Recent advances in assisted reproductive technology (ART) have resulted in increasing number of advanced maternal age pregnancies. They have to be managed carefully, as were associated with increased rates of obstetrical complications, such as threatened premature labor, malposition of the placenta, and hypertensive disorder of pregnancy. The aim of this study was to reveal the incidence of obsterical complications in advanced maternal age pregnancies involving patients aged ≧ 40 years and to clarify the correlation between obstetrical complications and the pregnancy established methods, parity, and maternal complications. [Subjects and Methods] We retrospectively reviewed the maternal and fetal information and obstetrical complications among 539 patients aged ≧ 40 years between 2006 and 2014, and 1117 patients aged < 40 years between 2013 and 2014, who delivered at ≧ 22 weeks of gestation. Incidence of obstetrical complications in patient aged ≧ 40 years were compared with those who aged < 40 years. Maternal background factors were analyzed that could increase the risk of obstetrical complications. [Result] Advanced maternal age pregnancy ≧ 40 years had higher rate of premature birth or premature rupture of membrane (PROM) at < 34 weeks of gestation, fetal growth restriction, hypertensive disorder of pregnancy, malposition of the placenta, and postpartum hemorrhage. Of these, premature birth at < 34 weeks of gestation and hypertensive disorder of pregnancy were significantly correlated with presence of diabetes/gestational diabetes. While premature birth or PROM at < 34 weeks of gestation, and fetal growth restriction were found to be common in multiple pregnancies. Malposition of the placenta was significantly more common in pregnancies achieved via egg donation, while postpartum hemorrhage was more common in pregnancies achieved via egg donation and ART. [Conclusion] Advanced maternal age pregnancies in patients aged ≧ 40 years can be relatively managed safely when carefully followed high-risk pregnancies while predicting possible complications in light of individual maternal background factors. It is particularly important to understand how the pregnancy was achieved, to determine if there are any underlying diseases such as diabetes, and to properly manage gestational diabetes. Awareness should also be raised regarding the risks of advanced maternal age pregnancy and background factors in patients planning to be conceived. [Adv Obstet Gynecol, 70 (3) : 257-262, 2018 (H30. 8)]

Ureteral injury is one of the most common complications of gynecological surgery. In literature, it is reported that postoperative serum creatinine over 0.8mg/dl may indicate ureteral injury. We hypothesized that any increase in postoperative day 1 creatinine levels are associated with ureteral injury. A retrospective chart review was conducted on patients who underwent a total hysterectomy at our hospital between January 2013 and June 2016, regardless of the preoperative diagnosis. Of the 1107 patients, the postoperative day 1 serum creatinine level was elevated in 198 patients. Of the 198 patients, four patients were diagnosed with ureteral injury following gynecologic operation. Conversely, the postoperative day 1 serum creatinine of 909 patients were either depressed or unchanged. None of these patients experienced ureteral injury after gynecologic operation. The increase of serum creatinine on postoperative day 1 indicates postoperative ureteral injuries, with 100% sensitivity and with 82% specificity. [Adv Obstet Gynecol, 70 (3) : 263-269, 2018 (H30.8)]

Objective: We aimed to evaluate the factors associated with poor outcome in growth-restricted fetuses born at less than 30 weeks of gestation (GW). Patients and Methods: This was a retrospective study including 92 fetuses with fetal growth restriction (FGR) who were born in our hospital between March 2011 and December 2015. Sixteen of the 92 FGR fetuses were born at less than 30 GW. The 16 FGR fetuses were divided into two groups according to the outcome: good (healthy) and poor (handicapped or dead). We investigated the differences in the clinical characteristics and findings between the two groups. Results: There were significant differences between these two groups in the number of gravidity (median [range], p-value) (good outcome group 4 [1-6] vs poor outcome group 2 [1-3], p<0.05), standard deviation (SD) of estimated fetal body weight (EFBW) at a diagnosis of FGR (-1.8 [-2.5--1.5] vs -3.0 [-4.6--2.2], p<0.05), the percentage of cases with highly abnormal findings in Doppler ultrasound (13% vs 75%, p<0.05). In addition, ten of the 16 (62.5%) pregnant women who had FGR fetuses born at less than 30 GW had hypertensive disorders of pregnancy (HDP), and, some women who were pregnant with FGR fetuses developed HDP after diagnosis of FGR. Conclusions: In this study, the small number of gravidity, low SD of EFBW at a diagnosis of FGR, and the presence of highly abnormal findings in Doppler ultrasound were associated with poor outcome among the FGR fetuses who were born at less than 30 GW. It was suggested that early-onset FGR was associated with HDP. [Adv Obstet Gynecol, 70 (3) : 270-277, 2018 (H30.8)]

Granulosa cell tumors (GCTs) are well known for recurrence many years after initial excision, and surgery is the primary treatment for recurrent disease. For advanced or unresectable recurrent tumors, chemotherapy or radiation therapy is generally used, but a standard treatment has not been established. We report a case of a recurrent unresectable GCT, surrounding the inferior vena cava and renal artery, that showed an impressive response to hormone therapy, especially aromatase inhibitor therapy. The patient was a 65-year-old woman, gravida 3, para 3. She was initially diagnosed with stage Ia GCT at the age of 53, underwent a right salpingo-oophorectomy, and was followed-up regularly after surgery. Seven years after surgery, she stopped receiving medical examinations. Twelve years after that, she presented with abdominal pain, and computed tomography (CT) showed a huge mass in her upper abdomen. She had a diagnosis of recurrent GCT on pathological examination by biopsy. We judged that the mass was unresectable and treated with taxan and carboplatin. The tumor reduced, but a sizeable tumor remained. It was decided to discontinue chemotherapy because of the side effects, and treatment with hormone therapy, including a GnRH agonist and aromatase inhibitor, was initiated. The tumor size reduced and no side effects were shown. Hormone therapy is effective for recurrent or advanced GCTs that are not resectable. Moreover, patients with GCT should be followed-up for more than 10 years after initial treatment. [Adv Obstet Gynecol, 70 (3) : 278-283, 2018 (H30.8)]

When performing a para-aortic lymphadenectomy, it is important to avoidlumbar artery injury during the operation. This is a report of a case of late-onset lumbar artery bleeding after a para-aortic lymphadenectomy in ovarian cancer. The patient was a 63-year-old woman (gravida 2, para 2) and was diagnosed with suspected early stage ovarian cancer. She underwent an abdominal total hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, and subtotal omentectomy. The para-aortic lymphadenectomy was performed with an ultrasonic scalpel (HARMONIC FOCUS LONG^Ⓡ). No artery injury was observed during the operation. After two days of surgery, the administration of unfractionated heparin was initiated due to a small pulmonary embolism. After six days, paralytic ileus occurred and a nasogastric tube was inserted. After seven days, the ileus improved and the nasogastric tube was removed. After nine days, unfractionated heparin was switched to rivaroxaban. The same day, she presented dull abdominal pain accompanied by left lumbago and groin pain, and developed shock. Blood tests showed a decreased hemoglobin level. Dynamic contrast-enhanced computed tomography showed massive left retroperitoneal hematoma with extravasation of contrast material at the level of the thirdlumbar vertebra. Selective left thirdlumbar artery angiography revealed the presence of an extravasation of contrast material. Selective coil embolization was successfully performed, the bleeding was controlled and the patient became stable. The present case highlights that late-onset lumbar artery bleeding can occur and cause hemorrhagic shock rapidly after para-aortic lymphadenectomy. Anticoagulant therapy and partial vascular injury by surgical procedure may cause late-onset lumbar artery bleeding. The diagnosis of postperitoneal hematoma after surgery is often delayed because symptoms of postperitoneal hematoma may be hidden by postoperative pain, analgesics, and other complications of surgery. It is vital that this diagnosis is not delayed. Endovascular trans-arterial embolization is effective for the treatment of late-onset lumbar artery bleeding. [Adv Obstet Gynecol, 70 (3): 284-290, 2018 (H30.8)]

Epidermoid cysts, also called atheromas, are keratin-containing cysts that develop under the skin. Epidermoid cysts can appear at any site, but show a predilection for the face, neck, back, and hip, and multiple vulvar cysts in women are rarely reported. We encountered a rare case of multiple epidermoid cysts of the external genitalia. A 62-year-old, gravida 4, para 2 woman consulted a dermatologist with multiple cysts of the external genitalia. One year before her first visit to the dermatology clinic, she had noticed multiple cysts of the external genitalia. They became larger, prompting her to consult a dermatologist, and atheromas were suspected. She desired to consult a gynecologist and visited our hospital. We surgically removed them. The pathological diagnosis was multiple epidermoid cysts. Vacuolated cells resembling koilocytes were observed in the cyst walls, but immunohistochemical staining and PCR for HPV were both negative. As of six months after the surgery, there had been no recurrence. It is important to excise all cyst walls in order to prevent recurrence. There are some case reports of carcinomas arising from atheromas. It is difficult to remove all cysts in cases of multiple epidermoid cysts, and so a high risk of recurrence remains, necessitating follow-up after surgery. [Adv Obstet Gynecol, 70 (3) : 291-295, 2018 (H30.8)]

Parasitic leiomyoma is a rare variant of uterine leiomyoma that separates from the uterus and attaches to the pelvis or an intra-abdominal organ instead, which may have a feeding vessel. We report a case of parasitic leiomyoma complicated with intestinal obstruction and torsion of an ovarian cyst. A 44-year-old unmarried woman with a history of uterine leiomyoma, which was excised via laparoscopic supravaginal amputation using a morcellator, complained of lower abdominal pain, fever, and vomiting. Computed tomography and magnetic resonance imaging indicated an intestinal obstruction, torsion of a left ovarian cyst, and a solid tumor. A laparotomy revealed that the small intestine was constricted by a solid tumor, which appeared to be part of the uterine leiomyoma, and a left ovarian cyst, resulting in intestinal obstruction. A delayed tumorectomy and sigmoidectomy were performed and the patient was diagnosed with parasitic leiomyoma upon histological examination. The post-operative course was uneventful with no recurrence for 1 year after the operation. [Adv Obstet Gynecol, 70 (3) : 296-304, 2018 (H30.8)]

We encountered a very rare case of torsion of the normal ovarian pedicle complicated by inguinal hernia in a 9-year-old girl before first menstruation. She was transported to our hospital for lower abdominal pain. MRI showed swelling of the left ovary to a 5-cm diameter. Torsion of the pedicle of the normal ovary was suspected, and emergency laparoscopic surgery was performed. The left ovary was 1080° twisted and congested, but color returned after release of the torsion. One year later, recurrence was also treated with emergency laparoscopic surgery, in which left inguinal hernia was confirmed, but not treated. After another six months, the condition recurred again. After similar emergency laparoscopic surgery, left inguinal hernia was closed by suture and oophoropexy was performed, in which the left ovary was sutured with the left pelvic peritoneum. At two years after surgery, there has been no further recurrence. The risk of torsion of the normal ovarian pedicle may be increased by concomitant inguinal hernia, and this may have caused loosening of the retinaculum uteri and repeating torsion of the pedicle of the left ovary in our case. Oophoropexy and repair of inguinal hernia may prevent recurrence of the normal ovarian torsion in childhood. [Adv Obstet Gynecol, 70 (3) : 305-310, 2018 (H30.8)]

Posterior reversible encephalopathy syndrome (PRES) is an encephalopathy with headache and seizures as the main symptoms. The pathogenesis of PRES remains unclear, but it appears to be related to endothelial dysfunction and breakdown of the blood-brain barrier leading to angiogenic brain edema. PRES seems to have some predisposing factors such as hypertension and immunosuppressant use. Reportedly, patients with preeclampsia are likely to have PRES. Here we report a case of PRES with challenging differential diagnosis in post-lumbar puncture headache (PLPHA) after cesarean section in a normotensive pregnancy. A 41-year-old multiparous woman underwent cesarean section using spinal and epidural anesthesia. She was normotensive during pregnancy. Although she had uncomplicated postoperative course until postoperative day 2, she developed frontal lobe headache on day 3. Her blood pressure and neurological examination were normal, and her pain was relieved in a lying position; hence, we diagnosed her with PLPHA. Conservative therapy was initiated, and the headache was resolved. However, her headache relapsed on day 5, accompanied with mild hypertension. Blood and urine tests did not reveal signs of preeclampsia, and oral caffeine was administered for PLPHA. However, she developed a tonic-clonic seizure on day 7. Head computed tomography scan post seizures did not reveal intracranial hemorrhage, and brain magnetic resonance (MR) imaging revealed edema of the bilateral posterior occipital lobes and cerebellum with hyperintense signal on T2-weighted signal. PRES was diagnosed, and infusions of magnesium sulfate and nifedipine were started. Subsequently, her blood pressure reduced to her baseline, and her headache was relieved. MR angiography revealed cerebral vasospasm on postoperative day 15; hence, lomerizine was started. Repeat MR angiography showed resolution of vasospasm, and she was discharged on postoperative day 25 without further seizure activity. The clinical course in this case was initially consistent with PLPHA. However, her headache from postoperative day 5 was atypical as in PLPHA; in some aspect, response to conservative treatment was weak and was accompanied by hypertension, suggesting that the headache was due to PRES. In other cases of PRES that occurred after PLPHA, blood pressure was initially normal and slightly elevated to the limit of mild hypertension, even when the patients had seizures. In conclusion, our case suggests that PRES should be considered when patients receive epidural or spinal anesthesia and develop headache atypical for PLPHA, such as headache with hypertension or refractory to conservative therapy, even if the blood pressure was normal during pregnancy. [Adv Obstet Gynecol, 70 (3) : 311-316, 2018 (H30.8)]

Although its incidence is low, uterine rupture in pregnancy following myomectomy can result in serious maternal and fetal compromise. Additionally, uterine rupture before the second trimester of pregnancy is considered to be extremely rare. A 39-year-old woman, gravida 1, para 0, underwent laparoscopically assisted myomectomy due to secondary infertility and myomas, and achieved spontaneous conception eight months after surgery. Genital bleeding was noted in the first trimester, and sudden lower abdominal pain and intraperitoneal bleeding occurred at seven week’gestation. Based on suspected uterine rupture, emergency laparotomy was performed. We found bleeding and villous tissue protruding from the myometrium, and repaired the wounds. A part of the region corresponding to the ruptured site had been histologically confirmed as adenomyosis at the previous surgery. This suggests that the myometrium had become weakened during its repairing process, which may have partly caused the uterine rupture. [Adv Obstet Gynecol, 70 (3) : 317-322, 2018 (H30.8)]