See & treat protocol for evaluation & management of cervical intraepithelial neoplasia.

BACKGROUND & OBJECTIVES: The incidence of cervical cancer in India remains high, largely due to ineffective screening and poor patient compliance for follow up. A one step procedure where evaluation and treatment are performed at the same sitting may be a good strategy. Therefore the present study was undertaken to evaluate the feasibility of a see and treat protocol for cervical intraepithelial neoplasia in a hospital population. METHODS: A prospective study was carried out on 285 women with using cytology and colposcopy followed by large loop excision of the transformation zone when indicated as a one step procedure. RESULTS: There was a concordance between colposcopic and cytologic diagnosis. Eighteen women underwent large loop excision. Over treatment rate was 61 per cent but 80 per cent of them occurred in the low grade squamous intraepithelial lesions. The over treatment rate in high grade lesions was 20 per cent. INTERPRETATION & CONCLUSION: A single step see and treat protocol is a feasible management strategy for high grade squamous intraepithelial lesions. However, patient education is essential before undertaking the procedure.

Management of prolonged pregnancy: a randomized trial of induction of labour and antepartum foetal monitoring.

BACKGROUND: The two methods of management of prolonged pregnancy, induction of labour and expectant management with foetal surveillance, have pros and cons. Therefore, we compared the induction of labour with serial antenatal foetal monitoring in the management of post-term pregnancy. METHODS: Seventy-four women with uncomplicated pregnancy at 41 weeks (287 days) of gestation were randomly assigned to undergo either induction of labour or serial antenatal foetal monitoring. Labour was induced in the latter group whenever there was evidence of foetal compromise. Antenatal monitoring consisted of the foetal kick count, non-stress test and biophysical profile. RESULTS: Fifty-seven per cent of women went into spontaneous labour by 41 weeks and 4 days (291 days) of gestation and only 14% developed foetal compromise before that. However, when the gestational age was more than 41 weeks and 4 days (291 days), the incidence of meconium staining of amniotic fluid and evidence of uteroplacental insufficiency increased significantly. The rate of caesarean section, instrumental delivery, foetal distress and duration of labour did not differ significantly between the two groups. CONCLUSION: The policy of inducing labour at 41 weeks and 4 days (291 days of gestation) in uncomplicated pregnancies is justified in our population. However, foetal monitoring should begin at 41 weeks of gestation.

Cervical intraepithelial neoplasia and human papilloma virus infection in renal transplant recipients.

An association between human papilloma virus (HPV) infection and cervical intraepithelial neoplasia has been well established Renal transplant recipients on long term immunosuppression are prone to viral infection. It is possible that there may be an increased prevalence of papilloma virus infection and associated cervical intraepithelial neoplasia in these women. Prospective study of 42 renal transplant recipients and 41 age and parity matched controls was undertaken to determine whether HPV infection and cervical intraepithelial neoplasia (CIN) occurred more often in renal allograft recipients and to assess the relative risk. All women underwent Pap smear, colposcopy, histological examination of biopsy specimen and polymerase chain reaction for HPV 16. Cytology did not pick up HPV infection in any of the women. Colposcopy revealed HPV infection in 15 and CIN in 14 women in the immunosuppressed group and HPV in 7 and CIN in 5 women in control group. Histological evidence of HPV was found in 24 and CIN in 10 women in immunosuppressed group and HPV infection in 13 and CIN in 3 women in control group, giving an odds ratio of 6.1. More women in the immunosuppressed group had CIN of higher degree as well. PCR revealed infection by HPV 16 in 17 cases and 14 controls giving an odds ratio of 1.3. Therefore renal allograft recipients on immunosuppression should be screened by colposcopy and directed biopsy at regular intervals.

Maternal zinc indices and small babies.

BACKGROUND: Maternal zinc deficiency has been reported to be associated with foetal growth retardation. This study aimed to determine if zinc deficiency is associated with foetal growth retardation in south Indian women. METHODS: A prospective study was undertaken to evaluate the maternal zinc indices in those bearing small-for-gestational age babies and in those with appropriate-for-gestational age babies. Zinc levels in plasma, red blood cells and white blood cells in both groups were assayed in 65 patients with small-for-gestational age babies (regardless of cause) and 51 women with appropriate-for-gestational age babies. RESULTS: There was no significant difference in the mean (SD) plasma [67.5 (9) v. 70.67 (13.9)], red blood cell [47.26 (5.8) v. 45.69 (8.2)] and white blood cell [55.61 (10.5) v. 54.77 (12.4)] zinc levels in mothers who gave birth to small-for-gestational age babies and those who delivered appropriate-for-gestational age babies. The presence of predisposing factors for intrauterine growth retardation also did not influence the maternal zinc levels. CONCLUSION: Maternal zinc levels were not associated with intrauterine growth retardation in our population.

Sclerosing stromal tumour of the ovary. A case report.

Sclerosing stromal tumors (SST) of the ovary are a distinct, but rare benign neoplasms. These tumors appear solid and are very vascular and therefore give the impression of a malignant tumor. They occur mostly in young women. Morphologically and histologically they have distinct characteristics, which make them different from other stromal tumors. The importance of this report is that, though the tumor appears malignant (solid and vascular) since it occurs in young women, care should be taken before embarking on radical surgery.

Detection of CIN by naked eye visualization after application of acetic acid.

A prospective study was undertaken to determine the sensitivity and specificity of acetic application to the cervix followed by naked eye visualization as a screening test for detection of cervical intraepithelial neoplasia. Three hundred and seventy two sexually active woman in the reproductive age group were studied. All the women underwent Papanicolaou test, acetic acid test and colposcopy. One hundred and seventy five woman were acetic acid test negative, 197 women were acetic acid test positive. The sensitivity of acetic acid test was 72.4%, specificity 54% and false negative rate 15.2%, as compared to papanicolaou test which had a sensitivity of 13.2%, specificity of 96.3% and false negative rate of 24.4%. The advantage of the acetic acid test lies in its easy technique, low cost and high sensitivity which are important factors for determining the efficacy of any screening programme in developing countries.

Transcervical endometrial resection when hysterectomy is dangerous.

Severe blood loss from dysfunctional uterine bleeding may be refractory to medical therapy and hysterectomy the only option. In two young women with severe bleeding where medical measures were ineffective and hysterectomy was a hazardous option, we performed a transcervical endometrial resection. In both of them the bleeding stopped immediately and no further treatment was required for dysfunctional uterine bleeding. They have had amenorrhea now for over six months. Transcervical endometrial resection is an option when hysterectomy is hazardous and the bleeding is refractory to medical treatment.

Prevalence of HIV infection in pregnant women in Vellore region.

All pregnant women attending the antenatal clinic of a large hospital in Vellore, India (Christian Medical College Hospital) were screened for HIV infection between October 1987 and June 1992. A total of 36,953 blood samples were thus screened and 20 infected women were identified. Among these 18 women had acquired HIV infection from their husbands, who were also detected to be HIV infected. While these 18 women were monogamous, all the husbands had multiple sex partners. Two of the 20 women in this series were commercial sex workers. Among the 20, 17 (85%) women belonged to low socio-economic status, while three were from well-to-do families, with the husbands being businessmen or teachers. As the overall prevalence (0.054%) of HIV infection among pregnant women was relatively high and equal to or higher than many States in the USA and in areas outside London in the UK, the authors recommend that strict universal precautions be instituted in all obstetric practice in India.

Cervical intraepithelial neoplasia and human papilloma virus infection.

Evidence of human papilloma virus (HPV) infection was sought in 50 patients with cervical intraepithelial neoplasia (CIN) and 50 controls. Cytologic, colposcopic and histopathological examinations were carried out in each one of them. Cytological evidence of HPV infection was found in 13 cases and two controls. Colposcopic evidence was found in 33 (66%) cases and 17 (34%) controls and histopathological evidence in 35 (70%) patients and 14 (28%) controls. These differences were statistically significant. Colposcopy proved to be a good method of diagnosing HPV infection with a sensitivity of 86% and specificity of 80% compared to histopathologic diagnosis.

Colposcopy in the diagnosis of cervical neoplasia.

Two hundred and ninety one women were evaluated for cervical cancer by cytology and colposcopy. Of these, 152 patients underwent colposcopically directed biopsy for histological evaluation. Colposcopy and cytology were in agreement in 88 per cent of cases whereas colposcopy and histopathology were in agreement in 79 per cent of cases. Cytology underestimated the severity of the lesion in nine per cent while colposcopy underestimated the lesion in 7.2 per cent (False negative rate). In 13.8 per cent of cases colposcopy overestimated the lesion (False positive rate). The cone biopsy rate in this series was 30 per cent. We conclude that since colposcopy shows excellent correlation with histopathology, it will be a useful tool to reduce cone biopsy rates, particularly in younger women in the child-bearing age group.