Knowledge Attitude and Practice of Postpartum Parturients Towards Cervical Cancer and Cervical Cancer Screening; Is Lack of Knowledge the Misleading Scapegoat?

OBJECTIVE: The aim of this study was to assess knowledge, attitude, and practices towards cervical cancer screening among postpartum subjects. STUDY DESIGN: This cross-sectional study was conducted at inpatient obstetrics ward at Thammasat University Hospital (TUH), Thailand. The period of study was between July 2020 and July 2021. Subjects were term Thai pregnant women who had age between 20 and 45 years old and delivered at TUH. Demographic characters, knowledge, attitude and practices regarding cervical cancer screening were collected. RESULTS: A total of 388 parturient was recruited into the study. Average age was 31 years old. Around 90 percent of subjects knew that every woman age between 21and 65 years old with or without children should be screened for cervical cancer despite having only 46.6 percent (181/388) of subjects that underwent postpartum cervical cancer screening. Almost half of the participant agreed that risky sexual behavior of both genders was not the cause of cervical cancer. Despite the availability of the HPV vaccine throughout the country, only 74.2 percent acknowledged that HPV was the cause and only 70.4% heard about the HPV vaccine. The mean attitude about the cervical cancer was relatively high with the mean of 3.19±0.46. Although the higher the score the better the attitude toward the statement, there were several correlations of having such attitude. CONCLUSION: Attention to postpartum cervical cancer screening was quite low even though high knowledge of cervical cancer and screening. Scant knowledge was not all of the troubles that we believed long time ago.

Cryotherapy Reduced Postoperative Pain in Gynecologic Surgery: A Randomized Controlled Trial.

OBJECTIVE: To examine the effectiveness of cryotherapy for reducing postoperative pain in patients who underwent exploratory laparotomy for gynecologic surgery. MATERIALS AND METHODS: Patients who had indication for an exploratory laparotomy gynecologic procedure were selected by attending physicians to undergo abdominal surgery via low transverse skin incision. The participants were randomized into study and control groups with simple random sampling methods. Cold packs were applied at two hours after operation for 6 hours. The visual analog scale (VAS) score was recorded at two, 6, and 12 hours after operation. RESULT: One hundred cases were recruited and then divided into study and control groups equally. The mean age of both groups was 43 years. There was no difference in demographics data of both groups. Half of the participants in both groups underwent hysterectomies. At two hours after surgery, both groups had similar VAS scores. The study group had a lower VAS score at 6 and 12 hours after surgery than the control group with statistical difference. Morphine consumption within 24 hours after surgery in both the study and control groups was 2.8±3.4 and 3.0±4.4 mg, respectively, with no statistical difference. However the registration time of the first morphine requirement in the study group was statistically more prolonged than that of the control group. The lengths of hospital stay in both groups were similar. There was no complication reported in this study. CONCLUSION: Cryotherapy can reduce postoperative pain. In this presented study the patients who underwent gynecologic surgery had improved pain relief and prolonged time for the first dose of the analgesic drug.

Efficacy of Intrauterine Lidocaine Instillation in Reducing Pain during Endometrial Biopsy by Novak.

Abnormal uterine bleeding in women aged 35 years or over is an important clinical sign of many gynecological conditions. The diagnoses of these conditions require the pathological report of the endometrial tissue. Outpatient-based endometrial biopsy is an excellent option compared to standard fractional uterine curettage or hysteroscopy with endometrial biopsy in providing a definite diagnosis for abnormal uterine bleeding as it is less painful and does not require high potency anesthesia. This study evaluates the effect of intrauterine lidocaine on the patient's pain score during endometrial biopsy by the Novak curette. We included patients aged 35 years or more who had abnormal uterine bleeding between December 2016 and March 2018. The study was conducted at Thammasat University Hospital, Pathum Thani, Thailand. 250 patients were randomly allocated to either receive intrauterine lidocaine (study group) or normal saline (control group). Assessment of pain severity was evaluated using a visual analogue scale (VAS) score at 6 time-points, namely, before performing the procedure, when grasping the cervix by the tenaculum, during the intrauterine instillation of lidocaine or normal saline, during the uterine curettage, and then 15 minutes and 2 hours after the procedure. This study showed that there was significant pain reduction in patients who received intrauterine instillation of lidocaine compared to placebo, during uterine curettage, as well as 15 minutes and 2 hours after procedure (p<0.0001). Patient satisfaction was not significantly different between the two groups, while physician satisfaction significantly improved in the lidocaine group. Serious complications were not found during this study. (This research project had been approved for registration at Thai Clinical Trials Registry. TCTR identification number is TCTR20161031003.).

Quality of Life in Cervical Cancer Survivors and Healthy Women: Thai Urban Population Study

Background : To determine a baseline quality of life (QoL) in cervical cancer survivors compared to that of healthy subjects in the tertiary Thammasat University Hospital, Thailand. Materials and Methods: The investigation was conducted at the outpatient gynecological department of Thammasat University Hospital between January and June 2016. A total of 192 women were entered into the study (97 cervical cancer survivors; 37 after radical hysterectomy (RH), 43 with concurrent chemoradiation (CRT), and 17 featuring both RH and CRT; and 95 control subjects from the same outpatient department with no history of malignancy). Participant QoL was assessed using a Thai version of the EORTC-QLQ-C30 (European Organization for Research Treatment of Cancer Quality-of-Life) and a general survey for the assessment of sociodemographic data was also conducted. Results: There were significant differences in physical, role, emotional and social functions between cervical cancer survivor and control groups. Global health, fatigue, pain, appetite loss, and financial difficulties also demonstrated statistically significant variation. Cervical cancer survivors treated by RH had higher scores for emotional and social function and global health than the control group. Moreover, they had less appetite loss, fatigue and financial difficulties. However, patients treated with CRT experienced more pain than the control group. All cervical cancer survivors had lower physical function scores than the control group. Conclusion: Quality of life in cervical cancer survivors is better than in healthy peers in some domains. Cervical cancer survivors treated with RH may have a better QoL than healthy peers. Early detection for early stage cervical cancer remains most important because treatment in early stages does not cause lowering of the QoL.

Clinical Factors Associated with Specimen Adequacy for Conventional Cervical Cytology in Thammasat University Hospital, Thailand.

PURPOSE: To study clinical factors related to adequacy of transformation zone (TZ) components in cervical smears. MATERIALS AND METHODS: Medical and Papanicolaou (Pap) smear reports from Thammasat University Hospital, Thailand during January to December 2015 were collected. Demographic data was reviewed by attending physicians and impact of clinical factors onTZ adequacy was primary outcome. A total of 3,251 smears were reviewed. Finally, 2,098 smears met The inclusion criteria and enrolled into this study. RESULTS: Average age and bodyweight of participants in this study were 43.0 years and 60.0 kg, respectively. Ninety seven percent of smears were classified as satisfactory for evaluation according to the Bethesda system 2001. Adequacy (group A) and inadequacy (group B) of TZ were equal in percentage (50.9/46.0). Prevalence of abnormal cervical cytology was 4.4%. Percentages of abnormal Pap smears in group A and B were 7.3 and 1.4, respectively (p<0.001). Factors associated with increased adequacy of TZ were old-age (≥ 50 yr), nulliparity, within 3-months postpartum, history of TZ inadequacy and abnormal smears. Sexually transmitted disease (STD), hormonal usage, previous cryotherapy and smears collected by staff were associated with inadequacy of TZ. CONCLUSIONS: Collection of cervical specimens should be carefully performed. STD history, hormonal usage and previous cryotherapy are risk factors for TZ inadequate specimens.

Silent High Grade Cervical Intraepithelial Neoplasia in Atypical Smears from Liquid Based Cervical Cytology - Three Years Experience in Thammasat University Hospital.

PURPOSE: To study the prevalence of CIN2+ diagnosis in women with atypical Papaniculoau (Pap) smears to suggest appropriate management option for Thai health care. MATERIALS AND METHODS: Data from all patients with liquid based cytology with human papillomavirus (HPV) testing between May 2013 - May 2016 were collected from medical records. Women with atypical cervical Pap smears were recruited. Results for age, HPV testing, HPV 16, 18, 45 and other genotypes tested, colposcopic examination and histopathological assessment were all collected. Atypical smears were defined as atypical squamous cells of undetermined significance (ASC-US) and atypical squamous cells cannot be exclude high grade squamous intraepithelial lesion (ASC-H). RESULTS: A total of 2,144 cases were recruited. Twenty six women with ASC-US on cytology had high risk (HR) HPV detection while eight cases with ASC-H had HR-HPV (40.0% VS 72.7%, p=0.005). Among the 26 women with ASC-US cytology and positive HR-HPV, HPV type 16 (n=8, 30.8%), type 18 (n=1, 3.8%), type 45 (n=1, 3.8%) and other HPV types (n=17, 65.4%) were found. Eight women with ASC-H and positive HR-HPV demonstrated type 16 (n=6, 75%) and other HPV types (n=2, 25%). Fifty seven women with ASC-US had normal colposcopy, CIN1 and CIN2+ at percentages of 80.7 (46/57), 14.0 (8/57) and 5.3 (3/57), respectively. In the ASC-H group, 7 out of 10 women had normal colposcopy and three (30%) had CIN2+ results. CONCLUSIONS: In women with ASC-US cytology, immediate colposcopy is highly recommended. HPV testing can be performed if colposcopy is not an available option because there was high prevalence (5.3%) of CIN2+ in our findings. ASCCP recommendations for ASC-H that colposcopy should be performed on all ASC-H cases regardless of HPV result are thereby supported by the findings of this investigation.

Experience of Combined Liquid Based Cervical Cytology and High-Risk HPV mRNA for Cervical Cancer Screening in Thammasat University Hospital.

BACKGROUND: Cervical cancer is the second most common of malignancy found in Thai women. Human papillomavirus (HPV) infection is a major cause. The objective of the present study was to evaluate the prevalence of HPV infection and association with abnormal cervical cytology in Thai women. MATERIALS AND METHODS: This study was conducted at the Gynecologic Clinic, Thammasat University, Pathum Thani, Thailand. A total of 2,144 cases who underwent annual cervical cancer screening by co-testing (liquid based cytology and HPV testing, DNA versus mRNA) during the priod from July 2013 to June 2016 were recruited in this study. RESULTS: Prevalence of positive high risk (HR) HPV DNA and mRNA test were 19.7 and 8.4%, respectively with a statistically significant difference. Majority of cases of abnormal cytology in this study were atypical squamous cells of undetermined significance (ASC-US). In patients with ASC-US, positive HR HPV DNA was greater than in the mRNA group (10.1 and 4.5%, p<0.001). Nonetheless, there was no significant difference in participants with cervical intraepithelial neoplasia (CIN). HPV mRNA test had slightly lower sensitivity but higher negative predictive value (NPV) than the DNA test to detect abnormal cytology during cervical cancer screening (p<0.001). Both HPV test (DNA and mRNA) had equally efficacy to detect high grade precancerous lesion or higher (CIN 2+). CONCLUSIONS: Prevalence of HR HPV DNA and mRNA were 19.7 and 8.4 percent, respectively. NPV of HPV mRNA was higher than DNA test. Both tests had equal efficacy to detect CIN 2+ with sensitivity and specificity of 63% vs 55.7% and 83% vs 92%, respectively.

Incidental Finding of Metastatic Cutaneous Malignant Melanoma at Uterine Leiomyoma, A Thai University Hospital Experience: A Case Report.

BACKGROUND: Metastatic malignant melanomas to the uterus are extremely rare; to our knowledge, no more than 13 cases have been reported to date. CASE REPORT: A 44-years-old multigravida woman presented with a black and irregular surface mass at medial aspect of left thigh. There was also an enlarged left groin node. Wide excision with lymph node dissection revealed malignant melanoma. Further examination found a huge pelvic mass with left deep vein thrombosis consequent by pressure effect. Chest and complete abdominal computed tomography revealed an enlarged, fibroid uterus with pressure effect at left common iliac vein. A total abdominal hysterectomy and bilateral adnexectomy were performed. Intra-operative finding was scattered hyperpigment spots at surface of the uterus and its tumor Histopathological report showed metastatic malignant melanoma involving myometrium and uterine serosa. Diagnosis of stage IV malignant melanoma (uterine metastasis) was achieved. The patient was counseled about her diagnosis, stage, prognosis and further treatment. CONCLUSION: Uterine metastatic malignant melanoma was a rare condition. This report represents the first case of a cutaneous malignant melanoma involving a uterine leiomyoma in Thailand.

Prenatal diagnosis of placenta accreta by colour Doppler ultrasonography: 5-year review.

OBJECTIVE: To determine the accuracy of colour Doppler ultrasonography to diagnose placenta accreta. MATERIAL AND METHOD: The authors reviewed cases of placenta accreta between January, 2008 and December, 2012. Ultrasonographic images consistent with signs ofplacenta accreta (numerous vascular lacunae, loss ofsubplacentalsonolucent space, absent lower uterine segment between bladder-placenta, turbulent or complicated blood flow at the uteroplacental interface) were correlated with findings at the time of surgery and pathologic examination. RESULTS: Over 60 months, 12 cases (0.48/1,000 deliveries) with suspected placenta accreta by ultrasonography were studied. The median gestational age atfirst diagnosis was 24 weeks. All cases had at least one previous cesarean delivery. At surgery, all cases had an adherent placenta requiring hysterectomy (five accreta, three increta, andfourpercreta). Four cases (33%) had accidental tear of urinary bladder Nine cases (75%) required blood transfusions. CONCLUSION: Colour Doppler ultrasonography appears useful in antenatal diagnosis ofplacenta accreta.

Is the correlation between Papanicolaou smear and histopathology results affected by time to colposcopy?

BACKGROUND: Time to colposcopy (TC) after abnormal Pap smears was evaluated for influence on cytohistologic correlation (CHC). MATERIALS AND METHODS: This retrospective study assessed the correlation between TC and CHC of women who had abnormal Pap smears. Colposcopic chart review included participants from 2010- 2013 who attended a colposcopic clinic, Thammasat University Hospital, Thailand. RESULTS: Four hundred and sixty cases who had abnormal Pap smears were recruited. Pap reports were atypical smears with low grade squamous intraepithelial lesion (SIL), high grade SIL and cancer at 339, 114 and 7 cases, respectively. One hundred and twenty four patients underwent loop electrosurgical excision procedure (LEEP). A half of the cases were colposcopically examined within 1-2 months after abnormal Pap collection. CHC was 88 percent and not affected at all by TC. Subjects who attended cervical cancer screening from affiliated health providers had shorter TC than those screened in our tertiary hospital. CONCLUSIONS: Time to colposcopy with abnormal Pap smears conducted at Thammasat University Hospital had a highest frequency of 42 days, in line with the literature. Length of TC does not affect the correlation between Pap and histopathologic reports. A longer waiting period for colposcopy did not alter progression or regression of the disease.

Misoprostol for cervical ripening prior to manual vacuum aspiration (MVA) in abnormal uterine bleeding: double blinded randomized controlled trialt.

OBJECTIVE: To study the effectiveness of sublingual misoprostol for cervical ripening before MVA in women aged between 35 and 55 years old. MATERIAL AND METHOD: Women aged between 35 and 55 years old who had indications for endometrial sampling were recruited. Exclusion criteria were gross pathology of cervix, pregnancy, allergy to misoprostol, and abnormal coagulopathy. Eighty women who had indication for MVA were then assigned by randomization (block of four). Participants were treated with either sublingual 200 microg of misoprostol (study group) or placebo (controlled group) for cervical priming at two hours before procedure. The largest diameter of the Hegar's dilator through internal so without any resistance before MVA was the primary collected data. Secondary data were operating time, immediate pain score, satisfactory score, complications, and side effects. RESULTS: Mean age of misoprostol and controlled group were 44.8 +/- 5.2 and 45.5 +/- 5.0 years old, respectively. One third of both groups had previously experienced uterine curettage. The initial cervical diameter before MVA of individuals receiving misoprostol and controlled group were 6.9 +/- 2.0 and 5.5 +/- 2.4 mm, respectively. The MVA time in misoprostol group was significantly shorter than controlled group (5.1 +/- 1.7 vs. 8.0 +/- 3.9 min, p < 0.001). The additional analgesia was not different in both groups. Side effect before MVA were more significantly found in misoprostol group (p = 0.001). Lower post MVA pain and satisfactory score were better reported in misoprostol group than placebo's (p < 0.001). CONCLUSION: Two hundred micrograms of sublingual misoprostol administration prior to MVA gave significantly effective result of cervical priming. Satisfactory and pain scores were more favorable in misoprostol group with manageable side effects.

Second trimester uterine artery Doppler screening in prediction of adverse pregnancy outcome in high risk women.

OBJECTIVE: To assess the value of uterine artery colour Doppler waveform analysis in the prediction of adverse pregnancy outcome such as preeclampsia, fetal growth restriction in high risk pregnancy women. MATERIAL AND METHOD: Uterine artery Doppler screening was performed as part of mid trimester screening between 20 and 24 weeks gestation in high risk pregnancy women at Matermal Fetal Medicine unit, Thammasat University Hospital between June 1, 2008 and May 31, 2009. A pulsatility index (PI) was calculated from each uterine artery and the presence or absence of a notch was determined. A PI of > 1.58 or the presence of any diastolic notch were defined as abnormal. The main outcome measures were pre-eclampsia and small for gestational aged baby (birth weight < 10th centile). RESULTS: Doppler examination of the uterine arteries were performed in 330 singleton pregnancies. Twenty-seven (8.18%) women developed pre-eclampsia, 16 (4.84%) women had SGA babies. The sensitivity ofPI > 1.58 and diastolic notch for preeclampsia, SGA were 59.25% and 56.25%, respectively.The specificity of PI >1.58 and diastolic notch for these outcomes were 66.67% and 65.60% respectively. CONCLUSION: In high-risk women, mid trimester uterine artery Doppler waveform analysis can not use as screening method in women at higher risk for the development of severe adverse outcome such as pre-eclampsia and SGA babies. However women with normal uterine artery Doppler results are unlikely to develop pre-eclampsia, fetal growth restriction (FGR) and therefore do not necessarily need repeated Doppler ultrasound follow-up.

Prevalence and management of abnormal pap smear in antenatal care clinic at Thammasat University Hospital.

OBJECTIVE: To investigate the prevalence of abnormal Papanicolaou smear in pregnant patients who attend the Antenatal Care Clinic at Thammasat University Hospital. MATERIAL AND METHOD: Pregnant patients who attended the antenatal care clinic at Thammasat University Hospital from August 2003 to December 2003 were recruited for Papanicolaou test. Patients who had abnormal results of equally or over "abnormal squamous/glandular cells of undetermined significance" were assigned for colposcopy and colposcopic biopsy to confirm the result. RESULTS: From 500 Papanicolaou smear performed, there were only four patients who had abnormal Pap tests, which were: 2 ASC-US and 2 LSIL. The prevalence of abnormal Pap smear in pregnant patients who attended the antenatal clinic at Thammasat University Hospital was 0.8 percent. CONCLUSION: The prevalence of abnormal Papanicolaou smear in pregnant patients attending antenatal care clinic at Thammasat University Hospital was quite low in compares with other literature.