Prenatal diagnosis of the umbilical cord torsion at the placental cord insertion site: A case report and literature review.

A 35-year-old woman (gravida 1, para 0) was admitted to our hospital at 28 weeks' gestation with vaginal bleeding from placenta previa. Severe fetal bradycardia was observed during fetal heart rate monitoring. Ultrasonography showed widely dilated veins on the fetal surface of the placenta and an extraordinarily low umbilical artery peak systolic velocity in the Doppler study. Umbilical cord torsion was suspected. On the subsequent day, we performed a cesarean section due to worsening fetal heart rate patterns. Umbilical artery blood gas analysis indicated severe acidemia (pH 7.063), and umbilical cord torsion was confirmed at the placental cord insertion site. Diagnosing UCT prenatally is challenging; however, it can be suspected by scanning for the widely dilated veins on the fetal placental surface, termed as the "Sunset Sign," an abnormally low umbilical artery peak systolic velocity, and other fetal Doppler abnormalities.

Does maternal oxygen administration during non-reassuring fetal status affect the umbilical artery gas measures and neonatal outcomes?

PURPOSE: To clarify whether maternal oxygen administration during vaginal delivery improves umbilical artery (UA) gas measurements and neonatal outcomes. METHODS: Singleton pregnancies requiring operative vaginal delivery or emergency cesarean section (CS) due to non-reassuring fetal status (NRFS) during vaginal delivery at our hospital from 2018 to 2021 were retrospectively investigated. Intrapartum fetal wellbeing was evaluated based on the 5-tier fetal heart rate (FHR) pattern which is a delivery management method widely used in Japan. Operative vaginal deliveries or emergency CS was performed under integrated judgment in NRFS. Patients were divided into the oxygen group to whom oxygen (10 L/min) was supplied by a facemask and the room air group. The UA gas measurements and neonatal outcomes were compared. The oxygen administration was classified by conditions before and after the coronavirus disease 2019 pandemic. As a secondary evaluation, stratification of FHR pattern levels and factors associated with UA pH < 7.15 were examined. RESULTS: A total of 250 patients required obstetric surgical delivery due to NRFS, including 140 (56%) and 110 (44%) in the oxygen and room air groups, respectively. No differences in maternal background factors were found between both groups, except for maternal age. UA gas measurements and neonatal outcomes also showed no significant differences. No significant factors were extracted in the multivariate analysis for UA pH < 7.15. CONCLUSIONS: Trans-maternal oxygen administration for intrapartum NRFS did not affect neonatal cord blood gasses or neonatal outcomes. Thus, routine oxygen administration for intrapartum NRFS may not always be necessary.

Antenatal Detection of a True Umbilical Cord Knot: Facilitating Optimal Delivery Management.

Prenatal diagnosis of a true umbilical cord knot is challenging. However, prenatal diagnosis is clinically valuable because it allows preparation for fetal distress during labor. Here, we report a case of prenatal diagnosis of true umbilical cord knot, with a favorable delivery management.

Descriptive Study on a Nationwide Exploratory Questionnaire Survey of Emergency Contraceptive Pills and Their Sexual History and Knowledge in Japan.

A shift towards obtaining emergency contraceptives without a prescription have been discussed in Japan. In response to this social background, we aimed at investigating the background of sexual intercourse, emergency contraceptive use, and knowledge of sexual and reproductive health education among women of reproductive age in Japan. In this study, we conducted a national wide cross-sectional questionnaire survey using a total of 4 web-based domains (background, sexual history, emergency contraceptives, and sexual and reproduction-related knowledge) composed of 50 questions. We obtained responses from a total of 4,631 participants of varying age groups (18-25, 26-35, and 36-45 years old) and 47 prefectures (84 to 118 from each prefecture). Among participant responses, 69.7% are sexually active, of which 49.0% had experiences of sexual intercourse with an unknown person. The responses from a total of 737 participants who have sexual intercourse, know of emergency contraceptives, and have experienced a situation that necessitated the use of emergency contraceptives, were analyzed. Of these participants, 46.4% (342/737) took emergency contraceptives, while 43.6% (321/737) participants did not take emergency contraceptives. Participants who have the knowledge for obtaining emergency contraceptives through the correct means were 52.6% (2438/4631). This study showed that approximately half of participants may not have correct knowledge of emergency contraceptives. In addition, approximately half of sexually active participants are facing unintended pregnancies due to a lack of sexual and reproductive awareness. Hence, comprehensive sex education is necessary to achieve social and regulatory changes centered on emergency contraceptives.

Does the timing of neuraxial analgesia initiation in elective induction of multiparous women prolong the duration of delivery?

AIM: To investigate whether the early initiation of neuraxial analgesia prolongs the duration of electively induced labor in Japanese multiparous women. METHODS: This retrospective study included multiparous term women who underwent elective induction of labor using combined spinal-epidural analgesia at the Showa University Hospital between October 2018 and March 2021. The participants were divided into two groups: early and late. If neuraxial analgesia was initiated when the cervical dilation was ≤3 cm, the patient was included in the early group. The remaining patients were included in the late group. The obstetric and neonatal outcomes were compared between the two groups. The primary outcome was the duration of delivery. The secondary outcomes were the rates of instrumental and cesarean deliveries. RESULTS: Two hundred and ninety-seven women (early group = 139, late group = 158) were included in the analysis. The duration of the first stage of labor did not differ significantly between the early and late groups (median: 232 vs. 260 min, p = 0.35). Similarly, there was no significant difference in the duration of the second stage (37 vs. 40 min, p = 0.20). Moreover, the rates of instrumental and cesarean deliveries did not differ significantly between the groups, and the neonatal outcomes were comparable. CONCLUSION: Early initiation of neuraxial analgesia in the elective induction of parous Japanese women did not prolong the duration of delivery. Our results suggest that neuraxial analgesia may be initiated whenever a parturient desires it.

The role of first-trimester ultrasound screening for women with positive noninvasive prenatal testing results.

AIM: This study aimed to assess the utility of ultrasound screening for pregnancies with positive noninvasive prenatal testing results for trisomy 21, trisomy 18, and trisomy 13. METHODS: We performed a retrospective analysis of positive noninvasive prenatal testing results and first-trimester ultrasound screening at our department between 2013 and 2019. Invasive genetic testing was performed if the patient had positive noninvasive prenatal testing results. Fetal ultrasound and cytogenetic data were collected. Noninvasive prenatal testing was performed in the women for advanced maternal age, nuchal translucency thickness, or history of abnormality in the previous child or relative. RESULTS: Forty-one pregnant women had positive noninvasive prenatal testing results for trisomy 21, trisomy 18, and trisomy 13. Twenty-three women had positive results for trisomy 21, 13 had positive results for trisomy 18, and 5 had positive results for trisomy 13 at 11 to 14 weeks of gestation. The positive predictive value of noninvasive prenatal testing was 100% for trisomy 21, 84.6% for trisomy 18, and 100% for trisomy 13. The positive predictive value of positive noninvasive prenatal testing results and fetal morphological abnormalities was 100% for trisomy 21, trisomy 18, and trisomy 13. CONCLUSION: Combining an ultrasound examination with noninvasive prenatal testing resulted in a higher positive predictive value for trisomy 18. Normal ultrasound examination results can help alleviate stress caused by false-positive noninvasive prenatal testing results. In contrast, the positive predictive value and negative predictive value for trisomy 21 were not altered by adding an ultrasound examination to noninvasive prenatal testing.

Long-term outcome of cases of fetal pleural effusion: A study at a single perinatal center in Japan.

PURPOSE: To analyze the long-term prognosis of primary and secondary fetal pleural effusion (FPE). METHODS: We investigated all cases of FPE in a single University hospital (2005-2020). Cases were classified as primary (cases with only pleural effusion) and secondary (cases with other abnormalities such as chromosomal abnormalities or fetal cardiac failure). We retrospectively reviewed the medical records from the time of diagnosis, to assess medical procedures performed, chromosomal test results, and clinical outcomes. RESULTS: Among 18 027 deliveries, 17 FPEs were identified (primary FPE: 8, secondary FPE: 9). Most primary FPEs were diagnosed in the second trimester of pregnancy, while all secondary FPEs were diagnosed in the third trimester. Secondary FPE was often associated with chromosomal abnormalities, including trisomy 21. The prognosis of pleural effusion caused by trisomy 21 was relatively good, except for cases with TAM. Cases of secondary FPE without trisomy 21 were of cardiac origin, and the neonatal prognosis was poor. The short-term prognosis was better in the primary FPE group, but long-term follow-up identified conditions such as acute encephalitis with refractory, repetitive partial seizures, developmental delay and attention deficit hyperactivity disorder. CONCLUSION: Fetal pleural effusion without the presence of chromosomal abnormalities or morphologies has a good short-term prognosis, but the long-term prognosis is poor. Thus, long-term follow-up is necessary for all cases of fetal pleural effusion.

Impact of first trimester determination of abnormal cord insertion on twin-to-twin transfusion syndrome and other adverse outcomes in monochorionic diamniotic twins: A retrospective cohort study.

OBJECTIVE: To assess the influence of abnormal cord insertion (CI) detected by first trimester ultrasonography on the development of twin-to-twin transfusion syndrome (TTTS) in monochorionic diamniotic (MCDA) twins. METHOD: In this retrospective cohort study, consecutive patients with MCDA twins who underwent fetal ultrasound screening in the first trimester between January 2011 and January 2017 were enrolled. The CI sites were evaluated between 11 + 0 and 13 + 6 weeks' gestation. All twin pairs were assigned to the abnormal CI group (twin pair with velamentous cord insertion (VCI) and/or marginal cord insertion (MCI) in one or both twins) or the normal CI group (twin pair with both normal CI). The relationships of adverse outcomes in two groups were analyzed. RESULTS: A total of 109 MCDA twin pairs were examined; 15 cases were classified into the abnormal CI group and 94 cases into the normal CI group. The incidence of TTTS was significantly higher in the abnormal than in the normal CI group (26.7% vs 7.45%, P = .04). In patients who developed TTTS, all donors had VCI. CONCLUSION: Ultrasound evaluation of abnormal CI at 11 + 0 to 13 + 6 weeks' gestation in MCDA twins is valuable in the assessment of the risk for TTTS.

Differences in perinatal outcomes according to forming period of single umbilical cord in singleton pregnancy.

OBJECTIVES: The aim of this study was to establish the frequency and associations of single umbilical artery (SUA) diagnosed until the first vs second or third trimester. METHODS: A retrospective cohort study was conducted on singleton pregnancies at a tertiary perinatal center. All women underwent both the first and second trimester scans in which the number of arteries in the umbilical cord was routinely documented. SUA was classified as aplastic type when the diagnosis was made in the first trimester and as occlusion type when diagnosed in the second or third trimester. Adverse perinatal outcome was calculated as occurrence of fetal death, birthweight centile < 10th , or Apgar score at 5 minutes < 7. RESULTS: A total of 8675 women underwent ultrasound examinations during the study period. Of the 32 SUA cases, 17 (0.2%) were of the aplastic type and 15 (0.2%) of the occlusion type. Congenital anomalies were more in aplastic than in occlusive SUA (58.8% vs 20%, .043). The occlusive SUA had higher postnatal coiling index (0.3 vs 0.2, .034) and diagnosis of hypercoiled cord (46.7% vs 5.9%, .013) than the aplastic type. CONCLUSIONS: The different gestational age at diagnosis and coiling characteristics suggest two types of SUA, namely, aplastic and occlusion types, which are associated with differences in perinatal outcomes.

Causes of intrauterine fetal death are changing in recent years.

OBJECTIVE: To investigate, how causes of intrauterine fetal death (IUFD) have changed in recent years with the advancement of prenatal diagnosis at a single perinatal center in Japan. METHODS: Medical records were retrospectively reviewed for all cases of IUFDs that occurred between 2001 and 2014. The most commonly associated causes of fetal deaths were compared between 2001-2007 and 2008-2014. RESULTS: The number of IUFD after 20 weeks' gestation/all deliveries in our center was 38/6878 cases (0.53%) in 2001-2007 and 35/7326 (0.48%) in 2008-2014. The leading cause of IUFD in 2001-2007 was fetal abnormalities (43.2%), the prevalence of which was only 8.6% in 2008-2014 (P<0.01). Meanwhile, the prevalence of umbilical cord abnormalities was relatively increased from 30.0% in 2001-2007 to 54.5% in 2008-2014 (P=0.06). In 2001-2007, chromosomal abnormalities were frequently observed (56% of IUFDs due to fetal abnormalities). Hyper-coiled cord (HCC) and umbilical ring constrictions were the most frequent cause of IUFD in both periods. The relatively decreased prevalence of IUFD due to velamentous cord insertion and umbilical cord entanglement, HCC and umbilical cord constriction was increased. CONCLUSIONS: The prevalence of IUFD due to fetal abnormalities was reduced, but IUFD associated with umbilical cord abnormalities tended to increase relatively.

Comparison of perinatal outcomes between long-term and short-term use of tocolytic agent: a historical cohort study in a single perinatal hospital.

AIM: The aim of this study was to evaluate the effect of long-term use of tocolytic agents to prevent preterm delivery and improve perinatal outcome. METHODS: A historical cohort study was performed in a single perinatal center. The maternal characteristics, frequency of preterm labor and prescribed dose of tocolytic agents were compared before and after changing the management protocol for threatened premature delivery. RESULTS: A total of 1548 deliveries were carried out before changing the protocol for the use of tocolytic agents for threatened premature delivery and 1444 deliveries afterwards. There was no significant difference in the maternal characteristics before and after the revision except for maternal age. The total number of ritodrine hydrochloride ampules used was reduced from 4654 to 514, and the total vials of magnesium sulfate used were reduced from 1574 to 193, but perinatal outcomes, such as rate of preterm birth, neonatal weight, and rate of NICU hospitalization were not different between the groups. CONCLUSION: There was no significant change in the frequency of preterm delivery before and after changing of the protocol for threatened premature delivery. Because a decrease in the given dose of tocolytic agents did not affect the timing of delivery and neonatal outcomes, long-term tocolysis in patients with threatened premature delivery should be restricted to prevent maternal and fetal adverse side-effects.

Repeated Measurement of Crown-Rump Length at 9 and 11-13 Weeks' Gestation: Association with Adverse Pregnancy Outcome.

AIMS: To clarify whether ultrasonographic measurements of crown-rump length (CRL) at 11-13 weeks - based on the number of gestational days determined using the CRL at 9 weeks - can predict fetal prognosis. METHODS: A prospective cohort study was conducted to evaluate the association between fetal growth in the first trimester and fetal prognosis. Fetal growth in the first trimester was evaluated measuring CRLs at 11-13 weeks determined using the CRL at 9 weeks. The subjects were divided into short CRL (s-CRL) and normal CRL (n-CRL). The prognoses were compared between the two groups. RESULTS: A total of 126 patients in the s-CRL group and 1,130 patients in the n-CRL group were enrolled. Abortion occurred in 7.1% of s-CRL and 0.9% of n-CRL subjects (p < 0.001). Among the patients with chromosomal abnormalities, the incidence of trisomy 18 was significantly greater in s-CRL (4.8 vs. 0.1%, p < 0.001). Without abortion, placental weight, frequency of small for gestational age (SGA) and birth weight in s-CRL were significantly higher than those in the n-CRL group (12.8 vs. 3.6%, p < 0.001). CONCLUSIONS: Measuring CRL at 9 weeks is useful for determining gestational days prior to measuring CRL at 11-13 weeks. After reconfirming the gestational age at 9 weeks, measuring CRL at 11-13 weeks is useful for predicting the incidence of trisomy 18 as well as SGA later in pregnancy.

Factors affecting the accuracy of fetal cardiac ultrasound screening in the first trimester of pregnancy.

PURPOSE: Most studies on the performance of first-trimester cardiac screening have concentrated on comparing the detection rate between different protocols and not on the actual reason for false-negative results. Herein, we report the performance of first-trimester congenital heart disease (CHD) screening and factors that may affect the detection rate of CHDs. METHODS: This retrospective observational study included patients who underwent first-trimester screening and subsequently gave birth at our facility. We analyzed the performance of first-trimester screening for CHD and major CHD (CHD requiring cardiac surgery or interventional catheterization within 12 months of birth). RESULTS: Of the 6614 fetuses included, 53 had CHD and 35 had major CHD. For the prenatal diagnosis of CHD, the detection rate, specificity, positive predictive value, negative predictive value, and first-trimester detection rate for CHD were 64.1%, 99.9%, 94.4%, 99.7%, and 82.9%, respectively; the respective values for major CHD were 85.7%, 99.96%, 93.75%, 99.92%, and 85.7%. The detection rate was not significantly different when classified by crown-rump length or number of fetuses. A weak correlation was observed between low detection rate of major CHD and lower maternal body mass index (BMI) (correlation ratio: 0.17). The detection rate was significantly higher when the fetus was scanned with its spine at the 5-7 o'clock position (posterior spine) than at other positions (odds ratio: 3.82, 95% confidence interval: 1.16-12.5, p = 0.02). CONCLUSION: Posterior spine contributes to an improved diagnostic rate in first-trimester CHD screening. In addition, sonographers must recognize that low maternal BMI is a risk factor of false-negative results.

Carbon nanotubes functionalized with fibroblast growth factor accelerate proliferation of bone marrow-derived stromal cells and bone formation.

Multi-walled carbon nanotubes (MWCNTs) were functionalized with fibroblast growth factor (FGF) and the advantages of their use as scaffolds for bone augmentation were evaluated in vitro and in vivo. The activity of FGF was assessed by measuring the effect on the proliferation of rat bone marrow stromal cells (RBMSCs). The presence of FGF enhanced the proliferation of RBMSCs and the FGF covalently conjugated to the nanotubes (FGF-CNT) showed the same effect as FGF alone. In addition, FGF-CNT coated sponges were implanted between the parietal bone and the periosteum of rats and the formation of new bone was investigated. At day 14 after implantation, a larger amount of newly formed bone was clearly observed in most pores of FGF-CNT coated sponges. These findings indicated that MWCNTs accelerated new bone formation in response to FGF, as well as the integration of particles into new bone during its formation. Scaffolds coated with FGF-CNT could be considered as promising novel substituting materials for bone regeneration in future tissue engineering applications.

Predictive ability of serum advanced glycation end products at 11 to 13 weeks of gestation for early-onset preeclampsia.

BACKGROUND: Placental hypoxia and resultant oxidative stress have been associated with the development of preeclampsia. Oxidative stress promotes the formation of advanced glycation end products. OBJECTIVE: This study aimed to assess whether serum levels of advanced glycation end products during the early stage of pregnancy are a predictive biomarker of early-onset and late-onset preeclampsia. STUDY DESIGN: This was a nested case-control study that included 6 women with early-onset preeclampsia, 21 women with late-onset preeclampsia, and 50 age- and body mass index-matched healthy female control subjects. All women enrolled in the study had a complete medical history, including mean arterial pressure and uterine artery pulsatility index measurements. Furthermore, the women underwent blood chemistry analysis, including circulating levels of advanced glycation end products, soluble fms-like tyrosine kinase-1, and placental growth factor. Clinical measurements and biochemistry were evaluated at 11 to 13 and 19 to 24 weeks of gestation. RESULTS: The median serum concentrations of advanced glycation end products at 11 to 13 weeks of gestation were significantly higher in patients with early-onset preeclampsia than in those with late-onset preeclampsia and control subjects (6.62 vs 4.10 vs 3.77; P<.05), but no significant difference was found in advanced glycation end products at 19 to 24 weeks of gestation among the 3 groups. The advanced glycation end product-to-placental growth factor ratio in the first trimester of pregnancy was significantly higher in patients with early-onset preeclampsia than in those with late-onset preeclampsia or control subjects (0.78 vs 0.10 vs 0.10; P<.05). The area under the receiver operating characteristic curve values for patients with early-onset preeclampsia were 0.782 (95% confidence interval, 0.522-0.922), 0.855 (95% confidence interval, 0.433-0.978), and 0.925 (95% confidence interval, 0.724-0.983) for the advanced glycation end product and placental growth factor levels and advanced glycation end product-to-placental growth factor ratios, respectively. This population achieved a 100% detection rate for predicting early-onset preeclampsia at a screen-positive rate of 10% by combining the advanced glycation end product-to-placental growth factor ratio and the mean arterial pressure. CONCLUSION: The study results suggested that an elevated advanced glycation end product-to-placental growth factor ratio and mean arterial pressure at 11 to 13 weeks of gestation could be a potential biomarker for predicting the future development of early-onset preeclampsia.

Perinatal outcomes of cases with umbilical hypocoiled cord: a study at a single perinatal center.

OBJECTIVES: To evaluate the perinatal outcomes of hypocoiled cord. METHODS: This retrospective study was carried out in the Department of Obstetrics and Gynecology at Showa University Hospital between 2011 and 2017. Umbilical cord index (UCI) was calculated by dividing the total number of coils by the total length of umbilical cord. All umbilical cords were measured and calculated coiling index by obstetrician after delivery. Perinatal outcomes like non-reassuring fetal status (NRFS), emergency cesarean sections, and other perinatal complications were compared. RESULTS: From January 2011 to December 2017, a total of 4047 fetuses were born at our hospital after 28 weeks' gestation. After excluding 100 fetuses of hypercoiled cord, a total of 3947 fetuses were included in this study, of which 71 fetuses were hypocoiled cord and 3876 fetuses were normal coiled cord. There were no association between maternal background and both UCI group. NRFS during labor was significantly associated with hypocoiled cord compared with normal cord (p = .02). Additionally, the rates of emergency cesarean section were raised in cases of hypocoiled cord (p = .02). CONCLUSION: In this study, it was found that hypocoiled cord is related to NRFS and emergency cesarean section. In addition, hypocoiled cord was not associated with any maternal factors. However, in previous studies, no opinion has been reported on the timing of diagnosis of hypocoiled cord during pregnancy. It is difficult to evaluate hypocoiled cord correctly in third trimester. It is a task to find the hypocoiled cord correctly before birth.

Ultrasonographic study of umbilical cord twist direction during second trimester.

OBJECTIVE: To explore/study/evaluate the relationships among umbilical twist direction, the degree of umbilical twist and differences of umbilical arterial diameters (UAD). METHODS: All obstetric patients presenting for prenatal care of singleton fetuses between 18 and 25 weeks gestation to a single provider (MN) from 2015 to 2018 had detailed umbilical cord Doppler measurements. Data including the cord twist direction, degree of twist and number of twists per cord segment length, and the diameters of each UA (UAD) and the umbilical vein (UVD) were extracted from the records. UAs were described as right or left depending on their position at the fetal cord insertion. Three groups were identified: Group A: right UAD > left UAD and Group B: left UAD > right UAD Group C: equal UAD. The coiling index was calculated as the inverse of the length of cord required for one complete 360 degrees wrap of the UA around the cord. According to the difference of UADs, the variables of right and left UADs, the coiling index, and frequencies of umbilical twist direction were analyzed using non-parametric methods. RESULTS: 485 singleton fetuses and umbilical cords were examined. The value of the antenatal coiling index in cases with left UAD greater than right was 0.43 ± 0.16, which was significantly higher than 0.38 ± 0.16 with right UAD greater than left (p = .001). There were significant differences between the two groups in the values of right and left UAD, value of right minus left UAD, absolute value between right and left UAD, antenatal coiling index, antenatal coiling index due to umbilical twist direction and frequencies of cord twist direction. CONCLUSION: The direction of umbilical twist may be in part dependent on differences in diameters of the umbilical arteries, in addition to other fetal characteristics such as fetal movement, or handedness of fetus or mother, fetal hemodynamic forces and structure of muscles of umbilical vessels.

Study for risks of amniocentesis in anterior placenta compared to placenta of other locations.

OBJECTIVE: This study aimed to compare the risks of amniocentesis between anteriorly located placentas and placentas in other locations and assess the factors that cause procedure-related complications. MATERIALS AND METHODS: We prospectively studied women with singleton pregnancies who underwent amniocentesis between 2014 and 2020. The amniocentesis puncture sites were determined using ultrasonography. Women were classified into two groups according to their placental location. Medical records were retrospectively reviewed and characteristics and complications were compared between the groups of patients with different placental locations. RESULTS: During the study period, 629 women underwent amniocentesis. Three cases (0.5%) of premature rupture of membranes and one case (0.3%) of fetal loss within four weeks of amniocentesis were found. Puncture failure was observed in 14 cases (2.2%). Puncture failure included procedures with failure to obtain an adequate sample and procedures requiring more than three needle insertions. There was no significant difference in the frequency of puncture failure between the two groups. Logistic regression analysis revealed that uterine myoma (odds ratio [OR] 11.92; 95% CI, 3.04-45.17) and tenting membrane (OR 33.57; 95% CI, 6.45-178.41) were associated with puncture failure. CONCLUSION: Anteriorly located placenta is not a risk factor for amniocentesis-related adverse outcomes. Instead, puncture failure frequently occurs in case of uterine myoma and tenting membrane. If puncture failure occurs, or if the puncture is difficult to perform, then the procedure should be considered technically difficult and postponed until it can be more easily performed.

Amnioinfusion and Bed Rest May Effectively Improve the Insufficient Circulation of the Umbilical Cord in Pregnant Women With Hyper-Coiled Cord and Oligohydramnios.

We experienced two cases with hyper-coiled cord in which fetal-umbilical-placental circulation was improved after amnioinfusion or bed rest. Therefore, amnioinfusion and bed rest to reduce the compression of the vulnerable umbilical cord in cases of hyper-coiled cord might improve the pathologic fetal-umbilical-placental circulation.

The routine use of prophylactic Bakri balloon tamponade contributes to blood loss control in major placenta previa.

OBJECTIVE: To verify the blood loss control effect of routine prophylactic Bakri balloon tamponade on major and minor placenta previa (PP). METHODS: We conducted a retrospective cohort study of all singleton pregnancies that involved cesarean section (CS) for PP at our hospital. All participants were divided into Bakri balloon (underwent routine prophylactic use just after placenta removal) and non-balloon groups, and into major and minor PP groups. Clinical outcomes in major and minor PP were compared between balloon and non-balloon groups. RESULTS: The balloon and non-balloon groups contained 74 and 89 patients, respectively. There were 41 and 33 (balloon group) and 48 and 41 (non-balloon group) major and minor PP cases, respectively. Intraoperative and perioperative blood losses of major PP were significantly lower in the balloon group than the non-balloon group (1045 ml versus 1553 ml, P = 0.016; and 1189 ml versus 1810 ml, P = 0.006, respectively). The frequency of massive postpartum hemorrhage (>500 ml) with major PP was lower in the balloon group than in the non-balloon group (2.4% versus 16.7%, P = 0.027), but with no significant difference with minor PP. CONCLUSION: Routine prophylactic use of Bakri balloon tamponade during and after CS is effective in controlling blood loss in major PP.