Association between Gestational Weight Gain and Risk of Hypertensive Disorders of Pregnancy among Women with Obesity: A Multicenter Retrospective Cohort Study in Japan.

The relationship between weight gain during pregnancy and the onset of hypertensive disorders of pregnancy in women with pre-pregnancy obesity remains unclear. We examined the effects of weight gain during pregnancy on hypertensive disorders of pregnancy among women with pre-pregnancy body mass index (BMI) ≥ 25.0 kg/m2. This multicenter retrospective cohort study included nullipara women who delivered at two units in Japan between 1 January 2013, and 31 December 2020. Singleton primipara (n = 3040) were categorized into two pre-pregnancy BMI groups: 25.0-<30.0, and ≥30.0 kg/m2. Using multiple logistic regression analyses (reported as adjusted odds ratio and 95% confidence interval), gestational weight gain effects on overall hypertensive disorders of pregnancy, gestational hypertension, and pre-eclampsia were determined. Gestational weight gain increased hypertensive disorders of pregnancy (1.09, 1.03-1.16, p < 0.05) and pre-eclampsia risk (1.10, 1.01-1.20, p < 0.05) among the BMI 25.0-<30.0 kg/m2 group and hypertensive disorders of pregnancy risk among the ≥30.0 kg/m2 group (1.07, 1.00-1.05, p < 0.05). Using receiver operating characteristic curve analyses, among the BMI 25.0-<30.0 kg/m2 group, for hypertensive disorders of pregnancy (area under the curve [AUC], 0.63, p < 0.05) and pre-eclampsia (AUC, 0.62; p < 0.05), the weight gain cut-off was 10.5 and 10.6 kg, with sensitivity/specificity of 0.47/0.73 and 0.50/0.73, respectively. For the BMI ≥30.0 kg/m2 group (AUC, 0.63, p < 0.05), the cut-off was 3.5 kg (sensitivity/specificity, 0.75/0.49). The optimal gestational weight gain for reducing hypertensive disorders of pregnancy among women with a pre-pregnancy BMI > 25 kg/m2 may facilitate personalized pre-conception counseling among women with obesity.

Gestational weight gain as a risk factor for dystocia during first delivery: a multicenter retrospective cohort study in Japan.

BACKGROUND: Dystocia is a common obstetric complication among nulliparous women, which requires medical intervention and carries the risk of negative maternal and neonatal outcomes. Our aim was to examine the association between body mass index (BMI) and the occurrence of dystocia. We also identified cutoffs of gestational weight gain, based on pre-pregnancy BMI, associated with the risk of dystocia. METHODS: This was a multicenter, retrospective, cohort study conducted in two tertiary Maternal-Fetal medicine units in Fukushima, Japan. The study population included nullipara women who delivered at either of the two units between January 1, 2013, and December 31, 2020. Women (n = 2597) were categorized into six groups (G) based on their pre-pregnancy BMI: G1 (< 18.5 kg/m2), G2 (18.5 to < 20.0 kg/m2), G3 (20.0 to < 23.0 kg/m2), G4 (23.0 to < 25.0 kg/m2), G5 (25.0 to < 30.0 kg/m2), and G6 (≥ 30.0 kg/m2). Using G3 as a reference, multiple logistic regression analyses were performed to estimate the risk of dystocia for each BMI category. Receiver operating characteristic curve analyses were performed to determine the cutoff value of gestational weight gain for the risk of dystocia. RESULTS: The highest BMI category (G6) was an independent risk factor for dystocia (adjusted odds ratio, 3.0; 95% confidence interval, 1.5-5.8). The receiver operating characteristic curve analysis revealed no association between gestational weight gain and the occurrence of dystocia in G5 and G6 (P = 0.446 and P = 0.291, respectively). For G1 to G4, AUC and predictive cutoffs of gestational weight gain for dystocia were as follows: G1, AUC 0.64 and cutoff 11.5 kg (P < 0.05); G2, AUC 0.63 and cutoff 12.3 kg (P < 0.05); G3, AUC 0.67 and cutoff 14.3 kg (P < 0.01); and G4, AUC 0.63 and cutoff 11.5 kg (P < 0.05). CONCLUSION: A pre-pregnancy BMI > 30.0 kg/m2 was an independent risk factor for dystocia. For women with a pre-pregnancy BMI < 25.0 kg/m2, the risk of dystocia increases as a function of gestational weight gain. These findings could inform personalized preconception care for women to optimize maternal and neonatal health.

Optimal gestational weight gain to reduce the risk of hypertension disorders of pregnancy among women with obesity: A single tertiary referral center study in Japan.

AIM: To examine the effect of weight gain during pregnancy on hypertension disorders of pregnancy among women with a prepregnancy body mass index ≥30.0 kg/m2 . METHODS: This retrospective cohort study included 257 Japanese women (116 primipara; 141 multipara) with singleton pregnancies with a prepregnancy body mass index ≥ 30.0 kg/m2 , who gave birth during 2013 to 2020 at Ohta Nishinouchi Hospital. Multiple logistic regression analyses were performed to identify the effect of gestational weight gain on early-onset (<34 weeks), late-onset (≥34 weeks), and overall hypertension disorders of pregnancy. RESULTS: The prevalence of hypertension disorders of pregnancy in primiparas and multiparas was 28.4% and 11.3%, respectively. By multiple logistic regression analysis, gestational weight gain during pregnancy increased the risk of early-onset (adjusted odds ratio: 1.20, 95% confidence interval: 1.03-1.39, p < 0.05) and overall hypertension disorders of pregnancy (adjusted odds ratio: 1.12, 95% confidence interval: 1.03-1.22, p < 0.05) among primiparas. Based on receiver operating characteristic curve analyses for early-onset (area under the curve 0.67, 95% confidence interval: 0.56-0.78; p < 0.05) and overall hypertension disorders of pregnancy (area under the curve 0.76, 95% confidence interval: 0.61-0.91; p < 0.05) among primiparas, we determined the cut-off weight gain during pregnancy for early-onset and overall hypertension disorders of pregnancy as 3.85 kg, with sensitivity/specificity of 0.76/0.59 and 0.91/0.53, respectively. CONCLUSION: We recommend that the optimal gestational weight gain for reducing HDP be under 3.85 kg. This information may facilitate personalized pre-conception counseling among women with obesity.

Establishing a Treatment Algorithm for Puerperal Genital Hematoma Based on the Clinical Findings.

Postpartum hemorrhage within 24 hours after delivery remains the leading cause of maternal mortality worldwide. Puerperal genital hematoma (PGHA) is a rare complication of postpartum hemorrhage, and PGHA can be life-threatening if hemostasis is not properly achieved. However, a reliable management algorithm for PGHA based on the clinical findings has not been developed. The objectives were to evaluate the management strategies for PGHA and identify the clinical findings that help select the treatment for PGHA. The medical records of women who were treated for PGHA in our department were reviewed, and data regarding the clinical findings and the treatment strategy for PGHA were analyzed. Thirty-four women who underwent treatment for PGHA were identified and divided into three groups according to the final procedure that achieved hemostasis: conservative management (CM) (n = 9), surgical management (SURG) (n = 15), and arterial embolization management (AEM) (n = 10). Regarding the clinical findings on initial evaluation, the shock index was significantly higher in the AEM group than in the CM or SURG group; and initial platelet count and fibrinogen level were significantly lower in the AEM group than in the CM group. There was no significant difference in any computed tomography (CT) finding among the three groups. In conclusion, this study clearly shows the difference in clinical findings among treatment strategies for PGHA. We suggest that the clinical findings of shock index, platelet count, and fibrinogen level together with CT findings are helpful and valuable for selecting the treatment strategy for PGHA.

Incisional pyoderma gangrenosum after caesarean section: Two case reports.

INTRODUCTION: Pyoderma gangrenosum (PG) in pregnant women is rare and resembles surgical site infection (SSI). Here we present two cases of PG after caesarean section. CASE 1: A 29-year-old woman, who had a history of recurrent wound dehiscence after surgery, exhibited wound ulceration and exudate 6 days after caesarean section. Antibiotics were ineffective and multiple wound cultures were negative. Skin biopsy indicated PG and oral steroid administration resulted in wound improvement. CASE 2: A 27-year-old woman, who had a history of PG, exhibited wound ulceration and exudate 5 days after caesarean section. The lesion developed despite antibiotic administration, and multiple wound cultures were negative. Skin biopsy indicated PG and the wound improved after oral steroid administration. DISCUSSION: Definitive diagnosis of PG is essential because its treatment differs from that of SSI. PG after caesarean section can be misdiagnosed as SSI, even when there is a history of wound dehiscence or PG.

The change of fetal heart rate short-term variability during the course of histological chorioamnionitis in fetal sheep.

OBJECTIVE: Histological chorioamnionitis (CAM) is related to neonatal mortality and morbidity. However, identifying intrauterine inflammation before delivery is challenging. The aim of this study was to investigate the changes in fetal heart rate (FHR) short-term variability (STV) during the course of histological CAM. STUDY DESIGN: Changes in STV were measured in 7 chronically instrumented fetal sheep at 111-120 days of gestation. Lipopolysaccharide (LPS) was infused into the amniotic cavity for 2 days following the 4th postoperative day to develop histological CAM. STV was determined based on the R to R interval of the fetal electrocardiogram. We continued to observe the changes in STV until the time of intrauterine fetal death (IUFD). The umbilical cord and fetal membranes were evaluated histologically after IUFD. The experiment was divided into two phases: 1) the acute phase, defined as the 24-hour period between the first and second injections of LPS and 2) the perimortem phase, defined as the period between the second injection of LPS and IUFD. Changes in STV in both the acute and perimortem phases were evaluated using Friedman's test. A probability of <0.05 was accepted as statistically significant. RESULTS: The fetuses died, on average, at 23.7 ±â€¯4.9 h after the second injection of LPS. Both the umbilical cord and fetal membranes showed histological evidence of severe inflammation. During the perimortem phase, there were statistically significant differences in STV at each time point. STV increased significantly at 6, 4, and 3 h before intrauterine fetal death compared to the baseline. CONCLUSION: Our study suggests that STV increased as the fetal condition deteriorated during the course of histological CAM.

Unique Learning System for Uterine Artery Embolization for Symptomatic Myoma and Adenomyosis for Obstetrician-Gynecologists in Cooperation with Interventional Radiologists: Evaluation of UAE From the Point of View of Gynecologists Who Perform UAE.

STUDY OBJECTIVE: To evaluate a unique learning system for uterine artery embolization (UAE) and examine its feasibility and clinical outcomes for the treatment of symptomatic uterine leiomyomas and adenomyosis when performed by obstetrician-gynecologists in cooperation with interventional radiologists (IVRs). DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: One hundred seventy-three patients who underwent UAE for symptomatic leiomyomas and adenomyosis. INTERVENTIONS: We examined the medical records of patients who underwent UAE for symptomatic uterine leiomyomas and adenomyosis at our department between 2003 and 2012 using our learning system for UAE for obstetrician-gynecologists in cooperation with IVRs. The charts of all patients were reviewed, and data on etiologic factors, past medical history of leiomyomas and adenomyosis, symptoms, details of UAE, and clinical outcomes after UAE were extracted. MEASUREMENTS AND MAIN RESULTS: A total of 173 patients who underwent 177 UAEs were identified, including 4 patients who underwent embolization twice because of primary treatment failure or symptom recurrence. During the study period, 2 gynecologists successfully acquired endovascular skills. The technical success rate was 97.7% (174 of 177). The duration of fluoroscopy in procedures performed by obstetrician-gynecologists who acquired endovascular skills was not significantly different from that in procedures performed by IVRs at our institution; however, this duration was significantly longer in procedures performed by obstetrician-gynecologists who did not have sufficient experience with our learning protocol for UAE because of inadequate live observation of UAEs performed by skilled IVRs. Complications that necessitated discontinuation of the procedure occurred in 2.3% of cases (4 of 177). The clinical outcomes were similar to those reported in previous studies. Adverse events after UAE included myeloid passages in 7.0% (11 of 158), infections in 2.5% (4 of 158), vaginal discharge in 2.5% of patients with leiomyomas (4 of 158), and vaginal discharge in 7.1% of patients with adenomyosis (1 of 14). All the adverse events were adequately treated by the obstetrician-gynecologists themselves. The timing of hysterectomy due to complications or recurrence of symptoms after UAE varied widely. CONCLUSION: UAE performed by obstetrician-gynecologists in cooperation with radiologists can be achieved safely and successfully with acceptable clinical outcomes. Live observation of the procedure performed by skilled IVRs is essential to improving the skills and reducing the fluoroscopic time of obstetrician-gynecologists.

Histological Chorioamnionitis as a Risk Factor for Preterm Birth without Disturbing Fetal Heart Rate: A Case-Control Study.

Histological chorioamnionitis (CAM) is one form of intrauterine inflammation that is often seen in cases of preterm birth and are usually confirmed based on pathological examination after delivery. Histological CAM is related to significant neonatal morbidity and mortality; however, its etiology is unknown. The objective of this study was to determine the risk factors for histological CAM, using medical background, including fetal heart rate (FHR) patterns in preterm birth cases. The preterm birth cases delivered between 28 and 36 weeks were categorized into two groups according to the presence of histological CAM. Ninety-five preterm infants were included: 48 infants without histological CAM and 47 cases with histological CAM. The odds ratio for histological CAM was adjusted for FHR patterns, gestational age, and delivery mode (vaginal delivery or Caesarean section). Logistic regression analysis showed that vaginal delivery and gestational age were associated with histological CAM (odds Ratio [OR]: 3.1, 95% confidence interval [CI]: 1.0-9.4, p < 0.05, and OR: 0.8, 95% CI: 0.6-0.9, p < 0.05, respectively). However, there were no specific FHR patterns associated with histological CAM. Our study indicates that in preterm birth cases, histological CAM is not related to any specific FHR pattern. However, labor uterine contraction and immature gestational age at the delivery are related to histological CAM. These results may provide better delivery management methods for preterm birth cases.

Long-term recurrence-free survival of a patient with advanced pure primary ovarian squamous cell carcinoma treated with dose-dense paclitaxel combined with carboplatin.

We describe an extremely rare case of advanced pure primary ovarian squamous cell carcinoma (SCC), treated by adjuvant chemotherapy with dose-dense paclitaxel combined with carboplatin (dd-TC) plus the combination chemotherapy with irinotecan and cisplatin (CPT-P), with long-term recurrence-free survival. A 71-year-old woman complaining of lower abdominal pain was referred to our hospital and a 7-cm-diameter solid tumor was identified. She was diagnosed with a left ovarian tumor that was highly suspicious for malignancy based on ultrasonography, magnetic resonance imaging, and contrast-enhanced computed tomography. Bilateral salpingo-oophorectomy, low-anterior colon resection, and colostomy were performed. Intra- and post-operative histopathological diagnosis revealed International Federation of Gynecology and Obstetrics stage IIIc well-differentiated pure ovarian SCC. As adjuvant chemotherapy, 2 courses of dd-TC were administered, followed by 3 courses of CPT-P; the patient then underwent 4 additional courses of dd-TC. Both regimens were effective and there has been no recurrence or metastasis thus far in the 5 years since the operation.

Prospective evaluation of the incidence of uterine vascular malformations developing after abortion or delivery.

STUDY OBJECTIVE: To describe the incidence of uterine vascular malformations (UVMs) including uterine arteriovenous malformations (AVMs) in patients after abortion or delivery and in outpatients. DESIGN: Prospective study (Canadian Task Force classification II-3). SETTING: Fukushima Red Cross Hospital. PATIENTS: Six patients with a UVM including 1 with an AVM. INTERVENTIONS: Clinical screening of patients using transvaginal color Doppler ultrasonography between April 2010 and March 2012. MEASUREMENTS AND MAIN RESULTS: The incidence of UVM developing after abortion or delivery or in outpatients was prospectively evaluated using transvaginal color Doppler ultrasonography. From 959 patients, we identified 6 (0.63%) with UVMs, including 1 (0.10%) with a uterine AVM. Specifically, we detected UVMs in 4 of 77 patients (5.2%) after abortion, 1 of 458 patients (0.22%) after delivery, and 1 of 424 outpatients (0.24%). Four patients after abortion and 1 after delivery reported mild symptoms, which were treated conservatively; however, the outpatient had a severe uterine AVM, which was confirmed via 3-dimensional computed tomography angiography. CONCLUSION: The incidence of UVMs was relatively higher, in particular in the patients after abortion, and was significantly higher than that in postpartum or outpatient groups. Therefore, it is important to consider the possibility of UVMs in any patient with episodes of unexplained uterine bleeding and to perform follow-up analysis using color Doppler ultrasonography. Such an approach will facilitate accurate diagnosis and lead to appropriate clinical management to prevent unnecessary dangerous repeat curettage, which might induce profuse uterine bleeding.