Complications of loop electrosurgical excision procedure for cervical neoplasia: a prospective study.

OBJECTIVES: To evaluate the complications following loop electrosurgical excision procedure (LEEP) for diagnosis and treatment of cervical neoplasia. MATERIAL AND METHOD: Descriptive cross sectional study in patients with abnormal cervical cytology who underwent LEEP at Chiang Mai University Hospital between November 2004 and July 2005 were prospectively evaluated for complications. RESULTS: During the study periods, 206 patients underwent cervical loop excision for a total of 226 procedures. The mean age of the patients was 41 years (range, 26-72 years). Sixty (29.1%) women were menopausal. The most common abnormal cervical cytology was HSIL (56.3%) followed by LSIL (12.1%). Twenty-five (11.1%) patients received re-excision for positive margin after the first procedure. Intraoperative hemorrhage occurred in 7.9% of the procedures. Early and late postoperative hemorrhage occurred in 0.4% and 2.6% of the procedures, respectively. Eight (3.5%) had postoperative infections and were cured with oral antibiotics. By logistic regression analysis, there was no significant correlation between age, menopausal status, HIV status, re-excision procedure, final histopathology, cone dimension and the complications of LEEP. CONCLUSION: Loop electrosurgical excision procedure is safe for evaluation and treatment of cervical neoplasia with an acceptable and manageable surgical morbidity.

Comparative study of bulky stage IB and IA cervical cancer patients treated by radical hysterectomy with and without neoadjuvant chemotherapy: long-term follow-up.

One hundred and ninety patients with bulky (> 3 cm) stage IB and IIA cervical cancer who underwent radical hysterectomy between 1991 and 1994 at Maharaj Nakorn Chiang Mai Hospital were reviewed to determine whether neoadjuvant chemotherapy (NAC) with MVAC (Methotrexate, Vinblastine, Adriamycin, Cisplatin) improved survival. There were 42 patients treated with pre-operataive NAC (MVAC 1-3 courses) and 148 patients treated by primary surgery (PS). In the NAC group, the overall response rate from MVAC was 88.1 per cent with 31.0 per cent having complete clinical response and 7.1 per cent with complete pathological response. Pelvic lymph node metastasis was not significantly different between the NAC group (16.7%) and the PS group (18.2%). At a median follow-up of 64.5 months, 19.0 per cent in the NAC group and 18.2 per cent in the PS group had tumor recurrence. The 5-year progression free and overall survival was 80.8 per cent and 92.0 per cent respectively for the NAC group which was not significantly different from 80.2 per cent and 92.9 per cent respectively in the PS group. In conclusion, although NAC can decrease the tumor size and produce a high response rate, it does not improve survival in bulky stage IB and IIA cervical cancer patients.

A comparison between 25 micrograms and 50 micrograms of intravaginal misoprostol for labor induction.

Our purpose was to compare the efficacy 25 micrograms and 50 micrograms dosage of intravaginal misoprostol for labor induction in patients with an unfavorable cervix. Fifty pregnant women were randomly assigned to receive either 25 micrograms (24 cases) or 50 micrograms (26 cases) of intravaginal misoprostol every 6 hours. The mean interval from induction to vaginal delivery was significantly shorter in the 50 micrograms group (13.8 +/- 6.6 hours) when compared with the 25 micrograms group (20.9 +/- 9.5 hours) (P = 004). The average number of misoprostol doses needed per patient was significantly fewer in the 50 micrograms group (1.6 +/- 0.7 versus 2.3 +/- 1.2, P = 0.018). The frequencies of uterine tachysystole were 4.2 per cent and 7.7 per cent in the 25 micrograms and 50 micrograms groups respectively which did not significantly differ. Requirement for oxytocin infusion in the 25 micrograms group was significantly more than in the 50 micrograms group (66.6% versus 23.1% respectively, P = 0.004). Analgesia requirement, delivery method, and perinatal outcomes were comparable in both groups. In summary, intravaginal application of 50 micrograms misoprostol at 6-hour interval is comparable in safety but more effective for labor induction than the 25 micrograms dosage.

Comparison of vacuum extraction delivery between the conventional metal cup and the new soft rubber cup.

To compare the effectiveness and complications of vacuum extraction delivery between the conventional metal cup and the silicone rubber cup. A prospective randomized clinical trial of 90 pregnant women requiring assisted vaginal delivery who met the predetermined criteria for vacuum extraction were allocated to delivery by the Malstrom metal cup (46 cases) or the silicone rubber cup (44 cases). The two groups were similar in respect of age, parity gestational age and indications for assisted vaginal delivery. The mean and median numbers of tractions and time from cup application to delivery were not significantly different between the groups. The overall success rate was higher in the metal cup (89.1%) than in the rubber cup (79.5%) but not significantly different. The silicone cup was more likely to fail in cases of occiput posterior position, excessive caput, and severe degree of molding. There were no significant differences between groups in terms of Apgar scores, birth canal injury, and maternal blood loss. Scalp injuries occurred more frequently with the metal than with the rubber cup (P = 0.006). Vacuum extraction delivery with the silicone rubber cup is associated with reduced scalp injuries but has a greater tendency to fail when the fetus presents in occiput posterior position, has excessive caput or severe degree of molding.

Termination of second-trimester pregnancy with intracervicovaginal misoprostol.

To evaluate the efficacy and side effects of intracervicovaginal misoprostol in termination of second-trimester pregnancy in women with live fetuses. A total of 50 pregnant women between 14 and 27 week's gestation undergoing termination of pregnancy for medical, obstetrical and genetic reasons were recruited to receive 200 ug misoprostol gel administered intracervicovaginally every 12 hours. The rates of successful abortions within 24 hours and 48 hours were 54 per cent and 92 per cent respectively. The mean time from induction to abortion was 27.5 hours. The rate of complete abortion, defined as the passage of the fetus and placenta without operative assistance was 80 per cent. Side effects were fever (8%), nausea and vomiting (6%) and diarrhea (2%). Thirty one patients (62%) required meperidine as analgesia. Two patients (4%) had postpartum hemorrhage. Intracervicovaginal misoprostol is an effective, cheap, safe and relatively convenient method for termination of second-trimester pregnancy with a live fetus.

Comparison of intracervical and intravaginal misoprostol for cervical ripening and labour induction in patients with an unfavourable cervix.

OBJECTIVE: To compare the efficacy of intracervical versus intravaginal misoprostol for cervical ripening and labour induction at term in patients with an unfavourable cervix. METHOD: A total of 100 pregnant women with indications for induction of labour and unfavourable cervix (Bishop score < or = 4) were randomly assigned to receive either 100 ug misoprostol administered intracervically (50 cases) or intravaginally (50 cases). RESULTS: No significant differences were noted between intracervical and intravaginal misoprostol in terms of Bishop score change, (score 7.2 vs score 7.5), interval from gel insertion to vaginal delivery (17.0 hours vs 16.4 hours), meperidine as analgesic requirement (80% vs 76%), route of delivery and perinatal outcome. Uterine tachysystole occurred in 24 per cent and 32 per cent in the intracervical and intravaginal groups respectively which did not significantly differ, however, all could be rapidly resolved by terbutaline injection. No evidence of fetal distress was noted in these events. Spillage of gel out of the cervix was observed in 70 per cent of patients receiving intracervical misoprostol. Fever was observed in one patient of each group. No other serious side effects were found in both groups. One patient in the intravaginal group had postpartum hemorrhage due to delayed placental separation and uterine atony. CONCLUSION: The two routes of misoprostol gel application appear to be safe and equally effective in ripening cervix and inducing labour, however, the intravaginal application is more convenient to administer practically compared with the intracervical.

Evaluation of colposcopic accuracy in diagnosis of cervical neoplasia.

OBJECTIVE: To evaluate the accuracy of colposcopy in the diagnosis of cervical neoplasia. STUDY DESIGN: A four year retrospective study from May, 1991 to May 1995 was conducted in 309 patients with abnormal cervical cytology who had undergone colposcopic examination at the Mc Cormick Hospital. The correlation between cervical cytology and colposcopically directed biopsy (CDB), colposcopic impression and CDB, CDB and subsequent conization or hysterectomy specimens were analyzed. The correlation was accepted as accurate when both reports were either the same or within one-step disparity of pathologic diagnosis and no invasive cancer was missed. RESULTS: In comparison of cervical cytology and CDB, the correlation was accurate in 212 of 241 cases (88%). The CDB was found to be less and more severe than cytology in 16 cases (6.6%) and 13 cases (5.4%) respectively. Colposcopic impression was accurate in 221 of 241 patients (91.7%) when compared to the CDB results. Sixty nine patients had undergone conization. The results of the CDB were comparable with those of the conization specimens in all but 8 patients, giving a total accuracy of 88.4 per cent. Four cases of invasive cancer were missed at the time of colposcopy and biopsy but subsequently diagnosed by conization. Of 67 patients who underwent hysterectomy, the surgical specimens were found to be more advanced than CDB in 4 patients, giving a total accuracy of 94 per cent. Two cases of minimally microinvasive cancer were missed. CONCLUSION: This study confirms the diagnostic value of colposcopy in the management of patients with abnormal cervical cytology.