Approximately 1% of ectopic pregnancies are peritoneal and could be life threatening. We present the case of a peritoneal pregnancy treated with laparoscopic surgery. A 29-year-old woman with abdominal pain and vaginal bleeding was suspected of a ruptured ectopic pregnancy on the basis of a trans-vaginal ultrasound. Emergency laparoscopic surgery was then performed. During the surgery, a gestational sac with blood clot was found on the vesico-uterine pouch and was completely resected. Primary peritoneal pregnancy was diagnosed after the surgery. Laparoscopic surgery could be useful for the treatment of peritoneal pregnancies as well as for the diagnosis of unusually located ectopic pregnancies. [Adv Obstet Gynecol, 69 (4):355-359, 2017 (H29.10)]

Most cases of the malignant transformation of endometriosis are associated with endometriosis of the ovary. On the other hand, some cases of uterine corpus cancer, which is estimated to be derived from adenomyosis have been reported, and the histopathology of such cases is typically endometrioid carcinoma. We report a rare case of serous carcinoma of the uterine corpus which might arise from adenomyosis. The patient was a 56-year-old female, who first visited a local clinic complaining of left lower abdominal pain and was referred to our hospital. Sonography showed a uterine corpus tumor resembling a degenerated fibroid. Contrast-enhanced MRI and contrast-enhanced CT revealed a sarcoma-like uterine corpus tumor, ascites retention, and the disseminated involvement of Douglas and the left lower part of the mesentery. The patient underwent abdominal total hysterectomy with bilateral salpingo-oophorectomy and resected peritoneal dissemination lesion. Histopathologically, the tumor was diagnosed as a serous carcinoma that coincided with adenomyosis, and the stage was estimated as pT3bNXM1. The tumor did not appear to the uterine lumen side, and no malignant aspect was found in the endometrium by pathological examination. On the other hand the adenomyosis and the serous carcinoma were in close proximity, which led us to the possibility that the malignant lesion was derived from the adenomyosis. The patient received six cycles of the combination chemotherapy of paclitaxel and carboplatin after the operation. One year and four months have passed since the final administration of chemotherapy, and no recurrence has been noted. [Adv Obstet Gynecol, 69 (4):360-364, 2017 (H29.10)]

Amniotic fluid embolism (AFE) is rare, but is one of the most devastating complications of pregnancy, the mortality rate of which is 20 to 60%. Recently, accumulating evidence has indicated that AFE is comprised of two types with different etiologies. One is the cardiopulmonary collapse type AFE which features sudden hypotension and dyspnea. The other is the DIC type AFE, characterized by atonic bleeding and disseminated intravascular coagulation (DIC). Here, we report three cases of AFE that have different clinical course patterns, and discuss the onset timing of AFE based on our literature review. Case 1 was a 27-year-old primigravida, diagnosed as having hypertensive disorders of pregnancy at 35 weeks of gestation. At 38 weeks of gestation, she had eclampsia and vacuum extraction was performed. Just after the delivery, she had an incoagulable hemorrhage, which totaled 14000 ml, and respiratory failure. She died of cerebral hemorrhage. Case 2 was a 34-year-old primigravida. At 41 weeks of gestation, she had a continuous vaginal bleeding and dyspnea during the induction of labor. As soon as an emergency cesarean section was started, a cardiac arrest occurred. Although maternal pulse was restored by percutaneous cardiopulmonary support, the bleeding amounted to 9500 ml and she died of multiple organ failure. Case 3 was a 34-year-old multigravida, and vacuum extraction was carried out because of insufficient progression. After two hours, she suffered cardiac arrest followed by 6400 ml of incoagulable bleeding and respiratory failure. Fortunately, aggressive blood transfusion and intensive resuscitation enabled her to recover without any aftereffects. Our literature review revealed that more than 50% of AFE cases occurred during delivery, but in approximately 10% of AFE cases, the onset timing was more than one hour after delivery. Therefore AFE should be listed in the differential diagnosis at any point of parturition, when the patient has a sudden onset of incoagulable vaginal bleeding with dyspnea. Furthermore, in order to save the mother’s life, it is imperative to transfer the patient to the tertiary emergency medical facility without delay, and to provide the multidisciplinary critical care quickly. [Adv Obstet Gynecol, 69 (4):365-372, 2017 (H29.10)]

We experienced a rare case in which an intracranial subdural hematoma developed after the induction of spinal anesthesia. A 30-year-old female, who was scheduled to undergo laser ablation for cervical and perineal condyloma, was placed under spinal and intravenous anesthesia. On postoperative day three, she suffered a severe headache and emesis when moving and was taken to our hospital by ambulance. Magnetic resonance imaging revealed a small (6 mm) intracranial subdural hematoma on the left side of the frontal lobe. The patient was treated with bed rest, hemostatic drugs, and analgesics. She was discharged from the hospital after 27 days because the size of the hematoma remained stable, and her symptoms resolved. Spinal anesthesia is commonly performed in obstetrics and gynecology. However, gynecological spinal anesthesia can cause intracranial subdural hematomas in rare cases. Delayed diagnosis can be fatal, and therefore, it is important that clinicians keep this condition in mind. [Adv Obstet Gynecol, 69 (4):373-377, 2017 (H29.10)]

We report cases of recurrence of smooth muscle tumor on the abdominal wall after removal of uterine myoma, and cases of diagnosis classified by pathological benign leiomyoma, STUMP and removal time. A 41-year-old-woman, gravida 0, was referred to our hospital because of excessive menstruation and anemia. Her past history included myomectomy at age 36. Transvaginal sonography and magnetic resonance imaging revealed a tumor with a degenerative portion in the uterine corpus. After improvement of anemia with gonadotropin-releasing hormone agonist (GnRHa) therapy, the patient underwent myomectomy. The tumor was histologically diagnosed as leiomyoma. At 46 years of age, a tumor with a degenerate portion in the uterine corpus recurred and a tumor that arose from the previous surgery wound was concomitantly found at the abdominal wall. She underwent total hysterectomy and tumor resection of the abdominal wall. During the operation, we also found an additional round tumor that was 30 mm in diameter on the peritoneum, and resected it. Histologically, the uterine corpus tumor was adenomyoma. Both tumors at the abdominal wall and the peritoneum were diagnosed as STUMPs based on the following histological findings; mitotic count of 2-3/10 high power fields, Ki-67 positivity of approximately 9%, both p16 and p53 positivity of 40%, and absence of coagulative necrosis. Under careful follow-up, we observed multiple cystic lesions of the bilateral ovaries and an abdominal wall tumor that was 5 mm in diameter at 45 years of age. As the treatment with GnRHa under the tentative diagnosis of pseudocyst of the ovaries failed, bilateral salpingo-oophorectomy and the extraction of the abdominal wall tumor were performed. Histological diagnosis of the ovarian tumors and the abdominal wall tumor was pseudocyst of the ovaries and leiomyoma, respectively. At age 46, a tumor recurred at the site adjacent to the first signs of STUMP at the abdominal wall, which progressively grew during the subsequent six months. There was no response to anastrozole treatment, and the abdominal wall tumor was resected at age 49. Histological findings similar with those of the tumors from the operation at 46 years of age diagnosed the recurrence as STUMP. The patient has not experienced further recurrence for more than three months. In this case, we have not studied that the primary uterine tumor and abdominal wall leiomyoma or STUMP are the same clone, but from the clinical course, smooth muscle cells generated from the uterus and metastatic ability are different Ki -67 labeling index. [Adv Obstet Gynecol, 69 (4):378-385, 2017 (H29.10)]

Pulmonary thromboembolism can be a cause of maternal death during pregnancy. We encountered a case of pulmonary thromboembolism caused by hyperemesis gravidarum. The patient was 29-years-old and was multipara. She developed symptoms of morning sickness, 10 weeks into her pregnancy. Thus, intravenous nutrition was provided daily. She started coughing and complaining of shortness of breath at 11 weeks, and subsequent enhanced computed tomography (CT) showed a pulmonary thromboembolism. We treated her with anticoagulant therapy and trans-catheter thrombectomy, but her symptoms and pulmonary hypertension did not improve. We administered recombinant tissue plasminogen activator (rt-PA) to treat the pulmonary thromboembolism at 13 weeks of pregnancy. Her symptoms and pulmonary hypertension improved significantly afterwards. We kept her on heparin for the rest of her gestation period. At 37 weeks and six days of pregnancy, she delivered the child via inducedlabor. The newborn was 3040 g and the Apgar score was nine points at one minute and 10 points at five minutes. There were no complications caused by the use of rt-PA. Both the mother and the newborn had an uneventful postpartum course and they were discharged from the hospital on the 30th postpartum day. In principle, rt-PA can not be used for pregnant women. This is the eighth case of rt-PA administration during pregnancy in Japan. There have been no reports of serious complications related to the use of rt-PA in Japan. We think the use of rt-PA for maternal life saving is permissible. [Adv Obstet Gynecol, 69 (4):386-392, 2017 (H29. 10)]