A case report of complete chorioamniotic membrane separation.

We describe a patient with complete chorioamniotic membrane separation (CMS). During embryologic development, the chorionic and amniotic membranes each arise from their own germ layers and form a celomic cavity in the first trimester of pregnancy. By the early second trimester, the cavity has shrunk and the membranes become conjugated. However, the membranes may separate spontaneously or because of an invasive intrauterine procedure. This pathologic condition is referred to as CMS. Extensive CMS can lead to miscarriage, fetal death, neonatal death, amniotic band syndrome, umbilical cord complications, and preterm delivery. In this case, CMS was detected in the 29th week of pregnancy with a routine ultrasonographic examination in the absence of a distinct non-reassuring fetal status or an abnormality of the intrauterine environment. The patient had undergone amniocentesis at 16 weeks of pregnancy for chromosomal analysis. Ultrasonography showed a floating membranous structure in almost every view of the intra-amniotic cavity. Thus, complete CMS was believed to have occurred. Therefore, precautionary checkups and examinations were periodically performed. Childbirth took place uneventfully by means of elective cesarean section in the 37th week of pregnancy. Because pathological examination showed complete CMS, the validity of the prenatal diagnosis was confirmed.

Does the use of labor-inducing drugs cause adverse perinatal outcomes?

There have been several studies of adverse perinatal outcomes associated with the indiscriminate use of labor-inducing drugs. However, the present results indicate that the appropriate use of labor-inducing drugs is not unsafe and improves neonatal outcomes in abnormal deliveries.

Neonatal small-for-gestational age status as a favorable factor for the complete vaginal delivery of both fetuses in Japanese dichorionic twins.

AIM: In singletons, neonatal small-for-gestational age (SGA) status is an unfavorable postpartum outcome leading to cesarean section (CS) and increasing the possibility of maternal operative complications. Perinatal characteristics of SGA newborns in dichorionic (DC) twins were investigated for the prognostic impact on their mothers. METHODS: A retrospective study was performed from 2004 to 2009 on 329 DC twins with two live births. Neonates were classified as SGA if they weighed less than the 10th percentile at birth according to Japanese singleton norms. Statistical differences between DC twins delivering appropriate-for-gestational age (AGA)/AGA pairs (control group) and AGA/SGA, SGA/AGA or SGA/SGA pairs (the first/second twins) were analyzed. RESULTS: The median (range) of the gestational ages at delivery for AGA/AGA, AGA/SGA, SGA/AGA and SGA/SGA pairs were 37.1 (27.1-40.3), 37.2 (29.0-40.9), 37.1 (28.1-40.7) and 37.3 (33.3-40.4) weeks, and the complete vaginal delivery rates of both fetuses were 66.2% (43/65), 84.8% (28/33), 82.4% (14/17) and 70.0% (7/10), respectively. Compared with AGA/AGA pairs, AGA/SGA pairs showed a higher incidence of spontaneous vaginal births of both fetuses (31.3% [26/83] vs 19.9% [37/186], OR 1.84, 95% CI 1.45-4.73) and a lower incidence of emergent CS (25.3% [21/83] vs 38.7% [72/186], OR 0.53, 95% CI 0.30-0.95). CONCLUSION: The relatively small size of SGA fetuses allows both fetuses to remain inside the uterus for a longer time and to easily pass through the maternal parturient canal for complete vaginal delivery. Neonatal SGA status is a favorable factor for avoiding operative complications of CS and optimizing maternal perinatal outcomes.

Isolated torsion of a left normal fallopian tube during pregnancy.

We present here a case of isolated torsion of a left normal fallopian tube at 37 weeks' gestation. Although uncommon, especially on the left side, torsion of the fallopian tube should be included in the differential diagnosis of abdominal pain during pregnancy.

Midwife-led care unit for 'low risk' pregnant women in a Japanese hospital.

OBJECTIVES: To examine the obstetric outcomes of our 'low risk' pregnant women under the midwife-led delivery care compared with those under the obstetric shared care. METHODS: A retrospective cohort study compared outcomes of labor under midwife 'primary' care with those under obstetric shared care. The factors examined were: maternal age, parity, gestational age at delivery, length of labor, augmentation of labor pains, delivery mode, episiotomy, perineal laceration, postpartum hemorrhage, neonatal birth weight, Apgar score, and umbilical artery pH. In this study, pregnant women were initially considered 'low risk' at admission when they had no history of medical, gynecological, or obstetric problems and no complications during the present pregnancy. RESULTS: There were 1031 pregnant women initially considered 'low risk' at admission. At admission, 878 of them (85%) requested to give birth under midwife care; however 364 of these women (42%) were transferred to obstetric shared care during labor. The average length of labor under the midwife 'primary' care was significantly longer than that under the obstetric shared care. However, there were no significant differences in the rate of prolonged labor (≥24 h). There were no significant differences in other obstetric or neonatal outcomes between the two groups. CONCLUSIONS: There was no evidence indicating that midwife 'primary' care is unsafe for 'low risk' pregnant women. Therefore, midwifery care is recommended for 'low risk' pregnant women.

Maternal risk factors for small-for-gestational age newborns in Japanese dichorionic twins.

AIM: To investigate the maternal risk factors for small-for-gestational age (SGA) newborns in Japanese dichorionic (DC) twins. METHODS: A retrospective study was conducted from 2003 to 2008 on 340 DC twin pregnancies resulting in two live births. Newborns were classified as SGA if their birth weight was below the 10th percentile according to Japanese singleton norms. Statistical differences were evaluated between pregnancies resulting in appropriate-for-gestational age (AGA) pairs and those resulting in at least one SGA neonate. RESULTS: The study population consisted of AGA/AGA (50.8%), AGA/SGA (37.0%) and SGA/SGA pairs (12.0%). Logistic regression analysis identified significant interrelations for SGA with maternal nulliparity (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.30-0.91), smoking (OR 3.25, 95% CI 1.09-9.66), assisted reproductive technology (OR 0.52, 95% CI 0.30-0.89), pregnancy-induced hypertension (OR 2.00, 95% CI 1.01-4.31), pregravid weight (kg) (unitary OR 0.94, 95% CI 0.91-0.97) and monthly weight gain (kg/month) (unitary OR 0.25, 95% CI 0.14-0.44). Bivariable receiver operating characteristic curves were generated for monthly weight gain (area under the curve [AUC] 0.626, cutoff 1.41 kg/month, P<0.001) and total weight gain (AUC 0.615, cutoff 14.0 kg, P<0.001). CONCLUSION: Cigarette smoking and weight gain control are relatively modifiable factors for which interventional management is necessary to avoid perinatal problems arising from SGA pregnancy. Further studies are needed to investigate optimal nutrition, health guidance and subsequent weight gain control that lead to concrete improvement in maternal and infant prognoses.

Clinical significance of singleton pregnancies complicated by placental abruption occurred at preterm compared with those occurred at term.

OBJECTIVE: This study investigated the clinical significance of placental abruption occurred at preterm compared with those that occurred at term. METHODS: We reviewed the obstetric records of 102 singleton deliveries complicated by placental abruption after 22 weeks of gestation. The χ(2) test for categorical variables was used and differences with p < 0.05 were considered significant. Odds ratios (ORs) and 95% confidence intervals (CIs) were also calculated. RESULTS: Of 102 cases of placental abruption, 60 cases (59%) occurred at preterm and 42 (41%) at term. There were no significant differences in perinatal outcomes between the two groups with preterm and term gestations. The incidence of histological chorioamnionitis in the preterm group was significantly higher than that in the term group (crude OR 3.4, 95% CI 1.4-8.2, p < 0.01) while that of placental embolisms and/or infarctions in the preterm group was significantly lower than that in the term group (crude OR 0.35, 95% CI 0.16-0.80, p = 0.01). Using logistic regression, preterm placental abruption was significantly more likely in multiparous patients (adjusted OR 2.5, 95% CI 1.0-6.2, p = 0.046) and those demonstrating histological chorioamnionitis (adjusted OR 3.5, 95% CI 1.4-9.1, p < 0.01), while term placental abruption was significantly more likely in cases of placental embolisms and/or infarctions (adjusted OR 3.5, 95% CI 1.2-10, p = 0.02). CONCLUSION: The current results indicate that the possible processes leading to placental abruption at preterm are different from those at term.

Time of delivery and perinatal outcome.

The purpose of this study was to examine the association between time of delivery and perinatal outcomes in singleton deliveries at Japanese Red Cross Katsushika Maternity Hospital. We performed a retrospective cohort study of all singleton deliveries at ≥ 22 weeks' gestation from 2002 through 2009 at our hospital. During the nighttime period (12 midnight to 8 am), although the rate of delivery of high-risk pregnancies was low, the rate of low umbilical artery pH (< 7) was higher than that during the daytime periods (8 am to 4 pm) (odds ratio 1.9, 95% confidence interval 1.1-3.4, p = 0.02). During the nighttime period, in addition, the rate of low umbilical artery pH in patients with emergent cesarean delivery was significantly higher than that during the daytime period (odds ratio 6.9; 95% confidence interval 2.5-19, p < 0.01). In our hospital, the rate of adverse neonatal outcomes associated with cesarean birth was increased at nighttime period.

Clinical significance of singleton pregnancies complicated by placental abruption associated with histological chorioamnionitis.

The aim of this study was to determine the perinatal outcomes of placental abruption associated with the presence of histological chorioamnionitis. We reviewed the obstetric records of 96 singleton deliveries complicated by placental abruption after 22 weeks' gestation. Of these 96 cases, 37 cases (39%) were diagnosed as having histological chorioamnionitis in the placenta. The incidence of premature delivery, preterm rupture of the membranes and low birth weight in the cases of placental abruption with chorioamnionitis were higher than in cases without chorioamnionitis. However, there were no significant differences in the incidence of other outcomes, such as fetal demise, low Apgar score, or low umbilical artery pH, between the cases of placental abruption with and without histological chorioamnionitis. Although the incidence of prematurity in the cases of placental abruption with chorioamnionitis was higher than that in cases without chorioamnionitis, there were no significant differences in fetal and neonatal conditions between the abruption cases with and without chorioamnionitis.

Increased rate of elective cesarean delivery and neonatal respiratory disorders in twin pregnancies.

We examined whether the incidence of neonatal respiratory disorders has increased with the increased rate of elective cesarean delivery in twin pregnancies. We reviewed the obstetric records of 292 twin deliveries with vertex presentation of the first twin after 37 weeks' gestation at our hospital from 2000 through 2008. The study period was divided into 3 parts as follows: period 1: 2000 through 2002 (n=76); period 2: 2003 through 2005 (n=104); and period 3: 2006 through 2008 (n=112). We compared the rate of elective cesarean delivery due to maternal request and the incidence of transient tachypnea of the newborn (TTN). There has been a significant increase in rate of elective cesarean delivery (period 1: 18%; period 2: 25%; period 3: 48%) over the past several years. This increase was observed to be due to an increase in maternal requests for elective cesarean delivery. However, there were no significant differences in the incidence of TTN in the 3 periods [period 1: 7.2%; period 2: 6.7%; period 3: 8.0%]. The recent increase in the rate of cesarean delivery did not cause the increase in the incidence of neonatal respiratory disorders in twin pregnancies.

Inhibition of DC-SIGN-mediated transmission of human immunodeficiency virus type 1 by Toll-like receptor 3 signalling in breast milk macrophages.

The majority of cells in early/colostrum milk are breast milk macrophages (BrMMø) expressing dendritic cell (DC)-specific intercellular adhesion molecule 3 (ICAM3) grabbing nonintegrin (DC-SIGN), and the expression level of DC-SIGN on BrMMø will determine cell-to-cell human immunodeficiency virus type 1 (HIV-1) transmissibility. Thus, one of the strategies to prevent vertical transmission of HIV-1 through breast-feeding is to find a way to suppress DC-SIGN expression on BrMMø. As for the expression of Toll-like receptors (TLRs) in BrMMø, TLR3 was always seen in BrMMø but not in peripheral blood monocytes (PBMo). Also, the expression of TLR3 was slightly enhanced in BrMMø when the cells were treated with interleukin (IL)-4. Moreover, when TLR3 was stimulated with its specific ligand, the double-stranded RNA (dsRNA) poly(I:C), DC-SIGN expression on BrMMø was reduced even in the IL-4-mediated enhanced state. Some reduction may be caused by type I interferons (IFNs), such as IFN-alpha/beta, secreted from BrMMø. Indeed, both IFNs, particularly IFN-beta, showed a strong capacity to suppress the enhancement of DC-SIGN expression on IL-4-treated BrMMø and such TLR3-mediated DC-SIGN suppression was partially abrogated by the addition of anti-IFN-alpha/beta-receptor-specific antibodies. As expected, DC-SIGN-mediated HIV-1 transmission to CD4-positive cells by BrMMø was inhibited by either poly(I:C) stimulation or by treatment with type I IFNs. These findings suggest a possible strategy for preventing mother-to-child transmission (MTCT) of HIV-1 via breast-feeding through TLR3 signalling.

History of abortion and perinatal outcomes associated with preeclampsia in nulliparous Japanese women.

The purpose of the present study was to examine the influence of history of abortion on the next pregnancy outcomes associated with preeclampsia. This investigation involved 5206 nulliparous Japanese women with singleton pregnancies who delivered after 22 weeks of gestation. The patients were divided into two groups: those with a history of spontaneous and/or artificial abortion during the previous pregnancies after the marriage with the same partner (n = 1029) and those without a history of abortion (n = 4173). There was no significant difference in the incidence of preeclampsia between the 2 groups with and without previous abortions (4.0% vs. 3.9%, p = 0.91). In addition, there were no significant differences in the incidence of perinatal complications associated with preeclampsia between the 2 groups. Although further studies may be needed, based on the current results history of abortion does not seem to affect perinatal outcomes associated with preeclampsia.

Referrals during labor in midwifery care.

In 2008, 84% (459) of 548 women with pregnancies initially considered "low risk" requested to give birth under midwifery care at Japanese Red Cross Katsushika Maternity Hospital. Of these, 42% (191) were referred to obstetric care during labor at term; however, we found no evidence that midwifery primary obstetric care is less safe for women with "low-risk" pregnancy than is standard obstetric care. Therefore, we recommend that midwifery care be promoted with an international collaborative effort.

Recurrence of urinary retention secondary to retroverted gravid uterus.

BACKGROUND: Although urinary retention caused by the retroverted gravid uterus is uncommon, acute urinary retention is an emergency condition. CASES: We present here two cases of acute urinary retention at 12 weeks' gestation secondary to retroverted gravid uterus. Although some preventive measures were suggested to the patients, recurrences of urinary retention occurred during the following 2-3 weeks and in their next pregnancies. CONCLUSION: In cases that urinary retention due to retroverted gravid uterus once occurred, we have to pay attention to the recurrence of urinary retention during the next pregnancies.

Ptyalism gravidarum.

CONTEXT: Ptyalism gravidarum is of unknown origin and is usually defined as an excessive secretion of saliva, common in women with nausea and vomiting who might have difficulty in swallowing their saliva. CASE REPORT: We present here 2 cases complicated by ptyalism gravidarum during all trimesters of pregnancy. In one case, ptyalism recovered spontaneously at 35-36 weeks' gestation, and in the other case, it recovered after delivery. CONCLUSION: Ptyalism gravidarum may not be a serious condition leading to adverse perinatal outcomes, however there may not be any satisfactory treatment.

Effect of sera on the adhesion of natural killer cells to the endothelium in severe pre-eclampsia.

OBJECTIVE: To investigate the effect of serum on the interaction between natural killer (NK) cells and endothelial cells in pre-eclampsia. METHODS: Seven severely pre-eclamptic patients, five normal pregnant women, and four normal non-pregnant women were included in this study. Freshly isolated NK cells labeled with Chromium-51 were incubated on an endothelial cell monolayer in the presence of patient serum. In regard to the characteristics of adhesive molecules, the endothelial cells were blocked by monoclonal antibodies (mAbs) to intracellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1); the NK cells were blocked by mAbs to leukocyte function-associated antigen (LFA-1) and very late antigen-4 (VLA-4) before co-incubation. After incubation, the adherent cells were solubilized with 1% Triton X. The lysates were collected and counted in a gamma counter. RESULTS: The adhesion of NK cells to the endothelium in the normal pregnancy group decreased significantly in comparison to the non-pregnant group (7%vs 72%; P < 0.01). Adhesion in the severe pre-eclamptic group was significantly higher in comparison to the normal pregnant group (44%vs 7%; P < 0.01). The blocking percentages of mAbs on NK adhesion in the severe pre-eclampsia group were 49 +/- 4% to LFA-1, 61 +/- 48%, 67 +/- 39% to VLA-4, ICAM-1, and 68 +/- 7% to VCAM-1. CONCLUSION: Sera from normal pregnant women suppress the adhesion between NK cells and endothelial cells, whereas the suppressive effect of sera from pre-eclamptic patients has a diminished affect.

Transmission of macrophage-tropic HIV-1 by breast-milk macrophages via DC-SIGN.

Recent findings suggest that macrophage-tropic human immunodeficiency virus type 1 (HIV-1) produced in colostrum/early breast milk may hold a clue to determine the mechanisms of transmission of HIV-1 via breast-feeding. Here, we show that the majority of CD4(+) cells in the colostrum are CD14(+) macrophages expressing both chemokine receptors and DC-SIGN, a dendritic cell-specific receptor for HIV-1. The R5-type macrophage-tropic HIV-1 isolate NL(AD8) infected such breast-milk macrophages and caused them to secrete virus particles efficiently; however, the secreted virions showed only a weak transmissibility to their susceptible target, MAGIC-5 cells. When stimulated with interleukin-4, the breast-milk macrophages demonstrated a striking enhancement of expression of DC-SIGN and showed a strong capacity to transmit NL(AD8) virions to MAGIC-5 cells, which was specifically blocked by anti-DC-SIGN-specific antibody. These results suggest that HIV-1 virions captured by DC-SIGN, but not secreted cell-free virions, may be more efficiently transmitted to other compartments, such as the gastrointestinal tract, through acidic gastric juice.