桑田 知之

Although recent studies have demonstrated that microRNAs (miRNAs or miRs) regulate fundamental natural killer (NK) cellular processes, including cytotoxicity and cytokine production, little is known about the miRNA-gene regulatory relationships in maternal peripheral blood NK (pNK) cells during pregnancy. In the present study, to determine the roles of miRNAs within gene regulatory networks of maternal pNK cells, we performed comprehensive miRNA and gene expression profiling of maternal pNK cells using a combination of reverse transcription quantitative PCR (RT-qPCR)-based miRNA array and DNA microarray analyses and analyzed the differential expression levels between first-and third-trimester pNK cells. Furthermore, we constructed regulatory networks for miRNA-mediated gene expression in pNK cells during pregnancy by Ingenuity Pathway Analysis (IPA). PCR-based array analysis revealed that the placenta-derived miRNAs [chromosome 19 miRNA cluster (C19MC) miRNAs] were detected in pNK cells during pregnancy. Twenty-five miRNAs, including six C19MC miRNAs, were significantly upregulated in the third-compared to first-trimester pNK cells. The rapid clearance of C19MC miRNAs also occurred in the pNK cells following delivery. Nine miRNAs, including eight C19MC miRNAs, were significantly downregulated in the post-delivery pNK cells compared to those of the third-trimester. DNA microarray analysis identified 69 NK cell function-related genes that were differentially expressed between the first-and third-trimester pNK cells. On pathway and network analysis, the observed gene expression changes of pNK cells likely contribute to the increase in the cytotoxicity, as well as the cell cycle progression of third-compared to first-trimester pNK cells. Thirteen of the 69 NK cell function-related genes were significantly downregulated between the first-and third-trimester pNK cells. Nine of the 13 downregulated NK-function-associated genes were in silico target candidates of 12 upregulated miRNAs, including C19MC miRNA miR-512-3p. The results of this study suggest that the transfer of placental C19MC miRNAs into maternal pNK cells occurs during pregnancy. The present study provides new insight into maternal NK cell functions.

To construct a model to calculating probability of requiring allogeneic blood transfusion on cesarean section (CS) for placenta previa (PP). A retrospective cohort study involving all 205 patients with PP who underwent CS in our institute. We determined the relationship between allogeneic blood transfusion and nine preoperative factors: (1) maternal age, (2) parity, (3) uterine myoma, (4) previous CS, (5) the placenta covering the previous CS scar (referred to as "scar covering"), (6) degree of previa, (7) ultrasound finding of lacunae, (8) preoperative anemia, and (9) preparation of autologous blood. Independent risk factors of allogeneic blood transfusion were identified by multivariate logistic regression analysis. These significant factors were included in the final model, and, the probability of allogeneic blood transfusion was calculated. Independent risk factors of allogeneic blood transfusion were scar covering, previous CS without scar covering, and lacunae. These three factors were used to create a predictive model. The model revealed that patients with scar covering and lacunae had the highest probability (0.73), while those with no risk factors had the lowest probability (0.02). This simple model may be useful to calculate probability of requiring allogeneic blood transfusion on CS for placenta previa.

During pregnancy, human placenta-associated microRNAs (miRNAs) derived from the miRNA cluster in human chromosome 19 are expressed in villous trophoblasts and secreted into maternal circulation via exosomes; however, little is known about whether circulating placenta-associated miRNAs are transferred into maternal immune cells via exosomes, and modulate expression of target genes in the recipient cells. We employed an in vitro model of trophoblast-immune cell communication using BeWo cells (a human trophoblast cell line) and Jurkat cells (a human leukemic T-cell line) and investigated whether BeWo exosomal placenta-associated miRNAs can suppress expression of target genes in the recipient Jurkat cells. Using this system, we identified PRKG1 as a target gene of placenta-associated miRNA miR-517a-3p. Moreover, we demonstrated that BeWo exosomal miR-517a-3p was internalized into Jurkat cells and subsequently suppressed the expression of PRKG1 in recipient Jurkat cells. Furthermore, using peripheral blood natural killer (NK) cells in vivo, we confirmed that circulating miR-517a-3p was delivered into maternal NK cells as it was into Jurkat cells in vitro. Placenta-associated miR-517a-3p was incorporated into maternal NK cells in the third trimester, and it was rapidly cleared after delivery. Expression levels of miR-517a-3p and its target mRNA PRKG1 were inversely correlated in NK cells before and after delivery. These in vitro and in vivo results suggest that exosome-mediated transfer of placenta-associated miRNAs and subsequent modulation of their target genes occur in maternal NK cells. The present study provides novel insight into our understanding of placentamaternal communication.

Uterine artery pseudoaneurysm (UAP) is considered a rare disorder after traumatic delivery or traumatic pregnancy termination such as cesarean section or dilatation and curettage, initially manifesting as genital hemorrhage. Our clinical impression contradicts these three assumptions; after traumatic delivery/termination, hemorrhage, and its rarity. Thus, we attempted to clarify these three issues. We retrospectively analyzed 22 UAP cases treated at our institute over a 6-year period. Uterine artery pseudoaneurysm occurred in 2-3/1,000 deliveries. Of 22 cases, half occurred after non-traumatic deliveries or non-traumatic pregnancy termination. Fifty-five percent (12/22) showed no hemorrhage; ultrasound or color Doppler revealed UAP. Thus, half of UAP occurred after non-traumatic deliveries or non-traumatic pregnancy termination and showed no hemorrhage at the time of their diagnoses. All patients received transarterial embolization, which stopped blood flow into UAP or achieved hemostasis. We must be aware that UAP may not be so rare and it may be present in patients after non-traumatic deliveries/pregnancy termination and without postpartum or postabortal hemorrhage.

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.

A disintegrin and metalloproteinases (ADAMs) are members of the metzincin family of zinc-dependent metalloproteinases that play pivotal roles in the proteolytic degradation of the extracellular matrix for cell invasion. Few studies have investigated the ADAM subtypes that are expressed in first trimester trophoblast cells. The purpose of this study was to elucidate the differential expression profiles of ADAMs between first trimester villous trophoblast cells (VTs) and extravillous trophoblast cells (EVTs). We isolated EVTs from explanted human first trimester chorionic villi and investigated the mRNA expression levels of five members of the ADAM family (ADAMTS1, ADAMTS2, ADAM10, ADAM12, and ADAM17) using real-time PCR. Chorionic villous tips were defined as first trimester VTs. Of the differentially expressed ADAM genes between first trimester VTs and EVTs, ADAMTS1 was expressed at a significantly higher level in EVTs than in VTs. In contrast, both ADAM10 and ADAM12 were expressed at significantly higher levels in VTs than in EVTs. No differences were found in the mRNA levels of ADAMTS2 and ADAM17 between the two cell types. Moreover, we demonstrated that in VTs, the expression level of ADAM12 was significantly downregulated in the late first trimester (10-13 gestational weeks) compared to the middle first trimester (7-8 weeks). These results suggest that first trimester trophoblast cells express ADAM genes in cell type- and gestational age-dependent manners. Our data provide additional insight into the functions of ADAMs in the human placenta.

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.

Various fetal or placental disorders cause Ballantyne's (mirror) syndrome. For the first time, we report a maternal manifestation of Ballantyne's syndrome occurring concomitantly with the development of fetal congenital mesoblastic nephroma (CMN). In a pregnant woman with a CMN fetus, lung edema, hypertension, hyperthyroidism, and high serum human chorionic gonadotrophin level occurred, all of which characterize maternal manifestation of Ballantyne's syndrome. The fetus and placenta were devoid of edema', lacking triple edema', and thus this condition was not diagnosed as Ballantyne's syndrome; however, we considered this condition as the maternal manifestation of Ballantyne's syndrome. We performed emergent cesarean section at 28 weeks. Delivery acutely ameliorated maternal symptoms. Tumor was resected and was confirmed as CMN. Maternal manifestations of Ballantyne's syndrome, such as lung edema and hypertension, can occur in a mother with fetal CMN even without fetal and/or placental edema. The clinical course of this patient may suggest an etiology of Ballantyne's syndrome.

A recent report indicated that vascular endothelial growth factor (VEGF)-D, regulating cell proliferation and/or differentiation, may be associated with the development of placental mesenchymal dysplasia (PMD), a disorder characterized by cell proliferation/differentiation. In PMD placenta, we examined the expression of five cell-proliferation/differentiation-associated genes, namely, Wnt3a, Wnt5a, -catenin, VEGF-D and Dickkopf-1 (DKK-1). In PMD, expressions of Wnt3a, Wnt5a and -catenin were decreased, whereas those of VEGF-D and DKK-1 were increased. These abnormal expressions suggest a relationship between these genes and PMD pathogenesis/pathophysiology.

Objectives: We evaluated the biological interaction between blood pressure (BP) and uterine artery Doppler (UAD) in the second trimester for early-onset preeclampsia (EO-PE) risk. Study design: A prospective cohort study. Main outcome measures: In 2410 pregnant women, mean pulsatility index (mPI) and mean notch depth index (mNDI) were examined by UAD at 16-23 weeks' gestation. We defined EO-PE as PE with onset at <34 weeks, abnormal UAD as coexistence of mPI >= 90th percentile and mNDI >= 90th percentile, and high BP as systolic BP/diastolic BP >= 120/80 mmHg. Abnormal UAD and high BP were combined as a series of dummy variables, and were entered into a logistic regression model. The relative excess risk due to biological interaction (RERI) was calculated using the following equation: RERI = odds ratio (OR) in women with both high BP and abnormal UAD - OR in women with high BP alone - OR in women with abnormal UAD alone + 1. RERI >= 10 was considered as strong. Results: EO-PE and late-onset PE (LO-PE) occurred in 1.1% and 1.2%, respectively. Adjusted odds ratio (95% CI) in women with abnormal UAD alone, high BP alone, and both high BP and abnormal UAD for predicting EO-PE was 4.3 (0.37-49), 12 (2.6-55) and 85 (17-422), respectively; and that for predicting LO-PE was 6.3 (1.5-27), 6.1 (2.1-17) and 15 (3.6-61), respectively. The RERI for EO-PE and LO-PE was 70 and 3.3, respectively. Conclusion: High BP and abnormal UAD may have a strong biological interaction for the occurrence of EO-PE. (C) 2013 International Society for the Study of Hypertension in Pregnancy Published by Elsevier B.V. All rights reserved.

Uterine artery pseudoaneurysm can occur after cesarean section or traumatic delivery, usually manifesting as postpartum hemorrhage. Pregnant women after adenomyomectomy sometimes suffer some adverse events, among which uterine rupture has been widely acknowledged. We describe a post-abortive woman who had uterine artery pseudoaneurysm occupying the entire uterine cavity. She underwent adenomyomectomy and became pregnant. She experienced a missed abortion and underwent evacuation and curettage, which caused bleeding. Several days later, ultrasound revealed an intrauterine mass with marked blood flow. Angiography revealed the un-ruptured left uterine artery pseudoaneurysm, with arterial embolization stopping the flow within the pseudoaneurysm. Adenomyomectomy with subsequent curettage was considered to have caused the pseudoaneurysm. We must be cautious that pseudoaneurysm may occur in post-abortive women after adenomyomectomy.

For cesarean hysterectomy with placenta previa accreta, "universally achievable" measures are required. We propose eight measures: (i) placement of intra-iliac arterial occlusion balloon catheters (ii) placement of ureter stents (iii) "holding the cervix" to identify the site to be transected (iv) uterine fundal incision (v) avoidance of uterotonics (vi) "M cross double ligation" for ligating the ovarian ligament (vii) "filling the bladder" to identify the bladder separation site and "opening the bladder" for placenta previa accreta with bladder invasion and (viii) to continue to clamp the medial side of the parametrium or the cervix or employment of the "double edge pick-up" to ligate it. These eight measures are simple, easy, effective, and thus "universally achievable". © 2013 The Authors Acta Obstetricia et Gynecologica Scandinavica © 2013 Nordic Federation of Societies of Obstetrics and Gynecology.

In 1997, B-Lynch pioneered the use of uterine compression sutures for postpartum hemorrhage. Since then, some researchers, including ourselves, have devised various uterine compression sutures. High-level evidence has not been demonstrated as to whether compression sutures achieve better and safer hemostasis for postpartum hemorrhage than other methods, and, if they do, whether one suture is more efficient and safer than another. However, generally speaking, uterine compression sutures have achieved hemostasis while preserving fertility in many women and thus their efficacy and safety have been time-tested. Each suture has both merits and drawbacks: obstetricians must be aware of the fundamental characteristics of various sutures. In this review, we summarize the technical procedures, efficacy, safety and complications of various uterine compression sutures. We add our own experiences and opinions where necessary.

Objective: This systematic review evaluated the existence of risk factors for the fetal manifestation of long QT syndrome (LQTS). Methods: Prenatal cardiac findings suggestive of fetal LQTS were studied using 30 English literature reports extracted from the Pubmed database (1979 to December 2011) using the search terms 'long QT syndrome', 'fetal arrhythmia' and 'congenital heart disease'. Results: LQTS accounted for 15-17% of fetal bradycardias &lt 110 bpm among fetuses with a normally structured heart. Of the patients with significant prenatal findings of LQTS, 17-35% exhibited a reduced baseline fetal heart rate (FHR) of 110-120 bpm on electronic cardiotocography. Other prenatal signs were sinus or intermittent bradycardia &lt 110 bpm arising from atrioventricular block, tachyarrhythmias, pleural effusion and hydrops. More than 30% of Japanese infants with LQTS born at or after the mid-1980s exhibited the above-mentioned in utero signs. Conclusions: Fetal factors including a slightly reduced baseline FHR of 110-120 bpm, bradycardia &lt 110 bpm, tachyarrhythmias or clinical signs of heart failure, such as pleural effusion and hydrops, were associated with a higher frequency of LQTS. The use of these signs may help to increase the perinatal diagnosis of LQTS. Copyright © 2012 S. Karger AG, Basel.

Congenital high airway obstruction syndrome (CHAOS) is diagnosed by characteristic features on US and MRI including fetal upper airway occlusion, lung hyperinflation with an inverted diaphragm, and sometimes massive ascites and hydrops. We describe a case of CHAOS in which improvement in the fetal condition was observed on three sequential fetal MRIs. Such an improvement was thought to represent decrease in intrathoracic pressure caused by a spontaneous perforation such as a tracheoesophageal fistula. However, a fistula was not observed in the present case. Therefore, we suggest that imaging improvements in patients with CHAOS do not always correspond to the presence of a fistula and other factors might contribute to decreasing fetal intrathoracic pressure.

Jaundice in hyperemesis gravidarum may cause physicians to suspect several underlying diseases. Jaundice appeared in a woman with hyperemesis gravidarum and an ultrasound revealed biliary sludge. Hydration concomitantly ameliorated the symptoms, jaundice and the biliary sludge. Another woman with hyperemesis gravidarum showed elevated aminotransferases, with biliary sludge also being present. Hydration ameliorated the symptoms and liver dysfunction, and reduced the total bilirubin level. Biliary sludge appeared, but was ameliorated according to the symptoms of hyperemesis gravidarum.

Objective. Recent findings suggest that cerebral edema is a characteristic finding on magnetic resonance imaging in women with eclampsia and that pregnancy-induced antithrombin deficiency (PIATD) may reflect enhanced vascular permeability and may allow the retention of excess water in the interstitial space. Whether PIATD and extraordinary weight gain (EOWG) are risk factors for eclampsia remains to be studied. Methods. The medical records of 11 women with eclampsia among 17,522 deliveries were reviewed retrospectively with respect to changes in the laboratory data and the maternal body weight. PIATD was defined as a perinatal antithrombin activity of <= 65% of the normal activity levels with an antenatal decline and/or a prompt postnatal increase. A large net weight gain during the last two antenatal weeks >97.5th percentile value (>4.01 kg) obtained from 272 control women with neither hypertension nor PIATD was defined as EOWG. Relative risk was obtained on the assumption that the prevalences of PIATD and EOWG were 2.0 and 2.5%, respectively, among 17,511 women who did not develop eclampsia. Results. The duration of hypertension until an eclamptic fit was within 7 days in all 11 cases. PIATD and EOWG were observed in 6 (54.5%) and 2 (18.2%) cases, yielding a relative risk (95% confidential interval) of 57.9 (17.7-188.7) and 8.65 (1.87-39.91) for eclampsia among women with PIATD and EOWG, respectively. Conclusions. PIATD and EOWG may be risk factors for eclampsia.

Aim: Data from Japanese women have been lacking regarding hemorrhagic complications due to low-molecular-weight heparin (LMWH) as thromboprophylaxis. Thus, targeting Japanese women, we made an effort to determine: (i) whether the administration of LMWH soon after cesarean section increases the risk of hemorrhagic complications compared to that of unfractionated heparin; and (ii) how it elongates the activated partial thromboplastin time. Materials and Methods: We administered unfractionated heparin in the first half of the study period, and LMWH in the latter half. We examined: (i) the incidence rate of hemorrhagic complications; and (ii) preoperative and postoperative activated partial thromboplastin time, and we compared these in cases using unfractionated heparin and LMWH. Results: No clinically discernable thromboembolism occurred in either group. Hemorrhagic complications occurred in two of 140 women in the unfractionated heparin group and one of 131 women in the LMWH group. LMWH prolonged the activated partial thromboplastin time from 29.8 +/- 2.6 to 34.8 +/- 4.0 s. This prolongation was significantly shorter than that with unfractionated heparin (from 30.2 +/- 2.6 to 36.5 +/- 6.2 s). Conclusions: Compared with thromboprophylaxis with unfractionated heparin, thromboprophylaxis with early administration of LMWH after cesarean section did not increase the incidence of hemorrhagic complications and caused less prolongation of the activated partial thromboplastin time in Japanese women.

We highlight the merit of fetal movement count to identify a fetus with neuromuscular disorder: nemaline myopathy. A 38-year-old 1-para woman not in a consanguineous marriage had decreased fetal movement. This, together with increased amniotic fluid volume, led us to perform detailed ultrasound examinations, which revealed stretch contracture of the knee joints, leading us to suspect fetal neuromuscular disorders. At 38(2/7), she gave birth vaginally to a 2444 g female infant. Her respiration was very weak, requiring respiratory support. Contractures of the upper/lower extremity joints and club feet were observed. All skeletal muscles were hypotonic. Biopsized muscle cells showed nemaline bodies, confirming the diagnosis of nemaline myopathy. Fetal movement count may contribute to the identification of fetal neuromuscular diseases, such as nemaline myopathy.

Headache in late pregnancy is warning of the presence of severe and/or lethal disorders. Here, we present a case of Vogt-Koyanagi-Harada disease (VKH), in which headache was the preceding and predominant symptom. At 37 weeks of pregnancy, a Japanese 1-para woman with an uneventful pregnancy complained of severe headache and then blurred vision. Although we initially diagnosed this condition as pregnancy-associated retinal detachment, headache and blurred vision persisted after delivery. Eye anterior segment lesions appeared and VKH disease was diagnosed, with systemic steroid administration completely ameliorating both the headache and visual disturbance. Obstetricians must be aware that headache may be the first sign of VKH disease.

Reports have indicated that maternal administration of ritodrine increased the ventricular rate and thus ameliorated signs of heart failure in a fetus with complete atrioventricular block (CAVB). A fetus from a mother without the anti-SS-A/SS-B antibody had CAVB, with atrial rate 148-154 bpm and ventricular rate 53-57 bpm. After maternal administration of ritodrine, the ventricular rate increased to 60-65 bpm, and then sinus rhythm resumed. Ritodrine may not only increase the ventricular rate but also induce sinus rhythm in a fetus with CAVB.

Introduction. Uterine rupture is an obstetric complication associated with significant maternal and fetal morbidity and mortality. This disorder usually occurs with a scarred uterus, especially in a uterus with prior Cesarean section. Uterine sacculation or diverticulum may also lead to a thin uterine wall during pregnancy. Case presentation. A 27-year-old Japanese primigravid woman was admitted to our hospital due to weak, irregular uterine contractions in her 38th week of gestation. She had no past history of uterine surgery or known diseases. A hard mass was palpable in her abdomen. An ultrasound revealed that the anterior uterine wall was thin and bulging, with a fetal minor part beneath it which corresponded to the palpated mass. A Cesarean section was performed which revealed a thin anterior uterine wall with incomplete uterine rupture. The woman and baby were healthy. Conclusions: Although extremely rare, an unscarred primigravid uterus can undergo incomplete rupture even without discernable risk factors or labor pains. Abdominal palpation and ultrasound may be useful in detecting this condition. © 2011 Matsubara et al licensee BioMed Central Ltd.

Introduction. Uterine rupture is a life-threatening condition both to mothers and fetuses. Its early diagnosis and treatment may save their lives. Previous myomectomy is a high risk factor for uterine rupture. Intestinal adhesion due to previous myomectomy may also prevent early diagnosis of uterine rupture. Case presentation. A 38-year-old primiparous non-laboring Japanese woman with a history of myomectomy was admitted in her 34th week due to lower abdominal pain. Although the pain was slight and her vital signs were stable, computed tomography revealed massive fluid collection in her abdominal cavity, which led us to perform a laparotomy. Uterine rupture had occurred at the site of the previous myomectomy however, the small intestine was adhered tightly to the rupture, thus masking it. The baby was delivered through a low uterine segment transverse incision. The ruptured uterine wall was reconstructed. Conclusion: Intestinal adhesion due to a prior myomectomy occluded a uterine rupture, possibly masking its symptoms and signs, which may have prevented early diagnosis. © 2011Kuwata et al licensee BioMed Central Ltd.

Aims: To evaluate uterine cervical consistency using a vaginal ultrasound gray-level histogram. Methods: Vaginal ultrasound and digital examination were performed for 214 women with low-risk singleton pregnancy during 27-30(th) pregnancy week. The mean gray-level (MGL) of an ultrasound gray-level histogram, representing the echogenicity of a region of interest, was measured in the midsection of anterior and posterior cervical walls. The difference in MGL between anterior and posterior (AP difference) was related to the Bishop sub-score for cervical consistency (0, 1, or 2), determined before ultrasound. Results: A larger positive AP difference indicated significantly lower Bishop sub-score. After analyzing the receiver operator characteristic curves for the AP difference, a value of 1.42 and -1.98 was the best cut-off value to determine a hard cervix (score 0) and a soft cervix (score 2), respectively. To identify a hard cervix, this test had 71% sensitivity and 82% specificity. For a soft cervix, it was 66% and 87%, respectively. Conclusions: A more echogenic anterior than posterior cervix indicates a hard cervix; the greater the difference in echogenicity between anterior and posterior walls the harder the cervix. The difference in MGL of the ultrasound gray-level histogram may enable objective evaluation of cervical consistency.

Uterine artery pseudoaneurysm is a rare complication mainly of abdominal or interventional delivery that can cause profuse postpartum hemorrhage if unrecognized or inadequately treated. There has been no report of this disorder accompanying uneventful second-trimester pregnancy termination. A primiparous Japanese woman underwent pregnancy termination at 24 weeks' gestation due to fetal death. Gradual dilatation of the cervix followed by administration of vaginal gemeprost led to an uneventful delivery without curettage. After 41 days, profuse vaginal bleeding occurred. Ultrasound revealed a mass within the uterine cavity and color Doppler indicated the presence of high-speed flow within the mass. Selective angiography revealed that the mass was connected to the right uterine artery, from which extravasation was observed. Uterine artery pseudoaneurysm was diagnosed, and we performed successful uterine artery embolization. This is the first report of uterine artery pseudoaneurysm after second-trimester pregnancy termination. Our experience indicates that even after uneventful pregnancy termination, clinicians must remain aware of the possibility of pseudoaneurysm, manifesting as postpartum/post-termination hemorrhage.

Cord entanglement is a leading cause of mortality of monochorionic monoamniotic twins. Few studies focused on entanglement features/structure itself. Three-dimensional color Doppler ultrasound was conducted to evaluate the cord entanglement in monoamniotic twins at 30 weeks of gestation. Ultrasound revealed detailed features: the two cords were entangled at several points with a chain-like appearance and this complicated structure led us to closely monitor fetal well-being. Seven days later, non-reassuring fetal heart rate pattern was observed, and cesarean section was performed at 30 6/7 pregnancy week, yielding female infants without neurological sequelae. Three-dimensional color Doppler clearly delineated the features of entanglement, and thus was useful for evaluating cord entanglement in monoamniotic twins.

Uterine artery pseudoaneurysm is a rare but important complication of cesarean section (CS). If treated inadequately, it may cause profuse life-threatening postpartum hemorrhage. We report an asymptomatic postpartum woman with uterine artery pseudoaneurysm after CS. We also provide a review of published reports of pseudoaneurysm after CS. A 31-year-old Japanese woman underwent CS, in which the uterine incision was extended laterally. Routine postoperative evaluation with vaginal ultrasound on postpartum day 6 revealed a parauterine mass with a maximum diameter of 49 mm with swirling flow. Selective angiography confirmed this mass as a uterine artery pseudoaneurysm. Uterine artery embolization was performed with success. Uterine artery pseudoaneurysm should be listed as a differential diagnosis of pelvic mass after CS.

Alport syndrome is a familial progressive nephritis. The most frequent type is X-linked Alport syndrome, caused by genetic abnormalities in the alpha 5 chain of type IV collagen. Skin biopsy is a useful tool for diagnosing this disease. It is not well known how this syndrome affects pregnancy and how it is affected by pregnancy, or whether the umbilical cord may provide material for detecting this collagen abnormality. We report a primigravida with Alport syndrome with mild proteinuria who gave birth abdominally to a term male infant without deteriorating renal function during pregnancy. The umbilical cord from not only this infant but also from an Alport (-) control infant showed negative immunofluorescence staining for the alpha 5 chain of type IV collagen. Women with Alport syndrome without renal dysfunction may follow an uneventful obstetrical course until term. The cord may not be suitable for diagnosing Alport syndrome with immunofluorescence staining.

Cesarean hysterectomy for placenta previa percreta with bladder invasion often induces not only massive hemorrhage but also severe bladder/ureter injuries. A 37-year-old woman with previous cesarean delivery suffered placenta previa percreta with bladder invasion. At the 34th week, we performed cesarean hysterectomy. Without separating the bladder from the uterus/cervix, we incised the bladder lateral wall using an automatic stapling/cutting device, leaving the bladder posterior wall adhering to the uterus and resecting it with the uterus. The bladder was easily repaired without urological sequelae. We suggest a new, simple and safe technique for cesarean hysterectomy for this disease.

Objective: To reconfirm that a low-lying placenta, with placental edge-internal os distance of 0-4 cm, is a risk factor for blood loss during delivery, and to determine whether blood loss differs between edge-os distance of <= 2 cm vs. >2 cm. Methods: We compared total blood loss between 73 singleton pregnant women with edge-os distance of 0-4.0 cm vs. controls. We also compared total blood loss between pregnant women with distance of 0-2.0 cm (lower) vs. 2.1-4.0 cm (higher). Results: Total blood loss was significantly greater in women with placental edge-os distance of <= 4 cm than controls in both delivery modes. The lower group showed a significantly higher incidence of excessive hemorrhage during vaginal delivery (60 vs. 19%, P=0.046) and bled more (median 1240 vs. 860 mL, P=0.059) than the higher group. Although this did not reach statistical significance, the lower group more frequently bled antepartum, required emergent cesarean section, and delivered abdominally. Regression analysis showed no association between the amount of blood loss and the edge-os distance in both delivery modes. Conclusion: Pregnant women with edge-os distance of 2.1-4.0 cm are of highest level of concern as are women with 0-2.0 cm distance.