Prevention of fetal brain injury in category II tracings.

INTRODUCTION: With category II fetal heart rate tracings, the preferred timing of interventions to prevent fetal hypoxic brain damage while limiting operative interventions remains unclear. We aimed to estimate fetal extracellular base deficit (BDecf ) during labor with category II tracings to quantify the timing of potential interventions to prevent severe fetal metabolic acidemia. MATERIAL AND METHODS: A longitudinal study was conducted using the database of the Recurrence Prevention Committee, Japan Obstetric Compensation System for Cerebral Palsy, including infants with severe cerebral palsy born at ≥34 weeks' gestation between 2009 and 2014. Cases included those presumed to have an intrapartum onset of hypoxic-ischemic insult based on the fetal heart rate pattern evolution from reassuring to an abnormal pattern during delivery, in association with category II tracings marked by recurrent decelerations and an umbilical arterial BDecf ≥ 12 mEq/L. BDecf changes during labor were estimated based on stages of labor and the frequency/severity of fetal heart rate decelerations using the algorithm of Ross and Gala. The times from the onset of recurrent decelerations to BDecf 8 and 12 mEq/L (Decels-to-BD8, Decels-to-BD12) and to delivery were determined. Cases were divided into two groups (rapid and slow progression) based upon the rate of progression of acidosis from onset of decelerations to BDecf 12 mEq/L, determined by a finite-mixture model. RESULTS: The median Decels-to-BD8 (28 vs. 144 min, p < 0.01) and Decels-to-BD12 (46 vs. 177 min, p < 0.01) times were significantly shorter in the rapid vs slow progression. In rapid progression cases, physicians' decisions to deliver the fetus occurred at ~BDecf 8 mEq/L, whereas the "decisions" did not occur until BDecf reached 12 mEq/L in slow progression cases. CONCLUSIONS: Fetal BDecf reached 12 mEq/L within 1 h of recurrent fetal heart rate decelerations in the rapid progression group and within 3 h in the slow progression group. These findings suggest that cases with category II tracings marked by recurrent decelerations (i.e., slow progression) may benefit from operative intervention if persisting for longer than 2 h. In contrast, cases with sudden bradycardia (i.e., rapid progression) represent a challenge to prevent severe acidosis and hypoxic brain injury due to the limited time opportunity for emergent delivery.

Association of severe maternal morbidity with bonding impairment and self-harm ideation: A multicenter prospective cohort study.

BACKGROUND: Evidence on the association between severe maternal morbidity (SMM) and mother-infant bonding and self-harm ideation is limited. We aimed to examine these associations and the mediating effect of Neonatal Intensive Care Unit (NICU) admission at one-month postpartum. METHODS: This multicenter, prospective cohort study was conducted in Japan (n = 5398). SMM included preeclampsia, eclampsia, severe postpartum hemorrhage, placental abruption, and a ruptured uterus. Lack of affection (LA) and Anger and Rejection (AR) were assessed using the Mother-Infant Bonding Scale (MIBS), and self-harm ideation was assessed using the 10th item of the Edinburgh Postnatal Depression Scale (EPDS). Linear and logistic regression models were used to examine the association between SMM and MIBS score and self-harm ideation. A structural equation model (SEM) was employed to examine the mediating effect of NICU admission on the association between SMM and mother-infant bonding and postpartum depressive symptoms. RESULTS: Women with SMM had a 0.21 (95 % confidence interval [CI]: 0.03-0.40) point higher MIBS score and a decreasing trend in the risk of self-harm ideation (odds ratio 0.28, 95 % CI: 0.07-1.14) compared to those without SMM. SEM analysis revealed that SMM was associated with MIBS partially through NICU admission. LIMITATIONS: EPDS scores during pregnancy could be an unmeasured confounder. CONCLUSIONS: Women with SMM had higher MIBS scores, particularly on the LA subscale, which was partially mediated by NICU admission. Psychotherapy to support parent-infant relationships is necessary for women with SMM.

Association between poor parent-daughter relationships and the risk of hyperglycemia in pregnancy: a hospital-based prospective cohort study in Japan.

BACKGROUND: Adverse child experiences (ACEs), childhood maltreatment and household dysfunction, are risk factors of hyperglycemia in pregnancy (HIP), including diabetes before pregnancy, gestational diabetes (GDM), and overt diabetes in pregnancy, through increased risk of unhealthy behaviors, obesity, and stress response system dysfunction. While ACEs are often difficult to be assessed in hospital settings, parent-daughter relationship, that is, pregnant women's relationship with their parents can be considered as a measurable maker for ACEs that may be associated with HIP. The purpose of this study is to examine the association between poor parent-daughter relationship and HIP. METHODS: Hospital-based prospective cohort study was conducted in Japan (N = 6,264). Women visiting participating 58 facilities for delivery between April 2019 and March 2020 were included. Parent-daughter relationship was assessed by a questionnaire asking whether participants were satisfied with their relationship with their parents. HIP was diagnosed based on the criteria used in Japan. A multiple logistic regression model was applied to adjust for covariates. RESULTS: Pregnant women who were not very satisfied and not satisfied at all with the relationship with their parents, and HIP were 343 (5.5%), 74 (1.2%), and 274 (4.4%), respectively. Pregnant women who were not very satisfied with their parent-daughter relationship showed a significant positive association with HIP in the crude model (odds ratio (OR): 1.71, 95% confidence interval (CI): 1.11-2.63). When stratified by psychiatric disease history, we found a significant positive association among those without psychiatric disease history (OR: 1.77, 95% CI: 1.11-2.84), but not among those with psychiatric disease history (OR: 0.61, 95% CI: 0.16-2.28). CONCLUSIONS: Poor parent-daughter relationship was associated with the risk of HIP among pregnant women without psychiatric disease history, suggesting that this simple question could be used to estimate the risk of HIP when it was challenging to inquire directly about ACEs. Further research is needed to elucidate the mechanism of the association.

Fetal heart rate evolution and brain imaging findings in preterm infants with severe cerebral palsy.

BACKGROUND: Cerebral palsy is more common among preterm infants than among full-term infants. Although there is still no clear evidence that fetal heart rate monitoring effectively reduces cerebral palsy incidence, it is helpful to estimate the timing of brain injury leading to cerebral palsy and the causal relationship with delivery based on the fetal heart rate evolution patterns. Understanding the relationship between the timing and the type of brain injury can help to identify preventive measures in obstetrical care. OBJECTIVE: This study aimed to examine the relationship between the timing of insults and the type of brain injury in preterm infants with severe cerebral palsy. STUDY DESIGN: This longitudinal study was based on a nationwide database for cerebral palsy. The data of infants with severe cerebral palsy (equivalent to levels 3-5 of the Gross Motor Function Classification System-Expanded and Revised), born between 2009 and 2014 at 28 to 33 weeks of gestation, were included. The intrapartum fetal heart rate evolution patterns were evaluated by 3 obstetricians blinded to clinical information other than gestational age at birth, and these were categorized after agreement by at least 2 of the 3 reviewers into (1) continuous bradycardia, (2) persistently nonreassuring (prenatal onset), (3) reassuring-prolonged deceleration, (4) Hon's pattern (intrapartum onset), (5) persistently reassuring (pre- or postnatal onset), and (6) unclassified. Infant brain magnetic resonance imaging findings at term-equivalent age were assessed by a pediatric neurologist blinded to the background details, except for gestational age at birth and corrected age at image acquisition, and these were categorized as (1) basal ganglia-thalamus, (2) white matter, (3) watershed cortex or subcortex, (4) stroke, (5) normal, and (6) unclassified based on the predominant site involved. The risk factors for the basal ganglia-thalamus group were compared with those of the combined white matter and watershed injuries group. RESULTS: Among 1593 infants with severe cerebral palsy, 231 were born at 28 to 33 weeks of gestation, and 140 met the eligibility criteria. Fetal heart rate evolution patterns were categorized as bradycardia (17% [24]); persistently nonreassuring (40% [56]); reassuring-prolonged deceleration (7% [10]); reassuring-Hon (6% [8]); persistently reassuring (7% [10]); and unclassified (23% [32]). Cerebral palsy was presumed to have an antenatal onset in 57% of infants and to have been caused by intrapartum insult in 13% of infants. Magnetic resonance imaging showed that 34% (n=48) of infants developed basal ganglia-thalamus-dominant brain injury. Of the remaining 92 infants, 43% (60) showed white matter injuries, 1% (1) showed watershed injuries, 4% (5) showed stroke, 1% (1) had normal findings, and 18% (25) had unclassified findings. Infants with continuous bradycardia (adjusted odds ratio, 1033.06; 95% confidence interval, 15.49-68,879.92) and persistently nonreassuring fetal heart rate patterns (61.20; 2.09-1793.12) had a significantly increased risk for basal ganglia-thalamus injury. CONCLUSION: Severe cerebral palsy was presumed to have an antenatal onset in 57% of infants and to have been caused by intrapartum insult in only 13% of infants born at 28 to 33 weeks of gestation. Although the white matter-watershed injury was predominant in the study populations, severe acute hypoxia-ischemia may be an important prenatal etiology of severe cerebral palsy in preterm infants.

Relationship trajectories of pregnant women with their parents and postpartum depression: A hospital-based prospective cohort study in Japan.

Backgrounds: A history of childhood abuse and subsequent poor relationship with parents in adulthood among pregnant women is a known risk factor for postpartum depression (PPD). Although parent-daughter relationship can change during pregnancy, little is known whether the trajectories have an impact on PPD. The aim of this study is to examine whether trajectories of parent-daughter relationship during pregnancy are associated with PPD in Japanese mothers. Methods: In a hospital-based prospective cohort study conducted in Japan, 4,772 women were followed from their first visit to their 1-month postpartum check-up (follow-up rate: 77.4%). Parent-daughter relationship was assessed whether participants were satisfied with their parents at first visit and after delivery. We defined four parent-daughter relationship trajectory categories: consistently satisfied, improving, deteriorating, and consistently unsatisfied. PPD was assessed by the Edinburgh Postnatal Depression Scale. Logistic regression model was applied to adjust covariates. Results: There were 129 (2.7%), 122 (2.6%), and 181 (3.8%) cases of improving, deteriorating, and consistently unsatisfied relationship, respectively. Compared to the group that was consistently satisfied, pregnant women of the deteriorating and consistently unsatisfied group showed 2.81 (95% CI: 1.73-4.55) and 2.39 (95% CI: 1.58-3.62) times, respectively, more likely to show PPD after adjustment for confounders. Conclusion: Women who felt that their relationship with parents "deteriorated" or was "consistently unsatisfactory" during pregnancy showed significant risk of PPD. Paying attention to the pregnant women's feelings about the relationship with their parents and promoting positive change may help predict and prevent PPD.

Development of Social Life Impact for Mother (SLIM) scale at first trimester to identify mothers who need social support postpartum: a hospital-based prospective study in Japan.

OBJECTIVE: To develop and validate the Social Life Impact for Mother (SLIM) scale to identify mothers in Japan who need social support postpartum. METHODS: Hospital-based prospective study was implemented nationwide in Japan. A total of 7462 pregnant women completed the SLIM scale in their first trimester, and postpartum social problems (postpartum depression and bonding disorders) were assessed at 1 month after delivery (N = 5768, follow-up rate 77.3%). Multivariate logistic regression was applied to investigate the association between SLIM scale and postpartum social problems. RESULTS: The SLIM scale is made up of nine risk factors for postpartum social problems, including relationship problems, lower financial status, and lack of social support. The SLIM scale predicted postpartum social problems with moderate accuracy (area under the curve 0.63, 95% confidence interval 0.60-0.65). Further stratification by local clinic and tertiary hospital did not affect the estimates. CONCLUSION: The SLIM scale at prenatal check-up may be useful for obstetricians to detect mothers with postpartum social problems. Further intervention studies using the SLIM score are warranted.

Fetal heart rate evolution patterns in cerebral palsy associated with umbilical cord complications: a nationwide study.

BACKGROUND: The aim of the present study was to clarify fetal heart rate (FHR) evolution patterns in infants with cerebral palsy (CP) according to different types of umbilical cord complications. METHODS: This case-control study included children born: with a birth weight ≥2000 g, at gestational age ≥33 weeks, with disability due to CP, and between 2009 and 2014. Obstetric characteristics and FHR patterns were compared among patients with CP associated with (126 cases) and without (594 controls) umbilical cord complications. RESULTS: There were 32 umbilical cord prolapse cases and 94 cases with coexistent antenatal umbilical cord complications. Compared with the control group, the persistent non-reassuring pattern was more frequent in cases with coexistent antenatal umbilical cord complications (p = 0.012). A reassuring FHR pattern was observed on admission, but resulted in prolonged deceleration, especially during the first stage of labor, and was significantly identified in 69% of cases with umbilical cord prolapse and 35% of cases with antenatal cord complications, compared to 17% of control cases (p < 0.001). CONCLUSION: Hypercoiled cord and abnormal placental umbilical cord insertion, may be associated with CP due to acute hypoxic-ischemic injury as well as sub-acute or chronic adverse events during pregnancy, while umbilical cord prolapse may be characterized by acute hypoxic-ischemic injury during delivery.

Correlation between fetal heart rate evolution patterns and magnetic resonance imaging findings in severe cerebral palsy: A longitudinal study.

OBJECTIVE: To investigate the association between hypoxic-ischaemic insult timing and brain injury type in infants with severe cerebral palsy (CP). DESIGN: Longitudinal study. SETTING: Database of the Recurrence Prevention Committee, Japan Obstetric Compensation System for Cerebral Palsy. SAMPLE: Infants with severe CP born at ≥34 weeks of gestation. METHODS: The intrapartum fetal heart rate (FHR) strips were categorised as continuous bradycardia; persistently non-reassuring (NR-NR); reassuring-prolonged deceleration (R-PD); Hon's pattern (R-Hon); persistently reassuring (R-R); and unclassified. The brain magnetic resonance imaging (MRI) scans were categorised based on the predominant site involved: basal ganglia-thalamus (BGT); white matter (WM); watershed (WS); stroke; normal; and unclassified. MAIN OUTCOME MEASURES: Manifestations of the brain MRI types and the association between FHR evolution pattern and MRI type were analysed. RESULTS: Among 672 eligible infants, 76% had BGT-dominant injury, 5.4% WM, 1.2% WS, 1.6% stroke, 1.9% normal, and 14% unclassified. Placental abruption and small-for-gestational age were associated with an increased (adjusted odds ratio [aOR] 8.02) and decreased (aOR 0.38) risk of BGT injury, respectively. The majority of infants had BGT injury in most FHR groups (bradycardia, 97%; NR-NR, 75%; R-PD, 90%; R-Hon, 76%; and R-R, 45%). The risk profiles in case of BGT in the NR-NR group were similar to those in the R-PD and R-Hon groups. CONCLUSION: BGT-dominant brain damage accounted for three-fourths of the cases of CP in term or near-term infants, even in prenatal onset cases. Hypoxic-ischaemic insult has a major impact on CP development during the antenatal period. TWEETABLE ABSTRACT: Basal ganglia-thalamus injury constitutes 76% of severe cerebral palsy cases, predominant even in antenatal-onset cases.

Clinical guide for women with mental health problems during the perinatal period.

Pregnancy and childbirth have various effects on the physical as well as mental aspects of women. Therefore, appropriate considerations must be given to the mental health of pregnant women. The Guideline Review Committee of the Japanese Society of Psychiatry and Neurology launched a liaison meeting for the Japanese Society of Psychiatry and Neurology and the Japan Society of Obstetrics and Gynecology, with a view to creating a "Clinical guide for women with mental health problems during the perinatal period" by cooperation of these two fields. After repeated discussions with input from both academic societies, they jointly formulated the "Clinical guide for women with mental health problems during the perinatal period: Overview" in May 2020, and reported its "Detailed Contents" in April 2021. We hope that this guide, which is the English overview of the detailed guide, will contribute to the mental health of pregnant women, facilitating healthy pregnancies and childbirth.

Risk factors for cerebral palsy in neonates due to placental abruption.

AIM: This study aimed to identify risk factors for the onset of cerebral palsy (CP) in neonates due to placental abruption and investigate their characteristics. METHODS: A retrospective case-control study was conducted using a nationwide registry from Japan. The study population included pregnant women (n = 122) who delivered an infant with CP between 2009 and 2015, where placental abruption was identified as the single cause of CP. The control group consisted of pregnant women with placental abruption, who delivered an infant without CP and were managed from 2013 to 2014. They were randomly identified from the prenatal database of the Japan Society of Obstetrics and Gynecology (JSOG-DB; n = 1214). Risk factors were investigated using multivariate analysis. RESULTS: Alcohol consumption (3.38, 2.01-5.68) (odds ratio, 95% confidence interval), smoking during pregnancy (3.50, 1.32-9.25), number of deliveries (1.28, 1.05-1.56), polyhydramnios (5.60, 1.37-22.6), oral administration of ritodrine hydrochloride (2.09, 1.22-3.57) and hypertensive disorders in pregnancy (2.25, 1.27-4.07) were significant risk factors. In contrast, intravenous administration of oxytocin (odds ratio, 95% confidence interval: 0.22, 0.09-0.58) and magnesium sulfate (0.122, 0.02-0.89) attenuated risk. CONCLUSION: Alcohol consumption, smoking during pregnancy, number of deliveries, polyhydramnios, oral administration of ritodrine hydrochloride and hypertensive disorders in pregnancy were identified as risk factors for CP following placental abruption. Regarding alcohol consumption and smoking during pregnancy, the results suggest the importance of educational activities targeting pregnant women to increase their awareness of placental abruption.

Obstetric factors associated with uterine rupture in mothers who deliver infants with cerebral palsy.

Objective: The aim of the present study was to clarify the obstetric factors associated with uterine rupture in mothers who deliver infants with cerebral palsy (CP) in Japan.Methods: This retrospective case-cohort study reviewed the obstetric characteristics and clinical courses of mothers who experienced uterine rupture and compared those who delivered an infant with CP (cases) with those who delivered an infant without CP (cohort). Data were obtained from the Japan Obstetric Compensation System for CP database (27 cases) and the perinatal database of the Japan Society of Obstetrics and Gynecology (312 cohorts). The subjects included live singleton infants delivered between 2009 and 2014 with a birth weight ≥2000 g and gestation ≥33 weeks.Results: Augmentation was performed 33% in cases and 8% in cohorts (p < .001). The amount of bleeding during surgery was 1819 g in cases and 1096 g in cohorts (p < .001). Length of gestational weeks and neonatal birth weight were significantly higher and Apgar scores and umbilical arterial pH were lower in cases compared to cohorts (p < .001). In cases with CP, 11 cases of uterine rupture involved scarred uteruses. Seven were trial of labor after a previous cesarean. On one hand, 16 cases occurred in unscarred uteruses. Five of the uterine fundal pressure maneuvers and four of tachysystole due to excessive augmentation were reported in association with uterine rupture.Conclusion: Two-third of the relevant obstetric factors for CP associated with uterine rupture were iatrogenic. At least, to reduce CP resulting from delivery-related uterine rupture, reckless delivery management should be avoided.

Weekend and off-hour effects on the incidence of cerebral palsy: contribution of consolidated perinatal care.

OBJECTIVE: This study estimated the effects of weekend and off-hour childbirth and the size of perinatal medical care center on the incidence of cerebral palsy. METHODS: The cases were all children with severe cerebral palsy born in Japan from 2009 to 2012 whose data were stored at the Japan Obstetric Compensation System for Cerebral Palsy database, a nationally representative database. The inclusion criteria were the following: neonates born between January 2009 and December 2012 who had a birth weight of at least 2000 g and gestational age of at least 33 weeks and who had severe disability resulting from cerebral palsy independent of congenital causes or factors during the neonatal period or thereafter. Study participants were restricted to singletons and controls without report of death, scheduled cesarean section, or ambulance transportation. The controls were newborns, randomly selected by year and type of delivery (normal spontaneous delivery without cesarean section and emergency cesarean section) using a 1:10 case to control ratio sampled from the nationwide Japan Society of Obstetrics and Gynecology database. RESULTS: A total of 90 cerebral palsy cases and 900 controls having normal spontaneous delivery without cesarean section were selected, as were 92 cerebral palsy cases and 920 controls with emergent cesarean section. A significantly higher risk for cerebral palsy was found among cases that underwent emergent cesarean section on weekends (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.06-2.81) and during the night shift (OR 2.29, 95% CI 1.30-4.02). No significant risk was found among normal spontaneous deliveries on weekends (OR 1.63, 95% CI 0.97-2.73) or during the quasi-night shift (OR 1.26, 95% CI 0.70-2.27). Regional perinatal care centers showed significantly higher risk for cerebral palsy in both emergent cesarean section (OR 2.35, 95% CI 1.47-3.77) and normal spontaneous delivery (OR 2.92, 95% CI 1.76-4.84). CONCLUSION: Labor on weekends, during the night shift, and at regional perinatal medical care centers was associated with significantly elevated risk for cerebral palsy in emergency cesarean section.

Fetal heart rate pattern in term or near-term cerebral palsy: a nationwide cohort study.

BACKGROUND: It is crucial to interpret fetal heart rate patterns with a focus on the pattern evolution during labor to estimate the relationship between cerebral palsy and delivery. However, nationwide data are not available. OBJECTIVE: The aim of our study was to demonstrate the features of fetal heart rate pattern evolution and estimate the timing of fetal brain injury during labor in cerebral palsy cases. STUDY DESIGN: In this longitudinal study, 1069 consecutive intrapartum fetal heart rate strips from infants with severe cerebral palsy at or beyond 34 weeks of gestation, were analyzed. They were categorized as follows: (1) continuous bradycardia (Bradycardia), (2) persistently nonreassuring, (3) reassuring-prolonged deceleration, (4) Hon's pattern, and (5) persistently reassuring. The clinical factors underlying cerebral palsy in each group were assessed. RESULTS: Hypoxic brain injury during labor (those in the reassuring-prolonged deceleration and Hon's pattern groups) accounted for 31.5% of severe cerebral palsy cases and at least 30% of those developed during the antenatal period. Of the 1069 cases, 7.86% were classified as continuous bradycardia (n=84), 21.7% as persistently nonreassuring (n=232), 15.6% as reassuring-prolonged deceleration (n=167), 15.9% as Hon's pattern (n=170), 19.8% as persistently reassuring (n=212), and 19.1% were unclassified (n=204). The overall interobserver agreement was moderate (kappa 0.59). Placental abruption was the most common cause (31.9%) of cerebral palsy, accounting for almost 90% of cases in the continuous bradycardia group (64 of 73). Among the cases in the Hon's pattern group (n=67), umbilical cord abnormalities were the most common clinical factor for cerebral palsy development (29.9%), followed by placental abruption (20.9%), and inappropriate operative vaginal delivery (13.4%). CONCLUSION: Intrapartum hypoxic brain injury accounted for approximately 30% of severe cerebral palsy cases, whereas a substantial proportion of the cases were suspected to have either a prenatal or postnatal onset. Up to 16% of cerebral palsy cases may be preventable by placing a greater focus on the earlier changes seen in the Hon's fetal heart rate progression.

Association between adolescent pregnancy and adverse birth outcomes, a multicenter cross sectional Japanese study.

We aimed to clarify how maternal physical characteristics explains the association between adolescent pregnancy and adverse birth outcomes, focusing on their height. We used a national multicenter-based delivery registry among 30,831 women under age 25 years with a singleton pregnancy between 2005 and 2011. Adolescent pregnancy was defined as younger than 20 years of age, and categorized into "junior adolescent" (aged ≤15 years) and "senior adolescent" (aged 16-19 years). We used multivariate Poisson regression and mediation analysis to assess the extent to which maternal height explained the association between adolescent pregnancy and risk of adverse birth outcomes. Risks for preterm birth [(adjusted risk ratio (aRR) 1.17, 95% confidence interval (95% CI), 1.08-1.27], low birthweight (aRR 1.08, 95% CI, 1.01-1.15), and low Apgar score (aRR 1.41 95%CI, 1.15-1.73) were significantly higher among adolescent women compared to women of 20-24 years of age. The mediation effect of maternal height on these outcomes were moderate for low birthweight (45.5%) and preterm birth (10.5%), and smaller for low Apgar score (6.6%). In all analyses, we did not detect significant differences between junior adolescent and senior adolescent. Adolescent women have higher risk of adverse birth outcomes. This association is partially mediated by shorter maternal height.

Relevant obstetric factors associated with fetal heart rate monitoring for cerebral palsy in pregnant women with hypertensive disorder of pregnancy.

AIM: The study identifies the relevant obstetric factors associated with fetal heart rate (FHR) monitoring for cerebral palsy (CP) in pregnant women with hypertensive disorders of pregnancy (HDP). METHODS: The subjects were neonates with CP (birth weight ≥ 2000 g, gestational age ≥ 33 weeks) who were approved for compensation for CP by the Operating Organization of the Japan Obstetric Compensation System between 2009 and 2012. After selection of women with antepartum HDP, obstetric characteristics associated with FHR monitoring were analyzed. RESULTS: The subjects included 33 neonates with CP whose mothers suffered from HDP during pregnancy and 450 neonates whose mothers did not develop HDP. The rates of placental abruption (48.5% vs. 20%; P < 0.001) and light-for-gestational age (12.1% vs. 2.2%; P = 0.011) were significantly higher in women with HDP than in those without HDP. Regarding FHR pattern analysis, fetal bradycardia was observed on admission to hospital in 94% of women with placental abruption. In women without placental abruption, FHR was likely to indicate a favorable pattern on admission, but became worse with the progression of labor. CONCLUSION: This is first study to clinically demonstrate FHR patterns in CP cases in association with HDP. Although antepartum CP is undetectable, pregnant women with HDP should be placed under strict observation and management to minimize fetal hypoxic conditions during labor.

Impact of risk factors for perinatal events in Japan: Introduction of a newly created perinatal event score.

AIM: A cohort study was performed to clarify the influence of risk factors on perinatal events (obstetric complications and/or perinatal deaths). METHODS: This cohort study reviewed 395 785 births from 2011 to 2013. Women with singleton pregnancies delivered after 22 weeks of gestation were included. The OR were determined on multivariate analysis. The perinatal event score (PES) for risk factors, which is the product of the OR of risk factors for obstetric complications, OR of risk factors for perinatal death, and OR of obstetric complications for perinatal death, was introduced to clarify the impact of each risk combination. RESULTS: There were 20 risk factors such as maternal age and medical complications relating to the 11 obstetric complications, including pregnancy-induced hypertension and preterm labor. As a result, 77 combinations of risk factors and obstetric complications were found to be significant. Six obstetric complications such as preterm labor and cervical insufficiency were found to be related to perinatal death. Two factors were found to be directly related to perinatal death: age >40 years old (OR, 1.24; 95%CI: 1.11-1.39) and essential hypertension (OR, 1.56; 95%CI: 1.19-2.05). As a result, PES ranged from 1.07 (primipara for premature rupture of membrane) to 40.1 (essential hypertension for placental abruption), and high PES (≥8) was identified in 21 combinations of risk factors and obstetric complications. CONCLUSION: This newly created score for perinatal events, PES, can be used as an indicator of the impact of risk factors on perinatal events.

Comparative analysis of cesarean section rates using Robson Ten-Group Classification System and Lorenz curve in the main institutions in Japan.

AIM: The aim of this study was to clarify the indication for cesarean section (CS) using the Robson Ten-Group Classification System (RTGCS) and to clarify the center variation using the Lorenz curve in the main institutions in Japan. METHODS: The records of 68 702 deliveries, which were performed in 125 institutions, were extracted from the Japanese perinatal database in 2013 and the cases were classified using the RTGCS, which classifies deliveries into one of 10 groups on the basis of five parameters. The equality of the CS rate of each hospital was evaluated by the Lorenz curve and the Gini coefficient. The standard error (SE) and 95% confidence intervals (95%CI) for the Gini coefficient were determined by the bootstrap method. The institutions were divided into three categories depending on their scale: comprehensive center (CC, Category I), regional center (RC, Category II) and others (Category III). RESULTS: The overall CS rate was 37.3%. The difference between Categories I (42.6%) and II (34.3%) was significant (P = 0.02). The CS rates that were classified as RTGCS group 3 (multiparous, single cephalic, ≥37 weeks, with spontaneous labor) were higher in Category I (4.0%) than in Category II (2.7%, P = 0.01). The Gini coefficient of Category I (0.119 ± 0.015; 95%CI, 0.092-0.152) was significantly lower than that of Category II (0.189 ± 0.013; 95%CI, 0.16-0.217). CONCLUSION: We clarified the indication of CS and center variation. These two types of methods are useful for the evaluation of medical intervention in the perinatal field.

Relevant Obstetric Factors for Cerebral Palsy: From the Nationwide Obstetric Compensation System in Japan.

OBJECTIVE: The aim of this study was to identify the relevant obstetric factors for cerebral palsy (CP) after 33 weeks' gestation in Japan. STUDY DESIGN: This retrospective case cohort study (1:100 cases and controls) used a Japanese national CP registry. Obstetric characteristics and clinical course were compared between CP cases in the Japan Obstetric Compensation System for Cerebral Palsy database and controls in the perinatal database of the Japan Society of Obstetrics and Gynecology born as live singleton infants between 2009 and 2011 with a birth weight ≥ 2,000 g and gestation ≥ 33 weeks. RESULTS: One hundred and seventy-five CP cases and 17,475 controls were assessed. Major relevant single factors for CP were placental abnormalities (31%), umbilical cord abnormalities (15%), maternal complications (10%), and neonatal complications (1%). A multivariate regression model demonstrated that obstetric variables associated with CP were acute delivery due to non-reassuring fetal status (relative risk [RR]: 37.182, 95% confidence interval [CI]: 20.028-69.032), uterine rupture (RR: 24.770, 95% CI: 6.006-102.160), placental abruption (RR: 20.891, 95% CI: 11.817-36.934), and preterm labor (RR: 3.153, 95% CI: 2.024-4.911), whereas protective factors were head presentation (RR: 0.199, 95% CI: 0.088-0.450) and elective cesarean section (RR: 0.236, 95% CI: 0.067-0.828). CONCLUSION: CP after 33 weeks' gestation in the recently reported cases in Japan was strongly associated with acute delivery due to non-reassuring fetal status, uterine rupture, and placental abruption.

Safety and efficacy of thromboprophylaxis using enoxaparin sodium after cesarean section: A multi-center study in Japan.

OBJECTIVE: Pulmonary embolism (PE) is the leading cause of maternal death in developed countries, and the prevention of venous thromboembolism (VTE) is a pivotal part of current obstetric care. This study evaluated the safety and efficacy of enoxaparin sodium for thromboprophylaxis after cesarean section (C/S), and analyzed the risk factors associated with VTE. MATERIALS AND METHODS: One hundred and forty-three women deemed to be at high risk of postoperative deep vein thrombosis (DVT) were enrolled between January 2011 and May 2012 in seven institutions in Japan. Subcutaneous administration of enoxaparin 4000 units/d was initiated 24-36 hours after C/S for 5 days. Adverse events, based on the Common Terminology Criteria for Adverse Events, Version 4, were recorded. The diagnoses of PE and DVT were made on clinical signs. Venous ultrasonography in the lower extremities was performed in 102 patients. The association between VTE and various risk factors was evaluated using univariate analysis. RESULTS: There were 10 (7.0%) Grade 1 adverse events: elevated aspartate aminotransferase or alanine aminotransferase levels in eight patients, chest pain in one patient, and subcutaneous hematoma in one patient. No patients showed clinical signs of PE and/or DVT. Among 102 patients who underwent venous ultrasonography, thrombus was detected in unilateral soleus veins in four (3.9%) patients. A body mass index (BMI) ≥ 25 kg/m(2) before pregnancy was associated with asymptomatic DVT. CONCLUSION: The current study demonstrates the safety and efficacy of enoxaparin for thromboprophylaxis after C/S. Further studies are required to determine the best method of preventing asymptomatic DVT.

Fetal/Placental weight ratio in term Japanese pregnancy: its difference among gender, parity, and infant growth.

PURPOSE: The "inappropriately heavy placenta" has been considered to be associated with various pregnancy disorders; however, data is scarce what factors affect it. To determine whether the following three affect it; (1) infant gender and mother's parity, (2) growth restriction, and (3) preeclampsia. METHODS: We employed fetal/placental weight ratio (F/P). Subjects consisted of 53,650 infants and their placentas from women who vaginally delivered singleton live term infants. First, we examined whether F/P differs among the infant's gender or mother's parity. We classified the population into 4 categories according to gender and parity: male, nulliparous (n=7,431), male, multiparous (n=7,859), female, nulliparous (n=7,559), female, multiparous (n=7,800), and, compared F/P among the four groups. Next, we determined whether F/P differs in "small" or "large" for gestational age (SGA or LGA) infants, compared with appropriate for gestational age infants. Last, we determined whether preeclampsia (representative disorder of SGA) affects F/P. RESULTS: (1) F/P significantly differed according to infant gender and parity: female and nulliparity had significantly smaller F/P. F/P was significantly smaller in (2) SGA infants, and (3) infants from preeclamptic mothers. CONCLUSION: We for the first time showed that in Japanese term vaginally-delivered singleton population, the following three had significantly smaller F/P than controls thus had "inappropriately heavy placenta": (1) female gender and nulliparity, (2) SGA infants, and (3) infants from preeclamptic mothers. We recommend that these factors should be taken into account in evaluating placental weight. These data may also be useful for further clarifying the fetal-placental pathophysiology in these conditions.