The validity of the 30-minute cesarean section (CS) rule has been questioned. A new classification of the urgency of CS was introduced by the NICE in the United Kingdom and has received considerable attention in recent years. In the guideline, categories 1 and 2 are defined as “immediate threat to the life of the woman or fetus” and “maternal or fetal compromise which is not immediately life-threatening”, respectively, and the recommendation is to “perform category 1 and 2 CS as quickly as possible after making the decision, particularly for category 1” and to “perform category 2 CS in most situations within 75 minutes of making the decision”. In consideration of these suggestions, the anesthetic method should be chosen from among general anesthesia following rapid sequence induction, rapid sequence spinal anesthesia, and epidural anesthesia converted from epidural labor analgesia.

Although there are various causes of hemorrhage at the time of cesarean delivery, they are largely divided into bleeding from the separated surface of the placenta and atonic bleeding. A combination of hemostatic techniques such as balloon tamponade, compression suture, arterial ligation, transarterial embolization (TAE), and hysterectomy is important for successful hemostasis. When choosing a technique, features of local hemostatic techniques and vascular blockage techniques may need to be considered. Normal blood coagulation function is also important for achieving successful hemostasis.

Aim: The aim of this study was to assess the effect of magnesium sulfate as a potent antihypertensive agent in patients with severe pregnancy induced hypertension (PIH).

Methods: To assess the antihypertensive effect of magnesium sulfate, we retrospectively analyzed 27 women who were administered magnesium sulfate for seizure prophylaxis without any other antihypertensive agents. Average blood pressure was compared before and after administration.

Results: Blood pressure after administration (155±9.5/96±8.4 mmHg) was significantly lower than that before administration (166±8.2/102±8.0 mmHg) (P<0.01). An antihypertensive effect was observed in 59.3% (16/27) of patients (“effective cases”). Among the effective cases, an adequate effect was observed in 14 patients and an excessive effect in two patients. The maximum antihypertensive effect was achieved just after initial loading and was maintained until delivery, as well as 2 h after loading in most effective cases. In patients aged ≥40 years, the proportion of effective cases (16.7%, 1/6) was significantly lower than that among patients aged <40 years (71.4%, 15/21; P=0.016). The proportion of effective cases among patients with early-onset PIH (16.7%, 1/6) was also significantly lower than that among patients with late-onset PIH (71.4%, 15/21; P=0.016).

Conclusion: We demonstrated that magnesium sulfate has an antihypertensive effect in patients with severe PIH. However, this effect was not sufficient for controlling the blood pressure of patients aged ≥40 years or those with early-onset PIH.

Aim: We prospectively compared the safety of enoxaparin sodium, a low-molecular-weight heparin (LMWH), with unfractionated heparin (UFH), both of which were administered within 24 hours of cesarean section.

Methods: A total of 205 pregnant women at increased risk of venous thromboembolism (VTE) who underwent cesarean section for obstetrical indications between December 2012 and February 2015 were eligible to participate in this trial under written informed consent at Hamamatsu University Hospital. They were randomized into two groups based on the subcutaneous injection of enoxaparin sodium or UFH (Enoxaparin [n=98] and UFH [n=107] groups, respectively) 6, 18, and 30 hours after cesarean section. Incidences of symptomatic VTE, symptomatic bleeding, thrombocytopenia, and other complications were subsequently compared.

Results: One woman in the Enoxaparin group developed symptomatic mild pulmonary embolism (PE). One woman in the UFH group developed a hematoma in the abdominal wound, which required operative evacuation.

Conclusion: The safety of thromboprophylaxis with enoxaparin sodium within 24 hours of cesarean section appeared to be similar to that achieved by UFH. A large-scale cohort study is needed to compare the efficiency of inducing thromboprophylaxis by enoxaparin and UFH, in consideration of its rare onset.

Aim: Oligohydramnios contributes to a negative fetal prognosis. Management of oligohydramnios in obstetric clinical practice is important. We assessed the clinical efficacy of Gorei-San for the treatment of oligohydramnios.

Methods: Single deepest pocket (SDP) changes before and after treatment for oligohydramnios (SDP decrease to less than 3 cm) were examined. A total of 51 pregnant mothers who were experiencing oligohydramnios were enrolled in the study. The changes in SDP were compared between 27 women treated with Gorei-San (7.5 g/day) and 24 untreated women. The first measurements of SDP in both groups were obtained when the SDP had decreased to less than 3 cm (start point: SP), and the second measurements were obtained at the next regular examination (end point: EP).

Results: The average SDP significantly increased in women treated with Gorei-San from the SP (2.37±0.41 cm) (mean±SD) to the EP (3.15±0.62 cm) (mean±SD) (P<0.001). In contrast, there were no significant changes in the untreated women from the SP (2.5±0.15 cm) (median±quartile) (non-normally distributed) to the EP (2.63±0.68 cm) (mean±SD) (P=0.59).

Conclusions: Gorei-San was helpful in the treatment of oligohydramnios. Although further studies are needed to confirm our findings, we believe that this new application of Gorei-San for the treatment of oligohydramnios is a clinically applicable strategy.

A 31-year-old woman, gravida 2 para 2, admitted due to acute abdominal pain and diarrhea at week 29 of her pregnancy was threatened with premature labor and acute enterocolitis; intravenous ritodrine hydrochloride was started. She showed bloody diarrhea and at 29 weeks and 2 days gestation, spontaneous labor began. Due to arm presentation, an emergency caesarean section was performed. On postoperative day 2, Shiga toxin 2 positive enterohaemorrhagic E. coli (EHEC) O157 was found. On postoperative day 4, thrombocytopenia, haemolytic uremic syndrome (HUS), and renal failure developed. After four plasma exchanges, her symptoms had improved and tested negative for O157 on day 10.

For the health of the mother, we recommend inducing early delivery for a pregnancy presenting with bloody diarrhea and testing positive for EHEC O157 which may progress to Shiga toxin 2 infection.

Preeclampsia is often complicated by visual disorder, but retinal detachment is comparably rare. We experienced two cases of serous retinal detachment in life-threatening placental abruption and preeclampsia. Both patients complained of visual disorder after the onset of placental abruption. Magnetic resonance imaging, scanning laser ophthalmoscopy, and optical coherence tomography were useful in the diagnosis of serous retinal detachment, which spontaneously resolved after several months in both cases. In a severe case of placental abruption, serous retinal detachment should be considered if the patient has disordered vision, although the prognosis is typically good.

Mitochondrial disease exhibits various symptoms and is rarely seen in young women. We report the case of a patient with mitochondrial disease complicated with maternal inherited diabetes-deafness (MIDD) who suffered a severe clinical course. A 33-year-old primipara woman had a history of diabetes, diagnosed when she was 18 years old, and was treated with insulin injection. At 24 years old, genetic testing was performed and a point mutation of mitochondrial DNA in m3243 was identified. She was admitted to our hospital at 23 weeks of gestation because of threatened preterm labor and was treated with magnesium sulfate infusion. General malaise developed shortly after and the tocolytic agent was changed to ritodrine hydrochloride. She developed preeclampsia at 33 weeks of gestation and an emergency cesarean section was performed. After the cesarean section, UAE was performed due to uterine hemorrhage after birth and, because of infection, a hysterectomy was performed. An increased risk of preeclampsia, preterm birth and magnesium toxicity has been reported in pregnancies complicated with mitochondrial disease. Obstetricians need to recognize this disease as a perinatal risk factor.

Uterine artery embolization (UAE) is a common treatment for postpartum hemorrhage, however, the influences on uterus have yet to be uncertain. Here, we present a case of uterine embrittlement and perforation after UAE. A 30-year-old primipara received UAE for postpartum hemorrhage. Enhanced magnetic resonance imaging (MRI) after UAE showed lack of enhancement on uterine fundus. She complained hypomenorrhea after UAE, thus hysteroscopy was performed for intrauterine synechia. During the surgery, uterine perforation, which identical with the ischemic part on MRI, was found. It was repaired laparoscopically together with vulnerable surrounded area. With the case, because UAE tend to choose for woman who desire for the next pregnancy, we recommend that UAE should be limited and performed only for cases that could not accomplished hemostasis even with other methods. When UAE was chosen reluctantly, uterine myometrium ischemia should be monitored by contrast enhanced MRI.