This study aimed to compare the efficacy and safety of bevacizumab (Bev) with paclitaxel(paclitaxel+ carboplatin) and maintenance with Bev in preoperative (neoadjuvant chemotherapy [NAC]) and palliative systemic chemotherapy for cervical cancer. We categorized 36 patients who received cervical cancer chemotherapy during 2016-2019 at Kansai Medical University and Kindai University Hospital into NAC and palliative chemotherapy groups. Bev was administered to eight and four patients in the NAC and palliative chemotherapy groups, respectively ; four in the NAC group and all in the palliative chemotherapy group were switched to maintenance therapy with Bev. Tumor reduction efficacy and adverse events were compared and evaluated with and without combined Bev use. No adverse events were observed during NAC and adjuvant chemotherapy with Bev ; however, treatment had to be interrupted during maintenance owing to gastroin-testinal perforation. The Bev combination therapy group included more patients with lymph nodal enlargement at baseline. There were no significant differences in intraoperative blood loss, operative time, down stage rate, or pathologic risk factors for recurrence between patients with and without Bev. Bev combination therapy for cervical cancer was feasible and could potentially improve NAC and palliative systemic chemotherapy efficacies, although adverse events should be carefully managed. [Adv Obstet Gynecol, 75 (1) : 1-9, 2023 (R5.2)]

In 2018, pembrolizumab, an anti-PD-1 antibody, was approved for treatment of microsatellite instability (MSI)-high solid tumors in Japan. Here, we retrospectively evaluated the relationship of patient background, treatment efficacy, adverse events, and treatment course with the neutrophil-to-lymphocyte ratio (NLR) in peripheral blood of patients treated with pembrolizumab for MSI-high gynecological cancer. Among 128 patients with recurrent gynecological cancer, the MSI positivity rate was 9.4% (12 patients) of which eight patients (median age, 71 years) were treated with pembrolizumab. The response rate was 50% (4/8 patients). The median progression-free period was 10 months, and the median duration of response in the responders was 12.5 months. Adverse events included arthralgia, edema, decreased vision, and pruritus, all of which were grade 1. Of the eight patients who received pembrolizumab, one underwent craniotomy for a benign brain tumor, and another, palliative irradiation for a recurrent pelvic lymph node. In addition, in six of the eight cases, the peripheral blood NLR fluctuated in conjunction with the treatment effect and tumor markers. These results confirm the clinical efficacy and safety of pembrolizumab against MSI-high gynecological cancer. They also support estimation of the treatment effect by evaluating change in the NLR. [Adv Obstet Gynecol, 75(1) : 10-15, 2023 (R5.2)]

The aim of this retrospective study was to assess the factors associated with exacerbation of psychiatric disorders (ePD) during and after pregnancy as well as the negative effects of psychiatric disorders (PD) on pregnant women and their newborns. From 2017 to 2019, 116 women with PD delivered at our hospital. Twenty-nine women (25.0%) had ePD during pregnancy, and 12 (10.3%) after delivery. In the group with ePD during pregnancy, the proportion of women who stopped antipsychotic medications and those who regularly consumed them were higher than in the group without it. The psychiatrists determined that the discontinuation of antipsychotics was responsible for 51.7% of ePD during pregnancy. The following adverse events occurred among the subjects: preterm birth (23.3%), emergency cesarean delivery (28.4%), and morphological abnormalities in infants (9.5%). Pregnant women with PD are at a higher risk of ePD, obstetrical complications, and congenital abnormalities in their newborns. As a result, pregnant women with PD should be closely monitored by a multidisciplinary team that includes obstetricians, psychiatrists, and neonatologists. [Adv Obstet Gynecol, 75(1) : 16-25, 2023 (R5.2)]

The advent of next generation sequencing (NGS) has made it possible to perform chromosomalanalysis even in small sample volumes. In this study, we compared the G staining and NGS methods for analyzing aborted chorionic villi tissue samples. In addition, short tandem repeat (STR) analysis was performed using the DNA extracted from maternal blood to confirm the presence of maternal cell contamination (MCC). The patients were clinically diagnosed with miscarriages, and the aborted chorionic villi were collected. We evaluated the concordance rate of the chromosome aneuploidy test results between the G staining and NGS methods. A comparison of the percentage of successfully tested and analyzed samples and the incidence of MCC due to contamination with maternal tissues was made between both the techniques. A total of 10 cases were selected for the study, and STR analysis was performed in four of them. One case was confirmed to have different results for G staining (47, XY, +14) and NGS(mos 48, XY, +13, +14/47, XY, +14). Chromosome aneuploidy was detected by NGS in 70% (7/10) of the cases and 30% (3/10) were found to have normal karyotypes. MCC was suspected in two of the four cases for which STR analysis was performed. Aneuploidy analysis of the aborted chorionic chromosome by NGS showed that NGS could be used to analyze cases that may be difficult to test using the G staining method, and STR analysis could be used to exclude false negatives that may occur due to contamination with maternal blood or tissue. [Avd Obstet Gynecol, 75(1) : 26-31, 2023 (R5.2)]

Administration of corticosteroids to pregnant women who are expected to deliver in late preterm has been reported to reduce neonatal respiratory complications, but in Japan guidelines for administration have not been established. The purpose of this study was to evaluate the efficacy of corticosteroids administration in late preterm. 49 cases of late preterm labor without steroids from 2014 to 2015 (non-treated group) and 31 cases of late preterm labor with steroids from 2016 to 2020 (treated group) were statistically compared. There was no significant difference in the incidence of TTN (Transient tachypnea of the newborn), RDS (respiratory distress syndrome) and surfactant treatment between the two groups. The incidence of neonatal hypoglycemia was not significantly different between the two groups. There were no maternal complications due to steroid administration. This single-center retrospective study did not demonstrate the effect of antenatal steroid treatment in late preterm. Future multicenter prospective studies are required to establish evidence for antenatal steroid treatment in late preterm in Japan. [Adv Obstet Gynecol, 75(1) : 32-38, 2023 (R5.2)]

Conjoined twins originate from monozygotic twins and they develop when incomplete or abnormal separation of the scutellum occurs at a very late stage of embryogenesis. We report a case of conjoined twins that developed after single blastocyst transplantation. A 33-year-old patient underwent in vitro fertilization (IVF) due to bilateral tubal blockage. Eggs were collected by the antagonist method, and seven blastocysts were obtained and completely frozen. A single thawed embryo was transferred to a frozen blastocyst 118 hours after IVF, and pregnancy was established. After transplantation, one heartbeat was observed at six weeks gestation, but extensive vaginal bleeding occurred at 10 weeks gestation, and fetal omphalocele and marked subcutaneous edema mainly on the right side of the neck were observed at 11 weeks gestation. Hydrops fetalis and fetal heartbeat arrest were confirmed at 12 weeks of gestation ; and, after administering medication for inducing a miscarriage, conjoined twins were delivered that were joined at the head, chest, and abdomen. Chromosome examination revealed 46XY without chromosomal abnormalities. [Adv Obstet Gynecol, 75(1) : 39-44, 2023 (R5.2)]

Vasa previa is a rare but clinically important obstetrical complication that occurs in 2-6 of 10,000 pregnancies. Approximately 93% of cases are diagnosed in the second trimester, and a late preterm cesarean section increases the neonatal survival rate. We report a case of vasa previa diagnosed in the second stage of labor and refer to five previous cases. A 35-year-old female was referred to our hospital at 34 weeks of gestation for further examination of her fetal heart malformation. Fetal echocardiography showed tricuspid atresia (Ic). Transvaginal ultrasound (TVUS) showed no vasa previa or placenta previa. Induction of labor was performed at 39 weeks of gestation because she and her family live far away from the hospital. No vasa previa was found on TVUS at admission. The delivery progressed, and a cord-like object was palpated by pelvic examination at the time of full opening of the uterine cervix. We diagnosed vasa previa by TVUS and performed an emergency cesarean section. A healthy 2904g female infant was successfully delivered, with an Apgar score of 6/9. There was no blood loss during delivery. Evaluation of the placenta confirmed the diagnosis of vasa previa. We could know that we should examine carefully when the delivery progressed especially we couldn’t determine insertion of the umbilical cord clearly. [Adv Obstet Gynecol, 75(1) : 45-50, 2023(R5.2)]

DID is defined as occurring when a pregnancy continues for at least 24 hours beyond the birth of a singleton in a multiple pregnancy. Some literature discuss DID, but not a single fetal demise in a twin pregnancy. We present a case of DID in a dichorionic diamniotic twin pregnancy after a single fetal reduction. The patient was 32-year-old pregnant Japanese woman, G1P0. At 15th weeks gestation, a large encephalocele was found in one twin, and the patient selected a fetal reduction at 17th weeks gestation in another hospital. At 28th weeks 4days gestation, the twin that had died in utero was delivered, and the remaining fetal membrane prolapsed into the vagina. The patient was admitted to our hospital and treated with tocolytic agents, progesterone replacement, antibiotics, and corticosteroids. The remaining fetus was delivered four days later at 29th weeks 1day gestation. The placental pathology of the demised fetus was chorioamnionitis. The baby’s progress was good, and she was discharged on the 76 days of life. There are reports of DID decreasing neonatal morbidity because too little gestational age is dangerous. The decision to select DID should be made with great care after considering gestational age and any signs of infection. [Adv Obstet Gynecol, 75 (1) : 51-56, 2023 (R5.2)]

Among ectopic pregnancies, the incidence of peritoneal pregnancies is approximately 1%. Peritoneal pregnancies are classified as rare cases. It has been reported that peritoneal pregnancy is less likely to be symptomatic than oviductal pregnancy. By the time symptoms appear, a large amount of intra-abdominal bleeding may occur leading to a high mortality rate (as high as 7.7 times). The technique of abdominal operation may be selected depending on the general condition of the patient. We report a case of peritoneal pregnancy managed laparoscopically. Our patient is a 35-year-old woman who was referred to us with suspected ectopic pregnancy. There was no intra-uterine fetal sac, however, fetal sac and fetal beat were found in the interstitial portion of the fallopian tube on transvaginal ultrasonography. On blood investigations and magnetic resonance imaging (MRI), she was suspected to be a case of tubal or peritoneal pregnancy and she underwent laparoscopic surgery. During the surgery, we were able to confirm the diagnosis of peritoneal pregnancy. [Adv Obstet Gynecol, 75 (1) : 57-61, 2023 (R5.2)]

This is a case of a 69-year-old woman diagnosed with uterine carcinosarcoma which metastasized to the skull. Uterine carcinosarcoma is a rare disease and few cases of bone metastasis in the setting of endometrial malignancies have been reported. The patient initially presented to the clinic complaining of genital bleeding and was febrile. A 12 cm-sized endometrial tumor was identified, and the patient underwent biopsies of the endometrium, which was later diagnosed endometrioid carcinoma. PET/CT showed high FDG uptake in the margin of the intrauterine tumor and the mass on the left frontal bone. MRI showed a 10 mmsized tumor at the left frontal bone and several cerebral infarctions. She was also diagnosed with Trousseau syndrome, which was treated with heparin. We performed total abdominal hysterectomy, bilateral salpingooophorectomy, and adhesiolysis. Pathological examination revealed uterine carcinosarcoma. We planned to begin treatment with postoperative chemotherapy, but the left frontal bone tumor increased rapidly to 35 mm in size three weeks after the operation. seven weeks after the initial total hysterectomy, neurosurgeons performed excision of the skull tumor. Pathological examination revealed metastasis of the carcinoma component of uterine carcinosarcoma. Currently, she is being treated with paclitaxel and carboplatin combination therapy. [Adv Obstet Gynecol, 75(1) : 62-70, 2023 (R5.2)]

Ovarian leiomyomas are rare and may be indistinguishable from ovarian fibromas; therefore, preoperative diagnosis is difficult. We report a case of ovarian leiomyoma shrinkage following preoperative gonadotropin-releasing hormone (GnRH) antagonist administration. A 36-year-old woman diagnosed with multiple uterine leiomyomas underwent transvaginal ultrasonography and pelvic magnetic resonance imaging (MRI), which revealed multiple uterine masses (up to 8 cm in diameter), a left ovarian cyst, and a pelvic mass (8 cm in diameter) above the uterus, with signal intensity resembling that of uterine leiomyoma. The right ovary appeared separate from the mass; therefore, the pelvic mass was diagnosed as a uterine leiomyoma. The uterine and pelvic mass reduced in size (to 6 cm in diameter) following 6-month GnRH therapy. Repeat pelvic MRI revealed that the pelvic mass was separate from the uterus; therefore, we corrected the diagnosed ovarian fibroma. The patient underwent fertility-preserving laparoscopic myomectomy and bilateral ovarian cystectomy. Intraoperatively, the pelvic mass was identified as a right ovarian tumor. Histopathological evaluation confirmed diagnosis of an ovarian leiomyoma. Ovarian leiomyoma should be considered in the differential diagnosis of an ovarian solid tumor and should be suspected in patients in whom GnRH antagonists administered for a uterine leiomyoma cause tumor shrinkage. [Adv Obstet Gynecol, 75(1) : 71-78, 2023 (R5.2)]

A 35-year-old, one gravidity and zero parity woman had labor induced at 36 weeks and three days of gestation due to a hypertensive disorder and emergency Caesarean section was performed at 36 weeks and five days due to labor arrest. On day five after surgery, wound dehiscence occurred, and blood examinations revealed an elevated inflammatory response. We suspected wound infection. However, the patient was refractory to treatment. On day seven after surgery, the induration had expanded, and nine days after surgery, ulcers were newly observed. We therefore suspected pyoderma gangrenosum and administered prednisolone 30 mg/day. The proliferation of granulation tissue was observed, and on day 150 after the operation, the wound had almost completely epithelialized, and steroid administration was discontinued. Pyoderma gangrenosum is a neutrophilic dermatosis characterized by painful, aseptic ulcers. It is often misdiagnosed as a wound infection when it occurs in a surgical wound and does not respond to antimicrobial therapy. Pyoderma gangrenosum is said to worsen when surgical treatments, such as debridement, are performed. This entity should be considered in the management of wound complications of patients who fail to respond to treatment of surgical site infection. [Adv Obstet Gynecol, 75(1) : 79-84, 2023 (R5.2)]

Hydronephrosis is a common gestational complication in pregnancy ; however, it is transient and generally improves by conservative treatment. Urinary drainage may be required during pregnancy by ureteral stents or renal fistulas in some patients, especially in cases of congenital renal urinary tract diseases including vesicoureteral reflux in childhood. We report a case of recurrent intractable severe hydronephrosis in pregnancy in a woman who underwent surgery for vesicoureteral reflux in childhood. The woman was diag-nosed with severe left hydronephrosis and hematoma in the renal pelvis at 26 weeks. She had been hospitalized continuously until delivery and received blood transfusions, antibiotics, a transurethral left ureteral stent placement, and a urethral catheter at this time. Her hydronephrosis improved rapidLy after her natural-term delivery. Four years later, she had her second pregnancy and received a transurethral left ureteral stent placement at 11 weeks for her left hydronephrosis. She continued to receive oral antibiotics while her pain and urinary tract infection were well controlled. She had a natural-term delivery, and her hydronephrosis disappeared at six months postpartum. Early initiation and continuation of urinary drainage and antibiotics are useful to prevent severe renal infections and protect the renal function. [Adv Obstet Gynecol, 75(1) : 85-92, 2023 (R5.2)]

The occurrence of acute leukemia during pregnancy is extremely rare. We report a case of pregnancy came to our hospital with a complaint of epistaxis and was diagnosed with B-cell acute leukemia, and was found to be 17 weeks pregnant at the same time. Since she was in a state of DIC (Disseminated Intravascular Coagulation) with markedly low platelet count and anemia, blood transfusion and chemotherapy were prioritized, and abortion was decided after waiting for improvement of blood data. However, hematopoietic deficiency did not improve, and intrauterine fetal death and rupture of membranes were confirmed at 18 weeks five days gestation, and the stillborn baby was delivered at 19 weeks zero days gestation while blood transfusion to the mother was continued. There was no increased bleeding or intrauterine infection, but her general condition did not improve, and she was pronounced dead on the 16th day after the delivery of the stillborn baby. Acute leukemia should be treated as soon as possible after diagnosis, but in early pregnancy, treatment often results in miscarriage and intrauterine fetal death, and there is often no choice but abortion. However, depending on the medical condition, abortion itself may be risky and may also affect the condition of the leukemia. In some cases, as in this case, treatment of the leukemia should be prioritized and the procedure performed during a lower-risk term. Appropriate decisions regarding the timing of treatment and obstetric procedures for leukemia-complicated pregnancies should be made in collaboration with hematology departments. [Adv Obstet Gynecol, 75(1) : 93-99, 2023 (R5.2)]