Shigeru Saito (University of Toyama)

ISSHP 2020

to be held in Nara, October 14–17, 2020

Kenjiro Takagi (Jichi Medical University Saitama Medical Center)

The 40^th Annual Congress of the Japan Society for the Study of Hypertension in Pregnancy

to be held in Saitama, 2019

Tomoaki Ikeda (Mie University)

The 41^st Annual Congress of the Japan Society for the Study of Hypertension in Pregnancy

to be held in Nara, October 14–17, 2020

Numerous trial-and-error approaches have been taken to achieve effective hemostasis for difficult obstetrical uterine hemorrhage cases. In the field of obstetrics, transcatheter arterial embolization (TAE) is known to be highly effective for controlling uterine hemorrhage and hematoma. This procedure achieves a high hemostasis rate, and the frequency of hysterectomy has thus sharply decreased. Although arterial ligation for massive hemorrhage at the time of cesarean section may fail to control bleeding in a number of cases due to an abundance of collateral circulation pathways, various new hemostatic techniques such as compression sutures of the uterus, uterine tamponade with gauze or a balloon, and intraoperative TAE have become available. However, complications including subsequent endometrial hypoplasia, menstruation disorder, infertility, pregnancy loss, placenta accreta, and uterine rupture have been reported even in cases undergoing successful hemostasis with TAE using absorbable embolus. Against this backdrop, we reconsidered fertility-preserving hemostatic strategies for critical obstetrical hemorrhage under these circumstances, and herein discuss how to select the optimal strategy based on our knowledge of and experience with various hemostatic procedures.

Couples with unexplained recurrent pregnancy loss (RPL) cannot achieve a live birth due to repeated sporadic abortions or undetected causes of RPL on routine examinations. Adverse intrauterine circumstances and endometrial decidualization are candidate risk factors for unexplained RPL. During peri-implantation and decidualization, endometrial stromal cells are transformed into decidual cells through acute inflammatory reactions, followed by an anti-inflammatory state, via reprogramming of the corticosteroid and retinoid signaling pathways. Inappropriate inflammation in mid-luteal endometrial stromal cells, such as chronic endometritis, is associated with aberrantly elevated uNK cell density, abnormal angiogenesis, and impaired endometrial decidualization, leading to repeated reproductive failure and complications of pregnancy such as hypertensive disorders. To the best of our knowledge, no efficient treatment for unexplained RPL has yet been established. The optimization of intrauterine circumstances and endometrial decidualization may be key to treating unexplained RPL.

Aim: Fundal pressure during labour is a frequently used manoeuvre for expediting delivery in cases of fetal distress, dystocia and maternal exhaustion. It is often underreported and therefore challenging to accurately estimate its prevalence. It remains a highly controversial topic, having been abandoned in many countries due to its potentially harmful consequences. Still, some health care professionals consider it safe and effective in life-threatening obstetric emergencies. Our objective was to evaluate the evidence behind the merits and drawbacks of its implementation into clinical practice.

Methods: This is a critical review based on utilising high-quality references on whether it is justifiable to insist on using fundal pressure in contemporary obstetrics.

Results: Fundal pressure is understudied with significant variations worldwide. Reports documenting of any substantial benefit are sparse in the literature. Nevertheless, there is a clear association with various adverse outcomes. An increasing number of experts suggest that fundal pressure should be relinquished.

Conclusions: Unless future randomised controlled trials change our views on traditional methods for shortening labour when needed, practitioners should be extra vigilant in avoiding dubious techniques, as deviation from national guidelines could jeopardise aspirations for optimal intrapartum care. In the time being, fundal pressure should be limited for research purposes only within well-designed studies.

Aim: This study aimed to examine the effects of the glycosaminoglycan (GAG) chain in urinary trypsin inhibitor (UTI) on uterine cervical fibroblasts (UCFs) and to apply the findings to the development of more effective therapeutic drugs for the management of preterm birth.

Methods: We prepared GAG chain-remodeled UTIs by hydrolysis and/or transglycosylation by testicular hyaluronidase. These UTIs were added to UCFs obtained from gynecology operations, and the effects of UTIs on the release of IL-8, IL-6, MMP-8, and MMP-9 were examined.

Results: UTIs that were not hydrolyzed tended to reduce IL-8 release more strongly than GAG chain-hydrolyzed UTIs. IL-6 was not affected by GAG chain hydrolysis of UTIs. GAG chain-hydrolyzed UTIs tended to reduce MMP-8 and MMP-9 release more strongly than non-hydrolyzed UTIs.

Conclusions: Our findings suggest that the GAG chain of UTI might reduce hyaluronan during cervical ripening by reducing IL-8 release and has opposite effects on reducing MMP-8 and MMP-9 release related to collagen degradation. This insight may be helpful in the development of more effective therapeutic drugs for the management of preterm birth.

We report a case of peripartum asymptomatic cerebral hemorrhage (hereafter “PEACH”) in the frontal lobe, which was not diagnosed until postpartum day 8. A 35-year-old woman underwent cesarean section at 40 weeks of gestation due to non-reassuring fetal status during labor and gave birth to a healthy female baby. Her general conditions during labor, cesarean delivery, and postpartum period were uneventful. However, she developed hypertension 8 days after delivery, had headache and vertigo, and could not maintain a sitting position. Computed tomography revealed an edematous lesion in the vicinity of a hemorrhagic lesion in the right frontal cortex. Diffusion-weighted magnetic resonance imaging confirmed these findings, suggesting that several days or more had passed since the occurrence of asymptomatic cerebral hemorrhage. PEACH may occur in normotensive patients and cause nerve compression symptoms and hypertension over the course of a few days.