Formation of the first plane of division relative to the pronuclear axis predicts embryonic ploidy.

RESEARCH QUESTION: Is there a relationship between the pronuclear axis and the first cleavage plane formation in human pronuclear-stage embryos, and what are the effects on ploidy and clinical pregnancy rates? DESIGN: Transferred embryos were followed up until their prognoses. A total of 762 embryos formed two cells and reached the blastocyst stage after normal fertilization in a time-lapse incubator. Embryos were classified into three groups: group A: embryos in which the first plane of division was formed parallel to the axis of the pronucleus; group B: embryos in which cases of oblique formation were observed; and group C: embryos in which cases of perpendicular formation were observed. RESULTS: The euploidy rate was significantly higher in groups A and B than those in group C (P < 0.01), whereas the aneuploidy rate was significantly higher in group C (P < 0.01) than in groups A and B. No differences were found between the three groups in frequency of positive HCG-based pregnancy tests, frequency of clinical pregnancies, miscarriage rates or delivery rates. CONCLUSIONS: The formation pattern of the first plane of division relative to the pronuclear axis was a predictor of embryonic ploidy, with a reduced rate of euploidy and a high probability of aneuploidy observed when the first plane of division was perpendicular to the pronuclear axis.

Hyaluronan-enriched transfer medium (HETM) can improve the implantation rate in morphologically poor euploid blastocyst transfer.

PURPOSE: Hyaluronan-enriched transfer medium (HETM) could improve the clinical pregnancy rate (CPR) for patients with repeated implantation failures (RIF). In contrast, there have been seldom reports addressing the potentially beneficial effects of HETM for morphologically poor blastocysts (MPBLs). Our study aimed to evaluate whether the use of HETM would improve the CPR for the patients who were transferred with euploid MPBLs. METHODS: Patients who underwent single euploid blastocyst transfer between July 2020 and June 2022 were enrolled. We included only those blastocysts confirmed as euploid by PGT-A, and those blastocysts were transferred after thawing. The natural ovulatory cycle or hormone replacement cycle (HRC) protocol were used for endometrial preparation for frozen embryo transfer (FET). A total of 1,168 FET cycles were performed in the study period, including 954 cycles of morphologically good blastocysts (≥ 4BB in Gardner's classification), and 85 cycles of MPBLs, of which 47 were transferred using HETM in FET (the HETM group), and the remaining 38 were transferred with the medium without hyaluronan (the control group). We compared the CPR between these two groups. RESULTS: The characteristics of patients were similar between the HETM and control groups. The CPR in the HETM group was significantly higher than the control group (47.4% and 21.5%, respectively, p = 0.019). The multiple logistic regression analysis found that the use of HETM was a predictive factor of positive pregnancy outcomes (OR = 5.08, 95% CI = 1.62-16.0, p = 0.019). CONCLUSION: Our data suggests that HETM used in the euploid blastocyst transfer can improve the clinical pregnancy rates of morphologically poor blastocysts.

A very rare case of endometriosis presenting with massive hemoperitoneum.

Endometriosis is a cause of acute abdomen because of the leakage or rupture of endometriotic cyst and tubo-ovarian abscess. However, massive hemoperitoneum as a cause of acute abdomen with endometriosis is very rare. We herein present a case of a 48-year-old woman who was urgently referred to our clinic with colic, abdominal distension, and hypovolemic shock during menstruation. Ultrasonography revealed massive hemorrhagic ascites. Exploratory laparoscopy was urgently performed to achieve hemostasis. The volume of hemoperitoneum evacuated from the pelvis was 1,890 mL. Although the uterus and bilateral ovaries were normal, fresh bleeding was observed from endometriosis on the left cul-de-sac peritoneum, and hemostasis was successfully performed. The potential occurrence of hemorrhagic shock associated with endometriosis, depending on the implantation site, needs to be recognized.

Decreasing full-term neonatal birthweight over the past 2 decades in a single institute in Japan.

AIM: The aim of this study was to investigate whether full-term neonatal birthweight is decreasing or not. MATERIAL AND METHODS: Subjects were selected from the registration database of full-term singletons from a single local practitioner at two time-points, 1991 (n = 750) and 2011 (n = 442). Maternal age, parity, and smoking habits were recorded. Baseline characteristics included pre-pregnancy bodyweight (BW), body mass index (BMI), bodyweight before parturition, and weight gain during pregnancy. Neonatal birthweight and height were recorded. Variables correlated with neonatal size were investigated. RESULTS: Male birthweight decreased from 3248 ± 409 (n = 373) to 3149 ± 430 g (n = 230) (P < 0.001). Female birthweight also decreased from 3148 ± 378 (n = 377) to 3063 ± 343 g (n = 212) (P < 0.01). Gestational age was shorter (40.1 ± 1.1 to 39.6 ± 1.1 weeks, P < 0.001). Pre-pregnancy maternal BMI did not change (20.7 ± 2.6, n = 750 to 20.5 ± 2.7, n = 442). Weight gain during pregnancy decreased (11.3 ± 3.8 to 10.8 ± 3.4 kg, P < 0.05) and was positively correlated with birthweight (P < 0.001). On multiple regression analysis, time was inversely correlated with birthweight, while it was positively correlated with pre-pregnancy BMI, weight gain during pregnancy, and gestational age. CONCLUSIONS: In addition to maternal slenderness, increasing lower weight gain during pregnancy and medical intervention by physicians may in part contribute to the decrease in full-term birthweight over the past 2 decades.

Successful Management and Birth After Perimortem Cesarean Delivery and Stillbirth Due to Anaphylaxis.

Perimortem cesarean delivery is an effective procedure for cardiopulmonary resuscitation during pregnancy. However, there are no reports documenting long-term outcomes in perimortem cesarean delivery survivors. This may be the first report of a successful live birth, occurring two years after perimortem cesarean delivery. A 29-year-old primipara was transferred to the emergency center on account of cardiopulmonary arrest, at 33 weeks of gestation. She was resuscitated 47 min after cardiopulmonary arrest by perimortem cesarean delivery amongst other treatment modalities, although the fetus died. Two months later, she was discharged with a preserved uterus, and no neurological damage. The couple suffered from posttraumatic stress disorder, which they overcame with the support of the multidisciplinary team, then gave birth to a healthy baby 2 years later. To overcome cardiopulmonary arrest during pregnancy, a seamless approach by a multidisciplinary team is essential for a good patient outcome.

Original delayed-start ovarian stimulation protocol with a gonadotropin-releasing hormone antagonist, medroxyprogesterone acetate, and high-dose gonadotropin for poor responders and patients with poor-quality embryos.

Introduction: The delayed-start gonadotropin-releasing hormone antagonist protocol seems effective for patients who are poor ovarian responders, but there are insufficient data on whether it is also effective for patients with poor-quality embryos and low rates of good blastocyst formation. Specifically, the effectiveness of delayed-start gonadotropin-releasing hormone antagonists with progesterone has not been adequately investigated. Therefore, we compared the efficacy of the original delayed-start gonadotropin-releasing hormone antagonist protocol using medroxyprogesterone acetate (MPA) and high-dose gonadotropin in patients with poor ovarian response. Methods: Overall, 156 patients with recurrent assisted reproductive technology failure who underwent the original protocol were included. They received cetrorelix acetate (3 mg) and MPA (10 mg) on cycle day 3, and high-dose gonadotropin was initiated on day 11. When the leading follicle reached 14 mm, ganirelix acetate (0.25 mg) was administered until the trigger day. The number of oocytes retrieved, metaphase II (MII) oocytes, two pronuclear (2PN) zygotes, and good blastocysts and live birth rates were compared between the previous (Cycle A) and original (Cycle B) cycles in three groups (Group A, all patients; Group B, poor responders; and Group C, patients with poor-quality embryos). Results: In Group A (n=156), the number of MII oocytes (3.6 ± 3.3 versus 4.5 ± 3.6), 2PN zygotes (2.8 ± 2.9 versus 3.8 ± 3.1), good blastocysts (0.5 ± 0.9 versus 1.2 ± 1.6), and live birth rates (0.6 versus 24.4) significantly increased in Cycle B. Similar results were obtained in Group B (n=83; 2PN zygotes [1.7 ± 1.7 versus 2.3 ± 1.8], good blastocysts [0.4 ± 0.7 versus 0.9 ± 1.3], live birth rates [0 versus 18.1]) and Group C (n=73; MII oocytes [5.1 ± 3.8 versus 6.6 ± 4.0], 2PN zygotes [4.0 ± 3.4 versus 5.4 ± 3.4], good blastocysts [0.7 ± 1.1 versus 1.6 ± 1.9], and live birth rates [1.4 versus 31.5]). Conclusion: This original protocol increased the number of MII oocytes retrieved, 2PN zygotes, good blastocysts, and live birth rates in both poor responders and in patients with poor-quality embryos.

Complete labial fusion with urinary incontinence in a postmenopausal woman: A case report.

An 83-year-old woman presented to a rural general hospital with urinary incontinence. She was diagnosed with complete labial fusion caused by genitourinary syndrome of menopause. She was successfully treated with surgical separation followed by hydrocolloid dressings. Genitourinary syndrome of menopause often remains undiagnosed due to patient embarrassment. Greater recognition of this condition in primary care can improve patient access to appropriate treatment and improve quality of life.

Successful management of vulvar proximal-type epithelioid sarcoma in pregnancy.

Vulvar proximal-type epithelioid sarcoma during pregnancy is extremely rare; only two reports are available to date. Herein, we describe a 36-year-old woman who presented with a pigeon-egg-sized solid mass with cystic component on the left labia majora at 18 weeks of gestation. The patient underwent tumor resection at 23 weeks of gestation and was diagnosed with epithelioid sarcoma, proximal-type. At 29 weeks of gestation, elective cesarean section, radical local resection of the vulva and vagina, and inguinal lymphadenectomy were performed. After surgery, she underwent six courses of adjuvant chemotherapy (doxorubicin 60 mg/m2 and cisplatin 50 mg/m2) every four weeks. The patient and her baby survived with neither recurrence nor complications until 5 years. Aggressive management for proximal-type epithelioid sarcoma, such as early termination of pregnancy and operation, can improve maternal outcomes.

Clinical outcome of stage Ia1 squamous cell carcinoma of the uterine cervix and pathological findings of initial conization.

AIM: The present study investigated the clinical outcome of stage Ia1 squamous cell carcinoma (SCC) of the uterine cervix at a single institute. MATERIALS AND METHODS: Subjects were 84 patients with cervical SCC, International Federation of Gynecology and Obstetrics stage Ia1 diagnosed according to conization findings between January 2000 and June 2009. Correlations between clinical outcome and pathological findings on initial conization were investigated. RESULTS: Of 65 hysterectomy (without pelvic lymphadenectomy) patients, two (3.1%) showed metastasis to the vaginal wall, and two (3.1%) to the pelvic lymph nodes. Five patients (6.0%) showed lymphovascular invasion, and three (3.6%) showed confluent patterns of stromal invasion (confluent invasion) on initial conization findings. All of these five patients were included in the hysterectomy group. Of 19 patients with conization alone, two showed vaginal metastasis. Of four patients with vaginal metastasis, two showed lymphovascular invasion and one showed confluent invasion despite negative conization margin. In patients with nodal metastasis, stromal invasion of 3.0 mm and 2.8 mm, and horizontal spread of 6.8 mm and 6.9 mm were observed on conization, respectively. All patients are currently alive due to adequa\e therapy including chemo-radiation for six patients with recurrent disease. CONCLUSIONS: In patients showing stromal invasion of nearly 3.0 mm and horizontal spread of nearly 7.0 mm in stage Ia1 cervical SCC, pelvic lymphadenectomy may be considered. Even for patients showing a negative conization margin, careful follow up is necessary, because vaginal metastasis sometimes occurs.

The Optimal Cutoff Level of D-Dimer during Pregnancy to Exclude Deep Vein Thrombosis, and the Association between D-Dimer and Postpartum Hemorrhage in Cesarean Section Patients.

OBJECTIVE: The main purpose was to clarify the optimal D-dimer cutoff level during pregnancy to exclude deep vein thrombosis (DVT) prior to Cesarean section. The secondary purpose was to determine whether D-dimer can predict severe postpartum hemorrhage (PPH) in Cesarean section patients. METHODS: Two hundred and seventy eight elective Cesarean section cases were enrolled. Clinical factors and blood parameters at 34-37 weeks of gestation were analyzed. To detect DVT, lower extremities veins were examined using color Doppler ultrasonography in cases with D-dimer level ≥ 1.5 µg/mL. In addition, postpartum blood loss amounts during Cesarean section were recorded. RESULTS: Five DVT cases occurred in 250 singleton pregnancies, and 2 DVT cases occurred in 28 twin pregnancies. The overall incidence of DVT was 2.5%. The D-dimer level was higher in DVT cases than in non-DVT cases (3.84±1.97 vs. 2.31±1.48 µg/mL, P<0.01). The optimal D-dimer cutoff level was 2.6 µg/mL with a negative predic tive value of 99.5%, and sensitivity of 85.7%. PPH during Cesarean section was positively correlated with D-dimer level in all pregnancies. However, this relationship disappeared after excluding twin pregnancies. CONCLUSION: A D-dimer level < 2.6 µg/mL at 34-37 weeks of gestation has the potential to exclude DVT. D-dimer can be an independent predictor for severe PPH for all Cesarean section cases, including twin pregnancies.

Cervical pessary plus vaginal progesterone versus long-term tocolysis for the prevention of preterm birth: An observational retrospective study.

OBJECTIVE: To compare cervical pessaries plus vaginal progesterone versus long-term tocolysis for preventing preterm birth for women with a short cervix. METHODS: Retrospective evaluation of women with singleton pregnancy who received cervical pessaries plus vaginal progesterone (combined group) or ritodrine hydrochloride (tocolysis group) for short cervix (≤25 mm at 20-24 weeks, or ≤20 mm at 25-34 weeks) at a general hospital in Kagoshima, Japan, 2015-2019. The primary outcome was rate of preterm birth (<36 weeks); secondary outcomes were maternal hospital admittance and treatment complications. RESULTS: Data were evaluated from 95 women (combined group, n=43; tocolysis group, n=52). There was no significant difference in cervical length or gestational age at intervention between the groups. Overall, 3/43 (7.0%) women delivered before 36 weeks in the combined group versus 16/52 (30.8%) in the tocolysis group (relative risk, 0.56; 95% confidence interval, 0.41-0.76; P=0.004). Median maternal admittance was shorter in the combined group (6.6 vs 41.0 days, P<0.001). Although 36/43 (83.7%) women in the combined group reported increased vaginal discharge, no major complications occurred. CONCLUSION: A combination of pessaries and vaginal progesterone reduced the rate of preterm birth (<36 weeks) for women with short cervix as compared with long-term tocolysis.

Predictive Factors for Efficacy and Safety of Prophylactic Theophylline for Extubation in Infants with Apnea of Prematurity.

PURPOSE: This study aimed to evaluate predictive factors involved in efficacy and safety in Japanese infants who received theophylline therapy to prevent apnea of prematurity (AOP) after weaning from mechanical ventilation. METHODS: We retrospectively reviewed the medical records of infants who were administered intravenous aminophylline (theophylline ethylenediamine) for AOP at the neonatal intensive care unit, Kagoshima University Hospital, Japan, between January 2009 and June 2013. RESULTS: A total of 100 infants were evaluated as two separate groups in terms of efficacy and safety of theophylline. Sixty-seven (67.0%) infants had effective theophylline therapy. Multivariate logistic regression analysis showed that gestational age at birth was significant, with an odds ratio of 0.59 (p < 0.001). Receiver operating characteristic analysis showed that the cut-off value was 31.1 weeks old for predicting the efficacy of theophylline (specificity, 66.7%; sensitivity, 86.6%; p < 0.001; area under the curve, 0.750; 95% confidence interval, 0.45-0.74). Adverse reactions were identified in 21 (21.0%) infants. Multivariate logistic regression analysis showed that the number of days of theophylline administration from birth was associated with an increased risk of adverse reactions after theophylline administration (p = 0.01). CONCLUSIONS: Physicians need to be aware of the possibility that theophylline fails to produce therapeutic effects for extubation in infants aged less than 31.1 weeks old, and adverse reactions can easily develop when theophylline is administered soon after birth.

Clinical Usefulness of Bakri Balloon Tamponade in the Treatment of Massive Postpartum Uterine Hemorrhage.

Intrauterine globe-shaped metreurynter tamponade has been used for some time to treat massive postpartum hemorrhage (PPH). More recently, the Bakri balloon has come into use to treat PPH. It is made of silicon, possesses a drainage lumen, and has a sausage-like spindle shape. The aim of the present study was to investigate the clinical usefulness of Bakri balloon tamponade for massive PPH. Subjects in the present study comprised 5 patients with uterine atony, 3 with placenta previa, and 2 with low-lying placenta. All patients exhibited massive PPH and resistance to conventional hemostatic managements. Bakri balloon tamponade was appliedto these 10 patients. The mean amounts of uterine bleeding (average ± SD) before and after Bakri insertion were2,732 ± 1,397 mL and 380 ± 376 mL, respectively. The median (third-first quartile ranges) volume of salineinflating the balloon was 200 mL (300-150 mL). The median (third-first quartile ranges) indwelling duration of Bakri balloon was 24 hours (24-11 hrs). The overall success rate of Bakri balloon tamponade was 90% (9/10).There were no cases of slipping out or complications regarding balloon placement. Our findings suggest that Bakri balloon tamponade may be applied to the treatment of massive PPH in uterine atony and placenta previa.The Bakri balloon appears to have the following merits: (1) easy insertion into the uterine cavity and low rate of slipping out, (2) proper conformability to the hemorrhagic area due to its spindle shape, (3) ability to monitor blood loss through the drainage lumen even after insertion.