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P653 Quality of life in Thai women diagnosed low grade squamous intraepithelial lesions of the uterine cervix after treatments
S600
Poster presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S413–S729
Success: A 100% success rate was achieved in first attempt in reparative surgery in our institution. The complications encountered were recurrent urinary tract infection and persistent abdominal pain in post LAVH fistulae repair, parauretheral leak in massive & multiple fistulae repair. These patients also had unaware incontinence after catheter removal because of small capacity bladder. Discussion: The smell of urine or faeces and inability to stay dry is most humiliating and uncomfortable. Majority of the obstetric fistulae are preventable. [3] The incidence of obstetric fistula in developing countries is 80% and that of surgical fistula in developed countries is 70%. [4] In our study we encountered similar percentage of obstetric and gynaecological fistula i.e. 50% in metropolitan population. None of the patient in our study was less than 20 years of age and only 2 patients had fistula following delivery/LSCS. This is unlike the series reported by Goswami etal 2 who reported 37.7% patients less than 20 years age and almost 50% fistulae following difficult delivery in an illiterate and low socioeconomic population. Two post abortal fistulae were recorded in our study, both of them with unusual presentations. One of the patient had persistent pus like vaginal discharge with secondary infertility and was later found to have small colouterine fistula and another nulliparous post abortal patient with urinary incontinence during intercourse only was found to have multiple high vesico vaginal fistula. This proves the fact that illegal abortions by untrained personnel carry a high risk of complications, including a permanent damage to uterus and genital tract. [5] Five cases in our study had post hysterectomy fistulae. One vesicovaginal and one rectovaginal fistula was seen following total abdominal hysterectomy. 2 ureteric injuries and 1 rectal injury was encountered following laparoscopic hysterectomy. Studies from Finland suggest a post hysterectomy fistula rate of 1 in 1000 abdominal hysterectomies and 1 per 450 laparoscopic hysterectomies. [6] Ureteric injuries are 6 times more common in laparoscopic as compared to open hysterectomy. Two massive fistulae were attributed to prolonged labour. One of them delivered vaginally and the other one through LSCS but both the babies were fresh still born. All the genitourinary fistulae in our study were approached transperitoneally. Simple vesico vaginal fistula can be repaired transvaginally, but 12–25% of complex fistulae involving ureters, bladder vagina and urethra require more difficult surgeries for their treatment. [7] Bilateral uretric orifices were secured with ureteric catheters. One patient required VVF repair with bladder neck reconstruction, two underwent VVF repair with ureteric implantation and psoas hitch. Continuous bladder drainage was ensured in the post operative period [8], however, dual drainage was not encouraged The ano vagino cutaneous fistula was repaired through perineal approach. The faecal fistulae were also repaired abdominally except one post hysterectomy high recto vaginal fistula in a very obese patient with previous multiple abdominal surgeries. This patient also had colostomy and big parastomal hernia. Fistula was repaired vaginally using laparoscopic instruments by converting high fistula to complete perineal tear. A colostomy closure and hernia repair followed 3 month later. The success rate in our study was 100% in 1st attempt inspite of complicated fistulae with very unfavourable tissues. The success rate for primary surgical repair ranges from 88% to 93% and decreases with each successive attempt. [1] Goswami et al [2] reported an overall success rate of 75.55%. It can not be over emphasized than the best prospect for cure is at the first operation by well acquainted team and there is no place for the well intentioned occasional fistula surgeon, be it a gynaecologist or a urologist. [4] Conclusion: The incidence of gynaecological fistula is on an increase in metropolitan middle class population. Faecal fistulas are considered to be a rarity but we encountered 4 such cases. As per WHO safe motherhood initiative (WHO 1989) [9], surgeons need to be aware of those factors which increase the likelihood
of lower urinary tract injury during surgery. Each surgeon must know her own limits and limits of her trainees. Early detection of injury & repair should be undertaken in the postoperative period. The transperitoneal approach for complicated genital fistula offers wider inspection, better dissection and excellent results. The key to success is careful dissection of planes, adequate haemostasis and proper repair in separate planes. [10] Omental interposition in between the planes gives the best possible results as also advocated by Turner Warwick [11]. Every woman who wishes to terminate her pregnancy should have ready access to reliable information, compassionate counseling and service for prevention and management of complications of unsafe abortions. The obstetric genital fistulae can be prevented by government’s recognition of fistulae as major health concern, improving socio economic conditions, extending primary education particularly for girls and advise against teenage pregnancy. There is a need for skilled birth attendant at every level. We as health providers can improve facilities and access for emergency obstetric care, provide social and psychological support to the patients and train doctors and nurses in the most affected parts of the world for reparative surgery. [1] Reference(s) [1] Mittal Suneeta, Gupta N. Vescico-vaginal fistula-Problems in management. JIMSA 2006; 19(2): 79. [2] Goswami BK, Biswas SC etal Genito urinary fistula – a review on 45 cases. JIMSA 2006; 19(2): 81–83. [3] Chakraborty SC, Gupta NP, Wadhwa SN. Uretero vaginal fistula following obstetric and gynaecological surgery. J Obstet Gynec India 1993; 43: 285–288. [4] Hilton P, Ward A. Epidemiological and surgical aspects of urogenital fistulae: a review of 25 years experience in southeast Nigeria. International Urogynaecology Journal and pelvic floor dysfunction. 1998; Vol 9:189–194. [5] Sharma TC, Bathla S, Agarwal N, Arya SC. An unusual case of colouterine fistula. Saudi Med J. 2006; Vol 27(3): 412–413. [6] Harkki-Siren P, Sjoberg J, Tiitinen A. Urinary tract injuries after hysterectomy.Obstetrics and Gynaecology 1998; Vol 92:113–118. [7] Demirel A, Polat O, Bayraktar Y et al. Transvescical & transvaginal reparation in urinary vaginal fistulas. Int. Urol. Nephrol 1993; 25:439–44. [8] Singh M, Ambasta SS. Transperitoneal repair of vescico vaginal fistula. J Obstet Gynec India, 1991; 41: 816–819. [9] World Health Organization. The prevention and treatment of obstetric fistulae: A report of a Technical Working Group.WHO, Geneva 1989. [10] Sapre S, Chhabra JS, Sharma N etal. Transperitoneal repair of vescicovaginal fistula. J Obstet Gynec India 1995; 45: 547–549. [11] Turner-Warwick R. The use of omental pedicle graft in urinary tract reconstruction. Journal of urology.1976; 116: 341–347.
P653 Quality of life in Thai women diagnosed low grade squamous intraepithelial lesions of the uterine cervix after treatments B. Chumworathayi1 , P. Blumenthal2 , P. Likittanasombut3 . 1 Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand, 2 School of Medicine, Stanford University, California, USA, 3 Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Objective: To compare quality of life (QOL) in Thai women who were diagnosed low grade squamous intraepithelial lesions (LSILs) of the uterine cervix at 6 months after 3 kinds of treatments. Materials and Methods: QOL was assessed by Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire version 4. One hundred eligible patients were approached by trained interviewers. The interviewer interviewed after informed consent was signed. Data from the three study groups (40 HPV-negative-observed, 29 HPV-positive-cryotherapy, and 31 HPVpositive-observed) were extracted, combined and analyzed using chi-squared test and t-test. Results: Demographic data among the three groups (age, weight, parity, duration of sexual activity, duration with current partner,
Poster presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S413–S729
monthly income, education of college or more, smoking status, partner’s smoking status, reported HIV positive, reported partner’s multiple sexual partner, reported multiple sexual partner) were all comparable. The third group had highest QOL that was significant different from the second group (39.74+2.04 vs 33.1+2.44, p = 0.04) but not significant different from the first group (39.74+2.04 vs 34.95+2.21, p = 0.57). Conclusions: In contrast to our experiences that Thai women prefer some kinds of treatment after they acknowledge having LSILs, the HPV-positive-observed group significantly had higher QOL score than the HPV-positive-cryotherapy group. The reason for this may relate to extensive counseling and side effect of treatment, respectively. P654 Introduction of automated BP devices intended for the low resource setting in rural Tanzania and Ethiopia C. Baker, K. Duhig, A. De Greeff, A. Van der Westhuizen, A. Shennan. King’s College London Objective: Regular blood pressure (BP) monitoring is a costeffective means for early identification and management of hypertensive disease in pregnancy. BP devices that fulfil the WHO recommendations for use in low resource settings were distributed to clinics in rural Africa as part of an evaluation of their impact on maternal and foetal mortality and morbidity. Methods: Thirty-three automated BP devices (Omron M1 Plus; Omron HEM-Solar; Nissei DS-400) were distributed to 18 clinics in Tanzania and Ethiopia. User training and error cards were provided for each device. Device condition, frequency of use and staff views was assessed at 1, 3 and 6 months. Results: Devices were used regularly, even in clinics with no previous access to BP devices. All devices were found to be in good working order. Only one clinic abandoned device use because of repeated error readings due to cuff malpositioning. Solar powered devices were well received, but concerns for the maintenance of battery operated devices were raised. Eighty percent of staff preferred automated devices to mercury devices despite raising concerns about device accuracy. Conclusion: Use of automated BP devices in low resource settings is feasible and potentially useful. User training and device maintenance protocols need to accompany device introduction. Implications for appropriate referral of women with hypertensive diseases as well as cost-benefit analyses are necessary to prove the utility of this intervention. P655 Process evaluation for the implementation of a cervical cancer see-and-treat program in rural El Salvador M. Cremer1 , L. Ditzian2 , M. Maza2 , E. Peralta2 , R. Masch2 . 1 NYU School of Medicine & Basic Health International, 2 Basic Health International Objectives: In low-resource settings, cytology programs are difficult to implement; however, see-and-treat programs utilizing visual inspection with acetic acid (VIA) and cryotherapy have gained popularity as a low-cost, low-technology alternative. The objective of this project was to conduct a process evaluation of the implementation of a governmental VIA and cryotherapy program in rural communities of El Salvador, and to provide quality improvement advice to program methodology. Materials and Methods: The process evaluation was conducted through an action research approach, in which VIA-trained healthworkers were accompanied by evaluators to their rural work sites. Data collection methods included expert observations, interviews, and an evaluation instrument containing 44 questions about the infrastructure of the rural health system, gynecological campaigns, VIA patient data tracking, clinical work environment, supplies
S601
and clinical exam. A feedback debriefing session was held to disseminate findings amongst stakeholders. Results: Process evaluation successfully identified technical and logistical limitations to screening and therapy. Inadequate portable lighting, lack of foot rests for gynecologic exams, and limited cryotherapy probe tips ranked high as programmatic barriers. Debriefing led to proposed acceptable and affordable remedies in all instances. Enthusiasm and acceptance for the program was universal. Conclusion: The process evaluation demonstrates that the seeand-treat method of cervical cancer screening can be implemented in low-resource settings of El Salvador. Potential barriers to program delivery can be easily averted through early programmatic evaluation and intervention. P656 Study of the effect of cognitive behavioral counseling on body image alterations in women who have undergone mastectomy S. Fadaei, M. Janighorban, T. Mehrabi. Nursing Midwifery Faculty – Azad Islamic University – Branch Najaf Abad Introduction: Breast cancer is the most common cancer in women throughout the world and for most women mastectomy results in the loss of a body part that is viewed as essential for maintaining feminity, attractiveness and self-esteem. In order to prevent impaired body image, one should accept the changes of her body shape. Objective: To determine the effect of counseling on mean of body image score in women undergone mastectomy. Methods: In this quasi experimental, 72 women undergone mastectomy referring to an oncology and radiotherapy center in Isfahan were randomly selected by convenient sampling and studied. The experimental group (n = 32) participated in six sessions of counseling. Data were collected using questionnaires and statistical analysis was performed by the paired and independent t test using SPSS software. Results: The results indicated a significant difference between mean of body image score before and after counseling in experimental group (P < 0.001). Also a significant difference was seen in mean of body image score after counseling between experimental and control groups (p < 0.001). Discussion: According to this results, psychotherapeutic treatment especially cognitive behavioral counselling in group setting are recommended. P657 Acceptability of HIV/AIDS counseling and testing of Sudanese pregnant women A. Fazari Bashir1 , K. Elmusharaf2 , A. Gerais2 , V. Berggren2 Objective: The objective of this study was to elucidate the attitudes of voluntarily counseling of HIV/AIDS with particular emphasis on voluntary counseling testing (VCT) among Sudanese pregnant women. Design: a cross sectional, clinic based study was performed. The data were analyzed using SPSS. Setting: six ante-natal clinics in Khartoum, Sudan. Participants: 961 ante-natal seeking pregnant women. Results: The general knowledge about HIV/AIDS among the participants where low. Only 36% of the participating women accepted the suggested VCT. 64% of the study sample did not accept the VCT. The majority of the study samples were of low socio economic status (73%). Conclusions: This study indicates that there might be less response in Sudan to the VCT in comparison to other African countries. In the era of the HIV/AIDS endemic, also Sudan must search ways to achieve increased knowledge and awareness in the community about HIV/AIDS and its treatment, one way can be improved and more access to voluntary counseling testing (VCT) and
Poster presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S413–S729
Success: A 100% success rate was achieved in first attempt in reparative surgery in our institution. The complications encountered were recurrent urinary tract infection and persistent abdominal pain in post LAVH fistulae repair, parauretheral leak in massive & multiple fistulae repair. These patients also had unaware incontinence after catheter removal because of small capacity bladder. Discussion: The smell of urine or faeces and inability to stay dry is most humiliating and uncomfortable. Majority of the obstetric fistulae are preventable. [3] The incidence of obstetric fistula in developing countries is 80% and that of surgical fistula in developed countries is 70%. [4] In our study we encountered similar percentage of obstetric and gynaecological fistula i.e. 50% in metropolitan population. None of the patient in our study was less than 20 years of age and only 2 patients had fistula following delivery/LSCS. This is unlike the series reported by Goswami etal 2 who reported 37.7% patients less than 20 years age and almost 50% fistulae following difficult delivery in an illiterate and low socioeconomic population. Two post abortal fistulae were recorded in our study, both of them with unusual presentations. One of the patient had persistent pus like vaginal discharge with secondary infertility and was later found to have small colouterine fistula and another nulliparous post abortal patient with urinary incontinence during intercourse only was found to have multiple high vesico vaginal fistula. This proves the fact that illegal abortions by untrained personnel carry a high risk of complications, including a permanent damage to uterus and genital tract. [5] Five cases in our study had post hysterectomy fistulae. One vesicovaginal and one rectovaginal fistula was seen following total abdominal hysterectomy. 2 ureteric injuries and 1 rectal injury was encountered following laparoscopic hysterectomy. Studies from Finland suggest a post hysterectomy fistula rate of 1 in 1000 abdominal hysterectomies and 1 per 450 laparoscopic hysterectomies. [6] Ureteric injuries are 6 times more common in laparoscopic as compared to open hysterectomy. Two massive fistulae were attributed to prolonged labour. One of them delivered vaginally and the other one through LSCS but both the babies were fresh still born. All the genitourinary fistulae in our study were approached transperitoneally. Simple vesico vaginal fistula can be repaired transvaginally, but 12–25% of complex fistulae involving ureters, bladder vagina and urethra require more difficult surgeries for their treatment. [7] Bilateral uretric orifices were secured with ureteric catheters. One patient required VVF repair with bladder neck reconstruction, two underwent VVF repair with ureteric implantation and psoas hitch. Continuous bladder drainage was ensured in the post operative period [8], however, dual drainage was not encouraged The ano vagino cutaneous fistula was repaired through perineal approach. The faecal fistulae were also repaired abdominally except one post hysterectomy high recto vaginal fistula in a very obese patient with previous multiple abdominal surgeries. This patient also had colostomy and big parastomal hernia. Fistula was repaired vaginally using laparoscopic instruments by converting high fistula to complete perineal tear. A colostomy closure and hernia repair followed 3 month later. The success rate in our study was 100% in 1st attempt inspite of complicated fistulae with very unfavourable tissues. The success rate for primary surgical repair ranges from 88% to 93% and decreases with each successive attempt. [1] Goswami et al [2] reported an overall success rate of 75.55%. It can not be over emphasized than the best prospect for cure is at the first operation by well acquainted team and there is no place for the well intentioned occasional fistula surgeon, be it a gynaecologist or a urologist. [4] Conclusion: The incidence of gynaecological fistula is on an increase in metropolitan middle class population. Faecal fistulas are considered to be a rarity but we encountered 4 such cases. As per WHO safe motherhood initiative (WHO 1989) [9], surgeons need to be aware of those factors which increase the likelihood
of lower urinary tract injury during surgery. Each surgeon must know her own limits and limits of her trainees. Early detection of injury & repair should be undertaken in the postoperative period. The transperitoneal approach for complicated genital fistula offers wider inspection, better dissection and excellent results. The key to success is careful dissection of planes, adequate haemostasis and proper repair in separate planes. [10] Omental interposition in between the planes gives the best possible results as also advocated by Turner Warwick [11]. Every woman who wishes to terminate her pregnancy should have ready access to reliable information, compassionate counseling and service for prevention and management of complications of unsafe abortions. The obstetric genital fistulae can be prevented by government’s recognition of fistulae as major health concern, improving socio economic conditions, extending primary education particularly for girls and advise against teenage pregnancy. There is a need for skilled birth attendant at every level. We as health providers can improve facilities and access for emergency obstetric care, provide social and psychological support to the patients and train doctors and nurses in the most affected parts of the world for reparative surgery. [1] Reference(s) [1] Mittal Suneeta, Gupta N. Vescico-vaginal fistula-Problems in management. JIMSA 2006; 19(2): 79. [2] Goswami BK, Biswas SC etal Genito urinary fistula – a review on 45 cases. JIMSA 2006; 19(2): 81–83. [3] Chakraborty SC, Gupta NP, Wadhwa SN. Uretero vaginal fistula following obstetric and gynaecological surgery. J Obstet Gynec India 1993; 43: 285–288. [4] Hilton P, Ward A. Epidemiological and surgical aspects of urogenital fistulae: a review of 25 years experience in southeast Nigeria. International Urogynaecology Journal and pelvic floor dysfunction. 1998; Vol 9:189–194. [5] Sharma TC, Bathla S, Agarwal N, Arya SC. An unusual case of colouterine fistula. Saudi Med J. 2006; Vol 27(3): 412–413. [6] Harkki-Siren P, Sjoberg J, Tiitinen A. Urinary tract injuries after hysterectomy.Obstetrics and Gynaecology 1998; Vol 92:113–118. [7] Demirel A, Polat O, Bayraktar Y et al. Transvescical & transvaginal reparation in urinary vaginal fistulas. Int. Urol. Nephrol 1993; 25:439–44. [8] Singh M, Ambasta SS. Transperitoneal repair of vescico vaginal fistula. J Obstet Gynec India, 1991; 41: 816–819. [9] World Health Organization. The prevention and treatment of obstetric fistulae: A report of a Technical Working Group.WHO, Geneva 1989. [10] Sapre S, Chhabra JS, Sharma N etal. Transperitoneal repair of vescicovaginal fistula. J Obstet Gynec India 1995; 45: 547–549. [11] Turner-Warwick R. The use of omental pedicle graft in urinary tract reconstruction. Journal of urology.1976; 116: 341–347.
P653 Quality of life in Thai women diagnosed low grade squamous intraepithelial lesions of the uterine cervix after treatments B. Chumworathayi1 , P. Blumenthal2 , P. Likittanasombut3 . 1 Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand, 2 School of Medicine, Stanford University, California, USA, 3 Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Objective: To compare quality of life (QOL) in Thai women who were diagnosed low grade squamous intraepithelial lesions (LSILs) of the uterine cervix at 6 months after 3 kinds of treatments. Materials and Methods: QOL was assessed by Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire version 4. One hundred eligible patients were approached by trained interviewers. The interviewer interviewed after informed consent was signed. Data from the three study groups (40 HPV-negative-observed, 29 HPV-positive-cryotherapy, and 31 HPVpositive-observed) were extracted, combined and analyzed using chi-squared test and t-test. Results: Demographic data among the three groups (age, weight, parity, duration of sexual activity, duration with current partner,
Poster presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S413–S729
monthly income, education of college or more, smoking status, partner’s smoking status, reported HIV positive, reported partner’s multiple sexual partner, reported multiple sexual partner) were all comparable. The third group had highest QOL that was significant different from the second group (39.74+2.04 vs 33.1+2.44, p = 0.04) but not significant different from the first group (39.74+2.04 vs 34.95+2.21, p = 0.57). Conclusions: In contrast to our experiences that Thai women prefer some kinds of treatment after they acknowledge having LSILs, the HPV-positive-observed group significantly had higher QOL score than the HPV-positive-cryotherapy group. The reason for this may relate to extensive counseling and side effect of treatment, respectively. P654 Introduction of automated BP devices intended for the low resource setting in rural Tanzania and Ethiopia C. Baker, K. Duhig, A. De Greeff, A. Van der Westhuizen, A. Shennan. King’s College London Objective: Regular blood pressure (BP) monitoring is a costeffective means for early identification and management of hypertensive disease in pregnancy. BP devices that fulfil the WHO recommendations for use in low resource settings were distributed to clinics in rural Africa as part of an evaluation of their impact on maternal and foetal mortality and morbidity. Methods: Thirty-three automated BP devices (Omron M1 Plus; Omron HEM-Solar; Nissei DS-400) were distributed to 18 clinics in Tanzania and Ethiopia. User training and error cards were provided for each device. Device condition, frequency of use and staff views was assessed at 1, 3 and 6 months. Results: Devices were used regularly, even in clinics with no previous access to BP devices. All devices were found to be in good working order. Only one clinic abandoned device use because of repeated error readings due to cuff malpositioning. Solar powered devices were well received, but concerns for the maintenance of battery operated devices were raised. Eighty percent of staff preferred automated devices to mercury devices despite raising concerns about device accuracy. Conclusion: Use of automated BP devices in low resource settings is feasible and potentially useful. User training and device maintenance protocols need to accompany device introduction. Implications for appropriate referral of women with hypertensive diseases as well as cost-benefit analyses are necessary to prove the utility of this intervention. P655 Process evaluation for the implementation of a cervical cancer see-and-treat program in rural El Salvador M. Cremer1 , L. Ditzian2 , M. Maza2 , E. Peralta2 , R. Masch2 . 1 NYU School of Medicine & Basic Health International, 2 Basic Health International Objectives: In low-resource settings, cytology programs are difficult to implement; however, see-and-treat programs utilizing visual inspection with acetic acid (VIA) and cryotherapy have gained popularity as a low-cost, low-technology alternative. The objective of this project was to conduct a process evaluation of the implementation of a governmental VIA and cryotherapy program in rural communities of El Salvador, and to provide quality improvement advice to program methodology. Materials and Methods: The process evaluation was conducted through an action research approach, in which VIA-trained healthworkers were accompanied by evaluators to their rural work sites. Data collection methods included expert observations, interviews, and an evaluation instrument containing 44 questions about the infrastructure of the rural health system, gynecological campaigns, VIA patient data tracking, clinical work environment, supplies
S601
and clinical exam. A feedback debriefing session was held to disseminate findings amongst stakeholders. Results: Process evaluation successfully identified technical and logistical limitations to screening and therapy. Inadequate portable lighting, lack of foot rests for gynecologic exams, and limited cryotherapy probe tips ranked high as programmatic barriers. Debriefing led to proposed acceptable and affordable remedies in all instances. Enthusiasm and acceptance for the program was universal. Conclusion: The process evaluation demonstrates that the seeand-treat method of cervical cancer screening can be implemented in low-resource settings of El Salvador. Potential barriers to program delivery can be easily averted through early programmatic evaluation and intervention. P656 Study of the effect of cognitive behavioral counseling on body image alterations in women who have undergone mastectomy S. Fadaei, M. Janighorban, T. Mehrabi. Nursing Midwifery Faculty – Azad Islamic University – Branch Najaf Abad Introduction: Breast cancer is the most common cancer in women throughout the world and for most women mastectomy results in the loss of a body part that is viewed as essential for maintaining feminity, attractiveness and self-esteem. In order to prevent impaired body image, one should accept the changes of her body shape. Objective: To determine the effect of counseling on mean of body image score in women undergone mastectomy. Methods: In this quasi experimental, 72 women undergone mastectomy referring to an oncology and radiotherapy center in Isfahan were randomly selected by convenient sampling and studied. The experimental group (n = 32) participated in six sessions of counseling. Data were collected using questionnaires and statistical analysis was performed by the paired and independent t test using SPSS software. Results: The results indicated a significant difference between mean of body image score before and after counseling in experimental group (P < 0.001). Also a significant difference was seen in mean of body image score after counseling between experimental and control groups (p < 0.001). Discussion: According to this results, psychotherapeutic treatment especially cognitive behavioral counselling in group setting are recommended. P657 Acceptability of HIV/AIDS counseling and testing of Sudanese pregnant women A. Fazari Bashir1 , K. Elmusharaf2 , A. Gerais2 , V. Berggren2 Objective: The objective of this study was to elucidate the attitudes of voluntarily counseling of HIV/AIDS with particular emphasis on voluntary counseling testing (VCT) among Sudanese pregnant women. Design: a cross sectional, clinic based study was performed. The data were analyzed using SPSS. Setting: six ante-natal clinics in Khartoum, Sudan. Participants: 961 ante-natal seeking pregnant women. Results: The general knowledge about HIV/AIDS among the participants where low. Only 36% of the participating women accepted the suggested VCT. 64% of the study sample did not accept the VCT. The majority of the study samples were of low socio economic status (73%). Conclusions: This study indicates that there might be less response in Sudan to the VCT in comparison to other African countries. In the era of the HIV/AIDS endemic, also Sudan must search ways to achieve increased knowledge and awareness in the community about HIV/AIDS and its treatment, one way can be improved and more access to voluntary counseling testing (VCT) and