772 Letters

Patients with premature rupture of membranes were generally managed expectantly, but delivery was consid­ered when rupture of membranes occurred after 32 weeks' assigned gestational age. One hospitalized patient had abruptio placentae. Five neonates, all born to women in the outpatient cohort, had retinopathy of pre­maturity. There were no cases of maternal HELLP syn­drome in this series, and there was only 1 instance of sig­nificant postpartum hemorrhage.

Richard K. Silver, MD Evanston Hospita~ 2650 Ridge Ave, Evanston, IL 60201

6/8/96297

Speculoscopy To the Editors: I read the August 1998 review of cervical screening adjuncts (Spitzer M. Cervical screening adjuncts: Recent advances. Am J Obstet Gynecol 1998;179:544-56), and I believe that Spitzer's review of the subject was inaccurate with respect to speculos­copy. I will take this opportunity to fill in some of the blanks.

Spitzer's referral to "flawed" methodology centers around his review of only 2 articles on speculoscopy. One report featured women with a previously abnormal Papanicolaou test result and the other featured women with atypical smears. He is correct when he states that these were not "screening" populations; in fact, neither study purported to be performed for the purpose of screening patients. Although Spitzer correctly states that to properly evaluate speculoscopy it would be necessary to subject healthy women to this examination in a prospective study, preferably with examiners who were not colposcopists, it is surprising that he did not review any of the 3 published studies with such a population.

Mann et all studied speculoscopy in a screening pop­ulation of 243 patients. Although that study was con­ducted largely by colposcopists, in the study of Edwards et al2 speculoscopy was performed by nurse practitioners who were not colposcopists on a screening population of 689 healthy patients. Wertlake et al3 published the data from a community-based study of 5692 women in Southern California, and these women were examined by physicians and nurse practitioners who were not col­poscopists. In each of these studies cervical biopsy served as the gold standard for determination of the presence or absence of cervical abnormality. It thus would appear that precisely the data that Spitzer said should be avail­able to evaluate speculoscopy as a screening adjunct are in fact available. They simply were not reviewed by Spitzer in the preparation of his review.

Spitzer also suggested that the lack of variable magni­fication and of a system for differentiation of tissue pathology is a drawback for speculoscopy. In deference to this opinion, speculoscopy is not a derivative of either colposcopy or cervicography. The use of acetic acid and magnification to assist with visualization is simply an ap­plication of long known principles for the recognition of potentially abnormal cervical tissue. Speculoscopy is, as a

March 1999 Am J Dbstet Gynecol

screening test should be, a test designed to assist in pop­ulation triage.

This letter is intended as a reminder to the Journal's readers that because Spitzer's review of speculoscopy was deficient in failing to review these applicable studies his conclusions regarding this technology should not be con­sidered even remotely valid. Readers are urged to review these studies and draw their own conclusions regarding the potential contribution of speculoscopy to cervical screening, particularly as an adjunct to the conventional Papanicolaou test.

Stewart A. Lonky, MD Chief Medical Officer, The TRYLON Corporation, 970 W 190th St, Suite 850, Torrance, CA 90502-1037

REFERENCES

1. Mann W, Lonky N, Massad S, Scotti R, Blanco J, Vasilev S. Papanicolaou smear screening augmented by a magnified chemiluminescent exam. IntJ Gynaecol Obstet 1993;43:289-96.

2. Edwards G, Rutkowski C, Palmer C. Cervical cancer screening with Papanicolaou smear plus speculoscopy by nurse practition­ers in a health maintenance organization. ] Lower Genital Tract Dis 1997;1:141-7.

3. Wertlake P, Francus K, Newkirk G, Parham G. Effectiveness of the Papanicolaou smear and speculoscopy as compared with the Papanicolaou smear alone: a community-based clinical trial. Obstet GynecoI1997;90:421-7.

6/8/96301

Reply To the Editors: I thank Lonky for his interest in my article, and I agree that the articles that he cited in his letter were not covered in my review. Of the 3 articles, however, that by Mann et all was similar to the 2 that I reviewed and would have added nothing new to the discussion. The other 2 articles were not reviewed mainly because they were published after my review was completed. Unfortunately, reviews are static, whereas the evolution of medical science remains dynamic. New things are al­ways being reported.

I agree with Lonky that the articles by Edwards et al2

and Wertlake et al3 represent screening speculoscopy by noncolposcopists, and they do add to our knowledge base. However, I am not sure that they support the use of speculoscopy as a screening adjunct. Although both arti­cles do show that speculoscopy with cytologic examina­tion detects more squamous intraepithelial lesions than does cytologic examination alone, the vast majority of these are low-grade lesions. Edwards et al2 found that the addition of speculoscopy indicated the need for 68 addi­tional colposcopies (compared with the 34 indicated by cytologic examination alone). Furthermore, their multi­variate analysis indicated that compared with both specu­loscopy alone and the Papanicolaou test alone the com­bination of the Papanicolaou test with speculoscopy did not increase the detection of low-grade or high-grade le­sions significantly and increased the cost of each high­grade lesion detected by 39%. The study by Wertlake et al3 found that the addition of speculoscopy indicated the need for 322 additional colposcopies (compared with the

Volume IHO, Number 3, Part 1 Am] Obstet Gynecol

77 indicated by cytologic examination alone) but found only 11 additional high-grade lesions. Although these au­thors did not do a cost analysis, the 4-fold increase in the number of colposcopies required would undoubtedly sig­nificantly increase the cost per case detected if specu­loscopy were used.

My comments comparing speculoscopy with col­poscopy and cervicography were related mainly to the ability to detect non-acetowhite-staining cervical can­cers. There remains insufficient evidence in the litera­ture to support speculoscopy's ability to detect cervical cancer. Even Massad,4 an author of some of the initial studies of speculoscopy, concluded, "Using speculoscopy as a routine adjunct to cytologic screening for women with a history of normal smears cannot be recommended until a larger trial incorporating cost analysis is under­taken and reported."

I encourage all attempts to improve our ability to screen for cervical cancer and its precursors. I also en­courage readers to review these studies and draw their own conclusions. However, I believe that the data cur­rently available do not yet show that speculoscopy is a useful adjunct.

Mark Spitzer, MD Department of Obstetrics and Gynecology, "B" Bldg, Rm 210, Queens Hospital Center; 82-68 164th St,jamaica, NY 11432

REFERENCES

l. Mann W, Lonkv N, Massad S, Scotti R, Blanco J, Vasilev S. Papanicolaou s~near screening augnlented by ~ magnified chemiluminescent exam. lnt] Gvnaecol Obstet 1993;43:289-96.

2. Edwards G, Rutkowski C. Palmer C. Cervical cancer screening with Papanicolaou smear plus speculoscopy by nurse practition­ers in a health maintenance organization . .J Lower Genita Tract Dis 1997;1:141-7.

3. Wertlake P, Francos K, Newkirk G, Parham G. Effectiveness of the Papanicolaou smear and speculoscopy as compared with the Papanicolaou smear alone: a community-based clinical trial. Obstet Gynecol 1997:90:421-7.

4. Massad LS. The role of speculoscopy in the diagnosis of cervical dysplasia . .J Lower Genital Tract Dis 1997; 1:1154-8.

6/8/96300

Laparoscopy-associated intestinal infarction: A new syndrome? To the Editors: Intestinal infarction seen as an acute ab­domen 4 days after diagnostic laparoscopy was recently reported (Sheikh HH. Uterine leiomyoma as a rare cause of acute abdomen and intestinal gangrene. Am] Obstet Gynecol 1998; 179:830-1). Mesenteric venous thrombosis was found at laparotomy, and the author postulated that prolonged venous compression by a 5 x 6-cm myoma was the precipitating factor. Although this mechanism was previously suggested in a patient with a huge myoma and chronic intestinal symptoms,l the nature and sequence of events and the relatively small myoma in the former case suggest an alternate origin.

Arterial and venous thrombotic mesenteric infarction within the first week after a laparoscopic operation has been reported in 5 female and 2 male patients since

Letters 773

1994.2, 3 Of these patients, who ranged in age from 30 to 76 years and underwent cholecystectomy (n = 6) or gas­tric fundoplication (n = 1), only 2 survived (l female pa­tient and 1 male patient). 2, 3 Arterial thrombosis (of the celiac artery, superior mesenteric artery, or inferior mesenteric artery) uniformly resulted in massive infarc­tion and death, whereas venous thrombosis (inferior mesenteric vein or hepatic vein) uniformly resulted in focal infarction and survival.2, 3

It has been postulated that a carbon dioxide pneu­moperitoneum predisposes a patient toward thrombosis by decreasing visceral blood flow through direct compres­sion of the splanchnic vasculature, reduced portal blood flow, increased vasopressin levels, and diminished vena caval flow, and that transperitoneal absorption of carbon dioxide produces hypercapnia, which in turn produces mesenteric vasoconstriction. 2, 3 This hypothesis does not explain the rarity of the condition, in light of the preva­lence of laparoscopic surgery among patients with risk factors for mesenteric thrombosis (eg, atherosclerosis, previous deep venous thrombosis, previous myocardial in­farction, cocaine use, and oral contraceptive use).

The clinical picture is remarkably similar in reported cases. Several days after an uneventfullaparoscopic oper­ation, acute abdominal pain develops and a segment of gangrenous bowel is found at reoperation. Diagnosis and treatment of mesenteric ischemia are often delayed, and progression to infarction carries a mortality rate of 50% to 80%. Survivors who lose large segments of bowel fre­quently require lifelong parenteral feeding.4

The diagnosis of acute ischemia is obscured by the ini­tial reflex intestinal spasm, which produces vomiting or bloody diarrhea but no distention, and by the lack of early peritoneal compromise and focal findings. Diffuse abdominal pain out of proportion to physical findings is characteristic of ischemia. When the acute abdomen be­comes evident, bowel infarction, necrosis, and perfora­tion have already occurred.4

Duplex ultrasonographic scanning is helpful in find­ing major arterial and venous occlusions. In the presence of severe ileus, bowel gas may interfere with ultrasono­graphic evaluation. Arteriography confirms mesenteric thrombosis. Computed tomography and magnetic reso­nance imaging are helpful in diagnosing mesenteric ve­nous thrombosis.4 Recommendations, currently conjec­tural, include avoiding laparoscopy in patients with mesenteric ischemia or risk factors, reducing pneu­moperitoneum pressure, limiting reverse Trendelenburg positioning, avoiding high blood carbon dioxide levels (through maintenance of adequate minute volume), and maintaining a high index of suspicion in the presence of unexplained postlaparoscopic abdominal pain.

Marco A. Pelosi III, MD, and Marco A. Pelosi, MD Pelosi Women's Medical Center, 350 Kennedy Blvd, Bayonne, NJ 07002

REFERENCES

1. Dimitrov R, Nachev A. [A case of mesenteric thrombosis occur­ring in a woman with a uterine myoma during her hospital stay.] Akush Ginekol (Sofiia) 1995;34:58-60.