Pelvic inflammatory disease (PID) often leads to the formation of a tubo-ovarian abscess (TOA) due to severe disease, and surgical treatment is required when conservative treatment is not effective.The present study aimed to investigate the need for surgical treatment in patients with PID and the extent to which relapse would occur. A total of 47 PID cases that presented from May 2015 to June 2017 at our hospital were retrospectively analyzed. In all, 31 cases (seven without TOA, 24 with TOA) required hospitalization for disease management. Of these 24 patients, eight (33%) with TOA required surgical treatment: of these eight patients, two required laparoscopic surgery and six required laparotomy. Patients in the surgical treatment group were older (p=0.034), had higher C-reactive protein levels at admission (p=0.009), and had a larger abscess diameter (p=0.009) than those in the conservative treatment group. In all cases, only abscess drainage was performed, whereas salpingo-oophorectomy and hysterectomy were not performed. None of the 31 patients presented again for PID relapse after discharge. A questionnaire survey provided responses from 10 cases, and no relapse of PID was observed in any of the cases. Patients with PID who require surgery tend to be older, exhibit more inflammatory findings on admission, and have larger abscesses. It is believed that abscess drainage alone does not have a high relapse rate when performing surgery. [Adv Obstet Gynecol, 72(3) : 193-198, 2020 (R2.8)]

To evaluate the importance of mental health care for pregnant women and the increase in pregnancy by assisted reproductive technology (ART) in Japan, the association between the incidence of postpartum depression-like symptoms and pregnancy by ART was retrospectively investigated. The Edinburgh Postnatal Depression Scale (EPDS) data from 1360 of 1615 women who delivered a single baby and received the 2nd and 4th week postpartum checkups at our hospital for one year since April 2017 were compared between natural conception (n=1066) and ART (n=294) groups, followed by propensity score matching. No significant difference was noted in the incidence of an EPDS score ≥9 or of contact with a health center. Furthermore, no significant difference was noted in the comparison between the two groups by propensity score matching in the incidence of contact with a health center. The present study suggests no association between the conception method and postpartum depression-like symptoms. [Adv Obstet Gynecol, 72 (3) : 199-204, 2020 (R2.8)]

To estimate the clinical outcomes of women with cervical intraepithelial neoplasia grade 2 (CIN2), we retrospectively investigated the outcomes and prognosis of 58 women with CIN2 treated in our hospital over the previous 15 years. We recognized that there were numerous cases with "CIN1-2" and "CIN2-3" lesions, these being the interim terms to classify lesions that could not be differentiated between CIN1 and CIN2 or between CIN2 and CIN3, respectively. Therefore, we also included 32 CIN1-2 and 43 CIN2-3 cases in our study. CIN1-2 and CIN2 regressed in 63% and 64%, respectively, of women kept under surveillance. For women younger than 30, the rate of regression was more favorable (89% and 75%, respectively). The rate of progression was 16% for CIN1-2, 16% for CIN2, and 12% for CIN2-3. Thirty-six patients with CIN2-3 underwent immediate cervical conization, 28 of whom (84%) were restaged as CIN3 after surgery. Our results suggest that CIN2 will regress in about 60% of women kept under surveillance. Conservative management with active surveillance, instead of immediate local excision, is therefore acceptable in selected patients, especially if further pregnancies are considered and compliance with surveillance is likely to be high. [Adv Obstet Gynecol, 72(3) : 205-210, 2020 (R2.8)]

When we make a pathological diagnosis before neoadjuvant chemotherapy (NAC), we choose either laparoscopic biopsy or the cell block (CB) technique. In this study, we have assessed and compared the utility of both techniques. From January 2009 to December 2018, patients who were suspected of having advanced ovarian cancer or primary peritoneal cancer at Kobe University Hospital were enrolled. Patients with a good performance status underwent laparoscopic biopsy (LB), and the other patients undertook CB biopsy. Diagnostic period, diagnostic accuracy, and complications were retrospectively assessed. Fifty three patients were enrolled. In the LB group (n=18), all final diagnoses were matched with the biopsy results. In the CB group (n=35), 22 of 28 cases with serous carcinoma were diagnosed with adenocarcinoma, and 17 out of these 22 cases were diagnosed with only serous carcinoma. In addition, 2 cases were diagnosed with gastric cancer and pancreatic cancer. On the other hand, all cases with mucinous carcinoma were false negative. In the LB group, the diagnostic period was longer than in the CB group. Both groups had no significant difference in the rate of complications. The CB technique is a useful method for diagnosis. However, in cases with non-high grade serous carcinoma, laparoscopic biopsy may be necessary. [Adv Obstet Gynecol, 72 (3) : 211-215, 2020 (R2.8)]

We aimed to clarify the difference in treatments and perinatal events between patients diagnosed with idiopathic thrombocytopenic purpura (ITP) during pregnancy and patients diagnosed with ITP before pregnancy. From July 2010 to July 2019, we reviewed 42 pregnancies in 34 pregnant women with ITP who were managed at our hospital. 26 cases were diagnosed with ITP before pregnancy, and 16 cases were diagnosed during pregnancy. There was no significant difference in patient background and treatment between the two groups. Comparison of perinatal events showed a significant difference only in maternal minimum platelet count : that of patients diagnosed with ITP during pregnancy [5.0 (1.2-9.0)× 10⁴/μl] [median (range)] was significantly lower than that of patients diagnosed before pregnancy [9.1 (1.6-21.1)×10⁴/μl] (p=0.046). Umbilical vein platelet count and neonatal platelet count on days 2 and 5 were not correlated with maternal platelet count at delivery and antiplatelet antibody levels. A strong positive correlation was observed between individual neonatal platelet count on days 2 and 5 in first and second siblings (Spearman’s r=0.75, p=0.066).In conclusion, there was no difference in treatment and perinatal complications according to time of ITP diagnosis. [Adv Obstet Gynecol, 72 (3) : 216-223, 2020 (R2.8)]

Uterine artery embolization (UAE) is an effective treatment for postpartum hemorrhage (PPH), but clinical failure can occur in the presence of unstable hemodynamics and disseminated intravascular coagulation (DIC).Therefore, we aimed to clarify the usefulness and safety of UAE for the treatment of PPH with DIC. The study included 26 patients who underwent UAE for PPH at a single center between 2013 and 2018. Patient characteristics and clinical courses were also investigated. In total, 22 patients had an obstetric DIC score of ≥ 8 (DIC group) and four patients had an obstetric DIC score of ≤ 7 or less (non-DIC group). Successful hemostasis was observed in 20 (90.9%) patients in the DIC group and four (100%) patients in the non-DIC group with no significant difference. There were two serious complications in the DIC group (abdominal aortic dissection and intrauterine infection) and one in the non-DIC group (uterine necrosis), but none required invasive treatment. Our results suggest that UAE is a relatively safe treatment that can provide effective hemostasis in patients with DIC. [Adv Obstet Gynecol, 72 (3) : 224-229, 2020 (R2.8)]

Purposes: Risk-reducing salpingo-oophorectomy (RRSO) is recommended for patients with hereditary breast and ovarian cancer syndromes (HBOC). The purpose of this study was to clarify the clinical concerns related to RRSO. Methods: Data on the background, complications, and prognoses of 304 patients who underwent HBOC-related genetic counseling at Kyoto University Hospital from 2010 to March 2019 were retrospectively assessed. Results: The number of HBOC-related genetic counseling increased from 2014. Forty-five women diagnosed with HBOC included 33 with breast cancer cases, eight with ovarian cancer cases, and four cases that were introduced for the family history. RRSO was performed in 13 cases since 2015. RRSO was performed in six of 11 cases with BRCA1 mutation and in seven of 21 cases with BRCA2 mutation (p=0.2826). All BRCA1 mutant breast cancer cases who underwent RRSO were also Estrogen receptor/progesterone receptor (ER/PR) negative, whereas all BRCA2 mutant breast cancer cases were ER/PR positive. RRSO was performed laparoscopically for all cases. The amount of intraoperative bleeding was minimal, and no complications were observed. Malignancy was not observed in all surgical specimens. Conclusions: Laparoscopic RRSO is safe. It is necessary to provide information about its effects on breast cancers and the risk of ovarian cancer when considering intervention in cases with BRCA2 mutation. [Adv Obstet Gynecol, 72 (3) : 230-236, 2020 (R2.8)]

Posterior reversible encephalopathy syndrome (PRES) is cerebral vasogenic edema induced by vascular endothelial cell dysfunction and usually shows reversible neurological symptoms and changes in the posterior area of the brain. Preeclampsia and eclampsia can induce pregnancy-related PRES. Optimal reduction in blood pressure may prevent the progression of vasogenic edema to cytotoxic edema. Therefore, failure to treat the hypertension promptly may cause intracranial hemorrhage, permanent neurological deficits, and death. Among the patients with neurological symptoms (headache, visual disturbance, confusion, seizure, vomiting, etc.) reported from 2007 to 2017 in our institution, we identified eight patients who were diagnosed with PRES by brain magnetic resonance imaging (MRI). Eclampsia was present in five patients, whereas all patients had hypertension. With the exception of one patient who had intracranial hemorrhage, and therefore, experienced persistent mild higher brain dysfunction, all other patients had good prognosis.In six out of eihgt patients, follow-up MRI was obtained after four to 27 days, which showed complete resolution. Initial MRI should be performed as soon as possible from the onset of neurological symptoms,because of its effectiveness in predicting prognosis.Early diagnosis of PRES enables early treatment and good prognosis. [Adv Obstet Gynecol, 72 (3) : 237-242, 2020 (R2.8)]

Avastin Use in Platinum-Resistant Epithelial Ovarian Cancer (AURELIA) trial achieved its primary efficacy end point of significantly improved progression-free survival (PFS) in patients treated with bevacizumab in combination with a single chemotherapy for platinum-resistant, recurrent ovarian cancer. However, patients who are treated with bevacizumab at recurrence are at high risk of side effects, for they have been treated with intestinal resection. We analyzed 13 patients who were treated with 19 regimens combined with bevacizumab in our department from July 2015 to January 2019, and investigated side effects of the treatments. The median prior treatment regimens were three regimens (range 1-5). Regimens of a single chemotherapy in combination with bevacizumab were six with irinotecan, eight with liposomal doxorubicin, three with gemcitabine, two with weekly paclitaxel. Bevacizumab-associated adverse events included, one of gastrointestinal perforation (GIP), two of deep venous thrombosis, one of hypertension and one of proteinuria. Grade3 events were gastrointestinal perforation, hypertension and proteinuria. Four patients (30.8%) discontinued because of adverse events. The median PFS was 4.3 months. Considering enterectomy and intestinal recurrence, we should be careful of sever adverse events such as GIP in bevacizumab treatment in combination with a single chemotherapy for heavily treated patients for platinum-resistant, recurrent ovarian cancer. [Adv Obstet Gynecol, 72 (3) : 243-250, 2020 (R2.8)]

The loop electrosurgical excision procedure (LEEP) is one of the treatments for cervical intraepithelial neoplasia. We performed a retrospective analysis of 299 patients who underwent a LEEP conization for cervical intraepithelial neoplasia(CIN)between 2011 and 2017 at our hospital. Following LEEP conization, 5 patients(1.7%) preoperatively diagnosed with CIN3 were upstaged and diagnosed with cervical cancer, stage IA1. Of all patients, 49 (16.4%) required an unscheduled examination because of post-operative genital bleeding. No patient suffered from cervical stenosis after LEEP conization. Of 290 diagnosed with CIN3, 12 (4.1%) patients required additional surgical treatment after the initial LEEP conization procedure. Nine patients showed disease involvement in endocervical and/or ectocervical margins, while 2 had disease-free margins. Forty subsequent pregnancies occurred in 36 (12.0%) patients. In those with delivery after 22 weeks of gestation, the rate for preterm birth was 10.0% (3/30). In the present cohort who underwent LEEP conization, preoperative diagnosis of CIN was accurate in nearly all cases and therapeutic efficacy was substantially demonstrated, though some showed residual or recurrent lesions. In addition, there were relatively few adverse effects related to the LEEP conization procedure on subsequent pregnancy. [Adv Obstet Gynecol, 72 (3) : 251-258, 2020 (R2.8)]

Surgical resection of large hypervascular uterine sarcoma is typically challenging owing to the high risk of uncontrollable bleeding. We report a case wherein preoperative embolization of uterine and ovarian artery facilitated successful surgical outcomes with minimal intraoperative bleeding. A 42-year-old primigravida woman was undergoing infertility treatment since nine years. She was admitted to another hospital because of an enlarged abdominal mass. The mass was suspected as large uterine sarcoma and was associated with liver and lung metastasis, as shown by MRI and PET-CT. She was diagnosed with leiomyosarcoma by transcervical needle biopsy and was treated with docetaxel/gemcitabine ; however, she developed. After changing to pazopanib, there was amelioration of lung metastases ; therefore, total hysterectomy and partial hepatectomy were performed. The uterine tumor was large and had abundant blood flow ; there was a high risk of intraoperative bleeding. Therefore, surgery was performed after embolization of the uterine and ovarian artery in the hybrid operating room ; the intraoperative blood loss was 270g.We examine the usefulness of preoperative arterial embolization for large uterine sarcoma by reviewing two other patients treated at our department and previous reports. [Adv Obstet Gynecol, 72 (3) : 259-265, 2020 (R2.8)]

Small cell neuroendocrine carcinoma (SCNEC) of the endometrium is a very rare disease. Because most cases have already progressed at the time of diagnosis and metastasis or recurrence occur early, the prognosis is poor. This report describes a case of SCNEC that was initially diagnosed as a grade one endometrioid carcinoma preoperatively.A 61-year-old, bipara woman complained of postmenopausal genital bleeding. Endometrial thickening was observed, and endometrial aspiration histology was consistent with endometrioid carcinoma G1. A pelvic MRI scan showed a tumor invading into the myometrium, affecting half or more in depth and judged to be equivalent to stage IB. Laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy of the intrapelvic and paraaortic lymph nodes were performed. Pathologically, the tumor consisted of a solid growth of cells with high chromatophores and dark chromatin; a rosette structure was conspicuous, and immunostaining demonstrated CD56 positivity, and partial positives for chromogranin A and synaptophysin. These characteristics confirmed a diagnosis of SCNEC of the endometrium. Co-existing components of endometrial intraepithelial neoplasia were observed. The patient was treated with postoperative adjuvant combination chemotherapy using irinotecan and cisplatin. Since the operation was laparoscopic, the postoperative recovery was quicker, and postoperative adjuvant chemotherapy could be started early. [Adv Obstet Gynecol, 72 (3) : 266-271, 2020 (R2.8)]

Angiomyofibroblastoma (AMFB) is a benign mesenchymal tumor that develops most commonly in the external genitalia of middle-aged women and rarely in the pelvic cavity. Herein we report a recent case of AMFB that developed along the pelvic ligament. A 76-year-old patient, gravida two, para two, underwent a surgery with a preoperative diagnosis of left inguinal hernia at another hospital eight years before. The pathological findings indicated AMFB, which was different from the preoperative diagnosis. This time, the patient visited the cardiology department of our hospital because of worsening of the varicose veins in her lower limbs. A computed tomography imaging test at our hospital revealed a pelvic mass.A gynecological disease was suspected, and she was referred to our department. Magnetic resonance imaging (MRI) revealed a cord-like undulated tumor in the interstitium of the left uterine corpus, extending from the uterus to the left suspensory ligament of the ovary or round ligament. We performed an abdominal total hysterectomy and bilateral salpingo-oophorectomy with the diagnosis of uterine tumor. The histological findings of the excised specimen was similar to those obtained by the previous physician, and the patient was diagnosed as pelvic AMFB.Because no preoperative imaging evaluation was performed by the previous physician, whether the lesion was a recurrence of AMFB or a remnant tumor after the previous resection surgery was unclear. The patient’s postoperative course was favorable. As of one year and three months after surgery, no recurrence has been observed.When a pelvic mesenchymal mass that shows an odd progression is detected, AMFB should be considered and ruled out. [Adv Obstet Gynecol, 72 (3) : 272-279, 2020 (R2.8)]

In recent years, the pregnancy of women with spinal cord injuries has increased, with the advancement of critical care medicine. However, there have been few reports of such birth cases in Japan. We experienced a case of a patient with a severe spinal cord injury who achieved a successful transvaginal delivery with epidural anesthesia.The case was 38-year-old woman who was not pregnant. At the age of 21, she injured her third thoracic vertebra in a traffic accident. After the injury, her menstruation resumed and sexual intercourse was possible. After marriage, the patient wished for a baby. She was treated at another hospital with timing therapy, but failed to become pregnant and was referred to our hospital. After sufficient informed consent, in vitro fertilization was performed, and she became pregnant.The patient subsequently experienced premature birth, urinary tract infection, and autonomic hyperreflexia (AH). We educated the patient about uterine contractions and premature rupture, because they had poor subjective symptoms.From the thirty-first week of pregnancy, she was hospitalized for imminent preterm birth, and we planned for delivery after 37 weeks of pregnancy.During vaginal delivery, epidural anesthesia was scheduled to prevent AH. We prepared a protocol in advance and worked closely with other departments. Her cervix was dilated for two days, from the 37 weeks three days of pregnancy. Spontaneous labor occurred on the 37 weeks five days of pregnancy, and we initiated delivery management according to our protocol.We anticipated possible complications in advance, managed cross-disciplinary cooperation with other departments, and achieved favorable outcomes for both mother and child. We started epidural anesthesia shortly after the onset of labor, but AH developed. We then administered antihypertensive drugs to manage the onset of AH. Our rapid, protocol-based response resulted in a successful vaginal delivery without severe AH complications, such as stroke. [Adv Obstet Gynecol, 72 (3) : 280-286, 2020 (R2.8)]

Giant uterine myomas concomitant with pregnancy predispose patients to venous thromboembolism (VTE). We describe a woman diagnosed with a giant uterine myoma during the early stages of pregnancy, who presented with massive VTE. A 38-year-old gravida one, para zero underwent myomectomy for multiple fibroids and conceived spontaneously thereafter. Genital bleeding occurred during the 6^th week of pregnancy, and she kept to rest at home. She was diagnosed with deep vein thrombosis (DVT) during the 9^th week of pregnancy and a giant uterine myoma that had enlarged to the level of her umbilicus. She was treated with unfractionated heparin. Unfortunately, she developed massive genital bleeding followed by a complete miscarriage. Contrast-enhanced computed tomography revealed pulmonary thromboembolism and massive DVT, which occluded most of her left-sided veins below the level of the external iliac vein. Considering the risk of bleeding associated with anticoagulation therapy, the risk of myoma recurrence and VTE in patients undergoing myomectomy, we offered her various therapeutic options; the patient and her family chose a total hysterectomy, which was performed after inferior vena cava filter placement. Clinicians should remain alert to the fact that women with giant uterine myomas show a higher risk of VTE even during early pregnancy. [Adv Obstet Gynecol, 72 (3) : 287-293, 2020 (R2.8)]