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January 8, 2003


Microculdoscopy: A New Procedure Used at Grady Memorial Hospital To Detect Ectopic Pregnancies

ATLANTA -- Emory University School of Medicine physicians working at Grady Memorial 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.

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 is normally used to evaluate infertility and chronic pelvic pain, but 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 A. McCall, MD, assistant professor of obstetrics and gynecology at Emory, and director of Gradyís Gynecologic Ambulatory Surgery, and Kimberly Kleiss, MD, a fourth-year obstetrics and gynecology resident at Emory, used microculdoscopy with hydroflotation 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.

Dr. Kleiss presented the studyís findings at the annual meeting of District IV of the American College of Obstetricians and Gynecologists (ACOG) in October 2001, where it received first-place honors for Junior Fellow Presentation. She also plans to present at the national ACOG meeting in April 2003.

According to Dr. McCall, Grady is one of the top two or three hospitals in terms of numbers of patients with ectopic pregnancies. The ectopic rate at Grady is 2 _ times greater than other hospitals nationwide. Gradyís patient population with ectopic pregnancies accounts for 5 percent of all pregnancies, while other hospitals rank at about 2 percent.

Prior to using microculdoscopy, patients suspected of having ectopic pregnancy had been routinely followed 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 itís before you can see a pregnancy on the ultrasound of the uterus, giving us no indication of whatís going on," Dr. McCall said. "The patient could have a miscarriage, a pregnancy thatís completely normal in the uterus but itís not far enough developed to see yet, or she could have a pregnancy thatís in the fallopian tube. What weíre hoping to do with this is manage the pregnancy better."

Microculdoscopy uses a 2.7 mm 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.

An ectopic pregnancy is one that occurs outside of the uterus, and is usually detected within the first four to six weeks of pregnancy. The 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.

According to the fourth edition of Comprehensive Gynecology by William Droegemueller, MD and co-authors, ectopic pregnancy is the most common cause of maternal death in the first trimester of pregnancy, with blood loss being the major cause of death. The majority of ectopic pregnancies affect women ages 25 to 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 is also the most common single cause of all maternal deaths among black women, causing about one-fifth of such deaths.

At Grady Hospital, the microculdoscopy procedure is done on an outpatient basis, using lidocaine, an anesthetic, to numb the pain and conscious sedation to make the patient more comfortable. Some patients are taken immediately to surgery if it is discovered they are bleeding internally.

Dr. Kleiss said that so far, the microculdoscopy procedure has been helpful and there have been no complications from the procedure.

"We donít 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."

Dr. McCall added that microculdoscopy is especially helpful in the cases where doctors are searching for answers regarding a womanís early pregnancy.

"Itís shown to be helpful in deciding if the patient has an early ectopic pregnancy, an early normal pregnancy, or a miscarriage," he said.

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