Intrapartum antibiotic prophylaxis (IAP) has reduced the incidence of early-onset group B streptococcus (GBS) infection in neonates, but the risk of antibiotic-resistant bacteria infection in the future is a cause for concern. To examine the possibility of decreasing the number of pregnant women with IAP responsive for resistant bacteria, we attempted local eradication of bacteria in pregnant women who tested positive for GBS from the 34th through the 37th weeks of pregnancy, by using chloramphenicol (CP) vaginal tablets. We also investigated the influence of the GBS carriage rate, rate of GBS transmission to newborns, time required between IAP and delivery, and time required between rupture of membrane and delivery for GBS transmission to newborns. On screening 982 pregnant women from the 34th through the 37th weeks of pregnancy, 139 (14.2%) were found to be GBS positive. Although 20 out of the 98 pregnant women (20.4%) who were given CP vaginal tablets became GBS negative, 3 out of the 11 pregnant women (27.3%) who were not treated with CP vaginal tablets also became GBS negative; thus, the CP vaginal tablets were not found to be very efficacious against the local eradication of bacteria. Seventeen of the 149 pregnant women (11.4%) with positive GBS cultures at the time of delivery had newborns whose cultures were positive for GBS. Of these women, 12 had been treated with IAP; however, the time between IAP and delivery for all of them, except one, was less than 4 hours. The time from membrane rupture to delivery was not associated with the rate of GBS transmission to newborns. During the current study, no cases of early-onset neonatal GBS infections were noted. The findings indicate that it is important to consider reexamination in the case of pregnant women when there is a period of more than four weeks after the initial culture and delivery and develop approaches to ensure a sufficient time interval between IAP and delivery. [Adv Obstet Gynecol, 65(2) : 119- 125, 2013 (H25.5)]

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Cushing syndrome, one of the causes of secondary hypertension, is a condition caused by excessive cortisol secretion because of adrenal hyperfunction. Hypercortisolism induces characteristic symptoms such as central obesity, moon face, and buffalo hump. Cushing syndrome rarely occurs in pregnant women because of menstrual disturbances ; furthermore, most women suffering from hypercortisolism also suffer from infertility. A diagnosis of Cushing syndrome during pregnancy is often difficult because some symptoms and signs of this condition are considered normal during pregnancy. Cushing syndrome in pregnancy is associated with a high frequency of maternal and fetal complications such as miscarriage, stillbirth, and maternal congestive heart failures. Some maternal deaths have also been reported. Here we present the case of a 34-year-old Japanese woman (gravida 0, para 0) who was diagnosed with Cushing syndrome during pregnancy but delivered a healthy infant via cesarean section. The patient who had conceived naturally was transferred to our hospital at 22 weeks of gestation because of hypertension since the first trimester, which worsened despite medications. Her blood pressure remained elevated at 158/100 mmHg despite intravenous hydralazine administration on admission. Blood and urine analyses to detect the cause of hypertension revealed low plasma adrenocorticotropic hormone levels, high plasma and urine cortisol levels, and hypokalemia. Abdominal magnetic resonance imaging revealed a round mass, approximately 4 cm in diameter, in the left adrenal gland. A diagnosis of Cushing syndrome secondary to adrenal adenoma was made, and left adrenalectomy was performed at 24 weeks of gestation. Histopathological examination of the resected specimen confirmed benign adrenal adenoma. After surgery, her blood pressure returned to normal ; however, it elevated again soon after. Furthermore, fetal growth restriction was observed from 31weeks of gestation. We diagnosed preeclampsia superimposed on chronic hypertension and performed an emergency cesarean section at 33 weeks of gestation. She delivered a female baby who weighed 1834 g with Apgar scores of 8/9 at 1/5 minutes. Histopathological findings of her placenta were indicative of pregnancy-induced hypertension. Both mother and child remained in good health after delivery. [Adv Obstet Gynecol, 65(2) : 126 - 132, 2013 (H25.5)]

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Pelvic actinomycosis is a rare disease caused by Actinomyces. As the clinical features resemble malignant disease, a correct preoperative diagnosis is sometimes difficult. Treatment with penicillin may completely cure the infection. We report a patient with pelvic actinomycosis associated with an intrauterine contraceptive device (IUD), who was successfully treated with antibiotic therapy. A 53-year-old, gravid one, para one, had used an IUD for the previous 20 years. She came to our hospital with complaints of lower abdominal pain and weight loss. On pelvic examination, the right adnexa was tender, and the parametrial induration was palpable. Cervical and endometrial smears were negative. CT and MRI showed a polycystic mass of the right adnexa. Rectum wall thickening and right hydronephrosis could be seen. The tissue fragment around the IUD contained organisms resembling Actinomyces, as revealed by Gram stains. We treated the patient with a large dose of penicillin for one month, followed by amoxicillin for six months. At follow-up visits, clinical and radiological remission was observed. She was asymptomatic at the one-year follow-up visit. [Adv Obstet Gynecol, 65(2) : 133 - 138, 2013 (H25.5)]

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Here, we present a case of left heart failure associated with peripartum cardiomyopathy (PPCM) in a pregnant woman on maintenance dialysis. Our patient was a 38-year-old primigravida who had been on maintenance haemodialysis for 16 years after developing renal failure due to IgA nephropathy. She visited our hospital after conceiving spontaneously, and was admitted at 19 weeks of gestation for dialysis six times per week. The patient’s dry weight (DW) for dialysis was set with reference to the post-dialysis inferior vena cava (IVC) diameter, human atrial natriuretic peptide (hANP) level, and amniotic fluid index (AFI). At 33 weeks and three days of gestation, she developed respiratory distress, with evidence of severe pulmonary edema and cardiomegaly on plain chest radiographs. Emergency cesarean section was performed, and the baby weighed 1422 g with Apgar scores of 5 and 9. The mother was admitted to the intensive care unit postoperatively. Echocardiography revealed an ejection fraction of 25%. As she had no pre-existing cardiac disease and left heart failure had occurred suddenly, we suspected PPCM. Dialysis was done three times weekly to reduce the DW, and her heart failure was treated with oral bromocriptine. At 16 days postoperatively, echocardiography showed an ejection fraction of 32.5%. Subsequent rehabilitation enabled rapid recovery and she was discharged at 26 days postoperatively. Serum levels of 16 kDa prolactin and activated cathepsin D were elevated, indicating that PPCM was the underlying cause of left heart failure. Her child has been managed in the neonatal intensive care unit as a very low birth weight infant, and is currently making good progress. This case demonstrates the importance of managing pregnant dialysis patients by setting the DW according to the IVC diameter and monitoring cardiac function by using hANP, echocardiography, and other modalities. [Adv Obstet Gynecol, 65(2) : 139 - 145 , 2013 (H25.5)]

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Thyrotoxic crisis typically occurs in patients in whom preexisting hyperthyroidism has not been diagnosed or has been treated insufficiently. The crisis has an abrupt onset, and is sometimes evoked by delivery. We herein report the case of a patient who developed thyroid crisis after delivery. A 28-year-old female who had fatigability and tachycardia but was followed as a normal pregnancy delivered a 2.06 kg baby at 35 weeks of gestation. The baby’s Apgar score was 2 at 1 minute and 3 at 5 minutes. He was transferred to a hospital equipped with a NICU. One hour later, the patient developed dyspnea, tachycardia, and hypertension. She was suspected to have a pulmonary thromboembolism or preeclampsia by an obstetrician at that clinic, and was transferred to the emergency department of our hospital. On arrival she had a disturbance of consciousness, and she showed tachycardia, hypertension, dyspnea, and a swollen neck. Ultrasonography revealed a swollen thyroid with elevated blood flow and severe heart insufficiency. She was diagnosed with heart failure caused by thyroid storm, and immediate treatment was started with a thyroid antagonist, potassium iodide and methylprednisolone in the intensive care unit. The tachycardia and thyrotoxicosis were improved within 24 hours, and she was discharged on postpartum day 14. Thyrotoxic crisis is a rare but often fatal condition. Therefore, it should be kept in mind that postpartum shock can lead to such disorders. This case may suggest that screening for thyroid function during pregnancy can prevent severe complications, such as cardiac failure. [Adv Obstet Gynecol, 65(2) : 146 - 152 , 2013 (H25. 5)]

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Spontaneous rupture of a mature cystic teratoma often causes chemical peritonitis induced by fat and hair present in the cyst. When rupture of a mature cystic teratoma is detected, an emergency surgery is usually performed for removal of the dermoid cyst contents ; however, complete removal is difficult in some cases of prolonged chemical peritonitis because of severe adhesion. We report a case of prolonged chemical peritonitis that was improved by corticosteroid administration. The patient was a 48-year-old woman who was transferred to our hospital after 12 days of hospitalization in another hospital because of lower abdominal pain and high-grade fever accompanying a left ovarian tumor. Continuous administration of antibiotics was ineffective and rupture of a mature cystic teratoma was observed on MRI 20 days after the onset of abdominal pain. The patient underwent emergency laparotomy. Operative findings revealed severe adhesion, pus, and a left ovarian tumor in the abdomen. Left salpingo-oophorectomy was performed, and the abdominal cavity was washed with 5000 ml of saline. In the upper abdominal cavity, adhesions were observed in the small intestine and omentum because of the abscess that was encapsulated as a single mass; however, complete removal of the dermoid cyst contents and abscess was difficult because of the high risk of intestinal injury. After the surgery, the high-grade fever and upper abdominal pain persisted, and antibiotics were ineffective. Chemical peritonitis was suggested as a main cause after precise investigations of other causes. According to a previous report, we started administration of hydrocortisone at a dosage of 20 mg/day. Serum C-reactive protein (CRP) decreased immediately. When we decreased the dosage to 5 mg/day prednisolone, chemical peritonitis recurred. We then increased the dosage of prednisolone to 30 mg/day and tapered the dosage during the one-year follow-up on an outpatient basis. No symptom of chemical peritonitis recurrence has been observed since discharge, and serum CRP levels were within a normal range for five months after treatment with prednisolone. There are some reports on chemical peritonitis after spontaneous rupture of a mature cystic teratoma or spillage of the cyst contents during surgery; however, there are only few reports about latent chemical peritonitis improved with steroid administration. As in this case, administration of corticosteroids is suggested to be effective in latent chemical peritonitis, in which re-operation is difficult because of the high risk of complications. [Adv Obstet Gynecol, 65(2) : 153 - 160 , 2013 (H25.5)]

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Anti-NMDA receptor encephalitis is a para-neoplastic encephalitis associated with ovarian teratoma, a form of non-herpetic limbic encephalitis occurring more frequently in young women than in other demographic groups. We describe our experience with a case of recurrent anti-NMDA receptor encephalitis with mature cystic teratoma of the ovary. A 35-year-old woman had encephalitis of unknown etiology at the age of 20, necessitating a two-month hospitalization. Subsequently, when she became pregnant at the age of 26, she was given a diagnosis of mature cystic teratoma of the ovary, which led to abdominal left ovarian cystectomy during pregnancy. Thereafter, although she maintained a healthy lifestyle, she suddenly experienced fever and psychiatric symptoms. Then, she showed consciousness disturbance, and encephalitis was suspected, prompting a referral to our hospital. After admission to our neurology department, she showed status convulsion, and was transferred to the ICU with intratracheal intubation. A whole-body CT screening examination at the time of admission revealed an ovarian tumor in the pelvis. Anti-NMDA receptor encephalitis was suspected, and she was transferred to our department for urgent abdominal bilateral adnexectomy. Histopathological examination of the resected specimen showed a mature cystic teratoma. The patient remained comatose after the operation, but after approximately one month later she was able to open her eyes. Thereafter, her consciousness gradually improved, and on the 116th hospital day she was discharged walking independently. The blood and spinal fluid specimens collected at the time of admission showed anti-NMDA receptor antibodies, which led to a definitive diagnosis. Since discharge, she has been followed up on an outpatient basis, and has been free of encephalitis recurrence. Mature cystic teratoma of the ovary occurs with a high frequency and can cause this type of encephalitis. Therefore, it is important to confirm in detail whether patients with ovarian teratomas have a previous history of encephalitis or other diseases related to the central nervous system. [Adv Obstet Gynecol, 65(2) : 161 - 167 , 2013 (H25.5)]

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