Neonatal respiratory complications in twins at 36-38 weeks of gestation.

BACKGROUND: Twin pregnancies are associated with a high risk of perinatal mortality and morbidity. Late preterm or early term delivery is frequently performed to avoid unexpected fetal death in uncomplicated twin pregnancies. Nonetheless, delivery before full term is associated with neonatal respiratory complications. This study aimed to evaluate perinatal respiratory complications in twins delivered between 36 and 38 weeks of gestation. METHODS: A retrospective cohort study was conducted on twins delivered between 36 and 38 weeks of gestation from January 2008 to June 2020. The primary outcomes were the incidence of composite neonatal respiratory morbidity, which included respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, mechanical ventilation or continuous positive airway pressure according to gestational age at delivery, and chorionicity. The relationship between gestational age at delivery and composite neonatal respiratory morbidity was evaluated using multivariate logistic regression analysis adjusted for potential confounders. RESULTS: This study included 1608 twins (614 monochorionic diamniotic twins, 994 dichorionic diamniotic twins). At 36, 37, and 38 weeks of gestation, the frequencies of composite neonatal respiratory morbidity were 19.4%, 10.7%, and 9.2% in dichorionic diamniotic twins and 13.6%, 8.7%, and 9.4% in monochorionic diamniotic twins, respectively. In dichorionic diamniotic twins, the composite neonatal respiratory morbidity rate was higher for twins delivered at 36 weeks of gestation than for those delivered at 37 weeks. No significant differences between monochorionic diamniotic twins were detected. CONCLUSIONS: In uncomplicated dichorionic diamniotic twin pregnancies, delivery should be considered after 37 weeks of gestation to reduce neonatal respiratory complications.

Perioperative risk factors of preterm delivery after fetoscopic laser photocoagulation for twin-twin transfusion syndrome.

OBJECTIVE: To identify risk factors for preterm delivery (PTD) in patients who received fetoscopic laser photocoagulation (FLP) of placental anastomoses for twin-twin transfusion syndrome (TTTS). METHODS: This retrospective cohort study prospectively analyzed and recorded perioperative data in a cohort of patients who had FLP for TTTS, identifying perioperative risk factors for PTD using a Cox proportional hazard regression model. RESULTS: Of 304 patients included, 26 (8.6%) delivered within 4 weeks of FLP. Independent predictors of delivery within 4 weeks of FLP were a history of PTD (hazard ratio [HR]: 5.91, 95% confidence interval [CI]:1.21-28.82, p = 0.03), vaginal bleeding in the second trimester (HR: 6.62, 95% CI: 1.76-24.90, p < 0.01), and amnioreduction ≥1715 mL (HR: 3.16, 95% CI: 1.11-9.05, p < 0.03). CONCLUSION: Patients with a history of PTD, preoperative vaginal bleeding, and amnioreduction ≥1715 mL were more likely to deliver prematurely.

Relationship between unremoved cervical polyp in pregnancy and spontaneous preterm birth.

BACKGROUND: Cervical polyps removed during pregnancy have been reported to be associated with preterm birth; however, the association between unremoved cervical polyps and preterm birth has not been elucidated. OBJECTIVE: This study aimed to clarify the relationship between cervical polyps detected before 12 weeks of gestation managed expectantly and spontaneous preterm birth. STUDY DESIGN: This retrospective cohort study included pregnant women who visited a tertiary perinatal center before 12 weeks of gestation between January 2015 and December 2019. The exclusion criteria were as follows: multiple gestations, loss or termination of pregnancy before 12 weeks of gestation, major fetal anomalies, fetal chromosomal abnormalities, fetal demise, having undergone removal of cervical polyps before the first visit to our hospital, and moving to other hospitals before delivery. A vaginal speculum examination was routinely performed during a prenatal visit before 12 weeks of gestation. When a cervical polyp was detected on speculum examination, it was managed expectantly, unless gynecologic malignancy was suspected. Relationships between cervical polyps and spontaneous preterm birth before 34 weeks of gestation were evaluated using logistic regression analysis and Cox proportional-hazards analysis adjusted for known confounders for spontaneous preterm birth. RESULTS: A total of 4172 pregnant women were included, of whom 92 (2.2%) had a cervical polyp detected before 12 weeks of gestation. None of the women underwent polypectomy during pregnancy. The incidence of spontaneous preterm birth before 34 weeks of gestation was higher in pregnant women with cervical polyps than in those without them (5.4% vs 0.7%; P<.01). Logistic regression analysis revealed that cervical polyps were an independent risk factor for spontaneous preterm birth before 34 weeks of gestation (adjusted odds ratio, 4.09; 95% confidence interval, 1.70-9.81; P<.01). The adjusted hazard ratio for spontaneous preterm birth before 34 weeks of gestation among women with vs without cervical polyps was 2.95 (95% confidence interval, 1.32-6.62; P<.01). CONCLUSION: Cervical polyps detected before 12 weeks of gestation managed expectantly are a significant risk factor for spontaneous preterm birth before 34 weeks of gestation.

Incidences of complications associated with cervical cerclage by indication of the procedure.

AIM: To investigate the incidence of complications associated with cervical cerclage by indication. METHODS: This was a retrospective cohort study of women with singleton pregnancies who underwent cervical cerclage in a single perinatal center between 2008 and 2019. The participants were divided into three groups according to indication: history-indicated cerclage (HIC) group, ultrasound-indicated cerclage (UIC) group, and physical examination-indicated cerclage (PEIC) group. The incidences of perioperative complications within 2 weeks after the procedure, including intraoperative rupture of membranes, intraoperative bleeding, anesthesia complications, clinical chorioamnionitis, premature rupture of membranes (PROM), preterm delivery, and displacement of the suture, and those of peripartum complications, including difficult suture removal and cervical laceration, for each group were compared using Fisher's exact test or Pearson's chi-square test. Factors associated with severe adverse event, defined as PROM or delivery within 2 weeks after the procedure, were analyzed using multivariate logistic regression analysis. RESULTS: A total of 279 women (HIC, 38; UIC, 96; PEIC, 145) were enrolled. The incidence of perioperative complications was different among the three groups (7.9%, 10.4%, and 27.6%, respectively; p < 0.01), whereas that of peripartum complications was similar (18.4%, 11.5%, and 12.4%, respectively; p = 0.54). Severe adverse events occurred only in PEIC group, with an incidence of 18.6%. The associated factor for severe adverse events in PEIC group was prolapsed membranes into the vagina. CONCLUSIONS: Incidences of perioperative complications of cerclage differed among the indications. Women who underwent PEIC had higher risk of severe adverse events, especially when accompanied with prolapsed membranes into the vagina.

Incidence of chest X-ray abnormalities early in the third trimester of twin pregnancy and its relationship with the subsequent development of preeclampsia.

AIM: To clarify the incidence of abnormal findings on chest X-ray (CXR) early in the third trimester of twin pregnancy and its relationship with the development of preeclampsia and preeclampsia-related diseases. METHODS: This was a retrospective cohort study conducted among women with twin pregnancies who underwent chest radiography for preoperative screening early in the third trimester and delivered at our center at >34 weeks' gestation from 2013 to 2017. The primary outcome was the incidence of positive CXR findings, defined either as cardiomegaly or blunting of the costophrenic angle. The secondary outcome was the incidence of maternal complications, including preeclampsia; hemolytic, elevated liver enzymes, and low platelet syndrome; eclampsia; cerebrovascular disease; and placental abruption. We evaluated the significance of positive CXR findings, in addition to confounding factors, in the subsequent development of preeclampsia. RESULTS: During the study period, 358 twin pregnancies were identified, and 330 were finally enrolled. The incidence of positive CXR findings was 18.2%. The incidence of preeclampsia in the CXR-positive group was 36.7% (22/60), which was significantly higher than that in the CXR-negative group (7.0% [19/270]) (p < 0.01). Moreover, positive CXR findings were independently associated with subsequent preeclampsia (adjusted odds ratio: 9.15, 95% confidence interval: 4.13-20.3). CONCLUSION: In twin pregnancies, the incidence of CXR abnormalities early in the third trimester was 18.2%, even without the development of hypertension. This should be considered a significant risk factor for subsequent preeclampsia.

Neuro-immune crosstalk and food allergy: Focus on enteric neurons and mucosal mast cells.

The nervous system and the immune system individually play important roles in regulating the processes necessary to maintain physiological homeostasis, respond to acute stress and protect against external threats. These two regulating systems for maintaining the living body had often been assumed to function independently. Allergies develop as a result of an overreaction of the immune system to substances that are relatively harmless to the body, such as food, pollen and dust mites. Therefore, it has been generally supposed that the development and pathogenesis of allergies can be explained through an immunological interpretation. Recently, however, neuro-immune crosstalk has attracted increasing attention. Consequently, it is becoming clear that there is close morphological proximity and physiological and pathophysiological interactions between neurons and immune cells in various peripheral tissues. Thus, researchers are now beginning to appreciate that neuro-immune interactions may play a role in tissue homeostasis and the pathophysiology of immune-mediated disease, but very little information is available on the molecular basis of these interactions. Mast cells are a part of the innate immune system implicated in allergic reactions and the regulation of host-pathogen interactions. Mast cells are ubiquitous in the body, and these cells are often found in close proximity to nerve fibers in various tissues, including the lamina propria of the intestine. Mast cells and neurons are thought to communicate bidirectionally to modulate neurophysiological effects and mast cell functions, which suggests that neuro-immune interactions may be involved in the pathology of allergic diseases.

Re-evaluation of the predictive value of Quintero staging of twin-twin transfusion syndrome for fetal death after fetoscopic laser photocoagulation.

OBJECTIVE: To elucidate the significance of sonographic indices, including Doppler waveforms, that constitute the Quintero classification for predicting death of the recipient or donor after fetoscopic laser photocoagulation (FLP) for twin-twin transfusion syndrome (TTTS). METHODS: Prospectively collected data of twins who underwent FLP for TTTS were reviewed. Among the abnormal indices of ultrasound performed just before FLP, factors that were significantly associated with fetal and neonatal deaths in the log-rank test, including fetal demise of co-twins and preterm birth before 28 weeks of gestation, were introduced into the Cox proportional-hazards model to calculate risk ratio (RR). RESULTS: We included 235 cases with a prevalence of recipient and donor deaths of 7% and 14%, respectively. In the proportional-hazards model, absent or reversed umbilical artery end-diastolic velocity (UA AREDV) of recipients (n = 7) was independently associated with recipient death (RR = 6.97). In recipients without UA AREDV, reversed ductus venosus (DV) a-wave of recipients (RR = 3.55) was independently associated with recipient death. In donors, UA AREDV with a visible bladder (stage III atypical donor) was independently associated with donor death (RR = 4.24). CONCLUSION: Some individual components of the Quintero stage are associated with death of either recipient or donor twins following FLP.

Prevalence of umbilical artery Doppler waveform abnormality during the early second trimester and the subsequent variation of waveforms in monochorionic diamniotic twin pregnancies: A prospective cohort study.

AIM: To investigate the prevalence of qualitative abnormal umbilical artery Doppler waveforms (Abnormal UA) during the early second trimester and the subsequent variation of waveforms in monochorionic diamniotic (MCDA) twin pregnancies. METHODS: This prospective cohort study included 153 MCDA twin pregnancies. Pulsed Doppler examinations for UA were performed at four points, including the free-loop (FL) and near the placental cord insertion site (CI) of each UA, between 16 and 17 weeks' gestation. Cases were classified into positive diastolic waveforms (Type I), persistent Abnormal UA (Type II), and intermittent Abnormal UA (Type III). When the diastolic velocity in UA Doppler was positive twice after different sequential recordings, the cases were determined to have achieved normalization. Follow-up Doppler examinations of the UA were performed at 24, 28, and 32 weeks' gestation. RESULTS: Of all 153 cases, 38 (25%; 19 Type II and 19 Type III cases) showed Abnormal UA at the first examination. Abnormal UA was detectable at FL in all selective intrauterine growth restriction (sIUGR) cases, whereas it was noted only at CI site in some non-sIUGR cases. Abnormal UA normalized in 12 (63%) Type II and 15 (79%) Type III cases. CONCLUSIONS: A quarter of MCDA twin pregnancies in the early second trimester demonstrated Abnormal UA. In MCDA twins with Abnormal UA between 16 and 17 weeks' gestation, it is preferable to follow them up to consider the possibility of normalization of Abnormal UA as well as features of UA waveforms specific to FL and CI.

Prevalence of Extraplacental Anastomoses in Monochorionic Twin Pregnancies.

OBJECTIVES: To evaluate the prevalence of extraplacental anastomoses (EPA) and the factors associated. METHODS: A retrospective study including 144 placentas from monochorionic diamniotic (MCDA) twins delivering at one institution was performed. EPA were defined as any intertwin anastomosis located outside the chorionic plate on macroscopic inspection. The association with perinatal factors and with umbilical cord insertion site was analyzed. RESULTS: The prevalence of EPA was 4.9% (7/144). Velamentous cord insertion of both twins was significantly associated with the presence of EPA in the multivariate logistic regression model (p = 0.045). DISCUSSION: EPA was found in ≈5% of MCDA twin pregnancies.

Isoflavones Suppress Cyp26b1 Expression in the Murine Colonic Lamina Propria.

Isoflavones have many biological activities and are major bioactive components of kakkonto, a traditional Japanese herbal medicine. We previously reported that the combined therapy of oral immune therapy (OIT) and kakkonto downregulates the mRNA expression of Cyp26b1, a major retinoic acid (RA)-degrading enzyme, in the colon of food allergy mice and thereby ameliorates allergic symptoms. In this study, we evaluated the effects of various isoflavones on Cyp26b1 expression in primary cultured lamina propria (LP) cells isolated from the mouse colon. The mRNA expression of Cyp26b1 was extremely downregulated by all isoflavones tested in the LP cells except for puerarin. In particular, genistein and genistin markedly suppressed Cyp26b1 mRNA expression without affecting RA-synthesizing enzyme expression. Moreover, to evaluate the effects of isoflavones on allergic reactions, genistein and genistin were administered to ovalbumin (OVA)-induced food allergy mice. Oral administration of genistin suppressed the development of allergic symptoms. These results raise the possibility that isoflavones elevated the level of RA in the colon by inhibiting RA degradation and then the high concentration of RA in the colon might exert immunosuppressive and antiallergic effects on food allergy mice.

Association between maternal height and mode of delivery in nulliparous Japanese women.

AIM: The primary aim of this study was to examine the association between maternal height and mode of delivery in nulliparous Japanese women. The secondary aim was to examine the association between maternal height and maternal and neonatal morbidities. METHODS: This retrospective cohort study included women who gave birth at Osaka Women's and Children's Hospital, a tertiary perinatal center in Japan, from January 2015 to December 2017. Nulliparous Japanese women with singleton gestation, who went into labor at term were included in the study. The primary outcome was mode of delivery, and the secondary outcomes were maternal and neonatal morbidities. The relationships between maternal height and the outcomes were evaluated using multivariate logistic regression analysis adjusted for potential confounders. Maternal height was categorized into five groups with 5-cm increments for the analysis. RESULTS: A total of 1593 women were analyzed in this study. Shorter women had higher rate of cesarean delivery (CD) than taller women. There were no significant differences in the rates of operative vaginal delivery, maternal morbidity and neonatal morbidity among the maternal-height groups. The adjusted odds ratios (95% confidential interval) of maternal heights of <150 cm, 150-154 cm, 160-164 cm and ≥165 cm for CD, compared with a maternal height of 155-159 cm, were 3.56 (1.79-7.09), 1.68 (1.06-2.64), 0.63 (0.40-1.00) and 0.57 (0.30-1.01), respectively. CONCLUSION: Shorter nulliparous Japanese women were more likely to undergo intrapartum CD. However, the rates of maternal and neonatal morbidities in shorter women were similar to those in taller women.

Perinatal outcomes of intrauterine transfusion for the surviving twin in monochorionic twin gestation involving a single fetal demise.

AIM: This study aimed to evaluate the feasibility and outcome of intrauterine transfusion (IUT) for the surviving co-twin in monochorionic diamniotic (MCDA) twin gestations involving single intrauterine fetal death (sIUFD). METHODS: Cases of MCDA twin gestations involving emergent IUT for co-twins experiencing acute feto-fetal hemorrhage (AFFH) subsequent to sIUFD during the second trimester were reviewed. Fetal anemia was confirmed via fetal blood sampling, and perinatal data were retrieved from medical charts to determine the outcomes of surviving co-twins. A poor outcome at 28 days of age was defined as fetal death, neonatal death or neurological impairment such as severe intraventricular hemorrhage or cystic periventricular leukomalacia (PVL). RESULTS: This study included 16 cases of sIUFD diagnosed at a median of 22.5 weeks of gestation (range: 18-25 weeks). The median interval in hours between diagnosis of fetal demise and IUT was approximately 4.2 (0-22) hours. All cases achieved IUT without significant intraoperative complications. Four cases experienced a fetal loss of the co-twin, whereas 12 co-twins were born alive (including 9 preterm births), with only 1 poor outcome in a preterm infant with PVL. CONCLUSION: IUT may be a feasible prenatal intervention for surviving co-twins with AFFH. However, more extensive or pooled studies are needed to determine the efficacy of this intervention.

The isoflavone puerarin induces Foxp3+ regulatory T cells by augmenting retinoic acid production, thereby inducing mucosal immune tolerance in a murine food allergy model.

The disruption of intestinal mucosal immune tolerance can lead to the development of intestinal immune diseases such as food allergy (FA). Regulatory T cells (Tregs) in the mucosa play a critical role in maintaining peripheral immune tolerance in the intestine, and retinoic acid (RA) is absolutely required for the induction of Tregs. We have previously reported that kakkonto, a traditional Japanese herbal medicine, suppresses FA in a murine FA model due to the induction of Tregs in the colonic mucosa. However, the precise molecular mechanisms underlying the induction of Tregs remain unclear. Puerarin, an isoflavone derivative, is a major constituent of kakkonto. Thus, we investigated the effect of puerarin on the induction of Tregs. BALB/c mice were systemically sensitized and then orally challenged with ovalbumin (OVA) as an FA model. Puerarin treatment suppressed the development of allergic diarrhea in FA mice. The gene expression levels of IL-4 and mast cell protease I (mMCP-1) were significantly upregulated in the proximal colon of FA mice but were reduced by puerarin. The proportions of Foxp3+CD4+ cells and CD103+CD11c+ dendritic cells (DCs) were significantly higher among the colonic lamina propria (cLP) cells of puerarin-treated FA mice than among those of untreated FA mice. The gene expression of Aldh1a1, an RA synthesis enzyme, in colonic epithelial cells (CECs) was significantly higher in the puerarin-treated FA mouse colon than in the untreated FA mouse colon. In addition, the preventive effect of puerarin was suppressed in the FA model by pretreatment with LE540, an RA receptor (RAR) antagonist. The induction of Foxp3+CD4+ cells and CD103+CD11c+ DCs by puerarin was reduced by pretreatment with LE540. The present findings indicate that the augmentation of RA production in CECs induced by puerarin enhances the induction of Tregs and suppresses the development of FA in a mouse model. Thus, a natural enhancer of RA production, such as puerarin, has the potential to treat immune diseases attributed to Treg deficiency.

The incidence of unexpected critical complications in monochorionic diamniotic twin pregnancies according to the interval period between ultrasonographic evaluations.

AIM: This study aimed to evaluate the incidence of unexpected critical complications (UCC) in monochorionic diamniotic (MCDA) twin pregnancies according to ultrasonographic scan interval. METHODS: This retrospective single-center cohort study, conducted between January 2005 and April 2015, investigated the incidence of UCC in patients with MCDA twin pregnancies undergoing weekly ultrasound (Group A) and those undergoing biweekly ultrasound (Group B). We also examined the incidence of predictable critical complications according to ultrasound interval. RESULTS: Of all 385 cases, the total incidence of UCC was 20 (5.2%), including 14 cases of twin-twin transfusion syndrome and 6 cases of intrauterine fetal death. The incidence of UCC was 3.9% in Group A and 9.0% in Group B (P = 0.046). In contrast, the incidence of predictable critical complications was 6.7% in Group A and 9.0% in Group B (P = 0.440). CONCLUSION: The incidence of UCC in patients with MCDA twin pregnancies was significantly lower in patients undergoing weekly ultrasound. Our results suggest that weekly ultrasound evaluation for patients with MCDA pregnancy is more effective for early detection of UCC such as intrauterine fetal death and twin-twin transfusion syndrome ; however, further investigations are needed to determine whether weekly ultrasound evaluation can improve clinical outcomes.

Factors associated with emergency cesarean delivery during induction of labor in nulliparous women aged 35 years or older at term.

AIM: To examine the intrapartum cesarean delivery rate following failure of induction of labor (IOL) as well as risk factors associated with failed IOL among nulliparous women of advanced maternal age (AMA). METHODS: This was a retrospective cohort study conducted at a single perinatal care center. We retrospectively reviewed the medical records of nulliparous AMA women (aged 35 years or older) with singleton vertex pregnancy who underwent IOL at term. Data regarding maternal baseline characteristics and pregnancy course, including complications during pregnancy and maternal status at time of IOL, were collected. Rate of emergency cesarean section (eCS) as well as risk factors associated with failed IOL were investigated by means of logistic regression analysis. RESULTS: Among 234 women included in this study, 103 (44%) had failed IOL and delivered by eCS. Hypertensive disorder during pregnancy (adjusted odds ratio [aOR], 2.01; 95% confidence interval [CI], 1.0-4.12; P = 0.025) and unfavorable cervical status (aOR, 1.92; 95% CI, 1.08-3.41; P = 0.038) were identified as independent risk factors for failed IOL. CONCLUSION: IOL failed in 44% of nulliparous AMA women. Hypertensive disorder and immature cervical status should be considered as independent risk factors for eCS among such women.

Rate of intrapartum cesarean section and related factors in older nulliparous women at term.

AIM: The aim of this study was to determine the effect of maternal age on emergency cesarean section (CS) during labor, and to identify the independent risk factors for emergency CS. METHODS: This was a retrospective cohort study using data from 2009 to 2014 from a tertiary perinatal care center in Japan. Inclusion criteria were maternal age ≥ 35 years, nulliparous singleton pregnancy at term and a cephalic presentation without indication of elective CS at onset of labor. The primary outcome was rate of emergency CS, while independent risk factors were elucidated using multivariate logistic regression analysis. RESULTS: Of 953 women, 199 (20.9%) delivered by emergency CS. Rates of emergency CS were 18.3% (129/706) in women aged 35-39 years and 28.3% (70/247) in those aged ≥ 40 years (P < 0.01). Adjusted odds ratios (95% confidence intervals) of independent risk factors were 1.50 (1.03-2.18) for maternal age ≥ 40 years, 1.51 (1.06-2.17) for body mass index ≥ 25 kg/m2 , 2.22 (1.24-3.98) for hypertensive disorder during pregnancy, 3.43 (1.31-8.95) for large-for-date fetus and 4.64 (3.23-6.69) for induction of labor. CONCLUSIONS: The rate of intrapartum emergency CS in older nulliparous women at term was approximately 21%. Induction of labor should be recognized as a significant factor for emergency CS.

Incidence of and risk factors for severe maternal complications associated with hypertensive disorders after 36 weeks' gestation in uncomplicated twin pregnancies: A prospective cohort study.

AIM: To elucidate the incidence of and risk factors for severe hypertensive disorders (HD) and related maternal complications in uncomplicated twin pregnancies that reached 36 weeks' gestation. METHODS: We conducted a prospective cohort study of twin pregnancies delivered after 36 weeks' gestation. Cases of twin-twin transfusion syndrome, twin anemia-polycythemia sequence, malformed fetuses, monoamniotic twins, selective reduction, fetal therapy and HD or fetal death before 35 weeks' gestation were excluded. The study's primary outcome was the incidence of severe maternal complications, including severe HD, eclampsia, placental abruption, HELLP (hemolysis, elevated liver enzyme and low platelet) syndrome, pulmonary edema and cerebrovascular disease. Perinatal factors associated with the primary outcome were identified using a multivariate logistic regression model. RESULTS: In 330 enrolled women, the number of cases with the primary outcome was 28 (8.5%; 95% confidence interval 5.9-12.0), including 25 cases of severe HD and each one case of placental abruption, HELLP syndrome and eclampsia. The rate of severe maternal complications significantly increased with gestational age, demonstrating 1.2% at 36 weeks, 3.9% at 37 weeks and 6.4% at 38 weeks. Only gestational proteinuria was identified as the independent risk factor for severe maternal complications (adjusted odds ratio 17.1 [95% confidence interval 6.71-45.4]). CONCLUSION: Severe maternal HD and related complications increased from late preterm to early term; particularly, patients with gestational proteinuria were at high risk.

Transient amniotic fluid leakage after fetoscopic laser photocoagulation for twin-twin transfusion syndrome.

AIM: Iatrogenic premature rupture of membrane (PROM) is one of the major complications related to fetoscopic laser photocoagulation (FLP) for twin-twin transfusion syndrome (TTTS). However, amniotic fluid leakage (AFL) sometimes spontaneously disappears. This study evaluated the incidence and clinical characteristics of transient AFL after FLP. METHODS: We retrospectively reviewed pregnancies that underwent FLP for TTTS at a single center. Patients with apparent AFL within 2 weeks after FLP were divided into two groups: transient AFL, defined by the disappearance of fluid leakage within a week; and PROM, if AFL persisted continuously for more than a week or premature birth occurred, including miscarriage, within a week of the first symptom of AFL. RESULTS: Among 201 monochorionic twin pregnancies that underwent FLP during the study period, nine patients (4.5%) were diagnosed with AFL within a week after FLP. Four patients (2.0%) were classified as transient AFL and five as PROM. Median gestational age at FLP was not significantly different between the groups; operative time in the PROM group was significantly longer (P = 0.01). The surgery to delivery interval and median gestational age at delivery were greater in the transient AFL group (87.8 vs 17.6 days, P = 0.01; 32.5 vs 23.6 weeks, P = 0.01, respectively). CONCLUSIONS: The incidence of transient AFL after FLP was 2%. Perinatal outcomes of transient AFL might be better than that of PROM.

Labor after cesarean delivery managed without induction or augmentation of labor.

BACKGROUND: This study aimed to describe the perinatal outcomes of women opting for vaginal birth after cesarean delivery (VBAC) managed without induction or augmentation of labor. METHODS: This was a retrospective cohort study of candidates for VBAC at a tertiary center in Japan from April 2003 to March 2012. Women with singleton gestations and one prior low-transverse cesarean delivery who intended VBAC at 36 weeks of gestation were identified as candidates for VBAC and included in the study. Participants were managed without induction or augmentation of labor. Maternal characteristics and perinatal outcomes were obtained from medical records. Factors associated with successful VBAC were analyzed with a multivariable logistic regression model. RESULTS: Of 333 candidates for VBAC, 242 (72.7%) had vaginal birth, 49 (14.7%) had repeat cesarean delivery with spontaneous labor, and 42 (12.6%) had repeat cesarean delivery without spontaneous labor. The rate of uterine rupture was 0.3% (1/333). Prior vaginal delivery and nonrecurring indications for prior cesarean delivery were associated with successful VBAC. CONCLUSIONS: Management of candidates for VBAC without induction or augmentation of labor resulted in a high VBAC rate and favorable perinatal outcomes. Such restrictive VBAC policies may be an acceptable alternative to standard management or abandonment of VBAC.

Induction of Regulatory T Cells as a Novel Mechanism Underlying the Therapeutic Action of Kakkonto, a Traditional Japanese Herbal Medicine, in a Murine Food Allergy Model.

BACKGROUND: The number of patients with food allergy (FA) has dramatically increased. Although satisfactory drug therapies for FA are not available, we have found that kakkonto, a traditional Japanese herbal medicine, suppressed the occurrence of allergic symptoms in an FA mouse model. Thus, we investigated whether kakkonto could regulate the activation and differentiation of T cells in the colon. METHODS: BALB/c mice were systemically sensitized and then orally challenged with ovalbumin. FA mice were orally treated with kakkonto. Lamina propria (LP) cells from their colons were isolated and analyzed. RESULTS: Kakkonto significantly reduced the proportion of CD69+ cells and the elevated helper T cell type 2-specific transcription factor GATA-3 mRNA expression in the LP CD4+ T cells, showing that kakkonto has a suppressive effect on the activation and Th2 differentiation of LP effector CD4+ T cells of the FA mouse colon. Furthermore, kakkonto significantly increased the proportion of Foxp3+CD4+ regulatory T cells in the LP CD4+ T cells of the FA mouse colon. Similarly, the number of Foxp3-positive cells was dramatically increased in the colonic mucosa of kakkonto-administered FA mice. However, the pharmacological effect and Foxp3+CD4+ regulatory T cell-inducing ability of kakkonto were not attenuated by the administration of an anti-CD25 monoclonal antibody in the FA model. CONCLUSIONS: The induction of Foxp3+CD4+CD25- regulatory T cells in the colon as a novel mechanism underlying the therapeutic action of kakkonto could be utilized for the development of a novel anti-FA drug.