Agreement about the terminology and descriptions of fetal heart rate (FHR) patterns (nomenclature) is now well established, largely based on the report of the National Institute of Child Health and Human Development (NICHD) workshop of 1997, but consensus on FHR interpretation and management has been extraordinarily difficult to achieve in US obstetrics. Interpretation deals with the significance for the fetus in terms of risk of potentially damaging metabolic acidemia. It is also now understood that part of this interpretation is recognizing or projecting the probability of a pattern of lower risk of acidemia evolving into one with a higher risk so that timely intervention can occur. Management means how the obstetrical team actually responds to a FHR pattern to minimize fetal metabolic acidemia without excessive operative or other interventions.
Many professional bodies and individuals, particularly overseas, have classified FHR patterns and recommended management approaches. For various reasons none of these guidelines has achieved widespread international adoption.
Evidence is accumulating that a 5-tier system does relate to degrees of acidemia and fetal damage and, if appropriately rule based, can improve consistency in interpretation among providers. There is also emerging evidence that if taught and accepted hospital-wide, such an approach can reduce newborn metabolic acidemia without increased obstetrical intervention.
An obvious solution is for professional associations to set up a framework that conforms to the currently available data (admittedly limited), which can be tested for effectiveness. The Japan Society of Obstetrics and Gynecology has done this with 5 tiers on a national level and is expecting validation (or the opposite) to emerge from subsequent studies.

View full abstract

Cervical maturation is one of the key events in the process of labor, either at term or preterm. The mechanisms involved in cervical ripening start early in pregnancy and increase near parturition. The main changes occur in the cervical connective tissue, mainly the extracellular matrix. They include disorganization of collagen network, increase in hyaluronic acid, increased water content and changes in the proteoglycan content, leading to dramatic changes in the consistency of the cervix.
The pharmacologic control of the cervical ripening process is of major interest, either to allow labor induction in case of an unfavorable cervix, or to prevent preterm delivery in case of premature cervical shortening.
Many substances are known to play a role in the physiologic and pathologic processes of cervical ripening: prostaglandins, relaxin, nitric oxide and inflammatory cytokines may induce cervical priming whereas progesterone play an inhibitory role in the process of cervical ripening and labor induction.
Based on these pathophysiological data, several compounds and/or interventions have been proposed to induce or conversely to prevent cervical ripening and labor with uneven success. Data from recent studies on cervical maturation and labor induction in case of unripe cervix are presented in this review.

View full abstract

The precise reporting of fetal station is important in the decision-making regarding whether instrumental vaginal delivery or cesarean section should be performed. However, accurate evaluation of fetal station is difficult because it is defined on the basis of a hypothetical vertical midline to the ischial spines. Moreover, during delivery, the fetal head descends anteriorly into the pelvis along the pelvic axis and not in the vertical direction. DeLee’s concept of fetal station, first reported in 1924, has been revised by taking into account the fetal head descent along the pelvic axis, and this concept has been in clinical use at the University of Tokyo Hospital since the 1970s.
In this review, we assess the problems associated with conventional fetal station and explain the new concept of fetal station based on the trapezoidal plane and assessment of head descent upon instrumental delivery.

View full abstract

Aim: To test the hypothesis that lipocalin-type prostaglandin D synthase (L-PGDS), a marker of vascular endothelial cell disorders, may be a diagnostic for preeclampsia.
Methods: Plasma and urine were collected from 36 preeclamptic patients and 94 normal pregnant women. L-PGDS concentrations were determined by sandwich ELISA assay. Receiver operating characteristic (ROC) curve validated the cut-off point of the assay.
Results: The plasma and urinary L-PGDS concentrations were significantly higher in the preeclamptic patients than the normal pregnant women. Urinary L-PGDS concentrations of the normal pregnant women were higher in the third trimester compared to earlier pregnancy, while plasma concentrations remained unchanged. Urinary L-PGDS levels were significantly higher in early onset of preeclampsia (onset <32 weeks gestation) compared with late onset and in the severe compared to mild preeclampsia. ROC curve showed the cut-off point of 58.85 μg/dl (sensitivity 76.5%, specificity 75.6%, positive predictive value [PPV] 46.4%, negative predictive value [NPV] 92.1% and area under the curve [AUC] 0.82) in the plasma and 2.195 μg/dl (sensitivity 84.6%, specificity 58.7%, PPV 33.8%, NPV 93.8% and AUC 0.76) in urine.
Conclusions: Our results indicate that plasma and urinary concentrations of L-PGDS may be a potential diagnostic for preeclampsia.

View full abstract

Aim: The aim of this study was to examine the occurrence rate and clinical characteristics of labor-onset hypertension (LOH).
Methods: This was a retrospective study. Subjects were patients diagnosed with LOH at Hachioji Medical Center of Tokyo Medical University between January 1998 and December 2012. LOH was defined as systolic blood pressure (sBP)≥140 mmHg after labor onset despite no symptoms of prior pregnancy induced hypertension. We classified LOH subjects into three groups as follows: mild (140 mmHg≤maximum sBP<160 mmHg), severe (160 mmHg≤maximum sBP<180 mmHg) and emergent (180 mmHg≥maximum sBP). The control group comprised 405 normotensive pregnant women. We assessed the occurrence rate of LOH, eclampsia and cerebrovascular disease. We then evaluated the clinical characteristics of each LOH group, and compared them to the control group.
Results: A total of 1312 women (20.7%) were diagnosed with LOH (mild, 834 (13.2%); severe, 406 (6.4%); emergent, 72 (1.1%)). Three women had eclampsia (0.047%) and two had stroke (0.032%). The maximum sBP and diastolic blood pressure (dBP) during labor, proteinuria before labor and Apgar score were significantly different between groups.
Conclusion: Although it had little effect on fetal and placental condition, LOH may occur in one-fifth of normotensive pregnancies.

View full abstract

Aim: The aim of the present study was to investigate whether oral administration of labetalol, an αβ-blocker, might be useful for managing blood pressure (BP) in women with severe pregnancy induced hypertension (PIH).
Methods: Thirty-four pregnant women with severe hypertension (≥160/110 mmHg) were enrolled (15 preeclampsia [PE] and 19 gestational hypertension [GH]). Labetalol was given orally at 300–400 mg daily, and mean arterial pressure (MAP), the numeric rating scale (NRS) for headache, the double product (DP) as a work index of cardiac function, and fetal heart monitoring were observed for 3 days.
Results: Thirty patients continued to take labetalol for 3 days. Four PE patients were dropped out. Fifteen showed a decrease of more than 10% in MAP and were considered responders, while 19 showed a decrease of less than 10% and were considered non-responders. Labetalol appeared to be more effective in GH (11/19) than in PE (4/15). The NRS was improved in both groups (6 PE and 7 GH), as was DP (13 GH and 8 PE). Unfavorable changes in fetal heart rates were seen in 3 (1 PE and 2 GH).
Conclusion: The oral administration of labetalol might control the hypertension as well as the clinical symptoms in GH.

View full abstract

Aim: The aim of this study was to investigate the incidence of, indications for, and risk factors associated with emergency postpartum hysterectomy.
Methods: Thirteen cases of emergency postpartum hysterectomy performed at Hachioji Medical Center of Tokyo Medical University (HMC) between January 1998 and February 2012 were evaluated retrospectively.
Results: Emergency postpartum hysterectomy was performed in 13 of 42,119 deliveries (0.31 per 1,000 deliveries). Uterine rupture was the most frequent indication (38.5%). Disseminated intravascular coagulopathy was the most frequent pre- and postoperative complication. It was evident that the incidence of emergency postpartum hysterectomy decreased upon introduction of active recombinant factor VII and uterine artery embolism in HMC (to 0.15 per 1,000 deliveries).
Conclusion: Emergency postpartum hysterectomy remains an effective procedure for managing postpartum hemorrhage. However, our findings suggest that new procedures can contribute to reducing the need for emergency postpartum hysterectomy.

View full abstract

Posterior reversible encephalopathy syndrome (PRES) presents with headaches, an altered mental status, seizures and visual loss, and generally exhibits a good prognosis. We herein report the case of a primiparous preeclamptic woman who developed severe PRES after cesarean delivery at term. She underwent emergency cesarean section due to the onset of HELLP syndrome at 37 weeks of gestation. She fell into a deep trance on the first day postpartum. Brain MRI showed diffuse brain edema involving the brainstem. Due to the considerable risk of brain herniation, we performed surgical decompression for brain swelling on that day in addition to intensive treatment for HELLP syndrome and DIC. The patient successfully recovered from the acute episode without any neurological deficits. Although most cases of PRES involve a good prognosis without the need for surgical intervention, physicians should keep in mind the potential for serious cases requiring decompressive brain surgery in women with PRES.

View full abstract

This article was retracted.

View full abstract