高橋 宏典

Objectives: Uterine artery pseudoaneurysm (UAP) has been considered to occur very rarely after traumatic delivery/abortion, and is usually detected after its rupture, yielding massive bleeding. Our hypothesis is: some UAP may be undetected without massive bleeding and may spontaneously resolve, and, thus, may not require transarterial embolization (TAE). We attempted: (1) to detect both ruptured and non-ruptured UAP, thereby characterizing candidates of spontaneously resolving UAP, and (2) to confirm that UAP is not rare and not always associated with traumatic events. Study design: This was a retrospective observational study of 50 women with angiographically confirmed UAP and treated by TAE. Angiograms and medical charts were retrieved to examine the associations among symptoms, ultrasound findings, and extravasation. Gray-scale ultrasound was performed for all women after delivery or abortion as our routine practice. Results: UAP occurred in 3-6/1000 deliveries and 40% occurred after non-traumatic deliveries/abortion. While 36% had active vaginal bleeding at admission, 64% did not. While 100% of patients with current active bleeding showed extravasation from the pseudoaneurysmal sac, patients without it showed a varied incidence of extravasation depending on the bleeding pattern/history and ultrasound findings. Interestingly, all patients with current bleeding (-), bleeding history (+), and ultrasound-discernable intrauterine low echoic mass (-) were devoid of extravasation, suggesting that UAP may show progression to thrombosis and, thus, resolve spontaneously. Conclusions: UAP may not be so rare and not associated with traumatic delivery/abortion. Some UAP may resolve, and, thus, may not require TAE, at least immediately. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Objectives Uterine artery pseudoaneurysm (UAP) has been considered to occur very rarely after traumatic delivery/abortion, and is usually detected after its rupture, yielding massive bleeding. Our hypothesis is: some UAP may be undetected without massive bleeding and may spontaneously resolve, and, thus, may not require transarterial embolization (TAE). We attempted: (1) to detect both ruptured and non-ruptured UAP, thereby characterizing candidates of spontaneously resolving UAP, and (2) to confirm that UAP is not rare and not always associated with traumatic events. Study design This was a retrospective observational study of 50 women with angiographically confirmed UAP and treated by TAE. Angiograms and medical charts were retrieved to examine the associations among symptoms, ultrasound findings, and extravasation. Gray-scale ultrasound was performed for all women after delivery or abortion as our routine practice. Results UAP occurred in 3–6/1000 deliveries and 40% occurred after non-traumatic deliveries/abortion. While 36% had active vaginal bleeding at admission, 64% did not. While 100% of patients with current active bleeding showed extravasation from the pseudoaneurysmal sac, patients without it showed a varied incidence of extravasation depending on the bleeding pattern/history and ultrasound findings. Interestingly, all patients with current bleeding (−), bleeding history (+), and ultrasound-discernable-intrauterine low echoic mass (−) were devoid of extravasation, suggesting that UAP may show progression to thrombosis and, thus, resolve spontaneously. Conclusions UAP may not be so rare and not associated with traumatic delivery/abortion. Some UAP may resolve, and, thus, may not require TAE, at least immediately.

PURPOSE: To clarify the present status of human papillomavirus (HPV) contamination of transvaginal probes in Japan and propose a preventive method. METHODS: This study was performed at three institutes: a tertiary center, secondary hospital, and primary facility. To identify contamination rates, probes were disinfected and covered with probe covers and condoms; the cover was changed for each patient. The probes were tested for HPV, and those with HPV detected were analyzed to identify the type of HPV. Next, nurses put on new gloves before covering the probe for each patient, and the probes were similarly tested for HPV. RESULTS: A total of 120 probes were tested, and HPV was detected from a total of five probes, a contamination rate of 4.2 % (5/120). HPV was detected in all three institutes. Importantly, high-risk HPV, i.e., HPV-52, 56, and 59, was detected. After the "glove change strategy" was implemented, HPV was not detected on any of 150 probes tested at any of the three institutions. CONCLUSIONS: In Japan, the HPV contamination rate of vaginal probes in routine practice was 4.2 %. There was no HPV contamination of probes after changing the gloves for cover exchange for each patient. This strategy may prevent HPV probe contamination.

AimIn hypertensive pregnant women, the protein-to-creatinine (P/C) ratio is well correlated with 24-h proteinuria and a P/C ratio of 0.27 (g/gCr) is used to reflect significant proteinuria (>0.3 g/day). The aim of this study was to obtain data on normotensive pregnant women, which have so far been lacking. MethodsThe study population consisted of 74 pregnant women who met the following criteria: (i) 22 gestational weeks; (ii) a positive result (1+) on dipstick test; (iii) a positive result (>0.27) for P/C ratio; and (iv) 24-h urine test performed within 2 days of the P/C ratio. The correlation between the P/C ratio and 24-h proteinuria, the incidence rates of significant proteinuria according to P/C ratios, and appropriate threshold of the P/C ratio to rule in significant proteinuria were determined using the appropriate statistical methods. ResultsThe P/C ratio was moderately correlated with the 24-h proteinuria, with a correlation coefficient of 0.64 (95% confidence interval, 0.487-0.76). The area under the receiver-operator curve was 0.76 (95% confidence interval, 0.66-0.87); however, no clear shoulder was identifiable. The incidence rates of significant proteinuria according to P/C ratios of 0.27-0.49, 0.50-0.74, 0.75-0.99, and >1 were 41, 66, 100, and 100%, respectively, indicating that all normotensive pregnant women with a P/C ratio > 0.75 had significant proteinuria. ConclusionNormotensive pregnant women showed a significant correlation between the P/C ratio and 24-h urine protein level. All normotensive pregnant women with a P/C ratio > 0.75 had significant proteinuria, suggesting that a P/C ratio > 0.75 may be the rule-in' threshold of significant proteinuria in this population.

Post-delivery/-abortion uterine artery pseudoaneurysm (UAP) sometimes causes life-threatening bleeding, requiring transarterial embolization (TAE). It is unclear whether some UAP resolve spontaneously. In three patients, UAP resolved spontaneously without TAE. Case 1 was after vacuum delivery with slight bleeding: at day 5 post-partum, a yin-yang sign on Color Doppler and an enhanced intrauterine sac-like structure were observed, leading to the diagnosis of UAP, which disappeared at 4 weeks post-partum. Case 2 was after vacuum delivery with manual placental removal and was asymptomatic: a hypoechoic intrauterine mass with a yin-yang sign were observed during a post-partum routine check-up and the intrauterine flow disappeared at 4 weeks post-partum. Case 3 was after dilatation and curettage in the first trimester with slight bleeding: UAP was detected at 4 weeks post-abortion, which disappeared at 6 weeks post-abortion. All three cases had a small UAP (diameter: 10-15 mm) and low-level or no symptoms. Some UAP may resolve spontaneously and, thus, may not require TAE.

To characterise congenital mesoblastic nephroma (CMN), with special emphasis on polyhydramnios and the neonatal prognosis, we summarise 31 CMN patients (30 reported patients and the present patient). CMN was detected at a median of 30 weeks' gestation, and infants were delivered at a median of 34 weeks' gestation. Of 27 patients with available data, 19 (70%) had polyhydramnios, of which 8 required amnio- drainage. Women with amnio-drainage gave birth significantly earlier (30.4 weeks' gestation) than those without polyhydramnios (36.7 weeks' gestation). Thus, CMN was frequently associated with polyhydramnios and this polyhydramnios was associated with a significant increase in the risk of preterm birth. Of 20 patients with available data, the affected-side kidney was 'compressed' in 16 and 'replaced' in 4: polyhydramnios was present in a half vs 100%, respectively, suggesting that a 'replaced' kidney may suggest a more aggressive tumour and may be associated with a poorer prognosis. Univariate analysis showed that early gestational week at diagnosis was the only feature significantly associated with poor prognosis. Thus, polyhydramnios, 'replaced' kidney and early gestational week at diagnosis, may indicate poor prognosis, to which obstetricians should pay attention.

新生児同種免疫性血小板減少症(Neonatal alloimmune thrombocytopenia:NAIT)とは、免疫学的機序により起こる児の一過性血小板減少症であり、同胞罹患率が高い。母親に患児の血小板と反応する抗血小板抗体が証明されることが診断基準の一つであるが、原因抗体が明らかでない同胞発症症例を経験した。臨床経過からNAITが否定できない場合には、原因抗体が不明であっても次の妊娠分娩の際にNAITに準じた慎重な管理が必要である。(著者抄録)

40歳(2経妊0経産)。妊娠19週4日に出血と腹部膨満感を主訴に来院し、切迫流産の診断で入院となった。塩酸リトドリンの経静脈投与を66μg/分から開始し、炎症所見が軽快した後、21週0日に緊急マクドナルド頸管縫縮術を行った。その後、子宮収縮や頸管所見に応じてリトドリンを200μg/分まで徐々に増量した。母体の心拍数はリトドリン投与前が80bpm台、投与後が90〜110bpmであった。リトドリン投与55日目、起床時に突然の強い動悸を訴えた。脈拍は150〜170bpm、血圧は118/56mmHg、SpO2は97%、12誘導心電図は心拍数160bpm、R-R間隔は不整でP波を認めず、心房細動と診断した。心房細動の原因を明らかにするため、原因となりうる「心疾患」「電解質異常」「甲状腺機能亢進症」「薬剤」について鑑別診断を行った結果、「心疾患」「電解質異常」「甲状腺機能亢進症」は否定的であり、投与中

新生児同種免疫性血小板減少症(Neonatal alloimmune thrombocytopenia:NAIT)とは、免疫学的機序により起こる児の一過性血小板減少症であり、同胞罹患率が高い。母親に患児の血小板と反応する抗血小板抗体が証明されることが診断基準の一つであるが、原因抗体が明らかでない同胞発症症例を経験した。臨床経過からNAITが否定できない場合には、原因抗体が不明であっても次の妊娠分娩の際にNAITに準じた慎重な管理が必要である。(著者抄録)

Introduction. To identify factors that determine blood loss during peripartum hysterectomy for abnormally invasive placenta (AIP-hysterectomy). Methods. We reviewed all of the medical charts of 11,919 deliveries in a single tertiary perinatal center. We examined characteristics of AIP-hysterectomy patients, with a single experienced obstetrician attending all AIP-hysterectomies and using the same technique. Results. AIP-hysterectomy was performed in 18 patients (0.15%: 18/11,919). Of the 18, 14 (78%) had a prior cesarean section (CS) history and the other 4 (22%) were primiparous women. Planned AIP-hysterectomy was performed in 12/18 (67%), with the remaining 6 (33%) undergoing emergent AIP-hysterectomy. Of the 6, 4 (4/6: 67%) patients were primiparous women. An intra-arterial balloon was inserted in 9/18 (50%). Women with the following three factors significantly bled less in AIP-hysterectomy than its counterpart: the employment of an intra-arterial balloon (4, 448 ± 1, 948 versus 8, 861 ± 3, 988 mL), planned hysterectomy (5, 003 ± 2, 057 versus 9, 957 ± 4, 485 mL), and prior CS (5, 706 ± 2, 727 versus 9, 975 ± 5, 532 mL). Patients with prior CS (-) bled more: this may be because these patients tended to undergo emergent surgery or attempted placental separation. Conclusion. Patients with intra-arterial balloon catheter insertion bled less on AIP-hysterectomy. Massive bleeding occurred in emergent AIP-hysterectomy without prior CS.

Serous retinal detachment is sometimes caused by hypertensive disorders in pregnancy and its associated conditions, in which the predominant eye symptoms are blurred vision, distorted vision, and reduced visual acuity. To our best knowledge, this is the first report of a puerperal woman with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome in whom color vision abnormality was the first and predominant manifestation of serous retinal detachment. At 32 weeks of gestation, the 34-year-old Japanese woman underwent cesarean section due to HELLP syndrome. She complained of color vision abnormality on day 1 post-partum and ophthalmological examination revealed serous retinal detachment of both eyes. The visual acuity was preserved. With supportive therapy, her color vision abnormality gradually ameliorated and retinal detachment completely resolved on day 34 post-partum without any sequelae. Obstetricians should be aware that color vision abnormality can be the first and predominant symptom of HELLP-related serous retinal detachment.