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When we see preexistent hypertension in pregnancy, subclinical Cushing's syndrome should be considered in the differential diagnosis since this disorder can cause perinatal complications. MRI can be useful for identifying adrenal incidental tumors during pregnancy.

AIM: Changes in glucose levels during labor have not been sufficiently investigated in pregnant women. Using real-time continuous glucose monitoring, we aimed to assess glucose kinetics during labor among pregnant women with gestational diabetes mellitus (PwGDM), and those with normal glucose tolerance (PwNGT). METHODS: Japanese PwGDM and PwNGT who had planned a transvaginal delivery at Okayama University Hospital were enrolled. The correlation between changes in glucose levels during labor among the PwGDM and PwNGT groups at four time periods was assessed: (i) active phase of 1st stage of labor; (ii) 2nd stage of labor; (iii) postpartum 0-12 h; and (iv) postpartum 12-48 h. RESULTS: In total, 18 and 22 PwGDM and PwNGT, respectively, were enrolled. During labor, both groups had similar changes in glucose levels over time, which peaked during period 3. The main effect of glucose level changes was the labor period (P CONCLUSION: During labor, both PwGDM and PwNGT groups showed similar changes in glucose levels over time. During delivery, the PwGDM who regularly measured their own glucose levels could be managed using the same nutritional management methods as those for PwNGT.

Background The aim of this randomized controlled trial (RCT) is to investigate whether Spiral-thread sutures are superior to conventional sutures (0-Vicryl) for preventing uterine scar thinning following elective cesarean section. Methods This multicenter, parallel-group RCT will be conducted in four hospitals across three medical regions in Japan to assess 200 women (≥20 years old) with singleton pregnancies who are scheduled to undergo cesarean sections. Eligible women will be randomly assigned (1:1 ratio) to receive either the conventional uterine suture continuous absorption thread, which is most commonly used in Japan, or the Spiral thread. The primary endpoint is the degree of scar thinning, measured by transvaginal ultrasonography 6–7 months postoperatively, to evaluate the position of the uterus (anterior or posterior tilt) and myometrial wound thickness. The degree of thinning will be compared between the groups, and four measurements (mm) of the thinning area, including caudal distance, depth of the depression, remaining thickness of the myometrium on the serous side of the most depressed area, and width of the depression, will be recorded in the sagittal view on transvaginal ultrasound. Secondary endpoints will include total operative time, suture application time (from birth to the end of uterine suturing), operative blood loss, number of additional Z-sutures or continuous sutures required to stop bleeding, maternal abnormality frequency (surgical complications and postoperative infections), surgeon's years of experience, and clinical interpretation of individual subscale scores. Discussion This study shall provide important evidence on the optimal suture for preventing hysterotomy wound thinning after the first cesarean section. Trial registration National Institute of Public Health, Japan: jRCT1062200001 (May 7, 2020; https://rctportal.niph.go.jp/en/detail?trial_id=jRCT1062200001 ) and Okayama University Certified Review Board: CRB6180001 (April 9, 2020, version 3.0).

We herein report the case of a 46-year-old pregnant woman with anti-muscle specific kinase (MuSK) antibody-positive myasthenia gravis (MG) who showed pregnancy-induced hypertension and developed respiratory failure at 30 weeks and 5 days of pregnancy, and who underwent an emergency caesarean section (CS). Her MG symptoms gradually improved in the subsequent weeks. The premature baby with positive MuSK antibodies was successfully delivered, but the male baby required temporary artificial ventilation. However, his condition also gradually improved over time. The present case suggests that an emergency CS could rescue both the mother, who was in critical condition, and the prematurely born baby, even when suffering from acute respiratory insufficiency.

We created a new reference standard focusing on the hemispheric anteroposterior cerebellar diameter (APCD) in addition to the transverse cerebellar diameter (TCD) and discussed whether or not the cerebellar measurement was useful for the detection of trisomy 18 (T18).In 150 normal fetuses between 14 and 36 weeks of gestational age (GA), the TCD and APCD were prospectively measured. In 26 cases with T18, the value was compared with the control.At

Polycystic ovary syndrome (PCOS) is a common endocrine disorder characterized by insulin resistance and hyperandrogenism. The interaction of these factors might result in increased risks of miscarriage and pregnancy complications such as gestational diabetes mellitus (GDM). To examine the pregnancy risks in women with PCOS, we compared obstetrical outcomes between patients with and without PCOS. We also studied the differences in maternal characteristics, glucose intolerance and pregnancy complications between PCOS patients with and without GDM, with and without obesity, and between successful pregnancies and miscarriages. We observed a high incidence of GDM and prevalence of GDM diagnosis in the first trimester in PCOS. Patients with GDM had higher body mass index (BMI) and lower homeostasis model assessment of β-cell function (HOMA-β) at preconception than those without GDM. Obese pregnant women with PCOS demonstrated a high incidence of GDM with severe insulin resistance, including high fasting insulin, HOMA of insulin resistance (HOMA-IR), and HOMA-β at preconception compared with normal-weight patients. BMI was significantly correlated with HOMA-IR or HOMA-β, and both indices were lower in PCOS patients with than without GDM for the same BMI. There were no significant differences in maternal characteristics (excluding maternal age) between PCOS patients with successful pregnancy and PCOS patients with miscarriages. Our data suggest that pregnant women with PCOS have an increased risk of GDM, especially if they have obesity and/or poorer insulin secretion. Measure of β-cell function, such as HOMA-β, at preconception might be a useful predictor of the risk of GDM in pregnant PCOS patients.

Preeclampsia is a heterogeneous disease, and there are major differences in severity, fetal growth and poor placentation between early- and late-onset preeclampsia. Here, we examined the effect of onset period on fetal and neonatal growth in preeclampsia with a cross-sectional study including 102 pregnant women with preeclampsia visited Okayama University Hospital from 2009 to 2013. The subjects were retrospectively compared in terms of body mass index (BMI), weight gain during pregnancy, complications, weeks of delivery, neonatal body weight and BMI at birth, fetal growth restriction (FGR), small for gestational age (SGA), pathological findings in the placenta, and infant’s weight at 1 month after birth. Neonatal body weight and BMI at birth were significantly lower and the extent of FGR and the frequency of SGA were higher in early-onset group compared with late-onset group. Mean daily weight gain during the neonatal period was significantly lower in the early-onset group compared with the late-onset group, however the weight gain rate during the neonatal period in the early-onset group was higher than that in late-onset group. In conclusions, there are significant differences in fetal and neonatal growth between early- and late-onset preeclampsia and the catch up for growth might start during neonatal period.

Aims/Introduction To measure longitudinal changes in resting energy expenditure and body composition of Japanese pregnant women with or without diabetes. Materials and Methods The study population consisted of women who had delivered a live singleton neonate after 22 weeks’ gestation at Okayama University Hospital from July 2013 to June 2017. Resting energy expenditure and body composition were measured in the first trimester, second trimester, third trimester and postpartum. Results A total of 144 women participated in this study: 103 with normal glucose tolerance and 41 with diabetes. The resting energy expenditure (kcal/day) of pregnant women with normal glucose tolerance was significantly higher in the third trimester (1,644 ± 234) than in the first (1,461 ± 215) and second trimesters (1,491 ± 219), and postpartum (1,419 ± 254), whereas that of pregnant women with diabetes did not significantly change during all periods (1,568 ± 404, 1,710 ± 332, 1,716 ± 251, 1,567 ± 249). The resting energy expenditure of women with good glycemic control was lower than that of women with poor control. Fat‐free mass was closely correlated with resting energy expenditure. Conclusions The resting energy expenditure of Japanese pregnant women with normal glucose tolerance was significantly increased in the third trimester. The resting energy expenditure of women with good glycemic control was lower than that of women with poor control. Resting energy expenditure and fat‐free mass are potential indexes for medical nutrition therapy in pregnant women with diabetes.

The aim of this retrospective case series report is to evaluate systemic methotrexate therapy in conjunction with uterine artery embolization (UAE) in the conservative management of cervical pregnancy. We examined clinical presentations, treatments, and therapeutic outcomes in fifteen patients with a cervical pregnancy who wished for preservation of fertility, treated at Okayama University Hospital between 1998 and 2012. Twelve patients received systemic methotrexate including five treated with UAE. One was treated with UAE alone. Two patients received neither UAE nor methotrexate because of a low human chorionic gonadotropin (hCG) level and poor blood flow around the gestational sac (GS). An increased GS size and the elevated hCG level during methotrexate therapy might be risk factors for emergent UAE. Two of six patients treated with UAE had subsequent confirmed viable pregnancies. In patients with a cervical pregnancy, methotrexate therapy in combination with UAE can be considered as an option before performing a hysterectomy with suitable counseling about the risk of loss of fertility. Careful observation of the GS size and hCG level during methotrexate therapy might be important for management.

Hypertrophic obstructive cardiomyopathy (HOCM) is cardiac hypertrophy of ventricular myocardium with left ventricular outflow tract obstruction. We report a pregnancy with HOCM after defibrillator implantation surgery. The patient was a 33-year-old nulligravida and was categorized as New York Heart Association class II. Her brain natriuretic peptide (BNP) level was 724.6 pg/dL at preconception. She received careful pregnancy management. However, because frequent uterine contractions were observed at 25 weeks and 6 days of pregnancy, she was hospitalized, and magnesium sulfate was started as a tocolytic agent. At 27 weeks and 5 days of pregnancy, she had respiratory discomfort and orthopnea with a sudden decrease in peripheral oxygen saturation. Cardiac ultrasonography showed a worsened condition of HOCM and her BNP level was 1418.0 pg/mL. We performed an emergent cesarean section and she delivered a boy weighing 999 g. The Apgar score was 8 and 9 points at 1 and 5 minutes, respectively. The mother’s heart failure quickly improved after birth and she was discharged at 10 days postoperatively. Fluctuations in circulatory dynamics during pregnancy may sometimes exacerbate heart disease. Therefore, the risks should be fully explained and careful assessment of cardiac function should be performed during pregnancy in patients with severe HOCM.

Objectives Newborns born to mothers with pregnancy-induced hypertension (PIH) are thought to be at high risk for lifestyle-related diseases, such as obesity and hypertension, in adulthood. Study design A longitudinal study of 78 pregnant women with PIH and their newborns, who visited Okayama University Hospital from 2009 to 2013. Main outcome measures We investigated the change in growth of offspring born to mothers with PIH and compared it with the standard growth curve in Japanese to examine whether there was rapid catch-up growth during the first 3 years of life. Results Subjects were 78 pregnant women with PIH and their offspring, who visited Okayama University Hospital from 2009 to 2013. Valid responses were obtained from 29 of 78 (37.1%) women. Body weight and length at birth were at the third percentile or less in females, and at the 10th percentile or less, in males. When body weight and length were compared at 6 months, 18 months, and 3 years old between male and female toddlers, male toddlers slowly caught up until 3 years old, but female toddlers rapidly caught up in the first 6 months. Furthermore, in newborns with fetal growth restriction caused by the intrauterine environment of PIH, differences in physical development between male and female toddlers were more remarkable. Conclusions There is a significant sex difference in catch-up growth during the first 3 years, which might be involved in lifestyle-related diseases in adulthood, suggesting continuous follow-up is necessary, especially for female offspring.

Umbilical arteriovenous malformation (AVM) is a rare congenital malformation. We report a case of umbilical AVM that was prenatally diagnosed by further color Doppler ultrasonography because of fetal cardiomegaly. At 35 weeks gestation, a male newborn was delivered by emergent cesarean section because of rapid progress of cardiomegaly and breech presentation. Three-dimensional reconstructed computed tomography after birth demonstrated the shunt was spontaneously closed. This is the first case report of umbilical AVM, which was prenatally diagnosed, and the boy was successfully delivered, suggesting that, when fetal cardiomegaly is identified, umbilical AVM must be taken into consideration.

We continuously measured bilateral uterine artery (UA) blood flow and compared differences in UA blood flow to investigate the differences in pathophysiology between early- and late-onset pregnancy-induced hypertension (PIH) and the usefulness of continuous monitoring of UA blood flow for the prediction of early-onset PIH. The subjects were 76 PIH patients. The mean pulsatility index of bilateral UA (UAPI), an early diastolic notch in the velocity waveform, and regression curves were retrospectively examined and compared between early- and late-onset groups and the groups with and without fetal growth restriction (FGR). Regression curves of the UAPI in the early-onset group persisted at +2.0 standard deviations or more from the second to third trimester, while the UAPI in the late-onset group stayed within the normal range. A significantly higher mean UAPI with a high frequency of an early diastolic notch was observed in the early-onset group compared with the late-onset group in all pregnancy trimesters. There was a significant difference in UA resistance between the mild and severe groups and between the FGR and non-FGR groups, but to a small extent compared with the onset period. There was a difference in pathophysiology between early- and late-onset PIH. Continuous monitoring of UA blood flow might be useful for the prediction of early-onset PIH if high UA resistance has been observed.

骨系統疾患は100種類以上存在するが，個々の疾患頻度は低く診断に苦慮することが多い．中には予後不良な疾患も含まれ，正確な出生前診断を要する．今回，骨系統疾患を同時期に2例経験したので報告する．症例1は24歳．妊娠29週に大腿骨短縮を指摘され紹介．四肢全て短縮のため全肢節短縮型骨系統疾患と診断．胎児頭蓋内構造は明瞭に描出され，超音波プローブで胎児の頭蓋を圧迫すると骨変形を認め，hypophosphatasia（低フォスファターゼ症）を疑った．3D-CTでは頭蓋骨や椎体，両手足指の描出は骨化不良のため困難であった．出生児は生後20分後に死亡し，臍帯血ALP 5IU/Lであった．症例2は31歳．妊娠20週に大腿骨短縮を指摘され紹介．四肢全て短縮のため全肢節短縮型骨系統疾患と診断．大腿骨の短縮と骨幹端の末広がり，胸郭低形成より予後不良な四肢短縮症を疑い，正確な出生前診断には至らずも，同意のもと中期中絶を行った．後日死産児の全身Ｘ線写真よりhypochondrogenesis（軟骨低発生症）と診断した．2症例とも一般的に生命予後不良な四肢短縮症である．超音波補助診断として，近年3D-CTの有用性が報告され，胎児超音波によりスクリーニングを行い，3D-CTで確定診断を行う方法が適切との見方もある．3D-CTでは長管骨の計測に加え，細かい形態の変化や骨化の程度といった超音波では描出し難い所見を得ることが可能とされるからである．大腿骨短縮を認めた場合は四肢全ての計測を行い，胸郭低形成の有無を確認し，重症度の鑑別診断が重要である．

胎児胸水を伴う肺分画症の予後は不良である．胎児胸水除去及びシャント術を行うことで，胎児水腫や肺低形成が予防でき，予後の改善につながると言われている．胎児胸腔‐羊水腔シャント術が有効であった胎児肺分画症の1例を経験したので報告する．症例は，34歳，経産婦．前医で胎児胸部腫瘤と心臓右方偏位を認め，妊娠28週6日に当科を紹介初診した．胎児超音波検査・MRI検査で左胸郭に43×46×41mmの腫瘤と多量の胸水を認めた．腫瘤は肺葉外に存在し，腹部大動脈から腫瘤へ向かう栄養血管を同定し肺葉外肺分画症と診断した．その他胎児構造異常や胎児水腫を認めず，ウィルス感染は否定的であった．同日胎児胸水を32 ml除去したが，翌日には胸水の再貯留を認めたため，妊娠29週1日に胎児胸腔‐羊水腔シャント術を施行（超音波ガイド下に八光社製ダブルバスケットカテーテルを留置）した．術後両肺は拡張し，胸水の再貯留・分画症肺の増大・羊水過多や切迫早産徴候なく経過した．妊娠38週5日，分娩誘発にて3,110 gの女児をAS9/9で経腟分娩した．児はNICUに入院，人工呼吸管理は不要であったが，日齢1より胸水が貯留し胸腔持続ドレナージを開始，150‐200 ml／日の排液を認めた．日齢8に分画肺摘出術を施行し，経過良好で日齢17に退院した．本症例は無治療であれば胎児水腫などを合併し予後不良であったと予想され，胎児胸腔‐羊水腔シャント術が有用であった．