Preeclampsia is a major complication of pregnancy and is associated with significant fetal and maternal morbidity and mortality. Timely prediction of preeclampsia facilitates referral of potential patients to an adequate tertiary center, which helps reduce adverse outcomes associated with the disease. Moreover, by accurately ruling out preeclampsia, patients can be discharged safely and relieved of anxiety. Numerous candidate biomarkers have been proposed for the diagnosis and prediction of preeclampsia. Among these, maternal circulating factors such as soluble FMS-like tyrosine kinase-1 (sFlt-1), an anti-angiogenic factor, and placental growth factor (PlGF), an angiogenic factor, are considered the most promising. Measuring these factors as a ratio allows assessment of the angiogenic imbalance that characterizes incipient or overt preeclampsia. The sFlt-1/PlGF ratio increases before the onset of preeclampsia and thus may help predict the disease. The test is used as a predictive tool in several countries but not yet routinely performed in Japanese hospitals.

We performed a systematic review of studies that assessed the performance of the sFlt-1/PlGF ratio in predicting preeclampsia in Japanese patients. Three studies were included in the systematic review. All studies reported high negative predictive values of the sFlt-1/PlGF ratio (i.e., for ruling out PE), in agreement with the current evidence of the test performance worldwide. The sFlt-1/PlGF ratio could be of significant relevance in the Japanese population.

Intrauterine balloon tamponade (IBT) is widely used for treating obstetric hemorrhage. However, only a few reports on IBT failure exist. We report a case of IBT failure caused by an over-expanded lower uterine segment (LUS). A 30-year-old woman with twin pregnancy presented with bleeding after cesarean section. During surgery, uterine atony was observed; however, intravenous administration of oxytocin and ergometrine resolved the condition. Continuous hemorrhage was observed postoperatively, despite the administration of uterotonics and uterine massage. Although IBT was performed, the bleeding persisted, as recognized from the drainage fluid. Enhanced computed tomography revealed that the bleeding spot could not be compressed by the inflated balloon due to the over-expanded LUS. The balloon was removed; uterine artery embolization was required to achieve hemostasis. Our experience indicated that over-expanded LUS could cause IBT failure. If bleeding continues post-IBT replacement and an over-expanded LUS is observed, alternative treatments should be promptly provided.

Uterine necrosis after uterine artery embolization (UAE) for postpartum hemorrhage (PPH) is relatively rare. A 29-year-old primiparous woman had a diamniotic dichorionic twin pregnancy following frozen blastocyst transfer. She developed preeclampsia at 34⁺³ weeks, and cesarean section was performed due to lung edema at 35⁺² weeks. UAE was performed using a gelatin sponge 3 hours after the operation due to PPH; however, the hemorrhage continued, and we performed a second UAE using n-butyl-2-cyanoacrylate. Uterine subinvolution continued after the second UAE, and her fever recurred 11 days after the operation. Magnetic resonance imaging suggested uterine necrosis 14 days after the operation, resulting in hysterectomy. The present study reviewed 17 cases of uterine necrosis following UAE in women with PPH, fever, abdominal/pelvic pain and found that delayed appearance of various symptoms was common. A long-lasting subinvolution may be a novel specific feature of uterine necrosis in women with UAE due to PPH.

Aim: Retained products of conception (RPOC) can cause postpartum hemorrhage. However, if intrauterine evacuation is performed for RPOC without adhesion, it can lead to massive hemorrhage due to an inability to identify bleeding points during the operation. Here, we describe the advantages of intrauterine evacuation of RPOC using contrast-enhanced ultrasonography (CE-US), which can identify bleeding points and contribute to successful hemostasis, and uterine balloon tamponade (UBT) in four clinical cases.

Methods: We encountered four cases of RPOC and performed intrauterine evacuation combined with CE-US and UBT from 2018 to 2019. The ultrasound contrast agent, perfluorobutane, was infused immediately before the operation. After intrauterine evacuation, the uterine balloon was retained.

Results: In all cases, CE-US identified bleeding points immediately, enabling retention of the uterine balloon on the bleeding points and subsequent hemostasis. None of the cases experienced complications the day after the operation.

Conclusion: CE-US facilitated the identification of bleeding points during intrauterine evacuation of RPOC and contributed to successful hemostasis when used in combination with UBT.

Pulmonary arteriovenous malformation (PAVMs) is a rare condition characterized by abnormal vascular connections between pulmonary arteries and veins. Increased pulmonary blood flow during pregnancy can exacerbate intrapulmonary shunt, which can cause stroke or pulmonary hemorrhage and lead to maternal death, miscarriage, and fetal growth restriction. PAVMs may be misdiagnosed, as their prominent symptoms are similar to those of pulmonary embolism (PE). We report herein a case of a 20-year-old woman diagnosed with PAVMs, who was initially suspected to have PE. She developed hypoxemia and deep vein thrombosis immediately after delivery that resulted in fetal growth restriction and asymptomatic acute cerebral infarction. Undiagnosed chronic hypoxemia was considered as a differential diagnosis of PE, since the patient showed signs of chronic hypoxia such as clubbing and cyanosis. Our findings underscore the importance of thorough systemic assessment during the first visit of patients with suspected PE.