doi:10.1111/j.1447-0756.2011.01653.x

J. Obstet. Gynaecol. Res. Vol. 37, No. 9: 1174–1197, September 2011

Guidelines for obstetrical practice in Japan: Japan Societyof Obstetrics and Gynecology (JSOG) and Japan
Association of Obstetricians and Gynecologists (JAOG)
2011 edition
jog_1653

1174..1197

Hisanori Minakami1, Yuji Hiramatsu2, Mitsuhiko Koresawa3, Tomoyuki Fujii4,
Hiromi Hamada8, Yoshinori Iitsuka9, Tomoaki Ikeda11, Hiroshi Ishikawa12,
Hitoshi Ishimoto14, Hiroaki Itoh15, Naohiro Kanayama15, Yoshio Kasuga16,
Masakiyo Kawabata5, Ikuo Konishi17, Shigeki Matsubara18, Hideo Matsuda19,
Takeshi Murakoshi20, Akihide Ohkuchi18, Takashi Okai6, Shigeru Saito21,
Masato Sakai10, Shoji Satoh23, Akihiko Sekizawa6, Masaaki Suzuki24, Tsuneo Takahashi13,
Akiteru Tokunaga22, Yuki Tsukahara7 and Hiroyuki Yoshikawa8
1

Department of Obstetrics, Hokkaido University Graduate School of Medicine, Sapporo, 2Okayama University Graduate Schoolof Medicine, Okayama, 3Sanraku Hospital, 4Graduate School of Medicine, University of Tokyo, 5Douai Memorial Hospital,
6
Showa University School of Medicine, 7National Center for Child Health and Development, Tokyo, 8Graduate School of
Human Comprehensive Sciences, University of Tsukuba, Tsukuba, Ibaraki, 9Chiba Kaihin Municipal Hospital, 10Tokyo
Women’s Medical University, Yachiyo Medical Center, Yachiyo, Chiba, 11National Cerebral and Cardiovascular Center, Suita,
Osaka, 12Kanagawa Children’s Medical Center, 13Yokohama City University Medical Center, Yokohama, 14Tokai University
School of Medicine, Isehara, Kanagawa, 15Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, 16Ashikaga Red
Cross Hospital, Ashikaga, Tochigi, 17Kyoto University Graduate School of Medicine, Kyoto, 18Jichi Medical University Schoolof Medicine, Shimotsuke, Tochigi, 19National Defense Medical College Hospital, Tokorozawa, Saitama, 20Seirei Hamamatsu
General Hospital, Hamamatsu, Shizuoka, 21Graduate School of Medicine and Pharmaceutical Science, University of Toyama,
22
Tokunaga Women’s Clinic, Toyama, 23Oita Prefectural Hospital, Oita, and 24San-ikukai Hospital, Tokyou, Japan

Abstract
Clinical guidelines for obstetrical practice were ﬁrst published by the Japan Society of Obstetrics and Gynecology (JSOG) and the Japan Association of Obstetricians and Gynecologists (JAOG) in 2008, and a revised
version was published in 2011. The aims of this publication include the determination of current standard carepractices for pregnant women in Japan, the widespread use of standard care practices, the enhancement ofsafety in obstetrical practice, the reduction in burdens associated with medico-legal and medico-economical
problems, and a better understanding between pregnant women and maternity-service providers. These
guidelines include a total of 87 Clinical Questions followed by several Answers (CQ&A), a Discussion, a Listof References, and some Tables and Figures covering common problems and questions encountered inobstetrical practice. Each answer with a recommendation level of A, B or C has been prepared based principallyon ‘evidence’ or a consensus among Japanese obstetricians in situations where ‘evidence’ is weak or lacking.
Answers with a recommendation level of A or B represent current standard care practices in Japan. All 87
CQ&A are presented herein to promote a better understanding of the current standard care practices for
pregnant women in Japan.
Key words: clinical question, complicated pregnancy, guideline, obstetrical practice, recommendation,
standard care practice.
Reprint request to: Dr Hisanori Minakami, Department of Obstetrics, Hokkaido University Graduate School of Medicine, N15W7
Kita-ku, Sapporo 060-8638, Japan. Email: minasho@med.hokudai,ac.jp1174© 2011 The Authors
Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology-1-Guidelines for obstetrical practiceIntroduction
In Japan, approximately 1 100 000 women give birthannually at 2800 facilities, at which approximately 8000
obstetricians are employed. Because guidelines forobstetrical practice were not previously available inJapan, remarkable diversity exists among these facilities, particularly with regard to the screening and treatment of fetal/pregnancy abnormalities. This diversity
in practice may partly explain the increased number ofmalpractice lawsuits. The Japan Society of Obstetrics
and Gynecology (JSOG) and the Japan Association of
Obstetricians and Gynecologists (JAOG) decided to
publish guidelines describing standard care practices
for pregnant women in 2005. The aims of this guideline
are to encourage the widespread use of standard carepractices, to enhance the safety of obstetrical practice,
to reduce burdens associated with medico-legal
and medico-economical problems, and to promote a
better understanding between pregnant women andmaternity-service providers.
The authors of this article have contributed greatly tothe preparation of this draft. The draft was frequently
revised as a result of frequent audits and opinions
gathered after the publication of the draft in the ofﬁcial
Journal of JSOG and on the JSOG and JAOG websites.
Then, the ﬁrst edition, ‘Guidelines for Obstetrical Practice in Japan 2008,’ consisting of 63 Clinical Questions
and 254 Answers (CQ&A), was published in April
2008. The second edition, ‘Guidelines for Obstetrical
Practice in Japan 2011’, containing the revised 63
CQ&A as well as 24 new CQ&A, was published in
April 2011.
As these guidelines were originally written in Japanese, non-Japanese speakers have been somewhat
inconvenienced; this English version may overcome
this problem. The original version of ‘Guidelines for
Obstetrical Practice in Japan 2011’ contains a Discussion, a List of References, and some Tables and Figures.
However, these sections have been omitted here
because of space limitations.

Implications of ‘A’, ‘B’, and ‘C’
Recommendation Levels
Several tests and/or treatments for pregnant womenare presented as answers with a recommendation levelof ‘A’, ‘B’ or ‘C’ to each clinical question. The answers
and recommendation levels are principally based onevidence or a consensus among Japanese obstetricians
when the evidence is considered to be weak or lacking.

Thus, the answers are not necessarily based on ‘evidence’. The answers usually begin with a verb, which
may promote changes in behavior among maternityservice providers in clinical practice. Answers with arecommendation level of A or B are regarded as
current standard care practices in Japan. Level A indicates a stronger recommendation than level B. Consequently, informed consent is required when maternityservice providers do not provide care corresponding toan answer with a level of A or B. Answers with arecommendation level of C are possible options that
may favorably affect the outcome but for which someuncertainty remains regarding whether the possible
beneﬁts outweigh the possible risks. Thus, care corresponding to answers with a recommendation level of C
does not necessarily need to be provided. Someanswers with a recommendation level of A or B include
examinations and treatments that may be difﬁcult for
general maternity-service providers to perform. In
such cases, the maternity-service providers must refer
the patient to an appropriate institution.

Contents
Chapter A. General practice (CQ001–CQ010)
Chapter B. Consultation (CQ101–CQ109)
Chapter C. Obstetrical complications during the ﬁrst
trimester of pregnancy (CQ201–CQ206)
Chapter D. Obstetrical complications during thesecond and third trimesters of pregnancy (CQ301–
CQ317)
Chapter E. Parturition (CQ401–CQ414)
Chapter F. Incidental complications (CQ501–CQ505)
Chapter G. Infection (CQ601–CQ614)
Chapter H. Twin pregnancies (CQ701–CQ705)
Chapter I. Newborns (CQ801–CQ804)
Chapter J. Others (CQ901–CQ903)

Chapter A. General practice
CQ001: How should uncomplicated healthy pregnant
women be cared for prenatally?
Answer
1 Provide antenatal care regularly and try to detect
early premature labor, gestational diabetes,
pregnancy-induced hypertension, low-lying placenta and placenta previa, fetal abnormalities (fetal
growth restriction, abnormal position, oligohydramnios, and polyhydramnios), and placental
insufﬁciency. (A)
2 Measure maternal weight, fundal height of theuterus, and blood pressure; semiquantify glucose© 2011 The Authors
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and protein concentrations in the urine; and assess
fetal heartbeat and maternal edema at each antenatal
visit. (B)3 Provide antenatal care according to the following
schedule: three times until the end of 11 gestational
weeks (GW); every 4 weeks between 12 GW andthe end of 23 GW; every 2 weeks between 24 GW
and the end of 35 GW; and once a week thereafter.
(C)
4 Regularly assess the fetal well-being at 41 GW. (B)
5 Consider the possibility that midwife-managed carefor healthy women, together with existing services(see CQ414), may be clinically effective and may
enhance the pregnant woman’s satisfaction. (C)CQ002: What information should be obtained fromwomen during an early stage of pregnancy?
Answer
1 Ask women to complete the questionnaire form (seesample in Discussion). (B)
2 Measure bodyweight and blood pressure and semiquantify glucose and protein concentrations in theurine. (B)3 Screen for cancer of the uterine cervix using a cytological examination. (C)CQ003: What blood tests should be performed
during the ﬁrst trimester?
Answer
1 The following blood tests are recommended: blood
typing including ABO and Rh (A), atypical antibody
against erythrocyte (indirect Coombs test) (A), complete blood count (A), HBs antigen (A), hepatitis C
virus (HCV) antibody (A), rubella antibody using
HI (A), screening tests for syphilis (A), human T-cellleukemia virus type 1 (HTLV-1) antibody (A, before
the end of the second trimester), screening test for
HIV (B), glucose concentration (B), and toxoplasma
antibody (C).
CQ004: How should pregnant women with anincreased risk of deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE) be screened andmanaged?
Answer1 Recommend the use of elastic stockings for womenwith risk factors such as dehydration during emesis,
long-term bed rest, obesity, and an older age. (C)2 Consider the use of unfractionated heparin for
women with the highest risk according to the 2004
guidelines for the prophylaxis of DVT/PTE. (C)1176

3 Do not administer warfarin to pregnant women
because of its teratogenicity. As an exception to therule, warfarin may be considered in pregnant
women who have undergone a heart valve replacement. (A)4 Assess PT, APTT, platelet count, and liver function at
appropriate intervals during anti-coagulation withheparin. Measure the platelet count 5–7 days after
the initiation of heparin for the early detection of
heparin-induced thrombocytopenia (HIT). (B)
5 Try to prevent perinatal DVT/PTE according to the2004 guidelines for the prophylaxis of DVT/PTE.
(B)
6 Rule out DVT prenatally based on symptoms andpalpation of both the legs before the postnatal prophylactic use of the intermittent pulse-pressure
method. (C)
7 Avoid placing the patient in a ‘lithotomy’ position
when performing a cesarean section. (C)
8 Initiate heparin calcium at a dose of 5000 units twice
daily (s.c.) after conﬁrming hemostasis and continue
for 3 to 5 days for the prophylaxis of DVT/PTE
when anti-coagulation is indicated after a cesarean
section. (B)CQ005: How should patients with hyperglycemic
disorders during pregnancy be screened?
Answer1 Screen all pregnant women for ‘gestational diabetes
mellitus (GDM)’ and ‘overt diabetes in pregnancy’.
(B)
2 Screen using the following stepwise method: (B)1) Measure random blood glucose level at an earlystage of pregnancy (each hospital should determine its own cut-off value). Check items ①–③ inAnswer 4 before planning a 75-g oral glucose
tolerance test (OGTT) in women with a random
blood glucose level of 200 mg/dL.
2) Give the pregnant woman a 50-g glucose challenge test (GCT; cut-off value 140 mg/dL) or
measure the random blood glucose level a second
time (cut-off value 100 mg/dL) between 24 and28 GW in women not diagnosed as having ‘GDM’or ‘overt diabetes in pregnancy’.
3 Give a 75-g OGTT to all women with a positive
screening test result except women diagnosed ashaving ‘overt diabetes in pregnancy’. Diagnose thepregnant woman as having ‘GDM’ if one or morethreshold values of a 75-g OGTT are fulﬁlled. Checkitems ①–③ in Answer 4 in women with a 2-h plasma
glucose (PG)  200 mg/dL. (A)© 2011 The Authors
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Guidelines for obstetrical practiceThreshold values for 75-g OGTT
① Fasting plasma glucose (FPG) 92 mg/dL(5.1 mmol/L)② 1-h PG  180 mg/dL (10.0 mmol/L)③ 2-h PG  153 mg/dL (8.5 mmol/L)
4 Diagnose the pregnant woman as having ‘overt diabetes in pregnancy’ if any of the following threecriteria are fulﬁlled. (A)① FPG  126 mg/dL② HbA1c  6.5%, expressed as National Glycohemoglobin Standardization Program (NGSP) value(HbA1c  6.1% according to Japan Diabetes
Society [JDS])*③ Deﬁnite diabetic retinopathy④ Random blood glucose 200 mg/dL with anyof ①–③, or 2-h PG  200 mg/dL with any of①–③.
*The HbA1c value (%) according to the NGSP criteria corresponds to the same value plus 0.4 according
to the JDS criteria.
5 Give a 75-g OGTT to all women with ‘GDM’ at
6–12 weeks postpartum. Assess the degree of
glucose intolerance once again in all postpartum
women diagnosed as having ‘overt diabetes inpregnancy’. (C)CQ006: How should patients with thyroid dysfunction during pregnancy be screened?
Answer
1 Determine the TSH, free T3, and free T4 levels inthe blood of women with suspicious clinical signs
and/or a medical history of thyroid dysfunction.
(B)
2 Try to normalize the thyroid function of patientswith thyroid dysfunction. Consult appropriate
specialists or other appropriate experts if any difﬁculty is encountered while treating the patient.
(A)
CQ007: How should women visiting a clinic andcomplaining of decreased fetal movements be dealt
with?
Answer
1 Tell the patient, ‘Some investigators have suggested
that decreased fetal movements are associated withfetal jeopardy.’ (C)2 Assess the fetal well-being in an appropriatemanner, such as a non-stress test (NST). (B)CQ008: How should women with an atypical antibody against red blood cells be treated? (see CQ302 forwomen with ant-Rh [D] antibody)Answer
1 Identify the antibody when a screening test, such as
the indirect Coombs test, suggests the presence of an
atypical antibody against red blood cells. (B)2 Assess the titer of the antibody if the antibody
belongs to an immunoglobulin (Ig) G that may cause
hemolysis in the fetus. (B)3 Monitor the fetal well-being, paying special attention to anemia and hydrops, in women with anelevated titer of an IgG antibody that may cause
hemolysis in the fetus. (B)4 Be prepared to administer un-crossmatched packed
red blood cells compatible with an ABO blood typeif the pregnant woman develops unexpectedmassive bleeding. (B)CQ009: How should the expected date of conﬁnement (EDC) be determined?
Answer
1 Determine the EDC based on the last menstrual
period (LMP) in principle, but use the date of ovulation or fertilization if available. (A)2 Use the EDC based on the crown–rump length(CRL) in cases with a CRL of 14–41 mm if the difference in the EDC is 7 days from the EDC basedon the LMP. (B)3 Use the EDC based on the biparietal diameter (BPD)
and the femur length (FL) in cases with an estimated
12–19 GW and/or a CRL of >50 mm if the differencein the EDC is 10 days from the EDC based on the
LMP. (C)4 Estimate the EDC according to Answer 3, withcareful consideration of fetal growth restriction(FGR) and post-term pregnancy, after taking possible deviations into account in cases with an estimated GW of 20. (C)
5 Determine the EDC based on ﬁndings of the earlyneonate if no relevant information is available
prenatally. (C)CQ010: What guidance regarding maternal bodycomposition and weight gain during pregnancy
should be provided?
Answer
1 Provide the following information when asked
about the association between maternal body composition and pregnancy outcome. (C)1) Lean women (body mass index [BMI] < 18.5
before pregnancy) are at an increased risk forpreterm labor, preterm delivery, and low birthweight newborns.

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2) Obese women (BMI  25 before pregnancy) areat an increased risk for pregnancy-induced
hypertension, gestational diabetes mellitus, stillbirth, fetal macrosomia, and fetal neural tube
defects.
2 Provide the following information when asked
about weight gain during pregnancy. (B)1) Japanese women of normal body composition(18.5  BMI < 25) are estimated to require aweight gain of 11 kg as of the 40th GW to have asingleton newborn weighing 3 kg, according tothe ‘Dietary Reference Intakes for Japanese’ published by the Ministry of Health, Labour, andWelfare, Japan (2010). However, considerable
individual differences exist.
2) Maternal weight gain during pregnancy is correlated with the birthweight of the newborn.
However, this correlation becomes weaker as the
pre-pregnancy maternal BMI increases. In casesof obese women, the pre-pregnancy BMI, rather
than the weight gain during pregnancy, tends toaffect the birthweight of the newborns morestrongly.
3 Consider the following items when providing nutritional advice.
1) Recommend a balanced intake of nutrients.
(A)2) Use the pre-pregnancy BMI. (B)3) Note that maternal weight gain is one of theparameters for assessing the maternal nutritional
condition, and several different guidelines formaternal weight gain during pregnancy exist inJapan. (B)4) Moderate nutritional guidance for pregnant
women is preferred because high-quality evidence is not available. (C)Chapter B. Consultation
CQ101: Which vaccines are safe for pregnant andlactating women?
Answer
1 Viable vaccines are contraindicated, in principle, forpregnant women. (A)
2 Non-viable vaccines can be given to pregnant
women. (B)
3 Both viable and non-viable vaccines can be given tolactating women. (B)CQ102: What considerations are necessary regarding
the administration of vaccines against inﬂuenza andantiviral drugs to pregnant women?

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Answer1 Administer vaccines after explaining that the beneﬁtof vaccination outweighs the risk derived from
infection with inﬂuenza when women want to be
vaccinated. (B)2 Consider that the beneﬁt outweighs the risk of using
antiviral drugs, such as oseltamivir and zanamivir,
for the treatment of inﬂuenza in pregnant andlactating women. (C)
3 Consider that the beneﬁt outweighs the risk of using
antiviral drugs, such as oseltamivir and zanamivir,
for the prophylaxis of inﬂuenza in pregnant andlactating women after they have come in close
contact with an infected person. (C)CQ103: How should women anxious about theadverse effects of radiation exposure during pregnancy
be treated?
Answer
1 Before counseling, determine the dose of the exposure and the stage of pregnancy (GW) when the
exposure occurred using the last menstrual period,
measurement of the conceptus by ultrasonography,or the date of a positive pregnancy test result. (A)2 Explain that the risk of a fetal anomaly does notincrease in cases with exposure within 10 days afterconception. (B)3 Explain that an embryo at stages ranging from
11 days after conception until 10 GW is vulnerable
but does not have an increased risk of malformation
at doses of <50 mGy. (B)4 Explain that the central nervous system of a fetus at
10–27 GW may be affected unfavorably at doses of100 mGy. (B)5 Explain that a dose of 10 mGy is associated with asubtle, but negligible, increase in the risk of childhood cancer. (B)CQ104: How should women who ask questions
regarding the effects of a drug on the fetus beanswered?
Answer1 First determine the date on which the drug was
taken and the corresponding GW. Use the last menstrual period, the date of a positive pregnancy test
(urinary human chorionic gonadotrophin [hCG]
level), and an ultrasound measurement to estimate
the GW accurately. (A)
2 Refer to Table 1, a textbook such as ‘Drugs in Pregnancy and Lactation,’ by Briggs et al. (Lippincott
Williams and Wilkins) or information on the© 2011 The Authors
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Guidelines for obstetrical practiceInternet. Inform the woman of the service provided
by the Japan National Center for Child Health andDevelopment. (B)CQ105: How should one respond when asked about
the association between folic acid and the occurrence ofneural tube defects (NTD) in the fetus?
Answer1 Explain as follows. (B)1) A reduction in the risk of an NTD is expected if
0.4 mg of folic acid is taken as a daily supplement
prior to the establishment of pregnancy.
2) A reduction in the recurrent risk of an NTD is
expected when a woman who has previously
given birth to an infant with an NTD takes 4.0–
5.0 mg of folic acid daily under the supervision ofa physician.
CQ106: How should women in whom a thickened
nuchal translucency (NT) is incidentally found betreated?
Answer
1 Remember that the accurate measurement of an NT
requires the following:
1) A stage of pregnancy between 10 and 14 GW. (C)2) Sufﬁcient magniﬁcation of the upper trunk of the
fetus. (C)3) Measurement on a sagittal section as shown inthe ﬁgure. (C)2 Explain the implications of a thickened NT towomen who have agreed to be informed of theresults of antenatal diagnosis using ultrasonographic testing. (B)3 Remember that some women do not wish to know
the results of antenatal diagnosis. (A)
4 Consider the ethical problems involved in both situations described in Answers 2 and 3. (A)5 Explain that the implications of a thickened NT are
as follows: (C)1) A fetus with an NT of 3 mm, 4 mm, 5 mm, or
6 mm has a 3-times, 18-times, 28-times, and36-times higher risk than the risk based on maternal age, respectively, of having 21-trisomy,
18-trisomy, or 13-trisomy, as shown in Figure 2.
2) More than 90% of fetuses with a normal karyotype but with an NT of 3.5 mm survive without
developing any congenital diseases.
3) Approximately 70% of fetuses with a chromosomal aberration have an NT that is 95th percentile value and that increases from 2.1 mm to
2.7 mm with advancing gestation during the 11th

to 14th GW. The 99th percentile value for NT is
3.5 mm, independently of the GW.
4) Chromosomal analysis using amniotic ﬂuid isneeded for a deﬁnite diagnosis of chromosomal
aberration.
CQ107: How should one respond when asked about
the effects of a drug during lactation on neonates/
infants?
Answer
1 Assure the patient that most drugs, with a few
exceptions, are not harmful to neonates/infants
when taken while a woman is lactating. (B)2 Recommend that the condition of the child, such as
the speed of suckling, sleep status, mood and activity, and weight gain, be observed when a lactating
woman decides to take a drug for which someconcern over possible unfavorable effects exists. (C)
3 Refer to a textbook such as ‘Drugs in Pregnancy andLactation,’ by Briggs et al. (Lippincott Williams andWilkins) or visit the website of the Japan National
Center for Child Health and Development. (C)CQ108: How should one respond to questions
regarding exercise during pregnancy?
Answer
1 Exercises to develop adequate strength may contribute to the maintenance and promotion of a healthy
lifestyle. (B)2 No evidence exists supporting any favorable effects
of exercise on the prevention of pregnancy-induced
hypertension, gestational diabetes mellitus, or
prolonged labor. (C)3 Women with the following complications should
refrain from regular exercise. (A)1) Serious diseases of the heart and lung.
2) Threatened preterm labor, cervical incompetency,
shortened uterine cervix, or premature rupture of
the membranes.
3) Genital bleeding, placenta previa, or a low-lying
placenta.
4) Pregnancy-induced hypertension.
4 Women should refrain from the following exercises.
(B)
1) Exercises requiring a supine or standing position
with minimal movement for long periods of time.
2) Activities with an inherent increased risk offalling or traumatic injuries.
3) Scuba diving.
5 Women with the following symptoms should
discontinue all exercise: dizziness, headache, chest© 2011 The Authors
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pain, dyspnea, muscle weakness, calf pain or aswollen calf, uterine contractions or discomfort in theabdomen, decreased number of fetal movements,
and bleeding or an increased watery discharge fromthe vagina. (B)
6 An appropriate heart rate target zone should bemaintained while performing aerobic exercise. (B)CQ109: How should pregnant women who smoke or
who are exposed to passive smoking be treated?
Answer
1 Ask women about their smoking status at an earlystage in their pregnancy. (B)2 Recommend that women quit smoking. (B)3 Respond as follows when asked about the effects ofactive and passive smoking: (B)
Active and passive smoking have unfavorable
effects on human health, pregnancy outcomes, andfetal and child development and health.
4 Recommend that the woman’s partner quit
smoking. (C)5 Recommend that women avoid passive smoke. (C)Chapter C. Obstetrical complications during theﬁrst trimester of pregnancy
CQ201: How should women with hyperemesis gravidarum be treated?
Answer1 Recommend ‘frequent small meals’ and the frequent intake of salt-containing ﬂuids, such as sports
drinks. (A)2 Administer i.v. ﬂuids in patients with dehydration.
(A)
3 Add thiamine hydrochloride (vitamin B1) to theﬂuid to prevent Wernicke’s encephalopathy. (A)
4 Consider the administration of oral pyridoxine(vitamin B6). (C)5 Be cautious of the possible occurrence of deep veinthrombosis. (C)CQ202: How should women with a presumed abortion at <12 GW be treated?
Answer
1 Consider the possibility of an ectopic pregnancy. (A)
2 Diagnose as a ‘missed abortion’ after at least two
examinations performed at an appropriate timeinterval. (B)3 Treat patients with abortions as follows.
1) For patients with missed, incomplete, or progressive abortions, active treatment with surgical1180

evacuation is recommended, although conservative treatment without surgical procedures may
be feasible. Provide information regarding therisks of unscheduled procedures to any remaining conceptus in utero even after surgical evacuation, and be cautious of possible molar or ectopic
pregnancies. (B)2) For patients with complete abortions, only follow
up without surgical intervention is sufﬁcient. (C)CQ203: How should patients with ectopic pregnancy
be treated?
Answer
1 An ectopic pregnancy should be suspected inwomen with a positive pregnancy test result(urinary or serum hCG) who exhibit any of the following signs. (B)1) No gestational sac (GS) within the uterus.
2) A GS-like mass outside the uterus.
3) A considerable amount of ﬂuid in the Douglas
pouch.
4) Signs indicative of a reduction in the circulating blood volume (anemia, tachycardia, or
hypotension).
5) No chorionic villi in the evacuated conceptus.
6) Complaints suggestive of an acute abdomen.
2 Choose surgical, medical, or expectant management
after a careful assessment of the general condition of
the patient, the site of the ectopic pregnancy, thehCG value, the presence or absence of fetal cardiac
activity, and the volume of the abnormal mass in thepelvic cavity. (B)
3 Closely monitor patients who are being treated
medically or expectantly with caution for intraabdominal bleeding, persisting ectopic pregnancy,and chorionic diseases. (B)4 Conﬁrm a non-pregnant level of hCG during afollow-up examination of patients treated medicallyor expectantly. (C)5 Remember that the incidence rate of heterotopic
pregnancy is higher among women using assisted
reproductive technology than among women withnatural conception. (C)CQ204: How should women with recurrent pregnancy loss be treated?
Answer
1 Diagnose patients with 3 successive spontaneousabortions as having ‘habitual abortion’. (A)2 Try to reduce the anxiety of couples throughsupportive counseling. (B)© 2011 The Authors
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Guidelines for obstetrical practice

3 Provide the following information: (C)Sixty to seventy percent of couples with unexplained
habitual abortions will go on to have successful pregnancies without any speciﬁc treatment, although thesuccess rate of the next pregnancy varies according tomaternal age and the number of previous abortions.
Investigations of the causes of habitual abortions areable to disclose a speciﬁc cause in only 50% of couples
with habitual abortions.
4 Recommend the following examinations if the couples want to seek the cause of the habitual abortions.
1) Anti-phospholipid antibodies, including lupus
anticoagulant, anticardiolipin antibody, and anticardiolipin b2GP1 antibody. (A)2) Quantity of coagulation factors. (C)3) Chromosomal analysis of the patient and thepartner after obtaining informed consent. (B)4) Transvaginal ultrasonography, hysterosalpingography, and/or hysteroscopy for the detection of
anatomical deformities of the genital tract. (A)5) Endocrinological environment. (C)
5 Diagnose patients with habitual abortion as having‘antiphospholipid antibody syndrome’ if they test
positive for an anti-phospholipid antibody 2times. (A)
6 Remember that ‘paternal lymphocyte immunization’is only effective in women with certain characteristics. Conduct lymphocyte immunotherapy using
irradiated lymphocytes only after a serious consideration of the indications (see corresponding paragraph in the Discussion). (A)CQ205: What cautions are required for induced abortion (dilatation and curettage) at <12 GW?
Answer
1 Before the procedure, conﬁrm the last menstrual
period, parity, and the presence or absence ofasthma, drug allergies, and current use of drugs. (A)2 Before the procedure, conﬁrm the anatomical features inside and outside of the uterus using digital
and ultrasonographic examinations. (A)3 Perform the following preoperative examinations:blood typing including ABO and Rh (D) (B), a complete blood count (B), electrocardiography before or
during the procedure (C), and tests for the detectionof infections such as hepatitis B virus (HBV). (C).
4 Obtain informed consent as to possible complications arising from the anesthesia or procedure. (C)
5 Conﬁrm that oxygen is easily available. (A)
6 Conﬁrm the presence or absence of chorionic villi inthe evacuated conceptus. (A)

7 Conﬁrm the completeness of the procedure usingtrans-vaginal ultrasonography just after the procedure. (C)8 Perform a second trans-vaginal ultrasonography
examination 1 week after the procedure. (C)CQ206: How should women with genital bleedingwith or without abdominal pains (threatened abortion)
at <12 GW be treated?
Answer
1 For patients with undetectable fetal cardiac activity
during an ultrasonography examination, consider
the possibility of early-stage pregnancy, missed
abortion, ectopic pregnancy, trophoblastic disease,and incomplete or complete abortions as differential
diagnoses. (B)2 Remember that no drugs have been proven tobe effective for improving pregnancy outcomes.
(B)
3 In patients with detectable subchorionic hematoma
and fetal cardiac activity, consider bed rest as apossible treatment. (C)Chapter D. Obstetrical complications during thesecond and third trimesters of pregnancy
CQ301: How should women with suspected cervicalincompetence be treated?
Answer
1 Treat women suspected of having cervical incompetency based on their history of previous pregnancies
using either of the following modalities: (B)1) Follow up the current pregnancy conservatively
with special attention to the length and dilatationof the uterine cervix.
2) Use prophylactic cervical cerclage.
2 Treat women suspected of having cervical incompetency based on the course of the current pregnancy
using either of the following modalities: (A)1) Monitor patients closely using cautions similar to
those for patients with threatened abortion/
preterm labor.
2) Use therapeutic cervical cerclage.
3 Use prophylactic cervical cerclage soon after12 GW. (B)4 Control any infection ﬁrst if the patient shows clinical signs of an infection, such as fever, leukocytosis,
and/or an elevated serum C-reactive protein level.
(C)
CQ302: How should pregnant women with a blood
type of negative Rh (D) be treated?

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Answer
1 Treat women without anti-Rh (D) antibody as
follows:
1) Administer anti-D immunoglobulin within 72 h
after the delivery of an Rh (D)-positive infant.
(A)2) Assess the anti-Rh (D) antibody titer at least twicearound 28 weeks and peripartum. (B)3) Administer anti-D immunoglobulin to womenaround 28 weeks for the prevention of Rh(D)alloimmunization, after obtaining informed
consent. (B)4) Administer anti-D immunoglobulin to womenwith the following characteristics to prevent
Rh(D) alloimmunization. (B)• Termination of pregnancy with a viableembryo at 7 weeks, including miscarriage,
induced abortion, and ectopic pregnancy.
• After invasive procedures, such as amniocentesis and external cephalic version ofbreech.
• A traumatic hit to the abdomen.
2 In women with anti-Rh (D) antibody, measure theanti-Rh (D) antibody titer every 2 weeks during thelatter half of pregnancy. (B)3 In patients who show a signiﬁcant increase in theanti-Rh (D) antibody titer, assess fetal well-being
with respect to anemia and hydrops fetalis. (A)CQ303: How should women with preterm labor betreated?
Answer
1 Remember that women with the following characteristics have a high risk for preterm delivery.
(A)
Current pregnancy: multiple pregnancy, bacterial
vaginosis, and/or shortened uterine cervix.
History: previous preterm delivery and/or postconization of the uterine cervix.
2 Diagnose as preterm labor in cases with regularuterine contractions and/or premature maturationof the uterine cervix (dilatation of the cervix and/or
shortened cervical length) and recommend thatthese patients be admitted to the hospital and/or
given a tocolytic drug. (B)3 Suspect a placental abruption in patients with anabnormal fetal heart rate (FHR) pattern. (B)
4 Measure the maternal body temperature, whiteblood cell count, and C-reactive protein (CRP) level
and initiate antibiotic therapy if an intrauterine
infection is suspected. (C)1182

5 Consider an early delivery in patients suspected ofhaving an amniotic ﬂuid infection. (C)
6 Cooperate with hospitals having neonatal intensive
care unit (NICU) beds, if necessary. (B)7 Administer betamethasone (12 mg twice, i.m., at aninterval of 24 h) to women if delivery at 22–33 GW is
considered to be inevitable. (B)CQ304: How should women with prematurerupture of the membranes (PROM) be treated?
Answer
1 Refrain from frequent digital examinations andexamine the vagina and uterine cervix using Cusco’s
speculum to minimize the risk of ascending infection. (B)2 Assess the body temperature, pulse rate, tenderness of the abdomen, complete blood count(CBC), CRP level, and NST ﬁndings (at 26 weeks)at an adequate interval to detect ‘clinical chorioamnionitis’ and to conﬁrm fetal well-being.
(C)
3 Consider an early delivery within 24 h in a patient
diagnosed as having ‘clinical chorioamnionitis’ at
26 GW. (C)4 Monitor the FHR patterns continuously in parturient febrile (38.0°C) women at 26 GW and pay
attention to maternal septicemia. (B)
5 Induce labor or expect the onset of spontaneous
labor in cases with 37 GW. (B)6 Treat women with 34–36 GW in a similar way towomen with 37 GW. (C)7 Treat women with <34 GW as follows:
1) Refer the patient to a facility with NICU beds
or cooperate with a facility with NICU beds intreating the patient. (B)2) Treat expectantly with the administration of antibiotics, in principle. However, an early delivery
is also an acceptable option in some situations.
(C)
8 Administer steroids to a mother with <32 GW tofacilitate fetal lung maturation and to prevent
fetal intracranial hemorrhage (see CQ303). (B)9 Treat women with <26 GW according to the policyof each hospital. (B)CQ305: How should women with placenta previa betreated?
Answer1 Screen all women around 20 GW with ultrasonography for the detection of women with an increased
risk of placenta previa and diagnose as placenta© 2011 The Authors
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previa before 32 GW using trans-vaginal ultrasonography. (B)Refer the patient to an appropriate facility before
33 GW if contingency plans are considered to be
insufﬁcient. (C)Prepare treatments, including the possibility of a
midnight emergency cesarean section, at around
34 GW once a decision has been made to continue
treating the patient at your facility. (C)Be cautious of placenta accreta, especially in womenwith a previous cesarean section and in women witha placental site close to the previous uterine scar.
(B)
Carefully assess the possibility of placenta accreta inwomen with a placental site that covers the previous
uterine scar. (B)
Perform an elective cesarean section before 38 GW.
(B)
Prepare for the possible need for a blood transfusion
before elective cesarean section or during an emergency cesarean section. (A)Inform women and their families of the risks ofblood transfusion and an emergency hysterectomy
in advance. (A)CQ306: How should women with a low-lying
placenta be treated?
Answer
1 Consider an elective cesarean section in womenwith a placental edge within 2.0 cm from the internal oriﬁce of the uterus at 36–37 GW. (C)2 Be cautious of placenta accreta in women withrepeat cesarean sections and a placental site on theanterior uterine wall. (B)3 Be cautious of postpartum hemorrhage. (A)CQ307: How should women with polyhydramnios
be treated?
Answer
1 Suspect polyhydramnios in women with an extraordinarily large uterus. (C)2 Diagnose as polyhydramnios based on the amniotic
ﬂuid index and/or the single deepest pocket measured using ultrasonography. (B)
3 Investigate the cause after the diagnosis of polyhydramnios. (A)
4 Consider amnioreduction in patients with symptoms derived from a large uterus or signs of premature labor. (C)CQ308: How should women with oligohydramnios
be treated?

Answer
1 Suspect oligohydramnios in women with an extraordinarily small uterus. (C)2 Diagnose as oligohydramnios based on the amniotic ﬂuid index and/or the single deepest pocket
measured using ultrasonography. (B)
3 Investigate the cause after the diagnosis of oligohydramnios at mid-gestation. (A)4 Be cautious of the fetal well-being. (B)CQ309: How should one screen for patients with
FGR?
Answer
1 Measure the fundal height of the uterus at eachantenatal visit to detect patients with FGR.
(C)
2 Estimate the fetal size in all women around 30 GW
using ultrasonography and repeat examinations if
necessary. (B)3 Be cautious of FGR, especially in women with risk
factors for FGR, such as hypertension, hyperglycemia, kidney diseases, inﬂammatory intestinal
diseases, anti-phospholipid antibody syndrome,autoimmune diseases, cardiac diseases, smoking,alcohol/caffeine abuse, previous FGR, a lean body,and inadequate weight gain during the current
pregnancy. Try to remove risk factors and to treat
them appropriately. (C)4 Diagnose as FGR when the estimated fetal weight(EFW) is below the -1.5 standard deviation value ofthe mean EFW but not the mean birthweight according to the GW. Refer to the abdominal circumferenceof the fetus and serial changes in the EFW when
diagnosing FGR. (C)CQ310: How should women with FGR be managed?
Answer
1 Investigate the cause of FGR, focusing on the following points:
1) Presence or absence of risk factors for FGR(see CQ309). (B)2) Malformation of the fetus and abnormal cord
insertion based on an ultrasonography examination. (B)3) Changes in blood pressure, protein in the urine,
and laboratory parameters, such as the platelet
count, antithrombin activity, aspartate transaminase (AST), lactate dehydrogenase (LDH), anduric acid levels. (C)4) Hyperglycemia, thyroid dysfunction, and antiphospholipid antibodies. (C)© 2011 The Authors
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5) Congenital infections, such as rubella, cytomegalovirus, and toxoplasma. (C)2 Suspect chromosomal aberration in a case with multiple malformations, characteristic malformations
suggestive of chromosomal aberration, and/or
severe FGR. A chromosomal analysis for a deﬁnite
diagnosis should only be performed with informed
consent. (B)3 Consider terminating the pregnancy after taking theresults of the following examinations into account:1) NST, contraction stress test, and biophysicalproﬁle score. (B)2) Umbilical artery ﬂow velocity waveform using
Doppler ultrasonography. (B)3) Serial changes in measurements of the fetus. (C)4 Monitor intrapartum FHR patterns continuously. (B)CQ311: How should women with placental abruption be treated?
Answer
1 Remember that pregnancy-induced hypertension,
previous placental abruption, premature labor,
including premature rupture of the membranes, andtrauma to the abdomen, such as a car accident, arerisk factors for placental abruption. (B)
2 Suspect placental abruption and perform the following tests when a woman shows abnormal FHR patterns concomitant with clinical signs of prematurelabor, such as genital bleeding, increased uterine
activity, and/or abdominal pain.
1) Ultrasonography. (B)2) Blood test, including platelet count, antithrombin(III) activity, FDP or D-dimer, AST, and LDH. (B)3 Monitor the FHR patterns continuously in womenwith an increased uterine activity after trauma to theabdomen. (C)4 Plan for prompt delivery, in principle, after the diagnosis of a placental abruption. (A)
5 Initiate treatment for disseminated intravascular
coagulation (DIC) promptly using packed red blood
cells, fresh frozen plasma, and antithrombin products when a patient/blood test shows signs of DIC.
(A)
6 Choose either of the following two modalities in apatient with a fetal death caused by placental abruption after considering the patient’s condition and thecapacity of the facility while simultaneously assessing and treating the DIC. (B)1) Facilitated vaginal delivery with the aid of anamniotomy and/or oxytocin.
2) Emergency cesarean section.

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7 Consider expectant management in a patient with aplacental hematoma if the patient shows all of thefollowing signs: unchanged size of the hematoma,
normal FHR patterns, no uterine contractions,and no exacerbation of laboratory parameters forhemostasis and coagulation. (C)CQ312: How should women with pre-eclampsia betreated?
Answer1 Recommend admission to the hospital. (C)2 Collaborate with facilities that have an NICU whentreating pre-eclamptic patients at <32 GW. (B)
3 Determine an appropriate timing for pregnancy termination through repeated assessments of physicaland blood chemistry ﬁndings in the mother andfetal development and well-being. (B)
4 If a patient complains of epigastric pain and/or
headache, measure the blood pressure and perform
blood tests, a non-stress test, and an ultrasonography examination to diagnose the patient as having
eclampsia, HELLP syndrome, or placental abruption. Take preventive measures for an eclamptic ﬁt
if indicated. (B)
5 Consider the induction of labor in patients with mild
pre-eclampsia at 36 GW. (C)
6 Measure the blood pressure regularly and prepare
for an emergency cesarean section during a trial
vaginal delivery. (B)7 Monitor the intrapartum FHR patterns continuously.
(B)
8 Refer to Table 1 in choosing an appropriate drug forthe control of hypertension. (C)CQ313: How should women with presumptive fetal
macrosomia be treated?
Answer
1 Consider possible macrosomia in a woman withglucose intolerance, an infant with a presumed
heavy-for-date weight, and previous macrosomia
and/or shoulder dystocia. (C)2 Inform the patient of the difﬁculty in making an
accurate antenatal diagnosis of macrosomia. Determine the delivery mode after discussing the issue
with the patient. (C)
3 Consider an emergency cesarean delivery in womenwith prolonged or arrested labor. (C)4 In treating women with shoulder dystocia, callthe medical staff and use a suprapubic pressure
with a combination of McRoberts’ maneuver and an
episiotomy. Do not use Kristeller’s maneuver. (C)© 2011 The Authors
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Guidelines for obstetrical practice

5 Recommend a 75-g OGTT at 6–12 weeks postpartum in women with macrosomia/shoulder dystocia
and an unknown status of glucose tolerance or
non-gestational diabetes mellitus in the current
pregnancy. (C)CQ314: How should women with GDM, overt diabetes in pregnancy, or diabetes mellitus be treated?
Answer
1 Control the blood glucose levels to a fastingmorning level 95 mg/dL, a pre-meal level100 mg/dL, and a 2-h post-meal level 120 mg/
dL. (C)
2 First, instruct the patient with regard to diettherapy; initiate insulin treatment in cases withuncontrolled blood glucose levels. (B)3 Assess fetal well-being using an NST and/or thebiophysical proﬁle score at 32 GW at an adequate interval. Recommend hospital admission if
indicated. (C)4 In women without problems of blood glucose
control, fetal well-being, or fetal development, treat
with either of the following two modalities. (B)1) Expectant management, including waiting forlabor onset, until the end of 40 GW and subsequent labor induction at 41 GW.
2) Active management with induction of labor at
37 GW, taking cervical maturation into
account.
5 Be cautious of shoulder dystocia in cases with prolonged labor, augmentation of labor, and/or
vacuum delivery. (C)
6 Determine the timing and mode of delivery individually for each case with uncontrolled blood
glucose levels, exacerbated complications derived
from glucose intolerance, and/or presumed macrosomia. (B)7 Be cautious of respiratory distress syndrome inneonates born by elective cesarean section in
women with <39 GW, uncontrolled blood glucose
levels, or an unknown due date. (C)8 Monitor intrapartum FHR patterns continuously inwomen with diabetes mellitus. (B)
9 Maintain a blood glucose level between
70–120 mg/dL during parturition. (C)10 Be cautious of hypoglycemia and monitor blood
glucose levels with changing doses of insulin
during parturition, as insulin demand decreases
abruptly after delivery. (B)CQ315: How should women with an increased riskof eclampsia be treated?

Answer
1 Measure the blood pressure (BP) and semiquantify
protein in the urine in all women who are admitted
for delivery. (B)
2 Measure the BP regularly at an appropriate interval in parturient women diagnosed as having
pregnancy-induced hypertension, a positive urine
protein result at admission, or the presence ofhypertension at admission. (B)
3 Measure the BP if parturient women complain ofheadaches, blurred vision, or epigastric pain. (B)4 Administer MgSO4 with or without antihypertensive drugs to parturient women withsevere hypertension (systolic BP  160 mmHg
and/or diastolic BP  110 mmHg). Try to maintaina BP in the range of 140–159/90–109 mmHg. (C)
5 When women experience a convulsive ﬁt, take all of
the following measures: (B)1) Measure the BP.
2) Administer diazepam (5–10 mg, i.v., in a bolus) or
MgSO4 (4.0 g, i.v., over 10 min).
3) Maintain the airway and administer oxygen after
the resolution of the convulsion.
4) Initiate a continuous 24-h i.v. of MgSO4 (1.0–
2.0 g/h) for the prevention of recurrence
6 When women are found to be unconscious (or convulsive), perform all three of the following tests torule out HELLP syndrome, brain hemorrhage, andbrain infarct, initiate treatment for an eclamptic ﬁt,
and consider the possibility of hysteria, epilepsy,
hypoglycemia, hyperventilation syndrome, and/or
local anesthetics intoxication as differential
diagnoses.
1) Physical examinations for the detection of palsyof the extremities, presence of abnormal reﬂex,
and anisocoria. (B)2) Blood test including a complete blood count(CBC), antithrombin activity, AST level, alaninetransaminase level, LDH, FDP or D-dimer level,
and an arterial blood gas analysis. (B)3) Brain computed tomography/magnetic resonance imaging, if necessary. (B)
7 Plan for an early delivery after stabilizing the condition of the patient, with careful attention to the
fetal well-being. (B)CQ316: How should women with peripartum
massive bleeding be treated?
Answer
1 Assess deﬁciency in the circulating blood volume
based on both the shock index (SI) value and© 2011 The Authors
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the measured blood loss volume as follows:(B)

SI = pulse rate ( per minute)÷ systolic blood pressure (mmHg ) .
2 When women exhibit an SI of 1.0 or an estimatedblood loss of 1.0 L during vaginal delivery (2.0 L
for cesarean delivery), treat as follows, while simultaneously clarifying and removing the cause of
bleeding:
1) Insert an i.v. catheter with a large gauge andreplace a sufﬁcient volume of ﬂuid. (A)2) Consider a blood transfusion and the transportation of the patient to a secondary or tertiary hospital. (B)3) Monitor blood pressure, pulse rate, bleeding
amount, and urine output. (A)4) Monitor the saturation of peripheral oxygen(SpO2) level. (C)3 When women exhibit continuous bleeding, a frequent SI of 1.5, an obstetrical DIC score of 8, orabnormal vital signs (oliguria, coldness of peripheral skin, or decreased SpO2), treat as follows, while
simultaneously clarifying and removing the cause of
bleeding:
1) Declare an ‘obstetrical critical hemorrhage’. (A)2) Initiate blood transfusion with packed red blood
cells and fresh-frozen plasma if available. (B)3) Transport the patient to an appropriate institution. (C)4) Administer anti-DIC drugs and platelet concentrate to women with an obstetrical DIC score of8. (C)
4 Uncross-matched group-speciﬁc blood, compatible
red cell concentrate transfusion with a different
ABO, compatible fresh-frozen plasma transfusion
with a different ABO, and compatible platelet concentrate transfusion with a different ABO can beadministered to women who are suffering from‘obstetrical critical hemorrhage’ or imminent
cardiac arrest as a result of hemorrhage in theabsence of cross-matched group-speciﬁed blood. (B)CQ317: How should ‘amnioinfusion’ be considered?
Answer
1 Consider the effects of amniotic ﬂuid infusion(amnioinfusion) as follows: (C)I. Intrapartum
1) Amnioinfusion may favorably affect the FHR
pattern by decreasing the compression of theumbilical cord.

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2) Amnioinfusion has not been demonstrated tohave a prophylactic effect on the developmentof meconium aspiration syndrome.
II. Antepartum
1) Amnioinfusion may be effective for improving the accuracy of antenatal diagnosis using ultrasonography in women witholigohydramnios.
2) Whether amnioinfusion is beneﬁcial to fetuseswith long-term oligohydramnios remains to
be studied.
2 Be cautious of amniotic ﬂuid embolism, pulmonary
edema and hypertonic uterus during the procedure.
(B)

Chapter E. Parturition
CQ401: What medicines and apparatuses should beavailable in or near the delivery room?
Answer
1. Equip the apparatuses, instruments, and drugs
shown in Tables 1 and 2.
CQ402: How should women with a breech presentation be treated?
Answer
1 Conﬁrm that a woman meets all of the following
three conditions necessary for the safe performanceof external cephalic version. (C)1) Emergency cesarean section is available.
2) No previous cesarean delivery.
3) Fetus is mature.
2 Choose elective cesarean delivery for a patientwith a knee or foot presentation, an estimatedfetal weight of <2500 g, GW of <37, or presumed
cephalopelvic disproportion. (C)3 Be able to consider a vaginal delivery in a women
without the characteristics described in Answer 2
after fulﬁlling both of the following two requirements: (C)1) Availability of well-trained and full-time medical staff with experience performing breech
deliveries.
2) Women are informed of the risks and beneﬁts ofboth vaginal and cesarean deliveries.
4 Obtain written informed consent before performinga vaginal breech delivery. (A)CQ403: How should women who wish to undergo atrial of labor after cesarean delivery (TOLAC) be
treated?
Answer© 2011 The Authors
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Guidelines for obstetrical practice

1 Obtain written informed consent for TOLAC inwhich the risks associated with a TOLAC aredescribed. (A)
2 Conﬁrm that a woman meets all of the following ﬁve conditions necessary for a safe TOLAC:(C)1) No presumed cephalopelvic disproportion.
2) Availability of emergency cesarean delivery andemergency treatment for uterine rupture.
3) Only one previous cesarean delivery.
4) Previous uterine incision was a low transverse
incision with an uneventful postpartum course.
5) No history of uterine rupture or trans-myometrial
surgery.
3 Do not use prostaglandin for the induction and/or
augmentation of labor. (A)4 Monitor FHR patterns using cardiotocographyduring TOLAC. (A)
5 Pay attention to vital signs and abdominal painin the mother after completing vaginal delivery.
(B)
CQ404: How should women with prolonged laboras a result of weak labor pains be treated?
Answer1 Recommend the oral intake of water or administeri.v. ﬂuids. (B)2 Adhere strictly to the ‘Guidelines for the use ofuterotrophic drugs in Japan 2011’ and perform all of
the following steps when using uterotrophic drugs.
(A)1) Obtain informed consent for the use ofuterotrophic drugs.
2) Do not use multiple uterotrophic drugs simultaneously.
3) Apply a cardiotocogram prior to the administration of the uterotrophic drugs.
4) Use an infusion pump for the i.v. administrationof the uterotrophic drug and increase the dose at
an interval of 30 min.
5) Assess uterine activities, maternal blood pressure, and pulse rate every hour, in principle.
6) Record the FHR pattern continuously using a
cardiotocogram, in principle.
7) Transient discontinuation of FHR monitoring with the cardiotocogram is feasible at thephysician’s discretion.
8) A well-trained nurse, midwife, or doctor should
watch the FHR pattern.
9) Consider withholding the uterotrophic drug if
an abnormal FHR pattern appears.

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10) Remember that no exceptional use is allowed forthe initiation dose, the dose increment, or the
maximum dose.
Remember that cord prolapse may occur after anamniotomy or the spontaneous rupture of the fetal
membranes. Perform an amniotomy after conﬁrming ‘the ﬁx of the fetal head, station plane of –2 cm’.
(B)
Record the FHR pattern continuously with a cardiotocogram in febrile women with a body temperature of 38.0°C. (B)Be careful of postpartum hemorrhage as a result ofuterine atony. (B)Do not inject prostaglandin F2a into the uterine muscle of postpartum women, in principle.
(A)

CQ405: How should the induction of labor at term
not medically indicated be dealt with?
Answer
1 Be able to induce labor on the demand of a woman
or after informed consent with respect to the
beneﬁts and risks associated with the induction oflabor. (B)2 Adhere strictly to the Answers in ‘CQ412’ regarding
the induction of labor. (A)3 Adhere strictly to the ‘Guidelines for the use ofuterotrophic drugs in Japan 2011’ regarding the useof uterotrophic drugs. (A)CQ406: What criteria are necessary for a safe operative delivery?
Answer
1 Only a well-trained physician or a physician supervised by a well-trained physician should perform
operative deliveries, such as vacuum and forceps
deliveries. (B)2 Monitor the FHR patterns continuously during
operative deliveries. (C)3 Use operative deliveries only in women who meet atleast one of the following conditions. (B)1) Prolonged labor or arrested labor.
2) A shortened second stage of parturition is desired
because of unfavorable maternal conditions.
3) A non-reassuring fetal status.
4 Use operative deliveries only in women who meet
all four of the following conditions.
1) Gestational age of 35 weeks. (C)2) No presumed cephalopelvic disproportion. (A)3) Completely dilated uterine cervix with ruptured
fetal membranes. (B)© 2011 The Authors
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4) After engagement of the fetal head (station planeof 0 cm). (B)Pull during uterine contractions, in principle. (B)Do not use vacuum delivery for more than 20 min.
Consider forceps or an emergency cesarean delivery
if necessary (20-min vacuum trial rule). (C)Do not use vacuum delivery after more than ﬁvevacuum trials, even in a situation meeting the
20-min vacuum trial rule (5-time vacuum trial rule).
(C)
Use outlet-, low-, or lower mid-forceps delivery
only in women with both a fetal rotation of <45
degrees and an occiput anterior, in principle. Only awell-trained physician or a physician supervised bya well-trained physician should perform a forceps
delivery in situations other than that describedabove. (B)CQ407: How should women with meconium staining be treated?
Answer
1 Pay attention to meconium staining in women withruptured fetal membranes. (B)
2 Apply cardiotocogram to women with meconium staining for at least 20 min to conﬁrm fetal
well-being. (B)3 No speciﬁc treatment is required in women withnormal FHR patterns. (B)4 Be cautious of respiratory problems, such as
meconium aspiration syndrome, in the neonate.
(B)
CQ408: How should a fetus with possible hypoxemia be resuscitated?
Answer
1 Remember that there are no reliable means ofimproving oxygenation in a fetus. (B)2 Consider withholding the uterotrophic drug, if sucha drug is being used. (A)3 The following methods may favorably affect the fetal
condition: (C)1) Change in the maternal position from supine tolateral.
2) Oxygen inhalation with a dose of 10–15 L/min.
3) Administration of a tocolytic drug, such as ritodrine (300 mL/h of a bottle containing 50 mg/
500 mL), while the mother is in a lateral position.
4) Rapid infusion of lactate Ringer solution(500 mL/20 min).
5) Infusion of warmed normal saline into the uterus(see CQ317).

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4 Perform an immediate delivery if fetal compromise
as a result of hypoxemia is strongly suspected(see CQ411). (A)CQ409: How should women at 41 GW be treated?
1 Conﬁrm the estimated date of conﬁnement using
fetal measurements obtained during the early stageof pregnancy. (A)2 Assess fetal well-being once or twice a week.
(B)
3 Induce labor or conduct watchful waiting (expectant
management) depending on the cervical maturation
between 41–0/7 and 41–6/7 GW. (B)4 Consider induction of labor in women at 42 GW.
(B)
5 Adhere strictly to the ‘Guidelines for the use ofuterotrophic drugs in Japan 2011’ when using
uterotrophic drugs. (A)CQ410: How should parturient women be treated?
Answer
1 A physician, mid-wife, or well-trained nurse canmanage parturient women. (A)2 Use a 3-cm/min ﬂow velocity for the paper that
traces the FHR pattern when using a cardiotocogram. (B)
3 Obtain a cardiotocogram for at least 20 min uponadmission or during the ﬁrst stage of labor to
conﬁrm fetal well-being. (B)
4 Once fetal well-being has been conﬁrmed as
described in Answer 3, fetal well-being may bemonitored using intermittent FHR auscultation(once every 15–90 min) until the next application ofa cardiotocogram within 6 h in women without
characteristics described in Answer 5. Continuous
FHR monitoring throughout the ﬁrst stage of laboris feasible. (B)5 Monitor the FHR pattern continuously in womenwith the following characteristics. Transient discontinuation of FHR monitoring is feasible at the physician’s discretion.
1) During the use of a uterotrophic drug, such as
oxytocin. (A)2) During the second stage of labor, in febrile
women (38.0°C), during the use of a metreurynter containing 41 mL, and during painless laborwith anesthetics. (B)3) Women requiring ‘increased monitoring’ according to Tables I, II, and III in CQ411. (B)4) High-risk pregnancies with any of the following
characteristics: (B)© 2011 The Authors
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Guidelines for obstetrical practice• Maternal factors, including diabetes mellitus,
pregnancy-induced hypertension, previous
stillborn or infant with cerebral palsy as aresult of intrapartum fetal hypoxemia at
30 GW, or a previous surgical incision into
the uterine cavity.
• Fetal factors, including a non-vertex presentation, an estimated fetal bodyweight of<2000 g, fetal growth restriction, and multiple
pregnancies.
• Placental factors, such as a low-lying placenta.
5) Other women suspected of having poorly controlled maternal complications. (C)
6 Apply a cardiotocogram for at least 20 min inwomen with any of the following situations:
1) Rupture of the fetal membranes. (B)2) Meconium staining or bloody amniotic ﬂuid.
(B)3) When bradycardia or tachycardia is noted during
intermittent FHR auscultation. (A)4) When the rapid progress of labor is noted or achange in the fetal position is anticipated afterurination or defecation. (C)
7 Review the FHR patterns that are being continuously monitored by a cardiotocogram at the following intervals: (C)1) For those who are not at a high risk or those whohave an FHR pattern of level 1 or 2: every 30 and
15 min during the ﬁrst and second stages of labor,
respectively.
2) For those at high risk or those who have an FHR
pattern of level 3: every 15 and 5 min during theﬁrst and second stages of labor, respectively.
3) For those who show an FHR pattern of level 4 or
5: watch continuously.
CQ411: How should various FHR patterns be interpreted and how should women with a non-reassuring
fetal status be treated?
Answer
1 Consider that the well-being of a fetus can beassured if the FHR pattern has a normal baseline, anormal baseline variability, the presence of acceleration, and the absence of deceleration. (A)
2 Consider that the well-being of a fetus may be
impaired if any of the following FHR patterns arepresent: (B)1) Recurrent late decelerations with absent baselinevariability.
2) Recurrent variable decelerations with absent
baseline variability.

3

4

5

6

3) Prolonged deceleration with absent baseline variability.
4) Severe bradycardia with decreased or absent
baseline variability.
Diagnose a fetus as having a non-reassuring fetal
status if an FHR pattern level of 3–5 (mild, moderate,and severe variant patterns, as shown in Table I) is
present as classiﬁed using a combination of threefactors: the baseline variability, the baseline, and thepresence of various decelerations. (C)Choose one of ﬁve treatments (no intervention,
increased monitoring, conservative measures forresuscitation of the fetus, preparation for prompt
delivery, and prompt delivery) in cases with an FHR
pattern of level 1–5, referring to Table III and taking
gestational age, the background of the women, andthe capacity of the facility into account. (C)Repeatedly assess the feasibility of a successful
vaginal delivery taking progression and the stage oflabor into account in those who continue to show alevel 3 or 4 FHR pattern. (C)Perform an emergency cesarean section soon after
abandoning vaginal delivery in the situation
described in Answer 5. (C)CQ412: How should labor be induced?
Answer

1 Adhere strictly to the ‘Guidelines for the use ofuterotrophic drugs in Japan 2011’ regarding the useof uterotrophic drugs, such as i.v. oxytocin, i.v. prostaglandin F2a, and oral prostaglandin PGE2 tablets.
(A)
2 Do not administer multiple uterotrophic drugs
simultaneously. (A)
3 Ripen the uterine cervix ﬁrst if the cervix is unfavorable for the induction of labor. (B)4 Remember the following three precautions regarding the use of hygroscopic mechanical dilators, suchas laminaria rods or a transcervical balloon catheterof 40 mL, for the ripening of the cervix.
1) Obtain informed consent as to the indications,
methods and possible adverse events associatedwith these procedures. (B)2) Perform the procedure in hospitalized women.
(B)3) Pay attention to the possibility of infection
regardless of the status of the fetal membranes.
Assess the maternal body temperature and theresults of laboratory tests, and consider theadministration of antibiotics in women withruptured fetal membranes. (B)© 2011 The Authors
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H. Minakami et al.

5 In addition, remember the following four cautions
regarding the use of a transcervical balloon catheterof 40 mL for the ripening of the cervix.
4) Obtain informed consent regarding the possible
risk of umbilical cord prolapse associated withthe use of transcervical balloon catheters. (B)5) Conﬁrm the absence of the umbilical cord near
the presenting part of the fetus prior to the startof the procedure. (B)6) Promptly apply a cardiotocogram after the commencement of labor. (B)7) Promptly conﬁrm the absence of prolapse or thedescent of the cord at the time of the rupture of
the fetal membranes or the balloon prolapse. (B)
6 In addition, remember the following three cautions
regarding the use of a transcervical balloon catheterof >40 mL for the ripening of the cervix.
8) Perform continuous FHR monitoring with a cardiotocogram. (B)9) Use a transcervical balloon catheter 150 mL
for vertex presentation. (B)10) Ensure the availability of an emergency caesarean section. (C)7 Do not administer uterotrophic drugs while using
laminaria rods and/or sodium prasterone sulfate
hydrate. (B)
8 When combining the use of a transcervical balloon
catheter and a uterotrophic drug, monitor the FHR
for at least 1 h after the application of the transcervical balloon catheter, then initiate the uterotrophic
drug. (B)
9 When using an i.v. uterotrophic drug after the use oforal PGE2, initiate i.v. oxytocin or i.v. prostaglandin
F2a at an ‘initiation dose’ at least 1 h after the lastoral PGE2 administration. Pay close attention toexcessive increases in uterine activity. (B)CQ413: How should a woman with labor pains orsome relevant problem be treated in the absence of datanecessary for the management of pregnant women
because of a lack of antenatal visits?
Answer
1 Consider her pregnancy to be high risk. (B)2 Assess the GW. (B)3 Perform tests recommended during routine antenatal care. (B)
4 Try to identify the patient and to conﬁrm that theaddress/phone number of her family contact isaccurate. (B)
5 Listen to her background in a supportive manner.
Consult a city ofﬁcer to seek public support for her

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as soon as possible if no support is available fromher family. (C)
6 Try to create better surroundings for the newborn bykeeping in contact with the woman after discharge
from the hospital through visits by regional publichealth nurses. (C)CQ414: How may safety be assured in a ‘midwifemanaged care system’?
Answer
1 A ‘midwife-managed care system’ is deﬁned as thatin which midwives care for pregnant and parturient
women in the absence of an attending physician byadhering to institutional rules made by responsible
physicians and midwives, with the assurance of aprompt switch from midwife care to physician carein the institution. (B)2 Midwife care for pregnant and parturient women is
low-risk when performed according to institutionalrules made by referring to Tables 1, 2, 3, and 4 in the‘midwife-managed care system’. (C)Chapter F. Incidental complications
CQ501: How should one respond when asked about
the outcome of pregnancy complicated with uterine
ﬁbroma?
Answer1 Respond as follows:
1) The pregnancy outcome is fairly good. However,there may be increased risks of complications,such as premature labor, an abnormal position of
the fetus, placenta previa, placental abruption,
poly- or oligohydramnios, pregnancy-induced
hypertension, or premature membrane rupture.
(B)
2) Approximately 20% of women experience transient pain (for 1–2 weeks) originating from theﬁbroma. (B)3) There may be increased risks of dystocia,
increased bleeding, labor arrest, and cesareandelivery. (B)4) The risks and beneﬁts of a myomectomy during
pregnancy and a cesarean section are uncertain atpresent. (C)5) There may be an increased risk of a hysterectomy
postpartum because of the degeneration/
infection of the ﬁbroma/uterus. (C)CQ502: How should women with an abnormal
uterine cervical cytology result during early pregnancy
be treated?

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Guidelines for obstetrical practice

Answer1 Perform colposcopy and biopsy, in principle, forpatients with abnormal cytology (LSIL, HSIL, andothers in the Bethesda system, and classes III, IV,
and V in the former system). (B)2 Treat women with histologically conﬁrmed cervicalintraepithelial neoplasia in the absence of cell cytology suggestive of invasive cancer conservatively
without conization. (B)3 Perform conization in cases with any of thefollowing characteristics: (A)1) Histologically conﬁrmed microinvasive squamous cell carcinoma.
2) Histologically conﬁrmed intraepithelial neoplasia but cell cytology indicative of invasive cancer.
3) Histologically conﬁrmed adenocarcinoma in situ.
4 Conservative treatment without termination of thepregnancy is feasible in cases with squamous cell
carcinoma stage Ia1 without lymphovascular spaceinvasion or adenocarcinoma in situ in the conization
specimen. (B)
5 Repeat the cytology examination during pregnancy
in women with conservative treatment. (A)
6 Vaginal delivery is feasible in women with conservative treatment. (A)
7 Reevaluate the disease status using cytology, colposcopy, and biopsy 4–8 weeks postpartum. (B)CQ503: How should pregnant women with postconization uterus be treated?
Answer
1 Note that women are at an increased risk of preterm
labor after undergoing cervical conization. (A)2 Be cautious of signs of preterm labor, such as theshortening of the uterine cervix and increased
uterine activity. (B)3 Consider therapeutic cervical cerclage in womenwith a shortened uterine cervix. (C)CQ504: How should women with an ovarian cyst
detected during early pregnancy be treated?
Answer
1 Use ultrasonography to visualize the ovarian cyst
and assess the possibility of malignancy; monitor
the size of the ovarian cyst to rule out the possibilityof a common ‘corpus luteum cyst’, which may
resolve spontaneously. (A)2 Treat women with ultrasonography ﬁndings suggestive of an ovarian cyst appearing as a tumor-likelesion, such as a corpus luteum cyst or an
endometriotic cyst, conservatively. (B)3 Treat women with an ovarian cyst with the characteristic ultrasonographic features of a benign lesion
as follows: (C)1) An ovarian cyst with a largest diameter of <6 cm
or a unilocular ovarian cyst with a largest diameter of <10 cm: conservative treatment without
surgical intervention.
2) An ovarian cyst with a largest diameter of10 cm or a multilocular ovarian cyst with alargest diameter of 6 cm: surgical removal of
the cyst, preferably after 12 GW.
4 Remove the tumor surgically, irrespective of the sizeand gestational age if a borderline or malignant
tumor is suspected. (B)
5 Remove the cyst surgically, irrespective of the natureof the cyst and the gestational age in cases withsevere abdominal pain as a result of ovarian torsion,
rupture, or bleeding. (A)CQ505: How should women with decayed teeth
and/or periodontal diseases be treated?
Answers
1 Recommend a visit to a dentist when asked about
decayed teeth and/or periodontal diseases, as pregnancy may have an unfavorable effect on the progression of these diseases. (B)2 Remember that favorable effects of treatment on
the risks of preterm birth and FGR have not been
demonstrated, although periodontal diseases arereportedly associated with preterm birth and FGR.
(C)

Chapter G. Infection
CQ601: How should pregnant women with bacterial
vaginosis (BV) be treated?
Answer
1 Treat women with symptomatic BV using antibiotics. (B)
2 Detect patients with BV by screening all womenwith known risk factors of preterm delivery, such asprevious preterm delivery, and treat patients with
BV using antibiotics as soon as possible. (C)CQ602: How should pregnant women with urogenital Chlamydia trachomatis infections be treated?
Answer1 Screen all women for the detection of C. trachomatis
infection using a swab specimen sampled from theendocervix for the prevention of neonatal C. trachomatis infection. (B)© 2011 The Authors
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H. Minakami et al.

2 Detect C. trachomatis in specimens using nucleic acidampliﬁcation tests, nucleic acid hybridization tests,
direct immunoﬂuorescence, enzyme immunoassay(EIA), or culture method. (B)3 Treat with a single dose of oral azithromycin (1.0 g)
or oral clarithromycin (200 mg ¥ 2/ day, 7 days). (B)CQ603: How should women with genitourinarygroup B streptococcal (GBS) infection be treated?
Answer1 Screen all women at 33–37 GW for the detection of
GBS infection using a culture method for specimensfrom the vagina, perineum, and rectum. (B)2 Administer i.v. penicillin/ampicillin to women withany of the following characteristics to prevent earlyonset GBS diseases of the infant during labor or after
premature membrane rupture: (B)1) GBS infection in a previous infant (even in theabsence of GBS in the current pregnancy).
2) All women with a positive GBS result except for
women undergoing an elective cesarean section.
3) Women with an unknown GBS status.
3 Remember that a 3-day antibiotic administration
period is sufﬁcient to eradicate GBS in women withpremature membrane rupture. (C)CQ604: How should pregnant women with anantibody against toxoplasma be treated?
Answer
1 Estimate the timing of the toxoplasma infection
using speciﬁc IgG and IgM antibodies against
toxoplasma. (B)2 Remember that a positive IgM antibody does notnecessarily indicate a recent infection occurring
within several months, since the phenomenon of‘persistent IgM’ in which positive IgM antibodies
sometimes persist for a long time (3 months) has
been known to occur. (B)3 Administer oral acetylspiramycin to women
infected after the establishment of the current pregnancy. (B)4 Consider the administration of pyrimethamine andsulphadiazine between 16 and 27 GW in womenwith a suspected fetal infection. (C)CQ605: How should women with rubella infection
during pregnancy be treated?
Answer1 Screen all women to detect patients with rubella
infection during an early stage of pregnancy using
HI (titer of antibody against rubella). (A)1192

2 Obtain the following information from women
during an early stage of pregnancy. (B)1) Contact with rubella patients during the past
3 months.
2) Skin rash during the past 3 months.
3) Febrile disease during the past 3 months.
4) Swelling of cervical lymph nodes during the past
3 months.
5) Occupation during the past 3 months.
3 Take diagnostic measures in women with any of thefollowing ﬁndings: (B)1) Symptoms suggestive of rubella infection, suchas skin rash, febrile condition, and swollen lymph
nodes.
2) Contact with rubella patients.
3) Titer of antibody (HI)  ¥256 during earlypregnancy.
4 Remember that diagnostic measures should include
both repeated measures of the HI titer in paired sera
samples and measures of speciﬁc IgM antibody. (B)
5 Administer vaccine to postpartum women with an
HI antibody titer  ¥16. (C)CQ606: How should women with HBs-antigen betreated?
Answer
1 Determine the status of HBe-antigen and liver function and tell women about the risk of HBV verticaltransmission. (A)2 Recommend a visit to an appropriate physician. (C)
3 Take measures, including the administrations of HB
immunoglobulin and vaccination against HBV toprevent HBV vertical transmission, in cooperation
with pediatricians. (A)
4 Tell women that breast-feeding does not increase
the risk of HBV vertical transmission, providing thatpreventive measures are being taken. (B)CQ607: How should women with HCV-antibody betreated?
Answer
1 Quantify HCV-RNA in the blood and examine liverfunction. (A)2 Tell women with undetectable HCV-RNA that HCV
vertical transmission does not occur. (B)
3 Tell women with detectable HCV-RNA that there
may be a risk of HCV vertical transmission. Recommend visit to appropriate physicians. (B)
4 Tell women with detectable HCV-RNA that breastfeeding does not increase the risk of HCV verticaltransmission. (C)© 2011 The Authors
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Guidelines for obstetrical practice

5 Provide information on the Japanese vertical transmission rates according to titers of HCV-RNA anddelivery modes in women with a higher HCV-RNA.
Help women to choose a delivery mode according
to these data. (C)CQ608: How should pregnant women with genital
herpes be treated?
Answer1 During the ﬁrst trimester, apply acyclovir ointment
to the lesions and advise the patient to refrain fromsexual activities. (B)2 During the second or third trimester, administersystemic anti-viral drugs to women with a primary
infection or ﬁrst-episode disease. (B)3 Recommend an elective cesarean section in womenwith any of the following statuses.
1) Presence of genital lesions at supposed time
when labor will occur. (A)2) Labor pains occurring within 4 weeks of the
manifestation of the primary infection. (C)3) Labor pains occurring within 1 week of the
manifestation of a recurrence or non-primaryﬁrst-episode disease. (C)
4 Pay attention to the neonate with respect to symptoms derived from vertical transmission. (B)CQ609: How should women with cytomegalovirus(CMV) infection be treated?
Answer
1 Remember that the clinical usefulness of screening
for CMV infection has not been established. (C)2 Consider that fetuses with growth restriction,
enlarged cerebral ventricle, microcephalus, ahigh-echoic periventricular area, ascites, and/or
hepatosplenomegaly may be infected with CMV.
(C)
3 Interpret the results of maternal CMV-antibody as
follows. (B)1) Diagnose as primary infection during pregnancy
when seroconversion (change from a negative
CMV-IgG during early pregnancy to a positive
CMV-IgG during pregnancy) is observed.
2) The effects of CMV on the fetuses are milder inwomen who acquired CMV before pregnancy (apositive CMV-IgG during early pregnancy), compared with those of a primary infection during
pregnancy, although adverse effects on thefetuses may occur.
3) Consider recent infection in women with a positive CMV-IgM, but be cautious of persistent

4
5
6

7

CMV-IgM (the phenomenon of long-lasting IgM
positivity).
Tell women with CMV infection that no helpful fetal
therapy has been established. (B)Remember that infected fetuses are likely to have anabnormal FHR pattern during labor. (C)Diagnose as congenital infection when CMV-IgM isdetected in the cord blood and/or CMV is detectedin the urine of neonates within 2 weeks after birth.
(B)
Refer infants with congenital infection to an appropriate physician for the long-term follow-up of auditory function. (B)CQ610: How should women with HIV infection betreated?
Answer1 Screen all women for the detection of patients with
HIV infection early during pregnancy using tests for
HIV screening. (B)2 In cases with a positive screening test result, do thefollowing: (A)1) Inform the woman that 19 out of 20 women witha positive screening test result are not actuallyinfected.
2) Perform a Western blotting test and a nucleic acidampliﬁcation test simultaneously to conﬁrm thescreening result.
3 Consult with a regional designated hospital regarding patients with HIV/AIDS. (C)4 Perform all of the following measures to prevent
vertical transmission. (B)1) Treat infected women with antiretroviral drugs
during pregnancy.
2) Elective cesarean delivery.
3) Formula milk feeding.
4) Prophylactic administration of antiretroviraldrugs to the neonate.
CQ611: How should pregnant women with varicellainfection be treated?
Answer
1 Tell women as follows when asked about varicellainfection during pregnancy:
1) Women with neither a history of varicella infection nor vaccination against varicella should
refrain from contact with patients with varicella.
(A)2) Congenital varicella syndrome is reportedly
seen in 0.55%, 1.4%, and 0.0% of neonates bornto mothers infected with varicella during the© 2011 The Authors
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H. Minakami et al.

2
3

4
5

6

ﬁrst-, second-, and third-trimesters of their pregnancies, respectively. (B)3) No infants with congenital varicella syndrome
and/or malformation as a result of varicella infection have been born to mothers in whom an erroneous vaccination was administered during the
3 months prior to the establishment of pregnancy
or during pregnancy. (B)Do not administer varicella vaccine to pregnant
women. (A)Administer prophylactic i.v. gammaglobulin (2.5 g
to 5.0 g) to women who have been in close contact
with a patient infected with varicella during the previous 2 weeks and who may be susceptible to varicella infection because of a possible lack of antibody.
(C)
Administer acyclovir to pregnant women with varicella infection to prevent serious complications. (C)Treat the mother and neonate as follows when themother manifests a varicella infection during the
5 days prior to delivery or 2 days postpartum:
1) Administer acyclovir to the mother. (B)2) Administer i.v. gammaglobulin to the neonate.
(B)
3) Administer acyclovir to neonates with symptoms
of varicella infection. (B)Isolate in-hospital pregnant women with varicellainfection in a private room away from other women
to prevent in-hospital horizontal transmission. (C)3) Short-term breast-feeding
3 months after birth.

withintheﬁrst

CQ613: How should women with syphilis betreated?
Answer1 Screen all women for the detection of patients withsyphilis using two methods (a non-speciﬁc test anda speciﬁc test for T. pallidum). (A)1) Non-speciﬁc tests include serological tests for
syphilis (STS), such as an agglutination test,
VDRL test, or RPR card test.
2) Speciﬁc tests include FTA-ABS and TPHA.
2 Promptly administer antibiotics, such as penicillin,
to women with active syphilis. (A)3 Assess the fetus during the latter half of the pregnancy with respect to signs of infection, such as
hepatomegaly, ascites, hydrops, and a thickened placenta, in infected women. (C)4 Assess the effect of treatment at 28–32 GW andperinatally using the STS titer. (C)5 Remember that physicians must notify the regional
public health center within 7 days of diagnosing a
new patient with syphilis according to the Infectious
Diseases Control Law, in which syphilis is classiﬁed
as a ﬁfth-class infectious disease. (A)
6 Examine the neonate born to an infected motherwith respect to congenital syphilis, according toTable 2. (A)CQ612: How should women with a positive screening test result for HTLV-1 infection be treated?
Answer

CQ614: How should women with parvovirus B19(PB19) infection be treated?
Answer

1 Note that a considerable number of women show afalse-positive result on screening tests for HTLV-1
infection (particle agglutination or enzyme-linked
immunosorbent assay). (A)
2 Diagnosis as an HTLV-1 carrier only after a conﬁrmation test (Western blot analysis) shows a positive
result. (A)3 Inform women of their diagnosis as an HTLV-1
carrier very carefully, with consideration of ethicalproblems. (A)4 Inform the patient’s family of her diagnosis as an
HTLV-1 carrier only after receiving the patient’s permission. (B)
5 Instruct the patient in the following methods asalternatives to breast-feeding for the prevention of
HTLV-1 vertical transmission: (B)1) Formula milk feeding.
2) Frozen-thawed breast milk.

1 Remember the following two points: (B)1) Co-living with a patient with PB19 infection is arisk factor.
2) Flu-like symptoms associated with erythema andarthralgia are signs of a PB19 infection.
2 Determine the anti-PB19 IgM titer if a PB19 infection
is suspected. (B)3 Assess fetal anemia and hydrops in cases withmaternal PB 19 infection, since approximately 10%
of such fetuses develop anemia, hydrops and/or
die. (C)
4 Consider PB19 infection as a differential diagnosis
for fetal hydrops. (B)5 Recommend that infected women wash their hands
and wear a ﬂu mask to prevent in-hospital horizontal transmission. (C)
6 Remember that the following facts are known about
PB infection during pregnancy: (C)1194© 2011 The Authors
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Guidelines for obstetrical practice1) Ninety percent of hydrops fetalis cases develop
within 8 weeks (median, 3 weeks) after maternal
infection with PB19.
2) Fetal mortality is higher for maternal infection at<20 GW than for maternal infection at >20 weeks.
3) Spontaneous remission occurs in one-third ofhydrops fetalis cases.
4) A blood transfusion to the fetus may be effective
for improving the outcome.
5) The outcome of surviving fetuses with PB19
infection is similar to that of non-infected fetuses.

Chapter H. Twin pregnancies
CQ701: How should chorionicity and amnionicity be
determined for a twin pregnancy?
Answer
1 Determine chorionicity until the end of 10 GW. (A)2 Count the numbers of chorions and amnions using
ultrasonography to determine the chorionicity andamnionicity. (A)1) Diagnose as monochorionic and dichorionic
twins in cases with one and two gestational sacs
(GS), respectively, as the number of GS equals
that of the chorion.
2) Diagnose as dichorionic in cases with a relatively
thick dividing membrane (inter-twin septum).
3) Diagnose as diamniotic in cases of monochorionic twins with a thin dividing membrane.
4) Presume monochorionic monoamniotic twins
and repeat the ultrasonography examinationin cases with an unrecognizable dividing
membrane.
3 Determine the chorionicity and amnionicity referring to the presence or absence of a twin peaksign, the number of placentas, and the fetal sex incases with undetermined chorionicity at 14 GW.
(B)
CQ702: How should women with monochorionic
twin pregnancies be treated?
Answer
1 Refer women to secondary or tertiary institutions ortreat the women in cooperation with those institutions. (B)2 Provide information on the risks associated withmonochorionic twins. Be cautious of the occurrenceof twin-to-twin transfusion syndrome and twinreversed arterial perfusion sequence. (B)
3 Determine amnionicity (mono- or di-) before 14 GW.
(B)

4 Examine using ultrasonography at least once every
2 weeks in cases with monochorionic diamniotic
twin pregnancy, paying attention to discordances involumes of the amniotic ﬂuid and/or fetal development. (C)
5 Provide information on the risk of sudden fetal
death as a result of cord entanglement in womenwith monoamniotic twins. (C)CQ703: How may twin-to-twin transfusion syndrome (TTTS) and a twin reversed arterial perfusion(TRAP) sequence be detected in monochorionic twin
pregnancies?
Answer1 Presume TTTS and examine extensively in a casewith a tendency toward polyhydramnios in one
twin and oligohydramnios in the co-twin. (B)2 Presume a TRAP sequence and examine extensively
when a dead twin is growing. (B)CQ704: How should women with twin pregnancies
and a single fetal death be treated?
Answer
1 Manage expectantly, but pay attention to maternal
DIC in dichorionic twin pregnancies. (B)2 Manage expectantly, but pay attention to anemia andthe well-being of the surviving twin in monochorionic twin pregnancies. (C)3 Inform women with a monochorionic placenta thatthe surviving twin is at an extraordinarily high riskof developing permanent disabilities or perinatal
mortality, even with the best of treatment. (C)CQ705: What general cautions are needed whenmanaging women with twin pregnancies?
Answer
1 Pay attention to clinical signs of preterm labor in thelatter half of the pregnancy. (A)2 Provide adequate tests for the detection ofpregnancy-induced hypertension, HELLP syndrome and venous thromboembolism during thelatter half of the pregnancy. (C)
3 Pay closer attention to fetal well-being at 37 GW in
twin pregnancies than in singleton pregnancies. (B)4 Refer to the following when choosing a delivery
mode: (C)1) Both twins are cephalic presentation: vaginal
delivery.
2) First twin is cephalic and the second twin is noncephalic: similar cautions to those for the vaginal
delivery of a singleton with a breech presentation© 2011 The Authors
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H. Minakami et al.

are required during the vaginal delivery trial (seeCQ402).
3) First twin is non-cephalic presentation: elective
cesarean section.
5 Monitor the FHR patterns of both fetuses continuously and simultaneously during labor. (B)
6 Conﬁrm the fetal position and FHR pattern of thesecond twin immediately after the vaginal birth of
the ﬁrst twin. (B)
7 Pay attention to postpartum hemorrhage andvenous thromboembolism. (C)Chapter I. Newborns
CQ801: How should neonates with birth asphyxia beresuscitated?
Answer
1 Physicians, midwives and nurses are required tomake every effort to acquire knowledge and thenecessary skills to perform neonatal resuscitation, as
one in 100 neonates requires resuscitation just after
birth. (A)2 Assess the following three points just after birth. (A)1) Not an immature infant.
2) Good breathing/crying.
3) Good muscle tone.
3 Care for neonates routinely as shown in Table 1 incases meeting all three conditions described in
Answer 2. (B)4 Perform the ‘primary resuscitative procedures’shown in Table 2 if any abnormality is present
among the three conditions shown in Answer 2. (B)
5 Take further resuscitative measures in cases inwhich ‘primary resuscitative procedures’ havefailed, referring to Figure 1 posted on the wall of thedelivery room. (C)
6 Determine the Apgar scores at 1 and 5 min andrecord them. (B)
7 Analyze the umbilical arterial blood gas and record
the ﬁndings. (C)8 Be cautious of maintaining an adequate neonatal
body temperature. (B)
9 Consult neonatologists or experienced physicians if
there is any concern regarding the neonate’s condition. (B)CQ802: How should newborns be cared for within
10 days after birth?
Answer
1 Apply eye drops or ointment containing antibiotics
to the eyes of newborns to prevent conjunctivitis.
(B)

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2 Attempt to ﬁnd any congenital anomalies. (B)3 Conﬁrm the absence of extremity paralysis andcephalohematoma. (A)4 Regularly assess body temperature, bodyweight,
respiration, feeding conditions, activities, and skincolor (jaundice and cyanosis). (B)
5 Remember that clinical impressions, such as a lackof vigor, bad skin color, or tachypnea, are often
clues for the diagnosis of speciﬁc abnormalities innewborns. (B)
6 Suspect a possible infection, hypoglycemia, congenital heart disease, gastrointestinal disease,hemolytic disease, or congenital metabolic disease
if a neonate exhibits any of the abnormalities
described in Answer 4. (B)7 Administer vitamin K to neonates in an adequate
manner (refer to the Discussion). (B)
8 Provide mass-screening tests for the detection ofcongenital metabolic diseases and an auditory test
to neonates after obtaining the parents’ informed
consent. (C)9 Remember that discharge from the hospital within
3 days after birth is associated with an increased
risk of re-hospitalization for jaundice and/or dehydration. (C)
10 Keep in contact with regional public health nurses
or city ofﬁcers who may be concerned with neonatal health, if necessary. (C)11 Support mothers to establish breast-feeding.
(C)
12 Pay attention to the safe preparation and preservation of formula milk, referring to Table 2.
(B)
CQ803: What information concerning respiratorysyncytial virus (RSV) is helpful for preterm infants(<36 GW) leaving the hospital?
Answer1 Preterm infants (<36 GW) with RSV infection arelikely to develop severe complications. (C)2 The prophylactic administration of certain drugs
to preterm infants during the RSV season preventsor reduces severe complications caused by RSV.
(C)
3 Provide information on clinics at which drugs for
RSV prophylaxis are available. (C)CQ804: How should the cause of intrauterine fetal
death (IUFD) at 22 GW be determined and how
should women with IUFD be treated?
Answer© 2011 The Authors
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Guidelines for obstetrical practice

1 Estimate the time of IUFD in an integrated manner.
(A)
2 Determine the cause of death using the following
tests:
Fetal factors
1) Macroscopic inspection of the stillborn infant,placenta and the umbilical cord. (A)2) Histopathological examination of the placenta
and umbilical cord. (C)3) Autopsy of the stillborn infant. (C)4) X-ray examination of the whole body of thestillborn infant, or equivalent examinations.
(C)5) Chromosomal analysis. (C)Maternal factors
6) Tests such as the indirect Coombs test for atypical antibodies against erythrocytes in cases withan undetermined antibody status. (B)7) Tests for antiphospholipid antibody, including
lupus anticoagulant, anti-cardiolipin antibody,and anti-cardiolipin b2GP1 antibody. (C)8) Tests for syphilis in undetermined cases.
(B)9) Tests for parvovirus B19 or other TORCH infections. (C)10) Tests for glucose tolerance and thyroid function.
(C)11) Tests for coagulation-ﬁbrinolysis system. (C)12) Test for feto-maternal transfusion. (C)3 Provide information regarding the risk of recurrencein siblings of IUFD cases with structural malformations and/or chromosomal aberrations at therequest of the mother/family. (B)4 Support the mother and family psychologically andemotionally with counseling and other forms ofassistance. (B)

Chapter J. Others
CQ901: How should one respond when asked about
the effects of car seatbelts during pregnancy?
Answer1 Explain as follows.
Damage from car accidents is reduced if seatbelts
are applied in an appropriate manner. The chest
belt should pass between the breasts, and the waist
belt should pass below the pubic bone; neither belt
should cross the protruding abdomen. (A)CQ902: How should female patients involved in
multiple casualty incidents be treated?
Answer
1 Consider the possibility of a casualty being pregnant
while performing triage and while treating andtransporting female casualties. (B)
2 Try to identify pregnant women using ultrasonography or a similar apparatus to detect the fetal
cardiac activity if female casualties are not able
to respond to questions during secondary triage. (C)
3 Tag pregnant patients who are suffering from arupture of fetal membranes, genital bleeding, pain in
the abdomen, and/or fetal death with a red card. (B)CQ903: How should one behave after experiencing
an incidental maternal mortality?
Answer
1 Notify the ‘accident investigation committee’ of
each hospital. (A)
2 Contact the central and prefectural ofﬁces of theJapan Association of Obstetricians & Gynecologists(JAOG) and report the incident in detail. (A)
3 Make every effort to obtain consent to perform an
autopsy. (A)© 2011 The Authors
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