Letters Wet smear compared with Gram stain diagnosis in asymptomatic pregnant women To the Editor: Mastrobattista et al (Obstet Gynecol 2000;96:504 – 6) concluded that Gram stain of vaginal fluid is the best technique for diagnosing bacterial vaginosis in preg- nancy. 1 I could not disagree more because the sample size (69 women) was inadequate for a study whose aim was to evaluate a diagnostic technique. Moreover, only 18 of 67 samples investigated were diagnosed as posi- tive for bacterial vaginosis. The composition of the study population was extremely heterogeneous, in which populations with very different rates of genital infection and bacterial vaginosis were mixed. The 14- month time span for the collection of these 69 cases seems very long, if they are meant to be consecutive cases, and implies a mean inclusion rate of barely five asymptomatic pregnant women per month. Furthermore, the title of the manuscript implies that the authors are going to present compelling data com- paring wet mount with Gram stain for diagnosis of bacterial vaginosis. Instead, they compare Gram stain with some of Amsel’s composite criteria. The latter was not used properly enough to call it a standard, as only two of three criteria were used, instead of three of four. Even if a proper standard were to have been used, it remains doubtful whether this study had the potential to show exciting or new messages. What is of real interest to clinicians is whether wet mount is as good as Gram stain for detecting abnormal vaginal flora. It is. Lactobacillary morphotypes and bacterial vaginosis flora can be recognized easily on wet mounts, and the resulting lactobacillary grades can be diagnosed more accurately in wet mounts than in Gram stains. 1,2 When lactobacillary grading was compared with vaginal lactate production as a gold standard, assessment of vaginal flora in wet mounts was superior to that in Gram stains. 3 Gilbert G. G. Donders, MD, PhD University Hospital Gasthuisberg, Ku Leuven Department of Obstetrics and Gynecology Leuven Belgium References 1. Donders GGG, Vereecken A, Salembier G, Van Bulck B, Spitz B. Assessment of vaginal lactobacillary flora in wet mount and fresh or delayed Gram’s stain. Infect Dis Obstet Gynecol 1996;4:2– 6. 2. Donders GGG, Desmyter J, Vereecken A. Vaginitis [letter]. N Engl J Med 1998;338:1548. 3. Donders GGG, Vereecken A, Dekeersmaecker A, Van Bulck B, Spitz B. Wet-mount microscopy reflects functional vaginal lactobacillary flora better than Gram stain. J Clin Pathol 1999;53:308 –14. In reply: This letter was sent to Dr Mastrobattista who failed to respond within 30 days. Rethinking maternal-fetal conflict: Gender and equality in perinatal ethics To the Editor: Harris, in her commentary on maternal-fetal conflict (Obstet Gynecol 2000;96:786 –9) makes an important contribution to the evolution of an obstetric moral theory. I admire it for pointing out similarities between supportive obstetric practice and relational feminist moral theory, like the mutually endorsed conceptual moral principle “care.” Yet, basing conclusions on clin- ical examples instead of further moral theory, weakens the arguments. First, reliance on feminist theory alone shifts the “conflict of rights” from mother and her fetus to moth- er-fetus and society, and thus only partially solves clinicians’ ethical dilemmas. Second, the article is writ- ten as if medical care is a social good. If that is true, moral theories governing resource distribution and social justice are as relevant as gender to constructing a durable obstetric moral theory. 1 One major contribution of feminist moral theory has been to point out that groups, defined by different sociologic variables, have differing perspectives. The article makes me wonder what influence socioeconomic position and cultural affinity would have on develop- ment of an obstetric ethic for the pluralistic society of the United States. I agree with Harris that ethical professional behavior requires clinicians to honor our professional power and agency. We can do this by reflecting on our clinical 482 0029-7844/01/$20.00 Obstetrics & Gynecology