高橋 宏典

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.

Introduction: Extravillous trophoblast (EVT) cell invasion plays a crucial role in establishment of successful pregnancy. CD44, a cell-surface receptor for hyaluronic acid (HA), plays a key role in HA-mediated remodeling and degradation that triggers cancer cell invasion. However, few studies have reported on the expression or functions of CD44 in human EVT cells. We hypothesized that CD44-HA interaction was involved in invasion by EVT cells. Methods: To test our hypothesis, we conducted in situ examinations of CD44 and HA expression in the human first-trimester placenta. We also assessed the methylation status of CD44 promoter and exon 1 regions in EVT cells. Finally, we conducted transwell cell invasion assays using EVT cell lines and EVT cells isolated from first-trimester human villous explant cultures. Results and discussion: EVT cells, but not villous trophoblast cells, in the first-trimester placenta expressed CD44. HA was strongly expressed in adventitia surrounding the spiral uterine arterial walls of the decidua. The extent of demethylation of CD44 promoter and exon 1 CpG islands was increased in EVT cells compared to those of first-trimester chorionic villi (including villous trophoblast cells), suggesting that CD44 expression was, at least in part, associated with methylation status. Data from transwell cell invasion assay with siRNA knockdown of CD44 revealed that CD44 expression significantly promoted invasion by EVT cells in an HA-dependent manner. Conclusions: The discovery of a CD44-HA interaction between EVT cells and the extracellular matrix contributes to our understanding of the mechanism underlying invasion by EVT cells. (C) 2013 Elsevier Ltd. All rights reserved.

Objective: To find a risk factor for "uncomplicated" preeclampsia (PE) comparing blood biochemical parameters between women with uncomplicated PE and healthy pregnant women in each trimester of pregnancy. Methods: A retrospective study was performed on 83 cases of uncomplicated PE, selected from 434 patients with PE, disregarding subjects with other complications relevant to hypertension during pregnancy. The study was limited to women with PE occurring in the third trimester, and records of blood biochemical parameters were evaluated. Controls were recruited from 108 healthy volunteers with normal singleton pregnancies. Results: A significant decrease in total protein was observed in the uncomplicated PE group in the second trimester prior to the onset of clinical symptoms. Conclusion: Hypoproteinemia during pregnancy may be a risk factor for this pathophysiology, and the maintenance of sufficient protein in early pregnancy could contribute to prophylaxis for women with uncomplicated PE.

Aim: We investigated trends in early-onset group B streptococcal disease (EOD) after the introduction of culture-based screening in Japan. Material and Methods: A retrospective cohort study examined EOD trends in 9506 pregnancies and 10 715 neonates at our center from 2002 to 2009. Results: EOD occurred in four neonates (4/7332: 0.55/1000 live births). The EOD incidence among infants born to women positive for GBS by screening was 0.90 cases per 1000 live births (1/1107). In contrast, the EOD incidence among infants negative by GBS screening was 0.48 cases per 1000 live births (3/6225). Thus, of the four affected neonates, three had mothers who tested negative on antepartum GBS screening. Two neonates had symptoms of infection during labor and intrapartum antibiotic agents were administered. The other two neonates received no antibiotics because deliveries were uneventful and they were negative on GBS screening. Conclusion: The incidence of EOD is 0.90 cases per 1000 live births among GBS-positive women and 0.48 cases per 1000 live births among GBS-negative women. The results of our study implied that EOD can develop regardless of GBS screening and intrapartum clinical course, although the method of sample collection, indications for antibiotic prophylaxis, and the antibiotics regimen should be considered.

Objective: We investigated persistent pulmonary hypertension of the newborn (PPHN) among monochorionic-diamniotic (MD) twins. Methods: A retrospective cohort study examined MD twins from 195 deliveries and 373 live-born neonates at our center. Results: PPHN occurred in three cases (3/373: 0.8%), all of which were recipients of twin-twin transfusion syndrome (TTTS), after fetoscopic laser surgery (FLS) (3/117: 2.6%). Although the clinical course of the three cases differed, all cardiothoracic area ratios exceeded 40%, and other cardiac parameters also worsened after FLS. Conclusions: The occurrence of PPHN in TTTS recipients should be noted, particularly when fetal cardiac function declines following FLS.

To investigate perinatal outcomes in late primiparous women aged 35-39 and >= 40 years. Our main research question: "Was the rate of cesarean section similar between these 2 groups of advanced maternal age?" Primiparous women aged >= 35 years, who delivered in our center between April 2004 and March 2007, were enrolled in this study. They were divided into two groups: women aged 35-39 years and those aged >= 40 years. Antenatal complications, deliveries, and neonatal outcomes were analyzed. Fetal abnormalities, abortions, and multiple gestations were excluded. We assessed 752 cases (35-39 years, 610 cases; >= 40 years, 142 cases). Incidence of cesarean section (CS) was significantly higher in pregnant women aged >= 40 years (P < 0.01). The CS rate amounted to 50.0% of all deliveries in this age group. Among patients with labor deliveries, the CS rate was also significantly higher in the older age group (P < 0.05). With regard to indication for CS with labor deliveries, the rate of non-progressive labor/dystocia was 19.4% in primiparous women aged >= 40 years and 11.0% in those aged 35-39 years, respectively (P < 0.05). In contrast, the rates of antenatal complications were not different between the two groups, except for gestational diabetes or leiomyoma. No significant differences between the two groups could be found for neonatal outcomes such as birth weight, Apgar score, and admission to neonatal intensive care unit. CS rate was 50.0% in primiparous women aged >= 40 years. In addition, CS caused by dystocia was almost twice as frequent in primiparous women aged >= 40 years as in women aged 35-39 years. Among late pregnancies, primiparous women aged 40 years and older had higher risk of CS.

Objective: Uterine artery embolization (UAE) is becoming a common treatment for symptomatic leiomyoma Several pregnancies following UAE have been reported However, reports are still limited and the risk of complications remains unknown Case Report: A primigravida conceived after UAE for leiomyoma She delivered spontaneously at 34 weeks plus 2 days after premature rupture of the membranes The placenta was located on the interstitial leiomyoma. The patient required manual placental extraction owing to retained placenta and subsequently underwent emergency supracervical hysterectomy for severe postpartum hemorrhage Placenta accreta was confirmed histologically Conclusion: Placenta accreta may occur during pregnancy following UAE When the implantation site is on the leiomyoma with a hyperechoic rim, there is a high risk of abnormal placental adherence [Taiwan J Obstet Gynecol 2010,49(2) 197-198]

Parvovirus B19-infected hydrops fetalis was treated using gammaglobulin injection into the peritoneal cavity (GIFPeC) with B19-IgG-rich immunoglobulin. Fetal anemia and hydrops resolved, and B19-DNA in fetal ascites decreased despite no change in maternal B19-IgG or B19-DNA. Gammaglobulin injection into the peritoneal cavity is thus useful for treating hydrops fetalis while avoiding intrauterine blood-transfusion risks.

Objective: The aim of this study is to identify suitable applications for cerebral MR (magnetic resonance) scanning in cases of severe preeclampsia and eclampsia through comparison of clinical course and easily accessible parameters. Methods: From January 2001 to December 2003, cerebral MR scans were performed on 43 women with severe preeclampsia; of those 41 were enrolled in data analyses. Twenty clinical parameters, including age, body mass index, blood pressure, liver and renal function, and coagulation status, were compared for each patient. Data were analyzed using the SPSS program on a VAX main frame. Results: Among 41 severe preeclamptic women, abnormal MR images were observed in 11 cases including six with systemic seizures. Predictive accuracy of eclampsia with abnormal cerebral MR imaging was 84.9% (P=0.00001), while only 14.3% of severe preeclampsia cases had been diagnosed radiologically. Statistical analysis suggests diastolic BP and serum AST as predictive parameters for abnormal MR images with 82.9% predictive accuracy (P=0.0007). Conclusions: Cerebral edema can be observed in preeclamptic patients developing eclampsia. Rapid delivery is indicated when diastolic BID and AST are elevated. MR scanning is useful when delivery is delayed due to fetal immaturityin cases of severe preeclampsia.

We analyzed midterm results using the Bicarbon valve in a single center. Forty-four patients had aortic valve replacement (AVR), 48 had mitral valve replacement (MVR), and 13 had both aortic and mitral valve replacement (DVR). The mean age of the 105 patients was 61.2+/-11.3 years. The mean follow-up was 1.8+/-1.1 years with a cumulative follow-up of 188 patient-years. There were 5 early deaths (4.7%: 4 in the AVR group and 1 in the MVR group) and 5 late deaths (2.7% per patient-year: 3 malignancy, 1 cerebral hemorrhage, 1 myocardial infarction). Survival at 3 years was 91+/-4% in the AVR group, 92+/-5% in the MVR group, and 66+/-23% in the DVR group. The linearized incidence of thromboembolic complications, hemorrhagic complications, and paravalvular leaks in all patients was 1.06+/-2.34%, 1.60+/-2.53%, and 0.53+/-2.22% per patient-year, respectively. No other complications were observed. In conclusion, the Bicarbon prosthetic heart valve has shown excellent clinical results associated with a low incidence of valve-related complications.