The aim of this study was to investigate clinical relevance of atypical squamous cells (ASC), cannot exclude squamous intraepithelial lesion (ASC-H). The ASC-H patients diagnosed at our hospital were studied retrospectively; of 6644 conventional Pap smears, there were 204 specimens of ASC of undetermined significance (ASC-US) and 82 specimens of ASC-H. We have investigated the clinical results of the ASC-H patients. The ratio of ASC-H/ASC was 28.7%. We found hyperchromatic crowded cell groups as a cytological characteristic of ASC-H. Biopsies were performed for all ASC-H patients and revealed cervical intraepithelial neoplasia (CIN) 2/3 in 48.4% and negative results in 19.4%. The incidence of CIN2/3 was significantly higher in patients with ASC-H than in those with ASC-US. There was no significant difference in the histological results between premenopausal and postmenopausal patients with ASC-H. Among six patients with negative biopsies, one (16.7%)was diagnosed with CIN2 at 28 months later. ASC-H diagnosis is associated with a high incidence of CIN2/3. Patients whose biopsies are negative after an ASC-H interpretation still require close follow-up. [Adv Obstet Gynecol, 70 (2) : 69-74, 2018 (H30.5)]

Adenosarcoma is a rare tumor characterized by a stromal component usually of low-grade malignancy and by a benign glandular epithelial component. In most cases, it occurs in the uterus of women with a mean age of 58 years old. Here we present an unusual case of adenosarcoma arising in an extragenital site, the pelvic peritoneum (serosa of uterus), in association with endometriosis. A 35-year-old nulliparous woman, presented to a local clinic with vaginal bleeding for three months. She was referred with a suspicion of corpus cancer as she was found to have a tumor from the fundus and CA 19-9 and CA 125 levels were elevated. She had a medical history of endometriosis and was on medication for several months but discontinued due to economic reasons. On magnetic resonance imaging, she was found to have a highly enhanced mass measuring 8 cm, arising from the anterior surface of the uterus. Following examination, we suspected a malignant tumor involving peritoneal carcinoma. The patient underwent a complete surgical staging including total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and pelvic and para-aortic lymphadenectomy. There was no gross residual disease at the completion of surgery. After surgery, she had no complications, and was discharged on day 14. Histology showed no metastatic lesions in the bilateral adnexa or lymph nodes, and no disseminated lesion in the omentum. Although pathological findings demonstrated extragenital adenosarcoma, no adverse prognostic features (i.e. sarcomatous overgrowth and no lymphovascular invasion etc.) were identified, so no adjuvant therapy was used in this case. As of now, two months post-surgery, the patient remains disease free. [Adv Obstet Gynecol, 70 (2) : 75-81, 2018 (H30.5)]

Hysterosalpingography (HSG) has been widely practiced as an infertility screening test. Here, we report a case where pelvic abscess formed after HSG, which was successfully treated with transvaginal puncture and drainage. The patient was a 35-year-old woman who was gravida 2, para 2. She was our new patient who wanted to have a baby with her new partner. Although HSG performed as an infertility test showed that both of her fallopian tubes were open, contrast medium accumulation was observed in the area surrounding the fallopian tubes. Therefore, bilateral peritubal adhesions were suspected. Fever and abdominal pain occurred in the evening of the test day, and she was diagnosed as having pelvic peritonitis. Although she was hospitalized and received antimicrobial administration, her symptoms were not relieved but complicated by ileus. On the basis of the echography and magnetic resonance imaging scans, we thought that the abscess was formed in the area surrounding the fallopian tubes where contrast medium accumulated. Conservative treatment by continued antimicrobial administration, and fasting, and infusion did not produce symptomatic improvement, so drainage of the abscess was considered necessary. However, laparotomy/laparoscopic surgery was expected to be difficult owing to the possible pelvic adhesion based on the HSG results and additional intestinal edema caused by ileus. Therefore, we performed abscess drainage by intravaginal ultrasonography-guided puncture. After drainage, the patient’s fever, abdominal pain, and ileus symptoms were improved, and she was discharged 14 days after the surgery. Since then, she has been receiving outpatient management, and her progress has not been associated with any signs of recurrence of infection. Generally, pelvic abscess drainage is performed with laparotomy/laparoscopic surgery. However, for cases which transvaginal approach is possible, transvaginal puncture and drainage can be considered. [Adv Obstet Gynecol, 70 (2) : 82-88, 2018 (H30.5)]

The incidence of ovarian malignant tumors during pregnancy are reported as 1/50,000 pregnancies. There is no consensus about treatment of ovarian cancer during pregnancy. We report a rare case of ovarian cancer during pregnancy. The patient was a 38-year-old gravida 0, and right ovarian solid tumor was found in her pelvis at 12 weeks’ gestation. She was introduced to our hospital for the purpose of close inspection medical treatment. We considered an ovarian malignant tumor by MRI image. Right salpingo-oophorectomy and omentectomy were performed at 16 weeks’ gestation, and the pathological diagnosis was serous carcinoma FIGO stage IC3 (pT1cNxM0). She received four courses of TC regimen (paclitaxel, carboplatin) from second trimester. Elective cesarean section and staging laparotomy were performed for pregnancy 37 weeks. The child was born at weight of 2282g, Apgar score was 9/10, and a deformity wan’t found. By the pathological diagnosis, the lesion of the viable cancer was pointed in the left ovary microscopically only. So finally pathological diagnosis was serous carcinoma, ypT1bN0M0. She received three courses of TC as adjuvant chemotherapy. And now she is alive with no evidence of disease and the growth of the child is well being after one year from the treatment. [Adv Obstet Gynecol, 70 (2) : 89-96, 2018 (H30.5)]

Cushing’s syndrome is a well-known cause of irregular menstruation and infertility ; however, only a small percentage of individuals with amenorrhea also have the disease. We report a case of Cushing’s syndrome caused by a large tumor in the adrenal gland of a patient with secondary amenorrhea. A 33-year-old woman (gravida 0) had regular menstruation since menarche at the age of 12 years. However, her menstrual cycles suddenly stopped without any obvious cause. No withdrawal bleeding was observed after administration of progesterone, or with estrogen plus progesterone. We suspected Cushing’s syndrome because her blood test result indicated a high level of testosterone. Further testing showed a high level of dehydroepiandrosterone sulfate. Cortisol was not suppressed during an overnight dexamethasone test. Contrast-enhanced computed tomography revealed an adrenal tumor more than 8 cm in diameter. The patient was diagnosed with Cushing’s syndrome and adrenalectomy was performed. The final diagnosis was benign adrenal cortical adenoma. One month postoperatively, menstruation resumed without any other treatment. Pre-operatively, the myometrium and endometrium had become atrophic (similar to what is observed during menopause), but not the cervix. The ovary contained some small follicles. We conducted a literature search to determine whether these findings were due to the high levels of testosterone. We briefly considered a differential diagnosis of polycystic ovary syndrome. Adrenal tumors and Cushing’s syndrome are a rare cause of secondary amenorrhea, but should not be overlooked. Physical finding as well as serological date should be evaluated when diagnosing patients with Cushing’s syndrome. [Adv Obstet Gynecol, 70(2) : 97-104, 2018(H30.5)]

Ectopic pregnancy demonstrates typical symptoms and laboratory and image findings; however, they overlap with the symptoms of intrauterine pregnancy. Particularly, it is not always easy to diagnose the site of ectopic pregnancy rupture. Sometimes, confirmed diagnosis is not achieved using serum human chorionic gonadotropin (hCG), ultrasound, or magnetic resonance imaging (MRI). We identified the site of continuous intraperitoneal bleeding from a ruptured fallopian tube using dynamic computed tomography (CT) and performed emergency laparoscopic tubal resection. A 34-year-old female who had given birth twice visited an emergency outpatient department with the chief complaint of left lower abdominal pain. Little fresh blood was observed upon vaginal examination. Serum hCG level was 1667 mIU/ml. Her last menstruation occurred six weeks ago. Vaginal ultrasound confirmed ascites in Douglas fossa, but no genital sac in the uterus. Pelvic MRI confirmed ascites in Douglas fossa and around the bladder. We could not find a gestational sac using ultrasound or MRI. We suspected ectopic pregnancy; however, the serum hCG level was not very high, intraperitoneal bleeding was minor, and severe anemia was not observed; hence, conservative treatment was considered. Given that the gestational sac was not confirmed in the uterus despite the serum hCG level being 1500 mIU/ml or greater, the possibility of normal pregnancy was considered extremely low, and dynamic CT was performed as one of the diagnostic modalities. Intraperitoneal bleeding spread under the left diaphragm, and a linear contrast effect was observed at the ventral side of the left ovary. Because heavy bleeding was expected, emergency laparoscopic tubal resection was performed using Cell Saver 5^Ⓡ. Autologous blood was returned (215g), and allogeneic blood transfusion was unnecessary. Hence, dynamic CT maybe useful when ultrasound or MRI cannot confirm a bleeding point. [Adv Obstet Gynecol, 70 (2) : 105-112, 2018 (H30.5)]

We performed hysteroscopy and laparoscopy on a 23-year-old, non-pregnant patient, diagnosed with a non-communicating rudimentary uterine horn. At the age of 18, vaginal drainage was performed for hematometra in the rudimentary horn. Irregular vaginal bleeding lasting up to one week persisted, with lower abdominal and back pain. Transvaginal sonography revealed a normal-appearing uterus on the right, but free space to the left of the visualized right uterus. Abdominal computed tomography and pelvic magnetic resonance imaging suggested hematometra and hydrosalpinx. Laparoscopy identified prominent inflammatory adhesions, with a swollen left fallopian tube adherent to the posterior wall of the left rudimentary uterine horn and rectum. A left ovary was not identified. We performed left salpingectomy and adhesiolysis, and identified the left rudimentary uterine horn. Hysteroscopy identified a narrow opening into the left rudimentary uterine horn, with drainage on the left side, beyond the cervix. We perfomed left laparoscopic rudimentary uterine horn hysterectomy and left oophorectomy. Postoperatively, the abdominal pain and irregular vaginal bleeding decreased. On outpatient follow-up, she reported that her menstrual cramps had gradually increased, and she started a painkiller two years seven months after surgery. We determined that the myometrial layer of the right unicornuate uterus had thickened, indicating likely adenomyosis on MRI. The patient is currently receiving dienogest, in addition to a painkiller, and the menstrual cramps have improved. [Adv Obstet Gynecol, 70 (2) : 113-119, 2018 (H30.5)]

Application of uterine manipulator has been increased in late years with growing use of laparoscopic surgery. We experienced a rare case of spontaneous uterine rupture during pregnancy following a history of perforation by uterine manipulator. A 37-year-old primipara, who had a history of iatrogenic uterine perforation 2 years ago, was transferred to our hospital due to preterm labor at 32 weeks of gestation. On admission regular but painless contractions were observed with reassuring fetal heart rate pattern. Three days later she complained of severe pain on uterine fundus, and CTG showed non-reassuring fetal heart rate pattern. Amniotic fluid was only seen in upper uterine cavity on ultrasound, therefore uterine rupture was strongly suspected. Rupture was confirmed and successfully repaired during emergent cesarean section. Both mother and neonate were discharged with no complications. Our experience could suggest importance of proper training with careful application of uterine manipulator. [Adv Obstet Gynecol, 70(2) : 120-125, 2018 (H30.5)]

Paroxysmal nocturnal hemoglobinuria (PNH) is a disease that leads to hemolysis in a complement-dependent manner. Increased complement activity during pregnancy in PNH patients is prone to induce thrombosis, resulting in an elevated risk of maternal death, fetal death, miscarriage, and intrauterine growth restriction, but the recently developed eculizumab reportedly reduces their chance of developing thrombosis. Here, we report our experience of three presentations of a pregnant woman with PNH who received conventional anticoagulant therapy in her first two pregnancies and eculizumab therapy in her third pregnancy. She was first transferred to our hospital at the age of 30, at 31 weeks of gestation with a diagnosis of threatened preterm labor given at another hospital at 25 weeks of gestation. We gave a diagnosis of PNH following admission. After starting unfractionated heparin for thrombosis at 33 weeks of gestation, spontaneous vaginal delivery occurred at 37 weeks of gestation. Later, she was hospitalized again (gravida 2, para 1, 34 years of age) due to the shortening of the uterine cervical canal at 28 weeks gestation and began treatment with unfractionated heparin. Intrauterine fetal death of an unknown cause occurred at 30 weeks of gestation despite the treatment. She fell pregnant again at age 36 (gravida 3, para 2) and was hospitalized due to an elevated levels of lactate dehydrogenase at 27 weeks of gestation. Eculizumab therapy was commenced from 28 weeks of gestation following a hemolytic exacerbation, and did not result in any adverse effects. We induced labor at 30 weeks of gestation because of non-reassuring fetal status, which resulted in a vaginal delivery. A baby girl was directly admitted to the neonatal intensive care unit because of persistent retractive breathing, but was discharged on the 46^th day of life. She was one year of age at the time of writing and healthy. Eculizumab therapy was effective in our management of pregnancy in PNH, and we anticipate that it will be useful in further cases. Coversely, our study confirmed an elevated level of lactate dehydrogenase at around 30 weeks of gestation, suggesting that care must be especially paid to the management og pregnancy in PNH at around 30 weeks of gestation. [Adv Obstet Gynecol, 70 (2) : 126-133, 2018 (H30.5)]

Here we present two cases of observed chronic abruption-oligohydramnios sequence (CAOS) with different infant outcomes. This report highlights the differences in placental pathology in cases of observed CAOS and the important role played by placental inflammation in the health and survival of the infant. In the first case, the patient presented to hospital complaining of persistent and abnormal vaginal bleeding and upon further investigation, subchorionic hematoma (SCH) was found at 14 weeks and four days of gestation. The patient was treated and sent home with instructions to check for worsening symptoms. At 23 weeks and four days of gestation, the patient returned to hospital with abdominal pain and abundant vaginal bleeding and was admitted. Due to the patient’s previous SCH, we observed the amniotic fluid index (AFI) for four days. During this time, there was evidence of oligohydramnios, and a diagnosis of CAOS was made. The patient was treated with antibiotics and tocolytic drugs. At 31 weeks and six days of gestation, the patient went into labor and gave birth vaginally to a normal infant. Placental pathology showed no signs of chorioamnionitis (CAM). In the second case, the patient first visited the hospital reporting persistent vaginal bleeding at 13 weeks and five days of gestation. She was treated and sent home with instructions to monitor for signs of worsening symptoms. The patient returned to the hospital a second time nine days later with evidence of SCH, and was again sent home after treatment. At 16 weeks and 1 day of gestation, the patient returned for the third time and was admitted for heavy vaginal bleeding and persistent uterine contractions. The AFI was monitored and a diagnosis of CAOS was made. In this case, the fetus showed a growth delay from 21 weeks and three days of gestation and the fetal heartbeat disappeared at 24 weeks and one day of gestation. At 24 weeks and six days of gestation, the infant was vaginally delivered. Placental histopathology found evidence of third degree CAM. It has been previously reported that long-term persistence of inflammation along with CAM is correlated with poor prognosis in infants. If cases of SCH present with evidence of oligohydramnios, perinatal management at a higher-level medical institution with a neonatal intensive care unit is recommended. [Adv Obstet Gynecol, 70 (2) : 134-142, 2018 (H30.5)]