High doses of intravenous immunoglobulin stimulate regulatory T cell and suppress natural killer cell in women with recurrent pregnancy loss

The aim was to evaluate whether natural killer (NK) cells and regulatory T (Treg) cells were involved in mechanisms underlying beneficial effects of a high dose of intravenous immunoglobulin (IVIG) on recurrent pregnancy losses (RPL) of unexplained etiology. In a double-blind, randomized, placebo-controlled trial of IVIG (400 mg/kg, for 5 days in 4-6 weeks of gestation) in women with RPL, blood samples were collected pre-infusion, one week after infusion (1 w), and eight weeks of gestation/when miscarried (8 w). Levels of NK and Treg cells in peripheral blood were compared between women with IVIG (n = 50) and placebo (n = 49), and between women with IVIG who gave live birth (n = 29) and those who had miscarriage with normal chromosome (n = 12). Effector Treg cell percentages in IVIG group at 1 w (mean 1.43 % vs. 1.03 %) and at 8 w (1.91 % vs. 1.18 %) were higher than those in placebo group (p < 0.01). Total Treg cell percentages in IVIG group at 1 w (4.75 % vs. 4.08 %) and at 8 w (5.55 % vs. 4.47 %) were higher than those in placebo group (p < 0.05). In women with live birth, total Treg cell percentages increased at 8 w (5.52 %, p < 0.001) compared with pre-infusion (4.54 %) and 1 w (4.47 %), while NK cell activity decreased at 1 w (20.18 %, p < 0.001) compared with pre-infusion (26.59 %). IVIG increased Treg cell percentages and suppressed NK cell activity very early in pregnancy, and these were associated with subsequent live birth. Stimulation of Treg cells and suppression of NK cell activity very early in pregnancy may be a mechanism of pharmacological effects of high dose IVIG.

Intravenous immunoglobulin treatment in women with four or more recurrent pregnancy losses: A double-blind, randomised, placebo-controlled trial

BACKGROUND

There is no effective treatment for women with unexplained recurrent pregnancy loss (RPL). We aimed to investigate whether treatment with a high dose of intravenous immunoglobulin (IVIG) in early pregnancy can improve pregnancy outcomes in women with unexplained RPL.

METHODS

In a double-blind, randomised, placebo-controlled trial, women with primary RPL of unexplained aetiology received 400 mg/kg of IVIG daily or placebo for five consecutive days starting at 4-6 weeks of gestation. They had experienced four or more miscarriages except biochemical pregnancy loss and at least one miscarriage of normal chromosome karyotype. The primary outcome was ongoing pregnancy rate at 22 weeks of gestation, and the live birth rate was the secondary outcome. We analysed all women receiving the study drug (intention-to-treat, ITT) and women except those who miscarried due to fetal chromosome abnormality (modified-ITT). This study is registered with ClinicalTrials.gov number, NCT02184741.

FINDINGS

From June 3, 2014 to Jan 29, 2020, 102 women were randomly assigned to receive IVIG (n = 53) or placebo (n = 49). Three women were excluded; therefore 50 women received IVIG and 49 women received placebo in the ITT population. The ongoing pregnancy rate at 22 weeks of gestation (31/50 [62·0%] vs. 17/49 [34·7%]; odds ratio [OR] 3·07, 95% CI 1·35-6·97; p = 0·009) and the live birth rate (29/50 [58·0%] vs. 17/49 [34·7%]; OR 2·60, 95% CI 1·15-5·86; p = 0·03) in the IVIG group were higher than those in the placebo group in the ITT population. The ongoing pregnancy rate at 22 weeks of gestation (OR 6·27, 95% CI 2·21-17·78; p < 0·001) and the live birth rate (OR 4·85, 95% CI 1·74-13·49; p = 0·003) significantly increased in women who received IVIG at 4-5 weeks of gestation as compared with placebo, but these increases were not evident in women who received IVIG at 6 weeks of gestation. Four newborns in the IVIG group and none in the placebo group had congenital anomalies (p = 0·28).

INTERPRETATION

A high dose of IVIG in very early pregnancy improved pregnancy outcome in women with four or more RPLs of unexplained aetiology.

FUNDING

The Japan Blood Products Organization.

A successfully treated case of an acute presentation of congenital thrombotic thrombocytopenic purpura (Upshaw-Schulman syndrome) with decreased ADAMTS13 during late stage of pregnancy

We herein report the case of a 28-year-old pregnant woman with an acute presentation of remarkable petechiae on her lower extremities and severe thrombocytopenia (16 000/mm³ ) at the 35th week of gestation. Although idiopathic thrombocytopenic purpura was initially suspected, subsequent examinations revealed that her ADAMTS13 (a Disintegrin And Metalloprotease, with ThromboSpondin type 1 repeats, member 13) titer was extremely decreased, while she was negative for antibodies against ADAMTS13. Infusion of fresh frozen plasma was immediately performed, and the platelet count was observed to increase. However, severe pregnancy-induced hypertension and proteinuria emerged at 36 weeks and 2 days of gestation, and a male infant was delivered by emergency cesarean section on the 37th week of gestation. The postnatal development was uncomplicated. After delivery, although the mother's platelet count and ADAMTS13 activity decreased temporarily, both values increased following fresh frozen plasma transfusion. This case showed interesting aspects of congenital thrombocytopenic purpura (Upshaw-Schulman syndrome) in pregnancy. Moreover, the rapid measurement of the patient's ADAMTS13 activity and the subsequent accurate diagnosis of congenital thrombocytopenic purpura made it possible to treat the patient with fresh frozen plasma infusion and avoid contraindicated platelet infusion. Close cooperation between obstetricians, hematologists and pediatricians is necessary to achieve successful outcomes in cases of thrombocytopenic purpura during pregnancy.

Enlarged uterine fibroid forming uterine diverticulum during pregnancy: a case report

BACKGROUND

Although uterine fibroids are a common gynecologic neoplasm, uterine diverticulum accompanied by a uterine fibroid is unique. In addition, pregnancy complicated with uterine diverticulum is extremely rare. We experienced a case of a uterine fibroid that was associated with a uterine diverticulum that enlarged during pregnancy and puerperium.

CASE PRESENTATION

A 25-year-old nulligravida woman had an abnormal uterine cavity surrounded by myomatous mass. After natural conception, the mass and pouch had enlarged during pregnancy. Six months after elective cesarean delivery, she underwent laparotomy because of abdominal pain caused by the myomatous mass and the fluid inside. The tumor was connected to the midline of the posterior wall of the normal uterus. The resected tumor was pathologically diagnosed as leiomyoma and diverticulum.

CONCLUSIONS

Pregnancy can stimulate uterine fibroids to form uterine diverticula. Resection of the diverticulum and fibroid is a useful option for symptomatic patients with desired future fertility.

Biology of the vernix caseosa: A review

The vernix caseosa is a complex membranous structure comprising 80% water, 10% protein, and 10% lipids including barrier lipids such as ceramides, free fatty acids, phospholipids and cholesterol, synthesized partly by fetal sebaceous glands during the last trimester of pregnancy in an antero-posterior and dorsoventral manner. Because of its lipid content, vernix is hydrophobic and protects the skin from excessive water exposure during the development of the stratum corneum. The vernix caseosa has various functions during fetal transition from an intrauterine to an extrauterine environment, including lubrication of the birth canal during parturition, barrier function to prevent water loss, temperature regulation, for innate immunity and for intestinal development. This review discusses the evidence supporting the prenatal and postnatal functions of vernix caseosa, along with its structure, composition, and physical and biological characteristics. Understanding the biology of the vernix may facilitate improved care of preterm infants immediately post-partum.

The analysis of chromosomal abnormalities in patients with recurrent pregnancy loss, focusing on the prognosis of patients with inversion of chromosome (9)

PURPOSE

Inversion of chromosome 9 (inv[9]) is considered to be a normal variant, and the inv(9) in patients or husbands with recurrent pregnancy loss (RPL) is believed to be harmless. However, there are few reports concerning the outcomes of pregnancy in patients with RPL when the patient or their partner has inv(9). In this study, we analyzed the outcomes of pregnancy in this patient population.

METHODS

Chromosomal karyotyping was performed for 2006 couples with RPL (two or more consecutive early pregnancy losses including non-visualized cases) with their informed consent. The frequency of various chromosomal abnormalities in the patient population was then analyzed, and the outcomes of pregnancy in patients with inv(9) were investigated.

RESULTS

The frequency of inv(9) in the overall population was 2.6% (52/2006). Thus far, 32 patients have conceived repetitively, resulting in live births in 23 cases and early pregnancy losses in nine cases. Four of the nine cases obtained a good outcome in the subsequent pregnancy. Thus, a successful outcome was obtained in 27 of the 32 (84.4%) cases.

CONCLUSIONS

This study suggests that inv(9) has no adverse influence on subsequent pregnancy.

Treatment for patients with recurrent fetal losses positive for anti-cardiolipin beta2 glycoprotein I antibody using Sairei-to (Chai-ling-tang) and low-dose aspirin

AIM

Recently, it is widely recognized that positivity for anti-phospholipid antibodies is a causative factor for a range of reproductive failures. Anti-cardiolipin beta2 glycoprotein I antibody (anti-CL-beta2-GPI) is a representative anti-phospholipid antibody, which strongly correlates with the development of thrombotic events and diversity of adverse pregnancies. In this series, we aimed to elucidate effective treatment for patients with recurrent fetal losses positive for anti-CL-beta2-GPI using Japanese-modified Chinese herbal medicine.

METHODS

Twenty-one patients with recurrent fetal losses who were positive for anti-CL-beta2-GPI were treated with the Japanese-modified Chinese herbal medicine, Sairei-to (Chai-ling-tang), and low-dose aspirin with or without adrenal corticosteroid hormone. Of the 21 patients, the value of anti-CL-beta2-GPI ranged from 1.9 to 3.4 in 10 patients, and it was over 3.5 in 11 patients.

RESULTS

Of the 21 patients treated with the current protocol, the pregnancy successfully continued in 17 patients (success rate: 81.0%). Of the four patients who showed repeated abortion, chromosome abnormality of chorionic villi was observed in two; thus, the success rate would be 89.5% (17 of 19 cases) on excluding these cases from the evaluation.

CONCLUSION

The efficacy of the current treatment adopting the modified Japanese version of the Chinese herbal medicine Sairei-to for patients with recurrent fetal losses positive for anti-CL-beta2-GPI was indicated.

Microdissection testicular sperm extraction in five Japanese patients with non-mosaic Klinefelter's syndrome

Cases

Microdissection testicular sperm extraction (micro‐TESE) was performed on five Japanese men with non‐mosaic Klinefelter's syndrome (KS) and non‐obstructive azoospermia in the authors' department. Here is reported the operative results and partner's clinical course for two cases where spermatozoa could be acquired. Also encountered was a man with non‐mosaic KS with the partial deletion of azoospermia factor (AZF)b. Because this is rare, it is reported in detail in the context of the previous literature. This case series describes the first experience of micro‐TESE by gynecologists in the current department.

Outcome

The egg collection date was adjusted to the micro‐TESE day by using the modified ultra‐long method. Intracytoplasmic sperm injection (ICSI) was implemented for two men whose spermatozoa were acquired by micro‐TESE, with these progressing to the blastocyst stage. Subsequently, one case conceived after the transfer of fresh embryos and a healthy baby was delivered. However, spermatozoa could not be retrieved from the man with non‐mosaic KS who was harboring the partial deletion of AZFb.

Conclusion

These findings suggest that ovulation induction by using the modified ultra‐long method with micro‐TESE and ICSI on the same day represents an effective treatment option for men with non‐mosaic KS. As there are cases where AZF deletion is recognized among patients with non‐mosaic KS, screening before micro‐TESE is strongly recommended.

Two cases of recurrent abortion in which isodicentric chromosome 15 was observed in the husbands

We report two cases of women positive for anticardiolipin antibodies who experienced recurrent abortion whose husbands had isodicentric chromosome 15 aberrations who eventually had successful pregnancies. Two women were referred to our hospital due to their medical history of recurrent abortion. Both were diagnosed as being positive for anticardiolipin antibodies and their husbands with isodicentric chromosome 15. After both patients were treated with a Japanese herbal medicine (Sairei-to) and low-dose aspirin for the positive anticardiolipin antibodies, they delivered appropriate-for-date infants at term gestation. Although both husbands were revealed to have isodicentric chromosome 15, and coincidentally both wives were positive for anticardiolipin antibodies, their next pregnancies continued uneventfully as a result of the treatment.

Prenatal molecular diagnosis of X-linked hydrocephalus via a silent C924T mutation in the L1CAM gene

We present a case of a patient whose L1CAM gene in X-chromosome has a C924T transition. Her first son's ventriculomegaly was prenatally detected. A mature infant was born, his head circumference was large, and thumbs were bilaterally adducted. X-linked hydrocephalus (XLH) was suspected. The DNA examination revealed that both her and boy's LICAM gene had a C924T transition. She became pregnant 5 years later and amniocentesis was performed. The results of cytogenetic analysis revealed that the fetus was female. She continued her pregnancy and delivered a healthy girl. She again became pregnant 3 years later. The chromosomal analysis revealed that the fetus was male. Fetal DNA analysis determined that the fetus had the inherited mutation. She chose to terminate the pregnancy. A C924T mutation can be disease causing for XLH, and the detection of this mutation would aid in genetic counseling for the prenatal diagnosis of XLH.

Successful management of severe intrahepatic cholestasis of pregnancy: report of a first Japanese case

BACKGROUND

Intrahepatic cholestasis of pregnancy (ICP) is a cholestasis condition caused by elevated levels of serum bile acids that mainly occurs in the third trimester of pregnancy. Maternal symptoms include pruritus; elevation of transaminases, biliary enzymes, and bilirubin levels; and abnormal liver function tests. Fetal symptoms include spontaneous preterm labor, fetal distress, and intrauterine death. It is more prevalent in the Caucasians and is rarely found in Asian countries, including Japan. The etiology of ICP has been reported as involving various factors such as, environmental factors, hormone balance, and genetic components. The genetic factors include single-nucleotide polymorphisms (SNPs) in the genes of canalicular transporters, including ABCB4 and ABCB11. It has also been reported that the combination of these SNPs induces severe cholestasis and liver dysfunction.

CASE PRESENTATION

Here, we report for the first time a 24-year Japanese case of severe ICP diagnosed by typical symptoms, serum biochemical analysis, and treated with the administration of ursodeoxycholic acid which improved cholestasis and liver injury and prevented fetal death. The sequence analysis showed SNPs reported their association with ICP in the ABCB11 (rs2287622, V444A) and ABCB4 (rs1202283, N168N) loci.

CONCLUSION

The risk of ICP has been reported to be population-specific, and it is rare in the Japanese population. Our case was successfully treated with ursodeoxycholic acid and the genetic sequence analysis has supported the diagnosis. Because genetic variation in ABCB4 and ABCB11 has also been reported in the Japanese population, we need to be aware of potential ICP cases in pregnant Japanese women although further studies are necessary.

Complex chromosomal rearrangements in couples affected by recurrent spontaneous abortion

OBJECTIVE

To determine the proportion of couples affected by recurrent spontaneous abortion in which one partner carries balanced translocations among three chromosomes.

METHODS

In a retrospective study, G-banded chromosome complements were analyzed for couples affected by recurrent spontaneous abortion who were referred to Niigata University Hospital, Japan, between January 1, 1990, and December 31, 2011. The frequency of couples in whom one of the partners carried balanced translocations among three chromosomes was determined, and the clinical outcomes for affected couples who subsequently achieved term pregnancies were reviewed.

RESULTS

Of 1415 couples with recurrent spontaneous abortion during the study period, there were two (0.1%) in which one of the partners (the woman in both cases) carried balanced translocations among three chromosomes. Both couples achieved a subsequent pregnancy that continued successfully and resulted in a phenotypically normal neonate.

CONCLUSION

The frequency of balanced translocations among three chromosomes was estimated to be approximately 0.1% in a population affected by recurrent spontaneous abortion. With appropriate treatment based on careful examinations, affected couples can go on to achieve a successful pregnancy outcome.

Twins with neonatal pemphigus vulgaris born to a mother with pemphigus vulgaris: a case report

Dichorionic diamniotic twins were born at 37 weeks of gestation by cesarean section to a 34-year-old primigravid Japanese woman because the first twin was in breech presentation. The mother had been diagnosed with pemphigus vulgaris prior to her pregnancy. In addition to a high antidesmoglein 3 autoantibody titer, flaccid bullae and erosions on both of the twins' lips and in their oral cavities at 13 days of age led to the diagnosis of neonatal pemphigus vulgaris. This case highlights the need for awareness that pemphigus vulgaris may not occur immediately after birth.

Significant Compatibility Does Not Exist at the HLA-DQB Gene Locus in Couples With Unexplained Recurrent Abortions

The polymerase chain reaction-restricted fragment length polymorphism (PCR-RFLP) method was used for both examining compatibility at the HLA-DQB1 gene locus and determining HLA-DQ antigen polymorphism in spouses of unexplained recurrent abortions. Genomic DNA samples were prepared from peripheral mononuclear cells from patient and control couples. Two hundred and thirty base pair fragments of the second exon of the HLA-DQB genes were selectively amplified. Amplified DNAs were digested with the restriction endonucleases, Fok I, Hae III, Hha I, Rsa I and Sau3A I, and subjected to electrophoresis in a polyacrylamide gel. The RFLPs showed that habitual aborters and their husbands had neither significantly frequent alleles nor shared common alleles at the HLA-DQB locus when compared to the control group. Since significant HLA-DQB compatibility was not observed between the spouses and unexplained recurrent aborters, in order to determine whether or not HLA compatibility is responsible for the genesis of unexplained recurrent abortions, it is imperative to further examine the compatibility between other HLA gene loci.

Effect of Sairei-To Combined with Aspirin and Prednisolone on Four Recurrent Reproductive Failure Women who are Positive for Anti-Phospholipid Antibodies

We treated four pregnancy cases positive for antiphospholipid antibodies (APLs) who had experienced recurrent second trimester fetal or neonatal losses using a Japanese modified Chinese herbal medicine, Sairei-to, low dose aspirin and adrenocorticosteroid hormone. The clinical courses of their new pregnancies in conjunction with the dynamic changes in their APL titers are described in this paper, and the possible efficacy of this treatment is discussed.

The concept that autoimmune abnormalities, especially positive APLs, are generative factors for a range of reproductive failures, such as recurrent abortions, intrauterine growth retardation, intrauterine fetal death and preeclampsia, is now attracting a great deal of attention in the fields of reproductive immunology and perinatal medicine (Yasuda et al., 1995). The main mechanisms in the generation of reproductive failures are considered to be direct damage to chorionic villi by APLs during the period of placentation (Rote et al., 1998), as well as the formation of thrombi intervillous spaces (Arakawa et al., 1999). Considering these mechanisms of the reproductive failure generation by APLs, the application of immune suppressive therapy in combination with anti-coagulation therapy should be reconsidered as a treatment option.

In this context, we treated four pregnancy cases positive for APLs who had experienced recurrent second trimester fetal or neonatal losses using a Japanese modified Chinese herbal medicine, Sairei-to, low dose aspirin and an adrenocorticosteroid hormone.

Severe Asherman's syndrome complicated with placenta increta conceived by intracytoplasmic sperm injection following hysteroscopic surgery

Although severe Asherman's syndrome is a disease that may cause infertility, pregnancy and childbirth are possible by performing hysteroscopic surgery. However, the obstetrical outcome is not always satisfactory. We report a case where severe Asherman's syndrome occurred following a cesarean section. Hysteroscopic surgery was performed due to secondary infertility, and pregnancy was achieved through a subsequent intracytoplasmic sperm injection. At 23 weeks of gestation, the patient was hospitalized due to the threat of premature labor, and a cesarean section was performed at 29 weeks of gestation after pregnancy-induced hypertension occurred. It was determined to be abnormal adherent placentation such as placenta increta through intraoperative findings, and a cesarean hysterectomy was performed. The pathological diagnosis of the uterus was placenta increta. Due to the risk of complications from placenta increta in pregnancies following hysteroscopic surgery in patients with severe Asherman's syndrome, it is important to realize the high risk involved in such cases during the pregnancy course, and careful perinatal management should be required.

Successful twin pregnancy in a patient with parkin-associated autosomal recessive juvenile parkinsonism

Background

Pregnancy in patients with Parkinson disease is a rare occurrence. To the best of our knowledge, the effect of pregnancy as well as treatment in genetically confirmed autosomal recessive juvenile parkinsonism (ARJP) has never been reported. Here, we report the first case of pregnancy in a patient with ARJP associated with a parkin gene mutation, ARJP/PARK2.

Case presentation

A 27-year-old woman with ARJP/PARK2 was diagnosed as having a spontaneous dichorionic/diamniotic twin pregnancy. Exacerbation of motor disability was noted between ovulation and menstruation before pregnancy as well as during late pregnancy, suggesting that her parkinsonism might have been influenced by fluctuations in the levels of endogenous sex hormones. During the organogenesis period, she was only treated with levodopa/carbidopa, although she continued to receive inpatient hospital care for assistance in the activities of daily living. After the organogenesis period, she was administered sufficient amounts of antiparkinsonian drugs. She delivered healthy male twins, and psychomotor development of both the babies was normal at the age of 2 years.

Conclusion

Pregnancy may worsen the symptoms of ARJP/PARK2, although appropriate treatments with antiparkinsonian drugs and adequate assistance in the activities of daily living might enable successful pregnancy and birth of healthy children.

Fetal atrioventricular block and postpartum augmentative QT prolongation in a patient with long-QT syndrome with KCNQ1 mutation

The case of a 32-year-old pregnant woman, who had had several syncopal episodes during swimming and running at 9 and 10 years of age and whose fetus had 2:1 AV block, is presented. The mother and baby had the same heterozygous single nucleotide substitution in KCNQ1 at T587M. After 27 weeks of gestation, the fetal 2:1 AV block disappeared, and 1:1 AV conduction resumed, with a fetal heart rate of 110-120 beats/min. The maternal electrocardiogram revealed a normal QTc interval (433 ms) without ST-T abnormalities at gestational week 23, but the QTc was 490 and 531 ms at 1 and 2 months postpartum, with biphasic T waves in leads V2 and V3. This case is the first report of fetal 2:1 AV block with KCNQ1 mutation (T587M) and unmasked maternal QT prolongation in the postpartum period.

A Case of Infantile Cardiac Rhabdomyoma Complicated by Tuberous Sclerosis

We experienced a case with fetal cardiac tumor, which was diagnosed by prenatal ultrasonographic examination, and the diagnosis was confirmed after birth. A pregnancy woman of the 26th week of gestation was referred to our hospital for close examinations of fetal cardiac tumor. Ultrasonographic examinations revealed single homogeneous tumor with the diameter of 14 mm intracardiac space. The tumor was considered to emerge from the ventricular septum and to be occupied in left ventricle. Other cardiac abnormalities were not detected. The fetus was diagnosed to be complicated with the intracardiac tumor, and with the possible rhabdomyoma of heart. The serial ultrasonographic examinations revealed that the fetal cardiac function was normal. The size of the tumor gradually increased, although the fetal cardiac function revealed within normal range. The patient delivered a female infant weighing 2716g with the Apgar score of 9 and 10 at one and 5 minutes after delivery. The infant was confirmed to have cardiac tumors after examination by pediatric cardiologist, and the cardiac function of the infant was diagnosed as normal condition. The computed tomography of the head revealed the intracranial multiple calcification lesions, which indicated the symptoms of tuberous sclerosis.

Large pseudocyst of the umbilical cord detected in the second trimester

We present a case of a large umbilical cord cyst detected at 21 weeks of gestation. Serial ultrasonographic examination revealed a single umbilical artery and progression of the cystic mass. A 2,842-g male infant was delivered at 37 weeks of gestation, and we confirmed that the umbilical cord cyst was a pseudocyst in our pathological examination. This case demonstrated an uneventful course of pregnancy despite the large umbilical cord pseudocyst.

Morgagni hernia with massive pericardial effusion diagnosed in the second trimester: prenatal diagnosis and perinatal management

Morgagni hernia is an extremely rare form of congenital diaphragmatic hernia. Only 6 cases of this condition have been reported in the English literature, as diagnosed prenatally. The prognosis of the disease is determined by the severity of the pulmonary hypoplasia and associated anomalies. Here we report a case of Morgagni hernia with massive pericardial effusion diagnosed by ultrasonography and MRI during the second trimester, enabling planning of appropriate treatment in the pre- and perinatal periods.

Fulminant type 1 diabetes mellitus acutely emerged during pregnancy

A pregnant woman at 32 weeks of gestation was emergently admitted to our hospital with symptoms of nausea, vomiting, and uterine contraction. Cardiotocogram demonstrated a loss of variability and late deceleration in fetal heart rate pattern. Emergency cesarean section was performed, and a male infant weighing 1750 g was born with Apgar scores of 1 at 1 min, and 3 at 5 min after delivery. After cesarean section, the patient developed an acetone breath odor, and blood examination demonstrated remarkable acidemia and an extremely high level of blood glucose. The patient was diagnosed with ketoacidosis with acute onset of fulminant type 1 diabetes mellitus. Intensive care was applied due to the severe diabetes mellitus conditions. The patient's general condition ameliorated during the postoperative period, although there was a possibility of neurological complications in the infant.

A case study of a pregnant patient with a congenital heart block accompanied by left isomerism and uncontrolled type 2 diabetes who was treated successfully with ritodrine

We present a case study of a patient with a congenital heart block associated with a left isomerism that was diagnosed during the 26th week of gestation. The mother had type 2 diabetes mellitus that was difficult to control during the early stages of the pregnancy. A fetal echocardiogram revealed an atrioventricular dissociation, with an atrial rate of 120 bpm and a ventricular rate of 55 bpm. Subsequent examinations also revealed a left isomerism in the fetus. To increase the fetal heart rate, a continuous intravenous infusion of ritodrine was administered. The fetal ventricular rate rapidly increased to 65 bpm. The pregnancy successfully continued until term and a female infant weighing 3,182 g was born via a cesarean section. A subsequent surgery was performed to provide the infant with a permanent cardiac pacemaker, and notably, the child is now 4 months of age and her growth has been within the normal range.

Abscess formation due to Mycoplasma hominis infection after cesarean section

A 27-year-old female patient underwent cesarean section and a postoperative hematoma occurred at the site of the uterine incision. The patient underwent relaparotomy to remove the hematoma. Four days later she developed a fever of over 39 degrees C and an abscess had formed at the site. Despite therapy with several antimicrobial agents, her fever persisted. Consequently, she underwent transvaginal abscess drainage, after which she promptly became afebrile. Mycoplasma hominis was considered to be the primary causative organism. There are two reasons that could explain why the wound infection became serious: (i) M. hominis is resistant to several antimicrobial agents that are usually used to treat obstetric infections; and (ii) a long time is required to identify the pathogen. In conclusion, M. hominis should be considered as a causative organism if an antimicrobial-resistant infection occurs at the surgical site after a cesarean section.

Antibody responses to Porphyromonas gingivalis outer membrane protein in the first trimester

BACKGROUND

Porphyromonas gingivalis (Pg) is one of the most harmful periodontal pathogens and it has been reported that Pg is associated with preterm birth (PTB), intrauterine growth retardation (IUGR) and pregnancy-induced hypertension (PIH), discovered by animal experiments and clinical research. The relationship between adverse pregnancy outcomes and maternal antibody response to Pg is controversial. On the other hand, the serum C-reactive protein (CRP) has been recognised as a reliable serum marker of periodontal disease.

AIMS

To determine the significance of antibody responses to Pg affecting pregnancy outcomes in the first trimester.

METHODS

A case-control study was carried out on women with PTB (n = 58), IUGR (n = 91), PIH (n = 32) and without any complications (control, n = 98). The serum level of the CRP and IgG1 against 40-kDa outer membrane protein of Pg (anti-40-kDa OMP Pg-IgG1) in the first trimester was measured.

RESULTS

The IUGR group, and PTB patients whose placentas were diagnosed as chorioamnionitis or whose vaginal flora included Lactobacilli, showed a lower level of anti-40-kDa OMP Pg-IgG1 than the control group. There was no difference in the serum CRP level between each case group and control group.

CONCLUSIONS

These results suggest that a lack of humoral immunity against Pg in early pregnancy is associated with IUGR and some PTB.

Studies of assisted reproduction techniques (ART) for HIV-1-discordant couples using washed sperm and the nested PCR method: a comparison of the pregnancy rates in HIV-1-discordant couples and control couples

In this study, the efficacy and safety of assisted reproduction techniques with the sperm-washing method and nested PCR assay were evaluated in HIV-1-discordant couples, as many HIV-1-positive people of reproductive age are getting married and wish to have children safely. Twenty-seven HIV-1-discordant couples (husband, positive; wife, negative) were enrolled in this study. The spermatozoa were separated from semen samples by density gradient centrifugation and the swim-up method. HIV-1 RNA and proviral DNA were checked using nested PCR with a detection limit of one copy before fertilization and before embryo transfer. Clinical outcomes were compared with those of matched control couples. Thirty-eight cycles of in vitro fertilization or intracytoplasmic sperm injection were performed in HIV-1-discordant couples, where the pregnancy rates per embryo transfer and per couple were 60.6 and 63.0%, respectively. These rates were significantly higher than those in control couples (P<0.05). Furthermore, all of the females and babies remained HIV-1 negative throughout the study period. Our data strongly suggest that this technique will allow HIV-1-discordant couples to conceive more safely and effectively.

HELLP syndrome, multiple liver infarctions, and intrauterine fetal death in a patient with systemic lupus erythematosus and antiphospholipid syndrome

We report a case of HELLP syndrome, multiple liver infarctions, and intrauterine fetal death in a woman in the 17th week of pregnancy with SLE and APS who had been in remission on a regimen of low-dose prednisolone and aspirin. An increase in the dosage of corticosteroid together with intravenous heparin infusion led to improvement of the clinical symptoms, laboratory parameters, and multifocal low-density liver lesions detected by computed tomography. Early onset and signs of severe organ involvement are the characteristic features of HELLP syndrome associated with APS, and patients that are at risk should be followed up carefully.

Studies on the prevalence of human papillomavirus in pregnant women in Japan

AIMS

In order to evaluate the prevalence of human papillomavirus (HPV) in the pregnant population in Japan.

METHODS

We examined cervical swabs of 1,183 pregnant women for HPV DNA using a PCR-RFLP method during October, 2000 and February, 2001. The overall prevalence of HPV in 1,183 pregnant women was analyzed and stratified by age.

RESULTS

The overall prevalence of HPV in pregnant women was 12.5% (148 of 1,183 cases). The prevalence in pregnant women younger than 25 years (22.6%, 28 of 124 cases) was significantly higher compared with that in pregnant women > or =25 years (11.3%, 120 of 1057 cases, P< 0.0005).

CONCLUSIONS

The data indicate a significantly higher prevalence of HPV infection in younger pregnant Japanese women.

Four cases of fetal hypoechoic hepatomegaly associated with Trisomy 21 and transient abnormal myelopoiesis

OBJECTIVE

Our objective was to determine the clinical significance of fetal hypoechoic hepatomegaly and serial change of liver sizes.

METHODS

The liver sizes of four fetuses with hypoechoic hepatomegaly were serially estimated by liver length, as measured from the dome of the right hemidiaphragm to the tip of the right lobe.

RESULTS

All cases were associated with trisomy 21 or transient abnormal myelopoiesis (TAM). Two cases were trisomy 21 with TAM, one case was a phenotypically normal newborn, who had developed TAM during the fetal period, and the last case was trisomy 21 without TAM. In the last case, it is speculated that TAM had developed and regressed completely before birth. Two cases, whose hepatomegaly had improved before birth, showed good prognosis and the other two cases, in whom improvement had not been observed, resulted in death after birth by liver failure.

CONCLUSION

These experiences show that one of the differential diagnoses of hypoechoic hepatosplenomegaly is TAM and that the change of live size is a predictor of prognosis.

Prophylactic Therapy for Patients with Reproductive Failure Who were Positive for Anti-Phospholipid Antibodies

PROBLEM

To elucidate the efficacy of the treatment using a Japanese-modified Chinese herbal medicine, Sairei-to, and low-dose aspirin with or without a corticosteroid hormone for the patients with adverse pregnancy histories positive for anti-phospholipid antibodies.

METHOD OF STUDY

Fifteen cases positive for anti-phospholipid antibodies, who had experienced preterm delivery in which an extremely low birthweight infant (<1000 g) was born as a result of intrauterine growth restriction with or without severe preeclampsia, were treated with the medication according to the current protocol. Four cases with the same condition, who were treated with only low-dose aspirin, or without medication, were chosen as a control population. The pregnancy outcome was compared between the two groups.

RESULTS

The rate of patients in whom the next pregnancy continued until the 36th week of gestation or later was significantly higher in treated patients (80.0%) compared with the control population (0%).

CONCLUSIONS

In this series, we obtained case report data that Sairei-to may provide some benefit for patients with reproductive disorders positive for anti-phospholipid antibodies; however, randomized controlled trial evidence is needed before current treatment can be recommended.

An Experience of Laser Surgery for Feto-Fetal Transfusion Syndrome Complicated with Unexpected Feto-Fetal Hemorrhage in a Case of Monochorionic Triamniotic Triplets

Feto-fetal transfusion syndrome (FFTS) in monochorionic triplets is a rare clinical entity which may share the principal adverse perinatal outcomes of twin-twin transfusion syndrome. Recently, favorable prognoses regarding morbidity and mortality in twins after selective laser photocoagulation of placental communicating vessels (SLPCV) have been described. But descriptions of this procedure in monochorionic triplet cases are limited. This is the case report of an experience of SLPCV applied to monochorionic triamniotic triplets with FFTS. Triplet A had polyhydramnios, while absent end-diastolic flow in the umbilical artery of triplet B, the triplet with anhydramnios, was persistent. Triplet C looked normal, vertical amniotic pocket and Doppler studies yielding normal results. At the beginning of the SLPCV procedure, feto-fetal hemorrhage, subsequent to the fetal death of the donor triplet, occurred. Both surviving cofetuses showed persistent bradycardia; and 1 fetus died while the other recovered from the fetal bradycardia. All vascular anastomoses between the 3 triplets could be identified and obliterated, requiring two trocars. Our fetoscopic observation revealed feto-fetal hemorrhage after demise of monochorionic triplet, which led to injury of other fetuses due to hypovolemia in an instant. In conclusion, SLPCV might be a valid option for FFTS in triplet cases, while further experience is required in order to evaluate the risks and benefits of this procedure in triplet cases.

Studies on the human leukocyte antigens in patients with polycystic ovary syndrome in a Japanese population--possible susceptibility of HLA-A11 and -DRB1*0403 to patient population with polycystic ovary syndrome

PROBLEM

The objective of this study was to identify the human leukocyte antigen (HLA) alleles that confer susceptibility or resistance to polycystic ovary syndrome (PCOS) in the Japanese population.

METHOD OF STUDY

HLA-A, -B and -C antigens were determined in 56 patients with PCOS using conventional serological method. HLA-DRB1 genotypes were determined using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method in 68 patients with PCOS. As a control population, 237 healthy individuals (males and females) were examined concerning HLA-A, -B and -C antigens, and 292 individuals were examined concerning HLA-DRB1 genotypes. The rate of possession of each antigen was compared between the two populations.

RESULTS

The rate of possession of the HLA-A11 and HLA-DRB1*0403 in the patients with PCOS was significantly higher compared with that in the control group. The rate of possession of HLA-B39 in the patients with PCOS was significantly lower compared with that in the general population group.

CONCLUSION

Human leukocyte antigen systems appear to be linked to PCOS.

Alteration of TH1 and TH2 cells by intracellular cytokine detection in patients with unexplained recurrent abortion before and after immunotherapy with the husband's mononuclear cells

OBJECTIVE

To elucidate the possible mechanisms of immunotherapy for unexplained recurrent aborters using their husband's mononuclear cells.

DESIGN

Prospective clinical study.

SETTING

Institutional practice at the Outpatient Clinic for Infertility, Niigata University Medical Hospital.

PATIENT(S)

Fifty-two unexplained recurrent aborters were chosen as an experimental group.

INTERVENTION(S)

Each patient was injected with her husband's mononuclear cells as immunotherapy. Peripheral blood was obtained from the patients.

MAIN OUTCOME MEASURE(S)

The percentage of CD4-positive cells, TH1 cells, TH2 cells, and the TH1/TH2 ratio were analyzed in the patients before and after immunotherapy. The same analyses were performed in the successful and the unsuccessful group.

RESULT(S)

To date, 42 of the 52 patients have become newly pregnant. Of the 42, 34 patients have already delivered (successful group) and 3 are now pregnant, while the remaining 8 cases experienced repeated abortion (unsuccessful group). The percentage of TH2 cells significantly increased in the total patient population, while the TH1/TH2 ratio significantly decreased in the total patient population and in the successful group.

CONCLUSION(S)

These findings suggest that immunotherapy with the husband's mononuclear cells for unexplained recurrent abortion induces a dominant state of TH2 cells in the patients.