Comparative study of obstetric and neonatal outcomes of live births between poor- and good-quality embryo transfers.

PURPOSE: To evaluate the effect of embryo quality on pregnancy outcomes. METHODS: This retrospective analysis included 80 live singleton births, resulting from morphologically good-quality embryo transfers, and 25 live singleton births that resulted from morphologically poor-quality embryo transfers between January, 2008 and December, 2014. Cleavage embryos that were graded as ≥2, according to the Veeck classification system, and blastocysts that were graded as ≥3BB, according to the Gardner classification system, were defined as good quality. The obstetric and neonatal outcomes were compared between the poor- and good-quality embryo transfer groups. RESULTS: The mean maternal age between the groups was similar. The blastocyst transfer rate was higher in the good-quality, than in the poor-quality, embryo transfer group. Other characteristics, including parity, infertility duration, the intracytoplasmic sperm injection rate, frozen-thawed embryo transfer rate, endometrial thickness, and hormone values before the embryo transfer, were similar between the groups. The obstetric and neonatal outcomes of live births between the two groups were not different in terms of preterm delivery, birthweight, small or large size for gestational age, malformation, umbilical artery cord pH of <7.20, hypertensive disorders of pregnancy, gestational diabetes mellitus, chorioamnionitis, placenta previa, and placental abruption. CONCLUSION: The obstetric and neonatal outcomes of live births between the poor- and good-quality embryo transfers were equivalent.

Acute congestive heart failure due to ruptured mitral chordae tendineae in late pregnancy.

A 31-year-old woman complained of dyspnea and orthopnea at 38 weeks of gestation. A grade 3/6 pansystolic murmur was heard, and echocardiography revealed severe mitral regurgitation with a hyperechoic obstacle on the posterior mitral valve leaflet, consistent with a diagnosis of acute heart failure due to a ruptured chordae tendineae or an infectious endocarditis. An emergency cesarean section was performed under general anesthesia. A male infant was born weighing 2928 g with Apgar scores of 7 and 8 at 1 and 5 min, respectively. The patient was managed in the intensive care unit and underwent open-heart surgery for mitral valve repair on postpartum day 3. The two chordal tendineae appeared torn and frail, and a mitral annuloplasty was performed. No finding of infectious endocarditis was observed. Because it is a dramatic and life-threatening clinical situation, proper diagnosis and treatment in the intensive care unit assure a good outcome for both mother and fetus.

Comparison between the gonadotropin-releasing hormone antagonist protocol and the gonadotropin-releasing hormone agonist long protocol for controlled ovarian hyperstimulation in the first in vitro fertilization-embryo transfer cycle in an unspecified population of infertile couples.

PURPOSE: We aimed to compare the efficacy of a gonadotropin-releasing hormone (GnRH) antagonist protocol and a GnRH agonist long protocol used in the first in vitro fertilization-embryo transfer (IVF-ET) cycle in an unspecified population of infertile couples. METHODS: Fifty and 34 patients were treated with a GnRH agonist long protocol (agonist group) and GnRH antagonist protocol (antagonist group), respectively, in the first treatment cycle. The primary and secondary outcome measures were cumulative live birth rates after fresh and cryopreserved-thawed ETs and incidence of grades II and III ovarian hyperstimulation syndrome (OHSS), respectively. RESULTS: No significant differences were observed in clinical pregnancy rates (38.0 vs. 32.4%) and live birth rates (22.0 vs. 23.5%), which included both fresh and cryopreserved-thawed ETs, between the 2 groups. However, the incidence of grade III OHSS was significantly lower with the GnRH antagonist protocol than the GnRH agonist long protocol. CONCLUSIONS: Used in the first IVF-ET cycle in an unspecified population of infertile patients, the GnRH antagonist protocol showed the same clinical outcome as the GnRH agonist long protocol.

Fetal ovarian cyst with prenatal torsion of the pedicle diagnosed in the third trimester: A case report.

Ovarian cysts develop rarely in fetuses during pregnancy and usually disappear after birth. However, during pregnancy, torsion and rupture of the cyst can occur and it is necessary to manage such cases. At present, there is no standardized prenatal or neonatal treatment. However, the preservation of ovarian function is an important consideration. Here, we present a case involving a 35-year-old woman who gave birth to an infant with a complicated ovarian cyst, which was resolved through laparoscopic surgery on the third day after birth. The prenatal diagnosis of the fetal ovarian cyst was performed prenatally using ultrasound and magnetic resonance imaging (MRI). However, torsion of the ovarian pedicle was suspected because of dorsal thickening of the cyst wall and fluid formation indicated by high intensity on T1- and T2-weighted MRI. Surgery was complicated due to involvement in the torqued pedicle of the left fallopian tubal fimbria, which was released. The cyst was drained and partially resected, and then the pedicle torsion was released. By four years and five months of follow-up, there had been no ovarian cyst findings on ultrasound or MRI. Larger cysts are more likely to involve torsion of the ovarian pedicle and potential bleeding. Considering that, in this case, the cyst was large and proved to be ischemic-hemorrhagic, the decision to operate seemed justified.

Hysteroscopic tubal catheterization under laparoscopy for proximal tubal obstruction.

PURPOSE: The purpose of this study was to investigate the fertility outcomes of infertile patients having proximal tubal obstruction treated with hysteroscopic tubal catheterization (HCT) for recanalization under diagnostic laparoscopy. METHODS: From January 2000 to December 2008, diagnostic laparoscopy was used to assess the tubal status of 61 patients with unilateral or bilateral proximal tubal obstruction, as confirmed by hysterosalpingography. Among them, 35 patients with tubal obstruction confirmed by chromopertubation under laparoscopy subsequently underwent HCT. The pregnancy outcomes and success rates of recanalization were investigated. RESULTS: In the 35 patients with confirmed tubal obstruction, HCT was performed in 54 fallopian tubes. The success rate of recanalization was 25.9% (14/54) per tube and 37.1% (13/35) per patient. Of the patients in whom tubal patency was restored, 4 achieved pregnancy, including 1 tubal pregnancy and 1 miscarriage. Among the 61 patients, excluding 14 who underwent in vitro fertilization-embryo transfer (IVF-ET) after laparoscopy, 13 were pregnant (27.7%), 9 gave live births, 1 had tubal pregnancy, and 3 had miscarriages. CONCLUSIONS: HCT under laparoscopy is an option for couples with tubal infertility who do not prefer IVF-ET.

Rupture of pseudoaneurysm after vaginal delivery successfully treated by selective arterial embolization.

BACKGROUND: Rupture of a pseudoaneurysm after vaginal delivery is a rare cause of postpartum hemorrhage. CASE: A 29-year-old primigravida delivered a healthy boy by vacuum extraction at 38 weeks of gestation. The patient underwent repair of a right mediolateral episiotomy and left vaginal wall laceration. On the third postpartum day she experienced massive vaginal bleeding with vaginal wall laceration, and the vaginal bleeding progressively increased. A selective angiogram of the left internal iliac artery showed a pseudoaneurysm with extravasation originating from the left internal pudendal artery. Complete occlusion of the pseudoaneurysm was achieved by embolization of the left internal pudendal artery. The postprocedural course was uneventful. CONCLUSION: A pseudoaneurysm should be considered in unclear cases of postpartum hemorrhage.

Sigmoid Volvulus in Pregnancy Assessed by Contrast-Enhanced Computed Tomography Scanning.

Sigmoid volvulus requires urgent treatment, and it is particularly rare among pregnant women without a history of laparotomy. A delay in diagnosis may lead to serious consequences for the mother and fetus, and a rapid diagnosis and treatment in this setting is essential. The patient was a 19-year-old primiparous woman. She complained of repeated exacerbations and remissions of abrupt lower abdominal pain for the past 2 days and was transported to our hospital at 33 weeks of gestation. Ultrasonography revealed no placental thickening, and maternal bowel dilation was difficult to identify. Plain abdominal X-ray showed a dilated colon on the left side of the abdomen. Contrast-enhanced CT scan of the abdomen revealed a volvulus on the dorsal side of the uterus. The proximal end of the transverse to sigmoid colon was markedly dilated, and the distal end was collapsed. The elevated lactate level on blood gas analysis suggested intestinal ischemia. She was suspected of having a sigmoid volvulus at 33 weeks and 3 days of gestation. We decided to perform a cesarean section to secure the operative field for an intestinal resection following delivery. A male weighing 1840 g with Apgar scores 8/8 was delivered. The sigmoid colon was approximately 80 cm in length. A 360-degree clockwise rotation of was observed with a very distended but viable sigmoid loop. Following reduction of the volvulus, the sigmoid colon was fixed to the left side of the peritoneum. The mother had an uneventful postoperative course, and the infant was discharged without any sequelae. This case demonstrates two important lessons. First, sigmoid volvulus can occur in pregnant women even if they never had a laparotomy. Second, abdominal contrast-enhanced CT is useful for rapid diagnostic and treatment decisions relative to this pathology.

Critical respiratory failure in pregnancy complicated with COVID-19: A case report.

The case is presented of a 29-year-old primiparous woman who was COVID-19-positive at 34 weeks of gestation and who developed severe acute respiratory distress syndrome. After a four-day history of fever and mild dyspnea, she was referred to hospital. Ciclesonide, dexamethasone, heparin sodium, and sulbactam/ampicillin were initiated, followed by remdesivir and tocilizumab. On the fourth day after admission (at 34 weeks 5 days of gestation), respiratory failure required ventilator management. An emergency cesarean section was performed and a 2565-g male infant was delivered with an Apgar score of 8/8 and negative COVID-19 status. However, on the following day the patient's respiratory condition deteriorated and mechanical ventilation was initiated. Subsequently, her respiratory condition quickly improved and mechanical ventilation was terminated 4 days after intubation. She was discharged 12 days after cesarean delivery. Our case provides additional evidence that raises concerns regarding the unfavorable maternal consequences of COVID-19 infection during pregnancy.

Evaluation of neonatal withdrawal syndrome in neonates delivered by women taking psychotropic or anticonvulsant drugs: A retrospective chart review of the effects of multiple medications and breastfeeding.

OBJECTIVES: Neonates delivered by women who were taking psychotropic or anticonvulsant drugs during pregnancy are at increased risk of developing neonatal withdrawal syndrome. We investigated the incidence of neonatal withdrawal symptoms and the effects of multiple maternal medications and breastfeeding on neonatal withdrawal symptoms. STUDY DESIGN: This study examined the overall incidence of neonatal withdrawal symptoms in neonates delivered from 2004 to 2016 by women who were taking oral antipsychotics, antidepressants, anxiolytics, sedatives, or anticonvulsant drugs during pregnancy. Moreover, we compared the incidence of neonatal symptoms between mothers taking single drugs and multiple drugs, and between breastfed and formula-fed neonates. We scored the neonates according to the neonatal withdrawal syndrome checklist created by Isobe et al., which is widely used in Japan. RESULTS: We examined 131 mothers and their 134 neonates. Withdrawal symptoms were found in 54.5 % of neonates. Symptoms were found in 32.4 % of neonates delivered by mothers taking single drugs and 62.9 % of neonates delivered by mothers taking two or more drugs (p = 0.0019). One or more withdrawal symptoms developed in 46.4 % of breastfed neonates and 66.1 % of formula-fed neonates (p = 0.034). Five infants had a score of 8 or more points on the withdrawal checklist, which is an indication to consider treatment with pharmacotherapy. All five of these neonates were mainly formula-fed, and their mothers were taking two or more drugs. CONCLUSIONS: The incidence of withdrawal symptoms was high in neonates delivered by women taking psychotropic or anticonvulsant drugs; however, there were few serious cases. The risk increased when a mother was taking multiple drugs. Breastfeeding appeared to protect against withdrawal symptoms.

Development of Vaginal Pseudoaneurysm 3 Years after Cesarean Section Possibly Induced by Anticoagulant and Antiplatelet Therapies.

Pseudoaneurysms generally develop when an arterial puncture site is inadequately sealed. We encountered a case of vaginal pseudoaneurysm that developed 3 years after cesarean section in a 35-year-old gravida 7 para 4 woman who was prescribed with anticoagulant and antiplatelet drugs after surgeries for ventricular septal defect and aortic valve replacement. Pelvic computed tomography scan revealed a large mass, which showed a dappled contrast filling on the arterial phase, located in the posterior vaginal wall. The vaginal pseudoaneurysm was completely occluded by embolization of the left vaginal artery. Anticoagulation and antiplatelet therapies can be potential causes of spontaneous pseudoaneurysm rupture. Extrauterine pseudoaneurysm has a long period of time between cesarean section and pseudoaneurysm discovery. Considering that pseudoaneurysm shows different clinical features for each patient, we should always consider pseudoaneurysm when we assess a patient with postpartum hemorrhage.

Elective use of aortic balloon occlusion in cesarean hysterectomy for placenta previa percreta.

BACKGROUND: Only few reports are available on the use of aortic balloon catheter for cesarean hysterectomy in placenta previa percreta. CASE: A 32-year-old woman with placenta previa percreta underwent cesarean hysterectomy at 34 weeks of gestation. Before starting the surgery, an aortic occlusion balloon catheter (30 mm balloon, 5 Fr) was inserted. For total hysterectomy, the aortic balloon catheter was inflated and there was a sudden and dramatic reduction in blood loss, and the surgery was completed safely. An aortic occlusion was sustained for 80 min, with blood loss estimated at 3,200 ml. The postoperative course was uneventful. At 3 months after the operation, the mother and baby remained healthy. CONCLUSION: An aortic balloon is rapidly and easily inserted, and is an option for major hemorrhage in placenta previa percreta.

Warfarin-associated fetal intracranial hemorrhage in woman with mitral valve replacements: a case report.

Warfarin-associated fetal hemorrhage is a fatal event. We report the case of a 39-year-old woman who had been taking warfarin for 23 years since undergoing mitral valve replacement. Thereafter, when she was found to be pregnant, the medication was switched to heparin from 6 to 21 weeks of gestation. Following this, she was prescribed oral warfarin again (3.5 mg per day), with a strict control of prothrombin time/international normalized ratio (PT/INR). At 23 weeks of gestation, fetal intracranial hemorrhage occurred because of maternal exposure to warfarin. Maternal PT/INR does not correlate well with the activity of warfarin in the fetus and currently, there is no direct way to prevent fetal intracranial hemorrhage. Hence, further research on the optimal coagulation therapy in pregnant women with valve replacement should be encouraged.

Delayed pneumothorax after laparoscopic ovarian cystectomy.

BACKGROUND: We describe a case that developed a delayed pneumothorax after laparoscopic surgery. CASE: A 40-year-old woman (BMI: 19.1) underwent a laparoscopic ovarian cystectomy. On the first postoperative day, she developed a pneumothorax. The subcutaneous CO2 tracked up through the fascial planes, and ruptured into the pleural space, where delayed pneumothorax developed. CONCLUSION: Gynecologists should be aware of pneumothorax after laparoscopic surgery and should also keep in mind its possible delayed development.

A Case of Cornelia de Lange Syndrome: Difficulty in Prenatal Diagnosis.

We report a case of Cornelia de Lange syndrome (CdLS) where prenatal diagnosis was not made even with major anomaly. A 33-year-old Japanese woman was referred to our institution at 23 weeks of gestation because of fetal forearm defect. Ultrasound examination revealed short forearms and short humeri and femurs (-2.1 SD). The fetal estimated body weight was 450 g (-1.3 SD). Fetal MRI at 26 weeks of gestation revealed short forearms and hypoplasty of hand fingers. Fetal growth restriction became evident thereafter, leading to intrauterine fetal death occurring at 29 weeks of gestation. A stillbirth baby was of 798 g in body weight and 33.0 cm in length. External examination showed a low hairline, synophrys, low-set ear, hypertrichosis, and smooth long philtrum with thin lips. The neck appeared short and broad. Finally, CdLS was diagnosed. The prenatal diagnosis might be possible as the arm findings were totally characteristic in a small fetus, regardless of whether an overhanging upper lip was identified. Because CdLS is a rare condition, it is important to consider its possibility as a part of differential diagnosis.

Massive Subchorionic Thrombohematoma (Breus' Mole) Associated with Fetal Growth Restriction, Oligohydramnios, and Intrauterine Fetal Death.

Massive subchorionic thrombohematoma (MST), termed Breus' mole, is a rare condition in which a large maternal blood clot separates the chorionic plate from the villous chorion. Common complications of MST include fetal growth restriction, preeclampsia, and intrauterine fetal death. Here, we present a case of a 17-year-old Japanese woman referred to our institution at 21 weeks of gestation. Ultrasound examination revealed a large placental mass with mixed high and low echogenicity measuring approximately 7.6 cm in thickness. Doppler examination showed absence of end-diastolic velocity of the umbilical artery. At 22 weeks of gestation, the patient had a stillbirth weighing 138g. The placenta weighed 502 g and was 8 cm thick, and the total blood loss was 270 g. Macroscopic examination revealed that a subchorionic blood clot measuring 12 cm × 5 cm covered a large portion of the placenta with well-defined margins on the fetal surface. Microscopic examination revealed an intervillous hematoma and fibrinous deposits directly beneath the chorionic plate with adjacent compressive effects. Based on these findings, MST was diagnosed. Because MST is rare, it must be considered in the differential diagnosis of parental conditions. Magnetic resonance imaging can be optimal for diagnosing MST when ultrasound diagnosis is difficult.

Thyroid function after hysterosalpingography using an oil-soluble iodinated contrast medium.

BACKGROUND: The objective of the present study was to evaluate the effect of an oil-soluble iodinated contrast medium (lipiodol) for hysterosalpingography (HSG) on thyroid function. METHODS: In 214 of 528 women with infertility examined by HSG using lipiodol between 1996 and 2006 at our institution, serum free thyroxine (FT4) and thyrotropin-stimulating hormone (TSH) were measured before and several months after HSG. RESULTS: The average age of the women was 34.5 +/- 4.6 years and their average infertility period was 2.9 +/- 2.5 years (mean+/-standard deviation). The 214 patients were divided into three groups based on the results of thyroid function before HSG: 180 in euthyroid, 28 in subclinical hypothyroidism and 13 in subclinical hyperthyroidism. The number of patients in the subclinical hypothyroidism group who developed hypothyroidism after HSG (ten of 28) was significantly higher than that of the euthyroid group (four of 180). Thyroid hormone replacement was required in three patients from the subclinical hypothyroidism group 1, 2 and 5 months after HSG. CONCLUSIONS: We conclude that thyroid function should be monitored closely after HSG using lipiodol to detect the development of hypothyroidism, particularly in patients with subclinical hypothyroidism, and TSH and FT4 measurements should be performed before HSG to identify patients at risk for hypothyroidism.

Squamous cell carcinoma arising in an ovarian mature cystic teratoma complicating pregnancy: a case report.

BACKGROUND: The question of whether patients with pure stage I squamous cell carcinoma in a mature cystic teratoma (MCT) should undergo conservative surgery, or postoperative adjuvant treatment remains unresolved. CASE: A 33-year-old woman with a left ovarian cyst underwent laparoscopic cystectomy at 16 weeks of gestation. Histological examination confirmed squamous cell carcinoma arising in an MCT. At 18 weeks of gestation, she underwent left salpingo-oophorectomy, and was diagnosed as having stage Ic malignant transformation of the MCT, and was observed closely without postoperative adjuvant chemotherapy. She delivered a healthy baby at 41 weeks of gestation. No evidence of recurrence was observed 14 months after the initial laparoscopic surgery. CONCLUSION: Although a thorough staging procedure , histopathologic evaluation, and long-term follow-up are indispensable, patients with early stage I squamous cell carcinoma in MCT may safely undergo conservative surgery.

Fetal Congenital Peripheral Bronchial Atresia Diagnosed by Magnetic Resonance Imaging: Two Case Reports.

Two types of congenital bronchial atresia (proximal and peripheral) have been classified. We report two cases of peripheral bronchial atresia diagnosed by prenatal ultrasonography (US) and magnetic resonance imaging (MRI). Evaluating an enlarged lung mass that is homogeneously hyperechoic on US and hyperintense on T2-weighted MRI can help in determining whether bronchial atresia is present. Proximal type is suggested when a dilated main bronchus is observed as a tubule structure of an involved lung hilum. In our cases, T2-weighted MRI revealed homogeneously hyperintense lung lesion with decreased signal intensity of adjacent lobe, flattening diaphragm, and mediastinal shift. Dilatation of the main bronchus was not observed and the opposite lung was normal in appearance. These findings were explained by secondary compression due to enlargement of the involved lung. The preservation of vascular structure and the retained normal shape, though enlarged, in the affected lobe were observed, which demonstrated undisrupted pulmonary architecture of the lobe. Thus, congenital cystic adenomatoid malformation was excluded because pulmonary architecture was relatively preserved. Finally, presumed diagnoses of the peripheral bronchial atresia were made and confirmed by postnatal chest computed tomography.

Fetal Sirenomelia Associated with an Abdominal Cyst Originating from a Saccular Cloaca.

A 40-year-old pregnant woman presented with a fetal abdominal cyst and oligohydramnios. Color Doppler scan revealed a single blood vessel from the fetal aorta into a single umbilical artery. Severe oligohydramnios limited ultrasonographic evaluation of the fetal lower limbs, kidneys, or bladder. The pregnancy was terminated; the fetus showed fused lower limbs, bulging abdomen, and absent external genitalia and was diagnosed with type III sirenomelia. On autopsy, no normal bladder was observed, but duodenal atresia, anorectal atresia, and right renal agenesis were found. An intra-abdominal cyst, diagnosed histologically as a saccular cloaca, occupied the abdominal cavity. Ultrasonographic diagnosis of fetal sirenomelia is difficult due to poor depiction of the lower limbs. A vitelline artery leading to a single umbilical artery and a fetal abdominal cyst occupying most of the abdominal cavity are considered fetal sirenomelia associated with large defects of the gastrointestinal and genitourinary tracts.

A Case of Intrathoracic Gastric Duplication Cyst Detected on Prenatal Ultrasound Examination.

A 37-year-old (G4P3) woman was referred to our hospital at 32 weeks of gestation for the evaluation of a fetus with an intrathoracic cystic lesion. Ultrasonography and magnetic resonance imaging revealed that a fetal cystic lesion without a mucosal layer was located in the posterior mediastinum. These findings were consistent with a bronchogenic cyst. At 38 3/7 weeks of gestation, an elective cesarean section was performed because of her previous cesarean section. A female neonate without any external anomalies, weighing 2,442 g, with Apgar scores of 8 and 9, and requiring no resuscitation was born. Four weeks after delivery, the neonate was admitted because of respiratory distress due to mass effect. At right lateral thoracotomy, a 105 × 65 mm of solitary smooth-walled cyst containing serosanguineous fluid was found in the posterior mediastinum, which was excised completely. Histologic examination revealed the diagnosis of the mediastinal gastric duplication cyst. The neonate made an uneventful recovery. Accurate diagnosis is not necessary, but detection and continuous observation are logical. Although gastric duplication, particularly intrathoracic, is a rare pathology, it should be considered in the differential diagnosis of any intrathoracic cyst.