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.

Comparative Study of Postoperative Pain between Maylard Incision and Pfannenstiel Incision in Gynecologic Surgery: A Randomized Controlled Trial.

Background: Postoperative pain has many adverse effects for the patients with laparotomy operation. There are few studies that compare between Maylard and Pfannenstiel incision in term of pain and wound complication after operation. Objective: To compare the postoperative pain and wound complications between the muscle-cutting Maylard incision and the Pfannenstiel incision in women who needed benign gynecologic surgery. Material and Method: This randomized controlled trial study compared two laparotomy techniques, Maylard and Pfannenstiel method. Ninety cases of benign gynecologic conditions were recruited and randomly assigned to receive either Maylard or Pfannenstiel incision from August 2014 to October2015 at Thammasat University Hospital, Thailand. Visual analogue scale (VAS) was applied to measure postoperative pain. Baseline characteristics of the study groups and postoperative outcomes were analyzed. Results: From the planned 90 recruited cases, there were 81 cases for complete analysis, 41 in Maylard and 40 in Pfannenstiel group. There were no difference in age, body mass index, education level, previous abdominal surgery and type of operation between Maylard and Pfannenstiel group. Duration of operation, type of anesthesia and dosage of analgesic drug were not statistically significant between both groups. Length of surgical wound was longer in Maylard than in Pfannenstiel group (17.27±0.6 vs. 14.13±0.8 cm, p = 0.04). Postoperative pain score (VAS) at 3, 6, 12, 24 and 48 hours were not statistically different between two groups. Pain score at 72 hours and 7th day in Maylard group showed significantly less than in Pfannenstiel group (0.51±0.5 vs. 1.10±1.0 p = 0.04, 0.12±0.3 vs. 0.23±0.4, p = 0.01, respectively). The numbers of participants with moderate to severe pain (VAS >4) in Maylard group were less than in Pfannenstiel group at 3, 6, 12 and 24 hours but after that there was no statistically difference. There were no postoperative wound complications such as disruption, infection or hematoma in all participants in this study. Conclusion: Postoperative pain up to 48 hours in both Maylard and Pfannenstiel group showed similar VAS but after 48 hours; the Maylard group showed less pain. Even though the surgical wound length in Maylard group was longer than Pfannenstiel group, numbers of cases with VAS >4 within 24 hours in Maylard were less than in Pfannenstiel group. Postoperative pain up to 48 hours in both Maylard and Pfannenstiel group showed similar VAS but after 48 hours; the Maylard group showed less pain. Even though the surgical wound length in Maylard group was longer than Pfannenstiel group, numbers of cases with VAS >4 within 24 hours in Maylard were less than in Pfannenstiel group.

Recurrence of Endometrioma Following Conservative Ovarian Endometrioma Cystectomy: Laparoscopy versus Laparotomy.

OBJECTIVE: To investigate the recurrence rate and disease-free interval between laparoscopy versus laparotomy for the conservative surgery of endometrioma. MATERIAL AND METHOD: A retrospective cohort study was conducted. The medical records of reproductive women who underwent conservative ovarian cystectomy surgery (laparoscopy or laparotomy) for endometrioma at Thammasat University Hospital were retrieved. The patients were followed through 24 months to evaluate the recurrence of endometrioma. Propensity scoring was used to adjust for confounding by indication and confounding by contraindication. Model for competing time to event was used in analysis. RESULTS: One hundred and twenty-eight and 114 patients were enrolled in laparoscopy and laparotomy groups, respectively. Mean age and body weight in laparotomy group were statistically higher than those in the other group were. Mean height and body mass index were, however not statistically different in either groups. In addition, the stage of disease and bilaterality in both groups were comparable. Diameter ofendometrioma in laparotomy group was significantly larger than that in laparoscopy group (7.0 ± 2.5 vs. 6.2 ± 1.8 cm, respectively; p = 0.004). After adjusting for propensity scoring, the endometrioma recurrence rate was significantly higher in laparoscopy group as compared to laparotomy group (27.3% vs. 14.9%, respectively; p = 0.02). However, the cumulative rate of pregnancy after surgery was not statistically different (4.7% vs. 4.4%, respectively; p = 1.0). CONCLUSION: The present study has demonstrated that the surgical technique has a strong impact on the recurrence or disease-free interval. Laparoscopy might not eradicate the disease pathology as effectively as open laparotomy in some situations, such as in cases with complexity of disease.

Twin Reversed Arterial Perfusion (TRAP) Sequence: A Case Report and Review of Treatment.

A cardiac twin or twin reversed arterial perfusion (TRAP) sequence is a rare unique complication of monozygotic multiple pregnancy. In this disorder, there is a normally formed donor (the pump twin) who has features of congestive heart failure (CHF) as well as a recipient (the acardiac twin) who lacks a well-defined a heart structure. Also evident are other structures, namely the TRAP sequencefrom pump to acardiacfetus via single artery-to-artery and vein-to-vein anastomoses directly between the two cords or indirectly on the chorionic plate. Overall, the perinatal mortality rate for the pump twin is 35-55%. Prenatal diagnosis and prognosis factors can be examined through ultrasound. The optimal management of a cardiac twin pregnancies is controversial. The expected treatment of acardiac anomaly presently relies on maximizing the chance ofterm delivery and preventing CHF in the healthy pump twin or interrupting vascularization between the two twins. This article reported the experience of acardiac twin management in Thammasat University Hospital and reviewed the current knowledge ofthe condition, prenatal diagnosis, prognosis factor and management options focusing on conservative management compared to invasive treatment.

Maylard incision in gynecologic surgery: 4-year experience in Thammasat University Hospital.

OBJECTIVE: To present the results of Maylard incisionfor gynecologic surgery in Thammasat University Hospital during the past four years. MATERIAL AND METHOD: A retrospective study of gynecologic surgery performed via the Maylard muscle cutting incision compare to Pfannenstiel muscle splitting and midline incision. Data came from subjects who underwent gynecologic surgey at Thammasat University Hospital, Pathumthani, Thailand friom January 2010 to December 2013. RESULTS: In the period of 4 years, there were 283 cases of elective surgery that performed via Maylard, Pfannenstiel and midline incision by the single experience gynecologic surgeon team. One hundred and six cases were performed via Maylard incision technique. The remaining 59 and 118 cases were performed via Pfannenstiel and midline incision technique, respectively. Two-thirds and one-thirds of cases underwent hysterectomy and conservative surgery, respectively. Benign conditions were the major indicationfor surgery at the percentage of 83.4. Operative results were not significantly different from well-known midline and Pfannenstiel incision in terms of blood loss, time to first meal and postoperative pain. Operative time in Maylard incision was longer than in Pfannenstiel incision. Length of stay in Maylard incision was longer than Pfannenstiel but shorter than midline incision. Overall complications (eoperation, bowel injuries, urinary bladder injuries and blood transfusion rate) were not significantly different. CONCLUSION: Maylard incision provides similar operative results with midline and Pfannenstiel technique. Even though it takes more time for abdominal entry but it gives more operative exposure than Pfannenstiel incision. In the woman with previous low transverse scar and gynaecologic surgery is needed, Maylard incision could be an optional technique that provides cosmetic and successfud results. Hand on training for Maylard incision from their mentors should be encouraged to more practice.

Spontaneous uterine rupture at non-cesarean section scar site with placenta percreta in the second trimester: a case report.

BACKGROUND: Uterine rupture was a common occurrence at previously cesarean-sectioned scar Early sign ofuterine rupture was a severe fetal bradycardia. CASE REPORT: A 30-year-old, 3 gravida, 1 para woman was presented with an acute abdominal pain and hypovolemic shock. Her gestational age was estimated at 18 weeks by emergency pelvic ultrasound. She had a lower segment scar from a previous caesarean section. Initially, alive intrauterinepregnancy with massive hemoperitoneum was a provisional diagnosis. During exploratory laparotomy, a ruptured of the right uterine fundus was found with placenta percreta. Hysterectomy was performed. Fetal weight was 450 grams, APGAR score 0, 0 and the fetus could not survive. The patient was discharged on the 4th day after surgery in healthy condition. CONCLUSION: Uterine rupture is a catastrophic kituation. Severefetal bradycardia might be an early sign. This case demonstrates the importance ofclinical judgment based on clinical acumen.

Antimullerian hormone changes after laparoscopic ovarian cystectomy for endometrioma compared with the nonovarian conditions.

Laparoscopic ovarian cystectomy is recommended for surgical procedure of endometrioma. The negative impact on ovarian reserve following removal had been documented. Little evidence had been reported for nonovarian originated effects. Objective. To evaluate the impact of laparoscopic ovarian cystectomy for endometrioma on ovarian reserve, measured by serum antimullerian hormone (AMH), compared to nonovarian pelvic surgery. Materials and Methods. A prospective study was conducted. Women who underwent laparoscopic ovarian cystectomy (LOC) and laparoscopic nonovarian pelvic surgery (NOS) were recruited and followed up through 6 months. Clinical baseline data and AMH were evaluated. Results. 39 and 38 participants were enrolled in LOC and NOS groups, respectively. Baseline characteristics (age, weight, BMI, and height) and preoperative AMH level between 2 groups were not statistically different. After surgery, AMH of both groups decreased since the first week, at 1 month and at 3 months. However, as compared to the LOC group at 6 months after operation, the mean AMH of the NOS group had regained its value with a highly significant difference. Conclusion. This study demonstrated the negative impact of nonovarian or indirect effects of laparoscopic surgery to ovarian reserve. The possible mechanisms are necessary for more investigations.