Restrictive versus routine episiotomy among Southeast Asian term pregnancies: a multicentre randomised controlled trial.

OBJECTIVE: To determine whether restrictive or routine episiotomy in term pregnant Southeast Asian women results in fewer complications. DESIGN: A multicentre randomised controlled trial. SETTING: Two tertiary and two general hospitals in Thailand. POPULATION: 3006 singleton pregnant women 18 years or older, ≥37 weeks of gestation, cephalic presentation and planned vaginal delivery. METHODS: This randomised controlled trial compared routine versus restrictive episiotomies in Thai women giving birth vaginally. Participants were singleton, term pregnant women with cephalic presentation. Block randomisation was stratified by study site and parity. Risk ratios (RR) and 95% confidence intervals (CI) were calculated to indicate between-group differences. MAIN OUTCOME MEASURES: Primary outcome was severe perineal laceration. Secondary outcomes included vaginal laceration, cervical laceration, and pregnancy outcomes. RESULTS: 3006 women were randomly assigned to restrictive (1502) and routine (1504) episiotomy. There was no difference in severe perineal laceration between the groups (RR 0.72, 95% CI 0.46-1.12). Restrictive episiotomy resulted in more intact perineums in multiparous women (RR 3.09, 95% CI 2.10-4.56). Restrictive episiotomy increased the risk of vaginal laceration in primiparous (RR 1.96, 95% CI 1.62-2.37) and multiparous women (RR 2.21, 95% CI 1.77-2.75) but did not lead to more suturing. There were comparable risks of cervical laceration, postpartum haemorrhage, wound complication, birth asphyxia, and admission to neonatal intensive care unit. CONCLUSIONS: Restrictive episiotomy results in more intact perineum in multiparous women. Risks of maternal and neonatal outcomes were comparable between the two practices. These results strengthen the certainty of the existing Cochrane review findings in supporting restrictive episiotomy. TWEETABLE ABSTRACT: Restrictive episiotomy results in more intact perineums after vaginal birth in multiparous Southeast Asian women.

Depot medroxyprogesterone acetate and epithelial ovarian cancer: a multicentre case-control study.

OBJECTIVE: To evaluate the effect of depot medroxyprogesterone acetate (DMPA) in protecting against epithelial ovarian cancer (EOC) and to evaluate factors associated with the risk of EOC. DESIGN: A multicentre, case-control study. SETTING: Twelve hospitals located across Thailand. POPULATION: Three hundred and thirty patients with EOC ('cases') and 982 matched controls were recruited from the 12 hospitals. Cases were newly diagnosed patients with EOC, demonstrated pathologically. Controls were age-matched patients admitted to different wards in the same hospital. METHODS: Cases and controls were interviewed by trained interviewers using a standardised pre-tested questionnaire. The factors associated with EOC were evaluated using univariate and multivariate analyses. MAIN OUTCOME MEASURES: The odds ratio (OR) and 95% confidence interval (95% CI) were calculated to assess the relationship between DMPA and EOC. RESULTS: The use of DMPA was found to be associated with a 39% reduction in the risk of EOC with an OR of 0.61 and a 95% CI of 0.44-0.85 (P = 0.002). A significant risk reduction (83%) was observed when the duration of DMPA use was >3 years (OR 0.17; 95% CI 0.07-0.39; P < 0.001). Other factors associated with a reduced risk of EOC were the use of combined oral contraceptive pills and breastfeeding. A factor associated with an increased risk of EOC was a family history of gynaecological cancer. CONCLUSIONS: The results suggest that DMPA may have a protective effect against EOC. If this effect is real, then it represents an important non-contraceptive benefit of DMPA.

An audit of colposcopy appointment processes in women with abnormal cervical cytology.

OBJECTIVES: This study was conducted to audit the waiting times and default rates of colposcopy using the standard requirements of the National Health Service Cervical Screening Programme (NHSCSP) 2004 guidelines. METHODS: The records of 291 women with abnormal cervical smears referred to the colposcopy clinic between January and December 2008 at Chiang Mai University Hospital, Thailand, were reviewed. RESULTS: The proportion of women with abnormal cervical smears of any grade receiving colposcopy appointments within 8 weeks of referral (96.9%) achieved the minimum requirements (≥ 90%). However, the waiting times for women with high-grade squamous intraepithelial lesion, glandular cell abnormality and invasive lesion smears were longer than recommended by NHSCSP guidelines. The default rate of 15.8% in this study was slightly higher than recommended by the guidelines (< 15%). Having no health insurance, being known to have HIV infection and waiting times longer than 4 weeks were independent predictors of default from an initial colposcopy appointment. CONCLUSION: The waiting times for colposcopy among women with high-grade smear abnormality and the default rate failed to meet standard requirements. Designing an effective protocol for colposcopy appointment processes is warranted.

Twelve years experience with radical hysterectomy and pelvic lymphadenectomy in early stage cervical cancer.

The objective of this study was to evaluate the outcome, prognostic factors and complications of early stage cervical cancer patients treated with radical hysterectomy and pelvic lymphadenectomy (RHPL). The medical records of cervical cancer patients undergoing RHPL at Chiang Mai University Hospital over 12 years, between January 1995 and December 2006 were reviewed. There were 1,253 patients in the study period. The mean age was 44 years of age. Of these, 26.9% had prior diagnostic conisation. The maximum tumour size was 8 cm. The most common histology was squamous cell carcinoma (67%) followed by adenocarcinoma (23%). The distribution of FIGO staging was: stage IA 8.7%; stage IB 15.8%; stage IB1 61%; stage IB2 6.2%; and stage IIA 8.5%. Pelvic nodes, parametrial and vaginal margin involvement were detected in 15.9%, 10.7% and 3.8% of the patients, respectively. A total of 66.5% of patients underwent RHPL without adjuvant treatment; 12.1% received neoadjuvant chemotherapy. The estimated 10-year recurrence-free survival rate was 90%. Stage IB2/IIA, non-squamous cell carcinoma, nodal involvement and positive vaginal margins were independent, significant, poor prognostic factors. The most common long-term complication was lymphoedema. It was concluded that early stage cervical cancer patients treated with RHPL have long-term favourable outcome with minimal morbidity. Stage IB2 and IIA, non-squamous cell carcinoma, nodal and vaginal involvement were independent adverse prognostic factors.

An audit of standards of the 'see and treat' approach in women with a high-grade squamous intraepithelial lesion on Pap smears.

This study was undertaken to audit the performances of the 'see and treat' approach in women with a high-grade squamous intraepithelial lesion (HSIL) cytology at Chiang Mai University Hospital using selective criteria from the National Health Service Cervical Screening Programme (NHSCSP) 2004 guidelines. Women with a HSIL smear, who had undergone colposcopy and immediate loop electrosurgical excision procedure (LEEP) during June 2006 and September 2008, were reviewed. The standard measurement was determined by the following criteria: (1) the proportion of women treated at the first visit who have evidence of cervical intraepithelial neoplasia (CIN) on histology to be >90%; (2) the primary haemorrhage must be <5%; (3) the proportion of patients admitted as inpatients owing to treatment complication to be <2%. Of 247 women in this study, the histopathological results were as follows: CIN II-III, 188 (76.1%); cancer, 31 (12.6%); adenocarcinoma in situ, 5 (2.0%); CIN I, 5 (2.0%); and no CIN, 18 (7.3%). The prevalence of CIN I or higher was 92.7%. Primary haemorrhage was observed in 13 (5.3%) women. Four (1.6%) women were admitted as inpatients because of LEEP-related complications. In conclusion, the 'see and treat' approach in our institute has acceptable overtreatment and complication rates.

Nerve-sparing class III radical hysterectomy: a modified technique to spare the pelvic autonomic nerves without compromising radicality.

The objectives were to describe our nerve-sparing class III radical hysterectomy technique and assess the feasibility and safety of the procedure as well as its impact on voiding function. From January to August 2005, 21 consecutive patients with FIGO stage IB-IIA cervical cancer and 1 patient with clinical stage II endometrial cancer underwent nerve-sparing radical hysterectomy with systematic pelvic lymphadenectomy. The transurethral catheter was removed on the seventh postoperative day. Then intermittent self-catheterization was performed and post-void residual urine volume (PVR) was recorded. The nerve-sparing procedure was completed successfully and safely in all of the patients. Eight (36%) and 6 (27%) patients had the PVR of < 100 ml and < 50 ml respectively at the initial removal of the catheter. On the fourteenth day, 82% and 77% of the patients had the PVR of < 100 ml and < 50 ml, respectively. The mean duration before the PVR became < 50 ml was 11.27 (5-26) days. In conclusion, the technique described in this preliminary study appears safe, adequate, and feasible in our population with satisfactory recovery of voiding function. A larger comparative study is needed on long-term urinary, bowel, and sexual function as well as recurrence and survival.

Outcomes of loop electrosurgical excision procedure for cervical neoplasia in human immunodeficiency virus-infected women.

The objective of this study was to evaluate the treatment outcomes and complications in human immunodeficiency virus (HIV)-infected women undergoing loop electrosurgical excision procedure (LEEP) for cervical neoplasia. The medical record of 60 evaluable HIV-infected women who had abnormal Papanicolaou (Pap) smear and underwent LEEP following colposcopy at Chiang Mai University Hospital between May 1998 and June 2004 was reviewed. Thirty-one (51.7%) had associated genital infection at screening. Twenty-five (41.7%) had opportunistic infection, but only 18 (30.0%) were treated with antiretroviral therapy. The most common abnormal Pap smear was high-grade squamous intraepithelial lesion (46.7%), followed by low-grade squamous intraepithelial lesion (40.0%). Forty (66.7%) women had clear surgical margins after LEEP. Only one (1.7%) woman had severe intraoperative hemorrhage. Early and late postoperative hemorrhage were noted in three (5%) women of each period. Localized infection of the cervix was detected in seven (11.7%) women. Two (3.3%) women developed cervical stenosis at 6 months after LEEP. There was no significant difference in overall complications between HIV-infected women and the control group (P= 0.24). Among 60 HIV-infected women, no statistical difference in the rate of margins involvement (P= 1.00) and complications (P= 0.85) could be demonstrated between HIV-infected women who received antiretroviral therapy and those who did not. Disease-free rate at 6 and 12 months were 97.1% and 88%, respectively. These data demonstrated that LEEP appears to be safe and effective in HIV-infected women.

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.