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.

A novel activation mechanism of cellular Factor XIII in zebrafish retina after optic nerve injury.

Cellular Factor XIII (cFXIII) mRNA is rapidly upregulated in the fish retina after optic nerve injury (ONI). Here, we investigated the molecular mechanism of cFXIII gene activation using genetic information from the A-subunit of cFXIII (cFXIII-A). Real-time PCR that amplified the active site (exons 7-8) of cFXIII-A showed increased cFXIII-A mRNA in the retina after ONI, whereas the PCR that amplified the activation peptide (exons 1-2) showed no change. RT-PCR analysis that amplified exons 1-8 showed two bands, a faint long band in the control retina and a dense short band in the injured retina. Therefore, we conclude that activated cFXIII-A mRNA after ONI is shorter than that of the control retina. Western blot analysis also confirmed an active form of 65 kDa cFXIII-A protein in the injured retina compared to the control 84 kDa protein. 5'-RACE analysis using injured retina revealed that the short cFXIII-A mRNA lacked exons 1, 2 and part of exon 3. Exon 3 has two sites of heat shock factor 1 (HSF-1) binding consensus sequence. Intraocular injection of HSF inhibitor suppressed the expression of cFXIII-A mRNA in the retina 1 day after ONI to 40% of levels normally seen after ONI. Chromatin immunoprecipitation provides direct evidence of enrichment of cFXIII-A genomic DNA bound with HSF-1. The present data indicate that rapid HSF-1 binding to the cFXIII-A gene results in cleavage of activation peptide and an active form of short cFXIII-A mRNA and protein in the zebrafish retina after ONI without thrombin.

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.

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.

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.

Risk assessment of hypertensive disorders in pregnancy with maternal characteristics in early gestation: A single-center cohort study.

OBJECTIVE: Hypertensive disorders in pregnancy are major causes of maternal mortality and morbidity. Although the combined risk assessments of maternal history, blood pressure, uterine artery Doppler, and maternal serum marker seem to be highly predictive of the development of hypertensive disorders, this method is a little complicated to be performed on many low-risk pregnant women. The aim of this study is to evaluate the use of maternal characteristics, and physical findings early in the second trimester, as predictive factors of hypertensive disorders. MATERIALS AND METHODS: This is a retrospective cohort study undertaken in a single tertiary care center in Japan. Singleton pregnant women without underlying disease and evaluated before 14 weeks of gestation were included. We conducted multivariate logistic regression analysis and decision tree analysis to elucidate the potential risk factors of hypertensive disorders, including gestational hypertension and preeclampsia. RESULTS: In total, 1986 women were evaluated, of whom 863 were nulliparous and 1123 were multiparous, and 166 (8.3%) were diagnosed with hypertensive disorders. In multivariate analysis, maternal age ≥ 40 years, prepregnancy BMI ≥ 30 kg/m(2), in vitro fertilization and embryo transfer (IVF-ET), family history of hypertension, and blood pressure ≥ 130/85 mmHg at first visit were independent risk factors for the nulliparous women. Maternal age ≥ 40 years, a history of previous hypertensive disorders, and blood pressure ≥ 130/85 mmHg at first visit were independent risk factors for the multiparous women. According to the decision tree analysis, high-risk populations were as follows: women ≥ 40 years old who conceived thorough IVF-ET and women with prepregnancy BMI ≥ 30 kg/m(2) who conceived spontaneously in nulliparous women; women with a history of hypertensive disorders and women with blood pressure ≥ 130/85 mmHg in the absence of the previous history. CONCLUSION: The combination of maternal background and physical findings is useful to identify the population with a high risk of hypertensive disorders.

Significance of high-normal blood pressure during early second trimester for predicting the onset of hypertensive disorders in pregnancy.

OBJECTIVE: The aim of this study was to determine the predictive value of high-normal blood pressure (HNBP) during the early second trimester for hypertensive disorders in pregnancy, including gestational hypertension (GH) and preeclampsia (PE). METHODS: This was a retrospective single-center cohort study of 2143 singleton pregnant women. The association of HNBP, ranging from 130/85 to 139/89 mmHg between 14 and 19 weeks of gestation, with the development of hypertensive disorders was assessed by multivariable logistic regression analyses. RESULTS: In a cohort of 2102 pregnant women, 93 (4.4%) pregnancies had HNBP during early second trimester. Pregnant women with HNBP more frequently developed hypertensive disorders than normotensive women (20.4% vs. 8.2%, p < 0.001). HNBP was significantly associated with the development of GH (adjusted odds ratio (aOR): 1.81; 95% confidence interval (CI): 1.16-3.25, p = 0.015) and PE (aOR: 6.05; 95% CI: 3.46-12.6, p = 0.013) after adjustment for confounders. CONCLUSION: HNBP during the early second trimester is an independent risk factor for both GH and PE.

Clinical features and antenatal risk factors for postpartum-onset hypertensive disorders.

OBJECTIVE: To identify the clinical features and risk factors for diagnosis of a postpartum-onset hypertensive disorder. METHODS: A retrospective cohort study of singleton pregnancies. Clinical features of postpartum-onset hypertensive disorders were evaluated, and prenatal risk factors were also identified with a multivariate logistic regression model. RESULTS: Of 1,964 women, 57 (2.9%) developed hypertensive disorder after delivery. The independent risk factors were assisted reproductive technology, pre-pregnancy body mass index, chronic nephritis, hypothyroidism, high-normal blood pressure before or at delivery, and cesarean section. CONCLUSION: Careful monitoring of blood pressure should be considered for women with the identified risk factors even after delivery.

Trichoepithelioma Arising in an Ovarian Mature Cystic Teratoma.

Here, we report an extremely rare case of trichoepithelioma (TE)-a benign epithelial tumor originating from the outer root sheath of a hair follicle-arising in an ovarian mature cystic teratoma (MCT) with fluorodeoxyglucose-positron emission tomography (FDG-PET) findings. A 48-year-old Japanese woman presented to our hospital for her annual follow-up of adenomyosis. Ultrasonography and magnetic resonance imaging revealed a left ovarian tumor with irregular-shaped septum, which was suspicious of malignancy. However, tumor marker levels were within normal range. On FDG-PET, the maximum standardized uptake value (SUVmax) of the tumor was 2.9. Laparotomy with left salpingooophorectomy was performed. Pathologic examination revealed the probability of TE, rather than basal cell carcinoma (BCC), arising in an ovarian MCT. After five years of follow-up, the patient had no sign of recurrence. The FDG-PET SUVmax was low in TE, as with other benign tumor. However, future investigation is needed to evaluate the findings of FDG-PET imaging in TE cases.

Antiviral Activity of Four New Resin Glycosides Calysolins XIV-XVII from Calystegia soldanella against Herpes Simplex Virus.

Four new resin glycosides, named calysolins XIV (1), XV (2), XVI (3), and XVII (4) were isolated from the leaves, stems, and roots of Calystegia soldanella ROEM.. et SCHULT. (Convolvulaceae). Their structures were determined based on spectroscopic and chemical evidence, and consisted of two different types: those (1) with a macrolactone structure and those (2-4) with a non-macrolactone structure. Their sugar moieties were partially acylated by specific organic acids, including tiglic, 2S-methylbutyric, and 2S,3S-nilic acids. Additionally, evaluation of the antiviral activity of 1-4 revealed effects against the herpes simplex virus type 1.

The use of amniotic fluid discordance in the early second trimester to predict severe twin-twin transfusion syndrome.

INTRODUCTION: The appropriate effectiveness of inter-twin amniotic fluid discordance (AFD) in the early second trimester for the prediction of severe twin-twin transfusion syndrome (TTTS) was evaluated. MATERIALS AND METHODS: The largest AFD between 16 and 18 weeks' gestation was analyzed in correlation with TTTS development defined by polyhydramnios with a maximum vertical pocket (MVP) ≥8 cm combined with oligohydramnios with a MVP ≤2 cm using the receiver operating characteristics curve. All pregnancies were stratified according to an AFD cutoff, and perinatal outcomes were compared between two groups. RESULTS: A total of 223 twin monochorionic pregnancies met the inclusion criteria and 20 patients (8.9%) developed TTTS. An AFD ≥4 cm was calculated to be the optimal point of demarcation to predict subsequent TTTS. The sensitivity and specificity of this AFD cutoff for the development of TTTS were 70 and 97%, respectively. An AFD ≥4 cm was associated with a significantly increased risk of the development of TTTS (70 vs. 2.9%; p < 0.01). Those pregnancies with AFD tended to deliver at an earlier gestational age and were also significantly associated with intrauterine fetal deaths. DISCUSSION: The AFD between monochorionic diamniotic twins in the early second trimester may be useful for the prediction of severe TTTS development.

Calysolins I-IV, resin glycosides from Calystegia soldanella.

Four new resin glycosides having intramolecular cyclic ester structures (jalapins), named calysolins I-IV (1-4), were isolated from the methanol extract of leaves, stems, and roots of Calystegia soldanella , along with one known jalapin (5) derivative. The structures of 1-4 were determined on the basis of spectroscopic data and chemical evidence. They fall into two types, one having a 22-membered ring (1 and 4) and the other with a 27-membered ring (2 and 3). The sugar moieties of 1-4 were partially acylated by some organic acids. Compound 4 is the first example of a hexaglycoside of jalapin.