Dear Colleagues,

The selection session for 2017 JSSHP Research Award was held on September 22, 2017 during the 38^th JSSHP Annual Congress in Kumamoto.

Now we are happy to announce the winners of the JSSHP Research Award. Congratulations!!

Basic research

Catechol-O-Methyltransferase Deficiency Leads to Hypersensitivity of the Pressor Response Against Angiotensin ll.

Norikazu Ueki

Department of Obstetrics and Gynecology, Juntendo University

Clinical study

Measurement of serum-circulating PlGF, sFlt-1, sFlt-1/PlGF ratio, and sEndoglin at the 2nd trimester is useful for predicting pregnant women with fetal growth restriction (FGR) who will subsequently develop preeclampsia (PE).

Sakiko Nanjo

Department of Obstetrics and Gynecology, Wakayama Medical University

A multicenter study on home blood pressure measurement (HBPM) targeting Japanese pregnant women by the Japan Society for the Study of Hypertension in Pregnancy (JSSHP) has been ongoing since 2016. To date, over 200 pregnant women have been enrolled. This is an interim report.

Obesity and pregnancy are both factors that complicate anesthesia management; when the two factors are combined as in the case of obese pregnant women, this creates difficult challenges for anesthesiologists and obstetricians. The most effective way to address this is to prepare for a cooperative effort between all medical personnel that involves strategic obstetric anesthesia management for an obese pregnant woman before labor begins. All involved must understand the physiological changes and the necessary application of anesthesia skills for labor pain relief, both for scheduled and emergency caesarean sections. This review article introduces the various methods of anesthesia used for obese pregnant women.

Oxidative stress is required for the development of hypoxic injury and has been investigated as a key factor in the pathogenesis of preeclampsia. In preeclampsia, hypoxia at the implantation site can contribute to lesion formation, leading to poor placentation. Hypoxia-inducible factor-1α (HIF-1α) is a known transcription factor involved in placentation. Increased levels of HIF-1α can induce secretion of soluble vascular endothelial growth factor receptor-1 (sFlt-1), which is known to be a major factor influencing the pathogenesis of preeclampsia. Meanwhile, HIF-1α and HIF-1β mediate the maintenance and production of endothelial progenitor cells and bone marrow-derived stem cells, which play important roles in placental vascular development. Related dysfunction can result in preeclampsia. It is also known that glycolytic enzyme phosphoglycerate mutase (PGAM) is deacetylated and activated by reactive oxygen species (ROS), the former of which may regulate cell proliferation through the effects of ROS without the participation of HIF-1α. In this review, we characterize the roles of HIF and PGAM in the pathogenesis of preeclampsia.

Animal models of preeclampsia are widely used to elucidate the underlying pathology and investigate the clinical utility of drugs. Although a large body of data has been generated that supports their usefulness, animal models are not necessarily suitable for all research objectives. A more thorough understanding of advantages and disadvantages of each animal model will facilitate selection of appropriate models for a given study area, thereby enabling researchers to obtain more useful research results. The metabolic domino theory offers an explanation for the time-course of increase in the risk of cardiovascular events due to complex interactions among lifestyle-related diseases, which is likened to the sequential falling of dominoes. This theory provides a valuable perspective for understanding the importance of lifestyle-related diseases, as well as the process leading to the onset of cardiovascular events. Preeclampsia has adverse effects on both pregnant women and their fetuses/infants in the short term, whereas in the long term, it also increases the frequency of cardiovascular events in patients approaching middle and old age. Therefore, from a clinical perspective, preeclampsia is considered similar to lifestyle-related diseases, and its pathology might be better understood in light of the metabolic domino theory; this, in turn, will facilitate the selection of an appropriate animal model. Various models are considered applicable for research aimed at elucidating the pathology of preeclampsia, including antiangiogenic factor overexpression models, reduced uterine perfusion pressure (RUPP) models, and risk- and regulatory-factor knock-out models. However, in light of the metabolic domino theory, these models do not accurately replicate the pathology of preeclampsia, and are thus not necessarily appropriate for the investigation of drug utility.

Aim: To determine the association between pregnancy-related thromboembolism and pre-existing risk factors, as well as the association between its severity and risk factors, among Japanese women.

Methods: We retrospectively analyzed cases of pregnancy-related thromboembolism over 10 years at a single Japanese tertiary obstetrics institute. Patients were divided into two groups based on thromboembolism severity.

Results: Our 22 thromboembolic patients had an incidence/detection rate of 0.18% (22/12,500). Deep venous thrombosis (DVT), PE, and DVT+PE occurred in 15 (68%), 3 (14%), and 4 (18%) patients, respectively. Of the 22 patients, 20 (91%) had pre-existing risk factors. Thrombophilia and bed rest were the most common, with each at 8/22 (36%). Of the 8 with thrombophilia, anti-phospholipid antibody syndrome (APS) and protein S (PS) deficiency accounted for 5 and 3 patients, respectively. Thrombophilia was detected in 7/15 (47%) and 1/7 (13%) in the severe and mild groups, respectively, showing that thrombophilia was more likely to accompany severe thromboembolism. All APS patients suffered severe thromboembolism.

Conclusions: Thrombophilia and bed rest were the most common risk factors for thromboembolism in a Japanese tertiary perinatal center. The most important thrombophilic factors accompanying thromboembolism were APS and PS deficiency. Patients with thrombophilia were likely to show severe thromboembolism.

Aim: To evaluate the maternal-neonatal complications of a forceps delivery (FD) by using trapezoidal-Station (t-St), a 3-dimensional assessment of fetal head descent.

Methods: This was a retrospective study of 1532 FDs conducted between 1985 and 2012. First, overall outcomes of FDs using t-St were analyzed between years. Second, for FDs from 2007 to 2012, a more detailed analysis of complications was drawn, making comparisons between normal deliveries (NDs) and FDs, and between t-St+2 and t-St+3/lower.

Results: Of the 1532 FD cases performed in 28 years, two cases (0.1%) failed. Comparison of ND and FD cases from 2007 to 2012 revealed no significant difference in incidence of 4th degree perineal laceration. No perinatal deaths or cerebral palsy were noted. Comparison of t-St+2 and t-St+3/lower revealed no significant differences in blood loss volume, umbilical cord arterial blood pH, incidence of 3rd/4th degree perineal lacerations (OR, 0.88; 95% CI, 0.35–2.23), or incidence of Apgar score<7 at 1 (OR, 1.93; 95% CI, 0.59–6.27) and 5 minutes (OR, 2.80; 95% CI, 0.25–31.59).

Conclusions: FDs using the 3-dimensional assessment were performed safely. The t-St may be an objective and precise assessment of fetal head descent, enabling safe management of FDs.

Placenta accreta is one of the causes of postpartum hemorrhage (PPH). Recently, interventional radiology (IVR) techniques, such as arterial embolization and balloon occlusion, have become widely used to manage hemorrhage associated with placenta accreta. Although IVR techniques could prevent maternal death and even preserve the uterus in PPH, in pregnancies after IVR, there have been reports that the risk of placenta accreta is increased. In this case report, a 39-year-old primiparous patient underwent IVR for the treatment of a retained placenta after vaginal delivery. However, IVR failed to stop uterine bleeding. Hysterectomy was finally performed for the patient’s survival. Histological examination of the extirpated uterus after IVR showed changes in the expression of myosin heavy chain isoforms (SM1 and SMemb) in vascular smooth muscle cells due to inflammatory changes in the uterus following ischemic damage.