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The effect of estrogen-progestin therapy for persistent bleeding women with retained products of conception
Abstracts / Placenta 46 (2016) 102e121
Genome Research Center, Tohoku University Graduate School of Medicine, Japan Trophoblast cells in the human placenta are classified into three main types: cytotrophoblast cells (CTs), syncytiotrophoblast cells (STs) and extravillous cytotrophoblast cells (EVTs). CTs are stem/progenitor cells of STs and EVTs. STs play roles in hormone production and the exchange of nutrients and gases and EVTs invade the maternal decidua and remodel uterine spiral arteries to ensure sufficient blood supply to the fetus. It is not fully understood how the proliferation and differentiation of trophoblast cells are regulated in vivo. In this study, we performed transcriptome profiling of uncultured CTs, STs and EVTs, using RNA- sequencing technology. We found that expression levels of more than 1000 genes dramatically changed (> 10-fold increase or decrease) during differentiation of CTs to EVTs or STs. In STs, genes encoding hormones and other pregnancy- specific secretory proteins were strongly induced and genes regulating the cell cycle were downregulated, suggesting that STs are highly specialized cells for the production of secretory proteins. In EVTs, immune-related genes such as chemokines and the human leukocyte antigens were significantly induced, which might be important for the migration of EVTs and their interaction with the maternal immune system. We also identified 100 genes specifically expressed in CTs, some of which are known to be essential for the maintenance of mouse trophoblast stem cells or labyrinth trophoblast progenitor cells. Furthermore, we found hundreds of exon-skipping events differentially regulated among trophoblast cells. These data will increase our understanding of normal placental development and t he pathogenesis of pregnancy complications.
VASA PREVIA PRENATALLY DIAGNOSED BY ULTRASOUND SCANNING AND MAGNETIC RESONANCE IMAGING; REPORT OF 3 CASES Erika Tanaka 1, Mayumi Morizane 1, Mihoko Uchiyama 1, Masashi Deguchi 1, Utaru Tanaka 2, Tetsuo Maeda 2, Hideto Yamada 1. 1 Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, Japan; 2 Department of Radiology, Kobe University Graduate School of Medicine, Japan Vasa previa is a rare complication which occurs when fetal blood vessels unsupported by Wharton’s jelly within the umbilical cord run over the internal cervical os. Vasa previa is associated with a high fetal mortality rate caused by the rupture of fetal blood vessels at the time of membrane rupture or labor if it is not diagnosed prenatally. We report 3 cases diagnosed with vasa previa prenatally. Case 1: A 34-year-old multiparous woman was hospitalized for the management of vasa previa with preterm contraction from 30 gestational weeks (GW). Magnetic resonance imaging (MRI) at 30 GW showed the fetal blood vessel in close proximity to the internal os, and another vessel running longitudinally along anterior lower uterine segment from the caudal side of placenta. Emergency cesarean section was performed when labor started at 36 GW. Case 2: A 36-year-old primiparous woman conceived by in vitro fertilization. She was diagnosed with vasa previa by transvaginal ultrasonography. MRI at 35 GW also showed that the vessels in the amniotic membrane extended over the fetal head. Planned cesarean section was performed at 36 GW. Case 3: A 34-year-old 1-parous woman conceived by in vitro fertilization. She was diagnosed with low-lying placenta at 30 GW. Velamentous cord insertion and fetal vessels running from the edge of the placenta to the internal os along with the posterior wall of the uterus were observed by ultrasonography and MRI. She was hospitalized for prophylactic management from 31 GW. Emergency cesarean section was performed when labor started at 35 GW. In all cases, macroscopic finding of vascular distribution was consistent with the finding of ultrasonography and MRI. In addition to ultrasonography, MRI is useful for the cases that require precise evaluation of vascular distribution to improve perinatal outcome of vasa previa.
109
THE EFFECT OF ESTROGEN-PROGESTIN THERAPY FOR PERSISTENT BLEEDING WOMEN WITH RETAINED PRODUCTS OF CONCEPTION Munekage Yamaguchi, Tomoko Honda, Yoshinori Okamura, Ritsuo Honda, Takashi Ohba, Hidetaka Katabuchi. Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Japan Introduction: Retained products of conception (RPC) is one of the causes of persistent vaginal bleeding after abortion. Blood transfusion may be needed if the bleeding is beyond control; however, there is still no consensus on the appropriate treatment for RPC. The aim of the present study is to investigate the efficacy of estrogen-progestin therapy (EPT) for persistent bleeding women with RPC following abortion. Methods: We retrospectively reviewed 12 patients diagnosed with RPC following abortion initially treated with EPT at Kumamoto University Hospital between July 2013 and June 2016. Women with positive serum hCG levels who complained of persistent genital bleeding after abortion were diagnosed as RPC when ultrasound examinations showed space occupying lesion with color flow by a Doppler imaging in the uterine cavity. Results: The median age of the patients was 30 years old (20-43 years old). The median gestational age at abortion was 10w2d (6w0d-19w3d), and the median duration from the abortion to the initial visit was 55.5 days (21-80 days). The median serum hCG level at the initial visit was 10.4 mIU/ml (0.6183.4 mIU/ml). Genital bleeding disappeared after withdrawal bleeding induced by the first EPT in all 12 patients. Space occupying lesion and blood flow in the uterine cavity resolved in 10 patients after the first EPT, in 1 patient after the second EPT, and in 1 patient whose serum hCG level was maximum after the third EPT. The hCG concentration fell below the normal limit 17.5 days (9-84 days) after the initial EPT. No additional treatments were necessary in all 12 patients. Conclusion: Vaginal bleeding disappeared and retained products in the uterus were conservatively evacuated without the need for additional treatments in all patients treated with EPT, suggesting that EPT is effective for persistent bleeding women with RPC following abortion.
ATHEROSIS OF THE SPIRAL ARTERIES IN ACUTE FATTY LIVER OF PREGNANCY: A CASE REPORT Rika Zen 1, Shunichiro Tsuji 1, Suzuko Moritani 2, Kazutaka Yamada 1, Kaori Hayashi 1, Daisuke Katsura 1, Tetsuo Ono 1, Akiko Ishiko 1, Kentaro Takahashi 3, Takashi Murakami 1. 1 Department of Obstetrics and Gynecology, Shiga University of Medical Science, Japan; 2 Division of Diagnostic Pathology, Shiga University of Medical Science, Japan; 3 Perinatal Center, Shiga University of Medical Science, Japan Introduction: Acute fatty liver of pregnancy (AFLP) has an incidence of 1 in 13,000 deliveries and comprises clinical findings such as preeclampsia and HELLP syndrome. Occasionally in AFLP, the prognosis is poor for the mother and fetus. The pathophysiology of AFLP is not completely understood; however, in the last decade, some reports have suggested that mitochondrial dysfunction related to the beta- oxidation of fatty acids may cause AFLP. We report a case of clinical AFLP with histopathological findings of acute atherosis in the decidua of the placenta. Case: A 28-year-old primipara woman with natural pregnancy was diagnosed with monochorionic diamniotic twin at a nearby private clinic. She was referred to our hospital for the perinatal management of monochorionic diamniotic twin and was admitted at 24 weeks for threatened premature delivery. The laboratory examinations at 34 weeks revealed a platelet count of 189103/mm3, serum AST of 383 U/l, serum ALT of 402 U/ l, and antithrombin-Ⅲ 28%. Subsequently, an emergency cesarean section was performed following the diagnosis of AFLP. However, the patient’s blood pressure was within normal range throughout the perinatal period. Histopathological examinations revealed acute atherosis of the uterine spinal arteries with fibrinoid necrosis in the decidua of the placenta.
Genome Research Center, Tohoku University Graduate School of Medicine, Japan Trophoblast cells in the human placenta are classified into three main types: cytotrophoblast cells (CTs), syncytiotrophoblast cells (STs) and extravillous cytotrophoblast cells (EVTs). CTs are stem/progenitor cells of STs and EVTs. STs play roles in hormone production and the exchange of nutrients and gases and EVTs invade the maternal decidua and remodel uterine spiral arteries to ensure sufficient blood supply to the fetus. It is not fully understood how the proliferation and differentiation of trophoblast cells are regulated in vivo. In this study, we performed transcriptome profiling of uncultured CTs, STs and EVTs, using RNA- sequencing technology. We found that expression levels of more than 1000 genes dramatically changed (> 10-fold increase or decrease) during differentiation of CTs to EVTs or STs. In STs, genes encoding hormones and other pregnancy- specific secretory proteins were strongly induced and genes regulating the cell cycle were downregulated, suggesting that STs are highly specialized cells for the production of secretory proteins. In EVTs, immune-related genes such as chemokines and the human leukocyte antigens were significantly induced, which might be important for the migration of EVTs and their interaction with the maternal immune system. We also identified 100 genes specifically expressed in CTs, some of which are known to be essential for the maintenance of mouse trophoblast stem cells or labyrinth trophoblast progenitor cells. Furthermore, we found hundreds of exon-skipping events differentially regulated among trophoblast cells. These data will increase our understanding of normal placental development and t he pathogenesis of pregnancy complications.
VASA PREVIA PRENATALLY DIAGNOSED BY ULTRASOUND SCANNING AND MAGNETIC RESONANCE IMAGING; REPORT OF 3 CASES Erika Tanaka 1, Mayumi Morizane 1, Mihoko Uchiyama 1, Masashi Deguchi 1, Utaru Tanaka 2, Tetsuo Maeda 2, Hideto Yamada 1. 1 Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, Japan; 2 Department of Radiology, Kobe University Graduate School of Medicine, Japan Vasa previa is a rare complication which occurs when fetal blood vessels unsupported by Wharton’s jelly within the umbilical cord run over the internal cervical os. Vasa previa is associated with a high fetal mortality rate caused by the rupture of fetal blood vessels at the time of membrane rupture or labor if it is not diagnosed prenatally. We report 3 cases diagnosed with vasa previa prenatally. Case 1: A 34-year-old multiparous woman was hospitalized for the management of vasa previa with preterm contraction from 30 gestational weeks (GW). Magnetic resonance imaging (MRI) at 30 GW showed the fetal blood vessel in close proximity to the internal os, and another vessel running longitudinally along anterior lower uterine segment from the caudal side of placenta. Emergency cesarean section was performed when labor started at 36 GW. Case 2: A 36-year-old primiparous woman conceived by in vitro fertilization. She was diagnosed with vasa previa by transvaginal ultrasonography. MRI at 35 GW also showed that the vessels in the amniotic membrane extended over the fetal head. Planned cesarean section was performed at 36 GW. Case 3: A 34-year-old 1-parous woman conceived by in vitro fertilization. She was diagnosed with low-lying placenta at 30 GW. Velamentous cord insertion and fetal vessels running from the edge of the placenta to the internal os along with the posterior wall of the uterus were observed by ultrasonography and MRI. She was hospitalized for prophylactic management from 31 GW. Emergency cesarean section was performed when labor started at 35 GW. In all cases, macroscopic finding of vascular distribution was consistent with the finding of ultrasonography and MRI. In addition to ultrasonography, MRI is useful for the cases that require precise evaluation of vascular distribution to improve perinatal outcome of vasa previa.
109
THE EFFECT OF ESTROGEN-PROGESTIN THERAPY FOR PERSISTENT BLEEDING WOMEN WITH RETAINED PRODUCTS OF CONCEPTION Munekage Yamaguchi, Tomoko Honda, Yoshinori Okamura, Ritsuo Honda, Takashi Ohba, Hidetaka Katabuchi. Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Japan Introduction: Retained products of conception (RPC) is one of the causes of persistent vaginal bleeding after abortion. Blood transfusion may be needed if the bleeding is beyond control; however, there is still no consensus on the appropriate treatment for RPC. The aim of the present study is to investigate the efficacy of estrogen-progestin therapy (EPT) for persistent bleeding women with RPC following abortion. Methods: We retrospectively reviewed 12 patients diagnosed with RPC following abortion initially treated with EPT at Kumamoto University Hospital between July 2013 and June 2016. Women with positive serum hCG levels who complained of persistent genital bleeding after abortion were diagnosed as RPC when ultrasound examinations showed space occupying lesion with color flow by a Doppler imaging in the uterine cavity. Results: The median age of the patients was 30 years old (20-43 years old). The median gestational age at abortion was 10w2d (6w0d-19w3d), and the median duration from the abortion to the initial visit was 55.5 days (21-80 days). The median serum hCG level at the initial visit was 10.4 mIU/ml (0.6183.4 mIU/ml). Genital bleeding disappeared after withdrawal bleeding induced by the first EPT in all 12 patients. Space occupying lesion and blood flow in the uterine cavity resolved in 10 patients after the first EPT, in 1 patient after the second EPT, and in 1 patient whose serum hCG level was maximum after the third EPT. The hCG concentration fell below the normal limit 17.5 days (9-84 days) after the initial EPT. No additional treatments were necessary in all 12 patients. Conclusion: Vaginal bleeding disappeared and retained products in the uterus were conservatively evacuated without the need for additional treatments in all patients treated with EPT, suggesting that EPT is effective for persistent bleeding women with RPC following abortion.
ATHEROSIS OF THE SPIRAL ARTERIES IN ACUTE FATTY LIVER OF PREGNANCY: A CASE REPORT Rika Zen 1, Shunichiro Tsuji 1, Suzuko Moritani 2, Kazutaka Yamada 1, Kaori Hayashi 1, Daisuke Katsura 1, Tetsuo Ono 1, Akiko Ishiko 1, Kentaro Takahashi 3, Takashi Murakami 1. 1 Department of Obstetrics and Gynecology, Shiga University of Medical Science, Japan; 2 Division of Diagnostic Pathology, Shiga University of Medical Science, Japan; 3 Perinatal Center, Shiga University of Medical Science, Japan Introduction: Acute fatty liver of pregnancy (AFLP) has an incidence of 1 in 13,000 deliveries and comprises clinical findings such as preeclampsia and HELLP syndrome. Occasionally in AFLP, the prognosis is poor for the mother and fetus. The pathophysiology of AFLP is not completely understood; however, in the last decade, some reports have suggested that mitochondrial dysfunction related to the beta- oxidation of fatty acids may cause AFLP. We report a case of clinical AFLP with histopathological findings of acute atherosis in the decidua of the placenta. Case: A 28-year-old primipara woman with natural pregnancy was diagnosed with monochorionic diamniotic twin at a nearby private clinic. She was referred to our hospital for the perinatal management of monochorionic diamniotic twin and was admitted at 24 weeks for threatened premature delivery. The laboratory examinations at 34 weeks revealed a platelet count of 189103/mm3, serum AST of 383 U/l, serum ALT of 402 U/ l, and antithrombin-Ⅲ 28%. Subsequently, an emergency cesarean section was performed following the diagnosis of AFLP. However, the patient’s blood pressure was within normal range throughout the perinatal period. Histopathological examinations revealed acute atherosis of the uterine spinal arteries with fibrinoid necrosis in the decidua of the placenta.