AIM: Pregnant women are at increased risk for severe illness associated with coronavirus disease 2019 (COVID-19) compared to nonpregnant women. The aim of this multicenter prospective study was to assess the current COVID-19 vaccination status of pregnant women in the southern Osaka district and to compare their antibody titers with those of nonpregnant women. METHODS: Serum antibody titers of anti-NCP antibodies (antibodies against the SARS-CoV-2 nucleocapsid) and anti-RBD antibodies (the receptor binding domain of the S1 subunit of the spike protein) were evaluated in 753 pregnant women at 34-35 weeks of gestation from October 2021 to March 2022. Anti-RBD antibody titre was also investigated in 1003 health care workers at Kindai University hospital 3 and 6 months after a second dose of the vaccine from March 2021 to April 2021. 519 (68.9%) pregnant women were vaccinated during pregnancy, of whom 497 (95.8%) received two doses. RESULTS: The COVID-19 infection rate calculated from the number of pregnant women with a positive anti-NCP antibody titre or with confirmed diagnosis was 5.1% (12/234) in the unvaccinated and 3.5% (18/519) in the vaccinated. The estimated half-life calculated from anti-RBD antibody titers and the number of days between vaccination and antibody testing was 39.9 days. The antibody titre and half-life in pregnant women were significantly lower and shorter than in nonpregnant women aged 20-39 years (109.4 days). CONCLUSION: Our study showed that pregnant women may have lower vaccine-acquired COVID-19 immunity than nonpregnant women.

BACKGROUND: Autologous blood donation for placental malposition is common in Japan, but no studies have scientifically evaluated its usefulness. The purpose of this study was to evaluate the necessity for autologous blood donation for placental malposition. METHODS: A retrospective study was conducted of patients who underwent autologous blood donation for placental malposition at Kindai University Hospital from 2012 to 2022. The primary outcome was the proportion of patients who were able to avoid allogeneic blood transfusion by autologous blood transfusion; secondary outcomes were autologous blood disposal rate, allogeneic blood transfusion rate, and complications of autologous blood donation and allogeneic blood transfusion. A systematic review of studies on autologous blood transfusion for placental malposition was conducted on PubMed. RESULTS: Fifty-two patients (total placenta previa 16; marginal placenta previa 20; low-lying placenta 16) were included. Eight (15%) had complications at the time of autologous blood donation, including non-reassuring fetal heart rate, but no sequelae. Allogeneic blood transfusion was avoided by autologous blood transfusion in only five cases (9.6%). Autologous blood was discarded in nine cases (17%), seven of which had a low-lying placenta positioned normally at delivery. Allogeneic blood transfusion was performed in eight cases (15%) with no complications. In the systematic review, seven articles that met the inclusion criteria were selected for further evaluation. The results showed that there were no publications that scientifically demonstrated the benefit of autologous blood transfusion. CONCLUSIONS: The results of this study indicate that autologous blood donation for placental malposition has little benefit.

Several studies in Europe and the United States have shown that sexual intercourse (SI) during pregnancy is not associated with preterm birth. However, it is unclear whether these findings apply to pregnant Japanese women. The aim of this prospective cohort study was to elucidate the influence of SI during pregnancy on preterm birth in Japan. A total of 182 women who underwent antenatal care and delivery were included in this study. The frequency of SI was assessed using a questionnaire, and its association with preterm birth was analyzed. The results showed that SI during pregnancy was associated with a significantly higher cumulative preterm birth rate (p = 0.018), which was more pronounced for SI more than once a week (p < 0.0001). Multivariate analysis showed that SI, bacterial vaginosis in the second trimester, previous preterm birth, and smoking during pregnancy were independent risk factors for preterm birth. The combination of SI and second trimester bacterial vaginosis was associated with a 60% preterm birth rate, whereas either factor alone was associated with a lower rate, suggesting a synergistic effect (p < 0.0001). Future studies are needed to investigate the effect of prohibiting SI in pregnant women with bacterial vaginosis on preterm birth.

This retrospective study aims to compare the early manual removal of placenta (MROP) and conservative management of retained products of conception (RPOC) after 34 weeks of gestation. Nineteen cases underwent MROP within 24 h of delivery, of which nine patients had no symptoms requiring emergent treatment. These 9 patients (group M) were compared with 22 patients who were treated conservatively (group C). Massive bleeding was observed in 5 (56%) patients in group M and 11 (50%) patients in group C, with no significant difference in frequency. However, the lowest hemoglobin level within 72 h after massive bleeding was lower in group M (median: 6.7 vs. 7.7 g/dL, p = 0.029), suggesting that massive bleeding occurred in a short period of time. On the other hand, a retained placenta was observed in four patients in group M after the MROP; however, the placenta disappeared more quickly than in group C (median; 1.0 vs. 99.0 days, p = 0.009). In group C, all bleeding and infection occurred within 60 days of delivery, including heavy bleeding in six cases during the placental-extraction trial. Human chorionic gonadotropin in group C fell below the measurable threshold at a median of 67 days postpartum. In conclusion, for RPOC without urgent symptoms, early MROP and conservative treatment have their advantages and disadvantages. Randomized controlled trials are needed to determine which of those treatments is superior.

In preeclampsia, plasma antithrombin activity is decreased, which leads to exacerbation of the disorder. We previously showed that long-term magnesium sulfate (MgSO4) administration prolonged the pregnancy period and may be able to improve pregnancy outcomes for patients with severe preeclampsia. The present study aimed to investigate the changes in plasma antithrombin activity during long-term MgSO4 administration for patients without severe hypertension. This multicenter retrospective study included patients with preeclampsia and superimposed preeclampsia without severe hypertension at diagnosis. The participants were divided into two groups: MgSO4 nontreatment group (three institutions) and MgSO4 treatment group (one institution). Antithrombin activity from time of diagnosis to delivery were compared between the two groups. In the MgSO4 nontreatment group (n = 16), antithrombin activity prior to delivery was significantly lower than at time of diagnosis (p = 0.015). In three cases, antithrombin activity was less than 60%. On the other hand, in the MgSO4 treatment group (n = 34), antithrombin activity did not change until just before delivery (p = 0.74). There were no cases in which antithrombin activity was decreased below 60%. Long-term MgSO4 administration for preeclampsia without severe hypertension may prevent a decrease in antithrombin activity and improve the disease state of preeclampsia.

BACKGROUND: A uterine manipulator cannot be used to elevate the ovary in benign ovarian surgery during pregnancy. This report describes our method of elevation of the ovary using a metreurynter with the success rate of the procedure and a comparison of surgical results and pregnancy outcomes between the successful and unsuccessful cases. METHODS: Between August 2003 and February 2020, 11 pregnant patients with a tumor found sunk in the Cul-de-sac underwent laparoscopic cystectomy for a benign ovarian cyst with a metreurynter. The surgical results, success and failure of the elevation by a metreurynter, pregnancy outcomes, and fetal status at delivery were evaluated. RESULTS: Elevation of ovarian tumors with a metreurynter was successful in nine cases. However, it was unsuccessful in the remaining two cases wherein the ovary was lifted with forceps while the uterus was in a compressed state. The operative time was also longer in these cases. The pregnancy prognosis, however, was good for both, successful and unsuccessful cases. CONCLUSIONS: The metreurynter is an inexpensive and practical obstetric device, and its optimal use allows the performance of a procedure with minimal burden on a pregnant uterus. Therefore, we recommend the appropriate use of this method to enable effective laparoscopic cystectomy of ovarian tumors during pregnancy.

[Abstract]HELLP syndrome, characterized by hemolysis,elevated liver enzymes, and low platelets,is one of the diseases related to hypertension in pregnancy. If the pregnancy is not terminated soon after HELLP is diagnosed, liver failure or disseminated intravascular coagulopathy (DIC)may occur. HELLP syndrome occurs in 0.2%–0.9% of all pregnancies; Onset before 24 weeks of gestation is extremely rare but is more likely to result in stillbirth. Women who have had a stillbirth often hope for another pregnancy soon after,but there is little information about the risks and outcomes for subsequent pregnancy in women who developed HELLP syndrome in early pregnancy.Thus, it is important to accumulate data on these outcomes in this population. Here, we report a case in which severe HELLP syndrome developed at 22 weeks of gestation, resulting in stillbirth, and was followed six months later by a pregnancy that with early intervention, produced a live birth.

Cervical elastography might be an objective method for evaluating cervical ripening during pregnancy, but its usefulness has not been fully investigated. We examined the significance of cervical elastography in the last trimester of pregnancy. Cervical elastography was performed at weekly checkups after 36 weeks of gestation in 238 cases delivered at our hospital from 2017 to 2018. The correlation with the onset time of natural labor, which is an index for judging maternal delivery preparation status, was examined. A total of 765 examinations were conducted, and cervical stiffness determined by cervical elastography was positively correlated with the Bishop score (r = 0.46, p < 0.0001). When examined separately for each week, only the examinations performed at 39 weeks were associated with the onset of spontaneous labor up to 7 days later (p = 0.0004). Furthermore, when stratified and analyzed by the Bishop score at 39 weeks of gestation, cervical elastography was associated with the occurrence of spontaneous labor pain for up to seven days in the groups with Bishop scores of 3–5 and 6–8 (p = 0.0007 and p = 0.03, respectively). In conclusion, cervical elastography at 39 weeks of pregnancy is useful for judging the delivery time.

We report a case of massive bleeding due to a coagulation disorder associated with acute fatty liver of pregnancy (AFLP); the patient survived by massive transfusion. She presented at 34 weeks of gestation, met six of the Swansea criteria, and was diagnosed with severe AFLP. We performed an emergency cesarean section because termination of the pregnancy was necessary for the treatment of the AFLP. After the surgery, which led to massive bleeding in the peritoneal cavity due to the coagulation disorder, she underwent two further operations and three transarterial embolizations. She received factor VII and underwent plasma exchange, and hemostasis was achieved on day 10 after hospitalization. The total volume of blood transfused was 772 units (170 units of red cell concentrate, 212 units of fresh frozen plasma, and 390 units of platelet concentrate). To the best of our knowledge, this is the most severe case of non-fatal AFLP reported to date in terms of the transfusion volume.

当院で2000〜2016年に出産し、遺残胎盤の保存治療を行った6症例について後ろ向きに解析した。それぞれの症例で臨床経過と血清ヒト絨毛性性腺刺激ホルモン(S-hCG)値を比較した。遺残胎盤は6例中3例で自然排出した。他の3例では再出血が起こり、止血治療が必要であった。最終的に全6例で子宮を保存することができた。以上より、子宮全摘出せずに遺残胎盤の保存治療ができることが示唆された。しかし、再出血に対応できる緊急止血治療が可能な先端医療施設で行うべきと考えられた。S-hCGについては、この値から保存的治療の成否を判断するのは難しいと考えられた

[抄録]緒言:近年内視鏡手術は患者のQOL 向上の観点から，スタンダードになりつつある．一方，近年産婦人科入局者は減少傾向にある．そこで学生時代から産婦人科や内視鏡手術に興味を持ってもらうために，医学生に腹腔鏡トレーニングボックスを用いた医学教育実習を導入した．今回われわれは，本実習の導入における経験とその有用性を報告する．方法と対象:産婦人科実習を行った医学部生97名を対象とし，２台のボックスを用いて実習を行った．実習内容は，① ５個のおはじきを移す手技（以下「おはじきうつし」），② ハサミで紙を切る，③ 縫合，④「おはじきうつし」を再度行う，とした．「おはじきうつし」はタイムを測定し，①と④のタイムを比較検討した．また２週間の実習終了後に，全員にアンケート調査を行い，満足度を検討した．結果:「おはじきうつし」の前後での平均タイムは前199±96秒と156±97秒と，実習施行後で有意に短くなった．また，２週間実習終了後のアンケートでは，ほぼ全員満足であるという結果が得られた．考察:腹腔鏡手術は満足度が高く，腹腔鏡トレーニングボックスを用いた実習は，医学生にとって，産婦人科ないしは内視鏡手術への興味を持ってもらう一助になると考えられた.

2000年〜2016年の16年間に待機的管理を施行した胎盤遺残の6症例(母体年齢31〜38歳、初産婦3例、経産婦3例)について報告した。その結果、遺残組織径は25〜107mm(平均60mm)で、3例で再出血を来たし止血処置を要したが、残り3例では産後20〜46日目に遺残組織の自然排出を認めた。再出血を来たした3例では、1例は緊急手術を施行して遺残組織を用手的に剥離した。もう1例は掻爬術、子宮動脈塞栓術(UAE)に加え、メトトレキサートの投与によりS-hCG値の陰転化後、子宮鏡下に摘出術を施行し、遺残組織を除去した。残り1例はUAE施行後、遺残組織は自然消出した。尚、遺残組織の自然排出の3例では遺残組織径が41〜65mmと比較的小さかった。以上より、止血処置を要した3例でも止血後は待機的に管理が可能であり、全例で子宮の温存が可能であった。

Monochorionic monoamniotic (MM) twin pregnancies occur in approximately 1% of monozygotic twins. MM twins are associated with perinatal mortality rates of between 28% to 47%. Cord entanglement, malformations, twin-to-twin transfusion syndrome (TTTS) and prematurity are responsible for their high perinatal morbidity and mortality. To clarify perinatal outcomes in MM twins at Hyogo Prefectural Kobe Children's Hospital (tertiary perinatal center), six cases of MM twins managed between 2001 and 2012 were retrospectively evaluated. Chorionicity was determined by placental examination. All six cases were admitted to hospital, for fetal closed monitoring (4) and threatened premature delivery (2). Mean gestational age (GA) at admission was 26w0d (23w2d-32w4d). All cases received tocolytic agents intravenously, closed ultrasound surveillance(1-2/week) and FHR monitoring(2-3/day). Cord entanglements were observed in all cases at delivery and all cases had been diagnosed by USG at the admission, but there was no sign of non-reassuring fetal status (NRFS) during the admission and the delivery by elective Cesarean section at average GA 31w2d (28w0d-32w5d), because the fear of perinatal mortality rises from around 32 weeks¹⁴⁾. Birth weight discordancy was 12%, cord entanglement ranged from 1-14 times, three cases had a true knot. There were no IUFD, though two cases (16%) were diagnosed with cerebral palsy. MM twins have risk of unexpected fetal demise, for cord compression. Perinatal outcomes in this study were relatively good, despite the high frequency of cord entanglement. Close fetal monitoring may allow MM twin pregnancies to extend GA, which may contribute to a reduction in both IUFD and neonatal morbidity by immaturity. [Adv Obstet Gynecol, 66 (2) : 163-168, 2014 (H26.5)]