To assess the outcomes of previable premature rupture of the membranes (pPROM) before 22 gestational weeks, data were collected retrospectively, including singletons and twins, from 2006-2013. Forty-one cases including four twins met the study criteria. Mean gestational age at pPROM was 17.8 weeks (range 13.6-21.7 weeks). Eighteen cases were delivered or experienced intrauterine fetal demise (IUFD) within 48 hours after pPROM and pregnancy termination was elected in 10. Thirteen cases received expectant management. Gestational ages at pPROM ranged from 13.6 to 21.2 weeks. Six patients (no twins) were delivered before 22 gestational weeks. Three cases showed IUFD and two cases experienced spontaneous abortion. One case with maternal infection underwent induced labor. Seven patients including three twins were delivered after 22 gestational weeks. Two cases (twin: one case) showed IUFD. Five cases (twins: two cases) were delivered at 26.2-33.9 weeks and seven neonates were born. Among 13 cases receiving expectant management, three had maternal infections, and one a retained placenta. Grade III histological chorioamnionitis was seen in one of five surviving cases as compared to six of eight non-surviving cases. All seven neonates were discharged from the NICU. None had IVH, NEC, sepsis, or lung hypoplasia. One case with congenital cytomegalovirus infection had physical/mental retardation and chronic lung disease after dry lung, necessitating home oxygen therapy. Another neonate was also diagnosed as having dry lung but showed improvement before discharge. Two neonates had limited hip abduction. One case showed resolution of this condition after birth and the other needed physical therapy. Five neonates were mentally normal. On balance, while we cannot always be optimistic about previable preterm PROM, expectant management should be offered as a treatment option. [Adv Obstet Gynecol, 68(3) : 217-223, 2016 (H28.8)]

Reported here are three cases of pyometra causing uterine perforation resulting in general peritonitis. The first case involved an 87-year-old woman with hypertension, diabetes mellitus, renal failure, and heart failure. The woman was bedridden in a nursing home due to severe dementia and a femoral neck fracture. The woman was seen by Gynecology for abnormal vaginal discharge. The patient was diagnosed with pyometra but her family elected to forego hospitalization and surgery, so the patient was followed. A month later, the patient was seen by the Emergency Department of this Hospital with a reduced level of consciousness. The patient was diagnosed with a bowel perforation based on a CT scan. An emergency laparotomy revealed general peritonitis caused by perforation of the uterus. In Gynecology, the patient underwent a total hysterectomy. However, the patient developed an SSI and her renal failure worsened. On day 65 of hospitalization, the patient passed away. The second case involved an 85-year-old woman who was bedridden and being care for at home due to severe dementia. The woman had inflammation and loss of appetite, so she was admitted to Internal Medicine at this Hospital. The patient was discharged on day 32 of hospitalization without identifying the cause of inflammation. Forty days later, the patient was seen again for genital bleeding and purulent discharge. A CT scan revealed pyometra and the patient was referred to this Department, where she underwent transvaginal drainage. The following day, the patient’s inflammation intensified and an emergency laparotomy was performed. The patient had general peritonitis caused by perforation of the uterus, so a subtotal (supravaginal) hysterectomy was performed and the patient was discharged 22 days postoperatively. The third case involved a 79-year-old woman residing in a facility due to severe dementia and a subtrochanteric fracture of the femur. The woman developed a fever, so she was given oral antibiotics by a nearby physician. However, she failed to respond, so she was seen by Internal Medicine at this Hospital. CT findings were interpreted as a bladder abscess, and conservative treatment was begun. Three days later, a bowel perforation was diagnosed and the patient underwent an emergency laparotomy. Surgery revealed general peritonitis caused by perforation of the uterus, so a subtotal (supravaginal) hysterectomy was performed and the patient was discharged 20 days postoperatively. Pyometra is a chronic condition that is usually benign, though in rare instances it may cause uterine perforation and severe peritonitis. Discerning this condition in elderly women with numerous symptoms and diminished ADL due to dementia or other causes is difficult. Thus, gynecologists are some of the few specialists who are capable of diagnosing this condition in its early stages. In their initial response, physicians in other specialties need to be informed of the pathology of pyometra and its risk factors. If, during a routine follow-up, a gynecologist notes that pyometra has worsened or grown, then transvaginal drainage must be attempted. The Japanese population is rapidly aging, so this condition will become increasingly prevalent in the future. A considered response should be used to deal with this condition. [Adv Obstet Gynecol, 68 (3) : 224-231, 2016 (H28.8)]

Retained surgical sponges (gossypibomas) are decreasing due to various preventive measures, but even in recent years, there have been dozens of case reports annually in Japan. We report a case of intrapelvic gossypiboma accompanied by an abscess, detected as a calcified mass. A 69-year-old woman, gravida 2 para 2, who underwent a cesarean section when she was 23 years old, presented with fever and abdominal pain. Abdominal X-ray showed a calcified mass in the pelvis, so she was referred to our hospital. On computer tomography, a 7.5 cm oval mass wholly encircled by calcification was found. Hematoma or abscess was considered as the preoperative diagnosis. Laparotomy revealed a mass with a calcified wall in the Douglas pouch, and an abscess and a surgical sponge were found in the mass. Thus, we diagnosed the case as gossypiboma with an abscess, originating from cesarean section 46 years ago. This was a unique case of gossypiboma for the following reasons: it was found after a very long period, an abscess formed after a long asymptomatic period, and a surgical sponge and an abscess were encapsulated by a calcified wall. [Adv Obstet Gynecol, 68 (3) : 232-236, 2016 (H28.8)]

Endometrial carcinoma is the most common gynecological cancer. About 5.3% of women with endometrial cancer are under 40 years of age, and cancer incidence in young women is rising. Conservative progestin therapy is common for young women of childbearing potential. However, repeat conservative progestin therapy is not recommended for patients with cancer recurrence. We evaluated progesterone receptor (PgR) and estrogen receptor (ER) expression in a patient who received multiple courses of conservative progestin therapy for recurrence of endometrial carcinoma. The patient, a-39-year woman, gravida 1, parity 0 with primary infertility, with endometrial adenocarcinoma G1. She received conservative high-dose medroxyprogesterone acetate (MPA) therapy. However, she had a recurrence six months after initial therapy, and received a second course of MPA therapy, because of her desire to preserve childbearing potential. Eight months after the second course of therapy, she had another recurrence and required repeat MPA therapy. Three months after the third course of therapy, considering the lack of response, she finally underwent total laparoscopic hysterectomy. Immunohistochemical staining for PgR expression was positive, before initial therapy and the second and third courses. In contrast, PgR expression was negative after all three courses of therapy. ER expression was positive throughout all courses of therapy. These finding suggested that PgR-negative, treatment-resistant cells remain throughout all courses of therapy. Several studies of PgR expression before initial therapy have demonstrated usefulness in predicting response to conservative progestin therapy. However, little is known regarding PgR expression post-treatment and its relationship to response to repeat conservative progestin therapy. The presence of PgR expression throughout therapy may be useful information when patients have recurrence and require repeat conservative progestin therapy. [Adv Obstet Gynecol, 68 (3) : 237-242, 2016 (H28.8)]

Retroperitoneal fibrosis is characterized by fibrosis of retroperitoneal cavity and causes the ureteral stricture and obstruction, and hydronephrosis is caused by impaired ureteral peristalsis. We report a case of cervical adenocarcinoma, which was diagnosed after detection of bilateral hydronephrosis caused by retroperitoneal fibrosis. The patient was a 35-year-old non-gravida woman with no past history. She was reffered to another physician, with a compliant of right abdominal pain. Bilateral hydronephrosis and high serum creatinine level (3.8 mg/dl) were detected. She underwent bilateral ureteral stent placement, but renal function did not improve, so she was reffered to the Department of Urology at our hospital. She underwent bilateral nephrostomy and reffered to our Department. No cervical tumor was detected by ultrasonography, but uterine cervix cytology was SCC suspected and colposcopy detected a small tumorous lesion of the cervix. Cervical biopsy was performed and the histology showed mucinous adenocarcinoma. Magnetic resonance imaging revealed no cervical tumor and no lymph node swelling in the pelvis. Computed tomography did not reveal any metastasis. She was diagnosed with cervical cancer stage I B1 and we performed radical hysterectomy and bilateral salpingo-oophorectomy. Intraoperatively, we found marked retroperitoneal fibrosis and harden, inflexible urinary ducts, so retroperitoneal fibrosis was suspected. Macroscopically, there was a mass of 5 mm diameter in the uterine cervix, but no lymph node swelling in the pelvis. Histopathological examination revealed usual-type endocervical adenocarcinoma, with bilateral parametrial invasion, bilateral ovarian metastasis, and retroperitoneal lymph node metastasis, and retroperitoneal infiltrate around bilateral ureters. We considered that this case was cervical adenocarcinoma complicated with bilateral hydronephrosis caused by retroperitoneal fibrosis. She received adjuvant chemotherapy, but she died of the disease 17 months after initial treatment and showed a poor prognosis. This case suggests that we should consider a diagnosis of retroperitoneal fibrosis, when hydronephrosis without obvious organic dysfuncion is detected. [Adv Obstet Gynecol, 68 (3) : 243-247, 2016 (H28.8)]

Ovarian remnant syndrome (ORS) is a condition in which residual ovarian tissue presents mass or hemorrhage after bilateral salpingo-oophorectomy. Risk factors include endometriosis, PID, and multiple surgeries, especially after difficult operation due to adhesion. Patients with ORS usually present with pelvic pain or bloating, but the symptoms could be consistent with endometriosis. We experienced a case of ORS which appeared in the form of peritoneal inclusion cyst (PIC). The case was 46-year-old woman who underwent multiple surgeries including Cesarean section and multiple adenectomy. She also had chlamydia infection and endometriosis treated by GnRH agonist. Cystic mass with low echogenicity was found on the left uterine wall on her regular checkup. Postoperative pathology diagnosed PIC with ORS based on findings that the cyst wall was remnant ovary and fibrous tissue. She experienced menstrual-like bleeding seven months after surgery, and adnexal mass with shading was seen by ultrasound and MRI. Considering severe adhesion, we continue careful observation since cases of ovarian cancer after ORS with endometriosis have been reported. [Adv Obstet Gynecol, 68 (3) : 248-251, 2016 (H28.8)]

A case of a vaginal foreign body in a prepubertal girl that presented as suspected resistant bacterial vaginosis is reported. A 6-year-old girl presented with a 2-year history of recurrent vaginal discharge and genital bleeding unresponsive to antimicrobial therapy. After vaginal lavage under intravenous anesthesia and antimicrobial therapy failed to relieve the patient’s condition, a hysteroscopic examination of the vagina was performed under general anesthesia. Using a thin hysteroscope, the interior vagina was examined, and a foreign body was identified. The foreign body was removed with forceps under hysteroscopic guidance and found to be a clumped elastic hair band. The vagina was then inspected with the thin hysteroscope to confirm that there were no internal wounds and washed with 300 ml of room temperature physiological saline to conclude the procedure. In postoperative follow-up of more than six months, no recurrence of symptoms has been seen. When genital bleeding of unknown cause persists, even in prepubertal girls, vaginal foreign bodies should be considered, so that diagnosis and treatment can be done at an early stage with proactive testing. Especially when the patient is a young girl, the physical burden can be reduced with the use of a thin hysteroscope under sufficient anesthesia. [Adv Obstet Gynecol, 68 (3) : 252-255, 2016 (H28.8)]

The presence of concurrent intrauterine gestation makes it more difficult to diagnose the ectopic gestation in heterotopic pregnancy and results in delay of the diagnosis. In many cases, the diagnosis is confirmed after laparotomy performed due to tubal rupture and hypovolemic shock. In this paper we reported two cases with heterotopic pregnancy, complaining of epigastric pain before the onset of tubal rupture. The case 1 had become pregnant after IVF-ET and was urgently conveyed because of the pain migrated from the epigastric region to the right lower quadrant at seven weeks of gestation. She was suspected to have appendicitis and treated with antibiotics. On the next day, the pain became worse and the ultrasound-sonography showed a larger amount of ascites and the gestational sac in right tube. An emergency laparotomy showed the rapture of right tube. The case 2 with epigastric pain visited the other hospital at nine weeks of gestation and urgently conveyed because of sudden onset of shock. The ultrasound-sonography showed a large amount of ascites and we suspected intraperitoneal bleeding. An emergency laparotomy showed the rupture of right tube. The amount of bleeding was accounted approximately 2500 ml. These two cases suggest that physicians had better suspect not only appendicitis, gastric ulcer but also heterotopic pregnancy, on the examination of pregnant women with epigastric pain. [Adv Obstet Gynecol, 68 (3) : 256-260, 2016 (H28.8)]

Most cases of cerebral venous sinus thrombosis (CVST) associated with pregnancy occurs in the third trimester or puerperium period. We report a case of CVST that occurred in the early period of the pregnancy, which was treated by anticoagulation therapy; the patient recovered totally without any complications. A 38 year-old nulliparous woman was transferred to our hospital because of loss of consciousness seven weeks of gestation. She had taken an intracytoplasmic sperm injection (ICSI) and hormonal administrations; even though vomiting and headaches had been observed ahead of the onset, these were considered to be symptoms of hyperemesis. At the time of admission, she was in a coma. CT and MRI studies showed that she had CVST, so we started anticoagulation therapy. At first, she presented severe neural symptoms including coma and systemic seizure, which were associated with her poor prognosis. The treatment was successful and no symptoms remained 14 weeks of gestation. Finally, she gave live birth at 40 weeks of gestation by Caesarean section. Many specialists of Neurology say that it is difficult to diagnose CVST quickly because it shows various symptoms; but it is very important to diagnose it quickly, otherwise prognosis can worsen. The risk of CVST can be increased by dehydration due to hyperemesis, hormonal administrations due to fertility treatments or congenital coagulation diseases such as Protein S deficiency (which is relatively common in the Japanese).[Adv Obstet Gynecol, 68 (3) : 261-268, 2016 (H28.8)]

Morcellation of uterine fibroids by morcellators enables the extraction of tumors from the peritoneal cavity through a small incision and contributes to minimizing the invasiveness of surgery. However, the increased risk of dissemination of uterine sarcomas has been recently reported. Herein, we report a case that recurred after laparoscopic myomectomy using a morcellator. The preoperative diagnosis was uterine myoma, but the final diagnosis was malignant mixed endometrial stromal and smooth muscle tumor. The case was a 34-year-old nulliparous woman. She underwent laparoscopic myomectomy using a morcellator in the previous hospital and was diagnosed as having cellular leiomyoma. At 18 months after the myomectomy, the uterine tumor recurred and enlarged in the following year, so she was introduced to our hospital. A huge elastic hard mass occupied the pelvic cavity, and magnetic resonance imaging (MRI) revealed a 10 cm ill-defined mass in the posterior myometrium and an 11 cm cystic mass with a solid component protruding to the peritoneal cavity. On a T2-weighted image, the mass showed slightly high intensity with low intense bands inside. On a diffusion-weighted image, it showed high intensity and strong but irregular enhancement. Low-grade endometrial stromal sarcoma of the uterus was suspected, and hysterectomy and bilateral salpingo-oophorectomy were performed. On pathological examination, the tumor invasion was observed from the myometrium to the uterine serosa, and lymphovascular space invasion was prominent. The tumor mainly consisted of low-grade endometrial stromal sarcoma but partially consisted of epithelioid leiomyosarcoma with marked nuclear atypia. The case was diagnosed as malignant mixed endometrial stromal and smooth muscle tumor. No dissemination in the peritoneum was found. When we reevaluated the specimen from the previous operation, the sample was morcellated into small pieces, so the arrangement of the normal myometrium and tumor cells were unclear. The tumor consisted of short spindle cells, with some small vessels resembling a spiral artery, indicating low-grade endometrial stromal sarcoma. The patient has been free of disease for two years after the second surgery. As pathological diagnosis of mesenchymal tumors of the uterus may be difficult when only small pieces of tissue are available for examination, a correct diagnosis may be difficult to make when morcellation of the tumor is performed. Preoperative MRI and careful postoperative follow-up is essential in such cases. [Adv Obstet Gynecol, 68 (3) : 269-273, 2016 (H28.8)]