Trial of labor can be offered to all the women with low-lying placenta except for those accompanied by marginal sinus.

Hyperreactio luteinalis (HL) is characterized by multicystic bilateral enlargement of the ovaries and is a self- CASE REPORTA 33-year-old woman, gravida 3 para 2, presented at the emergency room of our hospital owing to acute abdomen. Transabdominal ultrasound examination (TAS) revealedCorrespondence to: Dr Y. Sato, Department of Obstetrics and Gynecology, Otsu Red Cross Hospital, 1-1-35 Nagara, Otsu 520-8511, Shiga, Japan (e-mail: yukiyasu@kuhp.kyoto-u.ac.jp) Accepted: 17 March 2015bilateral multicystic tumors occupying the pelvic cavity, and the patient was subsequently admitted to the obstetrics and gynecology department. The patient's third pregnancy had ended, 9 days previously, in fetal demise at 24 weeks' gestation caused by hydrops fetalis associated with cystic hygroma (karyotype was normal 46,XX). On the 2 nd day postpartum, she had been discharged from the hospital with unremarkable transvaginal ultrasound findings.On admission to the obstetrics and gynecology department, the patient's lower abdomen was slightly distended and she had severe pain and tenderness, which were dominant on the left side. Subsequent blood testing found elevated white blood cell (WBC) count (12 900/μL), C-reactive protein (CRP) (0.7 mg/dL) and D-dimer (15.8 μg/mL) levels. Magnetic resonance imaging (MRI) confirmed bilateral ovarian multicystic enlargement, reaching more than 10 cm in diameter (Figure 1a). Aggregation of coiled tubular structures, which was considered to represent twisted and congested blood vessels, was observed between the uterus and the left ovarian tumor (Figure 1a). Some of these blood vessels contained nodules of low signal intensity, suggestive of intravenous clot formation. On T1-weighted MRI, the septa and surface of the left ovarian tumor were poorly enhanced by gadolinium, as compared with the right side (Figure 1b). From these observations, the patient was diagnosed with hyperreactio luteinalis (HL) complicated by torsion of the enlarged left ovary. Serum levels of β-human chorionic gonadotropin (β-hCG) and testosterone were 1550 mIU/mL and 3.22 ng/mL, respectively, both of which were consistent with the values recorded 9 days postpartum.Emergency laparoscopic detorsion of the ischemic left ovary was planned. Aiming to reduce the risk of cystic injury and bleeding at the trocar insertion site, volume reduction of the left ovarian tumor was performed by ultrasound-guided percutaneous transabdominal aspiration of the cyst. About 200 mL of thin yellow serous fluid was removed from three cystic components through

Strict adherence to our protocol improved neonatal outcomes without affecting maternal prognosis. Routine use of magnesium sulfate could be the most important component of the protocol.

We herein describe our experiences in vaginal deliveries for women with prenatally diagnosed vasa previa (VP).Case 1: A 29-year-old uniparous woman was referred to us at 34 +4 gestational weeks. Trans vaginal ultrasonography (TV-USG) showed a membranous fetal vein located 1.1cm apart from the internal cervical os. At 34 +6 gestational weeks, spontaneous rupture of membranes (ROM) occurred, and labor was naturally initiated at 36 +1 gestational weeks. The progression of labor was favorable and a non-anemic male baby weighing 2290g was vaginally delivered 9.5hours after the onset of labor.Case 2: A 32-year-old primiparous woman was referred at 39 +2 gestational weeks. TV-USG showed a pair of membranous fetal vein and artery located 1.0cm apart from the internal cervical os. At 40 +4 gestational weeks, spontaneous ROM occurred and labor was naturally initiated 2hours later. After labor augmentation with intravenous prostaglandin F2α, a non-anemic female baby weighing 2715g was vaginally delivered 22hours after the onset of labor.These experiences and a review of past case reports suggest that an early minimallytraumatic amniotomy, avoidance of excessive cervical manipulation, and the shortening of the expulsive stage could contribute to the prevention of VP rupture.

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