Building resilience in primate tourism: insights from the COVID-19 pandemic and future directions

The coronavirus disease 2019 (COVID-19) pandemic revealed the vulnerability of the tourism industry, triggering a call for a structural shift. This study focuses on COVID-19 impacts on primate tourism sites using the resilience-based wildlife tourism study of Jones et al. (2023) as an interpretive framework. Using an online survey, we collected data on impacts, changes, and challenges experienced at primate tourism destinations in various parts of the world. Based on 33 responses, the study found that the most profound impacts were financial, compromising the ability to run facilities and facilitate tourism due mainly to limitation of access to sites for tourists and/or staff/researchers. Seventeen respondents reported that their sites did not make substantial changes in response to the pandemic. This warrants further study to elicit the reasons for the lack of response. It may indicate difficulties in adaptation or implementation due to limited resources or other factors amid COVID-19 pandemic. We suggest that the framework proposed by Jones et al. (2023) has limitations in effectively addressing rapid and extensive repercussions of a disruption such as the COVID-19 pandemic.

Association between adenomyosis and placenta accreta and mediation effect of assisted reproductive technology on the association: A nationwide observational study

OBJECTIVES

To investigate the association between adenomyosis and placenta accreta spectrum (PAS) and to evaluate the effect of assisted reproductive technology (ART) in mediating this association.

METHODS

We retrieved data for singleton women from the Japanese nationwide perinatal registry between 2013 and 2019, excluding women with a history of adenomyomectomy. To investigate the association between adenomyosis and PAS among women, we used a multivariable logistic regression model with multiple imputation for missing data. We evaluated mediation effect of ART including in vitro fertilization and intracytoplasmic sperm injection on the association between adenomyosis and PAS using causal mediation analysis based on the counterfactual approach.

RESULTS

Of 1 500 173 pregnant women, 1539 (0.10%) had adenomyosis. The number receiving ART was 489/1539 (31.8%) and 117 482/1 498 634 (7.8%) in women with and without adenomyosis, respectively. The proportion of women who developed PAS was 21/1539 (1.4%) in women with adenomyosis and 7530/1 498 634 (0.5%) in women without adenomyosis. Adenomyosis was significantly associated with PAS (odds ratio [OR] 1.95; 95% confidence interval [CI] 1.26-3.00; P = 0.002). Mediation analysis showed that OR of the total effect of adenomyosis on PAS was 1.98 (95% CI 1.13-3.04), OR of natural indirect effect (effect explained by ART) was 1.15 (95% CI 1.01-1.41), and OR of natural direct effect (effect unexplained by ART) was 1.72 (95% CI 0.86-2.82). The proportion mediated (natural indirect effect/total effect) was 26.5%. Adenomyosis was also significantly associated with PAS without previa (OR 1.96; 95% CI 1.23-3.13, P = 0.005).

CONCLUSION

Adenomyosis was significantly associated with PAS. ART mediated 26.5% of the association between adenomyosis and PAS.

Clinical relevance of reversible cerebral vasoconstriction syndrome in pregnant women with posterior reversible encephalopathy syndrome: review of case reports in Japan

We systematically reviewed case reports of posterior reversible encephalopathy syndrome (PRES), and investigated the characteristics of PRES in pregnant Japanese women and the clinical relevance of reversible cerebral vasoconstriction syndrome (RCVS) in pregnant women with PRES. Articles were collected using the PubMed/Medline and Ichushi-Web databases. This review was ultimately conducted on 121 articles (162 patients). The clinical characteristics of PRES, individual sites of PRES lesions, edema types, and clinical characteristics of RCVS in PRES cases were examined. The most common individual site of PRES lesion was the occipital lobe (83.3%), followed by the basal ganglia, parietal lobe, frontal lobe, brain stem, cerebellum, temporal lobe, thalamus, and splenium corpus callosum (47.5, 42.6, 24.7, 16.1, 9.3, 5.6, 4.3, and 0.0%, respectively). Edema types in 79 cases with PRES were mainly the vasogenic edema type (91.1%), with very few cases of the cytotoxic edema type (3.8%) and mixed type (5.1%). Among 25 PRES cases with RCVS, RCVS was not strongly suspected in 17 (68.0%) before magnetic resonance angiography. RCVS was observed at the same time as PRES in 13 cases (approximately 50%), and between days 1 and 14 after the onset of PRES in the other 12. These results suggest that the basal ganglia is a frequent site of PRES lesions in pregnant women. RCVS may occur at or after the onset of PRES, even if there are no symptoms to suggest RCVS.

Automated electrochemiluminescence immunoassay for serum PlGF levels in women with singleton pregnancy at 9-13 weeks of gestation predicts preterm preeclampsia: a retrospective cohort study

Our aims were to obtain the gestational-age-specific median of common logarithmic placental growth factor (PlGF) values in the first trimester in women with a singleton pregnancy in order to generate the gestational-age-specific multiple of the median (MoM) of log10PlGF at 9-13 weeks of gestation, to evaluate screening parameters of MoM of log10PlGF at 9-13 weeks of gestation to predict preterm preeclampsia (PE), and to construct an appropriate prediction model for preterm PE using minimum risk factors in multivariable logistic regression analyses in a retrospective sub-cohort study. Preterm PE occurred in 2.9% (20/700), and PE in 5.1% (36/700). Serum PlGF levels were measured using Elecsys PlGF®. MoMs of log10PlGF at 9-13 weeks of gestation in Japanese women with a singleton pregnancy followed a normal distribution. We determined the appropriate cut-off value of MoM of log10PlGF to predict preterm PE at around a10% false-positive rate (0.854). The MoM of log10PlGF < 0.854 yielded sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio (95% confidence interval [CI]), and negative likelihood ratio (95% CI) of 55.0%, 91.9%, 17.5%, 98.5%, 6.79 (4.22-10.91), and 0.49 (0.30-0.80), respectively. The combination of MoM of log10PlGF and presence of either chronic hypertension or history of PE/gestational hypertension (GH) yielded sensitivity and specificity of 80.0 and 85.7%, respectively, to predict preterm PE. In conclusion, the automated electrochemiluminescence immunoassay for serum PlGF levels in women with singleton pregnancy at 9-13 weeks of gestation may be useful to predict preterm PE.

Uterine cervical conisation and chorioamnionitis: A nationwide observational study

OBJECTIVE

To investigate whether conisation increases chorioamnionitis (CAM) and assess whether this risk differs between preterm and term periods. Furthermore, we estimated mediation effects of CAM between conisation and preterm birth (PTB).

DESIGN

A nationwide observational study.

SETTING

Japan.

POPULATION

Singleton pregnant women derived from the perinatal registry database of the Japan Society of Obstetrics and Gynaecology between 2013 and 2019.

METHODS

The association between a history of conisation and clinical CAM was examined using a multivariable logistic regression model with multiple imputation. We conducted mediation analysis to estimate effects of CAM on PTB following conisation.

MAIN OUTCOME MEASURES

Clinical CAM.

RESULTS

Of 1 500 206 singleton pregnant women, 6961 (0.46%) underwent conisation and 1 493 245 (99.5%) did not. Clinical CAM occurred in 150 (2.2%) and 11 484 (0.8%) women with and without conisation, respectively. Conisation was associated with clinical CAM (odds ratio [OR] 3.09; 95% confidence interval (CI) 2.63-3.64; p < 0.001) (risk difference 1.57%; 95% CI 1.20-1.94). The association was detected among 171 440 women with PTB (OR 3.09; 95% CI 2.57-3.71), whereas it was not significant among 1 328 284 with term birth (OR 0.88; 95% CI 0.58-1.34). OR of total effect of conisation on PTB was 2.71, OR of natural indirect effect (effect explained by clinical CAM) was 1.04, and OR of natural direct effect (effect unexplained by clinical CAM) was 2.61. The proportion mediated was 5.9%.

CONCLUSIONS

Conisation increased CAM occurrence. Obstetricians should be careful regarding CAM in women with conisation, especially in preterm period. Bacterial infections may be an important cause of PTB after conisation.

Maternal outcomes of placental abruption with intrauterine fetal death and delivery routes: A nationwide observational study

INTRODUCTION

Placental abruption is a serious complication, especially when accompanied by intrauterine fetal death. The optimal delivery route for placental abruption with intrauterine fetal death for reducing maternal complications is still unclear. In this study we aimed to compare the maternal outcomes between cesarean delivery and vaginal delivery in women with placental abruption with intrauterine fetal death.

MATERIAL AND METHODS

Using the Japan Society of Obstetrics and Gynecology nationwide perinatal registry database, we identified pregnant women with placental abruption with intrauterine fetal death between 2013 and 2019. The following women were excluded: those with multiple pregnancies, placenta previa, placenta accreta spectrum, amniotic fluid embolism, or whose delivery route was missing data. The association between delivery routes (cesarean delivery and vaginal delivery) and the maternal outcome was examined using a linear regression model with inverse probability weighting. The primary outcome was the amount of bleeding during delivery. Missing data were imputed using multiple imputation.

RESULTS

The number of women with placental abruption with intrauterine fetal death was 1218/1601932 (0.076%). Of 1134 women analyzed, 608 (53.6%) underwent cesarean delivery. Bleeding during delivery (median [interquartile range]) was 1650.00 (950.00-2450.00) (mL) and 1171.00 (500.00-2196.50) (mL) in cesarean and vaginal delivery, respectively. Bleeding during delivery (mL) was significantly greater in cesarean delivery than in vaginal delivery (regression coefficient, 1086.39; 95% confidence interval, 130.96-2041.81; p = 0.026). Maternal death and uterine rupture occurred in four (0.4%) and five (0.4%) women, respectively. The four maternal deaths were noted in the vaginal delivery group.

CONCLUSIONS

Bleeding during delivery was significantly greater in cesarean delivery than that in vaginal delivery in women with placental abruption with intrauterine fetal death. However, severe complications, including maternal death and uterine rupture, occurred in vaginal delivery-related cases. The management of women with placental abruption with intrauterine fetal death should be cautious regardless of the delivery route.

Bleeding-related outcomes of low-risk total placenta previa are equivalent to those of partial/marginal placenta previa

OBJECTIVE

To clarify whether "low-risk total PP" patients bleed more than partial/marginal PP patients.

MATERIALS AND METHODS

The retrospective cohort study was performed involving patients with PP between April 2006 and December 2018. The placental position was determined by ultrasound. From medical charts, the backgrounds as well as obstetric and neonatal outcomes of PP patients were retrieved.

RESULTS

This study included 349 patients with PP, which was classified into three types according to the distance between the placenta and internal ostium: total (n = 174), partial (n = 52), and marginal (n = 123) PP. In total PP patients, three factors (prior CS, anterior placenta, and placental lacunae on ultrasound) significantly increased blood loss at CS, the need for hysterectomy, homologous transfusion (≥10 U), and ICU admission. No significant difference was observed in bleeding-related poor outcomes (rate of blood loss ≥2000 mL, amount of homologous transfusion, need for hysterectomy, and ICU admission) between total PP patients without all three factors: "low-risk total PP patients" and partial/marginal PP patients (19.8 vs. 17.1%; p = 0.604, 3.7 vs. 1.1%; p = 0.330, 1.2 vs. 1.1%; p = 1.000, and 1.2 vs. 1.1%; p = 1.000, respectively).

CONCLUSION

Prior CS, anterior placenta, and placental lacunae on ultrasound were risk factors for a bleeding-related poor outcome in total PP patients. Total PP patients without these three factors showed the same bleeding-related poor outcome as partial/marginal PP patients.

Hemostatic effect of combined procedures for placenta previa: cervix-holding, intrauterine balloon, and uterine compression suture

OBJECTIVES

Various procedures have been introduced to achieve hemostasis for postpartum hemorrhage (PPH) in placenta previa (PP). This study attempted to clarify the effectiveness of the combined use of three hemostatic procedures: Matsubara-Takahashi cervix-holding (MT-holding), intrauterine balloon (IUB), and uterine compression suture (UCS).

STUDY DESIGN

This was a historical cohort study on the hemostatic effect of combined procedures for patients with placenta previa (PP) undergoing cesarean section between April 2006 and December 2018. Until 2011 (2006-2011), we used MT-holding alone, whereas since 2012 we have also been using IUB and UCS: MT-holding alone was used in the former period whereas three procedures (MT-holding, IUB, UCS, and their combinations) have been used in the latter period. Perinatal outcomes were compared between 2006-2011 (before group) and 2012-2018 (after group).

RESULTS

Of 416 patients with PP, excluding 273 patients with cesarean hysterectomy or no hemostatic procedure, the remaining 143 patients were analyzed. In the after group, intraoperative blood loss, the percentage of patients with postoperative blood loss ≥ 500 ml, and incidence of autologous blood transfusion were significantly lower than in the before group. Multivariate analysis showed that postoperative blood loss ≥ 500 ml decreased in the after group (adjusted OR: 0.3, 95%CI: 0.1-0.8, compared with the before group).

CONCLUSION

PPH decreased after introducing the combination of hemostatic procedures in patients with PP. Further studies are needed to determine the best combination and optimal indication for combining hemostatic procedures for PP.

Long-term outcome of fetus with ameliorated cystic hygroma

OBJECTIVE

Cystic hygroma often ameliorates or disappears with pregnancy progression. Fetuses/neonates with amelioration, when without chromosomal or major structural abnormality, generally show a favorable outcome at birth. The present study was aimed to clarify the short/long-term outcomes of fetuses/neonates with the amelioration of cystic hygroma during pregnancy.

MATERIAL AND METHODS

This was a retrospective observational study. We focused on fetuses with cystic hygroma managed in our institute between January 2006 and June 2019. The infants were followed by pediatricians (neonatologist, pediatric cardiologist, and pediatric neurologist) and pediatric outcomes were retrieved from the medical records up to 3 years old.

RESULTS

One hundred and seven fetuses with cystic hygroma were included. Of the 107, cystic hygromas ameliorated in 31 fetuses (31/107: 29%). Of the 31, there were 26 livebirths. Half (n = 13) of the 26 fetuses had a good outcome, whereas the remaining half (n = 13) had abnormalities. Various abnormalities were detected in their infancies. A nuchal thickness (diameter of hygroma) of ≥5 mm was significantly correlated with abnormalities (P = 0.047).

CONCLUSION

Physicians should pay attention to fetuses/neonates with ameliorated cystic hygroma. Of those, special attention should be paid to fetuses/neonates with a nuchal thickness at diagnosis ≥5 mm.

Impacts of the COVID-19 pandemic on mammals at tourism destinations: a systematic review

The COVID‐19 outbreak is having an unprecedented effect on human society, but how is it affecting the mammals that people live with? Mammals that were part of tourism experiences are of concern, because they impact on people’s health and livelihoods and, since many of them are now dependent on people, we urge consideration of the status of these mammals as a result of the pandemic.

We provide a systematic review of the impacts the COVID‐19 outbreak has had on mammals in tourism venues. We examine reports of diverse species in various settings responding to changes in their environments that are occurring because of the pandemic.

We searched the scholarly literature, preprints, and online news sources using combinations of the search terms ‘tourism’, ‘animals’, ‘wildlife’, ‘coronavirus’, and ‘COVID‐19’. We searched Web of Science, SCOPUS, EBSCOHost, JSTOR, bioRxiv, OSFPREPRINTS, GDELT, Google News, and National Public Radio, and analysed a total of 39 news articles, one peer‐reviewed article, and six preprints.

In total, we identified 92 distinct animal reports representing 48 mammal species. We used an existing tourism classification schema to categorise each article based on the situation reported, with the new addition of one context. We classified 92 separate animal reports in 46 articles into four (of six possible) contexts: mammals as attractions (n = 40 animal reports), mammals as commodities (n = 33), mammals as threats (n = 2), and unusual sightings of mammals (n = 17). Shortage of food, in danger of losing home, having an enriched/relaxed environment, spatial expansion, disease transmission, and poaching are the major impacts or events reported in these contexts.

We suggest changes for each context with respect to how people interface with mammals, with the goal of improving the lives of mammals and the people dependent on them.

Expectant management of retained products of conception following abortion: A retrospective cohort study

OBJECTIVE

To clarify the natural history of retained products of conception (RPOC) following abortion at less than 22 weeks of gestation, and those who show major bleeding during course observation.

STUDY DESIGN

We retrospectively reviewed 640 patients who had spontaneous or artificial abortion at less than 22 weeks of gestation between January 2011 and August 2019 in our institute. Of those, patients with RPOC were included. The maternal background, RPOC characteristics, and subsequent complications including additional interventions were reviewed.

RESULTS

Fifty-four patients with RPOC were included. The incidence of RPOC was 6.7 %. The median (interquartile range: IQR) RPOC length was 29 (20-38) mm. RPOC hypervascularity was observed in 26 (48 %) patients. The median (IQR) periods of RPOC flow disappearance and RPOC disappearance on ultrasound from abortive treatment were 50 (28-76) and 84 (50-111) days, respectively. Of the 54, 44 patients were selected for expectant management. Of the 44, 34 (77 %) patients were observed without intervention (recovery group); the other 10 (23 %) patients required additional interventions associated with subsequent bleeding (intervention group). Compared with the recovery group, heavy bleeding (> 500 mL) at abortion (6/10: 60 %) and RPOC hypervascularity (8/10: 80 %) were more frequently observed in the intervention group.

CONCLUSION

Expectant management was successful in almost 80 % of patients with RPOC following abortion. The additional interventions were required in patients with heavy bleeding at abortion and RPOC hypervascularity.

P32 Do meteorological factors influence the occurrence of acute aortic dissection?A ten-year retrospective institutional review

Purpose

Some studies have reported a relationship between meteorological factors and the occurrence of acute aortic dissection (AAD). Nevertheless, the results of the studies are heterogeneous. Furthermore, whether the absolute values or fluctuation of meteorological factors influence the occurrence of AAD remains controversial. The aim of this study was to determine the meteorological factors associated with the occurrence of AAD.

Methods

Two hundred eighty-two consecutive patients (male, n = 178; female, n = 104; average age, 68 years) admitted to our hospital for AAD in the 10 years from September 1st 2008 were included in this study. One hundred fifty-seven patients had type A dissection. The correlation between the clinical data and the local meteorological data over the same period (provided by the National Meteorological Agency) was analyzed. We compared the following factors on days of AAD occurrence and non-occurrence: minimum and maximum temperature, minimum and maximum temperature difference between day of occurrence and previous day, difference between maximum and minimum temperature, atmospheric pressure and atmospheric pressure difference between day of occurrence and previous day (Δatmospheric pressure), and minimum and maximum temperature difference from climatological standard normal (CSN). Cutoff values were determined by ROC curve analyses and odds ratios (ORs) were calculated by a logistic regression analysis of meteorological factors with statistically significant differences.

Results

ignificant differences between the days of AAD occurrence and non-occurrence were observed for minimum and maximum temperature (p &lt; 0.0001), atmospheric pressure (p &lt; 0.0001) and Δatmospheric pressure (p = 0.0286), minimum temperature difference from CSN (p &lt; 0.0001), and maximum temperature difference from CSN (p = 0.0010).

The cutoff values were as follows: minimum temperature, 4°C; maximum temperature, 15.1°C; atmospheric pressure, 1008.9hPa; Δatmospheric pressure, 0.4hPa; minimum temperature difference from CSN, 1°C; and maximum temperature difference from CSN, -0.2°C.

The univariate logistic regression model showed revealed the following significant predictors of the occurrence of AAD; minimum temperature (OR2.42, p &lt; 0.0001), maximum temperature (OR2.23, p &lt; 0.0001), air pressure (OR1.75, p &lt; 0.0001), Δatmospheric pressure (OR 1.44, p = 0.0030), minimum temperature difference from CSN (OR1.80, p &lt; 0.0001) and maximum temperature difference from CSN (OR1.58, p = 0.0003). However, only minimum temperature (OR1.60, 95% CI 1.00-2.53, p = 0.0478) and maximum temperature difference from CSN (OR1.45, 95% CI 1.11-1.89, p = 0.0062) remained significant in the multivariate analysis.

Conclusion

Meteorological factors, especially a minimum temperature under 4°C strongly influenced the occurrence of AAD. A maximum temperature difference from CSN of over -0.2°C was also a significant predictor of AAD.

Perinatal outcome of pregnancy after adenomyomectomy: summary of 10 cases with a brief literature review

Objectives: The purpose of this study was the perinatal outcomes of patients who became pregnant after adenomyomectomy.Study design: The retrospective cohort study was performed involving pregnant women with a history of adenomyomectomy between 1 January 2011 and 31 December 2018. At 24-26 weeks, the patients were admitted even without symptoms or signs. When regular uterine contractions were observed, tocolysis was performed.Results: Ten patients were included. Elective and emergent cesarean section (CS) was performed in seven and three patients, respectively. Emergent CS was performed due to onset of labor (tocolytic failure) at 28, 24, and 32 weeks. Although no patients suffered uterine rupture, myometrial thinning was observed at the site corresponding to that of adenomyomectomy in three patients. Of these three patients, two required emergent CS due to tocolytic failure with cervical length (CL) shortening. In contrast, CLs were stable in the other seven patients with elective CS.Conclusions: Three patients after adenomyomectomy showed preterm delivery, and three had a very thin uterus to the extent that the fetus could be observed through the uterine wall. A short CL should be paid special attention in pregnant women with a history of adenomyomectomy.

Laterally-positioned placenta in placenta previa

Objectives: To clarify perinatal outcomes of patients with placenta previa (PP) with the placenta mainly positioned in the lateral uterine wall (lateral PP), thereby clinically characterizing this condition.Study design: The retrospective cohort study was performed involving patients with lateral PP between January 2006 and December 2016. The placental position was determined and classified by magnetic resonance imaging.Results: This study included 98 patients with PP, which was classified into three types according to the main placental position sites: lateral (n = 30), anterior (n = 32), and posterior (n = 36) PP. Overall, the median blood loss at cesarean section (CS) was 1808 mL and transfusion was performed for 78 patients (80%). Univariate analysis showed that patients with lateral PP bled less at CS than those with non-lateral PP (anterior + posterior PP) [median 1510 (interquartile range 1080-2168) versus 1975 (1570-2860) mL: p=.02]. The other parameters including rates of conception by assisted reproductive technology, prior CS, antepartum bleeding, and placenta accreta spectrum did not show the significances. Among the three groups of PP (lateral versus anterior versus posterior), patients with lateral PP bled less than those with anterior (p=.05) or posterior (p=.13) PP, but this was nonsignificant [lateral 1510 (1080-2168) versus anterior 2145 (1580-3348) versus posterior 1808 (1533-2555) mL]. When dividing into lateral PP to two types: placenta showing anterior dominancy versus posterior dominancy, patients with lateral PP and anterior dominancy bled more those with posterior dominancy [2430 (1410-3400) versus 1170 (1050-1588) mL: p=.002].Conclusion: Patients with lateral PP bled significantly less than those with non-lateral (anterior or posterior) PP. Patients with lateral PP and anterior dominancy bled more than those with posterior dominancy.

Vaginal Ureaplasma species increase chorioamnionitis in very preterm infants with preterm premature rupture of the membranes at < 28 weeks of gestation

Our aim was to investigate the association between vaginal Ureaplasma species (spp.) and the subsequent occurrence of chorioamnionitis (CAM), perinatal death, neonatal morbidity, and long-term neurodevelopmental impairments (NDIs) at 3 years of age. We analyzed 55 pregnant women with singleton pregnancy who had preterm premature rupture of the membranes (pPROM) at < 28⁺⁰ weeks of gestation, and delivered between 22⁺⁰ and 31⁺⁶ weeks at our tertiary hospital in 2007-2016. NDIs were defined as either cerebral palsy or developmental delay evaluated at 1.5 and/or 3 years old. The presence of Ureaplasma spp. and Mycoplasma hominis were evaluated using urea-arginine broth and Mycoplasma PPLO Agar. The presence of Ureaplasma spp. in the vagina was positive in 41%. Vaginal Ureaplasma spp. was a significant risk factor for CAM; however, it was not significantly associated with the occurrence of perinatal death, pulmonary hypoplasia, respiratory distress syndrome, transient tachypnea of the newborn, intraventricular hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia defined as oxygen required and occasional ventilatory assistance required at week 36 as modified (BPD₃₆), or NDIs. The crude odds ratio (95% confidence interval) of Ureaplasma spp. for the occurrence of CAM was 9.5 (1.10-82) (p = 0.041). In very preterm birth infants with pPROM, CAM, BPD₃₆, and NDIs occurred in 78, 60, and 36%, respectively. Vaginal Ureaplasma spp. was a significant risk factor for CAM in very preterm birth infants with pPROM. The incidences of BPD₃₆ and NDIs in such infants were very high, nearing 3/5 and 1/3, respectively.

Uterine-fundal hypoechoic mass: a possible ultrasound sign for cesarean scar pregnancy

PURPOSE OF INVESTIGATION

Cesarean scar pregnancy (CSP) is a life-threatening condition that requires early pregnancy termination. Its early ultrasound diagnosis is clinically important; however, previous studies focused on the CSP site itself. The present study was conducted to investigate the authors' clinical impression that a uterine-fundal hypoechoic mass is more frequently observed in CSP. Such a finding, if confirmed, may contribute to ultrasound diagnosis of CSP. The authors also determined the relationship between the treatment strategy and outcome, with special emphasis on conditions eventually requiring uterine artery embolization (UAE).

MATERIALS AND METHODS

This was a case-control study of CSP, and the authors analyzed all 14 women that were treated in this single tertiary institute over a period of ten years. Control subjects consisted of all pregnant women with prior cesarean section (CS) but no CSP.

RESULTS

Patients with CSP were significantly more likely to have a hypoechoic mass than controls (42.9 vs. 15.4%, respectively; p = 0.028). On confining results to a "fundal" hypoechoic mass, only CSP(+) patients showed it (CSP vs. control: 28.6 vs. 0%, respectively; p < 0.001). Six (43%: 6/14) received UAE: four following vaginal evacuation (artificial or spontaneous), and two for bleeding after methotrexate (MTX) treatment.

CONCLUSION

Patients with CSP more frequently had a uterine-fundal hypoechoic mass, whose detection may trigger a detailed observation of the CSP site, possibly leading to CSP diagnosis.

Ritodrine-induced rhabdomyolysis, infantile myotonic dystrophy, and maternal myotonic dystrophy unveiled

A primiparous pregnant woman in remission of myositis suffered very acute-onset ritodrine-induced rhabdomyolysis. At 29 gestational weeks, ritodrine was administered for threatened preterm labor. Just 3 h later, she complained of severe limb muscle pain, with serum creatinine phosphokinase elevated to 32 019 U/L and myoglobinuria. The muscle pain disappeared immediately after ceasing administration of ritodrine. At 31 weeks, premature rupture of the membranes occurred, necessitating cesarean section, yielding a baby with weak tonus, and the presence of infantile muscle diseases was suspected. Genetic analysis of the infant confirmed myotonic dystrophy (dystrophia myotonica, DM), which prompted us to perform maternal genetic analysis, confirming maternal DM. Ritodrine can induce rhabdomyolysis even in the prodromal phase with a mild phenotype of DM. A literature review suggested that ritodrine-induced rhabdomyolysis may be likely to occur more acutely after ritodrine administration in DM compared with non-DM mothers.

Spontaneous resolution of post-delivery or post-abortion uterine artery pseudoaneurysm: A report of three cases

Post-delivery/-abortion uterine artery pseudoaneurysm (UAP) sometimes causes life-threatening bleeding, requiring transarterial embolization (TAE). It is unclear whether some UAP resolve spontaneously. In three patients, UAP resolved spontaneously without TAE. Case 1 was after vacuum delivery with slight bleeding: at day 5 post-partum, a yin-yang sign on Color Doppler and an enhanced intrauterine sac-like structure were observed, leading to the diagnosis of UAP, which disappeared at 4 weeks post-partum. Case 2 was after vacuum delivery with manual placental removal and was asymptomatic: a hypoechoic intrauterine mass with a yin-yang sign were observed during a post-partum routine check-up and the intrauterine flow disappeared at 4 weeks post-partum. Case 3 was after dilatation and curettage in the first trimester with slight bleeding: UAP was detected at 4 weeks post-abortion, which disappeared at 6 weeks post-abortion. All three cases had a small UAP (diameter: 10-15 mm) and low-level or no symptoms. Some UAP may resolve spontaneously and, thus, may not require TAE.

Routine blood cultures in the management of pyelonephritis in pregnancy for improving outcomes

BACKGROUND

Pyelonephritis is a type of urinary tract infection (UTI) that affects the upper urinary tract and kidneys, and is one of the most common conditions for hospitalisation among pregnant women, aside from delivery. Samples of urine and blood are obtained and used for cultures as part of the diagnosis and management of the condition. Acute pyelonephritis requires hospitalisation with intravenous administration of antimicrobial agents. Several studies have questioned the necessity of obtaining blood cultures in addition to urine cultures, citing cost and questioning whether blood testing is superfluous. Pregnant women with bacteraemia require a change in the initial empirical treatment based on the blood culture. However, these cases are not common, and represent approximately 15% to 20% of cases. It is unclear whether blood cultures are essential for the effective management of the condition.

OBJECTIVES

To assess the effectiveness of routine blood cultures to improve health outcomes in the management of pyelonephritis in pregnant women.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register without language or date restrictions (31 December 2014).

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised trials comparing outcomes among pregnant women with pyelonephritis who received initial management with or without blood cultures. Cluster-randomised trials were eligible for inclusion in this review but none were identified. Clinical trials using a cross-over design were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed one trial report for inclusion.

MAIN RESULTS

We identified one trial report but this was excluded. No clinical trials met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

There are no large-scale randomised controlled trials to assess outcomes in the management of pyelonephritis in pregnancy with or without blood cultures. Randomised controlled trials are needed to evaluate the effectiveness of managing pyelonephritis in pregnant women with or without blood cultures, and to assess any adverse outcomes as well as the cost-effectiveness of excluding blood cultures from treatment.