School of Medicine physicians working at Grady Hospital are
among the first in the country to use a technique called microculdoscopy
to diagnose ectopic pregnancies. More than 100 patients a year at
Grady have ectopic pregnancies, which pose a disproportionate risk
to the lives of African American women.
An ectopic pregnancy is one that occurs outside of the uterus and
is usually detected within the first four to six weeks of pregnancy.
Microculdoscopy involves inserting a small camera into the vagina
and then behind the uterus into a space (known as the cul-de-sac)
between the uterus and rectum to allow direct visualization of the
fallopian tubes and ovaries.
The procedure normally is used to evaluate infertility and chronic
pelvic pain, but it is being applied at Grady to visualize and diagnose
ectopic pregnancies, a life-threatening condition in which a fertilized
egg begins to develop into a fetus outside the uterus, often in
In a recent study, Michael McCall, assistant professor of obstetrics
and gynecology and director of Grady’s Gynecologic Ambulatory
Surgery, and Kimberly Kleiss, a fourth-year obstetrics and gynecology
resident, used microculdoscopy to evaluate 10 women with suspected
ectopic pregnancy, while 10 more women with a possible ectopic pregnancy
served as the control group and were managed with surgery or methotrexate,
a chemotherapy drug.
Kleiss presented the study’s findings at a district meeting
of the American College of Obstetricians and Gynecologists (ACOG)
in October 2001, where it received first-place honors for Junior
Fellow Presentation. She plans to present the findings again at
the national ACOG meeting in April.
According to McCall, Grady is one of the top two or three hospitals
in terms of numbers of patients with ectopic pregnancies, with a
rate of incidence 2.5 times greater than other hospitals nationwide;
ectopic pregnancies account for 5 percent of all Grady pregnancies,
while other hospitals rank at about 2 percent.
Prior to using microculdoscopy, patients suspected of having ectopic
pregnancy had been followed routinely with pregnancy tests (beta-HCG
levels) and ultrasound examinations.
The addition of microculdoscopy allows physicians to confirm whether
an ectopic pregnancy is present by direct visualization of the fallopian
tubes with a camera and video monitor.
“The problem with ectopic pregnancies is they happen early
in pregnancy, and sometimes it’s before you can see a pregnancy
on the ultrasound of the uterus, giving us no indication of what’s
going on,” McCall said. “What we’re hoping to
do with this is manage the pregnancy better.”
Microculdoscopy uses a 2.7-millimeter endoscope to provide a definitive
view of an ectopic pregnancy in the fallopian tubes, which usually
float behind the uterus.
Gynecologists can then determine if the pregnancy is inside the
uterus, or if there is swelling in one of the tubes, indicating
an ectopic pregnancy.
Risk factors include previous tubal infections and scarring, mostly
from sexually transmitted infections like gonorrhea and chlamydia.
The best-known forms of treatment remain the drug methotrexate or
surgery to remove the ectopic pregnancy. Approximately 60 percent
of women with ectopic pregnancies are able to conceive again; the
other 40 percent are left infertile.
The majority of ectopic pregnancies affect women ages 25–34.
Overall, risk of death from ectopic pregnancy is about 10 times
greater than the risk of death from childbirth. The mortality rate
is similar in all age groups but is four times higher in blacks
and other nonwhites than in white women. A pregnant black woman,
for example, is about five times more likely to die of ectopic pregnancy
than a white woman. Ectopic pregnancy also is the single most common
cause of all maternal deaths among black women, causing about one-fifth
of such deaths.
At Grady, the microculdoscopy procedure is done on an outpatient
basis. Kleiss said that, so far, the procedure has been helpful
and there have been no complications.
“We don’t have enough patients to say that it makes
a true difference, but from a case-to-
case basis, it helps some of the patients that we use it on,”
she said. “This procedure is really useful for patient populations
that have a high ectopic rate. We think it helps prevent some patients
from having to get surgery. It also gives the patient a more definitive
answer earlier than we could do before.”