Dates: 21–22 September 2019

Venue: Saitama Prefectural Health Center (Saitama)

Congress President: Kenjiro Takagi (Professor, Jichi Medical University Saitama Medical Center, Saitama, Japan)

The 40th Anniversary Annual Congress of the Japan Society for the Study of Hypertension in Pregnancy was held at Saitama Prefectural Health Center (Saitama) for 2 days from September 21 (Sat) to 22 (Sun), 2019. Thanks to everyone’s hard work, we had 353 people had taken part in this year’s congress, exceeding our expectations. The following programs were held successfully.

Laparoscopic myomectomy (LSM) is a procedure often requested by patients because of its minimal invasiveness. This procedure has, therefore, been widely performed in recent years. However, there is a need for more reports from the obstetric field to determine the effects of this procedure on subsequent pregnancies. In this regard, we searched Japanese medical literature databases for articles on Japanese cases of uterine rupture, placenta increta, or placenta percreta in pregnancy following myomectomy. This review article aims to analyze the retrieved data to clarify the issues involved and to provide useful feedback to gynecologists by sharing information with them on such issues.

There were 32 cases with available detailed data between 2000 and 2017. There were 7 cases of uterine rupture in pregnancy following laparotomic myomectomy (LTM), comprising 1 full-term case (14.3%), 5 preterm cases (71.4%), and 1 case at 16 gestational weeks (abortion period, less than 22 gestational weeks) (14.3%). On the other hand, there were 25 cases of uterine rupture in pregnancy following LSM, comprising 2 full term cases (8.0%), 18 preterm cases (72.0%), and 5 abortion cases (at 7, 10, 16, 19, and 21 gestational weeks) (20.0%). There was no distinct difference between the frequencies of uterine rupture following LTM and LSM in relation to the abortion period or the preterm period. Cases of uterine rupture following LSM included 3 cases who had undergone subserous myomectomy in which electrocauterization alone was used for resection and hemostasis. In 4 cases, the submucosal myoma had been enucleated, with exposure of the endometrium.

Placenta accreta spectrum disorders occurred in the scar region in the following cases: placenta accreta, 7 cases; placenta increta, 3 cases; and placenta percreta, 12 cases. Three cases were described as having myometrial laceration or separation or incomplete uterine rupture. There were 5 cases of complete uterine rupture (at 16, 18, 18, 22, and 37 gestational weeks) accompanied by intraabdominal hemorrhage. In the other 20 cases, incomplete uterine rupture was diagnosed at the time of cesarean section. Total abdominal hysterectomy or Poro’s operation was performed in 11 cases during surgery.

In comparison with uterine rupture in pregnancy following cesarean section, uterine rupture in pregnancy following myomectomy often occurs at an earlier stage, and thus requires caution. Pregnancies and deliveries after myomectomy carry the risks of uterine rupture and the development of placenta accreta spectrum disorders. Precautions in the management strategies for such pregnancies and deliveries, as well as the gist of the feedback given to gynecologists, are discussed herein.

Endometriosis and adenomyosis not only cause symptoms such as dysmenorrhea, chronic pelvic pain, and infertility, but have also recently been implicated in a range of obstetric complications. The association between endometriosis and adenomyosis and adverse pregnancy outcomes has been developing as a new topic in the field of reproductive medicine over the past few years. This review aims to summarize in detail the latest evidence on the incidence of obstetric complications associated with endometriosis or adenomyosis and to discuss possible underlying pathophysiological mechanisms.

Aim: “En caul” cesarean section can prevent mechanical damage to preterm babies upon cesarean delivery, by intentionally not rupturing the fetal membranes. This survey investigates its prevalence, indications, and advantages and disadvantages in Japan.

Methods: Questionnaires were posted to all registered Level 2 and Level 3 maternal and perinatal centers (where most premature babies are delivered) in Japan (n=327). Percentages of centers are presented as survey results.

Results: Response rate was 53.2%. En caul cesarean section was employed in 43.2% and 81.6% of Level 2 and 3 centers, respectively. Gestational age considered for en caul cesarean section was less than 31 weeks in 75.9% of centers. Low transverse and vertical uterine incisions were made at 64% and 29% of centers, respectively. En caul cesarean section was considered useful by 87% of centers. However, nearly one-third of the respondents noted that this procedure presents some technical difficulties if membranes happen to rupture accidentally before the delivery of the fetus is complete.

Conclusions: En caul cesarean section is a routine cesarean delivery technique used for preterm babies born at Level 3 maternal and perinatal centers in Japan. However, certain technical and educational aspects should be considered to achieve better outcomes.

Aim: Velocity vector imaging (VVI) is a speckle-tracking ultrasonographic assessment technique used to evaluate myocardial function. However, VVI values show wide deviations. This study aimed to clarify the significance of serial VVI values for assessing fetal cardiac function.

Methods: Echocardiographic images of 50 fetuses (normal: n=29, fetal growth restriction [FGR]: n=21) were obtained in the four-chamber view during the second and third trimester. VVI images were analyzed for longitudinal velocity, strain, and strain rate in the global and segmental walls of the left ventricle (LV) and right ventricle (RV).

Results: Global longitudinal velocity (GLV) of the LV and RV during the third trimester did not significantly differ between FGR and normal fetuses. LVd and RVs appeared to be low in HDP cases, although there were no significant differences compared to no HDP cases. Eighty-two serial images obtained from 13 normal singleton fetuses revealed increased systolic GLV of the LV and RV, increased diastolic GLV in 10 cases, and increased longitudinal velocity in the basal and middle free wall of both the LV and RV.

Conclusions: The evaluation of fetal ventricular function using VVI revealed that GLV increases throughout gestation.

Aim: This study aimed to examine the clinical characteristics of pregnancies complicated by both fetal growth restriction (FGR) and placenta previa or low-lying placenta (PPLLP).

Methods: A retrospective cohort study was performed to compare clinical characteristics of pregnancies complicated by FGR and/or PPLLP in women who do not habitually smoke or consume alcohol and who underwent delivery of singletons at ≥22 weeks’ gestation at Japanese Red Cross Katsushika Maternity Hospital between 2002 and 2015. Assessed factors related to patients and perinatal outcomes included maternal age, parity, history of in vitro fertilization, hypertensive disorders, delivery mode, fetal ultrasonographic findings, delivery mode, gestational age at delivery, neonatal asphyxia, and postpartum hemorrhage.

Results: There were 24,118 singleton deliveries assessed for eligibility. Of these, 7 were complicated by both FGR and PPLLP. The development of FGR was not associated with the presence of PPLLP (odds ratio 1.12, 95% confidence interval 0.54–2.4, P=0.69). Multivariate logistic regression analysis revealed that the incidence of preterm cesarean delivery due to massive bleeding in pregnancies complicated by both FGR and PPLLP was higher than that in pregnancies complicated by PPLLP or FGR alone (vs. PPLLP alone: adjusted OR 7.11, P=0.03; vs. FGR alone: adjusted OR 195, P<0.01).

Conclusion: Obstetricians should be aware of the increased risk of preterm delivery related to antepartum massive bleeding in pregnancies complicated by both FGR and PPLLP.

Objectives: To clarify the effects of tight blood pressure control on pregnancy outcomes.

Methods: This retrospective study included 38 cases of singleton pregnancies which were diagnosed with essential hypertension either before pregnancy or during the first trimester of pregnancy. Patients were subdivided according to systolic blood pressure (<130 mmHg, 130–139 mmHg, ≥140 mmHg) between 8–11, 12–15, and 16–19 weeks’ gestation, respectively. The influence of systolic blood pressure in each gestational period was assessed with regard to the risk of preterm birth, foetal growth restriction, and superimposed preeclampsia.

Results: At 16–19 weeks’ gestation, systolic blood pressure ≥140 mmHg and in the range of 130–139 mmHg was strongly linked to a shorter gestational period and lower z-scores for birth weight. The incidence of early onset superimposed preeclampsia was lower in women who had systolic blood pressure <130 mmHg at 16–19 weeks’ gestation (11%) compared with those with a systolic blood pressure of 130–139 mmHg (27%) and ≥140 mmHg (75%).

Conclusions: Tight control of blood pressure, with a target systolic blood pressure <130 mmHg early in pregnancy improves pregnancy outcomes in patients with chronic hypertension.

We report a case of preeclampsia with severe organ dysfunction, diagnosed conclusively as antiphospholipid syndrome (APS), following the onset of severe thrombocytopenia 3 months after delivery.

A 21-year-old female (gravida 1, para 0) delivered preterm at 31 weeks of gestation due to preeclampsia. During pregnancy, hypertension remained in the mild range (<160/100 mmHg) during the day, but proteinuria (12.5 g/gCre) and thrombocytopenia (51,000/μl) were severe. After delivery, proteinuria and platelet count improved rapidly, but at 3 months after delivery, platelet count fell to 15,000/μl. Diagnostic workup for the cause of thrombocytopenia revealed positive lupus anticoagulants. The patient was diagnosed with APS based on her pregnancy course and positive antiphospholipid antibodies.

Long-term follow-up is imperative for patients with early-onset preeclampsia with severe organ dysfunction, even if their clinical symptoms improve.