Shunsuke Tamaru

Maternal transfer generally refers to the emergency transportation of a pregnant woman to a medical facility with more advanced capabilities when her condition, or that of the fetus, deteriorates or is expected to deteriorate, thereby ensuring the safety of both mother and fetus. This procedure is frequently performed in Japan, where childbirth at primary obstetric facilities is common. However, no reports have described attempts to remotely monitor maternal and fetal vital signs inside an ambulance during transport and use these data to support clinical care at a remote location. The current study aimed to assess the feasibility of a system that enables real-time remote monitoring (RM) using a small mobile cardiotocograph (CTG) in an ambulance during maternal transport from primary obstetric facilities to a higher-level perinatal medical center. This study included women with singleton pregnancies beyond 22 weeks of gestation who were transferred from nine private clinics to a university hospital because of medical complications. Using a small mobile CTG device, the CTG data were transmitted during maternal transfer to a university hospital. The obstetrician of the university hospital checked the data in real-time using tablets to select the appropriate treatment. A questionnaire survey was conducted on the medical staff of the primary facilities who accompanied the patients during maternal transport. An online survey was also administered to paramedics only after the recruitment period. The study period was from August 2021 to August 2023. In total, 68 pregnant women were enrolled in this study and analyzed. The median time from getting into the ambulance to arrival at the university hospital was 34.5 (range: 15.0–67.0) min. No monitoring sessions were discontinued because of connectivity issues. All 68 fetal heart rate records were legible, and the median proportion of the total legible period in each recording was 91.1% (range: 53.9%–99.8%). Twenty-three (33.8%) women delivered by the next day after the transportation. The questionnaire survey revealed high levels of medical staff satisfaction and paramedical acceptance of real-time CTG RM during maternal transfer. Real-time CTG RM during emergency maternal transport is feasible and useful for making a medical decision more precisely in tertiary perinatal medical centers. Further, the use of the system in an ambulance is also acceptable for paramedics.

We report a case of intra-abdominal hemorrhage associated with vascular injury in the recto-vaginal space and peritoneal injury in the Douglas pouch following vacuum-assisted delivery with an unsuccessful Kristeller maneuver. The patient was 41 years old, gravida 2, para 1. At 40 weeks gestation, labor was induced by administering oxytocin. Due to prolonged second stage of labor in breech presentation, vacuum-assisted delivery with the Kristeller maneuver was attempted in vain, followed by forceps delivery, resulting in the delivery of a female infant weighing 3,178 g. However, at two hours postpartum, the patient went into a state of shock, with a blood pressure of 59/41 mmHg and pulse rate of 98 beats/minute, and was transferred to our tertiary care center. Exploratory laparotomy revealed bleeding from peritoneal injury in the Douglas pouch, serosal injury of the rectum, and also from the vaginal venous plexus at the site of connective tissue injury in the recto-vaginal space. There were no other sources of bleeding, including no uterine rupture in the birth canal. We hypothesized that a shearing effect around the recto-vaginal space and the Douglas pouch, possibly generated by the forces associated with instrumental delivery and the Kristeller maneuver, may have contributed to the connective tissue injury in the retroperitoneal space and peritoneal injury in the Douglas pouch. Although no direct evidence of uterine or vaginal injury was found, it is important to recognize the potential for injuries to the retroperitoneal space and abdominal cavity when performing instrumental delivery along with the Kristeller maneuver.

Background: Neonatal resuscitation is crucial for transitioning to extrauterine life. The Neonatal Cardiopulmonary Resuscitation (NCPR) guidelines in Japan were first developed based on the 2005 International Liaison Committee on Resuscitation (ILCOR) recommendations and have since been revised approximately every 5 years. However, the extent of their implementation in clinical practice remains unclear. This study aimed to assess the current status of neonatal resuscitation practices. Methods: We conducted a survey targeting 2297 delivery facilities in Japan. The questionnaire assessed equipment availability, provider training, and adoption of updated practices. Results: In total, 1553 facilities responded, of which 1505 were actively conducting deliveries. Therefore, the analysis was performed based on the responses from 1505 delivery‐performing facilities. Pulse oximeters were widely available, whereas electrocardiogram monitors and oxygen–air blenders were less common. T‐piece resuscitators were used in 32% of the facilities. Only 11% of the facilities had experience using supraglottic airway devices. Although 81% reported that all or almost all staff had completed NCPR training, 23 clinics lacked trained personnel. Regarding umbilical cord management in infants born before 28 weeks of gestation, cut cord milking was the most common method, followed by intact cord milking, early cord clamping, and delayed cord clamping. Conclusions: Neonatal resuscitation systems are generally established across delivery facilities in Japan. However, the implementation of revised guidelines varies based on facility type. These findings offer important insights for the upcoming 2025 NCPR guideline revision and emphasize the need for targeted training and equitable resource distribution to improve neonatal outcomes.

Decidualization denotes the morphological and biological differentiating process of human endometrial stromal cells (HESCs). Fatty acid pathways are critical for endometrial decidualization. However, the participation of fatty acids as an energy source and their role in endometrial decidualization have received little attention. To identify fatty acids and clarify their role in decidualization, we comprehensively evaluated free fatty acid profiles using liquid chromatography/Fourier transform mass spectrometry (LC/FT-MS). LC/FT-MS analysis detected 26 kinds of fatty acids in the culture medium of decidualized or un-decidualized HESCs. Only the production of octanoic acid, which is an essential energy source for embryonic development, was increased upon decidualization. The expressions of genes related to octanoic acid metabolism including ACADL, ACADM, and ACADS; genes encoding proteins catalyzing the first step of mitochondrial fatty acid beta-oxidation; and ACSL5 and ACSM5; genes encoding fatty acid synthesis proteins were significantly altered upon decidualization. These results suggest that decidualization promotes lipid metabolism, implying that decidualized HESCs require energy metabolism of the mitochondria in embryo implantation.

Aim: This study aimed to clarify the feasibility of a mobile cardiotocogram (CTG) device for self‐monitoring fetal heart rate (FHR) in low‐risk singleton pregnant women.Methods: This study was conducted at six university hospitals and seven maternity clinics in Japan. Using a mobile cardiotocogram device (iCTG, Melody International Ltd., Kagawa, Japan), participants of more than 34 gestational weeks measured the FHR by themselves at least once a week until hospitalization for delivery. We evaluated the acquisition rate of evaluable FHR recordings and the frequency of abnormal FHR patterns according to the CTG classification system of the Japan Society of Obstetrics and Gynecology (JSOG). The participants also underwent a questionnaire survey after delivery to evaluate their satisfaction level of self‐monitoring FHR using the mobile CTG device.Results: A total of 1278 FHR recordings from 101 women were analyzed. Among them, 1276 (99.8%) were readable for more than 10 min continuously, and the median percentage of the total readable period in each recording was 98.9% (range, 51.4–100). According to the JSOG classification system, 1245 (97.6%), 9 (0.7%), 18 (1.4%), and four (0.3%) FHR patterns were classified as levels 1, 2, 3, and 4, respectively. The questionnaire survey revealed high participant satisfaction with FHR self‐monitoring using the iCTG.Conclusion: The mobile CTG device is a feasible tool for self‐monitoring FHR, with a high participant satisfaction level.

Abdominal wall hypoplasia is a widely known clinical finding of genetic disorders such as the prune belly syndrome. On the other hand, there are few cases of abdominal wall muscle hypoplasia associated with fetal ascites due to fetal hydrops caused by fetal anemia have been reported. We report a case of fetal chylous ascites without anemia, resulting in abdominal wall muscle hypoplasia and flabby skin. At 17 weeks of gestation, fetal ascites was first detected and deteriorated without anemia. At 28, 33 and 36 weeks of gestation, paracentesis was performed three times because of cardiovascular impairment, confirming chylous ascites. After birth, the baby exhibited a flabby skin and lateral abdominal wall hypoplasia, resulting in difficulties in maintaining a sitting posture at 10 months of age. The genetic test using the TruSight One Sequencing Panels found no genetic variants. This case suggests that abdominal wall hypoplasia could be associated with fetal ascites without anemia.

Clinical trials have shown that administering heparin during the luteal phase has beneficial effects on implantation and live birth rates. Heparin exerts direct effects on decidual human endometrial stromal cells (HESCs), which are independent of its anticoagulant effect. However, the accurate effects of heparin on the decidualization process remain unidentified. Here, we demonstrate that HESCs become dramatically resistant to oxidative stress upon decidualization, and we hypothesize a possible direct action of heparin on the decidualization of HESCs, which would lead to improved implantation. To test this hypothesis, we established primary HESC cultures and propagated them, and then we decidualized confluent cultures with 8-bromo-cAMP, with medroxyprogesterone acetate, and with or without heparin. We treated the cells with hydrogen peroxide (H₂O₂) as a source of reactive oxygen species (ROS). Adding heparin to decidualized HESCs induced prolactin secretion. Decidualized HESCs treated with heparin were prevented from undergoing apoptosis induced by oxidative stress. Heparin induced nuclear accumulation of the forkhead transcription factor FOXO1 and expression of its downstream target, the ROS scavenger superoxide dismutase 2. These results demonstrate that heparin-treated decidualized HESCs acquired further resistance to oxidative stress, suggesting that heparin may improve the implantation environment.