Most of the reports of pregnant women without antenatal care were analyzed by only a single institution unit. We investigated to determine the clinical or social backgrounds and perinatal outcomes of pregnant women without antenatal care in the whole Nara Prefecture. Pregnant women without antenatal care were defined as follows:a) Pregnant women who had less than three consultations with an obstetrician during the pregnancy period.b) Pregnant women who did not have a consultation for more than three months from the last consultation.All delivery institutions in Nara were queried regarding the number of deliveries and the existence of women without antenatal care from January to December in 2010. If these institutions had corresponded with women without antenatal care, they had to answer individual questionnaires about the condition of each mother and neonate. Eleven births of women without antenatal care, accounting for 0.10% of 11,168 births, were recognized. Four women were primipara. On the other hand, two women were multipara who had delivered more than five times. Nine women were unmarried. Moreover, five women could not contact their partners who were the fathers of the newborns. Two women had severe maternal complications, and three newborns were admitted to the Neonatal Intensive Care Unit. One woman cancelled the one-month medical examination of the neonate and her own postpartum health examination. Making sure that pregnant women undergo antenatal care will not only lead to favorable maternal and child outcomes but also promote the utilization of useful perinatal medical resources. Moreover, it is thought that the women without antenatal care constitute a high-risk group for abuse. To prevent subsequent child abuse, making a system to be followed by women without antenatal care, i.e., perinatal visit, will be an important solution to the problem. [Adv Obstet Gynecol, 65(1) : 1-10, 2013 (H25.2)]

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In recent years, the use of the regional midwife care system has been discussed as one of the solutions for the shortage in obstetricians and the collapse in obstetric care in Japan, as well as a means of meeting the diverse needs during pregnancy and delivery management of pregnant and parturient women. Between May 2007, when the midwife care system was established in this department, and December 2011, a total of 825 women have delivered under the midwife care system. Of the case subjects who gave birth at this facility between January 2009 and December 2010, we compared the perinatal prognosis of pregnant and parturient women and their infants in 937 low-risk pregnancy cases under a physician’s care and in 444 pregnancy cases under the midwife care system. Statistical analysis was carried out using the t-test for amount of bleeding and time from admission to start augmentation of labor in the cases of weak labor pain, while other statistical analyses were performed using the chi-square test. p<0.05 was judged as significant. No significant differences were observed in gestational week of delivery, duration of labor, cases of more than 1000ml of blood loss during delivery, degree of perineal tear, rate of cesarean section, Apgar score<7 points, cases with low cord blood pH, large infants (greater than 3500 g), low-birth-weight infants (less than 2500 g), and the rate of GCU (Growing Care Unit) admission. In a survey of reasons for GCU admission, no differences were observed between the two groups. On the other hand, in the study of the requirement for medical interventions during delivery, such as the induction or augmentation of labor, vacuum extraction or Kristeller’s expression, episiotomy, and postpartum administration of oxytocin, the rates were significantly higher in the group managed by physicians than in the group managed by hospital midwives. Moreover, among the group managed by hospital midwives, 62 cases were transferred to a physician’s care for fetal, maternal, or social factors. Thirty of these cases were transferred back to hospital midwife care for delivery after no abnormality in their progress was confirmed over multiple examinations by a physician. While medical intervention during delivery was significantly higher in the group managed by physicians, no significant differences were observed in postpartum progress and outcome of the infants. It is possible that the midwife care system can provide perinatal care that is equal to the care provided by a physician. [Adv Obstet Gynecol, 65(1) : 11-19, 2013 (H25.2)]

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A primary vaginal clear cell adenocarcinoma (CCA) is rare among gynecologic malignancies and generally occurs in young women with prenatal exposure to diethylstilbestrol (DES). We report a rare case of primary vaginal CCA in a 60-year-old female who had not been exposed to DES in utero, along with congenital malformation of the genitourinary tract resulting in left renal agenesis and uterus didelphys. The patient had experienced genital bleeding for the previous two years and lower abdominal pain. A physical examination showed a 5 cm tumor in the left anterior wall of the upper vagina and biopsy findings revealed a CCA. Radiological results indicated FIGO stageII vaginal cancer with congenital anomalies, including uterus didelphys and left renal agenesis. She was treated with a combination of brachytherapy and external-beam radiotherapy. Although MRI showed complete disappearance of the tumor, the patient developed multiple lung metastases seven years after radiation therapy, and received combination chemotherapy with irinotecan and cisplatin (CPT-P). Primary vaginal CCA without DES exposure is extremely rare, though there are several reports noting this type of carcinoma in conjunction with congenital malformation of the urogenital tract. Previous studies have speculated that vaginal adenosis is induced in association with Müllerian duct anomalies, which may provide a basis for carcinogenesis. It is important to perform careful examinations of patients with urogenital malformation. Based on the stage and tumor size in this case, and poor prognosis of affected patients, we speculate that there is room to consider the necessity of multidisciplinary treatments including chemotherapy in addition to irradiation. [Adv Obstet Gynecol, 65(1) : 20-25 , 2013 (H25.2)]

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Non-puerperal uterine inversion is an extremely rare condition that has been reported in only about a hundred cases since 1940, based on a literature search using the search terms "chronic non-puerperal uterine inversion". Furthermore, no cases with uterine inversion and ruptured bladder have been reported. We report a rare case of uterine inversion with ruptured bladder caused by a uterine carcinosarcoma. An 81-year-old menopausal woman, gravida 2 para 2, was referred to our hospital with abdominal distension and unconsciousness. A pelvic examination demonstrated numerous ascites and a huge mass filling her pelvis and vagina. MRI revealed a heterogeneous mass arising from the uterine fundus and U-shaped uterine cavity, which suggested a uterine inversion. Blood tests showed high levels of creatinine and C-reactive protein. At laparotomy, the uterus was totally inverted and her bladder was ruptured with a 3mm-sized hole. We performed a total abdominal hysterectomy with a bilateral salpingo-oophorectomy and bladder repair. The pathological diagnosis was uterine carcinosarcoma. We report our experience and discuss how the uterine carcinosarcoma caused the bladder rupture. [Adv Obstet Gynecol, 65(1): 26-31 , 2013 (H25.2)]

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Primary ovarian carcinoid tumors are rare neoplasms divided into four subtypes: insular, trabecular,strumal, and mucinous types. We report three cases of primary ovarian carcinoid tumors with different histological features. (Case1) An asymptomatic 60-year-old woman had a right ovarian tumor identified on a regular medical examination. MRI study revealed a unilocular cyst (60×47 mm) with a well-enhanced parietal solid mass. Abdominal bilateral salpingo-oophorectomy (BSO) was performed and the right ovarian tumor was diagnosed as strumal carcinoid (stage Ia). (Case2) An asymptomatic 55-year-old woman was found to have a high level of CA19-9 on a regular medical examination. MRI study revealed bilateral ovarian tumors (Rt.50 mm, Lt.60 mm). Total laparoscopic BSO was performed and the left ovarian tumor was diagnosed as strumal carcinoid (stage Ia). (Case3) A 73-year-old woman complained of dysuria and pelvic mass. MRI study revealed a multilocular cystic mass (160×140 mm) with well enhanced parietal components. Total abdominal hysterectomy with BSO was performed and the right ovarian tumor was diagnosed as mucinous carcinoid (stage IIa). In general, these tumors are slow growing, and have a good prognosis. But some cases of metastasis or recurrence have been reported. So careful attention should be paid to this borderline tumors. [Adv Obstet Gynecol, 65(1) : 32-39, 2013 (H25.2)]

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Introduction: Uterine diffuse leiomyomatosis (UDL) is a rare condition in which uterine myometrium is suffused with numerous myomas. Because of severe hypermenorrhea and dysmenorrhea, women who do not wish to have children are required to undergo hysterectomy. Although UDL frequently occurs even in women in their twenties, there is no consensus about the management of UDL for such women if they wish to remain fertile. We report here on the UDL cases of two sisters, both of whom were successfully managed. Cases: A 31-year-old nulliparous woman suffering from long-lasting severe dysmenorrhea and more than 10 years of anemia was referred to Kyoto University Hospital (Case 1). Her 27-year-old nulliparous younger sister was referred to us after suffering for two years from anemia caused by multiple myomas, some of which returned soon after a second myomectomy (Case 2). After preoperative administration of GnRH-analogue, 90 and 208 myoma nodules were removed in Case 1 and Case 2, respectively, with a vertical incision from anterior wall to posterior wall via fundus of the uterus in order to open the endometrial cavity. After reduction of the uterus size, symptoms accompanying menstruation were relieved. Case 2 conceived one year and four months after the surgery to deliver a 2174g baby by cesarean section without uterine perforation, and no myometrial defect was observed at cesarean section.Conclusion: Vertical incision made possible a radical myomectomy beneath the endometrial cavity. This procedure resulted in fertility-sparing as well as relief from dysmenorrhea. [Adv Obstet Gynecol, 65(1): 40-45 , 2013 (H25.2)]

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Labial adhesion is characterized by acquired labial fusion. It is caused by chronic inflammation, irritation, or trauma of the vulvar skin because estrogen deficiency. It occurs mainly in infants but is rare in the elderly. We describe a case of labial adhesion where voiding difficulty was observed. The patient was an 82-year old woman who was admitted to our hospital for hematuria and painful urination. On physical examination, she was found to have severe labial adhesion and a pin hole opening. Ultrasonography showed right hydronephrosis and a large bladder diverticulum. Consequently, we diagnosed the patient with labial adhesion. Because the adhesion was too severe to dissect under local anesthesia, we performed ,under lumbar anesthesia, adhesiotomy and plasty to which Heineke-Mikulicz polyroplasty was applied. To prevent readhesion, we applied estrogen ointment on the vulva after the operation. The patient did not exhibit recurrence of labial adhesion at the time of follow-up, that is, approximately nine months after the operation. [Adv Obstet Gynecol, 65(1) : 46-50, 2013 (H25.2)]

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Leiomyoma is a benign smooth muscle neoplasm that rarely metastasize. Some of them are difficult to be differentiated from leiomyosarcoma because they behave as borderline malignant tumors. Here we present a case of benign metastasizing leiomyoma (BML). A 42-year-old woman (gravida 1 para 1) was diagnosed uterine leiomyomas at the age of 30. She underwent GnRH agonist therapy and uterine arterial embolization at the age of 36. However, this therapy was unsuccessful, and abdominal hysterectomy was performed when she was 38 years old. Four years later, she visited our hospital presenting with lower abdominal pain. Magnetic resonance imaging revealed multiple retroperitoneal tumors, while computed tomography revealed lung tumors. Exploratory laparotomy confirmed that the tumor was BML. Surgical oophorectomy was temporarily effective in decreasing serum estradiol levels, and consequently, decreasing the size of the retroperitoneal and lung tumors. We suspect that the increase in serum estradiol levels after eight months was due to an ovarian remnant that was densely adeherent to the retroperitoneum. The patient is presently undergoing GnRH agonist therapy. [Adv Obstet Gynecol, 65(1) : 51-57, 2013 (H25.2)]

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Pyometra secondary to a colo-uterine fistula is extremely rare. A 74 year-old female visited a urologist complaining of dysuria and a fever lasting for one month. A continuous urethral catheter was placed by the doctor, after which dysuria improved, though the fever was not reduced. After a few days, the patient complained of lower abdominal pain and a computed tomography examination was performed, which identified a huge tumor in the pelvis. She was referred to us and diagnosed with obvious pyometra, then admitted to our hospital. Following pus drainage through the cervical ostium, dysuria was improved. However, colonic endoscopy and magnetic resonance imaging results revealed invasive sigmoid colon cancer and a colo-uterine fistula, for which abdominal sigmoidectomy and a hysterectomy were performed. Histopathological findings revealed a sigmoid colon carcinoma with deep invasion through the serosal surface and a colo-uterine fistula existing in the same portion. The postoperative course was uneventful. [Adv Obstet Gynecol, 65(1) : 58-63, 2013 (H25.2)]

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We report a case of ovarian abscess caused by Salmonella infection of an ovarian borderline tumor. The patient was a female in her late teens who had no history of sexual activity. She visited a clinic after experiencing progressively worsening lower abdominal pain and fever for two days. She was then referred to our hospital as a gynecological case. Magnetic resonance imaging revealed a large multilocular cystic lesion occupying the lower abdominal cavity. Her clinical course and physical symptoms indicated abscess or torsion of the ovarian tumor; thus, exploratory laparotomy was performed. The lesion was a tumor that expanded in size, resulting in an enlarged right ovary, and one of the lobes was infected with pus. Right salpingo-oophorectomy was performed, and antibiotics were administered. The patient followed an uneventful postoperative course. Pus culture yielded Salmonella sandiego, and pathological examination revealed a mucinous borderline tumor with an abscess. Stool culture after identification of the pathogen also showed S. sandiego. Intestinal salmonellosis seemed to have been hematogenously spread, resulting in an ovarian abscess. [Adv Obstet Gynecol, 65(1) : 64-68, 2013 (H25.2)]

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Since the use of both nifedipine (after 20 weeks of gestation) and labetalol during pregnancy was permitted by the Ministry of Health, Labour and Welfare in 2011, these drugs have been used more frequently. We experienced a case of a 35-week pregnant woman, in whom these two drugs were used. The fetus showed a non-reassuring state and the mother experienced prolonged renal dysfunction following DIC. We investigated this case retrospectively to determine the influence of these drugs on both the mother and the fetus. A nulligravida 34-year-old hypertensive woman became pregnant and checked-up in private clinic. Hypertension of approximately. 170/110 mmHg and occult blood in the urine were indicated seven years ago, but she received no treatment. Since she exhibited a blood pressure of 174/127 mmHg in the 11th week of pregnancy, administration of methyldopa was commenced at a dose of 750 mg/day. She was admitted to a hospital because she exhibited recurrent hypertension with a blood pressure of 169/108 mmHg in the 35th week of pregnancy. Administration of nifedipine was commenced and the dosage was increased to 60 mg/day. Her blood pressure became unstable during the administration day; between 113/97 and 183/121 mmHg. On the following day, she was transferred to our department because of non reassuring fetal status. Fetal bradycardia with tachysystole lead us to diagnose placental abruption, and an emergency Cesarean section was performed. She showed 80% placental abruption. The newborn was female with a body weight of 1859 g, Ap2/7, umbilical arterial blood gas analysis of pH 6.738 and BE-27.3. Obstetric DIC score was 10 points. For treatment of DIC, 10 units of FFP and 12 units of RCC were added in total. Acute renal failure developed due to vascular endothelial disorder and intravascular volume depletion, and the serum creatinine levels increased to 2.3, 3.9, and 4.7 mg/dl on post-delivery days 1, 3, and 5, respectively. On post-delivery day seven, creatinine clearance (Ccr) was 10 ml/min. On puerperal day 18, the renal function improved, and the serum creatinine level and Ccr were 1.2 mg/dl and 43 ml/min, respectively. A certain level of blood pressure control is necessary for pregnant patients in primary-care medical facilities. However, antihypertensive therapy should be administered carefully because such therapy may affect the maternal renal function and the prognosis of the fetus. Appropriate antihypertensive therapy with calcium blockers for pregnant patients should be known well broadly. [Adv Obstet Gynecol, 65(1) : 69-74, 2013 (H25.2)]

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If a fetus coexists with a hydatidiform mole in the uterus, most cases are partial hydatidiform moles. However, we can’t rule out the possibility of a complete hydatidiform mole coexists with a normal fetus (CHMCF). In such a case a fetus may survive, but the probability of neonatal survival is less than half of the cases. We report here a case of CHMCF, in which the patient was delivered of a live infant. The patient was a 30-year-old woman, and her pregnancy was achieved following ovulation induction. On the first examination at nine weeks gestation, trans-vaginal ultrasonography showed that the fetus and molar placenta were independent. Her serum human chorionic gonadotropin (hCG) level was 349,619 mIU/ml. Fetal chromosomal analysis of the amniotic fluid indicated a normal karyotype (46XX). Her serum hCG level showed a downward trend after 13 weeks of gestation. The signs of threatened abortion and threatened preterm labor became apparent since 20 weeks of gestation. Then, an emergency cesarean section was performed at 33 weeks of gestation because of a failure of tocolysis. Fortunately, the infant had a good prognosis. After delivery of molar placenta, the coexistence of a normal fetus and complete hydatidiform mole was confirmed using p57kip2 immunohistochemistry. Her serum hCG level decreased steadily, and no signs of post-molar gestational trophoblastic disease are apparent up to now. [Adv Obstet Gynecol, 65(1): 75-82, 2013 (H25.2)]

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Uterine perforation is a rare disease. Most cases are related to pregnancy, uterine surgery and pyometra. We report a case of spontaneous uterine perforation in pyometra presenting as acute generalized peritonitis in a patient with untreated cervical cancer. A nulligravida 41-year-old woman had been experiencing abnormal genital bleeding for several months. She visited her family doctor to seek treatment for abdominal pain and fever. However, her symptoms worsened; therefore, she consulted a local gynecologist and was referred to our hospital. We noted a bloody odorous discharge and a tumor in the uterine cervix. Physical examination indicated generalized peritonitis, and laboratory data showed high C-reactive protein (CRP) levels (24.1 mg/dl). We diagnosed cervical cancer with generalized peritonitis and started antibiotic therapy. However, subsequently, we decided to perform an emergent operation because antibiotic therapy was ineffective and magnetic resonance examination revealed perforation of the uterine wall. Modified radical hysterectomy, bilateral salpingo-oophorectomy, right external iliac lymphadnectomy, and peritoneal lavage and drainage were performed. The postoperative diagnosis was uterine cervical adenocarcinoma stage IB1. Histological examination showed no cancer cells in the perforated region, but the findings revealed right external iliac lymphadenopathy. Laparotomic lavage and drainage were performed because the inflammation did not improve, and computed tomography showed an abscess in the epiploic foramen. Two months after the 2nd operation, she recovered and postoperative chemotherapy (TC) was started. Most cases of uterine perforation involved a serious disease course because of the difficulty in diagnosis. Early diagnosis and treatment are required in cases with uterine perforation. The possible presence of uterine malignant tumor should also be considered. [Adv Obstet Gynecol, 65 (1) : 83-89, 2013 (H25.2)]

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We report a case of an ovarian cancer patient undergoing hemodialysis for chronic renal failure, successfully treated with paclitaxel and carboplatin combination chemotherapy. A 73-year-old single parous woman undergoing hemodialysis since the age of 61 for chronic glomerulonephitis was found to have tumors in the ascending and sigmoid colon, right adnexa, and liver on examining the cause of her abdominal pain. Her CA125 level was elevated. She underwent surgical laparotomy, after which, she was diagnosed with FIGO stageIV ovarian cancer and received postoperative chemotherapy. On the day of hemodialysis, paclitaxel was administered at 175 mg/m² as a 3-h intravenous infusion followed by a 30-min infusion of carboplatin. The carboplatin dose was chosen to produce a target AUC of 5.0 μg·h/ml. The hemodialysis was started 16 h after the completion of carboplatin infusion and was performed for 4 h. The pharmacokinetic study showed that the maximum plasma concentrations of free platinum was 8.18 μg/ml and the AUC of carboplatin was 5.3 mg·min/ml. After chemotherapy, the patient’s CA125 level decreased rapidly and computer tomography scans showed that the pelvic tumor had shrunk. Grade 3~4 leukopenia, grade 4 neutropenia, and grade2 thrombopenia were observed during the 12courses of chemotherapy. We conclude that paclitaxel and carboplatin combination chemotherapy is safe and efficacious for ovarian cancer patients undergoing hemodialysis. [Adv Obstet Gynecol, 65(1) : 90-94, 2013 (H25.2)]

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Depressed skull fractures (DSFs) in neonates occur rarely and are usually associated with extrinsic trauma during pregnancy and delivery. DSFs in the absence of any known trauma or obvious risk factors in neonates (so-called congenital DSFs) are very rare, ranging from 1/4000 to 1/10,000. We describe a case of a female neonate with a significant right frontal congenital DSF, her course of treatment, and a literature review of congenital DSFs. A 2640-g, female infant was delivered uneventfully in cephalic presentation to a 26-year-old woman (gravida 1, para 1) at 39 weeks of gestation, with Apgar score 9 and 10 at 1 and 5 minutes, respectively. The mother was low in height (149cm), but X-ray pelvimetry showed that her pelvis had not contracted she did not have a flat sacrum. She had no history of trauma during pregnancy, and neither forceps nor fundal pressure was applied at the time of delivery. At the birth, a right frontal skull depression of 3\times;4.5 cm was noted in the neonate. The physical and neurological findings were unremarkable except for the right frontal skull depression. Plain X-ray and CT scans of the skull revealed a depressed fracture of the right frontal bone without any fracture line or intracranial complication. We performed a careful follow-up for four weeks, but there was no spontaneous elevation of the depression. Therefore a skull-plasty was performed at 28 days old. In the literature, congenital DSFs have been described in association with a uterine tumor, pressure on the fetal skull by the L5 vertebra or prominences of the pelvis, multiple conception, and the fetal extremities. It is difficult to diagnose congenital DSFs before birth, but non-traumatic DSFs in neonates have been described to be associated with a favorable prognosis, unlike traumatic DSFs. Therefore, without any neurological abnormal finding or intracranial complication, we can choose conservative observation for several weeks in the hope of spontaneous improvement, and consider the indication of neurosurgical interventions. [Adv Obstet Gynecol, 65(1) : 95-99, 2013 (H25.2)]

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