Guidelines for obstetrical practice in Japan: Japan Society of Obstetrics and Gynecology (JSOG) and Japan Association of Obstetricians and Gynecologists (JAOG) 2014 edition.

The 'Clinical Guidelines for Obstetrical Practice, 2011 edition' were revised and published as a 2014 edition (in Japanese) in April 2014 by the Japan Society of Obstetrics and Gynecology and the Japan Association of Obstetricians and Gynecologists. The aims of this publication include the determination of current standard care practices for pregnant women in Japan, the widespread use of standard care practices, the enhancement of safety in obstetrical practice, the reduction of burdens associated with medico-legal and medico-economical problems, and a better understanding between pregnant women and maternity-service providers. The number of Clinical Questions and Answers items increased from 87 in the 2011 edition to 104 in the 2014 edition. The Japanese 2014 version included a Discussion, a List of References, and some Tables and Figures following the Answers to the 104 Clinical Questions; these additional sections covered common problems and questions encountered in obstetrical practice, helping Japanese readers to achieve a comprehensive understanding. Each answer with a recommendation level of A, B or C was prepared based principally on 'evidence' or a consensus among Japanese obstetricians in situations where 'evidence' was weak or lacking. Answers with a recommendation level of A or B represent current standard care practices in Japan. All 104 Clinical Questions and Answers items, with the omission of the Discussion, List of References, and Tables and Figures, are presented herein to promote a better understanding among English readers of the current standard care practices for pregnant women in Japan.

Placental mesenchymal dysplasia: chronological observation of placental images during gestation and review of the literature.

Placental mesenchymal dysplasia (PMD) is characterized by multiple hypoechoic vesicles which are similar to molar changes in the placenta; however, the process of such morphological changes of PMD during pregnancy has not been fully understood. We performed a review of all PMD cases published in English and identified 49 articles including 110 cases. With regard to the gestational age at which the multicystic pattern was seen, approximately 70% of cases were diagnosed at 13-20 weeks of gestation. Another characteristic feature of PMD is varicose dilation of fetal chorionic vessels. As many as 90% of cases were diagnosed as placenta with dilated fetal chorionic vessels in the third trimester. We also report a case of PMD which was found at 10 weeks of gestation according to ultrasonic molar patterns. Serial observations of the placenta using ultrasound and magnetic resonance imaging revealed that multicystic lesions became smaller after 23 weeks. In contrast, dilated placental vessels on the fetal side became apparent at 38 weeks. The present review highlights that placental vesicular lesions of PMD may precede dilation of fetal chorionic vessels during pregnancy. It also indicates the potential of a gradual reduction in size of PMD's placental vesicular lesions by serial study of placental images.

[A case of hypertrophic pachymeningitis treated successfully with antibiotics: the remarkable effect of minocycline hydrochloride in reducing the serum C-reactive protein value].

A 70-year-old man had hyperemia of the right cornea associated with a high serum C-reactive protein value. MRI of the head revealed hypertrophic pachymeningitis associated with a mass in the right cavernous sinus. The hypertrophic dura showed iso-intensity on T1 -weighted image, and very low intensity on T2-weighted image, and was markedly enhanced with gadolinium. In contrast, the mass in the right cavernous sinus was only slightly enhanced. Intravenous administration of some antibiotics (piperacillin sodium, ampicillin sodium/ sulbactam sodium, ampicillin sodium, cefozopran hydrochloride) was begun, but minocycline hydrochloride, which was subsequently administrated, proved remarkably effective in relieving symptoms and decreasing the serum C-reactive protein value, although other antibiotics showed little or no effect. MRI performed 9 days after initiation of minocycline therapy showed remarkable relief from hypertrophy of the dura compared with a scan obtained before admission. Although hypertrophic pachymeningitis in this case may have been associated with infection by bacteria that were especially sensitive to minocycline, the drug is believed to have anti-inflammatory and immunosuppressive effects similar to those of steroids used to relieve the symptoms of rheumatoid arthritis or Takayasu arteritis. We suspect that hypertrophic pachymeningitis in this patient may have been idiopathic or associated with an autoimmune disease, and may therefore have been relieved by the anti-inflammatory and immunosuppressive effects of minocycline in a manner similar to the Seffect of steroids on similar types of hypertrophic pachymeningitis.

Severe gastrointestinal bleeding during pregnancy in a case of blue rubber bleb nevus syndrome.

Blue rubber bleb nevus syndrome (BRBNS) is a rare disorder characterized by distinctive cutaneous and gastrointestinal venous malformations that usually cause massive or occult gastrointestinal hemorrhage and iron deficiency anemia secondary to the bleeding episodes. Only two reports of BRBNS in pregnant women can be found, according to the MEDLINE search. Both cases did not describe severe complications during pregnancy. This is the first case report of BRBNS with severe intestinal hemorrhage in a pregnant woman. The woman had been symptom-free for 5 years before the pregnancy and remained symptom-free for 2 years after delivery. This suggests that pregnancy induced the hemangiomas of the gastrointestinal tract to bleed. Celiotomy was needed to deal with massive gastrointestinal bleeding. We propose that women with BRBNS should be checked for systemic hemangiomas before pregnancy. However, it is difficult to check the small intestine thoroughly for hemangioma. Therefore, adequate attention needs to be paid to possible gastrointestinal bleeding when caring for patients with this condition. Our experience suggests that when dealing with pregnant women with BRBNS, it is essential to bear in mind the possibility that pregnancy may trigger the symptoms of hemangioma to become manifest, possibly causing life-threatening massive bleeding from the digestive tract.

[Atlanto-axial subluxation posssibly due to eosinophilic granuloma of the axis: a case report].

A 29-year-old male presented with symptoms of acute severe neck pain with no other neurological symptoms. He had noticed lymph node swelling with pain in his neck about 2 months before admission and had been treated by the transoral administration of antibiotics for about 10 days. His neck was protected with a neck collar and an evaluation of any possible neck lesion was performed. Plain X-ray film and CT scans of the cervical spine showed an anterior subluxation of the atlas and an anterior declination and erosion of the dens. The MRI findings showed long T1 and T2 values in many parts of the bone marrow of the body of the axis and the dens, and both the bone marrow and thickend soft tissue between the pharynx and the axis were slightly enhanced. Inflammatory disease, tuberculosis, rheumatoid arthritis, malignant lymphoma, and leukemia were all ruled out based on the laboratory data, Ga schintigrams and other examinations. Almost no changes in the lesion were observed on MRI at about 6 weeks after admission. As a result, we presumed that this lesion was not likely to be malignant, but might be some kind of granuloma, especially an eosinophilic granuloma. A laminectomy of the atlas and a resection of the posterior margin of the foramen magnum and upper portion of the lamina of the axis was performed to achieve decompression of the craniovertebral junction, and posterior fusion was performed with a rod betweeen the occipital bone and the C4 lamina. The rod was fixed with screws and wires to the occipital bone and with lamina hooks to the axis and C4 laminas. At 14 months postoperatively, the patient is doing well and the axis and the dens have been reconstructed without any need to resect the lesion, or perform either chemothrapy or radiotherapy. Our clinical findings of this case correlate with the opinion that an immobilization of the lesion is a sufficient treatment for many cases of eosinophilic granuloma. Although a biopsy or histological examination of the lesion was not performed, the clinical course of this case strongly suggests that this lesion was indeed an eosinophilic granuloma.

Gamma knife radiosurgery for GH-secreting microadenoma with empty sella.

We report a case of a growth hormone secreting microadenoma associated with empty sella treated by gamma knife radiosurgery and we evaluate the effectiveness of radiosurgery for this lesion. A 58-year-old female complained of an acromegalic appearance for 10 years. Magnetic resonance imaging revealed an enlarged sella floor with a compressed, but slightly enlarged pituitary gland. Serum GH values were 8.52 ng/ml. From these results, we diagnosed the presence of a GH-secreting pituitary microadenoma with empty sella. Stereotactic gamma knife radiosurgery was performed to treat the adenoma. The treatment dose was 30 Gy for the tumour margin (50% isodose). The patient was monitored for 5 years without any reported problem. Serum GH values were gradually decreased to 4.1 and 3.5 ng/ml at 1.6 and 3 years. Serum GH values at 5 years after radiosurgery were 1.8 ng/ml within 2 h after glucose load and serum IGF-1 was normalized. We conclude that gamma knife radiosurgery can be an useful alternative treatment modality for GH-secreting adenoma with empty sella in the selected patients when surgery is contraindicated as the primary treatment.

[A case of malignant lymphoma of the cranial vault].

We report a rare case of malignant lymphopma of the cranial vault. A 71-year-old woman developed an asymptomatic subcutaneous mass on the scalp. The skin over the lesion was normal and the mass was firm and attached to the skull. Neurological examination revealed no abnormalities. Plain CT scans showed a high-density lesion that was widely attached to the skull and the surface of the skull was slightly irregular. About 25 days later, enhanced CT showed that the mass was well enhanced and extended into the cranium, and decalcification of the skull adjacent to the lesion had progressed. MRI showed long T1 and T2 values of the mass and the adjacent bone marrow. Bone scintigraphy and gallium scintigraphy showed prominent accumulation of radioisotopes in the scalp lesion. The mass, dura, and infiltrated bone were resected, and the surface of the brain was found to be intact. Histological examination revealed that the tumor was non-Hodgkin's lymphoma (diffuse, medium-sized, B cell lymphoma). The fact that the tumor first developed extracranially and then extended into the cranium without severe bone destruction and the fact that the dura completely protected the brain surface may indicate that the malignant lymphoma originated from the skull and showed infiltrative growth, while the dura provided a strong barrier to its intracranial extension. Thus, malignant lymphoma originating from the skull may tend to extend outside the cranium first and within the cranium subsequently, as in our case, and this may be the reason why the complaint at presentation of more than half of the reported patients is a scalp mass rather than any neurological sign.