Maki Tamura

AIM: We evaluated the efficacy of antepartum screening for cord presentation by trans-vaginal ultrasonography (TVS) on predicting and preventing umbilical cord prolapse (UCP) in term breech delivery. METHODS: We investigated every woman with a breech-presenting fetus for cord presentation by weekly TVS after 36 weeks of gestation since 1995. If the cord was found in advance of fetal presenting parts, we recommended her to undergo elective cesarean section to avoid UCP. We studied the incidence of cord presentation by TVS and the clinical courses of the cases with it for 198 women who delivered breech after 36 weeks from 1995 to 2005 (group A). Further, the incidence of UCP was compared between group A and another 230 women who delivered breech at term from 1983 to 1994 (group B). RESULTS: Cord presentation was detected by TVS at least once in eight (4%) group A patients. Seven of them underwent elective cesarean section and, in six of these (86%), cord presentation was still found at the time of operation. The eighth patient became free of cord presentation at the later examinations and delivered vaginally without UCP. A hundred and twenty-one (61%) women in group A and 159 (69%) women in group B delivered vaginally. No UCP occurred in group A, while it occurred in 10 (4%) cases of group B (P < 0.01), and one baby died of it. CONCLUSIONS: Detection of cord presentation by TVS has a potential to predict and reduce UCP in breech delivery at term.

AIM: To evaluate the safety, effect on breastfeeding and efficacy of a combination of pethidine and levallorphan (Pethilorfan) for pain relief during labor. METHODS: We compared maternal or neonatal morbidities, suckling difficulties in newborns and breastfeeding rates between 177 women who received 50-200 mg (as pethidine) of Pethilorfan during labor (Pethilorfan group) and 354 women who delivered their infants without analgesic drugs immediately before or after each woman in the Pethilorfan group (control group) from January 1, 2005 to December 31, 2016. We performed univariate and multivariate analyses for comparison between the two groups. We also evaluated the efficacy of Pethilorfan retrospectively. RESULTS: The Pethilorfan group included more women with prolonged and/or operative deliveries than the control group. Nevertheless, no significant differences were seen between the two groups in the rates of Apgar scores less than 7 at 1 or 5 min, composite neonatal morbidities, hyperbilirubinemia or respiratory disturbances. The incidence of suckling difficulties lasting over 24 h and the breastfeeding rates at discharge or after 1 month were also similar. Maternal adverse effects of Pethilorfan were generally mild and transient. The efficacy ratio of Pethilorfan was 83.6%, although its analgesic effect was usually incomplete. CONCLUSION: Pethilorfan can be used safely for labor pain relief without increasing maternal or neonatal morbidities, or impeding breastfeeding, if it is administered at a prudent dosage. Parenteral opioids including Pethilorfan should remain as an option for treating women in labor pain, particularly when epidural analgesia is not readily available or contraindicated.

Diagnostic uterine curettage and pathological examination of the specimen can be used when a pregnancy's location is unknown. However, it may take a few days to confirm the histopathological diagnosis, and frozen section examination sometimes leads to false-negative results due to a limited specimen [1]. The aim of the present study was to evaluate the utility of cytodiagnosis of uterine specimens to differentiate between ectopic pregnancy and spontaneous abortion. Between January 1, 2000, and April 30, 2011, 22 women who had been diagnosed with a pregnancy of unknown location and were of stable physical status were examined. Normal gestation had been excluded, but a definitive diagnosis could not be made by ultrasound or quantitative human chorionic gonadotropin (hCG) test. The patients provided informed consent and the study received approval from the hospital's ethical review board. Uterine specimens were prepared by direct imprinting of suctioned or curetted uterine contents onto glass slides in 18 patients, while in 4 patients the samples were collected from the endometrium using cell samplers. All samples were stained with Papanicolaou stain and the cytological findings were confirmed within 1–2 hours on the same day they had been collected. The specimens were judged positive, suggestive of spontaneous abortion, if 1 or more syncytiotrophoblasts were detected (Fig. 1). The uterine specimens were also sent for histologic examination for confirmation of the diagnosis. Syncytiotrophoblasts (STs) in the specimens of suctioned uterine contents: (a) STs with a large cell cluster. Tadpole-like multinucleated large cells are characteristic of STs; (b,c) Scattered small STs (Papanicolaou stain × 200). Seven specimens were judged to be positive cytologically and in all cases the final diagnosis was spontaneous abortion. In 5 cases the histological diagnosis confirmed spontaneous abortion, while in 2 cases no chorionic villi were found histologically despite positive cytology; however, spontaneous abortion was confirmed by a promptly declining hCG value after curettage. Fifteen specimens were judged to be negative for chorionic villi both cytologically and histologically. Of these, 3 were diagnosed as complete spontaneous abortion, while 12 were finally diagnosed as ectopic pregnancy. Seven of these 12 patients had elective surgery and 5 were treated successfully with methotrexate (MTX). None of the patients had complications of significant intraperitoneal bleeding from a ruptured ectopic pregnancy. Previous reports on the use of cytodiagnosis in cases of pregnancy of unknown location concluded that the diagnostic procedure was helpful in differentiating between ectopic pregnancy and spontaneous abortion [2,3]. Although false-positives cannot be excluded because trophoblasts may migrate from ectopic implantation sites into the uterine cavity, such cases are considered uncommon. Early differentiation of pregnancy of unknown location has become more important because it facilitates successful MTX therapy for ectopic pregnancy and reduces unnecessary MTX therapy for spontaneous abortion. Cytological detection of trophoblasts is a rapid, low-cost, and reliable diagnostic tool to evaluate patients in whom the location of pregnancy is unknown. The authors have no conflicts of interest to declare.