大口 昭英

2Dおよび3D超音波を用いて出生前診断し,良好な経過を示した腹壁破裂の4症例を報告した.4症例のうち,出生前診断され母体搬送された2症例は,新生児搬送となった2症例と比較して予後良好であった.出生前診断を行ない,対応可能な施設に母体搬送することが予後を改善するものと考えられた

37歳女.不正性器出血を主訴とし,子宮頸癌疑いで紹介された.子宮頸癌Ib2期の診断で,広汎子宮全摘および骨盤リンパ節郭清が施行され,組織学的診断は非角化型扁平上皮癌であった.本症例は心筋生検所見は得られていないが,画像所見ならびに現病歴から,臨床的に子宮頸癌の心筋転移と診断された.全身状態が不良であり,長期間にわたる生存が期待できないことから,心筋生検による確定診断を回避した

妊娠16〜20週に子宮動脈血流速度波形を計測した306例を対象とし,notch depth index(NDI)が早発型妊娠中毒症の発症と関連があるか否かを検討した.妊娠中毒症は306例中13例,早発型妊娠中毒症は4例に発症した.resistance index(RI)を用いたsensitivityは妊娠中毒症全体では53.8%であったが,早発型妊娠中毒症では100%に増加した.NDIを用いたsensitivityも61.5%から100%に増加した.両側notchesのsensitivityも61.5%から100%に増加した.NDIの異常の有無別に妊娠中毒症の発生率をカブランマイヤー曲線で比較してみると,NDIが異常の群は,妊娠32週未満から妊娠中毒症の発生が始まっているのに対し,NDIが正常の群は,全て妊娠32週以降に妊娠中毒症の発生が始まっていた

高年妊娠とされる35歳以上の妊婦では35歳未満妊婦に比べ低出生体重児(<2500g)の危険が約1.2倍,巨大児(≧4000g)の危険が約2.0倍増大する.ことに,35歳以上の経産婦では1/40の確率で巨大児出産の危険がある.この巨大児の増加については現在,加齢による耐糖能異常妊婦の増加と関連している可能性があるとされる.したがって,加齢による低出生体重児増加の原因については不明であるが内科疾患有病率の増加と関連があると考えられる

症例1(37歳,初産婦).自然妊娠による二絨毛膜性双胎であり,入院時のdiscordancy rateは9.1%であったが,分娩時には30.3%にまで増加し,胎盤間血管吻合のため双胎間に生じた血流差が原因と推察された.症例2(30歳,1経産).排卵誘発剤にて妊娠した二絨毛膜性双胎であり,妊娠初期のdiscordancy rateは10%前後であったが,出生時には41.6%に及び,臍帯の卵膜付着が原因と考えられた.両症例は妊娠初期の超音波検査にて診断され,その原因は胎盤・臍帯(胎児付属物)異常によるものであった.また,過去11年間に経験した20%以上のdiscordancyを伴う二絨毛膜性双胎について検討した.その結果,discordancyの推定原因では臍帯の付着異常が最多であり,discordancy児のNICU入院率は有意に高かった.二絨毛膜性双胎の妊娠管理に際してはdiscordancyの有無を正しく診断し,discordancyを有する症例では臍帯付着異常,染色体異常,胎児形態異常などの精査が不可欠であると考えられた

A 28-year-old Japanese woman who had received continuous intravenous infusion of magnesium sulfate from 24 weeks of pregnancy until delivery underwent cesarean section at 30 weeks and gave birth to twins. Serum magnesium sharply declined to a subnormal level of 1.5 mg/dL on postpartum day 4. The patient exhibited sinus bradycardia (48 b.p.m.) with intermittent supraventricular contraction on postpartum day 2, intermittent ventricular bigeminy on postpartum day 3, and frequent selfterminated polymorphic ventricular tachycardia on postpartum day 4. The electrocardiogram (ECG) disclosed that the patient had prolonged QTc of 0.45-0.67. Correction of serum magnesium improved ECG findings promptly, resulting in the disappearance of arrhythmias. Hypomagnesemia due to postpartum diuresis may have played a role causing ventricular tachyarrhythmia in this patient.

26歳,妊娠15週時の妊婦健診で貧血(Hb7.5g/dl)を指摘された.鉄,葉酸,ビタミンB12の内服を開始されたが妊娠20週にHbが3.8g/dlまで低下し,間接ビリルビン高値,LDH高値,直接クームス試験陽性等の所見から自己免疫性溶血性貧血と診断された.人工妊娠中絶し,胎児に異常所見は認めなかった

Objective: To determine whether a rise in systolic blood pressure (SBP) greater than or equal to 30 mm Hg and/or diastolic blood pressure (DBP) greater than or equal to 15 mm Hg in the absence of hypertension during pregnancy is associated with adverse pregnancy outcomes. Method: We conducted a retrospective, longitudinal study of 1498 pregnant women without hypertension or proteinuria in the first trimester. The blood pressure levels measured during the first (7.8 +/- 2.3 weeks), second (20.7 +/- 1.2 weeks), and third trimesters (38.6 +/- 1.5 weeks) were analyzed. The perinatal outcome was compared between women who exhibited a rise in SBP greater than or equal to 30 mm Hg and/or DBP greater than or equal to 15 mm Hg during pregnancy (large Delta BP group) and women who did not (small Delta BP group) using one way analysis of variance, chi-square test, or Fisher's exact test. The contribution of gestational hypertension and a large Delta BP to the development of adverse pregnancy outcomes was evaluated using multivariate logistic regression analysis. Results: Of 1441 women who remained normotensive (SBP < 140 mm Hg and DBP < 90 mm Hg) during pregnancy, 238 (16.5%) and 1203 (83.5%) belonged to the large Delta BP and small Delta BP groups, respectively. There were no significant differences between the two groups in the occurrence rate of gestational proteinuria, preterm deliveries, low-birth-weight infants, or small-for-gestational age infants. A large Delta BP was not a risk factor in itself for the occurrence of gestational proteinuria or small-for-gestational age infants after controlling for the effect of gestational hypertension. Conclusion: A rise in SBP greater than or equal to 30 mm Hg and/or DBP greater than or equal to 15 mm Hg is not a risk factor of adverse outcome among women who remain normotensive during pregnancy.

Objective: An extensive study as to whether maternal age itself is a risk factor for blood loss during parturition. Method: A total of 10,053 consecutive women who delivered a singleton infant were studied. The excess blood loss was defined separately for women with vaginal and cesarean deliveries as greater than or equal to 90(th) centile value for each delivery mode. The effects of 13 potential risk factors on blood loss were analyzed using multivariate analysis. Results: The 90(th) centile value of blood loss was 615 ml and 1,531 ml for women with vaginal and cesarean deliveries, respectively. A low lying placenta (odds ratio [OR]. 4.4), previous cesarean (3.1), operative delivery (2.6), leiomyoma (1.9), primiparity (1.6), and maternal age greater than or equal to 35 years (1.5) were significant independent risk factors for excess blood loss in women with vaginal delivery. Placenta previa (6.3), leiomyoma (3.6), low lying placenta (3.3), and maternal age greater than or equal to 35 years (1.8) were significant independent risk factors for excess blood loss in women with cesarean sections. Conclusion: A maternal age of greater than or equal to 35 years was an independent risk factor for excess blood loss irrespective of the mode of delivery, even after adjusting for age-related complications such as leiomyoma, placenta previa, and low lying placenta.

Single intrauterine death may occur in twin-twin transfusion syndrome. We investigated why the outcome of the surviving twin is fairly good when the donor twin dies first compared with when the recipient twin dies first. A detailed hemodynamic study was performed using Doppler ultrasound in a twin pregnancy affected by twin-twin transfusion syndrome before and after a single intrauterine death that occurred in the donor twin at 2 6 weeks'gestation. The recipient twin was expected to dic due to severe right cardiac failure with functional stenosis of the pulmonary artery 2 days before the cotwin's death. The donor twin's death caused a prompt resolution of cardiac failure and improvement in other indices, including flow velocity waveform patterns of the umbilical vein, the middle cerebral artery and the ductus venosus. A healthy, premature female neonate weighing 1630 g with a hemoglobin concentration of 17.8g/dL was delivered by Cesarean section following rupture of the fetal membranes 28 days after the episode. Hemorrhaging from the surviving twin to the dead twin that occurred just before or after the cotwin's death may have contributed to the decrease in volume overload in the recipient twin, leading to a prompt amelioration of the critical hemodynamic indices. The early death of the donor twin may thus have played a significant role in improving the status of the recipient twin in this case of twin-twin transfusion syndrome.

前置胎盤症例88例ではそれ以外の帝王切開術施行例176例に比較して,早産になりやすく,術中出血量が多く,そのため輸血を要する頻度が高く,子宮摘出術を要する頻度が高かった.前置胎盤症例における分娩時大量出血の危険因子として,母体高年齢,帝王切開術の既往,流産の既往,全前置胎盤・子宮前壁優位,妊娠満期に近い時期の分娩,双胎があげられた.前置胎盤症例における早産の危険因子として,双胎,妊娠中の性器出血があげられた

A 27-year-old primiparous preeclamptic woman developed a skin rash in late pregnancy and was persistently febrile for 10 days after giving birth. Blood tests suggested that she developed the HELLP syndrome and had concomitant cytomegalovirus (CMV) infection. Hemolysis, slightly impaired liver function, and thrombocytopenia were explainable by either only the CMV infection or only the HELLP syndrome. A literature review of a limited number of such cases and our case suggests that laboratory data in patients with CMV infection can mimic those of the HELLP syndrome. Thus, it may be important to consider CMV infection as a possible cause of abnormal laboratory data similar to the HELLP syndrome.