鈴木 寛正

Although massive haemorrhage at caesarean section (CS) for placenta praevia is a serious concern, effective treatment is not yet determined. We performed a new uterine sandwich to achieve haemostasis at CS for total placenta praevia in five consecutive cases in whom the placenta reached up to >5cm from the internal cervical os in all directions of an uterine wall. A Matsubara-Yano (MY) uterine compression suture was placed, followed by placement of an intrauterine balloon. Haemostasis was achieved in all five cases with median blood loss of 1618mL. No short-term adverse events were observed. The MY sandwich can be used to achieve haemostasis at CS for placenta praevia.

Our aim was to develop a novel screening method to detect the imminent onset of preeclampsia (PE) within 4 weeks after blood sampling. We prospectively collected data regarding past history of PE/gestational hypertension (GH), blood pressure levels at 16-23 weeks and plasma levels of soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF) twice at 19-31 weeks, which were measured using an automated electrochemiluminescence immunoassay. We found that a three-step approach by sequential selection using maternal factors, including a past history of PE/GH or blood pressure levels >= 120/80mmHg at 16-23 weeks (first step), followed by plasma levels of PlGF in the < 5th percentile (second step) and plasma levels of sFlt-1 in the >= 95th percentile (third step) yielded both high sensitivity and specificity. The imminent onset of PE occurred in 2 of 1199 (0.2%) women recruited at 19-25 weeks and in 6 of 798 (0.8%) women recruited at 26-31 weeks. The sensitivity, specificity, positive likelihood ratio (95% confidence interval), negative likelihood ratio (95% confidence interval), positive predictive value and negative predictive value of the three-step approach for predicting the imminent onset of PE at 19-25 weeks were 100%, 99.8%, 599 (150-2390), 0%, 50% and 100%, respectively; and those at 26-31 weeks were 83%, 99.1%, 94 (42-214), 0.17 (0.03-1.01), 42% and 99.9%, respectively. In conclusion, the three-step approach is a highly sensitive and specific screening method for detecting the imminent onset of PE within 4 weeks after blood sampling at 19-31 weeks of gestation.

AimIn placenta previa (PP), anterior placentation, compared with posterior placentation, is reported to more frequently cause massive hemorrhage during cesarean section (CS). Whether this is due to the high incidence of placenta accreta, previous CS, or a transplacental approach in anterior placenta is unclear. We attempted to clarify this issue. Material and MethodsWe retrospectively analyzed the relation between the bleeding amount during CS for PP and various factors that may cause massive hemorrhage (>2400mL) (n=205) in a tertiary center. If the preoperatively ultrasound-measured distance from the internal cervical ostium to the placental edge was longer in the uterine anterior wall than in the posterior wall, we defined it as anterior previa, and vice versa. ResultsPatients with accreta, previous CS, total previa, and anterior placentation bled significantly more than their counterparts. Multivariate logistic regression analysis showed that accreta (odds ratio [OR] 12.6), previous CS (OR 4.7), total previa (OR 4.1), and anterior placentation (OR 3.5) were independent risk factors of massive hemorrhage. ConclusionsAnterior placentation, namely, the placenta with a longer os-placental edge distance in the anterior wall than in the posterior wall, was a risk of massive hemorrhage during CS for PP.

Recently, transient inferior vena cava (IVC) filters have been employed to protect against pulmonary embolism (PE) in pregnant women with deep vein thrombosis. A 34-year-old primiparous Japanese woman with a history of myomectomy was diagnosed with deep vein thrombosis by ultrasound at 27 weeks of gestation. Unfractionated heparin was administered, which soon ameliorated swelling in the right thigh. A transient IVC filter was implanted just before cesarean section. An enhanced computed tomography scan 2 days after cesarean section revealed a wide thrombus just distal to the filter. We performed catheter thrombus fragmentation with fibrinolysis just before the removal of the IVC filter, resulting in re-canalization of blood flow. No significant PE occurred. Although a transient IVC filter may work well for the prophylaxis of PE during labor and delivery, catheter fragmentation with fibrinolysis may become necessary at removal of the filter.

It has not been clarified whether high mean blood pressure (HBP) of >= 90 mm Hg and bilateral notching (BN) on uterine artery Doppler additively affect the subsequent circulating levels of placental growth factor (PlGF), soluble fms-like tyrosine kinase 1 (sFlt-1) and soluble endoglin (sEng). Serum levels of PlGF, sFlt-1 and sEng at 17-25 weeks and 26-32 weeks were measured in all women with HBP+BN- (n=272), HBP-BN+ (n=130) and HBP+BN+ (n=60) in 1239 eligible women, and 338 consecutive women with HBP-BN- were selected from the remaining 777 women. Only data before the onset of preeclampsia were evaluated. The cutoff value of an abnormal decrease of PlGF was set at the 5th percentile, and those of an abnormal increase of sFlt-1, sFlt-1/PlGF and sEng were set at the 95th percentile. The frequency of HBP in those with BN- was almost the same as that in those with BN+ (25.9% vs. 26.7%). In women with HBP-BN-, HBP-BN+, HBP+BN- and HBP+BN+, the frequency of abnormal sFlt-1/PlGF ratio at 26-32 weeks was 6.6%, 9.2%, 14.4% and 22.8%, respectively; and the frequency of abnormal sFlt-1/PlGF ratio at 26-32 weeks in those with HBP+BN+ was significantly increased than in HBP-BN-. Similarly, in the four groups, the frequency of abnormal sEng at 26-32 weeks was 5.4%, 2.5%, 12.2% and 19.0%, respectively; and the frequency in those with HBP+BN+ was significantly increased than in HBP-BN-. In conclusion, high BP levels and abnormal uterine artery Doppler may be additively implicated in circulating abnormalities of angiogenesis-related factors.