In women suffering a midtrimester pregnancy termination between 12 and 21 weeks of gestation, uterine rupture or massive bleeding may occur, requiring blood transfusion, uterine artery embolization, hysterectomy, and other procedures. These complications may sometimes result in maternal death. While dilation and evacuation are the common surgical procedure for midtrimester pregnancy termination overseas, labor induction using gemeprost is common in Japan. In this study, we investigated the risk of bleeding associated with midtrimester pregnancy termination induced by gemeprost in 68 women with singleton pregnancies for whom a midtrimester pregnancy termination (between 12 and 21 weeks gestation) was induced by gemeprost during the six-year period from April 2008 to March 2014 in compliance with the Maternal Protection Act. The women were divided into a massive bleeding group and a non-massive bleeding group, using the 90th percentile of blood loss as the cut-off value, for comparison. There were no significant differences between the two groups in maternal age, body mass index, parity, gestational age, fetal weight, fetal length, the duration of the third stage of labor, use of placental forceps for removal of the placenta, or presence or absence of abnormal placental position. In the massive bleeding group, there were significantly more women with a history of hysterotomy, and the placenta was significantly heavier. Moreover, the risk of bleeding was significantly higher in women in whom two days or more were required until labor was induced. None of the women had uterine rupture or required uterine artery embolization or hysterectomy, although two women required blood transfusion. In Japan, the number of deliveries by cesarean section has increased in recent decades, which may account for increasing midtrimester pregnancy termination cases with a high risk of bleeding. Because delay in treatment with blood transfusion and other procedures leads to worsening of the clinical situation in these cases, it seems that treatment at a higher-level facility should also be considered for such high-risk cases. [Adv Obstet Gynecol, 67 (2) : 47-52, 2015 (H27.5)]

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Female adnexal tumor of probable wolffian origin (FATWO) is a rare tumor. FATWO is low grade malignancy and sometimes develops distant metastasis and local recurrence. We herein report a case involving a 19-year-old female G0P0 patient with FATWO. She initially presented for irregular menstruation and was referred to our hospital for a solid left ovarian tumor seen on MRI. PET/CT was performed for further evaluation and showed FDG uptake in the tumor. Preoperatively, these results were highly suggestive of malignant tumor of the left ovary. Exploratory laparotomy revealed a normal left ovary with a tumor arising in the left mesosalpinx. Primary surgery was underwent only tumorectomy for the difficulty of diagnosis by pathohistological analysis during surgery. The tumor was solid and multilobulated with a tan-yellow cut surface. Histopathologically, the tumor mainly exhibited a highly cellular, diffuse growth of cells with slightly eosinophilic cytoplasm and oval to spindled nuclei. Some areas showed trabecular and tubular patterns. Immunohistochemical staining was positive for vimentin,cytokeratin AE1/3, CD10, and glutathione S transferase, but negative for epithelial membrane antigen. Our pathological diagnosis was FATWO. Laparoscopic left salpingo oophorectomy was underwent for additional surgery. Adjuvant chemotherapy was refused, the patient remains healthy twenty one months after the initial surgery. FATWO must undergo long-term observation because many progress as benign tumors; however, metastasis and recurrence sometimes develop. [Adv Obstet Gynecol, 67(2) : 53-59, 2015 (H27.5)]

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Herein, we report a case of low-grade endometrial stromal sarcoma (LGESS). There are very few reported cases of LGESS detected by FDG-PET (PET), and to the best of our knowledge, a case of LGESS detected by PET/MRI cancer screening has not been reported previously. A 46-year-old woman, with no primary complaint, was referred to our hospital because of a suspected malignant uterine tumor detected by PET/MRI cancer screening. PET showed focal light-intense FDG uptake (SUVmax = 2.885) above the urinary bladder in the pelvis. The superimposed PET/MRI image demonstrated that this area corresponded to the anterior wall of the uterus where a T2-weighted image revealed a mass measuring 45 mm with high signal intensity. Using conventional B-mode ultrasonography, it was initially thought to be a benign leiomyoma node. However, the intra-tumoral blood vessel patterns on ultrasonic power Doppler images were mosaic, thus disproving this possibility. Cytological examinations revealed that the uterine cervix was negative for intraepithelial lesion or malignancy, and the uterine endometrium was also negative. Fifty days after the initial cancer screening by PET/MRI, the dynamic enhanced-MRI was performed again at our hospital. The tumor in the uterus was found to be multi-lobular and had increased in size to about 55 mm. Flow-voids could also be observed at the peripheral edge of the tumor. Moreover, the tumor was prominently enhanced on dynamic contrast-enhanced T1-weighted images during the early phase, and high-intensity areas were visible in diffusion-weighted images. Therefore, a benign uterine tumor (e.g. cellular leiomyoma or degeneration of leiomyoma) was not excluded completely, a uterine sarcoma (e.g. leiomyosarcoma) was suggested preoperatively. Hysterectomy and bilateral salpingo-oophorectomy were performed upon the patient’s request. The tumor was hypercellular and was composed of markedly spindle-shaped cells with low mitotic activity (<2/10 HPF). Tumor cells extensively invaded neighboring vessels, while vessels were invaded to a lesser extent. Infiltration of the endometrium was also seen. Tumor cells were immunoreactive for CD10, estrogen receptor, and progesterone receptor, but negative for cytokeratin. A diagnosis of LGESS (pT1bNxM0) was made. After the operation she had no adjuvant therapy was not given following surgical intervention, and no recurrence has been detected after 24 months. LGESS is a rare malignant tumor of the uterus and that is symptomatic in approximately 25% of patients. PET/MRI cancer screening was able to detect early stage of LGESS in the present patient. [Adv Obstet Gynecol, 67 (2) : 60-66, 2015 (H27.5)]

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A 41-year-old woman, gravida 0, para 0, who received an infertility treatment and whose urine hCG was positive after a third round of artificial insemination with husband’s spermatozoa (AIH), was referred to our hospital because of acute abdominal pain 88 days after AIH (gestational age ; 14 weeks, 4 days). She was in shock, and we performed a vaginal ultrasound that showed no gestational sac in her uterus, but a 5 cm living fetus outside the uterus. Magnetic resonance imaging (MRI) showed an oval and well-defined GS and a crescent-shaped placenta. We performed a laparotomy, in suspicion of a tubal or abdominal pregnancy; 1040 ml of blood were drained, and we recognized a 5 cm fetus in a ruptured left adnexa. The ruptured site was the ampulla of the left ovarian tube, and a left salpingectomy was performed. She was discharged on the sixth postoperative day in good health. She had experienced a very rare case of tubal pregnancy at 14 weeks gestation without any symptoms. The images of an oval GS and/or a crescent-shaped placenta on the MRI may be helpful for distinguishing an advanced tubal pregnancy from an abdominal pregnancy. [Adv Obstet Gynecol, 67(2) : 67-73 , 2015 (H27.5)]

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Paraovarian tumors represent up to 5-20% of adnexal tumors. Most of them are benign, and malignant or borderline tumors were reported about 2-3% of paraovarian tumors. The presence of papillary projection, which is usually found in the malignant tumor, is detected 30% of benign paraovarian tumor, and that makes it difficult to predict whether tumor is benign before surgical treatment. The optimal clinical management of paraovarian borderline tumor remains to be fixed, we are supposed to treat it as we do for ovarian tumors. We report here a case of paraovarian tumor of borderline malignancy. A 48-year-old woman, gravida 0 para 0, was pointed out her left ovarian mass in a medical health checkup. Magnetic resonance imaging showed a multilocular cystic tumor of about 5 cm in diameter with solid part which has enhancing effect in the left adnexal area. We performed laparotomy to find in the left mesosalpinx egg-sized tumor where multiple papillary projections were seen on the inner surface. Intraoperative pathological diagnosis showed serous borderline tumor, so total abdominal hysterectomy, bilateral salpingo-oophorectomy and partial omentectomy were performed. Final pathological diagnosis of permanent specimen was made as left paraovarian serous borderline papillary cystic tumor stage Ia. The patient is now healthy, and there has been no evidence of recurrence six months after surgery. [Adv Obstet Gynecol, 67 (2) : 74-79, 2015 (H27.5)]

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Ovarian hyperstimulation syndrome (OHSS) is caused by gonadotropin administration. It leads to multicystic expansion of the ovary and leaking out of the plasma component to the third space owing to increased capillary permeability, resulting in hypovolemia, concentrated blood flow, pleural effusion, and ascites retention. In severe cases, cardiopulmonary failure may occur, and this state may be fatal. A 33-year-old woman (gravida 1, para 1) presented with stomachache and abdominal fullness. Although her cardiopulmonary state was stable, she had a remarkably high blood concentration and multicystic swelling of her bilateral ovaries on abdominal computed tomography. She was diagnosed with severe OHSS and was hospitalized. The patient was treated immediately to maintain circulating plasma volume and renal blood flow and to inhibit thrombus formation. However, urine output decreased remarkably, and pleural effusion and ascites were identified on the second day of hospitalization.The patient was in a respiratory distress state. Oxygen administration was initiated;however, oxygenation was still poor. Therefore, the ascites filtration, concentration, and reinfusion method (intravenous; cell-free and concentrated ascites reinfusion therapy [CART]) was used on the third day of hospitalization in the ICU. After the CART, the patient’s condition improved remarkably. She did not conceive and had got better afterwards. Here we report on a case of severe OHSS and review the literature.[Adv Obstet Gynecol, 67 (2) : 80-85, 2015 (H27.5)]

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Attention must be paid to the possibility of the late recurrence of granulosa cell tumors of the ovary, and reports of recurrence after more than 10 years have been made. In all cases, this has occurred after laparotomy, and there have been no reports to date of late recurrence caused by laparoscopic surgery in Japan. We report here on our experience with a case of the recurrence of a granulosa cell tumor of the ovary 13 years after laparoscopic surgery. The patient was a 65-year-old female. When she was 52, a tumor in the right ovary was identified at this hospital and extirpated by laparoscopic surgery. The histological diagnosis was stage IC adult-type granulosa cell tumor of the right ovary. A non-mobile right adnexal mass the size of a goose’s egg was palpated at an internal examination during a follow-up examination 13 years after the initial surgery. Transvaginal ultrasonography showed an endometrial thickness of 8.6 mm and revealed a multilocular neoplastic lesion having a cystic lesion of 4.9×4.1 cm and a solid lesion of 2.7×2.6 cm in the right ovary. An ¹⁸FDG-PET revealed an abnormal accumulation of ¹⁸FDG only in mural nodule sites of the right ovarian tumor. The recurrence of a right ovarian granulosa cell tumor in the right ovary was diagnosed, and a laparotomy was performed. The right ovarian tumor had invaded the right bladder cavity, was fused to the right external iliac vein, and was embedded in the right pelvis. A total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy were performed without intraoperative failure. No residual tumor was noted macroscopically. Pathological diagnosis was recurrence of adult-type granulosa cell and chemotherapy is currently being implemented. In addition to this case, recurrence, three years and five months after laparoscopic extirpation of granulosa cell ovarian tumors of the affected side has also been reported, thus, staging laparotomy should be considered after primary surgery. Additional treatment should be decided carefully considering the risk of recurrence and fertility preservation. [Adv Obstet Gynecol, 67(2) : 86-94, 2015 (H27.5)]

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The definition of giant ovarian tumor applies when the total weight of the tumor is 10 to 20 kg (or more), or the weight ratio is 20% or more of body weight. Torsion caused by giant ovarian tumors is quite rare, occurring in only 2.9% of cases. We report a rare case where torsion occurred when the tumor had reached a size of 34 cm and had a liquid content of 13 kg. In this case, the patient was 26-year-old, nonparous, and morbidly obese with a body mass index of 43. She had no previous history. She began to feel pain in her lower abdomen and received a medical examination from another physician three days later. The doctor suspected an unusually large ovarian cyst and referred the patient to our hospital for medical treatment. At the initial visit, the patient’s chief complaint was of lower abdominal pain and dyspnea. The suspected tumor was palpable as a large mass up to the hypochondrium, and mild Blumberg sign was seen in the lower left abdomen. Transabdominal ultrasonography revealed a single-wall cystic mass 32 cm in size. At the time, she was emergently hospitalized with the diagnosis of acute abdominal pain and giant ovarian cyst. The only tumor marker which was elevated was CA125 at 41.9 U/ml. A contrast CT examination revealed a mass 34 × 31 × 27 cm in size, and the patient was diagnosed with torsion of the left ovarian tumor due to the loss of contrast effect in that area. Thereafter, the patient underwent an emergency laparoscopic left salpingo-oophorectomy on the same day of hospitalization. The cyst surface was a deep violet-blue, and the left side adnexa was twisted 540 degrees counter-clockwise. The right side adnexa was normal. We used a SAND balloon catheter® to aspirate the intratumoral fluid at a rate of about 500 ml/min. A total of 13590ml of serous fluid was aspirated from the cyst. Although ovarian torsion was released, the color of tumor mass did not return to normal. After the left salpingo-oophorectomy, the cyst was recovered from the right side umbilical port by Endo Catch II®. Ascites fluid cytology revealed no malignant cells, and the intraoperative pathological diagnosis was a serous adenoma. Surgery time was 3 hours and 10 minutes, and intraoperative blood loss was 30g. The patient made an uneventful postoperative recovery and was discharged on the fifth postoperative day. The final pathological diagnosis was serous adenoma. [Adv Obstet Gynecol, 67 (2) : 95-100 , 2015 (H27.5)]

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Exophytic and pedunculated malignant neoplasm of the uterine corpus is rare. We report a case of exophytic and pedunculated high-grade endometrial stromal sarcoma (high-grade ESS) of the uterine corpus. A 61-year-old nulligravid woman presented with abdominal pain. Ultrasonography and magnetic resonance imaging showed a 20 cm abdominal mass with internal hemorrhage, suggesting rupture of ovarian cancer. However, laparotomy revealed a pedunculated mass arising from the surface of the uterine fundus, and both ovaries were intact. We performed total abdominal hysterectomy and bilateral salpingo-oophorectomy. The histopathological findings revealed high-grade ESS, arising from the myometrium, stageIB. We chose to follow up the patient’s condition without adjuvant therapy, but eight months postoperatively, abdominal dissemination of high-grade ESS occurred. Chemotherapy was not effective, and the patient died 12 months postoperatively. No other case of an exophytic and pedunculated uterine high-grade ESS has been reported, and it is difficult to distinguish preoperatively from malignant ovarian tumor. [Adv Obstet Gynecol, 67 (2) : 101-106 , 2015 (H27.5)]

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Primary condylomatous carcinoma of the uterine cervix is a subtype of squamous cell carcinoma that is rarely encountered. We describe a case of primary condylomatous carcinoma of the uterine cervix that was treated with radiotherapy. An 80-year-old woman was referred to our hospital with abnormal genital bleeding. During colposcopy and ultrasonography examinations, a necrotic mass was detected on the uterine cervix and vaginal wall. Histological examination by biopsy revealed condylomatous carcinoma. HPV type 16 was identified in the uterine cervical specimen by polymerase chain reaction analysis. Magnetic resonance imaging of the pelvis revealed cervical cancer with invasion of the vagina and parametrium. Positron emission tomography/computed tomography revealed no remarkable findings except for the cervical tumor. As condylomatous carcinoma of the uterine cervix was diagnosed, the patient received external beam radiotherapy and intracavity brachytherapy. She has experienced no recurrence for two and a half years since the radiotherapy. [Adv Obstet Gynecol, 67 (2) : 107-113, 2015 (H27.5)]

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Treatment with glucocorticoids is the most common drug-related cause of osteoporosis.Bisphosphonate therapy is an important option in the prevention and treatment of glucocorticoid-induced osteoporosis; however, it is generally advised that bisphosphonates should be avoided during pregnancy. Here, we present the case of a 37-year-old woman (gravida 2, para 0) with systemic lupus erythematosus, who presented with two episodes of acute back pain in the third trimester, due to lumbar compression fractures.The patient had previously received oral glucocorticoid therapy (20 mg/day) and risedronate. She conceived a child by intracytoplasmic sperm injection, three years after risedronate was stopped. The patient was positive for anti-β2-glycoprotein 1 antibodies, and had a history of two spontaneous miscarriages. She was therefore treated prophylactically during pregnancy with subcutaneous heparin and low-dose aspirin.At 29 weeks of gestation, she was admitted to our hospital with the first episode of severe pain. Magnetic resonance imaging (MRI) indicated loss of height in the L1 and L2 vertebrae and a fresh compression fracture at L4. The patient was diagnosed with glucocorticoid-induced osteoporosis, and her pain was successfully controlled with acetaminophen and tramadol hydrochloride/acetaminophen. At 32 weeks of gestation, a second episode of acute pain occurred; MRI indicated that this was due to a fresh compression fracture at L2. The severity of her pain increased, and treatment with transdermal fentanyl patches (12.5 µg/h) was started; patches were changed every 72 h. Her pregnancy proceeded otherwise uneventfully, and she continued to use the transdermal patches until delivery. At 35 weeks of gestation, a planned elective cesarean section was performed, and a female infant weighing 1896g was delivered. The Apgar scores were 8 at 1 min and 9 at 5 min; the infant was not assessed for opioid withdrawal symptoms.Three days after delivery, lactation was stopped and alendronate was commenced. The patient wore a corset and began a rehabilitation program. Six days following delivery, the transdermal patches were stopped, and loxoprofen was effective for pain relief. Nineteen days after delivery, teriparatide was commenced. Twenty-two days following delivery the patient’s L2-L4 bone mineral density was 0.884 g/cm³, 77% of the young adult mean. With rehabilitation, she regained the ability to walk unaided. The patient and her baby left our hospital 36 days after delivery. Patients at high risk of fragility fractures need preventive treatment during pregnancy. Use of transdermal fentanyl patches for chronic pain appears to be relatively safe during pregnancy.[Adv Obstet Gynecol, 67(2) : 114-119, 2015 (H27.5)]

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A placental hematoma is caused by the rupture of a placental vessel. The clinical symptoms vary depending upon the site of the hematoma. It has been reported that cystic tumors at the placental cord insertion site (PCIS) may lead to non-reassuring fetus status or fetal growth restriction. We report a case of a placental hematoma in which recurrent bleeding had occurred. Careful observation allowed the patient to progress to term. The 41-year-old gravida 3, para 2 was referred to our hospital at 25 gestational weeks (GWs) for evaluation of an enlargement of a cystic tumor on the placenta. At 31 GWs, she was hospitalized because of an acute increase in the size of the tumor; the fetal middle cerebral artery peak systolic velocity (MCA-PSV) was 66 cm/s (1.55 MoM). We suspected a subamniotic hematoma; therefore, we frequently assessed the fetal circulation, the tumor size, the amniotic fluid index, and the MCA-PSV. From 32 to 34 GWs, the MCA-PSV value was usually>1.8 MoM; thus, we suspected fetal anemia. However, the other indicators of fetal well-being were within normal limits. Beginning at 36 GWs, we intermittently performed a contraction stress test and confirmed fetal well-being. At 38 GWs, she delivered a 3380g female infant with Apgar scores of 8/9. The infant was not anemic and her postnatal course was uneventful. The pathologic diagnosis of the placental tumor was a subchorionic hematoma. In this case, we diagnosed a placental hematoma with ultrasound. Due to the high MCA-PSV, fetal anemia was suspected. Therefore, we carefully monitored fetal status and achieved a spontaneous vaginal delivery at term. [Adv Obstet Gynecol, 67 (2) : 120-125 , 2015 (H27.5)]

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FATWO (female adnexal tumors of probable Wolffian origin) is a rare group of tumors found in the adnexal region, and its origin is thought to be the Wolffian duct. Here we report a case treated with a laparoscopic surgery under a preoperative diagnosis of myoma uteri, which was postoperatively diagnosed as FATWO. A 40-year-old multiparous woman presented with right lower abdominal pain. Pelvic examination and MR imaging supported clinical diagnosis of degenerated myoma, and laparoscopic surgery was performed. At the operation, a solid tumor located in the right mesosalpinx was identified. The tumor was laparoscopically enucleated from mesosalpinx. Microscopic examination revealed a tumor showing tubular proliferation of cuboidal cells with scant cytoplasm and bland round nuclei, and the case was pathologically diagnosed as FATWO. Hysterectomy and bilateral salpingo-oophorectomy were performed later, but the removed specimen was free of tumor. The patient is well without recurrence of disease. Preoperative diagnosis of FATWO may be challenging, but FATWO should be considered as a differential diagnosis when a solid tumor was found in the leaves of the broad ligament or in the mesosalpinx. [Adv Obstet Gynecol, 67 (2) : 126-129, 2015 (H27.5)]

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Small cell carcinoma (SmCC) is a neoplasm characterized by differentiation into neuroendocrine carcinoma. While the female genital tract is rarely the initial site of presentation of SmCC, prognosis of SmCC of the uterine cervix is considered to be poor due to early relapse and/or metastasis to lymph nodes and internal organs. We present a case of SmCC with hormone production that initially presented in the uterine cervix. The patient, a 39-year-old woman, was examined at another clinic with primary complaints of genital bleeding, lower abdominal pain, and nausea. Pelvic examination, transvaginal ultrasonography, and magnetic resonance imaging showed diffuse enlargement of the uterine cervix, and blood work-up revealed hyponatremia. When the patient became deranged and disoriented, she was referred to our institution. Cytological examination and biopsy of the uterine cervical tumor was suggestive of SmCC. Additional laboratory examination showed hyponatremia (116 mEq/L), a hypoosmolar state (257 mOsm/L), increased urine osmolality (873 mOsm/L), and elevated antidiuretic hormone (ADH) levels (4.76 pg/ml). Fluid and saline replacement therapy improved the patient’s hyponatremia, although she showed depressive symptoms, moon-face, and hypertrichosis. Hypokalemia, elevated adrenocorticotropic hormone (ACTH) levels, and cortisone were found in both serum and urine on laboratory examinations. Considering these findings, the patient was diagnosed with stage IIB SmCC of the uterine cervix with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and ectopic ACTH syndrome under the "umbrella" of Cushing’s disease. The patient received three arterial infusions of cisplatin and epirubicin as neoadjuvant chemotherapy to reduce the tumor bulk, followed by abdominal radical hysterectomy. Postoperative histological examination confirmed the diagnosis of SmCC. After intervention, adjuvant chemotherapy with carboplatin and etoposide was continued ; however, 10 months after the initial presentation, the patient died due to diffuse metastases and septicemia, which were complications of her disease. The present case indicates the difficulty in treating advanced uterine cervical SmCC with SIADH and Cushing’s syndrome, and highlights the importance of early detection of these highly malignant tumors through screening programs. [Adv Obstet Gynecol, 67 (2) : 130-139, 2015 (H27.5)]

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