Twin pregnancy is increasing as infertility treatment is widely given nowadays using assisted reproductive technologies. Twin pregnancy is a risk factor for some complicated pregnancies and it may also cause a hard labor. Although cesarean delivery is frequently indicated in many hospitals in Japan for twin pregnancy in view of the risk of vaginal delivery of the second baby, we have tried vaginal delivery of twin pregnancy in a certain situation. We studied the methods of twin delivery, its outcomes and the early neonatal condition.
  We found 251 twin deliveries (4.6%) in a total of 5,464 deliveries after 22 weeks of pregnancy from January 2005 to December 2009 in the delivery record. Forty-six percent of women pregnant with twins delivered their babies after 33-36 weeks of pregnancy and 41% after 37 weeks of pregnancy. Sixty-five percent delivered by Cesarean section, 33% by vaginal delivery, and 2% vaginally for the first baby and by Cesarean section for the second baby. Fifty percent of the Cesarean deliveries were performed as patients so desired. Ninety women pregnant with twins chose vaginal delivery in which 92% (64/69) of vertex/vertex presentation and 86% (18/21) of vertex/ breech presentation succeeded in vaginal delivery. Neonatal outcome was assessed in 90 vaginally deliveried babies by use of the Apgar scoring system. One-minute Apgar scores of 0-3 (severe asphyxia) were given to 4.5% (8/180) of babies and scores of 4-6 (moderate asphyxia) to 3.3% (6/180) of babies. The incidence meant that a mother had 8.9% and 6.7% of high risk of severe and moderate asphyxia of her babies. But severe asphyxia decreased to 1.7% (3/180), moderate asphyxia to 1.1% (2/180) of babies on the assessment of 5-minute Apgar scores that reflected long-term neonatal outcome. Eleven cases were second babies of all 14 cases of asphyxia on the assessment of 1-minute Apgar scores. In the vaginal delivery group, 5 cases of umbilical cord prolapsed and 3 cases of placental abruption occurred in second babies. In conclusion, twin delivery should be attempted at the birth center where neonatologists and anesthesiologists are available 24 hours as extra-emergency Cesarean delivery can be performed because of the high incidence of emergency Cesarean delivery of second baby (5.6%) and asphyxia of neonates delivered vaginally.

  A 41-year-old woman, gravid 3, para 3, was admitted to the Department of Obstetrics and Gynecology at Tsuchiura Kyodo General Hospital, complaining of a tender, gradually enlarging mass in the right inguinal region during menses. Examination found the mass was about 2 cm in diameter, which protruded slightly (on lying position?). During menstrual periods, the mass enlarged and the pain intensified, but between menses, the mass decreased in size and the pain subsided. The case was diagnosed as inguinal endometriosis and then a preoperative GnRH analog therapy was given for six weeks to make a good operative local condition. Surgery was performed under general anesthesia and a mass about 4.0×3.0 cm in diameter near inguinal ligament was removed. The cut surface revealed small hemorrhagic areas or spaces. Microscopic examination of the dissected mass confirmed the diagnosis of inguinal endometriosis. It was found that the patient had a moderate inguinal swelling on the first visit to the hospital as an outpatient 7 days after operation, but the swelling disappeared shortly afterword. She has been receiving a post-operative GnRH analog therapy for 3 months to maintain a good local condition. The authors concluded thatthe appearance of a lump in the inguinal region and objective changes of the lesion in relation to the menstrual cycle should be considered as the symptoms of endometriosis.

  We report a case of new-onset depressive disorder in a patient with a history of rectal endometriosis treated with GnRH analog and no previous psychiatric history. This medical history allowed us to suspect the possibility of a link between GnRH analog and depression. It also highlighted the need to screen patients treated with GnRH analog for depression.
  The patient was 41-year-old woman who had been diagnosed with rectal endometriosis. She was referred to the Gynecology Department of Tsuchiura Kyodo General Hospital. The subjective symptoms included cyclic abdominal pains and rectal bleedings. The patient had undergone total abdominal hysterectomy and left salpingo-oophorectomy for endometriosis two years before. She was started by her first gynecologist on GnRH agonist (nafarelin acetate) and the symptoms disappeared soon. But several weeks after the initiation of the GnRH agonist treatment, she began to feel depressed and hopeless. She visited a psychiatric hospital and diagnosed as having depression. She was given anti-depressive drugs and inpatient treatment at the psychiatric hospital. Her clinical course was reviewed by her second gynecologist, and she was suspected to have developed depressive disorder by GnRH analog treatment. She stopped taking GnRH analog medication and started progestin (Dinagest) therapy. She became soon free of depressive disorder and then anti-depressive drugs with rectal endometriosis well controlled. This case also suggested Dinagest is a recommended drug for rectal endometriosis.

　　Placental abruption occurs suddenly and may cause maternal and fetal mortality. Forced delivery is the only way to improve perinatal outcome, but the aftereffects could be severe despite a high survival rate.　　Our hospital manages approximately 170 cases of maternal transport annually, including cases of severe placental abruption. Longer transport time can lead to undesirable maternal and fetal outcome. Hence this study, we compared the perinatal backgrounds and outcome of placental abruption retrospectively between the cases managed by maternal transport and by the local hospital (our hospital). The study included 54 cases of placental abruption during the period from January 2008 to December 2012, of which 27 cases were managed by our hospital, the other halves were managed by maternal transport. There were 6 intrauterine fetal deaths but not a single maternal death. There were no significant differences in the amount of blood lost and obstetric DIC (disseminated intravascular coagulopathy) score between two groups (p＝0.342, p＝0.649), and the number of cases that needed anti-DIC therapy and blood transfusion in each group was statistically similar (p＝0.807, p＝0.115). The time taken from the on-set of placental abruption to delivery was significantly shorter for the cases managed by our hospital (in-hospital management 143±133 minutes, maternal transport management 265±176 minutes, p‹0.05), while obstetric DIC score and Apgar score showed no significant differences (p＝0.336, p＝0.780) between the two groups. Thus, it could be said there were no correlations between the time taken from onset to delivery and perinatal outcome. It should be noted, however, maternal and fetal outcome of placental abruption could be fatal even with the rapid intervention, so quick diagnosis and management at the first contact are crucial. Thus, we concluded that forced delivery managed by the local hospitals is necessary for the potential better perinatal outcome, and an ideal system to manage maternal and/or neonate transport after the delivery should be established immediately.

　　Catamenial pneumothorax (CP) is defined as a form of thoracic endometriosis syndrome (TES) and the clinical manifestations and management of this disease are not consensual. Successful treatment depends on how closely pulmonary specialists and gynecologists work together. Such being the circumstances, we reviewed our experience with CP in terms of treatment and follow-up. We treated surgically many patients with pneumothorax during the period from 1989 to 2014, of which eight cases had endometriosis on the diaphragm, lung or pleura histologically. The median age at the time of operation was 37 (range, 17 to 41). CP was right-sided in seven of the eight patients (87.5%). Six patients underwent an examination with diagnostic laparoscopy and five had positive findings. The median period of follow-up after surgery was 33.5 months (range, 4 to 129 months). Two patients had no recurrence without hormonal therapy. Six other patients experienced a recurrence of pneumothorax, although two patients received dienogest after surgery. The use of only dienogest or both GnRHa and dienogest prevented recurrence in all patients. CP is a critical condition that requires prompt action, so after surgical treatment, the choice of hormonal therapy with a high rate of patient compliance are needed. No recurrence occurred in young patients who had only surgical treatment, suggesting that there were some associations between age and recurrence. Since we succeeded in preventing recurrence after using GnRHa in all cases, we recommend GnRHa or dienogest following GnRHa for the first choice of hormonal therapy after surgery. However, treatment with only dienogest could achieve successful results with no recurrence, so more case studies need to be done to make the best treatment choice for each case.

　　Adhesion formation after abdominal surgery is a commonly recognized entity. Many studies have shown that women giving birth by cesarean section are at the risk of developing complications related to the postoperative formation of adhesions including ileus, bowel obstructions, impaired fertility, and chronic abdominal pain. Among several adhesion barriers, one that has been tested in randomized, controlled trials is the hyaluronic cid-carboxymethylcellulose (HA/CMC) membrane (Seprafilm®: Genzyme, Cambridge, MA, USA). This bioresorbable membrane serves as a mechanical barrier between surgically damaged tissues and resorbs afterwards. At our institution, we have used HA/CMC in cesarean sections. We report our experience with this patient population using placement of HA/CMC.　　This study enrolled 45 women who had undergone cesarean sections twice or more who had received HA/CMC during the previous cesarean section between January 2013 and November 2014. The incidence of adhesions to the area of abdominal wall incisions and uterine surface, intestinal obstructive symptoms, and adverse events were studied. The incidence of adhesions to midline incisions was 4.4% (n＝2). The filmy adhesion by major omentum was detected in these two cases. The incidence of adhesions to uterine surface was 2.2% (n＝1). The moderate thickness adhesion was detected at the left side of the vesico-uterine peritoneal incision by pelvic peritoneum which did not affect the operative procedure. No symptoms related to intestinal obstructions such as abdominal pains, nausea and vomiting were observed. No adverse events were observed. These three cases had fever which had nothing to do with HA/CMC applications but was attributable respectively to influenza infection, mastitis, phlebitis associated with a needle procedure.　　HA/CMC was considered a useful adhesion barrier membrane for use in cesarean sections as an adjunct intended to reduce the incidence of postoperative adhesions between the abdominal wall and the underlying viscera such as omentum, small bowel, and between the uterus and surrounding structures.

  A 53-year-old Japanese man living in Thailand who was diagnosed with prostate cancer was scheduled for a prostate biopsy due to increased serum PSA. Two days prior to his admission, he returned to Japan. The next day he was taken for pre-operative screening and blood tests, which revealed extremely high serum creatine kinase (CK) levels (13,631 IU/L). The following day, his serum CK increased to 29,836 IU/L with 100% type MM isozyme. In addition, his serum myoglobin was 3,289.0 ng/mL and his urinary myoglobin was 26,000 ng/mL. Based on these test results, the patient was diagnosed with rhabdomyolysis.  The patient revealed that he had gone to a public bath and bathed in an “electric bath” for a total of 90 min over the previous 2 days. During hospitalization, he remained asymptomatic and had no renal dysfunction. The prostate biopsy was performed as scheduled and he was given post-procedure care, including intravenous administration of saline. The patient’s serum CK peaked at 42,355 IU/L on the second day of hospitalization, and on the fifth day it decreased to 5,979 IU/L and he was discharged without any complications.   After a retrospective review of literature, only three reports were found mentioning an “electric bath”. Two of these reports were related to asymptomatic hyper-CK-emia caused by the electric bath, and one was a case related to the malfunction of an implantable cardioverter defibrillator due to an electric bath. The former two reports concluded that increased time in the electric bath was related to the observed increase in CK level. Since extended bathing in electric baths may cause rhabdomyolysis, further investigation is required to determine what duration of use is safe.

BACKGROUND: Although organotin compounds are widely used as PVC stabilizers, catalysts and biocides, their effects on humans are not well known. However, their acute intoxication is known to cause neurotoxicity in the central nervous system, renal toxicity, and hepatotoxicity. As there has been no previously published case of organotin intoxication in Korea, we report here the first Korean case of acute exposure to organotin. CASE REPORT: A 43-year-old male with disorientation and behavioral change was admitted to a hospital. He had been working as a tank cleaner for several different companies in the previous 8 years and a week before admission, he had cleaned a tank containing dimethyltin (DMT) for 4 days. A day after finishing the job, he suffered decreased memory, behavioral change and progressive mental deterioration when he arrived at the emergency room. The result of spinal tapping was negative but on the 4th day of admission he deteriorated into a state of coma along with metabolic acidosis and severe hypokalemia. High levels of DMT and trimethyltin (TMT) were detected in a highly sensitive urine analysis. After conservative treatment and chelation therapy, the patient showed some clinical improvement but the neurological defects persisted. CONCLUSION: The patient appeared to have been intoxicated from the acute exposure to a high level of organotin while cleaning the tank.
Acidosis ; Adult ; Central Nervous System ; Chelation Therapy ; Coma ; Disinfectants ; Emergency Service, Hospital ; Humans ; Hypokalemia ; Korea ; Male ; Memory ; Organotin Compounds ; Poisoning* ; Spinal Puncture