Postpartum hematoma is one of the serious complications of delivery that requires a multidisciplinary approach. We analyzed 28 cases of postpartum hematoma managed by a multidisciplinary approach at Shiga University of Medical Science Hospital between January 2004 and December 2013. To identify factors associated with exacerbation of postpartum hematoma, we examined eight variables: maternal age, parity, gestational age at delivery, birth weight of the infant, total delivery time, vacuum extraction, episiotomy position, and time from delivery to initiation of treatment for the hematoma. The time from delivery to initiation of treatment for the hematoma was significantly related to performance of blood transfusion (p=0.03). Delayed treatment was associated with a worse outcome. Therefore, if a woman complains of pain after delivery, we should search for hematoma as soon as possible. All patients with retroperitoneal hematoma required blood transfusion or treatment of disseminated intravascular coagulation, which suggests that it is highly advisable to transfer the patient to a tertiary hospital if deterioration is predicted. [Adv Obstet Gynecol, 67 (3) : 241-246, 2015 (H27.8)]

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Adenomyosis is defined by the presence of endometrial tissue within the myometrium, and the malignant transformation of adenomyosis in premenopausal women with normal endometrium is extremely rare. We report a case of eight endometrioid adenocarcinoma arising from an adenomyotic focus in the uterus. 497 patients with endometrial cancer were identified, of which eight had tumors arising from uterine adenomyosis. Among the 8 patients, 6 presented at stage IA (75%), 1 at stage IB (12.5%), and 1 at stage IIIC (12.5%). The histological subtype of the eight tumors was endometrioid, with 3 at grade 1 and 5 at grade 2. In all cases, a transition between the carcinomas and the adenomyotic glands was observed. Additionally, there was no difference of in median age (p=0.42) and myometrium invasion (p=0.10) in all cases when compared with normal cases without carcinoma arising from uterine adenomyosis.The accuracy of endometrium biopsy for preoperative diagnosis with hysteroscopy was 75%, and the accuracy of myometrial invasion for preoperative diagnosis with magnetic resonance imaging was 88%. Moreover, the accuracy of intraoperative consultation was 100%. All patients are currently disease-free. Endometrial cancer arising from adenomyosis is rare and difficult to diagnose preoperatively. Although these eight cases resulted in a good prognosis, their number was few. Therefore, we should accumulate more cases of endometrial cancer arising in adenomyosis. [Adv Obstet Gynecol, 67 (3) : 247-253, 2015 (H27.8)]

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The aim of this study was to evaluate the safety and efficacy of pelvic exenteration for gynecological malignancies by retrospective analyses of 22 cases in our department, and by reviewing published articles. The 22 cases consisted of 18 cervical, 2 vaginal, and 2 vulvar cancers, of which 11 primary and 11 recurrent cases were included. Nine cases had been treated by radiotherapy in previous treatments. Total pelvic exenteration was performed for 10 cases and anterior pelvic exenteration for 12 cases. No perioperative death was recorded. Mean operation time was 12.7 hours, and mean blood loss was 2615g. The surgical margin was positive in three cases. Postoperative complications occurred exclusively in the total pelvic exenteration cases, including seven pelvic abscess and five ileus cases; complications were not severe in three cases who used omental transposition flap. Both the five year disease specific survival rate and the relapse-free survival rate of the 17 cervical or vaginal cancer cases without distant metastasis were 70%. Among them, six cases with response of PR (Partial Response) or SD (Stable Disease) to neoadjuvant chemotherapy did not have recurrences, whereas all three PD (Progressive Disease) cases had recurrences and died of the disease (p=0.01). Literature review indicated that perioperative mortality has been drastically decreasing with time. In conclusion, with the optimal choice of indicated cases, pelvic exenteration has now become a safe and effective treatment modality. However, in order to decrease the operative complications, further improvement of the technique, such as use of omental transposition flap, may be necessary. [Adv Obstet Gynecol, 67 (3) : 254-263, 2015 (H27.8)]

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Objective) Laparoscopic surgery is one of the treatment options for infertile endometriotic women. Although the revised American Fertility Society score (rAFS score) has been widely used to indicate the severity of endometriosis, it is difficult to predict the possibility of postoperative pregnancy using it. Recently, the Endometriosis Fertility Index (EFI) was proposed as a scoring system useful for predicting the possibility of non-IVF pregnancy after the surgery. Nevertheless, it remains unclear whether EFI is similarly useful in Japanese women. Therefore, in this study, we evaluated the usefulness of EFI in Japanese patients. Method) We enrolled 57 infertile endometriotic patients who underwent laparoscopic surgery followed by non-IVF treatment at Kyoto University Hospital between January 1999 and May 2012. Firstly, the EFI and rAFS score were compared between the pregnancy (n=35) and non-pregnancy (n=22) groups. Next, cumulative pregnancy rates in the EFI≦6 group and EFI≧7 group were compared using the Kaplan-Meier method. Finally, multivariate analysis was conducted to assess the correlation between pregnancy and each component of the EFI. Results) The EFIs in the non-pregnancy group was significantly lower than that in the pregnancy group (mean±SD: 5.68±1.42 vs. 6.86±1.42, respectively). On the other hand, the difference did not reach significance for rAFS scores. The cumulative pregnancy rate in the EFI≦6 group was significantly lower than that in the EFI≧7 group. On multivariate analysis of the EFI, the strongest (but not significant) correlation was observed for the age of patents. Subgroup analysis of patients aged 35 years or younger showed that the EFI of the non-pregnancy group was significantly lower than that of the pregnancy group. In contrast, no difference was observed in the patients aged 36 years or older. Conclusion) The EFI but not rAFS score was correlated with the possibility of postoperative non-IVF pregnancy in endometriotic Japanese women. EFI≦6 could be considered as a low pregnancy potential. The EFI might be useful to select patients who require an early treatment step-up to IVF after surgery for endometriosis. [Adv Obstet Gynecol, 67 (3) : 264-269, 2015 (H27.8)]

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Ovarian hyperstimulation syndrome (OHSS) is characterized by enlarged ovaries, fluid shift to the third space, and hemoconcentration. Recent research findings have identified that a major contributory factor in OHSS is excessive secretion of vascular endothelial growth factor induced by human chorionic gonadotropin. In assisted reproductive technology (ART) treatment for a group of individuals at high risk of OHSS, we prevented OHSS by using gonadotropin-releasing hormone (GnRH) agonist as a trigger of ovulation, coasting, or embryo cryopreservation for future use with avoidance of embryo transfer in the same cycle. However, the effect appeared insufficient in some cases. Recently several reports have described the effect of cabergoline in preventing OHSS. In this study, we retrospectively examined the effect of cabergoline in preventing OHSS. We evaluated eight patients who were expected to develop OHSS caused by controlled ovarian stimulation during ART treatment. All retrieved oocytes were fertilized, and embryos of good quality were cryopreserved. Patients started seven-day treatment with oral cabergoline and progesterone the next day after oocyte retrieval. No patients developed moderate or severe OHSS, although five patients developed mild OHSS. Our findings suggest that administration of cabergoline is useful in preventing moderate or severe OHSS in ART treatment. [Adv Obstet Gynecol, 67 (3) : 270-275, 2015 (H27.8)]

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Histopathological differentiation between benign and malignant uterine smooth muscle tumors (SMTs) is usually based on the Stanford criteria, which involves the comprehensive evaluation of three indices: cytological atypia, coagulative necrosis, and the mitotic index. These criteria are applicable only to the spindle cell type of SMT, not to other variations such as epithelioid SMT and myxoid SMT. We herein report a case of epithelioid leiomyoma that underwent four histopathological evaluations. A woman in her 30s underwent transcervical resection of a submucosal uterine myoma and developed two local recurrences at the Douglas pouch at 42 and 55 months postoperatively. She subsequently developed multiple pulmonary metastases at 74 months postoperatively. Tumor removal was performed for each recurrence. Ultrasonography and magnetic resonance imaging of the original submucosal uterine myoma, 42 and 55 month recurrences at the Douglas pouch, and 74month pulmonary metastases showed a 3.0 cm solid tumor, a 5.0 cm solid and cystic tumor, a 9.0 cm solid and cystic tumor, and solid tumors with a maximum size of 1.8 cm, respectively. Positron emission tomography of the 42 month recurrence and 74month pulmonary metastases revealed a maximum standardized uptake value of 2.1 and 1.5, respectively. Histopathological findings of the original epithelioid leiomyoma revealed spindle-shaped cells and focal round cells with an epithelial-like appearance. Both recurrences and the pulmonary metastases comprised only round cells with an epithelial-like appearance. No specimens exhibited coagulative necrosis. The mitotic index was 0, 1, 2, and 2, respectively. Immunohistochemical analysis of all specimens revealed αSMA(+)to(3+), estrogen receptor(+), and progesterone receptor(+). The MIB-1 labeling index was 1.2%, 3.4%, 3.7%, and 2.0%, respectively. Great difficulty may be encountered in distinguishing benign metastasizing leiomyoma from pulmonary metastasis in patients with leiomyosarcoma because no histopathological criteria for distinguishing benign from malignant uterine epithelioid SMTs have been established. [Adv Obstet Gynecol, 67(3) : 276-284, 2015 (H27.8)]

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Here, we report a case of a patient diagnosed with Sheehan’s syndrome after being transferred to our hospital due to hemorrhagic shock after vaginal delivery, despite achieving hemostasis with uterine artery embolization (UAE). Moreover, the patient developed hypogalactia and general fatigue in the early postpartum period. A 38-year-old multiparous female delivered a female infant weighing 2420g transvaginally at 37 weeks and 6 days of pregnancy. The Apgar score of the infant was 6/7, and the umbilical arterial pH was 7.194. Over the two hours after the delivery, the patient lost 4300 ml of blood and thereafter, was transferred to our hospital. Upon arrival at our hospital, she was found to have JCS II, and her vitals were: blood pressure below the measurable level (60 mmHg on palpation), pulse rate 120 bpm, hemoglobin (Hb) level 2.8 g/dl, and platelet count 3.6 × 10⁴/ml. Under general anesthesia with intubation, we packed the vagina with gauze and performed bimanual compression. Further, we performed massive blood transfusion and administered thrombomodulin and antithrombin III. Despite these measures, the amount of blood loss reached 3500 ml thirty minutes after arrival at our hospital, and therefore, we performed an emergent UAE. As a result, uterine bleeding progressively diminished, and the patient’s shock state resolved. The total amount of blood loss was estimated to be 11480 ml. The patient required transfusion with a total of 20 units of RBCs, 26 units of FFP, and 35 units of PC. Subsequently, she developed hypogalactia on postpartum day five and hyponatremia with complaint of fatigue approximately three days later. A close examination revealed low levels of the pituitary hormones (GRH, CRH, LHRH, and TRH) with poor responses to stimulation tests. Furthermore, brain MRI showed the absence of an anterior pituitary signal, leading to the diagnosis of Sheehan’s syndrome. We initiated steroid replacement treatment, and an improvement was observed in her symptoms. The patient was discharged from our hospital on postpartum day 13. By five months postpartum, oral steroid treatment was discontinued due to the partial recovery of pituitary function. In postpartum patients who experience large-scale blood loss with subsequent complaints of hypogalactia and fatigue, close examination is necessary while considering the possibility of Sheehan’s syndrome. Moreover, immediate steroid replacement treatment might contribute to partial recovery of pituitary function in Sheehan’s syndrome diagnosed in early postpartum period. [Adv Obstet Gynecol, 67 (3) : 285-290, 2015 (H27.8)]

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We report a case of myomatous erythrocytosis syndrome, wherein during the investigation of erythrocytosis, a large abdominal tumor and a brain tumor were discovered by computed tomography. A 52-year-old woman, whose menopause occurred at the age of 50 years, was introduced to our hospital because of erythrocytosis. Her blood test revealed a hemoglobin level of 20.4 g/dl and erythropoietin level of 32.1 mIU/ml. Whole-body computed tomography demonstrated a brain tumor of 4 cm diameter at the anterior base of the skull and a large abdominal tumor of 18 cm diameter. Based on the magnetic resonance images and owing to the lack of the elevation of tumor markers, the abdominal tumor was diagnosed as uterine myoma and the possibility of leiomyosarcoma was low. After discussion with a neurosurgeon, we decided to treat the abdominal tumor first because it was large and seemed to enlarge after the menopause, i.e., malignancy could be possible. After total abdominal hysterectomy and bilateral salpingo-oophorectomy, erythrocytosis disappeared and the erythropoietin level reduced to 3.3 mIU/ml. The tumor was diagnosed as leiomyoma by histological examination, and immunohistochemical study revealed that the cytoplasm of tumor cells was diffusely stained by anti-erythropoietin antibody and that of normal smooth muscle was partially and weakly stained. These results suggested the production of erythropoietin in the leiomyoma tissue. Subsequently, the tumor at the anterior base of the skull was removed. Its histological diagnosis was meningothelial meningioma (WHO grade1), and immunohistochemical study of anti-erythropoietin antibody was negative. It is necessary to suspect erythrocytosis at the diagnosis of leiomyoma. [Adv Obstet Gynecol, 67 (3) : 291-300, 2015 (H27.8)]

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Bladder endometriosis is a rare disease, for which standard treatment has yet to be established. Laparoscopic and endoscopic cooperative surgery (LECS), where tumor resection is completed by simultaneous use of laparoscopy and endoscopy, was recently introduced to the field of gastroenterological surgery. We here report a case of bladder endometriosis, which was successfully resected by laparoscopy-assisted cystoscopic partial cystectomy, a good example of LECS. The patient was a 32-year-old unmarried woman, who was referred to our hospital due to burning pain on urination, pollakiuria, and suprapubic pain, all of which were exacerbated during menstruation. Ultrasonography detected a tumorous lesion in the bladder dome. Cystoscopy revealed irregular elevation of the mucosal surface from dome through posterior wall of the bladder. Pelvic MRI detected numerous spots in the tumorous lesion that showed high signal intensity both on T1WI and T2WI and were considered to correspond to ectopic hemorrhagic endometrial glands, leading to the diagnosis of bladder endometriosis. After five cycles of GnRH agonist treatment to shrink the endometriotic lesion, laparoscopy-assisted cystoscopic partial cystectomy was performed. At time of operation, the vesicouterine pouch was completely obliterated due to firm adhesion between the bladder and the uterus. First, laparoscopic adhesiolysis was made to widely expose the bladder surface from the dome through the posterior wall. Next, under cystoscopy, the boundary of the endometriotic lesion was marked out and a deeper incision was made along the boundary line using bipolar diathermy. Full-thickness bladder wall incision was firstly achieved at the upper margin of the endometriotic lesion. Then, laparoscopically, the upper margin of the endometriotic lesion was grasped and pulled upwards by claw forceps to minimize urinary leak into the peritoneal cavity, allowing further cystoscopic incision along the boundary line. After depletion of intravesical urine impeded the cystoscopic view, the remaining circumferential incision along the boundary line was accomplished under laparoscopy. The incision in the bladder wall was then closed by single-layered continuous suture. Laparoscopy-assisted cystoscopic partial cystectomy overcomes the limitation of laparoscopy (i.e., difficulty in delineating the endometriotic lesion) and that of cystoscopy (i.e., inability to make full-thickness incision). In this respect, this method has the potential to become mainstream surgical management against bladder endometriosis. [Adv Obstet Gynecol, 67 (3) : 301-306, 2015 (H27.8)]

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Posterior reversible encephalopathy syndrome (PRES) is clinically characterized by seizures, headaches, altered consciousness, and loss of vision. Reversible subcortical edema in the occipital and parietal lobes without infarction is the key feature identified on neurological imaging. In previous reports, PRES has been associated with hypertensive encephalopathy, eclampsia, and immunosuppressive and chemotherapeutic drugs. We report a case of a 53-year-old woman with severe anemia (Hb: 3.8 g/dl) and a uterine myoma. After transfusion of eight units of red blood cells, her hemoglobin level increased to 8.4 g/dl. Fifty days after blood transfusion, she underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. In the morning of the day of the operation, she was normotensive (116/70 mmHg). Immediately prior to surgery, her blood pressure increased to 177/84 mmHg, and intraoperatively, it increased to 180/96 mmHg. Three hours after surgery, she had generalized tonic clonic seizures and stupor. Cranial CT scan revealed no abnormalities at that time. She was administered antiepileptic drugs. Cranial T2FLAIR MRI performed three days later showed increased signal intensity in the occipital lobe region bilaterally. She recovered consciousness that day and was diagnosed with PRES. Nine days later, cortical blindness developed. Although the results of the MRI performed 37 days later revealed diminished lesions, she still suffered from epileptic seizures. Previous reports indicated that PRES after blood transfusion or a surgical operation occurs almost only in women. In the present case, we postulate that severe changes in blood pressure around the time of surgery caused PRES to occur and that blood transfusion might affect the occurrence of PRES. Blood transfusions can increase the risk of PRES. When symptoms of PRES appear after blood transfusion, immediate therapy should be considered. [Adv Obstet Gynecol, 67 (3) : 307-313, 2015 (H27.8)]

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