1054 Sibai

III. Neonatal outcome, growth, and development. AM J OSSTET GYNECoLl983; 146: 307 -16.

10. Sibai BM, Spinnato JA, Watson DL, et al. Eclampsia. IV. Neurological findings and future outcome. AM J OSSTET GYNECOLI985; 152: 184-92.

11. PritchardJA, Cunningham FG, Pritchard SA. The Park­land Memorial Hospital protocol for treatment of eclamp­sia: evaluation of 245 cases. AM J OSSTET GYNECOL 1984;148:951-63.

12. Campbell DM, Templeton AA. Is eclampsia preventable? In: Bonnar J, MacGillivray I, Symonds EM, eds. Preg­nancy hypertension. Baltimore: University Park Press, 1980:483-8.

13. Donaldson JO. Does magnesium sulfate treat eclamptic convulsions? Clin Neuropharmacol 1986;9:37-45.

14. Lopez-Llera MM. Complicated eclampsia. Fifteen years' experience in a referral medical center. AM J OSSTET GYNECOLI982; 142:28-35.

15. Adetoro 00. A sixteen year survey of maternal mortality associated with eclampsia in Iiorin, Nigeria. ImJ Gynecol Obstet 1989;30: 117-21.

Editors' note: This manuscript was revised after these discussions were presented.

Discussion DR. THOMAS M. STUBBS, Charleston, South Carolina

(Official Guest). The disease eclampsia continues to threaten our patients, even as we enter the last decade of the twentieth century. In this large report of 254 cases, the sixth of a series, Dr. Sibai has shown five things of particular importance. First, we must beware of this disease, even in patients who lack either abnor­mal edema or abnormal proteinuria. Second, great cau­tion is required in the presence of central nervous sys­tem symptoms, even when other findings indicate only mild disease. Third, magnesium sulfate continues to be associated with the best outcomes. Fourth, transport of the patient is a dangerous time. Fifth, good commu­nications are important if there is a change of physi­cians. There are some differences in our management of these patients at the Medical University of South Carolina. We have had success with a continuous in­travenous infusion of hydralazine for the control of severe hypertension. Whether one gives this drug as a series of small intravenous boluses, as is done in Mem­phis, or as a continuous intravenous infusion, as is done in Charleston, the pitfall for the physician is the same. That pitfall is the fact that the drug doesn't reach its peak effect until 20 minutes after administration. Thus overzealous dosing can result in a greater fall in blood pressure than was originally intended. Also, stress headaches are common in our patients, including those who go on to have preeclampsia. The physician at the bedside must use clinical judgment in deciding whether a particular headache is a signal for magnesium sulfate therapy. Nonetheless, these data do show convincingly that the physician should consider a headache a major threat in a patient with preeclampsia. The low incidence of maternal complications in this report is remarkable. Six years ago, Dr. Jack Pritchard published a series of 245 cases of eclampsia with only a single maternal death and no maternal intracranial hemorrhages; these ma-

September 1990 Am J Obstet Gynecol

ternal outcomes are identical to those presented here. Dr. Sibai has shown again that in the most experienced hands only an occasional maternal death will occur. Even so, this article reports no decrease in the incidence of eclampsia over the past 30 years at Dr. Sibai's insti­tution. As we look to the future and as we look for a way to improve outcomes, the perils of maternal trans­port require our attention. Perhaps the most important finding in this article is that remaining maternal mw­bidity and mortality are so frequently linked to this transport problem. Dr. Sibai, how do you advise your colleagues in the Mississippi Valley regarding transport of patients with preeclampsia and eclampsia, including type of vehicle, accompanying personnel, drug choice, and route of drug administration? Also, do a patient'S reflexes or a great distance from the hospital affect your advice regarding magnesium sulfate?

REFERENCE

1. Pritchard JA, Cunningham FG, Pritchard SA. The Park­land Memorial Hospital protocol for treatment of eclamp­sia: evaluation of 245 cases. AM J OSSTET GYNECOL 1984; 148:951-63.

DR. HUGH RANDALL, Atlanta, Georgia. I can't tell you how much I enjoyed the article. It is always an enlightening event when Dr. Sibai presents the great work that he has done in hypertension. We have seen a number of complications occurring when the patient goes for imaging, either computerized tomographic im­aging or magnetic resonance imaging, particularly when the patient goes directly from the intensive care unit to the radiology department. Dr. Sibai, what type of monitoring would you recommend when patients undergo imaging and at what stage of the disease would you recommend that imaging be done?

DR. SIBAI (Closing). I thank Dr. Stubbs for his com­ments. I guess the key issue is maternal transport. It has been a problem, and it continues to be a problem. Actually 2 weeks ago we had new memos and letters handed down to all physicians and nurses in the region suggesting to them the proper way to send these pa­tients. It makes sense that when someone refers a pa­tient to you he will call. We still have physicians and nurses who will send patients to us without even telling us the patient is on her way. At the present time, when a physician or nurse calls us, the first thing we tell them is that it is their responsibility to stabilize the patient before sending her. Some patients have a long way to go. If the patient is seriously sick, the referring doctor must take care of her even if she is in a local level I or level II hospital. We recommend that every patient re­ceive magnesium sulfate irrespective of the severity of the disease. We recommend the use of 4 gm of mag­nesium sulfate intravenously plus 10 gm intramuscu­larly. If physicians don't like to use intramuscular mag­nesium sulfate, we recommend to them that they give a 6 gm intravenous loading dose plus 4 gm intravenous magnesium sulfate in 250 ml of fluid to be administered

Volume 163 Number 3

over 2 hours. If this 4 gm is injected rapidly, it will not be toxic to the patient because the total will be 10 gm, which is safe for any patient who is pregnant. If the patient has severe hypertension, we recommend to the physician that they should control the blood pressure of the patient before sending her. The patient should be sent in an ambulance because, despite the intrave­nous magnesium sulfate, patients can still have con­vulsions. More important, we tell them to send an ac­companying physician or nurse capable of handling her problems.

In regard to Dr. Randall's comments regarding com­puterized tomographic scans and magnetic resonance imaging, I have been doing them for research pur-

Maternal-perinatal outcome in eclampsia

poses. Some patients will lapse into coma, and some have more complicated cases of eclampsia, especially those that develop >3 days after delivery. In these cases the presence of other neurologic problems must be ruled out, and we would recommend doing comput­erized tomographic scan or magnetic resonance im­aging. When do we send the patients for radiologic examination? Again, the patient has to be in a stabilized condition. Patients who have already received magne­sium sulfate and patients whose blood pressure already has been controlled should be accompanied to the ra­diology department by faculty or a senior resident, who should be prepared to administer more magnesium sulfate or to perform emergency intubation.

Experience with the EndoPap device for the cytologic detection of uterine cancer and its precursors: A comparison of the EndoPap with fractional curettage or hysterectomy

James P. LaPolla, MD," Santo Nicosia, MD: Charles McCurdy, MD,c Curtis Songster, MD; Eugene Ruffolo, MD: William S. Roberts, MD," Mitchel S. Hoffman, MD," James V. Fiorica, MD," and Denis Cavanagh, MD"

Tampa and St. Petersburg, Florida

Cytologic assessment of the endometrium with the EndoPap sampler was compared with curettage or hysterectomy in 249 women with symptoms. The sensitivities for the detection of primary corpus cancer and hyperplasia were 0.90 (59/66) and 0.58 (18/31), respectively. All six cases of atypical endometrial hyperplasia were detected by the EndoPap device. Malignant EndoPap cytologic findings were present in 4 of 10 patients with a primary adnexal malignancy and normal endometrial histologic findings. Ninety-two percent of primary uterine cervical cancers were detected by EndoPap cytologic sampling. The specificity for the cytologic diagnosis of benign conditions was 0.93. EndoPap cytologic sampling has a reasonably high sensitivity for the detection of uterine cancers and preinvasive endometrial lesions with a high risk of progression to carcinoma. Further evaluation as to its usefulness in a screening program for uterine and adnexal cancers in postmenopausal women should be considered. (AM J OSSTET GVNECOL 1990;163: 1055-60.)

Key words: Endometrial cytology, uterine cancer

Endometrial cytologic sampling has lagged behind cervical cytologic sampling in its application and, most

From the Departments of Obstetrics and Gynecology" and Pathology' at the University of South Florida, and the Departments of Obstetrics and Gynecology' and Pathologyd at Bayfront Medical Center. Presented as Official Guest at the Fifty-second Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Palm Beach, Florida, January 28-31, 1990. Reprint requests: James P. LaPolla, MD, H. Lee Moffitt Cancer Center and Research Institute, Division of Gynecologic Oncology, 12902 Magnolia Dr., Tampa, FL 33612-9477. 6/6/22027

important, its impact on clinical practice. It is well known that the decline in the incidence of invasive cer­vical carcinoma has been primarily attributed to the widespread application of a cervical cytology screening program. A similar phenomenon has not occurred for endometrial carcinoma. Reasons for this are primarily because of the lack of an effective, inexpensive, and easy-to-use sampling method. In addition, greater ex­pertise is needed to accurately interpret endometrial cytologic specimens, which frequently are unavailable on a routine clinical basis.' The EndoPap endometrial

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