Late-diagnosed cesarean scar pregnancy resulting in unexpected placenta accreta spectrum necessitating hysterectomy

Cesarean scar pregnancy (CSP) is a rare complication involving the implantation of the gestational sac in a cesarean delivery scar. The authors report a case of unexpected placenta accreta spectrum (PAS) caused by late diagnosed CSP, necessitating emergent hysterectomy. A 28-year-old Japanese woman with two previous cesarean deliveries presented to our hospital at 11 weeks of gestation with abnormal transvaginal ultrasound findings obtained at another hospital;however, transabdominal ultrasound revealed that the fetus was already present in the uterine cavity at this time. At 28 weeks, there was no evidence of placenta previa. The woman developed preeclampsia at 29 weeks, and a cesarean section was conducted. Intraoperative findings confirmed PAS, and hysterectomy was conducted immediately.

Weekend and off-hour effects on the incidence of cerebral palsy: contribution of consolidated perinatal care

Objective

This study estimated the effects of weekend and off-hour childbirth and the size of perinatal medical care center on the incidence of cerebral palsy.

Methods

The cases were all children with severe cerebral palsy born in Japan from 2009 to 2012 whose data were stored at the Japan Obstetric Compensation System for Cerebral Palsy database, a nationally representative database. The inclusion criteria were the following: neonates born between January 2009 and December 2012 who had a birth weight of at least 2000 g and gestational age of at least 33 weeks and who had severe disability resulting from cerebral palsy independent of congenital causes or factors during the neonatal period or thereafter. Study participants were restricted to singletons and controls without report of death, scheduled cesarean section, or ambulance transportation. The controls were newborns, randomly selected by year and type of delivery (normal spontaneous delivery without cesarean section and emergency cesarean section) using a 1:10 case to control ratio sampled from the nationwide Japan Society of Obstetrics and Gynecology database.

Results

A total of 90 cerebral palsy cases and 900 controls having normal spontaneous delivery without cesarean section were selected, as were 92 cerebral palsy cases and 920 controls with emergent cesarean section. A significantly higher risk for cerebral palsy was found among cases that underwent emergent cesarean section on weekends (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.06–2.81) and during the night shift (OR 2.29, 95% CI 1.30–4.02). No significant risk was found among normal spontaneous deliveries on weekends (OR 1.63, 95% CI 0.97–2.73) or during the quasi-night shift (OR 1.26, 95% CI 0.70–2.27). Regional perinatal care centers showed significantly higher risk for cerebral palsy in both emergent cesarean section (OR 2.35, 95% CI 1.47–3.77) and normal spontaneous delivery (OR 2.92, 95% CI 1.76–4.84).

Conclusion

Labor on weekends, during the night shift, and at regional perinatal medical care centers was associated with significantly elevated risk for cerebral palsy in emergency cesarean section.

Successful Management of Platinum-resistant Ovarian Cancer by Weekly Nedaplatin Followed by Olaparib: Three Case Reports

BACKGROUND

Treatment for platinum-resistant ovarian cancer is difficult and challenging because available chemotherapeutic agents only offer short survival improvements. The efficacy of re-treatment with platinum-based agents including nedaplatin for platinum-resistant patients has not been fully investigated.

CASE REPORT

We describe herein three cases of heavily treated platinum-resistant ovarian cancer that were successfully treated with weekly nedaplatin followed by olaparib. After becoming platinum-resistant, the cases were treated with non-platinum chemotherapies. Following these regimens, weekly nedaplatin was introduced, followed by olaparib. At the time of writing, survival since the start of weekly nedaplatin was 30 months for case 1, 20 months for case 2, and 17 months for case 3, with all patients showing no evidence of disease.

CONCLUSION

Weekly nedaplatin followed by olaparib might represent a good treatment option for platinum-resistant ovarian cancer and is a solid candidate for further evaluation.

Risk factors for cerebral palsy in neonates due to placental abruption

Aim

This study aimed to identify risk factors for the onset of cerebral palsy (CP) in neonates due to placental abruption and investigate their characteristics.

Methods

A retrospective case–control study was conducted using a nationwide registry from Japan. The study population included pregnant women (n = 122) who delivered an infant with CP between 2009 and 2015, where placental abruption was identified as the single cause of CP. The control group consisted of pregnant women with placental abruption, who delivered an infant without CP and were managed from 2013 to 2014. They were randomly identified from the prenatal database of the Japan Society of Obstetrics and Gynecology (JSOG‐DB; n = 1214). Risk factors were investigated using multivariate analysis.

Results

Alcohol consumption (3.38, 2.01–5.68) (odds ratio, 95% confidence interval), smoking during pregnancy (3.50, 1.32–9.25), number of deliveries (1.28, 1.05–1.56), polyhydramnios (5.60, 1.37–22.6), oral administration of ritodrine hydrochloride (2.09, 1.22–3.57) and hypertensive disorders in pregnancy (2.25, 1.27–4.07) were significant risk factors. In contrast, intravenous administration of oxytocin (odds ratio, 95% confidence interval: 0.22, 0.09–0.58) and magnesium sulfate (0.122, 0.02–0.89) attenuated risk.

Conclusion

Alcohol consumption, smoking during pregnancy, number of deliveries, polyhydramnios, oral administration of ritodrine hydrochloride and hypertensive disorders in pregnancy were identified as risk factors for CP following placental abruption. Regarding alcohol consumption and smoking during pregnancy, the results suggest the importance of educational activities targeting pregnant women to increase their awareness of placental abruption.

Comprehensive metabolomic analysis of first-trimester serum identifies biomarkers of early-onset hypertensive disorder of pregnancy

Hypertensive disorders of pregnancy (HDP) lead to the death of approximately 30,000 women annually, and the identification of biomarkers to predict their onset before symptom occurrence is crucial. Here, we aimed to identify the first-trimester maternal serum biomarkers for predicting early-onset HDP via a comprehensive metabolomic analysis. This study was conducted by the Fukushima Regional Center as an adjunct study to the Japan Environment and Children’s Study. The study comprised 12 patients with early-onset HDP and 12 control subjects with healthy pregnancy whose medical background information was matched with that of the patients by propensity-score matching. Capillary electrophoresis and mass spectrometry-based quantitative analysis of charged metabolites were performed with the first-trimester maternal serum samples. Welch’s t-test was used to analyse metabolite peak areas in the two groups. A total of 166 charged metabolites were identified. The peak area of N-dimethylglycine and S-methylcysteine was significantly higher in the first-trimester serum of patients with early-onset HDP than in the controls. Conversely, the peak area of munic acid was significantly decreased in the serum of patients with early-onset HDP. Although we identified potential biomarkers for the prediction and diagnosis of early-onset HDP, no clear marker was identified because of a low statistical power.

Association between pre-pregnancy calcium intake and hypertensive disorders during the first pregnancy: the Japan environment and children's study

BACKGROUND

Determining the appropriate preconception care to reduce the occurrence of hypertensive disorder of pregnancy (HDP) remains a challenge in modern obstetrics. This study aimed to examine the association between pre-pregnancy calcium (Ca) intake and HDP in normotensive primiparas.

METHODS

We used data from the Japan Environment Children's study (JECS), which is the largest birth cohort study. A total of 33,894 normotensive Japanese primiparas were recruited for JECS between January 2011 and March 2014. Participants were categorized into five groups according to pre-pregnancy Ca intake quintiles (Q1 and Q5 were the lowest and highest Ca intake groups, respectively) to compare their basic background and obstetrics outcome. Multiple logistic regressions were performed to identify the effect of pre-pregnancy Ca intake on HDP, early onset HDP, and late-onset HDP, using Ca intake thresholds of 500, 550, 650, 700, 1000, 1500, and 1500 mg.

RESULTS

We found significant differences in maternal background among the Ca intake groups; in particular, there were more participants with low socioeconomic status, indicated by low education level and low household income, and smokers in the lowest Ca intake group. Multiple logistic regression did not show any significant difference with regard to HDP, early onset HDP, and late-onset HDP in each Ca intake threshold.

CONCLUSIONS

Despite considerable recommendations concerning Ca intake for women of reproductive age, the present study indicates that pre-pregnancy Ca intake was not associated with an increased risk of new-onset hypertension among primiparas during pregnancy. Further studies examining the effect of other pre-pregnancy dietary factors on obstetric outcomes should be considered in the formulation of earlier preventive strategies for primiparas.

Association Between Neutralizing Antibody Titers against Parechovirus A3 in Maternal and Cord Blood Pairs and Perinatal Factors

BACKGROUND

Parechovirus A3 (PeV-A3) is a pathogen that causes severe infectious diseases such as sepsis and meningoencephalitis in neonates and young infants. In this study, we aimed to measure the neutralizing antibody titer (NAT) against PeV-A3 in paired maternal and cord blood samples and to clarify the serum epidemiology of PeV-A3 and the association between the NAT and perinatal factors.

METHODS

NATs against PeV-A3 were measured in 1033 mothers (maternal and cord blood pairs; total of 2066 samples) who delivered their infant in Fukushima Prefecture between December 2013 and June 2014. RD-18S cells were used to measure NATs against PeV-A3. The association between NATs against PeV-A3 in maternal and cord blood and perinatal factors was determined using multivariate logistic regression analysis.

RESULTS

The median gestational age of the infants was 39 weeks 4 days (interquartile range, 38 weeks 4 days to 40 weeks 3 days). The NATs against PeV-A3 in maternal blood and in cord blood were almost the same. The proportion of samples assigned to the low-titer group (NAT ≤ 1:16) was approximately 70%, and the proportion of samples assigned to the high-titer group tended to increase with gestational age. The high-titer rate and geometric mean titers decreased with increased maternal age.

CONCLUSIONS

Cord blood indicates that neonates born at a lower gestational age and older mothers have a low NAT against PeV-A3. Thus, more attention should be paid to the onset of severe PeV-A3 disease in such neonates and young infants.

Unsupervised breastfeeding was related to sudden unexpected postnatal collapse during early skin-to-skin contact in cerebral palsy cases

Aim

This study aimed to identify the clinical features of infants who were healthy at birth, but developed sudden unexpected collapse and were then diagnosed with cerebral palsy before 5 years of age.

Methods

We retrospectively analysed 1182 records from the no‐fault Japan Obstetric Compensation System for Cerebral Palsy database up to 2016. This identified 45 subjects (3.8%) who were subsequently diagnosed with severe cerebral palsy due to sudden unexpected postnatal collapse (SUPC). They were all healthy at birth, based on the criteria of five‐minute Apgar scores of seven or more, with normal umbilical cord blood gases and no need for neonatal resuscitation within five minutes of birth.

Results

The median birth weight of the 45 subjects (26 males) was 2770 g (range 2006‐3695 g). Of these, 10 developed SUPC during early skin‐to‐skin contact (SSC). Medical personnel were not present in all 10 cases: nine were being breastfed at the time and eight of the mothers did not notice their infant's abnormal condition until medical staff alerted them.

Conclusion

This national study of children with cerebral palsy who appeared healthy at birth found that unsupervised breastfeeding was a common factor in cases of SUPC during early SSC.

Polyhydramnios and abnormal foetal heart rate patterns in a foetus with Prader-Willi syndrome: A case report

Introduction

Prader-Willi syndrome (PWS) is a complex neurodevelopmental genetic disorder. No definitive clinical signs of antenatal PWS have been identified.

Case

A healthy, nulliparous, 29-year-old woman demonstrated polyhydramnios at 27 weeks of gestation. Cardiotocography (CTG) showed an absence of foetal heart rate (FHR) acceleration and moderate FHR variability. Daily CTG demonstrated an absence of FHR acceleration. A male newborn was delivered by caesarean section, weighing 2492 g, which is appropriate for gestational age; the Apgar scores at 1 and 5 min were 6 and 6, respectively, and the umbilical artery pH was 7.295. The newborn exhibited marked hypotonia, lack of sucking, and cryptorchidism. FISH analysis performed due to severe hypotonia showed 46, XY. Ish del (15) (q11. 2q 11.2), which led to the diagnosis of PWS.

Discussion

Polyhydramnios and abnormal FHR patterns may be associated with feeding difficulty and hypotonia. These signs may be an indication for antenatal molecular genetic testing to diagnose PWS.

•

Prader-Willi syndrome (PWS) is a complex neurodevelopmental genetic disorder.

•

Polyhydramnios and abnormal foetal heart rate patterns may be associated with feeding difficulty and hypotonia.

•

These signs may be an indication for antenatal molecular genetic testing to diagnose Prader-Willi syndrome.

Risk of adverse obstetric outcomes in Japanese women with systemic lupus erythematosus: The Japan Environment and Children's Study

Systemic lupus erythematosus, simply known as lupus, is associated with adverse obstetric outcomes. This study evaluated the incidence of preterm births (before 37 and 34 weeks), low birthweight infants (<2500 g and <1500 g), small-for-gestational age infants, preterm premature rupture of membranes, and gestational hypertension in mothers with lupus and compared them with those of the Japanese general population. Data from participants in the Japan Environment and Children’s Study who gave birth between 2011 and 2014 were collected. Only participants with singleton pregnancies were included. Adjusted odds ratios for the variables were calculated using a logistic regression model, with a general population as the reference. In total, 88,017 participants were included in the analysis, and 63 of them had lupus. The adjusted odds ratios of preterm births before 37 and 34 weeks, low birthweight infants <2500 g and <1500 g, small-for-gestational age infants, and preterm premature rupture of membranes in the systemic lupus erythematosus group were 8.1 (95% CI, 4.7–14.1), 5.2 (1.6–16.5), 6.5 (3.9–10.8), 5.4 (1.3–22.4), 2.9 (1.4–5.9), and 12.1 (5.7–25.5), respectively. The adjusted odds ratio of gestational hypertension was 1.4 (0.4–4.5). This study revealed increased risk of preterm births, low birthweight infants, small-for-gestational age infants, and preterm premature rupture of membranes in patients with lupus when compared with those in the general population.

Effect of magnesium sulfate on baroreflex during acute hypoxemia in chronically instrumented fetal sheep

AIM

To investigate the effects of magnesium sulfate on fetal baroreflex in normoxemia or acute fetal hypoxemia.

METHODS

Fetal baroreflex response was elicited using phenylephrine (30 μg) in saline and magnesium sulfate in 8 chronically treated and instrumented fetal sheep. Hypoxemia was induced using nitrogen gas inflow for 30 min. Baroreflex, calculated as the ratio of the fetal heart rate change to the mean arterial pressure, was monitored after magnesium sulfate administration and in rapid and nonrapid eye movement (NREM) sleep states. Baroreflex was assessed in response to hypoxemia in control groups in both the rapid and NREM sleep states.

RESULTS

Baroreflex was not significantly affected by saline, magnesium sulfate and rapid or NREM sleep states in normoxemic sheep. Hypoxemia increased the baroreflex in the saline-treated group (hypoxemic vs normoxemic rapid eye movement sleep: 4.37 ± 2.48 vs 2.72 ± 0.83; P < 0.05; hypoxemic vs normoxemic NREM sleep: 4.30 ± 1.47 vs 3.15 ± 0.83; P < 0.001). Magnesium sulfate decreased the baroreflex in the hypoxemic fetuses (magnesium sulfate hypoxemic vs. control normoxemic fetuses: 1.42 ± 0.92 vs 3.15 ± 0.83, P < 0.05).

CONCLUSION

The hypoxemic fetal sheep, from the ewes that were receiving magnesium sulfate, showed a significantly reduced in the baroreflex response. In clinical practice, baroreflex-related decelerations in hypoxemic fetuses of mothers receiving magnesium sulfate should be carefully interpreted.

Malignant transformation arising from mature cystic teratoma of the ovary presenting as ovarian torsion: a case report and literature review

Objective: Ovarian torsion is an acute gynecological condition. Torsion is more likely to occur with benign rather than malignant tumors. Mature cystic teratoma of the ovary (MCTO) is frequent in women of reproductive age; however, the incidence of malignant transformation is approximately 2%. We report a case of malignant transformation of MCTO presenting as ovarian tumor torsion.

Case report: A 51-year-old premenopausal woman was diagnosed with mature cystic teratoma in the left ovary 7 years ago. The patient visited our hospital because she had been experiencing of pain in left lower abdomen for the past two days. She was diagnosed with ovarian tumor torsion and underwent emergency surgery. The left ovarian tumor was twisted, and left salpingo-oophorectomy was performed. Histopathological examination revealed squamous cell carcinoma arising from the MCTO. We carefully followed the patients without performing staging laparotomy. On postoperative day 112, multiple lymph node metastases in the pelvic and para-aortic areas were found by positron-emission tomography and computed tomography. After referral to a university hospital, total hysterectomy, right salpingo-oophorectomy, partial omentectomy, and pelvic and paraaortic lymphadenectomy were performed. Metastases of squamous cell carcinoma were confirmed in the pelvic and para-aortic lymph nodes. Six courses of adjuvant chemotherapy with paclitaxel and carboplatin were given following radical surgery to prevent the recurrence of malignant transformation of MCTO. No recurrence of the disease has been observed during 2 years of follow-up.

Conclusion: When physicians diagnose large ovarian tumor torsion cases, preoperative examinations should be performed, with the possibility of malignancy in mind.

Successful management of preoperatively diagnosed torsion of a subserosal uterine fibroid by pneumoperitoneum laparoscopic single-port surgery

OBJECTIVE

Preoperative diagnosis and successful management of acute torsion of a subserosal fibroid by using appropriate imaging modalities and single-port laparoscopic surgery.

CASE REPORT

A 44-year-old nulliparous woman presented with lower abdominal pain. Computed tomography and magnetic resonance imaging with contrast enhancement revealed a tumor in the pouch of Douglas with a low contrast at the center and thin-rim enhancement. Torsion of a uterine subserosal fibroid was diagnosed preoperatively. Laparoscopic single-port surgery by pneumoperitoneum was performed. Torsion of the pedicle attached to the uterine wall was excised by bipolar coagulation and cut with scissors. The extirpated fibroid was extracted from the umbilical wound. The pneumoperitoneum single-port laparoscopic surgery was completed as a gynecologic emergency operation.

CONCLUSION

Torsional uterine fibroids are difficult to diagnose preoperatively as symptoms are nonspecific and need emergent surgical management as an acute abdomen. Preoperative diagnosis using appropriate imaging modalities is important to perform single-port laparoscopic surgery.

Risk factors for placenta accreta spectrum: findings from the Japan environment and Children's study

Background

Placenta accreta spectrum (PAS) is a life-threating complication in the field of obstetrics. Sometimes we face with unexpected PAS cases which is potentially higher maternal mortality and morbidity compared with expected cases. The present study was conducted to examine the prevalence of PAS and to elucidate its risk factors using a large Japanese birth cohort study.

Methods

We reviewed the results of a nationwide prospective birth cohort study in Japan, and identified 90,554 participants treated from 2011 to 2014 in 15 regional centers. Multiple regression models were created to identify the risk factors for PAS. These data were obtained from self-reported questionnaires or patient medical records.

Results

This analysis consisted of 202 cases of PAS (18 with placenta previa and 184 without placenta previa) and 90,352 cases without PAS. The multiple logistic regression analysis showed that placenta previa (adjusted odds ratio [aOR]: 12.86, 95% confidence interval [CI] 7.70–21.45, P < 0.001), assisted reproductive technology-related pregnancies (aOR: 6.78, 95% CI 4.54–10.14, P < 0.001), smoking during pregnancy (aOR: 1.95, 95% CI 1.15–3.31, P = 0.013), more than two previous cesarean sections (aOR: 2.51, 95% CI 1.35–4.67, P = 0.004), and uterine anomalies (aOR: 3.97, 95% CI 1.24–12.68, P = 0.020) increased the risk of PAS.

Conclusion

In general population, placenta previa, assisted reproductive technology-related pregnancy, smoking during pregnancy, repeated cesarean sections, and uterine anomalies were risk factors for PAS in the Japanese population.

Clinical and reproductive outcomes of fertility-sparing surgery in stage I epithelial ovarian cancer

The aim of the present study was to evaluate the oncologic safety and reproductive outcome in patients with stage I epithelial ovarian cancer (EOC) treated with fertility-sparing surgery (FSS). Women aged ≤40 years with stage I EOC who had undergone FSS between 2000 and 2010 were retrospectively reviewed. Survival was examined using the Kaplan-Meier method and statistical significance was analyzed using the log-rank test. A total of 29 EOC patients (stage IA, n=14; stage IC1 n=6; stage IC3, n=9) from seven participating institutions belonging to the Tohoku Gynecologic Cancer Unit were enrolled. After a median follow-up duration of 60.6 months (range, 6–135 months), five patients (17.2%) experienced tumor recurrence. The respective five-year relapse-free survival (RFS) and overall survival (OS) rates were 90.9 and 100% for stage IA/IC1, and 43.8 and 87.5% for stage IC3. Significant differences in RFS were observed between stage IA/IC1 and IC3 patients (P=0.026). However, there was no significant difference in OS between patients with 1A/1C1 and those with 1C3 (P=0.712). After FSS, seven pregnancies occurred in five patients, which resulted in the birth of six healthy children. The results of the present study confirmed that FSS may be an acceptable treatment method for stage IA and IC1 EOC, exhibiting a favorable reproductive outcome. However, the safety of FSS for treating stage IC3 EOC is uncertain and warrants further investigation.

Effect of proinflammatory diet before pregnancy on gestational age and birthweight: The Japan Environment and Children's Study

The daily diet plays a role in systematic inflammation and may be one of the causes of preterm birth. We aimed to examine the effect of a daily proinflammatory diet before pregnancy on gestational age and birthweight using a large birth cohort in Japan. We used data of singleton pregnancies in the Japan Environment and Children's Study involving live birth from 2011 to 2014 to calculate the dietary inflammatory index. We used individual meals with 30 food parameters from a semiquantitative food frequency questionnaire, which assessed diet intake before pregnancy. Participants were categorized according to the quartile of dietary inflammatory index. A multiple logistic regression model was used to estimate the risk of a proinflammatory diet on preterm birth (PTB) before 37 or 34 weeks and low birthweight (LBW) less than 2,500 or 1,500 g, accounting for maternal age, body mass index before pregnancy, smoking status, education, and household income. After applying our inclusion criteria, 89,329 participants were eligible for the present study. Multiple regression analysis showed that the proinflammatory diet had an increased risk of PTB < 34 weeks (adjusted odds ratio: 1.29, 95% confidence interval [1.07, 1.55]) and <2,500‐g LBW (adjusted odds ratio: 1.08, 95% confidence interval [1.01, 1.16]) compared with the control. In conclusion, a proinflammatory diet before pregnancy was a risk factor for PTB < 34 weeks and LBW < 2,500 g. Therefore, proinflammatory diet needs to be controlled to improve perinatal prognosis.

Establishing a Treatment Algorithm for Puerperal Genital Hematoma Based on the Clinical Findings

Postpartum hemorrhage within 24 hours after delivery remains the leading cause of maternal mortality worldwide. Puerperal genital hematoma (PGHA) is a rare complication of postpartum hemorrhage, and PGHA can be life-threatening if hemostasis is not properly achieved. However, a reliable management algorithm for PGHA based on the clinical findings has not been developed. The objectives were to evaluate the management strategies for PGHA and identify the clinical findings that help select the treatment for PGHA. The medical records of women who were treated for PGHA in our department were reviewed, and data regarding the clinical findings and the treatment strategy for PGHA were analyzed. Thirty-four women who underwent treatment for PGHA were identified and divided into three groups according to the final procedure that achieved hemostasis: conservative management (CM) (n = 9), surgical management (SURG) (n = 15), and arterial embolization management (AEM) (n = 10). Regarding the clinical findings on initial evaluation, the shock index was significantly higher in the AEM group than in the CM or SURG group; and initial platelet count and fibrinogen level were significantly lower in the AEM group than in the CM group. There was no significant difference in any computed tomography (CT) finding among the three groups. In conclusion, this study clearly shows the difference in clinical findings among treatment strategies for PGHA. We suggest that the clinical findings of shock index, platelet count, and fibrinogen level together with CT findings are helpful and valuable for selecting the treatment strategy for PGHA.

Association of amniotic fluid sludge with preterm labor and histologic chorioamnionitis in pregnant Japanese women with intact membranes: A retrospective study

AIM

The presence of amniotic fluid sludge has been identified as a risk factor for preterm birth. We sought to validate the clinical characteristics of amniotic fluid sludge in Japanese pregnant women with preterm labor and intact membranes.

METHODS

This was a retrospective study of 54 patients. The presence of amniotic fluid sludge was confirmed using transvaginal ultrasonography data during pregnancy. The following data were collected: gestational age, the presence of histologic chorioamnionitis, time from the diagnosis of threatened premature labor to delivery, oncofetal fibronectin (onfFN) levels, C-reactive protein peak value levels, cervical length at the time of onset of threatened premature labor and types of neonatal complications.

RESULTS

Significant differences (P = 0.03) were observed in the age at delivery in relation to the presence of amniotic sludge: delivery occurred at 28.3 ± 4.5 weeks and 31.7 ± 4.3 weeks in sludge positive patients and sludge-negative patients, respectively. Presence of sludge in patients diagnosed with histological chorioamnionitis at <37 weeks of gestation differed significantly (P = 0.01): sludge-positive, 81.8%; sludge-negative, 20.9%. Among the sludge-positive patients, 100% were positive for serum onfFN (≥50 ng/mL), whereas only 54% of sludge-negative patients were positive for serum onfFN (P = 0.03). Presence of amniotic fluid sludge did not significantly affect neonatal complications.

CONCLUSION

Our results confirmed previous findings that amniotic fluid sludge is a self-determining risk factor for preterm birth and chorioamnionitis in pregnant Japanese women.

Pelvic Exenteration as Potential Cure and Symptom Relief in Advanced and Recurrent Gynaecological Cancer

BACKGROUND/AIM

Pelvic exenteration is a radical procedure for certain advanced or recurrent gynaecological cancers, performed with curative or palliative intent. Its validity has evolved as operative mortality and morbidity have improved. This surgery was evaluated to determine the validity of these claims.

PATIENTS AND METHODS

The details of surgery and outcomes of 13 patients who underwent pelvic exenteration (6 curative intent, 7 palliative intent) for advanced or recurrent gynaecological cancers in our Department were retrospectively evaluated.

RESULTS

There were no significant differences in blood loss, surgical time, hospital stay, and complications between curative pelvic exenteration and palliative pelvic exenteration. The curative intent group had a good prognosis; the palliative-intent group showed a trend to a worse prognosis. All patients' symptoms were relieved, but in patients with short survival, symptom relief lasted for up to 3 months.

CONCLUSION

Pelvic exenteration is an acceptable and valuable procedure for gynaecological cancers.

P943The impact of diabetes on patients with frail after endovascular treatments: from I-PAD registry

Background

Diabetes mellitus (DM) is known to be one of the risks of arteriosclerosis. However, it is still unknown whether DM is a risk factor also in secondary prevention of frail patients after endovascular treatments (EVT)

Purpose

To investigate impact of diabetes on patients with frail after EVT.

Methods

From July 2015 to July 2016, 371 consecutive PAD patients who performed EVT were enrolled in I-PAD registry. We could conduct follow up survey 361 patients (446 lesions) and divided into 2 groups; with diabetes (185 patients, 226 lesions) or without diabetes (176 patients, 220 lesions) and analyzed. And among them,we selected 96 patients with frail and divided into 2 groups; with diabetes (49 patients, 70 lesions) or without diabetes (46 patients, 58 lesions) and analyzed. We defined frail patients as the patients with Clinical Frailty Scale 5 (mild frail) or higher. The primary end point was all-cause-death and major adverse limb events (MALE: TLR, TVR, major amputations) at 1 year.

Result

At 1 years in the patients group with diabetes, overall survival and freedom from MALE were significantly lower (81.7% vs 95.8% P<0.0001; 80.0% vs 94.6%, P<0.0001) than the group without diabetes.Among the patients with frail, between the patients group with diabetes and the group without, there is no significant differences in overall survival and freedom from MALE (88.2% vs 88.9% P=0.83; 80.7% vs 84.1%, P=0.55) at 5 years.

Conclusion

The prognosis of patients with diabetes after EVT was worse than the patient without. On the other hand, the prognosis of frail patients with diabetes after EVT was no difference with the frail patient without diabetes in this study.

P942Impact of left ventricular ejection fraction in patients with critical limb ischemia: from I-PAD registry

Introduction

In patients with critical limb ischemia (CLI) it is known that malnutrition, low BMI, inflammation and so on are prognostic factors. But, it is unclear whether left ventricular ejection fraction (LVEF) affects prognosis of CLI patients. So we investigated that LVEF affects prognosis of CLI patients.

Methods

From July 2015 to July 2016, 371 consecutive peripheral artery disease patients who performed endovascular treatment (EVT) were enrolled in I-PAD registry. 179 of them were patients with CLI. We could conduct follow up survey about 126 (age 75.5±11.1, men 63.5%) and divided two groups according to their LVEF (group with LVEF≤40%, n=13, group without LVEF≤40%, n=113). The primary end point was major adverse limb events (MALE: TLR, TVR, major amputations) and secondary end point was all-cause death.

Results

The median follow-up period was 11.5±6.7 months. The 18 months MALE rate was significant higher in the group with low LVEF than group without low LVEF (76.9% vs 37.2% p<0.05). The 18months all-cause death tended to be higher in the group with low LVEF, however there was not statistical significance in the two groups (53.8% vs 24.8% p=0.09).

Conclusion

LVEF was associated with MALE in patients with CLI.

P936Impact of left ventricular ejection fraction in patients with peripheral artery disease: from I-PAD registry

Introduction

In patients with peripheral artery disease (PAD) it is known that CVD is one of prognostic factors. But, it is unclear whether left ventricular ejection fraction (LVEF) affects prognosis of PAD patients. So we investigated that LVEF affects prognosis of PAD patients.

Methods

From July 2015 to July 2016, 371 consecutive PAD patients who performed endovascular treatment (EVT) were enrolled in I-PAD registry. We could conduct follow up survey about 337 (age 73.8±9.6, men 72.4%) patients and divided two groups according to their LVEF (group with LVEF≤40%, n=18, group without LVEF≤40%, n=319). The primary end point was major adverse limb events (MALE: TLR, TVR, major amputations) and secondary end point was all-cause death.

Results

The median follow-up period was 13.6±5.7 months. The 18 months MALE and all-cause death rate were significantly higher in the group with low LVEF than group without low LVEF (61.1% vs 21.6% p<0.001, 44.4% vs 11.6% p<0.001).

Conclusion

LVEF was significantly associated with MALE and all-cause death in patients with PAD.

Incisional pyoderma gangrenosum after caesarean section: Two case reports

Introduction

Pyoderma gangrenosum (PG) in pregnant women is rare and resembles surgical site infection (SSI). Here we present two cases of PG after caesarean section.

Case 1

A 29-year-old woman, who had a history of recurrent wound dehiscence after surgery, exhibited wound ulceration and exudate 6 days after caesarean section. Antibiotics were ineffective and multiple wound cultures were negative. Skin biopsy indicated PG and oral steroid administration resulted in wound improvement.

Case 2

A 27-year-old woman, who had a history of PG, exhibited wound ulceration and exudate 5 days after caesarean section. The lesion developed despite antibiotic administration, and multiple wound cultures were negative. Skin biopsy indicated PG and the wound improved after oral steroid administration.

Discussion

Definitive diagnosis of PG is essential because its treatment differs from that of SSI. PG after caesarean section can be misdiagnosed as SSI, even when there is a history of wound dehiscence or PG.

Obstetric factors associated with uterine rupture in mothers who deliver infants with cerebral palsy

Objective: The aim of the present study was to clarify the obstetric factors associated with uterine rupture in mothers who deliver infants with cerebral palsy (CP) in Japan.Methods: This retrospective case-cohort study reviewed the obstetric characteristics and clinical courses of mothers who experienced uterine rupture and compared those who delivered an infant with CP (cases) with those who delivered an infant without CP (cohort). Data were obtained from the Japan Obstetric Compensation System for CP database (27 cases) and the perinatal database of the Japan Society of Obstetrics and Gynecology (312 cohorts). The subjects included live singleton infants delivered between 2009 and 2014 with a birth weight ≥2000 g and gestation ≥33 weeks.Results: Augmentation was performed 33% in cases and 8% in cohorts (p < .001). The amount of bleeding during surgery was 1819 g in cases and 1096 g in cohorts (p < .001). Length of gestational weeks and neonatal birth weight were significantly higher and Apgar scores and umbilical arterial pH were lower in cases compared to cohorts (p < .001). In cases with CP, 11 cases of uterine rupture involved scarred uteruses. Seven were trial of labor after a previous cesarean. On one hand, 16 cases occurred in unscarred uteruses. Five of the uterine fundal pressure maneuvers and four of tachysystole due to excessive augmentation were reported in association with uterine rupture.Conclusion: Two-third of the relevant obstetric factors for CP associated with uterine rupture were iatrogenic. At least, to reduce CP resulting from delivery-related uterine rupture, reckless delivery management should be avoided.