January 21, 2003

Procedure can detect problem pregnancy early

By Alicia Sands Lurry

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 a
fallopian tube.

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.”






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