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Letters to the Editors With respect to the NNT to prevent 1 early neonatal death according to risk status, we reanalyzed our data and we found that the NNT to prevent 1 early neonatal death in low-risk pregnancies is 9508, whereas the corresponding NNT for high-risk pregnancies is 251. This observation, coupled with our earlier finding that there was a dose-response relationship between gestational age and NNT (with lower NNT in early gestations), suggests that the association of EFM use and decreased neonatal and infant mortality may indeed be causal. We disagree with the notion that the randomized trials (and therefore their metaanalysis) “compared EFM with properly performed intermittent auscultation (IA).”2 With the exception of the Athens trial5 none of the other trials was a direct comparison of EFM vs IA as the primary and only method of intrapartum fetal surveillance. The remaining trials were comparisons of policies or protocols allowing for cross-over from IA to EFM (when there were fetal heart rate abnormalities by auscultation) and back-up methods, such as scalp pH, which apparently can mask any clinical outcome differences that exist between the 2 monitoring techniques. In conclusion, despite Drs Illuzzi and Bracken’s concern, we reiterate our earlier conclusions that “In the United States, the use of EFM was associated with a substantial decrease in early neonatal mortality and morbidity.1” We look forward to a large and adequately powered randomized, controlled trial to disf prove our conclusions.

www.AJOG.org Suneet P. Chauhan, MD Han-Yang Chen, MS Cande V. Ananth, PhD, MPH Anthony M. Vintzileos, MD Alfred Z. Abuhamad, MD Eastern Virginia Medical School Department of Obstetrics and Gynecology 825 Fairfax Ave., Ste 544 Norfolk, VA 23507 chauhasp@evms.edu The authors report no conflict of interest.

REFERENCES 1. Chen H-Y, Chauhan SP, Ananth CV, Vintzileos AM, Abuhamad AZ. Electronic fetal heart rate monitoring and its relationship to neonatal and infant mortality in the United States. Am J Obstet Gynecol 2011; 204:491.e1-10. 2. Alfirevic Z, Devane D, Gyte GM. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev 2006;3:CD006066. 3. Vintzileos AM, Nochimson DJ, Guzman ER, Knuppel RA, Lake M, Schifrin BS. Intrapartum electronic fetal heart rate monitoring versus intermittent auscultation: a meta-analysis. Obstet Gynecol 1995;85: 149-55. 4. Manning FA, Baskett TF, Morrison I, Lange I. Fetal biophysical profile scoring: a prospective study in 1,184 high-risk patients. Am J Obstet Gynecol 1981;140:289-94. 5. Vintzileos AM, Antsaklis A, Varvarigos I, Papas C, Sofatzis I, Montgomery JT. A randomized trial of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation. Obstet Gynecol 1993;81: 899-907. © 2012 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.10.004

Appropriate cervical cancer screening remains essential: the case of women with inflammatory bowel disease TO THE EDITORS: We read with interest the article by Dr de Bie and colleagues1 assessing the screening history of women with cervical cancer in which half were never screened before diagnosis. Given recent guideline revisions on cervical cancer screening,2 which no longer recommend routine annual examinations for all women, there is a need to promote the continued importance of screening, especially for women at increased risk. Women identified in guidelines as high-risk include women with human immunodeficiency virus or those previously treated for advanced cervical intraepithelial neoplasia. Although women with inflammatory bowel disease (IBD) are unnamed among the high-risk, numerous articles published in recent years support an increased risk of cervical abnormalities, largely attributed to the use of immunomodulators (eg, 6-mercaptopurine, antitumor necrosis factor), among these women.3 We evaluated the rate of cervical cancer screening in women with IBD treated with aminosalicylates or immunomodulators. The medical records of 177 women with IBD seen at a university medical center, during a 2-year period, were ree6

American Journal of Obstetrics & Gynecology FEBRUARY 2012

viewed. The mean age was 41 years (range, 19 – 85 years). Of the total, 75 patients between 20-35 years (mean 28 years) were identified. Papanicolaou (Pap) smears were performed in 48 (64%) from this younger cohort, and cervical dysplasia was found among the results of 8 (16.6%). None had a history of tobacco use. Women on aminosalicylates had 18 (37%) documented Pap smears, 2 (11%) exhibiting dysplasia, all human papilloma virus (HPV) negative. Women on immunomodulators had 30 (63%) documented Pap smears, 6 (20%) exhibiting dysplasia, 5 HPV positive. There were significantly less women on aminosalicylates with HPV compared with those on immunomodulators (P ⫽ .02). This study revealed that women with IBD had suboptimal Pap smear performance and increased rates of cervical dysplasia and HPV infection, particularly those on immunomodulators. Although this study is limited by sample size and single institution evaluation, it nevertheless offers useful information to the growing literature supporting increased risk of HPV infection and cervical dysplasia in women with IBD.


Letters to the Editors

www.AJOG.org de Bie and colleagues have shown that inadequate screening is the most important modifiable risk factor in the development of cervical cancer. Although current cervical cancer screening guidelines generally recognize immunosuppression as an indication for increased screening, we offer specific information on IBD as a condition requiring such vigilance. f Ruby C. Greywoode Division of Gastroenterology and Liver Disease George Washington University Washington, DC Sean D. Fine Division of Gastroenterology and Liver Disease George Washington University Washington, DC Marie L. Borum, MD, EdD, MPH Division of Gastroenterology and Liver Disease George Washington University Washington, DC

Department of Medicine George Washington University 2150 Pennsylvania Ave., NW Washington, DC 20037 mborum@mfa.gwu.edu The authors report no conflict of interest.

REPLY DECLINED REFERENCES 1. de Bie RP, Vergers-Spooren HC, Massuger LF, et al. Patients with cervical cancer: why did screening not prevent these cases? Am J Obstet Gynecol 2011;205:64.e1-7. 2. American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 109. Cervical cytology screening. Obstet Gynecol 2009;114: 1409-20. 3. Singh H, Demers AA, Nugent Z, Mahmud S, Bernstein CN. Risk of cervical abnormalities in women with inflammatory bowel disease: a population-based nested case-control study. Gastroenterology 2009;136: 451-8. Š 2012 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.10.007

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