大橋 麻衣

Progestin-primed ovarian stimulation法(以下PPOS法)は近年急速に広まりつつある調節卵巣刺激法であるが,臨床成績に関するデータが少なく刺激法として確立されていない。今回,2021年4月から2023年3月に当院で採卵した患者のうち,MPAを用いたPPOS法116例とGnRH antagonist法(以下antagonist法)108例の臨床成績を比較検討した。平均年齢はPPOS法で36.9±4.3歳,antagonist法で37.8±4.3歳,平均AMH値はPPOS法で3.3±3.8ng/mL,antagonist法で3.2±2.8ng/mLであった。採卵数,獲得胚盤胞数は,両群で差を認めなかったが,獲得良好胚盤胞数は,PPOS法で1.2±1.9個,antagonist法で0.7±1.1個とPPOS法で有意に多かった(p=0.02)。採卵後初回胚移植での臨床的妊娠率は,PPOS法で40.7%(37/91),antagonist法で26.1%(23/88)とPPOS法で有意に高かった(p=0.04)。AMH値で層化した解析では,獲得良好胚盤胞数は低・中反応群では有意差はなかったが,高反応群ではPPOS法で有意に多かった。本研究では,PPOS法はantagonist法と比較し獲得良好胚盤胞数が多く妊娠成績が良好であった。(著者抄録)

Assisted reproductive technology (ART) requires transvaginal oocyte retrieval (TVOR), and ovarian bleeding after TVOR rarely occurs. We present a case of a 37-year-old woman (0-gravida) who was diagnosed with possible hemorrhagic telangiectasia (HHT) and had a history of three laparotomies for ovarian bleeding and an inclusion cyst adjacent to the right ovary after the third operation. HHT is a hereditary disease characterized by spontaneous hemorrhage of some organs, such as the nose, brain, lungs, gastrointestinal tract, and liver. She desired ART after fertility treatment and then had abdominal pain with ovarian swelling five days after TVOR. Moreover, both the right ovary and inclusion cyst were gradually swollen with hematoma. Finally, abdominal pain and the hemoglobin level deteriorated, necessitating an emergency surgery on the eighth day. We notify reproductive physicians that patients with HHT may readily develop ovarian bleeding with or without inclusion cysts after TVOR, although inclusion cysts may also be associated with late-onset bleeding.

Retained products of conception(RPOC)は,流産や分娩後に絨毛,胎盤組織が子宮内に残存する状態を指し,癒着胎盤と関連している。ARTは癒着胎盤のリスク因子の1つだが,ARTによる妊娠において,その分娩後に形成されたRPOCの臨床的特徴は十分に分かっていない。今回,2006年1月～2021年6月の間に,当院において分娩後に形成されたRPOCをARTで妊娠した群(ART妊娠:21症例)とART以外で妊娠した群(非ART妊娠:38症例)とに分け,後方視的に比較検討した。帝王切開既往,分娩週数,胎盤用手剥離,分娩時出血量,輸血は,ART妊娠と非ART妊娠で有意差を認めなかったが,RPOC消失までの期間はART妊娠で有意に長かった(P=0.015)。ART妊娠で形成されるRPOCは非ART妊娠のそれとは自然史が異なる可能性があり,さらなる検討を要する。(著者抄録)

Caudal regression syndrome (CRS) is rare congenital malformation, which is characterized by abnormal development of the lower end of the spine and complicated with neurodevelopmental disorders of vesico-rectal functions and the lower extremities. We report the case of a woman with CRS who became pregnant and gave birth following continent bladder reconstruction (CBR) for intractable urinary incontinence. A 25-year-old primigravida woman with CRS became pregnant naturally and was referred to our department. She had undergone CBR in our institute at 14 years old. Emergency cesarean section (CS) was performed at 30 + 5 weeks of gestation due to severe preeclampsia. This is the first report of a woman with CRS who became pregnant and gave birth following CBR. A multidisciplinary team is needed to manage pregnant women with CRS following CBR. Collaboration with a urologist is especially important for managing pregnancy and performing CS. The CBR is performed for the purpose of improving quality of life by gaining urinary continence and may increase sexual behavior in women with CRS, and so obstetricians may encounter pregnancies more frequently in the future.

OBJECTIVE: To clarify the natural history of retained products of conception (RPOC) following abortion at less than 22 weeks of gestation, and those who show major bleeding during course observation. STUDY DESIGN: We retrospectively reviewed 640 patients who had spontaneous or artificial abortion at less than 22 weeks of gestation between January 2011 and August 2019 in our institute. Of those, patients with RPOC were included. The maternal background, RPOC characteristics, and subsequent complications including additional interventions were reviewed. RESULTS: Fifty-four patients with RPOC were included. The incidence of RPOC was 6.7 %. The median (interquartile range: IQR) RPOC length was 29 (20-38) mm. RPOC hypervascularity was observed in 26 (48 %) patients. The median (IQR) periods of RPOC flow disappearance and RPOC disappearance on ultrasound from abortive treatment were 50 (28-76) and 84 (50-111) days, respectively. Of the 54, 44 patients were selected for expectant management. Of the 44, 34 (77 %) patients were observed without intervention (recovery group); the other 10 (23 %) patients required additional interventions associated with subsequent bleeding (intervention group). Compared with the recovery group, heavy bleeding (> 500 mL) at abortion (6/10: 60 %) and RPOC hypervascularity (8/10: 80 %) were more frequently observed in the intervention group. CONCLUSION: Expectant management was successful in almost 80 % of patients with RPOC following abortion. The additional interventions were required in patients with heavy bleeding at abortion and RPOC hypervascularity.

OBJECTIVES: To clarify the outcome of retained products of conception (RPOC) without placenta previa. STUDY DESIGN: This was a retrospective cohort study consisting of 59 patients who abdominally or vaginally gave birth to infants after 14 weeks without placenta previa and had RPOC between April 2006 and December 2018. Patients' background, characteristics, and outcomes were compared between those requiring and not-requiring intervention for RPOC. RESULTS: Of the 59 patients, pregnancies after assisted reproductive technology accounted for 18 (31%). The ultrasound-measured RPOC length was 4 cm (median) and 39 (66%) showed hypervascularity within RPOC. Interventions were required in 36 patients (61%), with all due to bleeding-related events. Multivariate regression analyses revealed that the interventions were significantly more likely in the following situations: younger than 35 years (aOR: 4.2, 95%CI: 1.1-18.5), RPOC length ≥4 cm (aOR: 8.6, 95%CI: 2.4-39.2), and RPOC hypervascularity (aOR: 4.6, 95%CI: 1.3-18.8). Methotrexate was administered to 8 patients, of whom 4 (50%) required further hemostatic interventions. CONCLUSION: In patients with RPOC without previa, 61 and 39% did and did not require hemostatic interventions, respectively. In the latter, a wait-and-see strategy resulted in the resolution of RPOC. Patients with larger RPOC (≥4-cm fragment length) and hypervascularity were significantly more likely to require hemostatic intervention.

卵巣成熟嚢胞性奇形腫の悪性転化はほとんどが扁平上皮癌であり、腺癌への悪性転化は稀である。また、腹膜偽粘液腫の多くは虫垂由来で、卵巣原発例は少数であるとされている。今回、我々は卵巣成熟嚢胞性奇形腫から腹膜偽粘液腫を伴う粘液性腺癌へ悪性転化を示した1例を経験した。本症例から、腹膜偽粘液腫は卵巣成熟嚢胞性奇形腫から発生し得ることを学んだ。腹膜偽粘液腫の原発臓器の特定には、虫垂切除および卵巣成熟嚢胞性奇形腫の有無についての詳細な病理学的検索が重要である。(著者抄録)

BACKGROUND: In Japan, the cervical cancer screening rate is extremely low. Towards improving the cervical cancer screening rate, encouraging eligible people to make an informed choice, which is a decision-making process that relies on beliefs informed by adequate information about the possible benefits and risks of screening, has attracted increased attention in the public health domain. However, there is concern that providing information on possible risks of screening might prevent deter from participating. METHODS: In total, 1,912 women aged 20-39 years who had not participated in screening in the fiscal year were selected from a Japanese urban community setting. Participants were randomly divided into 3 groups. Group A received a printed reminder with information about the possible benefits of screening, group B received a printed reminder with information about possible benefits and risks, and group C received a printed reminder with simple information only (control group). RESULTS: Out of 1,912 participants, 169 (8.8%) participated in cervical cancer screening. In the intervention groups, 137 (10.9%) participated in cervical cancer screening, compared to only 32 (4.9%) of the control group (p < 0.001). In addition, logistic regression analysis revealed that there was no significant difference in screening rate between group A and group B (p = 0.372). CONCLUSIONS: Providing information on the possible risks of screening may not prevent people from taking part in cervical cancer screening among a Japanese non-adherent population.

2011-2012年の2年間に自治医科大学附属病院婦人科にて確定診断された婦人科悪性腫瘍(卵巣がん77例、子宮頸がん93例、子宮体がん113例)の発見契機を後方視的に検討した。各々の婦人科がんには特徴的な発見契機があり、これらを詳細に検討することは、早期発見の手掛かりとなると考えられる。特に卵巣がんにおいては、約半数の症例が婦人科以外の科を初診しており、他科との連携が重要であることが浮き彫りとなった。このような情報は婦人科から他科へ発信すべきものと考えられた。(著者抄録)