To reveal the relationship between maternal serum C-reactive protein (CRP) level pre-delivery and the presence of histological chorioamnionitis (hCAM). Sixty-one women with singleton pregnancies with previable premature rupture of the membranes (pPROM) occurring at <less than 34 weeks’ gestation were registered in this study. We retrospectively examined the relationship between perinatal factors associated with the prognoses of newborns and compared them between women with or without hCAM using medical records. We classified 61 patients with placental pathology based on Blanc’s classification . Women with hCAM grade III had significantly earlier rupture of membranes and deliveries (29 ± 4.6 weeks vs.vs 27 ± 3.0 weeks, p=0.048) (31 weeks vs. 28 weeks, p=0.003), significantly lower birth weights (1622±600 g vs. 1198±456 g, p=0.004), and significantly higher pre-delivery maternal serum CRP levels (1.3±1.4 mg/dl vs. 2.9±2.4 mg/dl, p=0.003) than women without hCAM III. In the ROC analysis for hCAM III onset in the maternal serum CRP value, the cutoff value was over 0.51 mg/dl and was extracted as a significant risk factor for hCAM III. The presence of hCAM III may be diagnosed based on maternal serum CRP levels 0.51 mg/dl. Therefore, the well-being of the infant, maternal fever, and infant tachycardia with elevated maternal serum CRP could indicate hCAM III. [Adv Obstet Gynecol, 74 (1) : 1-11, 2022 (R4.2)]

In some cases, atypical glandular cells (AGC) are detected by cervical cytology in the advanced lesions originating from the cervix, uterus, adnexa, and peritoneum, but the positive diagnosis rate is low. In our hospital, approximately 9932 patients underwent cervical cytology from June 2011 to March 2016, of which 177 patients were diagnosed with AGC, and 138 required a follow up for at least six months after the diagnosis. Of the 138 patients, 60 had pathological conditions such as invasive cancer (20 patients), cervical carcinoma (four patients), uterine carcinoma (14 patients), ovarian carcinoma (one patient), and peritoneal carcinoma (one patient). Pathological changes were detected by colposcopy plus cervical curettage, colposcopy only, and cervical curettage only in 11 of 24, 9 of 16, and 1 of 16 cases, respectively. The cervical cytology was repeated in 46 patients after initial AGC detection, of which only four patients were detected with pathological conditions. A timely colposcopy could have detected the pathological condition earlier in two of these cases. Therefore, it is inevitable to examine not only the cervix and uterus, but also extrauterine lesions, as early as possible after the detection of AGC. [Adv Obstet Gynecol, 74(1) : 12-20, 2022 (R4.2)]

Uterine torsion is not commonly found and is rarely diagnosed preoperatively. We report a case of uterine torsion with giant uterine fibroids, cervical wall rupture, and secondary omental torsion caused by adhesion of the omentum to uterine fibroids. A 53-year-old woman (five gravida, three para) presented to our hospital with lower back and abdominal pain. Contrast- enhanced computed tomography revealed giant uterine fibroids, uterine torsion, and adhesions between the uterine fibroids and the omentum. Laparotomy revealed a three-turn clockwise twist from the uterine body to the cervix and a huge uterine fibroid that developed on the left side of the uterine body. Furthermore, the omentum was twisted and adhered to the fibroid. The cervical wall was ruptured, and the bilateral appendages were highly congested. Supracervical hysterectomy, bilateral adnexectomy, and partial omental resection were performed. The postoperative course was unremarkable. Although uterine fibroids are benign and uterine torsion and its sequelae are rare, uterine torsion can be considered as the cause of acute abdomen in women with large uterine fibroids. [Adv Obstet Gynecol, 74(1) : 21-26, 2022 (R4.2)]

Although GnRH agonists are widely used for the treatment of uterine fibroids, the risk of cerebrovascular/cardiovascular events and venous thrombosis is described in the package insert. In the present case, a patient with bilateral internal carotid artery stenosis and submucosal myoma with severe anemia was treated with a GnRH antagonist rather than a GnRH agonist. The patient was 47 years old, had two pregnancies and two deliveries (two vaginal deliveries). She came to our clinic with complaints of excessive menstruation and anemia. On initial examination, transvaginal ultrasonography showed a mass of 90 mm in diameter that was thought to be a submucosal myoma. Pelvic MRI revealed a mass of 86 mm in diameter in the uterine corpus, which was diagnosed as submucosal myoma. Blood tests showed severe anemia with Hb 5.4 g/dl, and the patient was decided to undergo surgical treatment. In addition, head MRA showed severe stenosis of bilateral internal carotid arteries, and the patient was treated only with iron injection without estrogen-progesterone combination, but the anemia did not improve. Thereafter, an oral GnRH antagonist (Relugolix) 40 mg/day was started, and after administration, genital bleeding stopped and anemia improved to Hb12.3 g/dl. The diameter of the tumor mass was reduced to about 60 mm in length by MRI immediately before surgery. As for the surgical technique, we explained that laparotomy was safer than laparoscopy because of the adverse effect on cerebral circulation caused by the low head position of laparoscopy. However, the patient strongly desired laparoscopic surgery, so we performed a laparoscopic total hysterectomy, and the patient was discharged on the fifth postoperative day. Although GnRH agonists are known to increase the risk of thromboembolism in patients with prostate cancer, only five cases of thromboembolism associated with the use of GnRH agonists for benign gynecological diseases have been reported so far. Considering the description in the package insert, GnRH antagonist rather than GnRH agonist may be a promising option in patients with high risk of cerebral infarction as in the present case, but whether the risk of thromboembolism is truly lower with GnRH antagonist in benign gynecological diseases requires further evidence in a large number of cases. However, whether the use of GnRH antagonists is truly associated with a lower risk of thromboembolism in benign gynecological diseases requires further evidence from a large number of patients. [Adv Obstet Gynecol, 74(1) : 27-31, 2022 (R4.2)]

Carcinoids are low-grade neuroendocrine tumors that often occur in the gastrointestinal tract. Primary ovarian carcinoid tumors are rare, accounting for approximately 1.3% of all carcinoid tumors. While neuroendocrine cells in tumors cause carcinoid syndrome, peptideYY often causes constipation in patients with primary ovarian carcinoid tumors. We report two cases of ovarian carcinoids with different symptoms and pathological findings. Case 1 : A 55-year-old woman consulted a doctor with complaints of irregular bleeding and constipation, and was referred to our hospital with a right ovarian tumor. Imaging examinations revealed a solid lesion. Since there was the possibility of a malignant ovarian tumor, we performed abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy. She was diagnosed with a carcinoid tumor based on histopathological findings. PeptideYY was widely stained. Case 2 : A 64-year-old woman was referred to our hospital with a pelvic tumor. Imaging examinations revealed mature teratomas in both ovaries and a solid mass in her right ovary. We performed laparoscopic bilateral salpingo-oophorectomy. Histopathological findings showed bilateral mature teratomas with right corcinoid tumor. Her loose stools improved postoperatively. Preoperative diagnosis of ovarian carcinoid tumors is difficult. It is important to consider carcinoid tumors in cases of teratomas with solid components and complaints of digestive symptoms. [Adv Obstet Gynecol, 74(1) : 32-38, 2022 (R4.2)]

The incidence of ovarian tumor in pregnancy is 0.2 to 2%. The most of them are benign tumors and malignant ovarian tumor is about 1-6% and is rare. Decidualization of ovarian endometriosis during pregnancy mimics malignancy. We report the rare case of decidualized ovarian endometriosis which was operated by hand assisted laparoscopic surgery (HALS) at 17 weeks of gestation. A 31 years old primigravida with right ovarian endometriosis was referred to our hospital at 12 weeks of gestation because of the progressive enlargement of ovarian endometriosis from 4.7 cm to 6.6 cm. MRI showed ovarian endometrial nodules with thickened wall measuring 8.2 cm in diameter at 15 weeks gestation. Diffusion weighted MRI suggested a non-malignant cyst. All tumor markers were negative. Considering the risk of ovarian rupture during the pregnancy, a laparoscopic surgery was performed at 17 weeks of gestation. Visualization of the endometrial cyst was difficult because of the enlarged uterus and adhesion of the cyst in the pouch of Douglas. The umbilical wound was enlarged to 8 cm and the adhesion was released manually using single hand. Intraoperative blood loss was 320ml and the operation time was two hours and 40 minutes. Pathological diagnosis was decidualized ovarian endometriosis. [Adv Obstet Gynecol, 74(1) : 39-45, 2022 (R4.2)]

Fulminant hemolytic streptococcal infection is a highly lethal infection that develops suddenly and leads to septic shock due to β-hemolytic streptococcus that rapidly progresses to multiple organ failure, but it is rare to develop in 20s years young women. A twenty-year-old healthy woman suddenly developed peritonitis which rapidly progressed to streptococcal toxic syndrome(STSS), which was initially difficult to distinguish from bacterial enteritis due to the presence of severe abdominal pain, fever, and diarrhea. The next day, Streptococcus pyogenes was detected in the blood bacterial culture and a diagnosis of STSS was made. Antibiotic treatment with large doses of penicillin G and clindamycin were started immediately, and the woman survived. This is the rare report of STSS associated with pelvic peritonitis in 20-year-old healthy young woman.Since it is possible for even 20s years juvenile women to have STSS associated with pelvic peritonitis, it is important to watch the test data including blood cultures, and not delay the diagnosis by even one day. [Adv Obstet Gynecol, 74(1) : 46-50, 2022 (R4.2)]

Umbilical cord cysts are present in 0.4-3.4% of early pregnancies, but 80% disappear after midgestation or at birth due to spontaneous regression. There is no consensus regarding pregnancy management or the delivery method when a huge umbilical cord cyst is present. We report a case of a huge umbilical cord cyst and umbilical cord edema during pregnancy. A 30-year-old primipara was referred to our hospital at 25 weeks of gestation. Ultrasonographic findings revealed an umbilical cord cyst of 4 cm in diameter, which was suspected to be a urachal remnant. From 30 weeks of gestation the patient was admitted to our hospital. On 36 weeks of gestation, highly protracted bradycardia appeared during NST, so an emergency caesarean section was performed. Although amniotic fluid was turbid, a male baby was successfully delivered : birth weight : 2385g. The umbilical cord cyst was 6 cm in diameter and the liquid content was colorless, transparent, and serous. The umbilical cord edema continued from the cyst had a diameter of 4 cm and length of 15 cm. The cyst collapsed at the time of delivery, there was no communication with the infant, and there was no evidence of a urachal remnant in the infant. [Adv Obstet Gynecol, 74(1) : 51-57, 2022 (R4.2)]

Congenital left ventricular diverticulum and aneurysm are rare cardiac malformations. A 31-year-old woman presented to our hospital at 28 weeks gestation with fetal arrhythmia characterized by premature ventricular contraction and abnormal cardiac chamber. Fetal echocardiography revealed a cystic structure measuring 17.0 mm × 9.0 mm protruding from the left ventricle apex. M-mode echocardiography showed the cystic structure contracted simultaneously with the left ventricle, suggesting a left ventricular diverticulum and not an aneurysm. Because of fetal arrhythmia, monitoring cardiotocography was difficult. Therefore, we performed a cesarean section at 38 weeks gestation. Within two weeks of delivery, premature ventricular contraction disappeared spontaneously. To prevent blood clots, the newborn was administered aspirin from the fourth day after birth. We performed magnetic resonance imaging and cardiac catheter test 17 and 41 days after birth, respectively, based on which we diagnosed with left ventricular diverticulum. Left ventricular function was good, and there was no sign of heart failure. He was discharged 50 days after birth and followed up for six months in an outpatient setting with no complications. Most cases of ventricular diverticulum are asymptomatic, but complications, such as rupture, embolism, and heart failure could occur. Therefore, early diagnosis and careful follow-up are required. [Adv Obstet Gynecol, 74(1) : 58-63, 2022 (R4.2)]

Currently, approximately 200 cases of uterine torsion are reported in the available literature and most of these are known to have occurred during pregnancy. We report a rare case of uterine torsion, which occurred as a complication of a large uterine leiomyoma in an elderly woman. A 72-year-old woman diagnosed with schizophrenia presented with a several-day history of severe abdominal pain. Although she was diagnosed with chronic kidney disease and anemia, she refused medical evaluation for self-neglect. On admission, physical examination showed a mobile, hard and tender abdominal mass (approximately the size of an adult's head) on palpation. Laboratory test results revealed renal failure (serum creatinine 8.63 mg/dl, potassium 8.5 mmol/l) and severe macrocytic anemia (serum hemoglobin 4.3 g/dl, mean corpuscular volume 100.8 fl). Computed tomography revealed an ischemic uterine corpus containing a leiomyoma (20 cm in diameter), suggestive of uterine torsion. Laparotomy was performed following blood transfusion and reduction in serum potassium levels. Intraoperatively, we observed that the uterus was twisted 540° at the lower segment with bilateral dark red and atrophic adnexae, which showed gangrenous changes. We performed supracervical hysterectomy with bilateral salpingo-oophorectomy. The patient's postoperative course was uneventful except that she required temporal hemodialysis. Although torsion of the non-pregnant uterus is extremely rare, it should be considered in the differential diagnosis of acute abdominal pain in postmenopausal women with large uterine leiomyomas. [Adv Obstet Gynecol, 74(1) : 64-69, 2022 (R4.2)]

Gallstones occur more frequently in pregnant women than in nonpregnant women. However, choledocholithiasis rarely occurs (0.1% of pregnancies) and endoscopic retrograde cholangiopancreatography (ERCP) is useful for its treatment. We report a case of pregnancy with choledocholithiasis treated twice by ERCP. A 36-year-old woman (gravida two, para one) previously had a prenatal check-up at another clinic. At 24 weeks and five days pregnant, she visited the previous clinic with the chief complaint of epigastric pain. Abdominal ultrasonography revealed common bile duct stones, and the patient was diagnosed with choledocholithiasis. We found eight stones by MRI and it was judged that treatment with ERCP was necessary. At 26 weeks and two days pregnant, ERCP was performed, but the stones could not be removed. Bile and pancreatic duct stents were placed. We then performed ERCP again at 27 weeks pregnant to remove the eight stones. Afterward, the patient’s abdominal pain improved significantly and she was discharged in her 27th week of pregnancy. Subsequently, the pregnancy proceeded without incident and the mother gave birth safely at 39 weeks and five days. In this study, we succeeded in removing gallstones by two-stage therapeutic ERCP with a radiation dose that was not harmful to the fetus. Although therapeutic ERCP can be performed during pregnancy, the difficulty of the procedure increases and the fetal exposure may increase as the length of the procedure increases. We need to carefully consider the risks and benefits before deciding whether to perform ERCP in pregnant patients. [Adv Obstet Gynecol, 74(1) : 70-76, 2022 (R4.2)]

Tamoxifen (TAM) and aromatase inhibitors (AIs) are used as standard therapy for postoperative breast cancer (BC). TAM is associated with an increased risk of uterine cancer (UC), whereas AIs exert antitumor effects in UC. Therefore, the development of UC in women receiving AIs is not considered a major concern. We report the case of an advanced UC patient who received AI therapy for 10 years after mastectomy. She was followed up with regular CT to evaluate BC recurrence. She was referred to our clinic for suspected UC after CT showed a mass in the uterine cavity and peritoneal dissemination. Endometrial biopsy revealed endometrioid adenocarcinoma (EC). She underwent debulking surgery after MRI and PET-CT showed stage 3 EC. The pathological findings were consistent with uterine serous carcinoma (USC). The development of USC may not have been related to the AI because USC is estrogen independent. Because a higher incidence of USCs are seen in women with a history of BC, it has recently been suggested that BRCA gene mutations, which are linked to BC, are associated with an increased risk of USC. We conclude that regular endometrial surveillance during AI treatment after mastectomy is needed for the early detection of USC, even if abnormal vaginal bleeding is not shown. [Adv Obstet Gynecol, 74(1) : 77-85, 2022 (R4.2)]

Adenoid cystic carcinoma (ACC) is a rare tumor that is usually found in salivary glands. Uterine cervical ACC is extremely rare. We report the case of cervical ACC in a 35-year-old woman. Although cytological results indicated adenocarcinoma in situ (AIS), further examination did not reveal any abnormal findings. Histopathologically, diagnostic cervical conization revealed AIS, atypical cervical glands showing a focal cribriform appearance, small solid nests with numerous mitotic cells spreading invasively in the deep layer, and glandular structures containing eosinophilic material in the nests. The tumor cells were diffusely positive for p16, and p63-positive cells outlined the nests. The patient was therefore diagnosed with cervical ACC StageIB1, and a radical hysterectomy with bilateral adnexectomy and para-aortic lymphadenectomy were performed. The patient was given six courses of adjuvant chemotherapy with paclitaxel, carboplatin, and bevacizumab. No recurrence was observed at 48 months after surgery. The rate of ACC among all cervical cancers in Japan is 0.037%. Diagnostic cervical conization should be considered when abnormal cytology is detected in glandular cells, even though abnormal symptoms or colposcopic lesions are not detected, because cervical ACC is often complicated with malignancy of other histologic types. [Adv Obstet Gynecol, 74(1) : 86-93, 2022 (R4.2)]

Some malignant ovarian tumors may be metastasis from other primary tumors, and it has been reported that 8.4% to 19.2% of ovarian malignancies were metastatic tumors¹⁾, with the 5-year survival rate reported to be 0% to 29.1%²⁾. Krukenberg’s tumor was first reported in 1895 as a solid ovarian tumor characterized by signet ring cell proliferation showing abundant mucus production and marked sarcomatoid growth of stromal connective tissue³⁾. It was expanded to be a metastatic ovarian tumor mainly originating in the gastrointestinal tract in 1902⁴. In this paper, we report a case of advanced malignant ovarian cancer, which was revealed to be metastasis from pancreatic cancer. [Adv Obstet Gynecol, 74(1) : 94-102, 2022 (R4.2)]

Ovary-sparing total hysterectomy is rarely followed by adnexal torsion. Here, we report a case of bilateral ovarian torsion after total laparoscopic hysterectomy (TLH). A woman in her late 40s underwent TLH for adenomyosis. Six months later, she visited our department on day X for right lower abdominal pain. Magnetic resonance imaging (MRI) revealed that her right ovary was enlarged to 7 cm with ovarian torsion, leading to ischemia. The patient was discharged without any surgical intervention. On day X+16, she developed left lower abdominal pain. MRI revealed that the left ovary was enlarged to 6 cm, with ovarian torsion, leading to ischemia. Since the pain did not diminish, a laparoscopic single-port bilateral oophorectomy was performed. Intraoperatively, bilateral ovarian torsion was observed. TLH renders the remaining ovaries more mobile than abdominal or vaginal hysterectomy by leaving the peritoneal membrane open and causing less adhesions. The risk of torsion may be higher due to less damage to the ovaries in TLH, resulting in higher ovarian functions, causing more frequent ovulation and larger ovaries. Postoperative ovarian torsion may occur after ovary-sparing TLH. It is currently unclear whether ovarian fixation leads to the prevention of ovarian torsion. [Adv Obstet Gynecol, 74(1) : 103-108, 2022 (R4.2)]

59 adult cases of paraurethral cysts in the vulva are reported in Japan, of which onset in pregnancy is only one case. We report a case of paraurethral cyst in pregnancy for which marsupialization was performed after delivery. The patient was 26 years old, gravida one, para zero. At the 18th week of pregnancy, she was introduced to our hospital for detailed examination of vulvar swelling. A walnut-sized cyst was palpable on the dorsal side of the urethral meatus and cyst puncture was performed. Re-swelling of the cyst during pregnancy led to transvaginal delivery without collapse. Six weeks postpartum, the cyst started growing and the outflow of pus through the external urethral meatus was noted. Cystoscopy was performed in the urological department, but the orifice in the urethra and bladder was not found. The cyst was diagnosed as paraurethral cyst by MRI at this point. As symptoms were improved by oral antibiotics, cystectomy was not performed at the desire of patient. However, the symptoms recurred and marsupialization was carried out under local anesthesia. There has been no recurrence during follow-up for six months. In most cases, paraurethral cysts are considered a urological disease, although gynecological examinations are performed for vulval swelling in some cases. Similar to Bartholin’s gland cysts, marsupialization should be considered a therapeutic option. [Adv Obstet Gynecol, 74(1) : 109-113, 2022 (R4.2)]

Transabdominal cerclage (TAC) is the surgery of choice when performing transvaginal cerclage (TVC) is difficult, such as in cases of deep conization. However, it is not covered by Japan’s health insurance; therefore, it is rarely performed and few reports of its complications are available. This report presents a case of hysterectomy after atonic bleeding in a patient with placenta previa.A 40-year-old woman (gravida, four; para, three) with a history of conization and spontaneous abortion at week 20 of gestation visited our hospital because of genital bleeding. Her cervix was 18.6 mm long, with no vaginal fornix. At week 14 of gestation, TAC was performed. Pregnancy continued, but she had placenta previa with alarming bleeding. She underwent cesarean section at week 35 of gestation. Consequently, placenta was delivered smoothly, with no placenta accreta findings. After the placenta was delivered, atonic bleeding started. Various uterotonics were administered, but the bleeding persisted. Therefore, we performed hysterectomy. Pathological examination detected no placenta accreta or amniotic fluid embolism. In conclusion, we hypothesize that changes in uterine shape or some kind of blood flow disorder caused by TAC possibly affected the pathology of this case. [Adv Obstet Gynecol, 74(1) : 114-119, 2022 (R4.2)]

Polypoid endometriosis is a rare type of endometriosis, considered to be a benign tumor with a high risk of recurrence.Herein, we report a case with polypoid endometriosis undergoing in vitro fertilization (IVF) resulting in a successful pregnancy without tumor growth. A 37-year-old nulligravid woman went to a local physician for abnormal genital bleeding. Magnetic resonance imaging revealed a tumor in the right adnexa area. She was referred to Kitano hospital. Exploratory laparotomy revealed a solid tumor in the pouch of Douglas. Partial tumorectomy was performed as the mass was closely adhered to the rectal serosa. Histopathology revealed polypoid endometriosis. Postoperative Dienogest administration was prescribed for the cessation of tumor growth. At 40 years of age, the patient wished to conceive, and was referred to our clinic. Concern of tumor growth post Dienogest suspension led to the ovum collection and fresh embryo transfer in her first menstrual cycle soon after discontinuation of Dienogest. She had a successful pregnancy and delivery without tumor re-growth. Furthermore, there are no reports of successful pregnancy by IVF in such cases. Further elaborate studies on such cases are needed. [Adv Obstet Gynecol, 74(1) : 120-127, 2022 (R4.2)]

Peritoneal pregnancies occur in approximately 0.01% of all pregnancies and 1% of ectopic pregnancies. The mortality rate of peritoneal pregnancy is 3%, which is 7.7 times higher than that of other ectopic pregnancies. Preoperative diagnosis is difficult, and diagnosis is therefore often performed intraoperatively during emergency surgery. Herein, we investigated the differences and risks of peritoneal pregnancy, depending on the site of implantation, in five cases of peritoneal pregnancy and compared the clinical findings with those of fallopian tube pregnancy.The clinical findings of five peritoneal pregnancies treated surgically at our department between April 2010 and December 2018 were reviewed and compared with those of 74 fallopian tube pregnancies treated in the same time period.All peritoneal pregnancies were successfully treated with emergency laparoscopic surgery. Case 1 was a 41-year-old patient, G2P0, with implantation in a stalked subserosal uterine fibroid, and required an operation time of two hours and 17 minutes. Case 2 was a 40-year-old patient, G6P3, and Case 5 was a 34-year-old patient, G1P0, both with implantation on the sacral uterine ligament, and with operation times of three hours and 28 minutes. Case 3 was a 40-year-old patient, G1P0, with implantation in the Douglas fossa, with an operative time of one hour and 59 min. Case 4 was a 40-year-old patient, G3P1, with implantation in the posterior wall of the uterine fundus, and with an operation time of one hour and 49 min. Compared to fallopian tubes, peritoneal pregnancies have a significantly higher maternal age (P=0.004), and have no significant difference in other items.Patients with older maternal age may be at a higher risk of peritoneal pregnancy, but preoperative diagnosis of ectopic pregnancy is difficult in cases where blood hCG levels are low, and diagnosis of ectopic pregnancy is uncertain. The possibility of a peritoneal pregnancy should always be considered when operating on the suspicion of an ectopic pregnancy with an unknown implantation site. [Adv Obstet Gynecol, 74(1) : 128-135, 2022 (R4.2)]

We report a case of PRES after a laparoscopic total hysterectomy for myoma. The patient was a 48-year-old woman who had never been pregnant, and her prior medical history and family history were unremarkable. She was seen by a nearby physician for menorrhagia. Multiple myoma were found, and a laparoscopic total hysterectomy was performed. Her preoperative blood pressure was high but she had no previous history of hypertension, so she was put on observation. During surgery, however, her blood pressure remained higher than 200 mmHg and headaches occurred, so an a hypotensive drug IV drip was started, but symptoms did not improve, and impair consciousness (III-200 on the JCS) and tonic convulsions were noted. Head CT and MRI suspects PRES, and antihypertensive therapy was continued, but tonic convulsions were noted again, so an anticonvulsant were started, and there were no subsequent convulsions. Visual impairment and visual field loss were noted after the onset of PRES, but blood pressure was stabilized and symptoms tended to improve. A head MRI scan seven days after surgery revealed that the lesion had shrunk. If hypertension causes impaired consciousness or convulsions after surgery, prompt treatment is required, and the onset of PRES should be considered. [Adv Obstet Gynecol, 74(1) : 136-141, 2022 (R4.2)]

While performing a total hysterectomy, utmost care has to be taken to avoid urinary tract injury. We report two cases of pseudo-renal failure due to delayed bladder injury after gynecological surgery. The first case was a 41-year-old woman who underwent total laparoscopic hysterectomy for uterine leiomyoma. Massive ascites were observed and renal failure detected on blood tests 12 days post-surgery. She was diagnosed with bladder injury and consequent pseudo-renal failure by cystoscopy. She recovered in 28 days with conservative treatment including an indwelling urinary catheter. The second case was a 70-year-old woman who underwent an abdominal modified radical hysterectomy for endometrioid carcinoma, G3, cT1aN0M0. Massive ascites were detected and blood tests indicated renal failure on the third postoperative day. She was diagnosed with pseudo-renal failure due to bladder injury by cystoscopy. She was catheterized and was cured after 36 days. Even when using energy devices for gynecological surgeries, urinary tract damage may go unnoticed intraoperatively. Our observations highlight the importance of considering delayed urinary tract if we find massive ascites and biochemical features of uremia. [Adv Obstet Gynecol, 74(1) : 142-150, 2022 (R4.2)]

Ectopic pregnancies (EPs) account for 0.3 - 1.2% of all pregnancies, and commonly occur in fallopian tubes. A remnant tubal EP after ipsilateral salpingectomy is rare, accounting for 0.3 - 0.4% of all EPs. We report a case of a recurrent tubal EP after laparoscopic ipsilateral salpingectomy. A 36-year-old woman with a history of laparoscopic right salpingectomy for an EP, was suspected of having a recurrent EP. Magnetic resonance images showed a corpus luteum in the right ovary and a gestational sac around the remnant right tube. We suspected a remnant tubal EP arising from ipsilateral ovulation. She underwent laparoscopic gestational sac resection. The pathological diagnosis was a tubal pregnancy. A recurrent tubal EP after ipsilateral salpingectomy is rare, but we should think about the possibility of an EP even if ipsilateral ovulation is detected. [Adv Obstet Gynecol, 74 (1) : 151-156, 2022 (R4.2)]

Ovarian clear cell carcinoma which comprises approximately 25% of epithelial ovarian cancer, is often resistant to chemotherapy and often has a poor prognosis. Recent case reports have demonstrated a remarkable clinical response to treatment with immune checkpoint inhibitors for ovarian clear cell carcinoma. The anti-PD-1 immune checkpoint inhibitor Pembrolizumab (Keytruda^Ⓡ) was approved in Japan in December 2018 for the treatment of advanced recurrent MSI-High solid tumors that exacerbated after standard chemotherapy. We describe a chemotherapy-resistant patient with MSI-High ovarian clear cell carcinoma with multiple lung and liver metastases experiencing successful clinical response to treatment with pembrolizumab. A 52-year-old woman, gravida 0, para 0, was referred to our hospital with bilateral ovarian tumors. Surgery was performed and the postoperative diagnosis was made with bilateral ovarian clear cell carcinoma, pT2aN1M1, StageIVB (FIGO2014). Resistance towards 1st to 3rd line chemotherapy was shown but once MSI test returned positive, we began the administration of pembrolizumab. After the pembrolizumab administration, lesions including distant metastasis shrank and the tumor marker tested negative. After nine courses, no re-exacerbation was observed and administration is being continued. [Adv Obstet Gynecol, 74 (1) : 157-165, 2022 (R4.2)]

Oil-based iodinated contrast media are widely used for hysterosalpingography. Oil-based iodinated contrast media can remain in the body for extended periods of time, which can show a CT value similar to that of metal on radiographic evaluation, which may result in misdiagnosis of such lesions postoperatively. We describe a patient with a history of hysterosalpingography, who presented with a shadow that was misdiagnosed as a metallic foreign body on radiography performed after cesarean delivery. The patient conceived after thawed blastocyst transplantation. She underwent an emergency cesarean delivery, and postoperative radiography revealed a pelvic mass with a clear margin and an area of uniformly high absorption. Computed tomography (CT) revealed a suspected foreign body on the right side of the Douglas fossa with a CT value of 3000 Hounsfield units (HU), which was comparable to that of metal. The patient’s re-interview revealed a history of hysterosalpingography ; therefore, based on a literature review, we strongly suspected residual contrast medium in the abdominal cavity, and the patient was followed-up without any intervention, per our hospital policy. Subsequent radiography revealed deformation and reduction in the size of the shadow, and the patient was diagnosed with residual oil-based iodinated contrast medium in the abdominal cavity. It is necessary to remember the possibility of residual contrast media in patients with a history of hysterosalpingography. [Adv Obstet Gynecol, 74(1) : 166-170, 2022 (R4.2)]

The malignant transformation rate of ovarian mature teratomas is <1%, and adenocarcinomas account for approximately 7% of these malignant transformation cases. Mucinous carcinomas account for most adenocarcinomas; however, adenocarcinomas with intestinal differentiation(intestinal adenocarcinomas) are less common. Here, we report a case of intestinal adenocarcinoma considered to be caused by the malignant transformation of a teratoma with benign goiter morphology, which was immunohistochemically positive for the special AT-rich sequence-binding protein-2 (SATB2) that is specifically expressed in the colon. An 80-year-old woman consulted with her previous physician owing to a sensation of abdominal distension. Ultrasound revealed an ovarian enlargement that led her to consult our department. Magnetic resonance imaging revealed a cystic lesion that was 20 cm long, with contrast enhancement and diffusion limitation. Imaging revealed no evidence of metastasis to other organs such as the lymph nodes or peritoneum. Furthermore, there were no significant lesions in the gastrointestinal tract. However, serum carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9, and CA125 levels were all elevated, suggesting ovarian cancer. Biopsy of the cervix revealed clear-cell carcinoma, suggesting simultaneous duplication of cervical and ovarian cancer or metastasis of ovarian cancer to the cervix. Because of the patient’s low activities of daily living score, modified radical hysterectomy, bilateral adnexectomy, and omentectomy were performed. Intraoperative rapid ascitic fluid cytology was negative, and there was no evidence of metastases to the lymph nodes or peritoneum. The final pathological diagnosis was a complication of cervical clear-cell carcinoma in situ (pT1b1NxM0) with intestinal adenocarcinoma and goiter carcinoid tumor (pT1aNxM0) of the ovary. The patient is currently being followed up without additional treatment. Because of the presence of an intestinal adenocarcinoma, we considered the case to be a malignant transformation of the primary teratoma of the left ovary. The intestinal adenocarcinoma was identified as a colorectal-type intestinal adenocarcinoma because immunohistochemical analysis showed that it was negative for cytokeratin (CK) 7 but positive for CK20, caudal type homeobox 2, and SATB2. Thirteen cases of intestinal adenocarcinoma have been previously reported, all of which were derived from teratomas, and the present case was considered to be similar to the previous cases. SATB2 staining was not performed in any of the previously reported cases, which made our case report. [Adv Obstet Gynecol, 74(1) : 171-178, 2022 (R4.2)]

Hydatidiform mole coexistent with a fetus is a rare complication occurring in one in 22,000 to 100,000 pregnancies. In the case of a complete hydatidiform mole, the probability of a live birth is reported to be around 70% if the pregnancy can progress until 24 gestational weeks (GW) or later. We report a case of hydatidiform mole coexistent with a fetus and complicated with preeclampsia, thus resulting in termination. The patient was 39-years-old, unipara. At 12 GW, there was a multivesicular pattern lesion in the uterus, and her blood hCG level at 15 GW was 856,398.2 mIU/ml.Amniocentesis showed no chromosomal abnormalities, and the diagnosis of a complete hydatidiform mole was made. At 20 GW, the patient’s blood pressure was 158/72 mmHg, and urinalysis showed proteinuria 3+, thus indicating preeclampsia. At 21 GW, her blood pressure had risen 170/68 mmHg, and the pregnancy was terminated due to the risk of serious damage to maternal health. Labor was induced, and a female fetus and cystic lesion were delivered. Five weeks later, the patient’s blood hCG was 17,041.1 mIU/ml, so she underwent further testing. MRI showed a 5 cm mass in the pelvis, and we diagnosed a clinically invasive mole. Chemotherapy was subsequently administered. [Adv Obstet Gynecol, 74(1) : 179-187, 2022 (R4.2)]