Preterm birth is a major cause of perinatal morbidity and mortality. A short cervical length on transvaginal ultrasound examination in the mid-trimester is one of the best predictors of preterm birth. Many methods are now being reported to predict preterm labor and preterm delivery, and many treatments to prevent preterm labor and preterm delivery. When cervical shortening is diagnosed, cervical cerclage has been proposed to prevent preterm birth, although several randomized trials have not supported this practice. As inflammation plays a central role in the pathology of preterm delivery, suppressing such inflammation as cervicitis and chorioamnionitis is crucial for treating preterm delivery. However, Mg sulfate and beta-2 agonists, which are currently used to treat threatened preterm delivery by inhibiting uterine contractions, do not reduce inflammatory response. As a result, Mg sulfate and beta-2 agonist therapy are considered to only treat the symptoms of cervicitis and chorioamnionitis. The use of antibiotic and anti-inflammatory therapies to treat cervicitis and chorioamnionitis has been recently reported. From these background and the various causes of premature birth, it is hard to make a uniform explanation of the mechanism. It is not uncommon for premature birth to occur due to medical reasons or diagnosis due to maternal complications, etc., due to an increase in maternal age. There is also an iatrogenic aspect due to an increase in multiple births and in utero fetal growth retardation due to an increase in assisted reproduction treatment. While focusing on these iatrogenic premature births, it remains important to understand the cascade of premature births based on traditional infections and inflammation. It is no doubt that reducing premature birth itself is important. However, there are a number of researches to prevent premature labor and to treat preterm birth.

 Neonatal hemochromatosis（NH）is a disease with poor prognosis causing severe liver failure in both fetal and neonatal periods and is assumed to be an allogeneic immunological fetal liver injury which ultimately requires liver transplantation.

 Up till date, no survey has outlined management of NH in Japan, due to its difficulty in diagnoses and treatment.

 Here we reported the first nationwide survey for management of cases diagnosed clinically with NH in a 5 years period from 2010 to 2014.

 From 275 hospitals included in the survey a total of 197 hospitals responded.

 The responds included managements of 19 cases.

 Only 2 cases were completely fulfilling the diagnostic criteria given by the Japan Society of Pediatric Nutrition and Gastroenterology Liver, suggesting the possibility that the given diagnostic criteria need to be revised. Based on this result, new diagnostic criteria were created.

 A wide variation in diagnostic investigations and treatments for the included cases were observed among hospitals.

 From this survey, a standardized management for NH is warranted.

 Furthermore, NH diagnosis was less successful in postnatal period as many cases could not receive the diagnostic investigation. Additionally, suspected cases could not receive the ultimate treatment due to their poor condition. Therefore, it would be crucial to improve NH prognosis by focusing on diagnosis and treatment during fetal period.

 We targeted 57 cases of maternal transport to Japanese Red Cross Mecical Center by postpartum hemorrhage（PPH）with more than 1,000ml blood loss in 6 years from April 2011 until March 2017.

 In this study, we have performed a retrospective analysis of the mode of delivery, examinations, amount of bleeding, final diagnosis and treatment. In recent years, the number of postpartum transport with PPH has been increasing. One-third of these cases were due to atonic bleeding, another one-third of these cases were due to the injury of the birth canal. Epidural analgesia was performed in 50％ of PPH cases. In 43％ of atonic bleeding cases and 60％ of injury of the birth canal cases, epidural analgesia was also performed. In more than 70％ of injury of the birth canal cases with the history of vaginal delivery, epidural analgesia was performed.

 In 32 cases diagnosed with atonic hemorrhage before transport, 11 cases had another cause of bleeding. In 11 cases with different final diagnosis, 4 cases were the injury of the birth canal, 5 cases were retention of the placenta and 2 cases were amniotic fluid embolism.

 It is recommended that patients with massive puerperal hemorrhage who are judged to be difficult to treat at primary or secondary institutions should be transported to a higher medical institution promptly.

 On the other hand, in the facilities accepting maternal transport, the key of the mother’s lifesaving is to diagnose the accurate cause of the puerperal massive hemorrhage quickly, and to treat it in cooperation with another department.

 Emergency medical care for perinatal and neonatal patients requires advanced knowledge and skills; it often poses a challenge to paramedics due to lack of training. Accordingly, we are aiming to develop self-learning materials tailored to the needs of paramedics. In the development of materials, we adopted the ADDIE model, a design model for instructional materials and systems. The purpose of this study was to perform an analysis of learners, which is the first phase of the ADDIE model.

 Semi-structured interviews were conducted with 11 paramedics. The interviews suggested that the skills which paramedics need are the abilities to assess changes in patients and perform the necessary procedures according to the changes. In order to improve their skills, it is important for each paramedic to understand specifically what to assess, how to assess, and what procedures to perform based on the assessment findings. The development of a simulation training program that combines e-learning and practical experience to facilitate self-learning is needed.

 Aim

 To investigate the knowledge of pediatricians in Japanese hospitals on the “Clinical Guidelines for Obstetrical Practice in Japan, 2017 Edition,” as a source of information about drugs used during pregnancy and lactation.

 Materials and methods

 We distributed a mail-in survey to 502 pediatric departments of clinical training hospitals in Japan.

 Results

 A total of 298 hospitals（59％）responded to our questionnaire. Almost all the pediatricians stated that the information about drugs used during pregnancy and lactation described in the guidelines was useful; however, the actual proportion of pediatrician who were familiar with the guidelines was only 21％（63 of 298 hospitals）. The Food and Drug Administration（FDA）pregnancy risk category was known to 169 of the included pediatricians （57％）, whereas only 16（5％）were aware of the removal of the risk category from the label. Twenty-seven of included pediatricians（9％）were acquainted with the revision of “The Points of Compilation for Ethical Drug Package Insert in Japan,” and 13（4％）knew these points in detail.

 Conclusion

 Although the “Clinical Guidelines for Obstetrical Practice in Japan, 2017 Edition” are useful source of information about drugs used during pregnancy and lactation, only 21％ of the interviewed pediatricians knew the content of the guidelines. Therefore, it seems advisable to improve the exchange of information between obstetrician and pediatrician practicing neonatology.

 Objective: To investigate the outcomes of pregnant women complicated with mental disorders.

 Methods: A retrospective investigation of 146 singleton pregnancies complicated with mental disorders were performed between January 2013 and December 2017 at our institution. Mental disorders were diagnosed according to the International Classification of Diseases, 10th version（ICD10）.

 Results: Among the 146 women, 36（24.7％）relapsed in perinatal period, of which 32 during pregnancy, 2 during labor, and 2 during postpartum. Seven cases needed psychiatric admission. Eighty-three women were medicated before pregnancy. Among 49 who maintained their medication throughout their pregnancy, 7（14％）relapsed compared with 14（41％）of the 34 women who discontinued or reduced medication. Women who discontinued or reduced medication relapsed significantly more frequently over the course of their pregnancy compared with women who maintained their medication（odds ratio, 3.3; 95％ confidence interval, 1.1-10.2; P ＜ .001）. Among the 145 neonates born in the institute, 29（20％）required pediatric hospitalization, of which 5 for neonatal withdrawal syndrome, 9 for preterm birth and low birth weight, 9 for respiratory failure, 4 for infection, 2 for nursery disability, 1 for neonatal asphyxia, and 1 for meconium aspiration syndrome.

 Conclusion: The pregnant women with mental disorders have a potential risk for relapse in perinatal period, especially according to discontinuation or reduction of medication.

 The author developed a touch-screen based computer program created by 4D® for preparation and administration of injectable medication using of barcode verification linked with a self-programmed computerized physician order entry（CPOE）to support and control its complex tasks and mitigate medication errors for the processes conducted in an NICU. The program, which displays special information for the dissolution or mixing procedure aside from the required amounts of medications and dissolution liquids on a touch-screen, allows proper preparations of compounded medicine without repetition nor omission by making progress while turning a medicine finished with the dispensing white colored by a touch of the name on screen after verifying each medicine with its barcode, and eventually have reduced the workers’ occupational stress during the procedure. It also allows a subsequent verification of the label with its barcode after the printout of a barcode label, on which the contents and necessary information for administration are printed, at the completion of the preparation in order to secure a right barcode label to be invariably affixed to a right compounded product completed and eventually enables a proper administration of a medication product to a right patient after three points of certification by barcodes at the bedside. The program automatically records these processes throughout the procedures to secure traceability and documentation for the medication administration.

 Therefore, a closed-loop EMM system communicating only with digital data through the processes from prescription via the CPOE to administration of medication for patients has been established by using of barcode scanning with securing the right “patient, drug, dose, time, and route” in the NICU.

 Objectives: The number of pregnancies following infertility treatment has been increasing worldwide. The aim of this study was to investigate the maternal and neonatal outcomes associated with infertility treatments.

 Methods: We conducted a secondary data analysis using electronic clinical records from one hospital in Narita, Japan. We included all women who gave birth between 2015 and 2018（N＝2,243）. We compared outcomes of pregnancies achieved using an ART（ART group）or a general infertility treatment（Non-ART group）with the outcomes of unassisted pregnancies（natural pregnancy group）. We investigated 7 maternal outcomes and 6 neonatal outcomes. We conducted multiple logistic regression to assess the differences in outcomes while adjusting for potential confounders.

 Results: We found a significantly higher risk of placenta previa in the general infertility treatment group（ORs＝2.41; 95％ CI＝1.03-5.63; p＝.043）and the ART group（ORs＝2.70; 95％ CI＝1.30-5.60; p ＜ .01）compared to the unassisted pregnancy group. The risks of major postpartum hemorrhage（ORs＝2.34; 95％ CI＝1.47-3.73, p ＜ .01）and low Apgar score at one minute（ORs＝1.81; 95％ CI＝1.05-3.11, p＝.034）were also higher in the ART group compared to the unassisted pregnancy group.

 Conclusions: This study indicates a possibility of increasing adverse maternal and neonatal outcomes associated with infertility treatment. Further studies with a large sample from multiple settings are needed for developing robust evidence on the impact of infertility treatment and for the prevention of adverse outcomes.

 【Objective】To compare elastase in amniotic fluid with other indices for prolonged pregnancy.

 【Method】We examined the cervical length, maternal blood markers（WBC, CRP）, and amniotic fluid markers （elastase, glucose, LDH）among 622 singleton pregnant women complicated with threatened premature labor or a premature rupture of the membranes who underwent amniotic aspiration at our hospital from May 2013 to May 2018. We analyzed the accuracy of predicting the occurrence of labor within 7 days using ROC curves. The accuracy was compared using AUC.

 【Result】It was found that elastase in amniotic fluid and prolonged pregnancy were significantly negatively correlated with the Spearman’s correlation coefficient -0.528（P value ＜ 0.001） . For predicting the occurrence of labor within 7 days, the AUC of elastase in amniotic fluid was 0.79, which was the highest compared with the other indices. The AUC was even higher, at 0.857, in the group of women with no rupture of the membranes. A similar trend was observed in cases at 22-33 weeks of gestation.

 【Conclusion】Elastase in amniotic fluid can be a highly accurate index for predicting the occurrence of labor within 7 days.

 Objective:

 We examined the role of first trimester fetal ultrasound screening in decision making on prenatal genetic testing in pregnant women of advanced maternal age.

 Design: Cross-sectional study.

 Methods:

 From December 2013 to November 2018 at Kumamoto University Hospital（Japan）, women aged ≥35 years at delivery and who underwent genetic counseling were given the results of their fetal nuchal translucency（NT） measurement. The women were classified into two groups: screening-negative with NT ＜ 3.0 mm and screening-positive with NT ≥3.0 mm. The women’s preference for prenatal testing after genetic counseling, and the fetal outcome, were retrospectively examined.

 Results:

 Of 627 women who had a singleton pregnancy and received NT measurement and genetic counseling, 598 （95.4％）were screening-negative and 29（4.6％）were screening-positive. Among the screening-negative group, 478（79.9％）opted for further diagnostic tests consisting of non-invasive prenatal testing（NIPT） （n＝440, 73.6％）, serum marker tests（n＝31, 5.2％）, and amniocentesis（n＝7, 1.2％） . A total of 120（20.1％）women did not wish to undergo further tests and decided to continue their pregnancy. In the screening-negative group, those who chose NIPT were significantly older and had a more positive impression of assisted reproductive technology. In the screening-positive group, 21（72.4％）women chose NIPT following the NT measurement. They tended to choose NIPT for mild NT thickening and amniocentesis for higher thickening.

 Conclusion:

 Genetic ultrasonography for pregnant women of advanced maternal age and who wished to undergo prenatal genetic testing influenced the choice regarding additional testing. Systematic prenatal genetic testing should be implemented at each institution to aid appropriate decision making.

 【Aim】To know the perinatal factors in involving the onset of intractable patent ductus arteriosus during NICU admission.

 【Subjects and Methods】The study subjects were 179 VLBWI whose gestational age were under 30 weeks after gestation（27.5±2.2wks, 950±297grams）. They were divided into two groups whether PDA was complicated or not. Secondary, PDA（+）was divided into two groups whether surgical ligation was required or not. Clinical eight factors were compared between two group, and logistic regression analysis was done to detect the significant variables.

 【Results】Total numbers of PDA（+）was 83 and PDA（-）was 96. Ligation（+）was 14 and Ligation（-）was 69. By multivariate analysis, gestational age（p=0.001, OR0.78, 95%C.I. 0.68-0.91）and antenatal steroid administration（p=0.012, OR0.40, 95%C.I. 0.20-0.82）was selected as a significant variable to symptomatic PDA occurrence. Gestational age（p=0.003, OR0.58, 95%C.I. 0.41-0.83）was selected as a significant and antenatal diclofenac sodium administration（p=0.074, OR5.12, 95%C.I. 0.86-30.7）was select as a possible variable to require surgical ligation.

 【Conclusion】In addition to gestational age, antenatal administration of steroid and diclofenac sodium may affect the severity of premature patent ductus arteriosus.

 The number of women undergoing radical trachelectomy（RT）for early cervical cancer is increasing with late marriage and cervical cancer. Furthermore, when such women become pregnant, the rate of premature delivery is high. But no established management method exists. In this study, we retrospectively examined the perinatal management and prognosis of five post-RT pregnancies at our hospital.

 In all five cases, abdominal RT and cervical cerclage were performed for IB1 stage cervical cancer. The average age at the time of pregnancy was 35.6 years. The median gestational age was 32 weeks and 1 day, with one miscarriage and three premature births. The four premature cases were due to premature rupture of membranes. Upon a pathological examination of the placenta, three cases（excluding a premature case at 35 weeks）showed chorioamnionitis. Infection was most likely the factor that most contributed to premature delivery. At our hospital, measures such as antibiotics, intravaginal administration, probiotic use, and bed rest management were performed.

 However, infections could not be controlled completely, and new management methods are necessary.

 Objective：The number of foreign tourists visiting in Okinawa reached a record high of 2.90 million in 2018. A concomitant increase in pregnant tourists visiting our emergency center also occurred during this time. The aim of this study was to determine the number of pregnant foreign tourists who visited our hospital and identify problems particular to their charactars and treatments.

 Methods：We reviewed the medical records of all the pregnant foreign tourists who visited our emergency center during the five years from January, 2014 to December, 2018.

 Results：There were 37 pregnant tourists who visited our hospital during this time. Of these, foreign tourists were hospitalized in four cases. Two women had preterm deliveries, which cost around 3 million yen each for hospitalization including the maternal and neonatal care. Additionally There were complicating factors such as different languages and customs, and different health insurance systems that made medical practice difficult.

 Conclusion：The number of pregnant foreign tourists visiting our hospital increased in the last five years, which put a lot of strain on our medical service both financially and in terms of the quality of care. So, we need to improve social resources and medical environment.

 Uterine hemorrhage is one of the leading causes of maternal mortality and it requires prompt treatment. These days, uterine artery embolization（UAE）is more often selected as the treatment for uterine hemorrhage. However, the fertility of women who undergo UAE remain unclear. The aim of the current study was to reveal the long term effects of UAE for uterine hemorrhage on menses resumption, fertility, and perinatal outcome of the succeeding pregnancy. Out of 78 patients who underwent UAE, 53 patients were included in the study. Menstruation resumed in 52 patients（98.1％） . Out of 15 patients who desired the subsequent pregnancy, 11 patients became pregnant. Eight patients gave birth to a baby. Three patients were complicated with placenta accrete and underwent cesarean hysterectomy. Our results suggested that UAE for uterine hemorrhage does not adversely affect the menstrual and fertility outcome. However, the history of UAE is possibly a risk factor of placenta accrete. When the pregnant woman has the history of UAE, the careful perinatal management and the adequate explanation of the perinatal risk is needed.

 Background: The neonatal cardio-pulmonary resuscitation（NCPR）training course accepts paramedics as trainees. The course includes scenario training that is conducted in a hospital setting and is different from scenes that emergency medical services（EMS）personnel work. Current NCPR training course may be unsuitable for EMS personnel.

 Objective: The aim of this study is to describe the following: pass rate of the NCPR qualifying exam, current certification status, our NCPR training course evaluation, and behavioral change of EMS personnel after the course.

 Method: In total, 22 EMS personnel who attended the NCPR training course held by the researchers from 2017 to 2018 were invited to participate in this survey using a questionnaire designed to meet the objective.

 Results: A total of 21 responses were analyzed. Eighteen subjects（85.7％）passed the NCPR qualifying exam. Thirteen subjects did not apply NCPR certification because the certification fee was expensive for them and certification was unnecessary for their practice. Three（14.3％）subjects failed the exam, and none of them have emergency medical technician（EMT）license. Twenty subjects（95.2％）recommended colleagues to attend the NCPR training course. Sixteen subjects（76.2％）responded that it would be difficult to deal with perinatal cases after completing their training.

 Conclusion: The survey found a disparity in the abilities between EMTs and EMS personnel. Further, despite succeeding in the exam, most respondents do not acquire NCPR certification, raising the concern that they lack continuous training. A maternal and neonatal resuscitation training course program designed for EMS personnel is necessary.

 Fetal complete atrioventricular block（CCAVB）occurs in 1 to 2％ in anti-SS-A antibody positive pregnant women.

 Case: A 35-year-old woman was gravidity 2 para 1.

 She has not been diagnosed with Sjogren’s syndrome before pregnancy.

 In the previous pregnancy, she was performed an emergency caesarean section because of NRFS. In this pregnancy, she was admitted because of her fetal advanced bradycardia at the examination of 30 weeks’ gestation. The fetal atrium / ventricle beat rate was 136/63 bpm and diagnosed as CCAVB.

 In addition, maternal anti-SS-A / SS-B antibody was positive and Sjogren’s syndrome was diagnosed.

 Ritodrine hydrochloride instillation was started and it was evaluated fetal heart function with CVPS and maintained 8 points or more.

 At the 37th week and 5th pregnancy, a selective caesarean section was performed.

 The baby was 2878g, male, Apgar score is 5/5 points. Umbilical arterial blood pH 7.289.

 The Baby’s heart rate was 49 bpm at birth, and bradycardia was continuing, so a pacemaker implant surgery went to the day-old 45. It is important to always be conscious of fetal arrhythmia during pregnancy examination and to evaluate fetal heart function appropriately, because there are undiagnosed antibody positive pregnant women and CCAVB may develop even in the late pregnancy as in this case.

 In recent years, various effects of intestinal flora were validated. Therefore, probiotics are widely used even in newborns. Although only few studies reported on the adverse events of probiotics, we encountered a case considered non–IgE-mediated gastrointestinal food allergy due to the probiotics in an infant. Herein, we report the case of an extremely low-birth-weight preterm infant with a gestational age of 27 weeks and birth weight of 984 g. The infant immediately received probiotics and breast milk after birth. Artificial milk and human milk fortifier caused abdominal distension and eosinophilia. Even though they were discontinued, the symptoms persisted. The infant got dermatitis and did not gain adequate weight. Discontinuation of probiotics resulted in improvement of skin condition and a slight increase in weight. Finally, the infant gained adequate weight after receiving hydrolyzed milk instead of breast milk. Allergen-specific lymphocyte stimulation tests were positive for lactoferrin, and drug-induced lymphocyte stimulation tests were positive for probiotics and weakly positive for breast milk. The infant was strongly suspected of non–IgE-mediated gastrointestinal food allergy to artificial milk, human milk fortifier, probiotics, and breast milk. It was assumed that the antigen in probiotics was a milk protein contained in the bacterial culture medium. Under various conditions, influence of probiotics must be considered.

 Although uterine rupture is rare, its incidence is higher among pregnant women with a history of uterine surgery. Use of epidural anesthesia can possibly delay the diagnosis of uterine rupture. In this case, a 34-year-old gravida 2 para 1 women with no history of uterine surgery developed uterine rupture during induction with epidural anesthesia which was diagnosed early and immediate lifesaving intervention was provided. She was admitted for labor induction at 39+6 weeks of gestation. The labor was prolonged at 6-cm cervical dilation. She experienced sudden pain in her left abdomen, and fetal heart rate abnormalities were observed after frequent contraction. We diagnosed NRFS and decided to perform a cesarean section. During laparotomy, the baby was extracted from the abdominal cavity and delivered. The postoperative period was good for both the mother and baby. Uterine rupture can occur in pregnant women with unscarred uterus. In particular, sudden-onset abdominal pain and fetal heart rate abnormalities with good pain relief indicate uterine rupture.

 Hyperreactio luteinalis（HL）is a rare condition that causes multicystic bilateral ovarian enlargement because of chorionic diseases or pregnancy. Although the clinical practice guidelines provide information on HL, it may be misdiagnosed or considered as an ovarian tumor that rapidly increases during pregnancy, and surgical intervention may accordingly be considered necessary. However, HL is a benign condition and surgical intervention may not be essential. Herein, we report two cases of HL. In one case, surgery was performed during pregnancy. We diagnosed the second case easily based on the experience of the first case and provided conservative management. The first case involved a 31-year-old woman, gravida 0, who underwent an emergency operation at 35 weeks’ gestation because of ovarian torsion. HL was not considered in the differential diagnosis before surgery; we had suspected a functional cyst due to ovarian hyperstimulation syndrome. Thus, a part of the ovary was resected for histopathological examination. The second case involved a 27-year-old woman, gravida 0 with multicystic bilateral ovarian enlargement found at 12 weeks’ gestation. We could diagnose HL based on our experience with the first case and from the clinical course and imaging findings. The patient was treated conservatively with follow up. HL can be accurately diagnosed by imaging findings and clinical history of rapidly increasing or gradually decreasing. Adequate knowledge about HL can lead to a reliable diagnosis and, eventually, avoid unnecessary surgical excision.

 Two cases of pregnancy complicated with achondroplasia（ACH）are described. We performed cesarean section in both cases for cephaloplelvic disproportion. In addition, we chose general anesthesia because spinal anesthesia was difficult for thoracolumbar junction kyphosis in both cases. Case1 needed the management of the threatened premature delivery, but was able to continue the pregnancy until 36 weeks. In Case2, fetus was suspected to have ACH because of recognition of disproportionate small stature on ultrasonography. It is reported that there are various obstetric complications in ACH for its characteristic features. In those cases, vaginal delivery is difficult and choose cesarean section due to small and contracted pelvis. In the case of pregnancy with achondroplasia, it is necessary to manage carefully in facilities which can cooperate with anesteologists because there is a difficult case about the anesthesia.

 Sirenomelia is a very rare congenital malformation, devided according to how their lower limbs fused. Most of them present oligohydramnios in second trimester due to renal agenesis or hypoplasia. On the other hand, Potter sequence refers to a typical physical features and associated pulmonary hypoplasia of neonates as a direct result of oligohydroamnios. And it is difficult clinically differentiate both diseases as much of their features overlap. We suspected the case as Potter sequence because of oligohydramnios and renal agenesis at 18 weeks of gestation. After stillbirth at 21 weeks of gestation, we performed three-dimensional computed tomography（3D-CT）as Autopsy imaging（Ai）, there was fused lower limbs with one fibula and two tibia, right renal hypoplasia, left renal agenesis, finally we diagnosed in detail sirenomelia（symmelia TypeII）. It is necessary when there was severe oligohydramnios and renal agenesis, suspected Potter sequence, to consider the sirenomelia as one of the differential diagnosis. Only one previous study reported of sirenomelia diagnosed by 3D-CT as Ai. 3D-CT is excellent for representing bones, it would be useful for diagnosis of diseases which present a bone morphological abnormalities like sirenomelia.

 Extralobar pulmonary sequestration（ELS）accounts for 25％ of all sequestrations, and intraabdominal ELS is rare with 10-15％. A 29-year-old multipara woman was reffered to our hospital for further evaluation of a fetal left subdiaphragmatic mass at 27 weeks’ gestation. A well circumscribed and hyperechogenic intraabdominal suprarenal mass was detected on prenatal ultrasonography（US）. Magnetic resonance imaging（MRI）at 33 weeks’ gestation revealed well-defined mass with homogenious high-signal intensity being similar to normal lung. A combination of color and power Doppler US at 35 weeks’ gestation allowed visualization of a vessel arising from the descending aorta and supplying the mass. These results of imaging studies favored an ELS. A 2,904g male infant was vaginally delivered at 39 weeks’ gestation, and asymptomatic at birth. After follow-up on the outpatient department, laparoscopic resection was undergone at 1 year old. Fetal intraabdominal ELS was often found as suprarenal mass. Combination of US and MRI allows a more accurate diagnosis, and therefore it’s made possible to give counseling and manage more effectively.

 Cardiac tumors are rare during childhood. The most common cardiac tumor in infants and in children is rhabdomyoma accounting for up to 64％ of all pediatric cardiac tumors. Cardiac rhabdomyoma is often asymptomatic and spontaneous regression is frequently observed. On the other hand, cardiac dysfunction, outflow obstruction and arrhythmia has been reported, resulting in sudden death in some cases. The principal therapy of cardiac rhabdomyoma is symptomatic treatment, although surgical intervention could be a choice for cases with severe symptoms. Recently mTOR inhibitor such as everolimus became available for cardiac rhabdomyoma and is reported to be effective especially in the treatment during fetal to neonatal periods.

 We report a case diagnosed as cardiac rhabdomyoma by fetal echography at 34-week of gestation. The tumor size was around 3.0cm² showing a left ventricular obstruction. As the risk of sudden death is considered to be high because ventricular premature contraction rapidly increased, treatment with everolimus was introduced from the day of birth. As a result, the tumor size reduced from 3.0cm² to 1.4cm² at 14th day following administration, resulting in disappearance of ventricular premature contraction. Administration of everolimus was ceased at 32-day old. Thereafter, the tumor has increased slightly but no symptoms of obstruction of left ventricular out flow tract have been observed. To provide early and appropriate treatment intervention, careful follow up of cardiac function and arrhythmia from pre-natal period is essential.

 Preterm ovarian hyperstimulation syndrome（POHS）occurs in preterm female infants of less than 32 weeks of gestational age and is characterized by symptoms, such as swelling of the vulva, ovarian cysts, and increased level of estradiol（E2）and gonadotropin, that become evident at around 37 weeks postconception age（WPCA）. Case1: A 131-day-old（42 WPCA）female infant was detected the presence of a lower abdominal mass in ultrasonography. She also presented with swelling of the vulva. Laboratory studies showed elevated levels of luteinizing hormone and E2, and normal level of follicle-stimulating hormone. We identified a 50mm diameter ovarian cyst that we subsequently punctured using ultrasonography. 4 months after presentation, swelling had improved and an ovarian cyst had disappeared. Case2: A 97-day-old（40 WPCA）female infant presented with swelling of the vulva. Ultrasonography revealed the presence of a 35mm diameter ovarian cyst. Laboratory studies showed elevated levels of luteinizing hormone and E2, and normal level of follicle-stimulating hormone. 3 months after presentation, swelling had improved and an ovarian cyst had disappeared. Our findings suggest that ultrasonography should be performed for preterm infants who present with swelling of the vulva at around 37WPCA in order to determine the presence and the size of ovarian cysts.

 Background

 During pregnancy, triglyceride（TG）levels multiply to 2-3 fold. Acute pancreatitis（AP）, diagnosed in approximately 3/10,000 pregnancies, can be caused by severe hypertriglyceridemia（HTG）. Previous studies report maternal and fetal mortality rates of 20％ and 50％, respectively. Recent literature indicates that, improved diagnosis and treatment, can reduce maternal and fetal mortality rates（to ＜ 1％ and 5％, respectively）. Herein, we present a case of HTG-induced AP during pregnancy.

 Case presentation

 This case is of a 40-year-old primigravida woman with HTG. Prior to pregnancy, TG levels were maintained at approximately 200 mg/dL, through diet therapy.

 The patient had no family history of HTG, and she was admitted to our hospital at 31 + 6 weeks, following complaints of an acute onset upper abdominal pain, back pain, nausea, and vomiting. Laboratory reports indicated the levels of TG and serum pancreas amylase to be 5,665 mg/dL and 783 U/L, respectively. Contrast-enhanced computed tomography（CT）indicated pancreatitis. Following administration of aggressive fluid resuscitation, opioids, and antibiotics, an emergency cesarean section was performed. Milky ascites was observed in the peritoneal cavity. The newborn was a healthy male infant, weighing 1698 g, with 1- and 5-minute Apgar scores of 3 and 8, respectively. The pH of blood in the umbilical artery was 7.30. Following surgery, the patient was transferred to the intensive care unit. On postoperative day（POD） 1, TG levels improved to 665 mg/dL. However, norepinephrine and high-flow nasal cannula oxygen therapy was required, and the patient was diagnosed with severe AP. On POD5, a low-fat soft diet was recommended. Once the HTG and AP levels improved, patient was discharged on POD19, and fibrates were continued orally.

 Conclusions

 AP should be considered as a differential diagnosis for acute onset upper abdominal pain during pregnancy. We must be aware of AP, in a pregnant woman with HTG.

 Transient abnormal myelopoiesis（TAM）usually occurs in neonates with Down syndrome, and in approximately 20％ of those affected develop acute megakaryoblastic leukemia（AMKL）. We report a case of TAM without the physical and clinical features of Down syndrome. The percentage of peripheral blood mononuclear cells with trisomy 21 in which the GATA1 mutation was detected was 11-20％. However, cells with trisomy 21 were not detected in the buccal mucosa. The blasts and trisomy 21-positive cells possessing the GATA1 mutation disappeared without therapeutic intervention. The patient is in remission without development of AMKL. She also presents normal psychomotor development at the age of 2 years and 7 months. This article also briefly reviews previously published cases of TAM in phenotypically normal neonates. These cases were not significantly different from Down syndrome cases in terms of remission rate of TAM and AMKL incidence. Psychomotor development was normal. This is the first report confirming the disappearance of the GATA1 mutation. Considering our results, we recommend serial examination of the GATA1 mutation in patients with TAM.

An extremely low birth weight male infant born at 664g was operated for ileostomy and the abdominal drainage on day12 at regional hosital because of focal intestinal perforation. He was transferred to our institution for the purpose of laser therapy due to severe retinopathy of prematurity at the age of 2months old. After 7days from admission, he developed a necrotizing enterocolitis（NEC）due to MRSA infection and successful conservative management was done. Although the contrast study at the time of admittion showed the patency of the distal ileostomy to the anus, most of the distal intestine developed atrophic and strictured after NEC. A laparoscopic total colon resection and trans-anal endorectal pull through of the ileum was performed at the age of three.

An intestinal stricture after conservative management of NEC is a well-known complication. The colonic stricture following to NEC often occurs on the left side of the colon and the stricture is reported as sporadic in many cases, unlikely to our case which has no previous similar case report. We herein report this extremely rare case with review of the literature.

 Transient abnormal myelopoiesis（TAM）occurs in approximately 5-10％ of newborns with Down syndrome, and approximately 20％ of cases are severe. In recent years, it has been reported that early chemotherapy with low-dose cytarabine improves the prognosis of severe TAM. However, the use of cytarabine to treat newborns with severe TAM and persistent pulmonary hypertension of the newborn（PPHN）has not been reported previously. We report four cases in which infants with Down syndrome presented with TAM and persistent PPHN. Case 1: A female infant was delivered after 40 weeks and 0 days of gestation, with a birth weight of 2,635g. She was treated with a steroid for pericardial effusion. She was discharged from hospital on day 34. Case 2: A female infant was delivered after 32 weeks and 1 day of gestation, with a birth weight of 2,309g. She received chemotherapy from day 11, but died of hepatic failure on day 45. Case 3: A female infant was delivered after 36 weeks and 1 day of gestation, with a birth weight of 2,743g. She showed evidence of advanced hepatic fibrosis and died on day 34. Case 4: A male infant was delivered after 37 weeks and 0 days of gestation, with a birth weight of 3,122g. He received chemotherapy from day 16, but died of multiple organ dysfunction on day 28. At our hospital, only neonatologists treat severe TAM. Three of the 4 abovementioned patients could not be saved, and there is a possibility that low-dose cytarabine treatment was delayed too long. It is difficult for neonatologists to determine whether cytarabine chemotherapy should be administered in the early stages after birth. As it is difficult to treat newborns with severe TAM, it is necessary for neonatologists and pediatric hematologists to cooperate in such cases.

 Non-invasive nitric oxide（NO）inhalation therapy has been reported as an effective treatment for chronic lung disease（CLD）complicated with pulmonary hypertension（PH）. However, there are few reports on the environmental effects of excreted NO and nitrogen dioxide（NO₂）. This study aims to evaluate the effectiveness of non-invasive NO inhalation therapy for patients with CLD–PH（chronic lung disease associated PH）and the environmental effects of NO and NO₂.

 We report a patient who was born at 25 weeks of gestation by cesarean section from a 24-year-old mother. Postnatally, the neonate was provided inhaled NO therapy from 1^st to 31^th days of age for persistent pulmonary hypertension of the neonate. He was intubated and placed on mechanical ventilation for 60 days. Although he was supported by non-invasive positive airway pressure after extubation, labored breathing emerged as an exacerbation of PH at 7 months of age. Because he needed a high concentration of oxygen, non-invasive NO inhalation therapy was initiated. His PH findings immediately improved after the initiation of NO inhalation, and no side effects were observed. However, from 11 months of age, he continued to show cyanosis when he was crying and non-invasive NO inhalation therapy was re-initiated. He was unable to withdraw from NO therapy. He diagnosed to have tracheomalacia using fiberoptic bronchoscopy. Therefore, he received a tracheostomy at 15 months and was discharged home with a mechanical ventilator at 19 months. During the treatment, concentrations of NO and NO₂ were not detected around 40cm away from him.

 Thus, non-invasive NO inhalation for patients with CLD–PH is effective and safety therapy. In addition, we should consider early intervention for severe CLD-PH with airway involvement.

 For pregnancies with congenital heart diseases（CHD）, there are some scoring systems to predict the risk of heart failure during pregnancy by types of CHD or pre-pregnancy cardiac function. However, obstetric complications were not taken into consideration for them. We experienced a suggestive case of pregnancy with tetralogy of Fallot（TOF）which is a relatively lower risk of maternal heart failure. This case was a woman with a history of repairing TOF and two previous cesarean sections without complications. She was NYHA class I in early gestation of her 3rd pregnancy. She had placenta previa with repeated bleeding, and she was admitted at 18 weeks of gestation. The storage of her autologous blood started from 24 weeks of gestation. She developed preterm labor, and we administrated magnesium sulfate at 28 weeks of gestation and a steroid in 29 weeks of gestation. Then she developed right heart failure reaching up to NYHA class IV. We conducted emergent caesarean section and hysterectomy at 30 weeks of gestation. Increase of cardiac pre-load caused by magnesium sulfate administration, water retention by steroids, and anemia caused by autologous blood storage might promote right heart failure. For pregnancies with CHD, even patients with low risk heart failure for pre-pregnancy assessments can develop heart failure by obstetrical complication and its treatments. Thus, strict monitoring of cardiac function is needed.

 Pregnant women with severe hyperemesis gravidarum can develop catheter-induced bloodstream infections. Stenotrophomonas maltophilia is a multidrug-resistant bacterium. We report hyperemesis gravidarum-associated bacteremia caused by S.maltophilia. A 36-year-old woman was administered intravenous fluids for hyperemesis gravidarum between the 5^th and 19^th weeks of gestation. She developed high fever at 19 weeks of gestation; however, fever subsided spontaneously the following day without treatment. Two sets of blood cultures yielded S.maltophilia, although this organism was not isolated from urine and vaginal cultures. She was treated with intravenous levofloxacin for 5 days and delivered a healthy neonate at 37 weeks’ gestation.

 We have started preconception transabdominal uterine cervical cerclage（TAC）for patients with an ultra-short uterine cervix who are impossible to perform transvaginal approach, and we experienced 13 operations and 10 successful deliveries so far. In patients with missed abortion after TAC at the time of late first trimester of pregnancy, or in those with several types of abnormal pregnancies, transvaginal operation for these conditions is very difficult because the dilatation of the uterine cervix is almost impossible. They usually have to choose transabdominal approach for those conditions.

 We report a case of missed abortion at 8 weeks of pregnancy after TAC. She underwent TAC because she had ultra-short cervix after vaginal radical trachelectomy. Fetal and villus components were not excreted even 3 months after the detection of abortion. Transvaginal approach was impossible, so we underwent the general administration of methotrexate（MTX）for this patient. Fetal and villus components were completely excreted after 3courses of MTX treatment without any troubles. Blood hCG level also became normal after the treatment. This patient conceived again after MTX treatment and got a healthy baby of 1,912g at 33 weeks of pregnancy by scheduled cesarean section. Administration of MTX might be an useful treatment modality for patients with these conditions.