Utility of pelvic examination in assessing women with bleeding in early pregnancy: a multicenter Canadian emergency department study.

BACKGROUND: Bleeding in early pregnancy is a common emergency department (ED) presentation. Although variability in approaches has been demonstrated, research is relatively uncommon on practices and outcomes. This study investigated the influence of clinical pattern of care, utility, and contribution of pelvic examination aimed at diagnosing and managing bleeding in early pregnancy at three Canadian EDs. METHODS: After obtaining informed consent, data were collected from adult women who were pregnant and from treating ED physicians using a structured questionnaire. We defined the change in management based on the initial clinical plan at the time of the initial physician assessment in the ED and any subsequent changes made after the pelvic examination was performed. Patient telephone follow-up was supplemented by linking with provincial administrative data for births. Univariable and multivariable binary logistic regression analyses were performed to identify factors associated with a change in patient management following pelvic examination in the ED. RESULTS: Overall, 200 women were enrolled. The mean age was 31 years, patients had been bleeding for a median of 1 day and stayed in the ED for a median of 5 h. Of these, 166 (83.0%) received a pelvic examination, including speculum examination and/or bimanual palpation. Pregnancy outcome data were available for 192 pregnancies; 107 (56%) experienced a miscarriage. Factors significantly associated with a change in management after pelvic examination in the univariate logistic regression analysis were brown/dark-red bleeding per vaginam (physician determined), tachycardia, right lower quadrant tenderness, and bimanual palpation. In the multivariate logistic regression analysis, brown/dark-red bleeding per vaginam was independently associated with a reduced likelihood of a change in management after pelvic examination (aOR = 0.37; 95% CI: 0.14-0.98). CONCLUSION: Among women presenting to the ED with bleeding in early pregnancy prior to 20 weeks gestation, only brown/dark-red vaginal bleeding, potentially indicative of bleeding resolution, significantly independently influenced the baseline odds of a change in management after pelvic examination. Until the debate on the utility of pelvic examination in the ED for this presentation is resolved, physician preferences and shared decision making with patients should guide practice regarding speculum examination/bimanual palpation for the management of bleeding in early pregnancy.

Expanding management strategies for cervical precancerous lesions in resource-limited settings: insights from a training center in a district hospital in Ghana.

BACKGROUND: Cervical cancer continues to disproportionately burden women in low/middle-income countries like Ghana. We examined treatment patterns and histopathological outcomes among women screened using visual inspection with acetic acid (VIA) and/or mobile colposcopy who subsequently underwent thermal ablation, large loop excision of the transformation zone (LLETZ), or cold knife conization at the Cervical Cancer Prevention and Training Centre, Battor. We also assessed the prevalence of cervical intraepithelial neoplasia 2+ (CIN2+) or micro-invasive disease and their associated factors for women who underwent excisional treatments. The treatment choices for cervical precancerous lesions suitable for resource-limited settings have also been described from the perspective of a center that manages a heterogenous population. METHODS: We conducted an analysis of secondary data collected between June 2016 and June 2023 among women with positive findings on VIA or mobile colposcopy who subsequently underwent thermal ablation or large loop excision of the transformation zone (LLETZ). The prevalence of histopathology outcomes, including no dysplasia, CIN1 - 3, and micro-invasive disease, were estimated with 95% confidence intervals (CIs). Factors associated with histopathological findings were modeled using multinomial logistic regression. RESULTS: For the study period, 14 (10.6%) of the total 132 participants underwent cervical lesion treatment at outreach locations, all via thermal ablation. The remaining 118 (89.4%) were treated at the Catholic Hospital, Battor using LLETZ (n = 66, 55.9%), thermal ablation (n = 51, 43.2%), and cold knife conization (n = 1, 0.9%). Among 65 women with histopathology reports, the most frequent histopathological finding was no dysplasia (47.7%; 95% CI, 35.1 - 60.5), followed by CIN2 and CIN3 (20.0%; 95% CI, 11.1 - 31.8 each), CIN1 (7.7%; 95% CI, 2.5 - 17.0) and micro-invasion (4.6%; 95% CI, 1.0 - 12.9). Those with micro-invasive disease were significantly older than those with CIN1, CIN2, and CIN3 (p = 0.036, 0.022, 0.009, respectively), but not significantly older than those who showed no dysplasia (p = 0.088). For each unit increase in age, the likelihood of CIN3 was relatively significantly reduced compared to no dysplasia (crude relative risk ratio [RRR] = 0.93; 95% CI, 0.86 - 0.99). This association was neither observed with the remaining histopathological groups nor for parity and persisted after controlling for parity (adjusted RRR = 0.92; 95% CI, 0.85 - 0.99; p = 0.025). CONCLUSION: This paper largely demonstrates treatment options available to women and practitioners in LMICs. The high combined prevalence of high-grade precancerous lesions and micro-invasive disease underscores the need to increase cervical cancer awareness that would enhance screening attendance and hasten efforts at moving from opportunistic to organized screening in Ghana. This will enhance early cervical lesion detection and treatment, while simultaneously re-evaluating and cutting down on unnecessary treatment.

Prevalence of high-risk human papillomavirus infection among women with diabetes mellitus in Accra, Ghana.

BACKGROUND: There is increasing evidence of a higher risk and poorer prognosis of cervical cancer among women with diabetes mellitus (DM) compared to the general population. These are mediated by higher susceptibility to persistent high-risk human papillomavirus (hr-HPV) infection due to dysfunctional clearance in an immunocompromised state. We aimed to determine the prevalence of hr-HPV infection and cervical lesions in a cohort of women with DM in Ghana. We further disaggregated the prevalence according to DM type and explored factors associated with hr-HPV infection. METHODS: This retrospective descriptive cross-sectional study assessed 198 women with DM who underwent cervical screening via concurrent hr-HPV DNA testing and visual inspection with acetic acid in an outpatient department of the National Diabetes Management and Research Centre in Korle-Bu Teaching Hospital, Accra from March to May 2022. Univariate and multivariable binary logistic regression were used to explore factors associated with hr-HPV positivity. RESULTS: Among 198 women with DM (mean age, 60.2 ± 12.1 years), the overall hr-HPV prevalence rate was 21.7% (95% CI, 16.1-28.1), disaggregated as 1.5% (95% CI, 0.3-4.4) each for HPV16 and HPV18 and 20.7% (95% CI, 15.3-27.0) for other HPV genotype(s). Respective hr-HPV prevalence rates were 37.5% (95% CI, 15.2-64.6) for type 1 DM, 19.8% (95% CI, 13.9-26.7) for type 2 DM, and 25.0% (95% CI, 8.7-49.1) for unspecified/other DM types. Past use of the combined contraceptive pill independently increased the risk of hr-HPV infection by approximately three times (adjusted odds ratio [aOR] = 2.98; 95% CI, 1.03 - 8.64; p-value = 0.045), whereas each unit increase in FBG level increased the odds of hr-HPV infection by about 15% (aOR = 1.15; 95% CI, 1.02 - 1.30; p-value = 0.021). CONCLUSION: Our study points to a high prevalence of hr-HPV among women with DM and highlights a need for glycemic control among them as this could contribute to lowering their odds of hr-HPV infection. The low overall rates of HPV vaccination and prior screening also indicate a need to build capacity and expand the scope of education and services offered to women with DM as regards cervical precancer screening.

Prevalence of high-risk human papillomavirus infection and cervical lesions among female migrant head porters (kayayei) in Accra, Ghana: a pilot cross-sectional study.

BACKGROUND: Little attention has been given to the risk of high-risk human papillomavirus (hr-HPV) infection and cervical precancerous lesions among female migrant head porters (kayayei) in Ghana, as a vulnerable group, and to promote cervical screening in these women. This pilot study aimed to determine the prevalence of hr-HPV infection and cervical lesions among kayayei in Accra, the capital of the Greater Accra Region of Ghana and to describe our approach to triaging and treating these women. METHODS: This descriptive cross-sectional cohort study involved the screening of 63 kayayei aged ≥ 18 years at the Tema Station and Agbogbloshie markets in March 2022 and May 2022. Concurrent hr-HPV DNA testing (with the MA-6000 platform) and visual inspection with acetic acid (VIA) was performed. We present prevalence estimates for hr-HPV DNA positivity and VIA 'positivity' as rates, together with their 95% confidence intervals (CIs). We performed univariate and multivariable nominal logistic regression to explore factors associated with hr-HPV infection. RESULTS: Gross vulvovaginal inspection revealed vulval warts in 3 (5.0%) and vaginal warts in 2 (3.3%) women. Overall, the rate of hr-HPV positivity was 33.3% (95% CI, 21.7-46.7), whereas the VIA 'positivity' rate was 8.3% (95% CI, 2.8-18.4). In the univariate logistic regression analysis, none of the sociodemographic and clinical variables assessed, including age, number of prior pregnancies, parity, past contraceptive use, or the presence of abnormal vaginal discharge showed statistically significant association with hr-HPV positivity. After controlling for age and past contraceptive use, only having fewer than two prior pregnancies (compared to having ≥ 2) was independently associated with reduced odds of hr-HPV infection (adjusted odds ratio, 0.11; 95% CI, 0.02-0.69). CONCLUSION: In this relatively young cohort with a high hr-HPV positivity rate of 33.3% and 8.3% of women showing cervical lesions on visual inspection, we posit that kayayei may have an increased risk of developing cervical cancer if their accessibility to cervical precancer screening services is not increased.

Antenatal and postnatal cervical precancer screening to increase coverage: experience from Battor, Ghana.

Background: Cervical precancer screening in low-resource settings is largely opportunistic with low coverage. Many women in these settings, where the burden of cervical cancer is highest, only visit health institutions when pregnant or after delivery. We explored screening during antenatal and postnatal visits aimed at increasing coverage. Methods: Pregnant women (in any trimester) attending antenatal care (ANC) and women attending postnatal care (PNC; 6-10 weeks) clinics were screened at Catholic Hospital, Battor and at outreach clinics from February to August 2022 (08/02/2022 to 02/08/2022). At the same visit, cervical specimens were obtained for high-risk human papillomavirus (hr-HPV) DNA testing (with the Sansure MA-6000 PCR platform) followed by either visual inspection with acetic acid (VIA) or mobile colposcopy with the enhanced visual assessment system. Results: Two hundred and seventy and 107 women were screened in the antenatal and postnatal groups, respectively. The mean ages were 29.4 (SD, 5.4) in the ANC group and 28.6 (SD, 6.4) years in the PNC group. The overall hr-HPV prevalence rate was 25.5% (95% confidence interval (CI), 21.1-29.9) disaggregated as 26.7% (95% CI, 21.4-31.9) in the ANC group and 22.4% (95% CI, 14.5-30.3) in the PNC group (p = 0.3946). Overall, 58.9% of pregnant women (28.3% hr-HPV+) and 66.4% of postnatal women (22.5% hr-HPV+) only visited a health facility when pregnant or after delivery (at Child Welfare Clinics). The VIA 'positivity' rate for all screened women was 5.3% (95% CI, 3.1-7.6), disaggregated into 5.2% (95% CI, 2.5-7.8) in the ANC group and 5.7% (95% CI, 1.3-10.1) in the PNC group (p-value = 0.853). Conclusion: A significant number of women in Ghana only visit a health facility during pregnancy or after delivery. ANC and PNC clinics would offer opportunities to increase coverage in cervical precancer screening in low-resource settings. Relying on community nurses ensures that such programs are readily integrated into routine care of women and no opportunity is missed.

Transformation zone types: a call for review of the IFCPC terminology to embrace practice in low-resource settings.

Most cervical cancers develop in the transformation zone (TZ). Type 3 TZs, where the full circumference of the squamocolumnar junction (SCJ) is not visible pose problems during cervical screening with visual inspection methods, as (pre)cancerous lesions may be missed. Several practical strategies can be implemented to convert type 3 TZs into TZ 1 or TZ 2, including the use of an endocervical speculum or hygroscopic cervical dilators, opening the vaginal speculum more widely, skillful use of cotton-tipped applicators, performing colposcopy in midcycle, and use of oral or vaginal misoprostol and estrogen to 'ripen' the cervix. With the 2011 International Federation for Cervical Pathology and Colposcopy (IFCPC) terminology, settings with better resources to manipulate the cervix for a better view of the endocervical canal may assign patients to different categories from those in low-resource settings during a colposcopic examination. Here, we propose a colposcopic revision to the current IFCPC classification by segregating TZ 2 according to the extent of endocervical involvement and TZ 3 according to whether any attempt is made to open the endocervical canal, if such attempt(s) were successful, and the extent to which the practitioner can visualise parts of the uterine cervix beyond the border of the SCJ in the endocervical canal. In this proposed reclassification, TZ 2A has no part of the SCJ extending beyond 5 mm into the endocervical canal, whereas TZ 2B has part or all of the SCJ extending beyond 5 mm into the endocervical canal. TZ 3 is further subclassified into TZ 3A if the practitioner does not attempt to open the endocervical canal or the endocervical canal is opened, but not beyond 5 mm and TZ 3B if the full circumference cannot be visualised after opening the endocervical canal beyond 5 mm. We believe this revision will improve and better standardise the classification of TZ types, with huge implications for practice in low-resource settings, due to limited options for referral and treatment, to reduce the risk of missed cervical cancers and suboptimal treatment resulting from ablating lesions that extend too far into the endocervical canal.

Tritesting in Battor, Ghana: an integrated cervical precancer screening strategy to mitigate the challenges of multiple screening visits and loss to follow-up.

Background: Human papillomavirus (HPV) DNA testing is more sensitive than cytology for detecting cervical precancer; however, increasing reports of high-risk HPV (hr-HPV)-negative cases of cervical intraepithelial neoplasia (CIN) and even malignancy motivate the use of combined testing. We present our experience with 'tritesting', defined as the performance of HPV DNA testing, cytology and visual inspection in a single session at the Cervical Cancer Prevention and Training Centre, Ghana. We further determined the prevalence rates of hr-HPV infection, abnormal cytology and cervical lesions among women screened using tritesting. Methods: This descriptive retrospective cross-sectional study assessed all women screened via tritesting between April 2019 to April 2023. HPV DNA testing was performed using the Sansure MA-6000, GeneXpert or AmpFire platforms. Visual inspection was performed using enhanced visual assessment mobile colposcopy or visual inspection with acetic acid. Liquid-based cytology was performed using cervical samples taken with a Cervex-Brush® and fixed in PreservCyt, while samples for conventional cytology were taken using an Ayre spatula and cytobrush. Results: Among 236 women screened (mean age, 39.1 years (standard deviation, 10.9)), the overall prevalence rates of hr-HPV infection and cervical lesions were 17.8% (95% confidence interval (CI), 13.1-23.3) and 11.9% (95% CI, 8.0-16.7), respectively. Cytology yielded findings of atypical squamous cells of undetermined significance or worse in 2.5% (95% CI, 0.9-5.5) of women. Histopathology following loop electrosurgical excision procedure revealed CIN I (tritest positive) and CIN III (hr-HPV-positive, visual inspection 'positive', cytology-negative) in one woman each. Factors independently associated with hr-HPV infection among 'tritested' women were age ≥ 39 years, tertiary level of education and current contraceptive use. Twenty-seven out of 39 hr-HPV-positive women (69.2%; 95% CI, 52.4-83.0) showed a type 3 transformation zone and would have needed to be recalled for a cytologic sample to be taken in a 'see and triage' approach with HPV DNA testing and a visual inspection method. Conclusion: This study brings tritesting into the spotlight, as an alternative to other methods, particularly for women who prefer this due to the advantage of a single visit to a health facility and being more cost-effective, if they have to travel long distances to access cervical screening services.

Determining the prevalence of high-risk human papillomavirus infection using a novel cervical precancer screening approach in incarcerated women at the Nsawam Medium Security Prison, Ghana.

BACKGROUND: Across Ghana, females comprise 1.2% of the entire prison population (n = 15,463). Cervical cancer screening services are however nonexistent and the prevalence of high-risk human papillomavirus (hr-HPV) and cervical precancer is undocumented. We aimed to screen and treat inmates for cervical precancer and determine the prevalence of hr-HPV using the novel AmpFire HPV detection system combined with colposcopy by trained nurses using a mobile colposcope (the Enhanced Visual Assessment (EVA) system). METHODS: A descriptive cross-sectional study design was employed, involving all incarcerated women at the Nsawam Medium Security Prison, Ghana. After counselling and informed consent, women underwent a structured questionnaire-based interview entered into a Microsoft Excel spreadsheet. Women were co-tested for cervical pre-cancer and hr-HPV by two trained nurses using dry brush cervical samples for 15 hr-HPV types (AmpFire HPV test) after which mobile colposcopy with the EVA system was performed. EVA images were reviewed by a gynaecologist. Frequencies and percentages were used to describe categorical data, while means, standard deviations, medians and interquartile ranges (IQRs) were used to describe continuous data. RESULTS: 75% of the women were convicts with a median sentence of 5 years (IQR: 2-10 years). Their mean age was 41.1 years (standard deviation: 15.5 years, range: 19-97 years). The self-reported prevalence rate of HIV was 13.1% (95% confidence interval (CI): 7.5%-21.9%), all of whom were receiving treatment. The hr-HPV prevalence rate was 47.6% (CI: 36.9%-58.3%) in the general population of imprisoned women and 63.6% (CI: 35.4%-84.8%) among HIV positive women. Six percent (6%) had lesions on the cervix, of which 3.6% were treated with thermal coagulation and 2.4% were treated with loop electrosurgical excision procedure. The average age of hr-HPV positive women was 37.8 years. CONCLUSIONS: There is a high prevalence of hr-HPV infection among women in custody at the Nsawam Medium Security Prison. These women will benefit from structured cervical cancer prevention services, including treatment for abnormalities that are picked up during such screening.