Is The “See and Treat” Approach Appropriate for Management of Women with Abnormal Cervical Cytology in Thailand?

At present, the “see and treat” approach for women with abnormal cervical cytology is widely accepted. It has been proven to be more cost-effectiveness than conventional management, making it particularly attractive for many regions in Thailand where resources are limited and poor patients’ compliance is expected. However, the main disadvantage of the “see and treat” approach is the risk of overtreatment. National Health Service (NHS) guidelines recommend that the overtreatment rate in the “see and treat” approach must be less than 10%. The overtreatment rate appears to be acceptable if the “see and treat” approach is carried out in women with high-grade squamous intraepithelial lesion (HSIL) cytology or in women with lesser grades of smear abnormality whose colposcopic findings suggest high-grade disease

Adenocarcinoma in situ of the uterine cervix

Adenocarcinoma in situ (AIS) of the uterine cervix has been acknowledged as a precursor lesion of invasive adenocarcinoma. AIS is histologically characterized by the presence of endocervical gland lined by atypical endocervical epithelium resembling the cells of adenocarcinoma but has no evidences of stromal invasion. AIS occurs within the endocervical clefts, it is difficult to screen cytologically. Incorporating high-risk HPV-DNA testing into cytologic screening could better identify AIS lesion. For definitive diagnosis of AIS, cervical conization either with knife, electrical loop, or laser is required to ensure the exclusion of coexisting invasive adenocarcinoma. Hysterectomy remains the most preferred method of definite treatment. Conservative management by conization alone is only acceptable for whom preservation of fertility is an issue. The occurrences of recurrent or persistent disease for women treated for AIS are mostly noted during the first 3 years of follow-up emphasizing the necessity of extensive surveillance in this period

Abnormal Hysterosalpingographic Findings in Infertile Women

Objectives:To determine the rate and patterns of hysterosalpingography (HSG) abnormality among infertile women at Srinagarind Hospital, Khon Kean University, Thailand.Materials and Methods:The study patients were identified through the reports of the Infertile Clinic. In our hospital, HSG was routinely performed in all women undergoing an evaluation of infertility problems. Medical records were extracted for baseline characteristics, types of infertility, and details of HSG findings. A 95% confidence interval (CI) was calculated to demonstrate the precision of data. Logistic regression model was used to determine an independent impact of the type of infertility on abnormal HSG findings.results:Overall, 589 women were reviewed. The mean ± SD age was 32.9±5.0 years. Secondary infertility was noted in 163 (27.7%) women. Abnormal HSG was noted in 227 (38.5%, 95% CI, 34.6%-42.6%) women. The most common abnormal HSG findings were tubal occlusion and hydrosalpinx. When adjusted with patients’ age, women with secondary infertility carried a higher risk of having abnormal HSG finding compared to those with primary infertility (an adjusted odds ratio, 2.44; 95% CI, 1.68-3.54). Conclusion:Rate of abnormal HSG findings among infertile women in our setting was approximately 40%. Type of infertility was independently associated with abnormal HSG findings

Evaluation of Completeness of Operative Records in Women Undergoing Gynecologic Surgery at Chiang Mai University Hospital

Objective: To evaluate the completeness of operative records at the general gynecologic surgery unit using the Good Surgical Practice (GSP) 2008 guidelines as a gold standard.Materials and methods: The operative records of women undergoing gynecologic operation at Chiang Mai University Hospital between January and July 2009 were reviewed. According to GSP 2008, the operative record should include all of the following data: (1) date and time of operation; (2) types of surgery ; (3) name of the operating surgeon and assistant; (4) operative procedure carried out; (5) incision; (6) operative diagnosis; (7) operative findings; (8) operative complications; (9) any extra procedure performed and its reason; (10) details of tissue removed, added or altered; (11) identification of any prosthesis used including serial numbers of such materials; (12) details of closure technique; (13) postoperative care instruction and (14) a signatureResults: During the study period, the medical records of 232 women who underwent gynecologic surgery were reviewed to determine the quality of the operative record. Postoperative care instruction was completely recorded in all operative notes (100%). Only 2 of the 14 items failed above 10% including details of incision (10.3%) and details of closure technique (12.9%). The signature was absent in 13 operative notes (5.6%).Conclusion: The evaluation results of operative records as per GSP 2008 guidelines in this study appear to be favorable. The details of incision and closure technique should be improved and periodic audit is required to assure that these standards are maintained

Borderline Clear Cell Adenofibroma of the Ovary

Borderline clear cell tumors are extremely rare, and few cases have been reported in the literature. Herein, we present a case of borderline clear cell adenofibroma of the ovary in a 58-year-old woman who presented with a pelvic mass and constipation. Physical examination revealed a 10 cm solid midline pelvic mass. Computed tomography showed an 8 cm heterogeneous enhancing mass attached to the left posterolateral wall of the uterus. The patient’s serum CA 125 levels were slightly elevated (80.9 U/ml). The patient was given a total abdominal hysterectomy with bilateral salpingooophorectomy. On gross examination, it was found that the left ovarian tumor was an 8.0 × 7.5 × 8.0 cm solid multilobulated mass containing tiny cysts. Histologically, the tumor was composed of small glands in dense fibrous and myxoid stroma. The glands were lined with cuboidal cells with clear cytoplasm and mild to moderate nuclear atypia. No stromal invasion was observed. The pathological diagnosis was borderline clear cell adenofibroma of the left ovary. There was no reoccurrence 36 months post operation

A Case Report of High-Grade Endometrial Stromal Sarcoma: A Rare Cause of Abnormal Uterine Bleeding in a Young Woman

High-grade endometrial stromal sarcoma (HG-ESS) is a rare clinical entity, particularly among young women, and only few cases have been reported in the literature. Herein, we describe the case of a 21-year-old woman who presented with a four-month history of excessive bleeding per vagina. Endometrial curettage and cervical biopsy revealed a malignant round cell tumor suggestive of metastatic sarcoma of uterine origin. Computed tomography of the abdominopelvic region showed an enlarged uterus with diffused thickening throughout the entire endometrial cavity. Intraabdominal lymphadenopathy and ascites in the pelvic cavity were noted. The patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, resections of the enlarged pelvic nodes, omentectomy, and biopsy of the peritoneal nodules in the cul-de-sac. Histological examination revealed a tumor with a permeative growth pattern composed of uniformly high-grade round cells with brisk mitotic activity and extensive lymphovascular space invasion. Sections of the pelvic lymph nodes on both sides and the peritoneal nodule revealed multiple metastatic foci. Immunohistochemical studies showed positive diffuse staining for vimentin, CD 10, and cyclin D1. The pathological diagnosis was HG-ESS stage IIIC. The patient experienced rapid progression of the disease while receiving adjuvant treatment and succumbed eight months after the operation. HG-ESS is a rare cause of AUB in adolescents and young women but should be considered in the differential diagnosis

Endometriosis-Associated Massive Ascites in an Asian Woman: A Case Report of a Rare Clinical Entity

Massive ascites as a presentation of endometriosis is a rare clinical entity that is most commonly seen in black nulliparous females. Herein, we describe a case of a 32-year-old multiparous Thai woman who presented with a two-year history of abdominal distension. Computerized tomography of the abdominopelvic region showed an infiltrative enhancing lesion involving the cul-de-sac and perirectal region with massive loculated ascites, suggesting carcinomatosis peritonei. Abdominal paracentesis was performed to yield fluid samples for evaluation, which revealed no malignant cells, and polymerase chain reaction (PCR) was negative for tuberculosis. The patient underwent exploratory laparotomy which revealed a large amount of serosanguinous ascites, thickened matted bowel loops, and necrotic debris covering the entire surface of the peritoneum and visceral organs. The surgical procedures included drainage of 6.5 liters of ascites, lysis adhesion, biopsy of the peritoneum, and right salpingo-oophorectomy. Histologic examination revealed benign endometrial glands with stroma at the peritoneum tissue and broad ligament. Other causes of ascites were excluded. The ascites responded to drainage and hormonal suppression. A final diagnosis of endometriosis was made based on these findings. Endometriosis should therefore be considered in differential diagnosis in women of childbearing age who present with ascites

Risk of Severe Adverse Maternal and Neonatal Outcomes in Deliveries with Repeated and Primary Cesarean Deliveries versus Vaginal Deliveries: A Cross-Sectional Study

Objective. To determine risks of severe adverse maternal and neonatal outcomes in women with repeated cesarean delivery (CD) and primary CD compared with those with vaginal delivery (VD). Methods. Data of this cross-sectional study were extracted from 2,262 pregnant women who gave birth between August 2014 and December 2016, at Srinagarind Hospital, Khon Kaen University. Severe maternal outcomes were categorized based on the World Health Organization criteria. Adjusted odds ratio (aOR) and 95% confidence intervals (CI) were calculated to indicate the risk of severe adverse maternal and neonatal outcomes among women underwent CD compared with those who underwent VD. Results. There were no cases of maternal death in this study. CD significantly increased risk of severe adverse maternal outcomes (SMO) (aOR 10.59; 95% CI, 1.19-94.54 for primary CD and aOR 17.21; 95% CI, 1.97-150.51 for repeated CD) compared with women who delivered vaginally. When compared with vaginal delivery, the risks of neonatal near miss (NNM) and severe adverse neonatal outcomes (SNO) were significantly higher in primary CD group (aOR 1.71; 95% CI 1.17-2.51 and aOR 1.66; 95% CI 1.14-2.43), respectively. For repeated CD, the risks were borderline significant (aOR, 1.58; 95% CI, 0.98-2.56 for NNM and aOR, 1.61; 95% CI, 0.99-2.60 for SNO). Conclusion. Primary and repeated CD significantly increased the risk of SMO compared with VD. Risks of NNM and SNO were also significantly increased in women with primary CD. The risks of NNM and SNO for repeated CD trended toward a significant increase

Appropriateness of Preoperative Screenings in Patients Undergoing Elective Gynecologic Surgery at Srinagarind Hospital, Khon Kaen University, Thailand: An observational study

Objectives: To evaluate the appropriateness of routine preoperative screening for patients who undergoing elective major gynecologic surgery at a tertiary care university hospital, Khon Kaen Province based on the hospital guideline.Materials and Methods: This retrospective descriptive study reviewed 808 medical records of gynecologic patients undergoing elective surgery in 2014.results: The mean age of the patients was 44.2 years. Approximately 36% of patients had associated co-morbidity. Almost 90% of the patients had inappropriate screening tests. Complete blood count and chest x-ray were the two most appropriate screening test. The most inappropriate tests were urinalysis and fasting blood sugar. Patients were classified into 4 groups: 1) patients < 45 years old with no underlying conditions; 2) patients < 45 years old with at least one underlying conditions; 3) patients ≥ 45 years old with no underlying conditions and 4) patients ≥ 45 years old with at least one underlying conditions. The first group had highest rate of performing inappropriate preoperative tests with blood urea nitrogen/creatinine as the most overuse test. The costs of inappropriateness preoperative tests were 39.8% of the total costs of preoperative assessment.Conclusion: Almost 90% of the patients had inappropriate screening tests which increased the cost by about 40%. Hospital administrators should find appropriate mechanisms to reinforce doctors to strict their requests for only tests that are necessary