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.

Research Article Quality of life after laparoscopic hysterectomy versus abdominal hysterectomy.

BACKGROUND: Laparoscopic surgery has been described as a minimally invasive surgery. The purpose of this study is to clarify its minimal invasive features using a patient questionnaire on the postoperative quality of life (QOL) over various time periods following either laparoscopic hysterectomy (LH) or abdominal hysterectomy (AH) and to compare the results. METHODS: This study enrolled 28 patients who underwent total hysterectomy for uterine fibroids in 2012 (14 AH cases and 24 LH cases) were enrolled in this study. The 36-Item Short Form Survey (SF-36) questionnaire was completed on postsurgical day 3; weeks 1, 2, and 4; and month 6. The results were compared between the two groups. RESULTS: Patients who underwent LH scored significantly higher on physical functioning on postoperative day 3 and week 2; physical role and bodily pain on day 3 and week 1; general health on postoperative day 3, weeks 1, 2, and 4, and month 6; social functioning on day 3; and emotional role on day 3 and week 1. No significant differences were found between vitality and mental health at any time point or in the categories above at any other time point. CONCLUSIONS: Postoperative QOL in LH cases was improved on day 3 and week 1; however, no significant differences between the LH and AH groups were found in most categories at week 4 and month 6. LH leads to superior short-term QOL early in the postoperative period relative to AH.

Ovarian cyst elevation using a metreurynter for laparoscopic cystectomy of a benign ovarian cyst during pregnancy.

BACKGROUND: A uterine manipulator cannot be used to elevate the ovary in benign ovarian surgery during pregnancy. This report describes our method of elevation of the ovary using a metreurynter with the success rate of the procedure and a comparison of surgical results and pregnancy outcomes between the successful and unsuccessful cases. METHODS: Between August 2003 and February 2020, 11 pregnant patients with a tumor found sunk in the Cul-de-sac underwent laparoscopic cystectomy for a benign ovarian cyst with a metreurynter. The surgical results, success and failure of the elevation by a metreurynter, pregnancy outcomes, and fetal status at delivery were evaluated. RESULTS: Elevation of ovarian tumors with a metreurynter was successful in nine cases. However, it was unsuccessful in the remaining two cases wherein the ovary was lifted with forceps while the uterus was in a compressed state. The operative time was also longer in these cases. The pregnancy prognosis, however, was good for both, successful and unsuccessful cases. CONCLUSIONS: The metreurynter is an inexpensive and practical obstetric device, and its optimal use allows the performance of a procedure with minimal burden on a pregnant uterus. Therefore, we recommend the appropriate use of this method to enable effective laparoscopic cystectomy of ovarian tumors during pregnancy.

Severe fatty liver of pregnancy requiring an extremely large amount of blood transfusion, surgery and transarterial embolization: A case report.

We report a case of massive bleeding due to a coagulation disorder associated with acute fatty liver of pregnancy (AFLP); the patient survived by massive transfusion. She presented at 34 weeks of gestation, met six of the Swansea criteria, and was diagnosed with severe AFLP. We performed an emergency cesarean section because termination of the pregnancy was necessary for the treatment of the AFLP. After the surgery, which led to massive bleeding in the peritoneal cavity due to the coagulation disorder, she underwent two further operations and three transarterial embolizations. She received factor VII and underwent plasma exchange, and hemostasis was achieved on day 10 after hospitalization. The total volume of blood transfused was 772 units (170 units of red cell concentrate, 212 units of fresh frozen plasma, and 390 units of platelet concentrate). To the best of our knowledge, this is the most severe case of non-fatal AFLP reported to date in terms of the transfusion volume.

Nontuberculous Mycobacterial Infection in the Uterine Cervix Mimics Invasive Cervical Cancer in Immunocompetent Woman.

Nontuberculous mycobacterial (NTM) infection is increasing across the world. Although the most common clinical manifestation of NTM disease is lung disease, a rare form of disseminated NTM disease has also been documented. Disseminated NTM usually develops in severely immunocompromised individuals, especially those with advanced AIDS. This manifestation is rare in non-HIV-infected hosts and is associated with immunosuppressed conditions. However, recent reports have suggested that disseminated NTM disease in immunocompetent patients without HIV infection has been increasing. Dissemination may involve any organ system, but a case in the female genital tract has never been reported. We report a case in a 67-yr-old previously healthy woman who presented with a disseminated NTM infection in the uterine cervix. The primary presentation was general fatigue and body weight loss. The patient also presented with a mass formation that mimicked cervical cancer on magnetic resonance imaging. In addition to the cervical mass, the patient presented with a mass formation in the omentum; wall thickening of the vagina, bladder, and ureter; and retention of pleural/peritoneal fluid. Vaginal cytology was negative. A diagnosis was made only after detecting acid-fast bacilli in a biopsy specimen of cervical mass, which was conducted under suspicion of cervical malignancy. Then, Mycobacterium avium was confirmed in a polymerase chain reaction test of cervical tissue. After administration of antimycobacterial therapy, the mass and other findings on magnetic resonance imaging disappeared. Infection in multiple organs leads to the diagnosis of disseminated NTM. This case indicates that, for prompt and accurate diagnosis, efforts to detect specific lesions by an imaging study and to confirm diagnosis pathologically are equally important, especially when local cytology is not convincing. The clinical course of this case may serve as a useful reference in the diagnosis and treatment of NTM.

Reproductive Outcome of Infertile Patients with Fibroids Based on the Patient and Fibroid Characteristics; Optimal and Personalized Management.

AIMS: To analyze the detailed clinical course of infertile patients with uterine fibroids and to identify optimal and personalized treatment based on the patient or fibroid characteristics. METHODS: Retrospective analysis of a case series was performed on 176 infertile patients with fibroids. The patients were classified into different groups according to different treatments (conservative infertility treatment, myomectomy and non-myomectomy surgery). Patient or fibroid characteristics for different groups were analyzed for a possible correlation with the reproductive outcome. RESULTS: The cumulative pregnancy rates by conservative treatment plateaued in 1 year. Myomectomy improved the reproductive outcome in patients who did not conceive with conservative infertility treatments. The most important determinant of the reproductive outcome in patients by conservative treatment prior to surgery was a past patient history of pregnancy. The most important determinant of the reproductive outcome after myomectomy was patient age. CONCLUSION: Myomectomy should be considered when infertile patients with fibroids do not conceive within 1 year of conservative infertility treatments. The most important determinant of reproductive outcome after myomectomy is patient age. Therefore, for patients younger than 40, the treatment schedule should be carefully considered so that the patients can sufficiently benefit from myomectomy and assisted reproductive technology.

Exposure to ethinyl estradiol prenatally and/or after sexual maturity induces endometriotic and precancerous lesions in uteri and ovaries of mice.

Unrecognizable exposure to estrogenic substance may cause estrogen-dependent diseases, endometriosis and cancer. Pregnant mice (ICR/Jcl, CLEA) were exposed to 0.01 mg ethinyl estradiol (EE2 )/kg per day or vehicle (olive oil) through oral intubation from day 11 to 17 of gestation. They delivered their offspring and raised them. When the experimental female F1 mice were at 8 weeks of age, they were not exposed to EE2 or to the same dose of EE2 or to vehicle twice a week until 20 weeks of age. The control female F1 mice were exposed to the same dose of EE2 or vehicle alone, similarly. All mice were killed at 28 weeks of age. The resected uteri and ovaries were processed for microscopic examinations and for determination of the aromatase mRNA levels and aromatase protein through quantitative RT-PCR and Western blotting, respectively. Adenomyosis and adenocarcinomatous changes were significantly discernible in the EE2 -exposed uteri, and incidence of ectopic glands and serous cysts were significantly increased in the prenatally EE2 -exposed ovaries as compared with respective controls. Significant upregulation of the aromatase mRNA was seen in the prenatally EE2 -exposed uteri and in the EE2 -exposed ovaries. The aromatase protein was identified in all ovaries examined, and in EE2 -exposed uteri but not in controls and confirmed its localization in eutopic and ectopic glands, abnormally proliferated lesions and the lining of the cysts. Taken together, continuous EE2 exposure may cause endometriotic and precancerous lesions due to excessive estrogen synthesis in both target organs.

Risk factors for deep-vein thrombosis and pulmonary thromboembolism in benign ovarian tumor.

Pulmonary thromboembolism (PE) is a serious postoperative complication. Reported rates of PE following gynecologic surgery are between 0.3% and 0.8%, with deep-vein thrombosis (DVT) as the major cause (via seeding of the lungs). Benign ovarian tumors are treated principally by surgery. Possible risk factors for DVT and PE in patients with benign ovarian tumors include tumor size, patient age, and obesity. To date, however, there has been no report addressing the association of these risk factors in patients with benign ovarian tumors. This study offers a retrospective analysis of the incident of preoperative DVT by age, tumor size, and BMI in patients undergoing surgery for benign ovarian tumors. A total of 843 Japanese patients with a preoperative diagnosis of benign ovarian tumor who underwent tumorectomy or adnexectomy at our institution between July 2003 and December 2010 were enrolled. The incidence of preoperative DVT was monitored and statistically stratified by age (< 50 years and ≥ 50 years), largest tumor diameter (< 10 cm and ≥ 10 cm), and BMI (< 25 and ≥ 25). The result indicates that tumor diameter of ≥ 10 cm is not a risk factor for preoperative DVT in patients with benign ovarian tumor. On the other hand, age ≥ 50 years and BMI > 25 are independent risk factors for preoperative DVT in Japan. The patients with each risk factor should be treated with preoperative, intraoperative, and postoperative precautions against development of PE.

Deep-vein thrombosis is associated with large uterine fibroids.

Pulmonary thromboembolism (PE) may occur upon a patient's first postoperative attempt of ambulation. PE is a serious complication, often leading to shock or sudden death. Reported rates of PE following gynecologic surgery are between 0.3% and 0.8%, while the incidence of postoperative deep-vein thrombosis (DVT), the major cause of PE, is between 17% and 20%. Therefore, effective preventive measures, such as preoperative assessment for asymptomatic DVT, should be considered. It is well known that DVT and/or PE are associated with large uterine fibroids, the common, benign tumor of myometrium. Here, to establish the statistical relationship between DVT risk and uterine fibroid size/weight, we assessed the preoperative DVT rate with respect to three possible risk factors: age, obesity level, and uterine size/weight. A total of 361 patients with uterine fibroids undergoing hysterectomy between July, 2003 and December, 2009 were enrolled. All patients were evaluated for preoperative DVT; the results were stratified for statistical comparison by patient age, BMI, and uterine weight. There was no statistical difference in the DVT rate for patients stratified by age (below age 45 years or older) or BMI (below 25 or higher). By contrast, the rate of DVT was significantly higher for patients with uterine weights of 1,000 gm or more (11.5% [7/61]) compared with weights below 1,000 gm (3.0% [9/300]). None of the patients studied developed PE. In conclusion, the incidence of DVT is significantly higher in cases where uterine weight is 1,000 gm or more (ie, adult head size on pelvic examination).

Laparoscopic mucin removal in patients with pseudomyxoma peritonei.

BACKGROUND AND OBJECTIVES: Pseudomyxoma peritonei results from ovarian and appendiceal mucinous tumors. Cyst rupture results in intraabdominal mucin accumulation, leading to abdominal distension. No effective treatment has yet been established. Pseudomyxoma peritonei is generally associated with a poor prognosis. In a recent Mayo Clinic report, the 5-year survival rate for this disease was 53% and the 10-year survival rate was 32%, while the Memorial Sloan-Kettering Cancer Center reported 5- and 10-year survival rates of 75% and 10%. METHODS AND RESULTS: In this report, we describe 4 patients with a laparoscopically confirmed recurrence of pseudomyxoma peritonei who subsequently underwent repeated laparoscopic mucin removal. CONCLUSION: Because laparoscopic surgery can be performed frequently, it appears that laparoscopic surgery, a minimally invasive procedure, greatly improves the quality of life of patients with pseudomyxoma peritonei.

Definitive diagnosis of primary adenocarcinoma of the appendix by laparoscopic appendectomy.

We report a 62-year-old woman with a primary adenocarcinoma of the appendix mimicking ovarian tumor. We had diagnosed it definitively by laparoscopic appendectomy, and additional surgery was required in this case. However, the present case suggests that, in some cases, if cancer of the appendix can be diagnosed early, laparotomy can be avoided and the cancer treated with minimally invasive laparoscopic surgery alone.

Feasibility of concurrent cisplatin use during primary and adjuvant chemoradiation therapy: a phase I study in Japanese patients with cancer of the uterine cervix.

BACKGROUND: Although the prognostic advantages of concurrent cisplatin (CDDP) chemoradiation therapy (CCRT), for uterine cervical cancer (UCC) has been demonstrated, the feasibility of concurrent CDDP administration has not yet been evaluated. We determined the optimal CDDP dose for both weekly and monthly schedules during primary and adjuvant CCRT in patients with UCC. METHODS: The study was conducted as a phase I, dose-escalation trial. Concurrent CDDP was started at the dose of 30 mg/m(2) for the weekly schedule and at 50 mg/m(2) for the monthly schedule, and the doses were steadily escalated to the maximum tolerated dose (MTD). RESULTS: A total of 45 patients with UCC (25 receiving primary CCRT and 20 receiving adjuvant CCRT) were entered in the study. In both the primary and adjuvant CCRT patients, the MTD was observed to be 40 mg/m(2) for the weekly schedule and 80 mg/m(2) for the monthly schedule. Dose-limiting toxicity was observed in 10 patients (granulocytopenia in 9 patients and diarrhea in 1 patient). Disease recurrence was confirmed in 6 patients in the primary CCRT group during a mean follow-up period of 22.4 +/- 13.2 months, and in patients 3 in the adjuvant CCRT group during a mean follow-up period of 17.7 +/- 6.8 months. CONCLUSION: For Japanese patients with UCC receiving primary or adjuvant CCRT therapy, the recommended CDDP dose was determined to be 30 mg/m(2) for the weekly schedule and 75 mg/m(2) for the monthly schedule.