桑田 知之

Background The efficacy of maternal administration of ritodrine in cases of congenital atrioventricular block (CAVB), especially with fetal heart failure, is not yet determined. Case At 21 2/7 weeks of gestation, isolated CAVB with a ventricular/atrial rate of 55-70/130-140 bpm was found in a fetus from a 30-year-old Japanese nulliparous woman with anti-SSA antibody. Cardiothoracic area ratio (CTAR) was 40% and no fetal hydrops was observed. At 30 2/7 weeks, the ventricular rate decreased to 49 bpm with an atrial rate of 125 bpm. CTAR increased to 53.8% and ascites appeared. Maternal continuous ritodrine infusion was started with rapid improvement of fetal cardiac function; increment in the ventricular rate to 57 bpm and atrial rate to 137 bpm, with a decrement in CTAR to 44.6%. Ascites also gradually decreased and by the fourth day, it had completely disappeared with CTAR of 40.2%. On the 12th day after ritodrine treatment (32 1/7), amniotic fluid volume decreased and fetal weight gain stopped, which led us to assume a worsening intrauterine environment, and cesarean section was performed. A 1,178 g male infant was born with a 5-min Apgar score of 8. Continuous isoproterenol infusion was started, increasing the ventricular rate from 71 to 80 bpm. Pacemaker implantation is under consideration to treat this infant. Conclusion Maternal administration of ritodrine not only increased the fetal heart rate but also ameliorated the signs of fetal heart failure, and thus is considered one treatment of choice in CAVB.

Aims: To establish a reference value for the frequency of fetal movements perceived by the mother during the second half of pregnancy. Methods: The study subjects consisted of 705 low risk Japanese pregnant women who continuously received antenatal care. We asked women to record the time required to perceive 10 fetal movements ('count to 10' time) everyday. We asked women to record it, not at a fixed time (i.e. evening time), but whenever they felt the fetus move the most actively. The position during counting (i.e. sitting position) was also not specified, and thus we named this method as modified 'count to 10' method. Satisfactory recordings were obtained from 690 women, which we used for analysis. Results: The 'count to 10' time was almost the same from 22 weeks (10.9; 7.3-18.0 (median; interquartile range)) until 32 weeks (10.0; 6.2-15.6), and it Thirty-two weeks showed the shortest time, which gradually increased toward 40 weeks (14.8; 9.5-24.0). Its 90th percentile was approximately 25 and 35 min at 22-36 weeks and at 37-40 weeks, respectively. Conclusions: For the first time we established a reference value for perceived fetal movements throughout the second half of pregnancy. The present modified 'count to 10' method requires less time than the previous method. Approximately 98% (690/705) of women gave us satisfactory recordings. This reference value may be of use in identifying mothers with decreased fetal movements.

We report on three pregnant women with ritodrine-induced neutropenia who were successfully treated with granulocyte-colony stimulating factor (G-CSF). The neutropenia occurred after continuous intravenous infusion of ritodrine for preterm labor. Ritodrine was discontinued and G-CSF was administered. Neutrophil counts returned to normal an average of 4.3 days after the administration. No infectious morbidity or adverse side-effects occurred in the mothers or infants. G-CSF is one possible treatment in women with ritodrine-induced neutropenia.

Objective To identify fetal heart rate (FHR) patterns reflecting the severity of placental abruption, and to determine the incidence of normal FHR pattern in cases of placental abruption. Materials and methods We analyzed FHR tracings from 40 pregnant Japanese women with placental abruption. We analyzed which FHR patterns appeared more frequently in cases of low 5-min Apgar score, low cord arterial pH, and large separation. Results Eight out of 40 cases showed a normal FHR pattern, while 32 cases did not show a normal FHR pattern. Undetectable variability and bradycardia appeared more frequently in cases with 5-min Apgar < 7, with cord blood pH < 7.1, and with larger placental separation than in cases without these features. The normal FHR pattern was associated with 5-min Apgar >= 7, cord blood pH >= 7.1, and separation of < 25%. Conclusion Fetal heart rate pattern reflected the severity of placental abruption. Undetectable variability and bradycardia occurred significantly more frequently in cases of severe placental abruption, and thus may reflect the severity of placental abruption.

Background: Intracystic papillary excrescence is a characteristic morphological feature of ovarian malignancy. A few recent reports have demonstrated that ovarian endometriotic cysts, undergoing decidualization during pregnancy, occasionally show excrescence, necessitating surgery during pregnancy; however, this phenomenon is not well recognized among clinicians. Cases: Three pregnant women with decidualized ovarian endometriosis showed excrescence. Both ultrasound and magnetic resonance imaging (MRI) preoperatively suggested the presence of underlying ovarian endometriotic cysts in 2 women, but not in the other. Intracystic papillary excrescence prompted us to perform laparotomy at 14, 14, and 19 weeks of pregnancy, respectively, with 1 woman aborting in the 21st week, and with 2 delivering healthy term infants. Histological examination confirmed the diagnosis of decidualized ovarian endometriotic cysts in all 3 patients. Conclusions: We provide the first report of pregnant women in whom excrescence occurred from ovarian endometriotic cysts without preoperative evidence. Decidualized ovarian endometriosis, even without preoperative morphological features of endometriosis, should be added to the differential diagnosis of ovarian malignancy during pregnancy. Copyright (C) 2008 S. Karger AG, Basel

Objectives: Mirror syndrome is the association of triple edema, i.e. fetal, placental and maternal edema, with maternal preeclampsia. We here report the first case of mirror syndrome resulting from hydropic acardius in triplet pregnancy. Methods/Results: A 26-year-old nulliparous woman spontaneously conceived two living fetuses and one acardius, and suffered preterm rupture of the membranes at 23 2/7 weeks of gestation. We observed triple edema, hydropic acardius, placental edema, and maternal edema, together with maternal high blood pressure, proteinuria and low hematocrit, and therefore suspected the presence of mirror syndrome. Due to the prematurity of the fetuses, we closely observed her, awaiting fetal maturity. Three days later (23 5/7 weeks), cord prolapse occurred, leading to emergent cesarean section. Female infants, weighing 492 and 554 g, respectively, were born alive; the former died on the 13th postnatal day and the latter was healthy with no sequelae. An acardius weighing 860 g had vascular communication with the 492-gram fetus. Histological examination confirmed a monochorionic, triamniotic single placenta. The mother suffered from pulmonary edema and was treated in the intensive care unit under respiratory support, but soon improved. Conclusions: When dealing with multifetal pregnancy, especially when complicated by an acardius, obstetricians must have the highest level of concern for the occurrence of mirror syndrome, a life-threatening condition both to the mother and the fetus. Copyright (C) 2008 S. Karger AG, Basel

Aim: Hepatocyte growth factor (HGF) was originally identified as a factor that stimulates the mitogenesis of hepatocyte, and also plays a role in maintaining pregnancy. We conducted this study to evaluate the changes in plasma concentrations of HGF and its associated factors during normal pregnancy. Methods: Blood specimens were obtained from 14 healthy non-pregnant and 175 healthy pregnant and post-partum women (189 women in all). The women's plasma concentrations of total HGF, active HGF, active HGF activator (HGFA), HGF activator inhibitor type 1 (HAI-1) and HGF activator inhibitor type 2 (HAI-2) were determined by enzyme-linked immunosorbent assay. Results: The levels of active HGF and HGF activator were significantly lower in pregnant women compared with those of non-pregnant women. The level of plasma HAI-1 significantly increased as pregnancy progressed, while it fell post-partum. Also, there were no differences in the concentrations of total HGF and HAI-2 in non-pregnant and pregnant women. Conclusions: A high concentration of HAI-1 during pregnancy may decrease the plasma level of active HGFA. This may in turn inhibit the activation of the precursor form of HGF, leading to a decrease in the level of plasma active HGF.