A lack of obstetricians, gynecologists and emergency departments in hospitals make it difficult to accept emergency patients for obstetrics and gynecology (OBGY), and has recently become a serious social problem. The primary contributing factor is that emergencies are not sorted according to severity. To improve primary emergency care, for OBGY in particular, we will here analyze the patients who have visited Chibune General Hospital's emergency department in the recent past. From January to December 2008, 2913 OBGY patients visited the emergency department. Of those patients, 66.3% (1932 patients) were first-time patients with no introduction documentation from other institutions, 22.9% (667 patients) were our clients, and 10.8% (314 patients) were transferred from other institutions, including maternal transfers.The total number of all patients who arrived to Chibune hospital by ambulance was 1920. However, only 17.8% (519) OBGY emergency patients needed admission. Most walk-in patients visited from 20:00 to 0:00 and these patients decreased from 0:00 to 8:00. However, the numbers of ambulance transfers were not effected throughout these time periods. Moreover, we researched the reason for consultations, the number of admissions, and operations of first-visit cases, including patients introduced from other institutions. For the most part, in maternal transfer cases, there was a threat of premature labor.The major reasons for patients to be transferred from another institution other than maternal transfers were ectopic pregnancy and ovarian tumors. On the other hand abortion, dysmenorrhea, and pelvic inflammatory disease were major factors for first-visits without introduction documentation from other institutions. In half of all OBGY emergence cases, these patients were transferred by ambulance, but most patients went home without admission. Most consultations were tentative and appeared to be so-called “convenient store” visits. This is an indication that these patients probably do not have a primary care physician. This also leads to another difficulty in which severe cases needing emergency operations, or high-risk pregnancies had no prior OBGY data to consult. As a result of these emergency cases, and increasingly difficult working conditions, physician's duties are getting heavier and more stressful. This can be directly linked to a decrease in the number of OBGY doctors and therefore leads to the reduction of maternal neonatal medical institutions. In order to prevent what could become a very slippery slope, doctors have an obligation to educate patients about the use of ambulances and must reevaluate the problem of emergency OBGY cases, and thus contributing to achieve a proper system for the sake of medicine and patients. [Adv Obstet Gynecol,62(4):321-326, 2010(H22.11)]
In 1998, Elliott et al described CAOS (Chronic Abruption-Oligohydramnios Sequence) as a condition in which vaginal bleeding occurs without any identifiable cause while amniotic fluid level appears to be normal. This report highlights the need for safer and more reliable options to predict/treat this prenatal condition so as to improve the outcome for newborns. Our own experiences in treating such cases have lead to this conclusion. During the last 2 years 4 cases of CAOS were treated at the Japan Baptist Hospital. All 4 cases had episodes of recurrent bleeding occurring in the first trimester of pregnancy, and developed oligohydramnios . Of these four cases two cases resulted in IUFD and neonatal death. The infants survived in the remaining two cases. The first case developed oligohydramnios from 21 weeks of gestation and IUFD was seen in one month. The second case had preterm PROM at 22 weeks of gestation, and developed intrauterine infection within one week. The patient later delivered vaginally at 23 weeks of gestation but the infant died 2 hours after birth. The remaining 2 cases, the infection progressed and underwent cesarean section at 25 weeks of gestation. The both infants later developed CLD (chronic lung disease), but at six months old, they shows no signs of developmental abnormality. The four cases above suggest that 1) recurrent genital bleeding that occurs from the early stage of pregnancy is an important factor that can influence perinatal prognosis 2) prognosis is usually worsened if accompanied by oligohydramnios. Our observations are in keeping with Elliott et al. who reported that infants delivered preterm due to CAOS can have a worse perinatal prognosis in comparison with other preterm infants born at similar gestational stages. Having a reliable bio-marker useful for making obstetrical decision in these high risk cases may result in better prognosis for newborns. At present, the histopathology of CAOS is not clear, therefore any discussion of potential treatment options is usually limited. Generally however, for patients at an early gestational stage, the tendency is to try to prolong pregnancy for as long as possible. To ameliorate the perinatal result, patients at high risk of delivering VLBW (very low birth weight) infants should be referred to an obstetrical center with a highly developed NICU from the onset of this syndrome. Here, patients should be closely observed for maternal and fetal infection, and fetal well-being should be monitored to decide the best timing for pregnancy termination.[Adv Obstet Gynecol, 62 (4) : 327-332, 2010 (H22.11)]
Carcinosarcoma of the ovary is a rare neoplasm representing 1% of the malignancies arising from this organ. The incidence is less than that of endometrium. We report a case of this tumor complicated with pseudo-Meigs syndrome. A 76-year-old woman who was complicated with abdominal spanning initially consulted another clinic, where massive ascites was pointed out. She was referred to our hospital for treatment of this condition. Computerized tomography (CT) and magnetic resonance imaging (MRI) showed a huge solid mass occupying the pelvic cavity with massive ascites. This condition was suspected of being peritonitis carcinomatosa due to a malignant gynecological tumor. Serum LDH (1582 IU/l) and CA125 (410 U/ml) were elevated. We performed peritoneal tap, removed 4500ml bloody ascites and infused carboplatin 450mg into her abdominal cavity. Thereafter, 4000ml of the ascites was passed through a membrane filter and re-infused intravenously, while the remaining 500ml of ascites was analyzed cytologically. No malignant cells were detected in it. Twelve days later, ascites progressively increased again and pleural effusion also appeared. An additional 6 days later, we performed thoracocentesis and removed 2200ml pleural effusion over 4 days. The cytological analysis of this fluid showed no malignant cells. Abdominal surgery performed the following day demonstrated a huge pelvic tumor, but the origin could not be determined macroscopically. First, we performed en bloc extirpation of the tumor, uterus and right salpinx, followed by left salpingo-oophorectomy, omentectomy, appendectomy, pelvic-paraaortic lymphadenectomy and intra-peritoneal infusion of carboplatin (450mg). Postoperatively, ascites and pleural effusion completely disappeared. Macroscopically this huge tumor demonstrated a large central area of necrosis next to the right elongated salpinx and invasion of almost the entire posterior wall of the uterus. However, there was no tumor in the endometrium or in the endosalpinx. Microscopically, the tumor was composed of both epithelial and mesenchymal components including chondrosarcoma. There were no detectable tumor cells in the ascites or pleural effusion. In conclusion, this tumor was heterologous carcinosarcoma originating in the right ovary and complicated with pseudo-Meigs syndrome. Postoperative clinical stage was pT2cN0M0 because this tumor ruptured during surgery. She received 6 courses of paclitaxel and carboplatin chemotherapy after the surgery and has remained in complete remission for ten months. This case could be the first report of primary ovarian carcinosarcoma complicated with pseudo-Meigs syndrome. [Adv Obstet Gynecol,62 (4) : 333-339, 2010 (H22.11)]
Estrogen-producing tumors usually originate from the ovarian matrix. We present a rare case of uterine tumor resembling ovarian sex-cord stromal tumor. A 59-year-old woman presented with postmenopausal bleeding. Magnetic resonance imaging revealed endometrial thickening and a 45-mm mass right of the uterus. The patient's serum estrogen level was slightly elevated. Therefore, we suspected ovarian sex-cord stromal tumor, and total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. The tumor was found to be surrounded by myometrium. Therefore, we diagnosed uterine tumor resembling ovarian sex-cord stromal tumor type II. Uterine tumors resembling ovarian sex-cord stromal tumor were reported by Clement and Scully in 1976, who classified them into 2 types. Type I tumors are endometrial stromal tumors that show focal epithelial-like differentiation similar to that seen in ovarian sex-cord tumors. Type II tumors are uterine mural masses with predominant or exclusive histological appearance of sex-cord elements. Although type I and type II tumors have a similar presentation, the clinical behavior of these tumors differs. In type I tumors, the prognosis depends on the type, grade, and stage of the underlying stromal neoplasm. In contrast, type II tumors usually have a benign clinical course. The precise histological diagnosis is important, and the immunostaining may be useful for diagnosis. [Adv Obstet Gynecol,62 (4) : 340-344, 2010 (H22.11)]
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