Evaluation of brain development and damage using magnetic resonance imaging of congenital diaphragmatic hernia survivors: An analysis using the global brain abnormality score.

BACKGROUND: The short-term prognosis of central nervous system in congenital diaphragmatic hernia (CDH) survivors has been determined by magnetic resonance imaging (MRI), but its relationship with acute management is unclear. We aimed to investigate the association between the intubation period and the Global Brain Abnormality Score (GBAS) in CDH survivors using brain MRI. METHODS: Fifty-seven patients with CDH who were hospitalized at a single NICU between January 2004 and December 2019 were retrospectively reviewed. After excluding 5 patients who died shortly after birth and two who could not be weaned from the ventilator, the acute management of the 50 remaining patients was investigated. We also investigated the relationship between the GBAS and intubation period in 25 patients who underwent brain MRI at discharge. RESULTS: The long-intubation group (intubation ≥12 days) had lower Apgar scores and fetal lung-thoracic ratios, and longer time to radical surgery, and parenteral nutrition and tube feeding periods. Nitric oxide inhalation, liver prolapse, patch closure, and extracorporeal membrane oxygenation were independent risk factors for long-intubation. Eighty-four percent of CDH survivors had some imaging abnormalities, including developmental and signaling abnormalities. In the long-intubation group, the body of the corpus callosum was thin and the cerebral hemispheric space was widened, and GBAS deterioration was significantly related to the intubation period. CONCLUSION: Brain MRI abnormalities were found in 84% of CDH survivors. Prolonged intubation is associated with worsening of the GBAS. Thus, the duration of intubation may be a surrogate outcome for the neurological prognosis of CDH survivors.

Placenta Accreta Spectrum with Ureteral Invasion due to Progression of Cesarean Scar Pregnancy.

Expectant management is not recommended for cesarean scar pregnancies because they are often associated with placenta accreta, cesarean hysterectomy, and massive life-threatening hemorrhages during delivery. Herein, we report a case of placenta accreta spectrum with ureteral invasion due to the progression of a cesarean scar pregnancy. Case. A 41-year-old woman, with a history of three cesarean sections and two miscarriages, was referred to our hospital at 25 weeks of gestation with a diagnosis of placenta accreta spectrum and bladder invasion. Although the gestational sac was located anterior to the lower uterine segment, a cesarean-scar pregnancy was not diagnosed. A cesarean hysterectomy was performed at 31 weeks of gestation with the placement of an aortic balloon. The placenta was found to adhere to the ureter with more than the expected parenchymal tissue displacement (FIGO Classification 3b). The ureter was not obstructed and was preserved by leaving the placenta slightly on the ureteral side. Postoperatively, a ureteral stent was placed because of the ureteral stricture in the area where the placenta had adhered. Two months after surgery, the ureteral stent was removed after observing an improvement in stenosis. An adherent placenta due to continued cesarean scar pregnancy should be managed by assuming placental invasion beyond the parenchyma into the ureter.

Endometrial and vaginal microbiomes influence assisted reproductive technology outcomes.

OBJECTIVE: The role of Lactobacillus-dominant microbiota in the endometrium in reproductive function is unclear. We therefore aimed to explore the impact of the balance of Lactobacillus and pathological bacteria in the endometrial and vaginal microbiomes on the pregnancy outcomes of women treated with assisted reproductive technology (ART). METHODS: This study included 35 women with infertility submitted to good-quality embryo transfers. The cutoff values for abundance of Lactobacillus species (spp.) and pathological bacteria in the endometrium and vagina were calculated. Women with Lactobacillus spp. and pathological bacteria abundance above the cutoff values were categorized in the high-abundance group, whereas those with abundance below cutoff values were categorized in the low abundance group. We divided the patients into four groups based on the combination of high/low abundance of Lactobacillus spp. and pathological bacteria. RESULTS: The 35 cases of good-quality embryo transfer resulted in 21 pregnancies. Pregnant women were present in significantly higher proportions in the high Lactobacillus spp. abundance and low pathological bacteria abundance group, whereas the opposite combination (i.e., low Lactobacillus spp. abundance and high pathological bacteria abundance) saw a significantly higher proportion of nonpregnant women (p=0.022). CONCLUSIONS: The balance between Lactobacillus and pathological bacterial abundance in the endometrial and vaginal microbiomes is associated with pregnancy from ART.

Microbiome analysis in women with endometriosis: Does a microbiome exist in peritoneal fluid and ovarian cystic fluid?

Purpose: To investigate the relationship between the microbiome of the female genital tract and endometriosis. Methods: This prospective cohort study included 36 women who underwent laparoscopic surgery for ovarian tumor from July 2019 to April 2020. Of them, 18 had endometriosis, and 18 did not have endometriosis. Vaginal secretions, endometrial fluid, peritoneal fluid, and ovarian cystic fluid were collected during surgery. Next-generation sequencing of bacterial 16S rRNA was performed to characterize the microbiome. Results: Specific microbiomes were not detected in either peritoneal fluid or ovarian cystic fluid regardless of the presence or absence of endometriosis and the type of cyst. When the cutoff value of infectious bacterial abundance in the vagina was set as 64.3%, there were many cases more than a cutoff value in the endometriosis group significantly (p = 0.01). When the cutoff value of infectious bacterial abundance in the endometrium was set as 18.6%, there were many cases more than a cutoff level in the endometriosis cases significantly (p = 0.02). Conclusion: Peritoneal fluid and ovarian cystic fluid are almost sterile, although dysbiosis may occur in the vaginal and endometrial microbiome in women with endometriosis.

Hyperbaric Oxygen Therapy for Suburethral Vaginal Mucosal Necrosis after Interstitial Irradiation for Recurrent Cervical Cancer.

Patients with gynecological malignancies can develop radiation injuries, such as cystitis, proctitis, and soft tissue necrosis which have approved indications for hyperbaric oxygen therapy (HBOT). A 76-year-old Japanese woman with vaginal recurrence of cervical cancer was treated with the high-dose rate interstitial brachytherapy. Twenty-one months after the irradiation, she developed radiation necrosis on the external urethral opening. Two cycles of HBOT were performed. HBOT consisted of delivering 100% oxygen for 60 minutes at 2.4 atmospheres absolute. Pressure exposure was performed once daily, 5 days a week for 6 weeks. Eventually, the necrotic mucosa was completely replaced by the normal mucosa. No adverse effects were observed. We successfully treated a case of late adverse events of radiation therapy with HBOT. It was noninvasive and appears to be a useful treatment option which should be considered standard treatment practice.

Two cases of polycystic ovary syndrome with onset of severe ovarian hyperstimulation syndrome following controlled ovarian stimulation with aromatase inhibitors for fertility preservation before breast cancer treatment.

OBJECTIVE: The risks of ovarian hyperstimulation syndrome (OHSS) involve high estrogen (E2) levels. We report two breast cancer patients with polycystic ovarian syndrome who underwent fertility preservation and had severe OHSS; their E2 levels were lowered using aromatase inhibitors (AI). CASE REPORTS: A 36-year-old woman underwent controlled ovarian stimulation (COS) with AI and cryopreserved 10 blastocysts. She was hospitalized with OHSS (E2 = 139.1 pg/mL). She improved with infusion alone. A 31-year-old woman underwent COS with AI and cryopreserved 8 blastocysts. She was hospitalized for OHSS (E2: 429 pg/mL). Her vascular endothelial growth factor (VEGF) levels were high (62 pg/mL) at 8 days after the procedure. She needed hospitalization for 9 days. The planned adjuvant therapy was delayed for a week in both cases. CONCLUSION: Elevated VEGF levels should be considered as a risk factor of OHSS even if E2 levels are low with AI treatment.

A high-risk gestational trophoblastic neoplasia derived from a complete hydatidiform mole with coexisting fetus identified by short tandem repeats analysis: A case report.

A complete hydatidiform mole coexisting with a fetus (CHMCF) is a rare form of twin pregnancy. High-risk gestational trophoblastic neoplasia (GTN) can occur after a CHMCF pregnancy, although the frequency is low. In cases of GTN, the clinical diagnosis and that based on the International Federation of Gynecology and Obstetrics (FIGO) scoring system can differ. This case report concerns a patient with a choriocarcinoma that was initially diagnosed and treated as a low-risk stage III GTN following a live birth from a CHMCF pregnancy. We used short tandem repeat (STR) analysis to identify the causative pregnancy as the patient's earlier complete hydatidiform mole. Clinicians should anticipate a high-risk GTN when treating persistent trophoblastic disease (PTD) in patients with a non-typical course.

Transabdominal cerclage in early pregnancy for cervical shortening after radical trachelectomy: A case report.

Radical trachelectomy (RT) is a method of fertility preservation for patients with early invasive uterine cervical cancer stage IA2 or IB1 with a tumor diameter of ≤2 cm. However, women who have undergone RT have high risks of abortion and premature birth. To prevent premature birth, cervical cerclage is performed in patients with an ultra-short cervix, but the portio vaginalis is not visible in these patients, and transvaginal uterine cervical cerclage is almost impossible. In such cases, transabdominal cerclage (TAC) is considered. The patient reported here was a 39-year-old Japanese woman, gravida 2, para 0. At 37 years, she was diagnosed with cervical cancer, stage IB1 (according to the International Federation of Gynecology and Obstetrics [FIGO] classification), so abdominal modified RT was performed. One year after the operation, she became pregnant through in vitro fertilization and embryo transfer. The cervical length was 17 mm at 13 weeks of gestation but was shortened to 5 mm at 16 weeks of gestation, so TAC was performed. An emergency cesarean section was performed because of increased genital bleeding at 34 weeks of gestation and a live baby was delivered.

Threatened uterine rupture following laparoscopic surgery in interstitial tubal pregnancy.

Contraception is recommended for a certain period following a hysterotomy; however, no consensus exists on the required duration of contraception. A 21-year-old female was brought to the emergency room in a state of shock due to intraperitoneal bleeding. An emergency laparoscopic cornuostomy indicated for ruptured interstitial pregnancy was performed. Despite contraception, the patient got pregnant 1.5 months after surgery. At 16 weeks of gestation, threatened uterine rupture was suspected, as magnetic resonance imaging (MRI) revealed hematogenous amniotic fluid and a subchorionic hematoma near the interstitial portion of the fallopian tube. An MRI at 21 weeks showed hematoma shrinkage and disappearance of the hematogenous amniotic fluid. At 37 weeks, an elective cesarean section was performed, which resulted in a live birth. Pregnancy shortly after surgery is a risk factor for uterine rupture. In such cases, MRI could be useful in the evaluation of threatened uterine ruptures.

Long-term Outcomes of Cervical Adenocarcinoma Treated With Concurrent Chemoradiotherapy Using Paclitaxel and Cisplatin.

BACKGROUND/AIM: We retrospectively analyzed the locally advanced adenocarcinoma (AC)/adenosquamous carcinoma (ASC) of the uterine cervix treated with concurrent chemoradiotherapy using cisplatin plus paclitaxel (TP-CCRT). PATIENTS AND METHODS: Thirty patients with stage IB-IVA AC/ASC were treated with whole pelvis external beam radiotherapy. A high-dose-rate intracavitary brachytherapy was delivered once per week at a fractional dose of 6 Gy. For TP-CCRT, the patients received cisplatin and paclitaxel. RESULTS: A complete response was achieved in 17 patients (77.3%) in the TP-CCRT group and 4 patients (50.0%) in the P-CCRT group. The 5-year OS rate in the TP-CCRT and P-CCRT groups was 74.2% and 25.0% (p=0.0094), the central DFS rate was 58.0% and 12.5% (p=0.0267), and the distant DFS rate was 63.6% and 12.5% (p=0.0042), respectively. CONCLUSION: TP-CCRT achieves a considerably better disease control for AC of the cervix, leading to a better OS.

Hysterectomy for Recurrent/Residual Cervical Cancer Following Definitive Radiotherapy.

BACKGROUND/AIM: Radical hysterectomy has been used for local recurrent or persistent (LR) cervical cancer after radiotherapy (RT), but the rate of serious complications is high and tolerance is low. This study determined the efficacy, safety, and prognostic factors of adjuvant simple hysterectomy in LR cervical cancer post-RT. PATIENTS AND METHODS: A total of 21 patients who underwent hysterectomy for LR cervical cancer post-RT in our Department between May 2007 and September 2018 were included in the study. Primary, definitive RT was performed. Histological response by definitive RT in the extirpated uterus was classified on the basis of histological response criteria: effect (Ef) 0-3. RESULTS: The 5-year overall survival (OS) and disease-free survival (DFS) rates were 51.9% and 50.1%, respectively. Ef 1 was significantly associated with poorer prognosis compared to Ef 2 or Ef 3. CONCLUSION: Adjuvant hysterectomy could be a treatment of choice for LR cervical cancer post-RT.

A Phase II Study of Neoadjuvant Chemotherapy Followed by Extended Field Concurrent Chemoradiotherapy for Para-aortic Lymph Node Positive Cervical Cancer.

BACKGROUND/AIM: We conducted a phase II study of neoadjuvant chemotherapy followed by extended field concurrent chemoradiotherapy in patients with cervical cancer with para-aortic node metastasis. PATIENTS AND METHODS: Thirty-seven women with stage IB1-IVA cervical cancer were enrolled. RESULTS: The median age was 52 years. Thirty-four patients other than 3 progressive disease, proceeded to extended field concurrent chemoradiotherapy. The 3-year overall survival and progression-free survival rates were 70.1% and 48.5%, respectively. The 3-year overall survival according to stages was significantly worse in stage IIIB. Twelve of the 17 patients with stage IIIB died of the disease. CONCLUSION: Neoadjuvant chemotherapy followed by extended field concurrent chemoradiotherapy may improve the prognosis of patients with stages IB and II cervical cancer with positive para-aortic node. However, new strategies should be investigated to improve a poor prognosis in stage IIIB disease with positive para-aortic node.

Silicone Plate for the Prevention of Postoperative Adhesions in Patients with Asherman Syndrome.

PURPOSE: Re-adhesion rates following hysteroscopic adhesiolysis have remained high. Accordingly, we present a case involving temporary placement of an intrauterine silicone plate to prevent re-adhesions following hysteroscopic adhesiolysis in a 36-year-old woman with Asherman syndrome. METHODS: After hysteroscopic adhesiolysis, a silicone plate molded to the uterine cavity's shape was inserted into the uterine cavity and left in place for 1 month. RESULTS: The patient had a history of endometrial curettage for endometrial polyps. After the procedure, she developed amenorrhea and experienced infertility for 5 years despite four cycles of in vitro fertilization and embryo transfer. Following admission to our hospital, hysteroscopic examination showed a wide area of intrauterine adhesions for which hysteroscopic adhesiolysis and silicone plate insertion were performed. The silicone plate was removed after 1 month. No intrauterine adhesions were observed during the subsequent hysteroscopic examination. After a thawed embryo transfer, the patient became pregnant and delivered a healthy baby. CONCLUSIONS: A silicon plate may be considered a useful tool for preventing re-adhesion following hysteroscopic adhesiolysis without serious complications.

A Case of Intrathoracic Gastric Duplication Cyst Detected on Prenatal Ultrasound Examination.

A 37-year-old (G4P3) woman was referred to our hospital at 32 weeks of gestation for the evaluation of a fetus with an intrathoracic cystic lesion. Ultrasonography and magnetic resonance imaging revealed that a fetal cystic lesion without a mucosal layer was located in the posterior mediastinum. These findings were consistent with a bronchogenic cyst. At 38 3/7 weeks of gestation, an elective cesarean section was performed because of her previous cesarean section. A female neonate without any external anomalies, weighing 2,442 g, with Apgar scores of 8 and 9, and requiring no resuscitation was born. Four weeks after delivery, the neonate was admitted because of respiratory distress due to mass effect. At right lateral thoracotomy, a 105 × 65 mm of solitary smooth-walled cyst containing serosanguineous fluid was found in the posterior mediastinum, which was excised completely. Histologic examination revealed the diagnosis of the mediastinal gastric duplication cyst. The neonate made an uneventful recovery. Accurate diagnosis is not necessary, but detection and continuous observation are logical. Although gastric duplication, particularly intrathoracic, is a rare pathology, it should be considered in the differential diagnosis of any intrathoracic cyst.

Fetal Congenital Peripheral Bronchial Atresia Diagnosed by Magnetic Resonance Imaging: Two Case Reports.

Two types of congenital bronchial atresia (proximal and peripheral) have been classified. We report two cases of peripheral bronchial atresia diagnosed by prenatal ultrasonography (US) and magnetic resonance imaging (MRI). Evaluating an enlarged lung mass that is homogeneously hyperechoic on US and hyperintense on T2-weighted MRI can help in determining whether bronchial atresia is present. Proximal type is suggested when a dilated main bronchus is observed as a tubule structure of an involved lung hilum. In our cases, T2-weighted MRI revealed homogeneously hyperintense lung lesion with decreased signal intensity of adjacent lobe, flattening diaphragm, and mediastinal shift. Dilatation of the main bronchus was not observed and the opposite lung was normal in appearance. These findings were explained by secondary compression due to enlargement of the involved lung. The preservation of vascular structure and the retained normal shape, though enlarged, in the affected lobe were observed, which demonstrated undisrupted pulmonary architecture of the lobe. Thus, congenital cystic adenomatoid malformation was excluded because pulmonary architecture was relatively preserved. Finally, presumed diagnoses of the peripheral bronchial atresia were made and confirmed by postnatal chest computed tomography.

Multimodality imaging in secondary postpartum or postabortion hemorrhage: retained products of conception and related conditions.

Secondary postpartum hemorrhage (PPH) and postabortion hemorrhage are rare complications. Retained products of conception (RPOC) is among the most common causes of both secondary PPH and postabortion hemorrhage. Other less common causes of secondary PPH are uterine vascular abnormalities such as arteriovenous malformations and pseudoaneurysms. These are usually related to a history of a procedure such as dilation and curettage or cesarean delivery. Subinvolution of the placental site is an idiopathic cause of secondary PPH; this condition may be underrecognized and therefore could have a higher incidence than currently reported. Gestational trophoblastic disease is rare but commonly presents as secondary PPH and resembles RPOC in radiologic appearance. The first-line imaging modality for secondary PPH is ultrasound, but computed tomography and magnetic resonance imaging may be used if the ultrasound findings are indeterminate. Angiography is an important tool for the definitive diagnosis of uterine vascular abnormalities. Appropriate management requires radiologists to be familiar with the multimodality imaging features of secondary PPH or postabortion hemorrhage.

Subchorionic hematoma occurs more frequently in in vitro fertilization pregnancy.

OBJECTIVE: Obstetric complications occur more frequently in pregnancies after in vitro fertilization (IVF). We attempted to determine the correlation between subchorionic hematoma and IVF pregnancies. STUDY DESIGN: We analyzed 194 pregnancies achieved by infertility treatment between January 2008 and February 2012 at our hospital. Among these, 67 were achieved by IVF and 127 by non-IVF approaches. We compared the frequency of subchorionic hematoma between the groups and examined the risk factors for subchorionic hematoma in the IVF group. RESULTS: No significant differences regarding age and the number of uterine surgery were observed between the groups. The duration of infertility was longer, parity and the rate of luteal support were higher in the IVF group compared with that in the non-IVF group. The frequency of subchorionic hematoma was significantly higher in the IVF group (22.4%) than that in the non-IVF group (11%) (P=0.035). Univariate analysis in the IVF group demonstrated that frozen-thawed embryo transfer (OR, 6.18; 95% CI, 1.7-22.4), parity≥1 (OR, 3.67; 95% CI, 1.0-13.2) and blastocyst transfer (OR, 3.75; 95% CI, 1.1-13.3) were risk factors for the subchorionic hematoma. CONCLUSION: The frequency of subchorionic hematoma is high in IVF pregnancies, and frozen-thawed embryo transfer, parity≥1, and blastocyst transfer may contribute to subchorionic hematoma onset.

Hysteroscopic tubal catheterization under laparoscopy for proximal tubal obstruction.

PURPOSE: The purpose of this study was to investigate the fertility outcomes of infertile patients having proximal tubal obstruction treated with hysteroscopic tubal catheterization (HCT) for recanalization under diagnostic laparoscopy. METHODS: From January 2000 to December 2008, diagnostic laparoscopy was used to assess the tubal status of 61 patients with unilateral or bilateral proximal tubal obstruction, as confirmed by hysterosalpingography. Among them, 35 patients with tubal obstruction confirmed by chromopertubation under laparoscopy subsequently underwent HCT. The pregnancy outcomes and success rates of recanalization were investigated. RESULTS: In the 35 patients with confirmed tubal obstruction, HCT was performed in 54 fallopian tubes. The success rate of recanalization was 25.9% (14/54) per tube and 37.1% (13/35) per patient. Of the patients in whom tubal patency was restored, 4 achieved pregnancy, including 1 tubal pregnancy and 1 miscarriage. Among the 61 patients, excluding 14 who underwent in vitro fertilization-embryo transfer (IVF-ET) after laparoscopy, 13 were pregnant (27.7%), 9 gave live births, 1 had tubal pregnancy, and 3 had miscarriages. CONCLUSIONS: HCT under laparoscopy is an option for couples with tubal infertility who do not prefer IVF-ET.

Delayed pneumothorax after laparoscopic ovarian cystectomy.

BACKGROUND: We describe a case that developed a delayed pneumothorax after laparoscopic surgery. CASE: A 40-year-old woman (BMI: 19.1) underwent a laparoscopic ovarian cystectomy. On the first postoperative day, she developed a pneumothorax. The subcutaneous CO2 tracked up through the fascial planes, and ruptured into the pleural space, where delayed pneumothorax developed. CONCLUSION: Gynecologists should be aware of pneumothorax after laparoscopic surgery and should also keep in mind its possible delayed development.