Frequency of cesarean section is 3.7% in 1961, 6.2% in 1962 and 12% in 1963. C. P. D. was increased in 1963.
In anesthesia, subarachnoid anesthesia was unfaborable and epidural anesthesia was the best.

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The present report deals with the condition of following labor who had previous Cesarean section in past 7 years and 8 months.
The total labors were 4, 249 cases, in which 93 cases (47.2%) had repeated Cesarean section and 104 cases (52.8%) had trans-vaginal labor.
Our indication of repeated Cesarean section is as follows: aged primigravida, contracted pelvis, cephalopelvic dysproportion. All of the aged primigravida had complications.
The results were summarized as follows:
1) Rupture of uterus was three cases (1.5%). Two cases (utero-cervical transverse incision had been proceeded) were found at the time of operation. The other one was a complete rupture (who had taken vertical incision of corpus) and the womb was died already, the emergency operation was done only to save the mother.
2) Adhesion was seen in 38 cases (40, 8%) of 93 cases and for the most part adhesions were found between uterus and great omentum or parietal peritoneum.
3) The average interval of repeated section was three years and one month. Most cases were above the age of 30 years old.
4) The death of womb were observed in one case of repeated section and one case of transvaginaI labor, but no death of mother.
5) In trans-vaginal labor 84 cases (80.8%) were normal labor and 20 cases (19.2%) were instrumental labor.

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症例1：29歳，女性．分娩1年後より手術瘢痕部に皮下結節が出現．下腹部正中の手術瘢痕上端に45×35 mmの淡紅褐色の硬い腫瘤あり．全身麻酔下に腹直筋鞘前葉を含めて摘出した．症例2：31歳，女性，分娩7年後に左下腹部の皮下腫瘤に気づいた．下腹部横切開による手術瘢痕の左側やや頭側に径50 mmの皮下腫瘤あり．生検で確定診断した．最近26年間の本邦報告58例を集計すると，手術内容の記載がある30例中, 癒着や浸潤のため腹直筋鞘を中心とする筋膜を含めて摘出した例が11例，さらに筋肉，腹膜を含めて摘出した例も5例ずつみられた．正中付近に生じた腹壁腫瘍では術前に十分な検討が必要である．

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2001年，岩手医科大学附属病院は， 24時間体制でハイリスク妊娠に対応できる総合周産期母子医療センターを設置した．その役割に産科危機的状況を回避すべく超緊急‹通称；Grade A›がある．このGrade A構築に至った要因と過程を報告する．始めに，院内外で発生しGrade A 構築の要因となった症例を分析し，次に，フローチャート作成と多職種間でのシミュレーションについて検討．要因となった症例は23例‹1.27%›であり，その児の転帰は，子宮内胎児死亡が1例，脳性麻痺合併が2例であった．フローチャートは，主に母子集中治療室担当医師が，多施設の資料，医療安全対策推進室からのアドバイス，麻酔科・新生児集中治療室・手術室・看護部・輸血検査部・医療事務などから意見を集約し作成した．シミュレーションを3回施行した結果，到着から児娩出までの時間は6から19分間とばらつきがあった．今後，安定したGrade Aを運用することで，妊産婦死亡・脳性麻痺児ゼロを目指す．

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兵庫県下の帝切の現状を知る目的で,年間分娩数が250例以上あると推定される98産婦人科施設に1997年の1年間における分娩および帝切に関するアンケート調査を行った・回答数は72で,回収率は73.5%であった.アンケート参加施設におけるこの間の総分娩数は34152例でそのうち4652例に帝切が行われ,帝切率は13.6%であった.また施設別の平均帝切率は14.0%であった・帝切率は常勤医師数の多い施設,NICUをもつ施設で高い傾向にあった.帝切の適応としてもっとも多いのは前回帝切であり,これに骨盤位,CPD,胎児仮死がつづいた.また,前回帝切,骨盤位,多胎の施設別平均帝切率はそれぞれ845%,7&1%,55.9%であり,症例別帝切率もほぼ同様であった.なお,前回帝切,骨盤位の帝切適応については,帝切への傾向が強いものの施設問で方針に大きな差がみられた.〔産婦の進歩51(6);568～572,1999(平成11年11月)〕

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Objective: To present a case of cesarean scar pregnancy（CSP）undergoing a hysteroscopic resection of the villi following temporal laparoscopic uterine artery ligation
Case: A 31-year-old woman, with a past history of two cesarean sections, presented a chief complaint of irregular vaginal bleeding. The diagnosis of CSP was made by ultrasonography when a gestational sac was detected in the area of the cesarean scar. In addition, an examination of contrasted computed tomography showed that the gestational sac was depicted in the same area. The level of serum hCG was 2694mIU/ml. We laparoscopically ligated uterine arteries on both sides with vessel tapes. The villi were confirmed to be located in the cesarean section scar portion. We completely resected the villi through a hysteroscope. No bleeding from the scar section appeared after the ligations of the uterine arteries were released. The serum hCG level rapidly decreased in the postoperative period. It was demonstrated that the procedures shown here could be safely performed as a treatment for CSP.

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瘢痕部妊娠(cesarean scar pregnancy: CSP) は，既往瘢痕部に着床する異所性妊娠である．妊娠が継続し胎嚢(gestational sac: GS) が成長するとともに，卵膜を覆う筋層が菲薄化していると着床部位が破裂し，大量出血を合併するため母体の慎重な管理が必要である．今回我々は，瘢痕部妊娠流産の症例を経験したため報告する．

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  A cesarean scar pregnancy (CSP) is one of the most dangerous forms of ectopic pregnancy. We report a case of a 33-year-old gravida 5 para 3 who was referred to our hospital at 6 weeks, 2 days of gestation from another facility with a diagnosis of CSP. A sagittal view of a transvaginal ultrasonogram imaged a gestational sac 32 mm in diameter in the anterior wall of the uterine isthmus, a fetus with a fetal heart beat, and abundant vascular flow around the gestational sac. The serum hCG level was 64,999 IU/l. It increased for a short interval to 125,512 IU/l after the systemic administration of methotrexate (MTX). We performed uterine artery embolization (UAE). Subsequently, the serum hCG level gradually declined, and we identified the disappearance of the fetal heart beat and vascular flow around the gestational sac. After another UAE, we performed a hysteroscopic resection when the serum hCG level declined to < 10,000 IU/l. The serum hCG level showed a negative conversion 60 days after the first MTX administration. During the follow-up period the thickness of the muscular layer of the uterine isthmus became remarkably thin; therefore, we performed a laparoscopic repair of the uterine scar. The patient subsequently achieved a normal pregnant and delivered a live infant at 30 weeks, 0 days of gestation by cesarean section. We stress that it is extremely important to avoid situations such as hemorrhage or rupture during treatment of a CSP. Therefore, we must carefully employ a combination of MTX administration, UAE, and hysteroscopic resection. This case suggests that laparoscopic repair of a uterine scar is a useful procedure, which leads to a better prognosis for future pregnancy, particularly in cases in which the muscular layer is extremely thin. Further study of CSPs is needed.

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子宮腺筋症の核出は筋層の欠損を招く恐れがあるため，術後の妊娠は子宮破裂をきたすリスクがある．症例は40 歳女性，未経産，2 年前に子宮腺筋症核出の既往あり．不妊クリニックにて，体外受精にて妊娠成立．妊娠7 週時の診察にて胎嚢周囲の子宮筋層が高度に菲薄化しており当科を紹介受診．経腟超音波検査にて胎嚢の前壁筋層内への埋没，週数相当の胎児とその心拍が確認された．胎嚢外側の子宮筋層は2.4 mm と薄く，絨毛の位置から瘢痕部への着床が疑われ，周囲は血管が顕著に発達していた．瘢痕部妊娠のため妊娠継続は危険と判断し，十分なインフォームドコンセントのもと保存的加療の方針となり，メトトレキサートを第1 回目は胎嚢内に，以後は全身投与した．しかし，肝機能異常と血清hCG 値の再上昇が認められたため，妊娠組織の手術摘出を行う方針とした．レゼクトスコープ下では妊娠組織の切除が困難であったので，当科で考案した経頸管トロッカー法を用いた．まず子宮頸管拡張を追加して腹腔鏡手術用12 mm カメラトロッカーを挿入し，そこから5 mm 硬性鏡，腹腔鏡手術用の把持鉗子と吸引送水管を同時に操作して，筋層内の妊娠組織を直接的に把持，摘出することができ，結果的に子宮の温存が可能であった．本手法では，子宮鏡下で不可能な筋層に対する操作が，同時に使用する複数の鉗子操作によって実施可能であった．

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Endometriosis is a benign disease in which endometrial tissue exists outside the endometrium and the myometrium, and it occurs in all parts. We report two cases of abdominal wall endometriosis. Case 1 : A 37-year-old woman complained of a subcutaneous mass with pain associated with her menstrual cycle. She had a solid mass on the right side of the scar 8 years after undergoing a cesarean section. The biopsy from the mass indicated a diagnosis of endometriosis, and she underwent a complete resection of the tumor. Case 2 : A 42-year-old woman presented with persistent lower abdominal pain. She had had a cesarean section 12 years earlier. Computed tomography showed a 12mm mass in the context of the scar associated with tenderness. Wide surgical excision was performed and the pathological diagnosis was endometriosis.
Although endometriosis is a common disease in reproductive women, some reports about abdominal wall endometriosis have been published. Most abdominal wall endometriosis is associated with obstetrics and gynecological surgeries, especially a cesarean section. Many patients complain of a painful subcutaneous mass at the surgical scar. We should consider endometriosis for the differential diagnosis of an abdominal wall mass on a surgical scar and resect totally without residual tumor.

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　A 40-year-old G0P0 presented with uterine leiomyomas and underwent total laparoscopic hysterectomy and bilateral salpingectomy for management of worsening hypermenorrhea. Intraperitoneal findings included an endometriotic lesion (approximately 1 cm) in the peritoneum of the Douglas pouch and partial adhesion. The vaginal canal was incised, and the uterus was transected and removed after transvaginal morcellation. Histopathological examination of the resected specimen revealed uterine leiomyoma without salpingeal abnormalities or endometriotic lesions. The patient observed monthly genital bleeding, 2 and 5 months postoperatively; however, no apparent clinical abnormalities were detected. She experienced similar genital bleeding accompanied by periumbilical pain, 9 months postoperatively. Colposcopy revealed several red endometriosis-like lesions involving the vaginal stump, and the patient was diagnosed with vaginal stump endometriosis. Oral dienogest administration initiated at 11 months postoperatively was continued as maintenance therapy, and the patient's symptoms nearly resolved 5 months later.

　Preoperative diagnosis of small lesions in the Douglas pouch is challenging in patients in whom imaging does not reveal endometriosis in any other region. Endometriotic lesions may remain in the vaginal stump, even in the absence of uterine or adnexal endometriosis, and such lesions may occur even in patients with mild pelvic endometriosis. Vaginal stump endometriosis should be considered in the differential diagnosis in women with periodic genital bleeding or abdominal pain after total laparoscopic hysterectomy. Detailed patient interviews and physical evaluation within a wide area are necessary. Vaginal stump endometriosis can be histopathologically diagnosed based on biopsy specimen evaluation, and dienogest therapy is useful for symptom relief.

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