton pregnancies and the proportion of women with IGP who subsequently developed preeclampsia (IGP-PE) among all PE cases. MATERIAL AND METHODS: This was an observational study of 6819 women with singleton pregnancies at 12 centers, including 938 women with at least once determination of protein-to-creatinine ratio (P/Cr). Significant proteinuria in pregnancy (SPIP) was defined as P/Cr (mg/mg) level >0.27. IGP was defined as SPIP in the absence of hypertension. Gestational hypertension (GH) preceding preeclampsia (GH-PE) was defined as preeclampsia (PE) in which GH preceded SPIP. Simultaneous PE (S-PE) was defined as PE in which both SPIP and hypertension occurred simultaneously. RESULTS: IGP and PE were diagnosed in 130 (1.9%) and 158 (2.3%) of 6819 women, respectively. Of 130 women with IGP, 32 (25%) progressed to PE and accounted for 20% of all women with PE. Hence, women with IGP had a relative risk of 13.1 (95% CI; 9.2-18.5) for developing PE compared with those without IGP [25% (32/130) vs. 1.9% (126/6689)]. At diagnosis of SPIP, P/Cr levels already exceeded 1.0 more often in women with S-PE than in those with IGP-PE [67% (33/49) vs. 44% (14/32), respectively, p = 0.031]. CONCLUSIONS: IGP is a risk factor for PE, and IGP-PE accounts for a considerable proportion (20%) of all PE.

Urinary protein-to-creatinine ratio in pregnant women after dipstick testing: prospective observational study.

BACKGROUND: The dipstick test is widely used as a primary screening test for detection of significant proteinuria in pregnancy (SPIP). However, it often shows a false positive test result. This study was performed to determine which pregnant women should be recommended to undergo determination of urinary protein-to-creatinine ratio (mg/mg, P/Cr test) after dipstick test for confirmation of SPIP. METHODS: This was a multicenter, prospective, and observational study of 2212 urine specimens from 1033 pregnant women who underwent simultaneous dipstick and P/Cr tests in the same spot urine samples at least once. SPIP was defined as P/Cr > 0.27. Preeclampsia was diagnosed in women with both hypertension and SPIP. RESULTS: Preeclampsia, hypertension alone, and SPIP alone developed in 202 (20 %), 73 (7.1 %), and 120 (12 %) women, respectively. Creatinine concentration [Cr] varied greatly, ranging from 8.1 to 831 mg/dL in the 2212 urine samples. Rate of positive dipstick test results increased with increasing [Cr], while SPIP prevalence rate was lower in urine samples with higher [Cr], yielding higher false positive rates in samples with higher [Cr]. Postpartum urine samples had significantly lower [Cr] compared to those obtained antepartum (60 [8.7-297] vs. 100 [10-401] mg/dL, respectively). At the first P/Cr test among women with similar dipstick test results, the risk of having SPIP was consistently and significantly higher for hypertensive women than for normotensive women at any dipstick test result: 18 % (14/77) vs. 3.2 % (8/251), 47 % (26/55) vs. 8.7 % (37/425), 91 % (82/90) vs. 59 % (44/75) for negative/equivocal, 1+, and ≥ 2+ test results, respectively. The risk of SPIP was 16 % (9/55) for normotensive women when two successive antenatal urine samples showed a dipstick test result of 1 + . CONCLUSIONS: For prediction of SPIP, the dipstick test was more likely to show a false positive result in concentrated urine samples with higher [Cr]. Hypertensive women with ≥ 1+ as well as normotensive women with ≥ 2+ on dipstick test should be advised to undergo the P/Cr test.

Polyarteritis nodosa with uterine involvement.

Polyarteritis nodosa (PAN) is characterized by multisystem necrotizing vasculitis, primarily affecting small-to-medium-sized muscular arteries, and it is typically found in middle-aged men. PAN is rarely found in the female genital tract (including the uterus), and imaging of the uterus with PAN has not previously been reported. Reported is a case of a 78-year-old patient with uterus enlargement who was diagnosed with PAN through clinical findings and images. Computed tomography and magnetic resonance imaging findings of a uterus affected by PAN are presented and reviewed, and potential characteristic findings of the uterine with PAN are discussed.