Evaluating the effectiveness of lateral postural management for breech presentation: study protocol for a randomized controlled trial (BRLT study).

BACKGROUND: Breech presentation is observed in 3-4% at term of pregnancy and is one of the leading causes of cesarean section. There is no established treatment for breech presentation before 36 weeks. A retrospective cohort study was conducted to demonstrate that the lateral position is effective for breech presentation. However, there are no randomized controlled trials evaluating lateral position management for breech presentation. Here, we described the methodology of a randomized controlled trial of a cephalic version for breech presentation in the third trimester by lateral postural management (BRLT study). METHODS: The BRLT study is an open-label, randomized controlled trial with two parallel groups allocated in a 1:1 ratio to examine the lateral position management for breech presentation, as compared with expectant management care. An academic hospital in Japan will enroll 200 patients diagnosed with a breech presentation by ultrasonography between 28 + 0 weeks and 30 + 0 weeks. Participants in the intervention group will be instructed to lie on their right sides for 15 min three times per day if the fetal back was on the left side or lie on their left sides if the fetal back was on the right side. The instruction will be given every 2 weeks after confirmation of fetal position, and the lateral position will be instructed until the cephalic version, and after the cephalic version, the reverse lateral position will be instructed until delivery. The primary outcome is cephalic presentation at term. The secondary outcomes are cesarean delivery, cephalic presentation 2, 4, and 6 weeks after the instruction, and at delivery, recurrent breech presentation after cephalic version, and adverse effects. DISCUSSION: This trial will answer whether the lateral positioning technique is effective in treating breech presentation and, depending on the results, may provide a very simple, less painful, and safe option for treating breech presentation before 36 weeks, and it may impact breech presentation treatment. TRIAL REGISTRATION: UMIN Clinical Trials Registry UMIN000043613. Registered on 15 March 2021 https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000049800 .

Neonatal Respiratory Morbidity after Late Preterm, Singleton, Cesarean Delivery before Labor by Mothers Who Did Not Receive Antenatal Corticosteroids.

BACKGROUND: Some evidence suggests that administration of antenatal corticosteroids (ACS) reduces neonatal respiratory complications among women at risk for late preterm birth. However, because of concerns regarding long-term outcomes of children, ACS is not recommended in Japan for pregnant women at risk in late preterm. We assessed the risk of neonatal respiratory morbidity after late preterm, singleton, cesarean delivery before labor by mothers who did not receive ACS. METHODS: We retrospectively reviewed and analyzed data on singleton cesarean deliveries of late preterm infants. The prevalence of neonatal respiratory morbidity requiring ventilatory support, such as continuous positive airway pressure or mechanical ventilation, was analyzed in relation to gestational age in late preterm. Respiratory distress syndrome (RDS) in neonates was also evaluated. RESULTS: We analyzed data from 100 late preterm, singleton, cesarean deliveries: 22 neonates were delivered at 34 weeks, 34 at 35 weeks, and 44 at 36 weeks. Respiratory morbidity significantly decreased in relation to gestational age (p < 0.001). Similarly, there was a significant difference in RDS, which was most frequent at 34 weeks (18.2%, p = 0.017). There were no cases of RDS at 36 weeks. CONCLUSION: Late preterm, singleton, cesarean delivery before labor in mothers who did not receive ACS was associated with a need for ventilation, especially for infants born at 34 and 35 weeks. ACS treatment might therefore be beneficial before elective cesarean section for mothers with a risk of preterm delivery before 35 weeks and 6 days.

Exponential increase of the gestational-age-specific incidence of preeclampsia onset (COPE study): a multicenter retrospective cohort study in women with maternal check-ups at <20 weeks of gestation in Japan.

According to the 2004 Japanese definition, early-onset (EO) preeclampsia (PE) is defined as PE occurring at <32 weeks of gestation. This was based on the presence of "dual peaks" (30-31 and 34-35 weeks) in the prevalence of severe forms of hypertension. In contrast, the international definition adopted a cutoff of 34 weeks based on the consensus. Our aim was to investigate whether there were "dual peaks" in the gestational-age-specific incidence or prevalence of PE onset in pregnant women who underwent maternal check-ups at <20 weeks of gestation in a multicenter retrospective cohort study. Diagnoses of PE and superimposed preeclampsia (SPE) were based on the new Japanese definition. A total of 26,567 pregnant women with singleton pregnancy were investigated. The best fitting equations for the distribution of the onset of gestational-age-specific incidence (hazard) rates of PE/SPE, PE, and PE with severe hypertension (a systolic blood pressure ≥160 and/or a diastolic blood pressure ≥110 mmHg) were investigated using the curve estimation function in SPSS. PE/SPE occurred in 1.83% of the patients. EO-PE/SPE with onset at <32 and <34 weeks of gestation and preterm PE/SPE occurred in 0.38, 0.56, and 1.07% of the patients, respectively. Gestational-age-specific incidence rates of PE/SPE, PE, and PE with severe hypertension showed exponential increases, with very high R2 values (0.975, 0.976, and 0.964, respectively). There were no "dual peaks" in the prevalence rates of women with SPE/PE, PE, and PE with severe hypertension. In conclusion, the absence of "dual peaks" refutes the previous rationale of EO-PE being defined as PE at <32 weeks of gestation. Further studies to determine an appropriate definition of EO-PE/SPE are needed.

Maternal cell contamination in embryonic chromosome analysis of missed abortions.

AIM: The fetal sample used for embryonic chromosome analysis is often contaminated with maternal cells, making it difficult to evaluate the fetal chromosomes. We examined on the rate of maternal cell contamination and its relationship with maternal information in the embryonic chromosome analysis of missed abortions using the Giemsabanding method. METHODS: Chromosome analysis was performed in 200 cases of delayed miscarriages in first trimester between July 1, 2000 and May 31, 2019. Chorionic villi were collected and were analyzed using the Giemsa banding method. Among the 20 cells for which chromosomal examination was performed, cells wherein 46,XX chromosomes were found together with normal male karyotype or abnormal chromosomes were defined as maternal cell contamination. RESULTS: Of the 200 cases analyzed, 136 had abnormal chromosomes. The normal female karyotype (n = 52) was four times more prevalent than the normal male karyotype (n = 12). Maternal cell contamination was seen in 15.4% of the abnormal chromosome cases and 8.3% of the normal male karyotype cases. There was no significant difference in the gestational age between the contaminated and noncontaminated groups at the time of miscarriage diagnosis. However, miscarriage before fetal heartbeat confirmation was significantly associated with higher maternal cell contamination. CONCLUSION: We found maternal cell contamination in 15% of all the cases. Moreover, in many cases of the normal female karyotype, it was suspected that only maternal chromosomes were cultured. When performing embryonic chromosome analysis in recurrent miscarriages, we should pay attention to maternal cell contamination and interpret the results accordingly.

Proportion of Late Pregnant Women with Anxiety Symptom under COVID-19 Pandemic in Japan.

INTRODUCTION: The COVID-19 pandemic has caused stress and anxiety for pregnant women worldwide. We examined the anxiety symptom in Japanese women during pregnancy using a self-administered questionnaire under the COVID-19 pandemic. METHODS: Between April 2020 and March 2021 (2020, the COVID-19 pandemic), we asked 248 Japanese women without history of mental disorders who delivered singleton neonates at 37-41 weeks' gestation to answer the two-item generalized anxiety disorder scale (GAD-2) at first, second, and third trimesters of gestation. We also asked 311 women with the same situation between January 2019 and December 2019 (2019) as control. RESULTS: The women with anxiety symptom were common during the first trimester of gestation irrespective of COVID-19 pandemic. In 2019, the proportion of the women with anxiety symptom decreased as the trimester of pregnancy progressed (p < 0.01); however, in 2020, the proportion of women with anxiety symptom did not decrease during pregnancy. During the late pregnancy, the proportions of women with anxiety symptom in 2020 were significantly higher than those in 2019 (p < 0.01) regardless of maternal parity or age in Japan. CONCLUSION: The COVID-19 pandemic seemed to prevent the decrease in anxiety symptom that should decrease as pregnancy progresses regardless of maternal parity or age in Japan.

Prevalence of common aneuploidy in twin pregnancies.

The incidence of chromosomal abnormalities in twin pregnancies is not well-studied. In this retrospective study, we investigated the frequency of chromosomal abnormalities in twin pregnancies and compared the incidence of chromosomal abnormalities in dichorionic diamniotic (DD) and monochorionic diamniotic (MD) twins. We used data from 57 clinical facilities across Japan. Twin pregnancies of more than 12 weeks of gestation managed between January 2016 and December 2018 were included in the study. A total of 2899 and 1908 cases of DD and MD twins, respectively, were reported, and the incidence of chromosomal abnormalities in one or both fetuses was 0.9% (25/2899) and 0.2% (4/1908) in each group (p = 0.004). In this study, the most common chromosomal abnormality was trisomy 21 (51.7% [15/29]), followed by trisomy 18 (13.8% [4/29]) and trisomy 13 (6.9% [2/29]). The incidence of trisomy 21 in MD twins was lower than that in DD twins (0.05% vs. 0.5%, p = 0.007). Trisomy 21 was less common in MD twins, even when compared with the expected incidence in singletons (0.05% vs. 0.3%, RR 0.15 [95% CI 0.04-0.68]). The risk of chromosomal abnormality decreases in twin pregnancies, especially in MD twins.

Effects of Thrombophilia and Antithrombotic Therapy on Embryonic Chromosomal Aberration Rates in Patients with Recurrent Pregnancy Loss.

BACKGROUND: Miscarriage occurs in 10-15% of pregnancies and recurrent pregnancy loss (RPL) occurs in 1% of couples hoping for a child. Various risk factors, such as thrombophilia, uterine malformation, and embryonic chromosomal aberration cause RPL. We hypothesized that antithrombotic therapy for RPL patients with thrombophilia would reduce miscarriage due to thrombophilia, which would reduce the total miscarriages and result in a relative increase in miscarriage due to embryonic chromosomal aberrations. In this study, we investigated the incidence of chromosomal aberrations in products of conception in RPL patients with and without antithrombotic therapy. METHODS: We performed a single-center, retrospective review of cases diagnosed as miscarriage with embryo chromosome analysis between July 1, 2000, and May 31, 2019. Rates of chromosomal aberration were compared between RPL patients with and without thrombophilia or antithrombotic therapy. RESULTS: One hundred and-ninety RPL cases were analyzed. The average age was 37.4 ± 4.3 years, and the average number of previous pregnancy losses was 2.2 ± 1.1. The overall chromosomal aberration rate was 67.4% (128/190). There was no difference in the chromosomal aberration rate between the factors for RPL, with or without thrombophilia, and antithrombotic therapy. Only advancing maternal age had significant correlation to increased embryo chromosomal aberration rates. CONCLUSIONS: With or without antithrombotic therapy, miscarriage was caused by embryonic chromosome abnormalities at a certain rate. Antithrombotic therapy in RPL patients with thrombophilia may reduce abortions due to thrombophilia, which may also normalize the rate of embryonic chromosome aberrations in the subsequent miscarriages.

Evaluation of the clinical performance of noninvasive prenatal testing at a Japanese laboratory.

AIM: We aimed to evaluate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of noninvasive prenatal testing (NIPT) in high-risk pregnant women. METHODS: Pregnant women who underwent GeneTech NIPT, the most commonly used NIPT in Japan, between January 2015 and March 2019, at Japan NIPT Consortium medical sites were recruited for this study. The exclusion criteria were as follows: pregnant women with missing survey items, multiple pregnancy/vanishing twins, chromosomal abnormalities in the fetus other than the NIPT target disease, and nonreportable NIPT results. Sensitivity and specificity were calculated from the obtained data, and maternal age-specific PPV and NPV were estimated. RESULTS: Of the 45 504 cases, 44 263 cases fulfilling the study criteria were included. The mean maternal age and gestational weeks at the time of procedure were 38.5 years and 13.1 weeks, respectively. Sensitivities were 99.78% (95% confidence interval [95% CI]: 98.78-99.96), 99.12% (95% CI: 96.83-99.76), and 100% (95% CI: 88.30-100) for trisomies 21, 18, and 13, respectively. Specificities were more than 99.9% for trisomies 21, 18, and 13, respectively. Maternal age-specific PPVs were more than 93%, 77%, and 43% at the age of 35 years for trisomies 21, 18, and 13, respectively. CONCLUSION: The GeneTech NIPT data showed high sensitivity and specificity in the detection of fetal trisomies 21, 18, and 13 in high-risk pregnant women, and maternal age-specific PPVs were obtained. These results could provide more accurate and improved information regarding NIPT for genetic counseling in Japan.

Statistical Evaluation of the First Year of a Neonatal Intensive Care Unit Established in a Medical School Hospital.

BACKGROUND: There has been significant progress in reducing perinatal mortality in Japan. However, due to changes in social conditions, the total fertility rate and the number of births are decreasing, whereas the number of low birth weight infants is increasing along with the number of newborn babies that require intensive care. Further, although the number of high-level perinatal medical centers has increased, so has that of infants who need long-term hospitalization. Conversely, the number of regular obstetric facilities has decreased, thus resulting in insufficient beds for neonatal care. To fill this gap, we established a neonatal intensive care unit (NICU) at our hospital. This study aimed to evaluate our new type by comparing the data from ours with that from other facilities. METHODS: The other facilities assessed were two high-level NICU facilities and two regular obstetric facilities. Data, including sex, gestational age, birth weight, Apgar scores at 1 and 5 min, delivery method, and presence of breathing disorders, were extracted from medical records. RESULTS: The birth weight and gestational age distributions were significantly different in the institutions, except in one facility without a NICU. The new NICU saw more infants with low birth weight and respiratory disorders than the regular obstetric facilities. CONCLUSION: The comparison of birth weight and gestational age distributions, cases of respiratory disorders, and delivery methods indicate that our new NICU is positioned as an intermediate facility between a high-level NICU and a regular obstetrics facility.

Successful Management of Complicated Uterine Displacement Caused by Unilateral Incarceration of the Bicornuate Uterus.

Uterine incarceration is a serious complication of pregnancy, in which the gravid uterus becomes trapped in the posterior pelvis. When labor occurs, delivery does not progress, and the uterus may rupture. Therefore, preoperative diagnosis of uterine incarceration is important, and a caesarian section is indispensable except when the polarity of the uterus can be successfully restored. We report the case of a 35-year-old primipara with a complication of a bicornuate uterus who became pregnant after in vitro fertilization and embryo transfer. No abnormality was observed on regular checkups until the second trimester. At 28 weeks' gestation, the uterine cervix revealed marked dislocation, and, at 31 weeks, magnetic resonance imaging (MRI) revealed uterine cervix elongation and left horn incarceration. At 37 weeks' gestation, an elective cesarean section was performed. On laparotomy, the uterus was found to be markedly dislocated, and distended blood vessels were observed on the surface. Ultrasound examination was performed directly on the uterine wall to decide the incision site. After delivery of the baby, manual repositioning of the uterus revealed the unique concurrent clockwise rotation and retro-vertical deflection. Thus, we concluded that incarceration accompanied by a bicornuate uterus can cause complicated uterine displacement, and preoperative MRI and intraoperative ultrasound examination are useful for managing this condition.

Diversity of progesterone action on lipopolysaccharide-induced expression changes in cultured human cervical fibroblasts according to inflammation and treatment timing.

PROBLEM: The effectiveness of progesterone (P4) treatment for preventing preterm births is unclear. Its effects on the uterine cervix were tested using cultured human uterine cervical fibroblasts (UCFs). METHOD OF STUDY: UCFs were incubated with lipopolysaccharide (LPS) in the presence or absence of P4 under various conditions. mRNA was subjected to PCR arrays and real-time RT-PCR to assess IL-6, IL-8, IL-1beta, PTGS2, MMP-1, and CXCL10 expression. RESULTS: When exposed to a high-LPS concentration (2.0 µg/mL), expression of these genes was not suppressed by simultaneous P4 (1.0 µmol/L) treatment, but it was significantly inhibited when P4 was administered 1 hour prior to LPS, with the exception of the chemokines IL-8 and CXCL10. Expression of all genes was restricted by P4 under low-level LPS (0.2 µg/mL) stimulation, especially when administered prior to LPS treatment. CONCLUSION: These data suggest that early or prophylactic P4 administration is an effective and important measure for reducing preterm birth risk.

Placenta-specific miRNA (miR-512-3p) targets PPP3R1 encoding the calcineurin B regulatory subunit in BeWo cells.

AIM: The microRNAs (miRNAs) derived from the chromosome 19 miRNA cluster (C19MC) are exclusively expressed in the human placenta, but the origin and functions of C19MC miRNAs are not fully understood. The purpose of this study was to elucidate which cells express C19MC miRNAs in chorionic villi and identify their miRNA targets. METHODS: A combination of laser microdissection (LMD) and real-time polymerase chain reaction (PCR) to examine the localization of five C19MC miRNAs (i.e. miR-512-3p, miR-518b, miR-520a, miR-524 and miR-1323) in the human placenta was performed. Furthermore, to identify miR-512-3p-target genes, we analyzed gene expression profiles of the trophoblast cell line BeWo using a DNA microarray. Predicted target genes were validated by real-time PCR, western blotting, and 3'-untranslated region reporter assay. RESULTS: By LMD and subsequent PCR analysis, five C19MC miRNAs examined in this study were predominantly expressed in villous trophoblast cells; little expression, if any, was observed in villous stroma cells or fetal endothelial cells. Microarray data showed that 334 genes were downregulated in BeWo cells treated with Pre-miR-512-3p (mature miR-512-3p mimic). We found six candidate target genes of miR-512-3p using DNA microarray data and target prediction software. Furthermore, we revealed that protein phosphatase 3, regulatory subunit B, alpha (PPP3R1), one of the six genes, was a miR-512-3p target using an in vitro experimental validation system. CONCLUSION: These data suggest that miR-512-3p participates in human trophoblast function[s] by targeting PPP3R1, encoding a regulatory subunit of calcineurin.

Hydroxysteroid (17-ß) dehydrogenase 1 is dysregulated by miR-210 and miR-518c that are aberrantly expressed in preeclamptic placentas: a novel marker for predicting preeclampsia.

In this study, to search for novel preeclampsia (PE) biomarkers, we focused on microRNA expression and function in the human placenta complicated with PE. By comprehensive analyses of microRNA expression, we identified 22 microRNAs significantly upregulated in preeclamptic placentas, 5 of which were predicted in silico to commonly target the mRNA encoding hydroxysteroid (17-ß) dehydrogenase 1 (HSD17B1), a steroidogenetic enzyme expressed predominantly in the placenta. In vivo HSD17B1 expression, at both the mRNA and protein levels, was significantly decreased in preeclamptic placentas. Of these microRNAs, miR-210 and miR-518c were experimentally validated to target HSD17B1 by luciferase assay, real-time PCR, and ELISA. Furthermore, we found that plasma HSD17B1 protein levels in preeclamptic pregnant women reflected the decrease of its placental expression. Moreover, a prospective cohort study of plasma HSD17B1 revealed a significant reduction of plasma HSD17B1 levels in pregnant women at 20 to 23 and 27 to 30 weeks of gestation before PE onset compared with those with normal pregnancies. The sensitivities/specificities for predicting PE at 20 to 23 and 27 to 30 weeks of gestation were 0.75/0.67 (cutoff value=21.9 ng/mL) and 0.88/0.51 (cutoff value=30.5 ng/mL), and the odds ratios were 6.09 (95% CI: 2.35-15.77) and 7.83 (95% CI: 1.70-36.14), respectively. We conclude that HSD17B1 is dysregulated by miR-210 and miR-518c that are aberrantly expressed in preeclamptic placenta and that reducing plasma level of HSD17B1 precedes the onset of PE and is a potential prognostic factor for PE.

Spontaneous uterine perforation due to clostridial gas gangrene associated with endometrial carcinoma.

Few cases of clostridial gas gangrene associated with uterine malignancy have been reported. We report on a 46-year-old woman with clostridial sepsis. On the day of admission due to severe abdominal pain, peritonitis was diagnosed, and computed tomography showed free air in the abdomen. At emergency laparotomy, perforation of the necrotic uterine wall was observed. During hysterectomy, septic shock developed, and life-saving therapy was performed in the intensive care unit after surgery. Pathological examination of the necrotic uterine wall showed grade III endometrial adenocarcinoma of the uterine endometrium (International Federation of Gynecology and Obstetrics stage IIIa) with gas gangrene due to Clostridium perfringens. This report aims to alert gynecologists to the possibility that clostridial gas gangrene of the uterus can occur in patients with peritonitis and intra-abdominal free air. Early recognition and aggressive therapy can save patients' lives.

Significance of cervical gland area in predicting preterm birth for patients with threatened preterm delivery: comparison with cervical length and fetal fibronectin.

BACKGROUND/AIMS: Absent cervical gland area (CGA) has been considered a predictor of preterm delivery (PTD) for women at low risk. Predictive efficacy was analyzed in women at high risk for PTD and compared with cervical length (CL) <20 mm and fetal fibronectin (fFN) in cervicovaginal secretions. METHODS: Case notes were reviewed for 108 subjects with gestation of 22-33 weeks who had been admitted to hospital with threatened PTD. The uterine cervix was observed by vaginal sonography and fFN was sampled on admission. Relationships between findings and outcome of PTD at <34 weeks' gestation were analyzed. RESULTS: Delivery at <34 weeks' gestation occurred in 14.8% of patients. Absent CGA (68.8%), short CL (75.0%), short CL without CGA (62.5%) and positive fFN (62.5%) were more frequent in these patients than in patients undelivered at <34 weeks' gestation (p < 0.05). Logistic regression analysis identified positive fFN and short CL with absent CGA as independent predictors for PTD (p < 0.0001). The mean interval from admission to delivery was 2.9 weeks in cases with fFN and both sonographic findings, compared to 9.3 weeks in cases with fFN but both sonographic finding (p = 0.0005). CONCLUSION: Short CL with absent CGA represents an independent predictor for PTD, as does fFN.