Uterine arterial embolization for the treatment of uterine leiomyomas

OBJECTIVE: The purpose of this study was to establish guidelines for using uterine artery embolization for the treatment of uterine leiomyomas accompanied by adenomyosis in Korea. This study was performed to investigate 1) the effects of uterine embolization on leiomyoma accompanied by adenomyosis, 2) the outcome of uterine embolization according to the embolization materials used, 3) the relationship between the Resistance Index (RI) and the change in uterine volume. MATERIALS AND METHODS: We performed a retrospective study on 37 women who had uterine leiomyomas accompanied by adenomyosis. Bilateral uterine artery embolization was performed over a period of 17 months in 37 patients (age range 25 - 65) experiencing pain, hypermenorrhea, urinary frequency, etc. due to leiomyomas. Ultrasound imaging was performed before the procedure and at mean 6.9 months after the procedure. RESULTS: All procedures were technically successful. Mean clinical follow-up time was 12.8 months. Minor complications occurred in 82% patients following the procedure. After follow-up imaging, the median uterine volume decreased by 34.4% and the dominant myoma volume decreased by 86%. There was no statistical difference in the uterine volume reduction and the dominant myoma size reduction, whether the occluding agent was polyvinyl alcohol, polyvinyl alcohol plus gelfoam, or gelfoam, and whether the ultrasound measured Resistance Index value before the procedure was low or high. CONCLUSION: Primary candidates for uterine artery embolization include those with symptomatic uterine leiomyomas, who no longer desire fertility, but who wish to avoid surgery or are poor surgical risks. According to the results of our study, adenomyosis should not be considered as a contraindication for uterine artery embolization. However, because little data is available about the subsequent reproductive potential following this procedure, it should not be routinely advocated for infertile women. Further investigation is warranted regarding the choice of occluding agent and the role of the Resistance Index.     

Predictive factors for pelvic magnetic resonance in response to arterial embolization of a uterine leiomyoma

OBJECTIVE:

Minimally invasive methods are used as alternatives to treat leiomyomas and include uterine artery embolization, which has emerged as a safe, effective method. This study aims to evaluate the magnetic resonance imaging predictors for a reduction in leiomyoma volume in patients undergoing uterine artery embolization.

METHODS:

This prospective longitudinal study was performed at a university hospital. We followed 50 symptomatic premenopausal women with uterine leiomyomas who underwent uterine artery embolization. We examined 179 leiomyomas among these patients. Magnetic resonance imaging was performed one month before and six months after uterine artery embolization. Two radiologists who specialized in abdominal imaging independently interpreted the images. Main Outcome Measures: The magnetic resonance imaging parameters were the uterus and leiomyomas volumes, their localizations, contrast perfusion pattern and node-to-muscle ratio.

RESULTS:

Six months after treatment, the average uterine volume reduction was 38.91%, and the leiomyomas were reduced by 55.23%. When the leiomyomas were submucosal and/or had a higher node-to-muscle ratio in the T2 images, the volume reduction was even greater (greater than 50%). Other parameters showed no association.

CONCLUSIONS:

We conclude that symptomatic uterine leiomyomas in patients undergoing uterine artery embolization exhibit volume reductions greater than 50% by magnetic resonance imaging when the leiomyomas are submucosal and/or had a high node-to-muscle ratio in the T2 images.     

子宫动脉栓塞术联合宫腔镜治疗 子宫黏膜下大肌瘤的效果

目的 探讨子宫黏膜下大肌瘤实施子宫动脉栓塞联合宫腔镜治疗的临床效果。方法 选择我院2017年1月~2018年7月收治的60例子宫黏膜下大肌瘤患者,随机分为宫腔镜组和联合组,各30例。宫腔镜组患者运用宫腔镜电切治疗,联合组在此基础上联合子宫动脉栓塞治疗,比较两组宫腔镜手术时间、术中出血量、术后排气时间、治疗总有效率、术后并发症情况及术后3个月血红蛋白、月经量、月经时间变化情况。结果 联合组宫腔镜手术时间、术中出血量、术后排气时间及术后并发症发生率分别为（52.23±5.67）min、（32.29±5.38）ml、（12.83±2.18）h、6.67%,均低于宫腔镜组的（72.44±6.54）min、（75.46±4.53）ml、（22.15±4.23）h、26.67%,差异有统计学意义（P＜0.05）;联合组治疗总有效率为96.67%,高于宫腔镜组的80.00%,差异有统计学意义（P＜0.05）;联合组术后3个月血红蛋白水平高于宫腔镜组,差异有统计学意义（P＜0.05）;联合组月经量、月经时间低于宫腔镜组,差异有统计学意义（P＜0.05）。结论 子宫黏膜下大肌瘤实施子宫动脉栓塞联合宫腔镜治疗效果好,且可有效减轻手术创伤,降低术后并发症风险,促进患者术后恢复。     

Effects of hormone replacement therapy on postmenopausal uterine myoma

OBJECTIVES: To evaluate the effects of sequential continuous hormone replacement therapy (HRT) on myoma size and on pulsatility index (PI) of uterine arteries and to verify the correlation between uterine artery flow impedance and the growth rate of myoma in women receiving HRT. METHODS: In a prospective 1-year study 60 postmenopausal women were enrolled into three study-groups to receive continuous transdermal 17beta-oestradiol 0.05 mg/day plus nomegestrolo acetate 5 mg/day sequentially added: 20 patients (group A) unaffected by uterine myomas, 20 patients (group B) with single asymptomatic myoma <3 cm/14 cm3, 20 patients (group C) with single asymptomatic myoma >3 cm/14 cm3. The changes in myoma volume and in PI were assessed by means of transvaginal ultrasonographic scan every 3 months. The patients with myoma were divided into two subgroups: quiescent myoma (B1, C1) and growing myoma (B2, C2). RESULTS: No significant increase of uterine fibroids volume was found after 1-year HRT (24.14+/-20.02-->28.81+/-30.02 cm3). Six out of eight myomas growing during HRT belonged to group C. The uterine artery basal PI value of group A was significantly higher (P<0.01) than the corresponding PI in group B and C. At 3 months follow-up, uterine artery PI was significantly higher (P<0.01) than the basal value in both group B (1.70+/-0.22-->1.88+/-0.16) and C (1.59+/-0.28-->1.92+/-0.21). The baseline PI values in group B1 and C1 were significantly higher than the baseline values observed in group B2 and C2 (1.76+/-0.17 vs. 1.32+/-0.02, 1.76+/-0.16 vs. 1.24+/-0.08) and significantly lower than those observed in group A (2.39+/-0.47). After 3 months of HRT, the PI values were not significantly higher than the baseline values in groups B1 and C2 (1.76+/-0.17-->1.90+/-0.17; 1.24+/-0.08-->1.74+/-0.16), while they were significantly higher in group C1 (1.76+/-0.16-->2.01+/-0.17). CONCLUSIONS: Sequential continuous HRT does not increase the volume of the uterine myoma. The findings of very low resistance index in the uterine arteries of women with growing myoma may indicate the risk of growth of the neoplasia during HRT. The assessment of PI in the uterine arteries could be helpful in predicting the growth rate of the myomas before starting HRT.     

Long term effects of Tibolone on postmenopausal women with uterine myomas.

OBJECTIVES: The aim of the present study is to evaluate the long term effects of Tibolone (Livial) on uterine myomas volume as well as on uterine arteries pulsatility index (PI) in postmenopausal women. METHODS: This study included 66 naturally menopausal women. Twenty of them (group A) had no uterine myomas; 23 of them (group B) had a single, asymptomatic, intramural or subserous myoma of a maximum diameter less or equal than 2 cm; 23 of them (group C) had a single, asymptomatic, intramural or subserous myoma of a maximum diameter between 2 and 5 cm. The volume of the myomas as well as the pulsatility index of the uterine arteries was assessed by transvaginal ultrasonography every 6 months after administration of Tibolone (2.5 mg daily). RESULTS: No statistically significant difference on myomas volume was found after a 3-year period of Tibolone administration. The uterine artery basal PI was significantly higher in group A compared to that of groups B and C. After 6 months of Tibolone administration the PI in group A was significantly lower compared to the basal one whereas in groups B and C was significantly higher compared to the basal value. CONCLUSIONS: Our results suggest that treating postmenopausal woman with Tibolone on a long-term basis: (a) does not increase the volume of uterine myomas and (b) has an early effect on uterine haemodynamics (decrease of PI in women without myomas and increase of PI in women with myomas).     

Temporary uterine artery occlusion for treatment of menorrhagia and uterine fibroids using an incisionless Doppler-guided transvaginal clamp: case report

We report the successful treatment of a 43-year-old woman with menorrhagia and multiple uterine fibroids by temporary uterine artery occlusion. Using a Doppler-guided transvaginal clamp, her uterine arteries were non-invasively identified and occluded by mechanical compression against the cervix for 6 h. Following removal of the clamp, blood flow in the uterine arteries returned immediately. Menorrhagia symptoms were tracked with the Ruta Menorrhagia Severity Scale. Uterine and fibroid volumes were measured by analysis of magnetic resonance images. The patient's self-reported menorrhagia symptoms were significantly reduced at 6 months (70% reduction in Ruta score) and both uterine volume and fibroid volume had decreased by more than 44% at 6 months. This case report illustrates the potential applicability of a simple-to-use, non-surgical device for the treatment of menorrhagia and uterine fibroids by temporary uterine artery occlusion.     

Comparison of the Inhibitory Effect of Gonadotropin Releasing Hormone (GnRH) Agonist,Selective Estrogen Receptor Modulator (SERM), Antiprogesterone on Myoma Cell Proliferation In Vitro

Uterine myomas are the most common gynecologic tumor in women of reproductive age. Treatment options of uterine myomas consist of surgical, medical and interventional therapy such as uterine artery embolization or myolysis. Given that it is the most common type of tumor in women of reproductive age, the treatment of uterine myomas must prioritize uterine conservation. There are several drugs for medical treatment of uterine myoma such as gonadotropin releasing hormone (GnRH) agonist, selective estrogen receptor modulator (SERM) and antiprogesterone. The objective of this study was to compare the effect of GnRH agonist, SERM, and antiprogesterone in the treatment of uterine myomas in vitro. The effect of drugs was evaluated through the cell viability assay in cultured leiomyoma cells, western blot analysis of proliferating cell nuclear antigen (PCNA), and BCL-2 protein expression. As a result, mifepristone single-treated group represents the most significant reduction in myoma cell viability and proliferation. When pretreated with leuprolide acetate, raloxifene shows more significant reduction in myoma cell viability and proliferation than mifepristone. This study suggests one of the possible mechanisms how medications act on uterine myoma, especially at the molecular level.     

Incomplete vaginal expulsion of pyoadenomyoma with sepsis and focal bladder necrosis after uterine artery embolization for symptomatic adenomyosis: case report

The major complications secondary to uterine artery embolization (UAE) are rare. We report a case involving a patient who underwent UAE for symptomatic adenomyosis, and experienced complications including incomplete vaginal expulsion of a large focal pyoadenomyosis, sepsis and focal bladder necrosis. The serial changes of uterine echogenicity reflected the intracavity sloughing tissue, and cystourethroscopy revealed a focal bladder necrosis. Administration of appropriate antibiotics and timely expulsion of the focal pyoadenomyosis vaginally resulted in successful preservation of the uterus and spontaneous recovery of focal bladder necrosis without surgical intervention. A review of the relevant literature was conducted to explore the mechanisms of bladder necrosis after UAE, summarize post-embolization intervention and the outcome of vaginally expelled myoma, and to discuss the value of UAE for adenomyosis.     

三丙烯微球栓塞子宫动脉对子宫内膜血管的影响

背景：子宫动脉栓塞已广泛应用于临床治疗多种妇产科疾病,但对于子宫动脉栓塞后子宫内膜微血管密度的有何变化及新生血管的形成至今少有文献报道。 目的：观察子宫动脉栓塞对子宫内膜微血管密度及新生血管形成的影响。 方法：60只雌性豚鼠随机分为对照组(n=15)及子宫动脉栓塞组(n=45),子宫动脉栓塞组动物应用三丙烯微球行双侧子宫动脉栓塞。子宫动脉栓塞组再随机分为E1,E2及E3三个亚组(n=15),分别于子宫动脉栓塞后7-15 d,16-30 d及31-45 d内获取子宫标本。 结果与结论：常规病理染色显示豚鼠子宫动脉一级分支、浆膜下动脉支及子宫肌层微小动脉血管内均可见大小不等栓塞微球分布。子宫动脉栓塞豚鼠子宫内膜基底层微血管密度CD34在子宫动脉栓塞后降低,而后随时间的延长而增加(P < 0.05);而子宫动脉栓塞豚鼠子宫内膜基底层微血管密度CD105在子宫动脉栓塞后增加,而后随时间的延长而降低(P < 0.05)。提示随着栓塞后时间推延,新生微血管数量显著增加,基底层微血管密度有逐渐恢复趋势。     

CalliSpheres载药微球子宫动脉栓塞术治疗宫颈癌的疗效评价

目的　评价CalliSpheres载药微球子宫动脉栓塞术治疗局部晚期宫颈癌疗效。 方法　选取2016年2月至2018年9月本介入科收治的宫颈癌患者48例（平均年龄49岁）,采用随机数字分配法将患者分为普通微球子宫动脉栓塞+表阿霉素子宫动脉灌注化疗组24例（A组）,表阿霉素载药微球子宫动脉栓塞化疗组24例（B组）。每组治疗2个周期,间隔3周。记录出血减少情况,以CT评价肿瘤大小变化,分析骨髓抑制及消化道反应。 结果　（1）两组患者阴道出血均减少;普通微球组术后出血持续时间为（6±1.5）d,载药微球组为（3± 0.8）d,差异有统计学意义,P<0.01。（2）肿瘤缩小率：普通微球组客观缓解率为83.8%,载药微球组为95.8%,差异有统计学意义,P<0.01。（3）副反应：两组患者均出现腹痛,VAS评分普通微球组（8±2）分,载药微球组（3±1）分,差异有统计学意义,P<0.01;骨髓抑制仅发生于普通微球组。 结论　CalliSpheres载药微球治疗宫颈癌较传统的化疗栓塞术具有更高的肿瘤缩小率,术后阴道出血时间更短,无骨髓抑制且腹痛可控。     

Ultrasound evaluation of uterine wound healing following laparoscopic myomectomy: preliminary results.

The purpose of our work was to study the evolution of the uterine scar following laparoscopic myomectomy, as imaged by ultrasonography and Doppler velocimetry of the uterine arteries. We prospectively studied 30 patients. In the first phase, 15 patients were submitted to two-dimensional (2D) endovaginal ultrasound on day -1, 1, 7, 30 and 60 (surgery = day 0). In the second phase an additional 15 patients were studied by both 2D ultrasound and by Doppler velocimetry. The resistance index (RI) was calculated from the flow velocity waveform of the uterine arteries, at the origin of their ascending branch. Only one ultrasonic pattern was found, which was a dense echogenic area having an ill-defined, heterogeneous texture. In one case a small anechoic area (1 cm) was detected in the scar, possibly due to a haematoma. The evolution of uterine healing showed a progressive reduction in the size of the scar. On day 1 its mean diameter was 37.04% less than the myoma diameter and on day 30 71.7% less. The difference was significant at P < 0.001. A further significant (P < 0.001) reduction was found at day 60 in the 15 patients studied in phase I. On both day 1 and day 30 following surgery, there was no correlation between the sizes of the myoma and the scar. There was a statistically significant increase (P < 0.01) in the RI value of the ipsilateral uterine artery from 0.64 on day -1 to 0.79 on day 1. On day 30, 12/15 (80%) cases had RI values ranging between 0.80 and 0.98, while in three cases there was absence of end diastolic flow. The RI values of the contralateral uterine artery were high (0.90) before surgery and did not change afterwards. There was no correlation between the size of the myoma and the increase in the uterine artery RI value following surgery. Considering the velocimetric findings, 30 days are a reference point for assessing the healing process. Ultrasound imaging and Doppler velocimetry can be used for studying the evolution of the uterine scar following myomectomy.     

探讨子宫肌瘤行子宫动脉栓塞介入治疗临床疗效

目的研究栓塞术治疗子宫肌瘤的临床应用疗效。方法 38例症状性子宫肌瘤患者,年龄29～58岁,平均年龄39岁。选择性双侧子宫动脉插管造影明确子宫肌瘤血液供应后,分别行栓塞术。结果栓塞技术成功率100%,子宫动脉栓塞术后12个月,总有效率为89.5%。术后38例患者月经量较术前均有不同程度减少,贫血及压迫症状均得到改善。副反应有盆腔疼痛、发热、阴道排液,余无其他严重并发症。结论子宫动脉栓塞术治疗子宫肌瘤安全、有效。     

Loss of ovarian reserve after uterine artery embolization: a randomized comparison with hysterectomy

BACKGROUND: Ovarian failure as a complication of uterine artery embolization (UAE) for symptomatic uterine fibroids has raised concerns about this new treatment modality. METHODS: We investigated the occurrence of ovarian reserve reduction in a randomized trial comparing UAE and hysterectomy by measuring follicle stimulating hormone (FSH) and anti-Mullerian hormone (AMH). A total of 177 pre-menopausal women with menorrhagia due to uterine fibroids were included (UAE:n=88; hysterectomy:n=89). FSH and AMH were measured at baseline and at several time-points during the 24 months follow-up period. Follow-up AMH levels were also compared to the expected decrease due to ovarian ageing during the observational period. RESULTS: FSH increased significantly compared to baseline in both groups after 24 months follow-up (within group analysis: UAE:+12.1; P=0.001; hysterectomy:+16.3; P<0.0001). No differences in FSH values between the groups were found (P=0.32). At 24 months after treatment the number of patients with FSH levels>40 IU/l was 14/80 in the UAE group and 17/73 in the hysterectomy group (relative risk=0.75; P=0.37). AMH was measured in 63 patients (UAE: n=30; hysterectomy: n=33). After treatment AMH levels remained significantly decreased during the entire follow-up period only in the UAE group compared to the expected AMH decrease due to ageing. No differences were observed between the groups. CONCLUSIONS: This study shows that both UAE and hysterectomy affect ovarian reserve. This results in older women becoming menopausal after the intervention. Therefore, the application of UAE in women who still wish to conceive should only be considered after appropriate counselling.     

子宫缺血再灌注损伤大鼠模型的建立

背景：子宫缺血再灌注损伤可导致能量代谢障碍、大量自由基产生及细胞凋亡等。 目的：建立一种简易、实用、可靠的子宫缺血再灌注损伤大鼠模型。 方法：将50只健康Wistar雌性大鼠随机等分为5组。子宫缺血组(共3组)开腹后采用线栓法分别阻断大鼠子宫动脉45 min、阻断大鼠腹腔动脉30 min或阻断大鼠腹腔动脉45 min进行子宫缺血处理;子宫缺血再灌注组开腹后采用线栓法阻断大鼠腹腔动脉30 min再灌注60 min;假手术组不阻断子宫供血动脉。 结果与结论：子宫动脉纤细,结扎过紧,子宫动脉常常断裂,结扎过松,不能够充分阻断血液,不适宜建立子宫缺血再灌注损伤模型。苏木精-伊红染色显示,阻断大鼠腹腔动脉30 min后子宫细胞及间质肿胀,肌纤维排列尚整齐;阻断大鼠腹腔动脉45 min及子宫缺血再灌注组的子宫细胞及间质明显水肿,渗出增加,肌纤维排列紊乱,有大量中性粒细胞浸润。分光光度计检测显示,阻断大鼠腹腔动脉45 min及子宫缺血再灌注组子宫丙二醛水平升高最明显 (P < 0.01)。提示采用线栓法结扎腹腔动脉30 min后进行再灌注可建立大鼠子宫缺血再灌注损伤模型。     

Pregnancy following treatment of symptomatic myomas with laparoscopic bipolar coagulation of uterine vessels

BACKGROUND: Laparoscopic bipolar coagulation of uterine vessels (LBCUV) has been employed for women with symptomatic uterine myomas, but its effect on subsequent pregnancy has not been characterized. METHODS: Four-hundred and twenty-three women entered the study between March 1999 and December 2001. Of these, 142 women (33.6%) were under the age of 40 years at the time of LBCUV, 36 of whom (36/142, 25.3%) were sexually active without contraception. In a prospective study of 142 patients (<40 years old) undergoing LBCUV for symptomatic myomas, 15 women became pregnant (17 total pregnancies) and were evaluated by physical and ultrasound examinations. RESULTS: The volume of the dominant myoma was 117.4 +/- 118.4 and 36.8 +/- 56.8 cm(3) before and after LBCUV respectively. Volume of the dominant myoma after pregnancy was 46.2 +/- 76.7 cm(3) (mean +/- SD). There was a significant difference in myoma volume before and after LBCUV (P = 0.002), but no significant difference in myoma volume when comparing post-partum size with post-LBCUV size (P = 0.269). Pregnancy outcomes included seven miscarriages in the first trimester and one premature rupture of membrane (PPROM). Although the other pregnancies were regarded as uncomplicated, only two women were delivered of normal neonates as the other seven pregnancies were terminated secondary to patient request. CONCLUSIONS: The pregnancy and term pregnancy rates in sexually active women without contraception were 41.6% (15/36) and 5.6% (2/36) respectively. Because a relatively high rate (7/17, 41.2%) of early miscarriages was observed, we recommend that this procedure be employed only for women who do not desire additional children.     

Leiomyosarcoma with dedifferentiation in a premenopausal patient discovered after uterine artery embolization

Although a hysterectomy is the most common treatment for relieving the symptoms attributable to uterine leiomyomas, uterine artery embolization (UAE) is now being used more frequently as an alternative to a hysterectomy. However, it is difficult to differentiate a leiomyoma from a leiomyosarcoma without performing a pathological examination. Reported herein is a rare case of leiomyosarcoma that showed dedifferentiation of the tumor cells after UAE. A premenopausal 48-year-old woman had been suffering from hypermenorrhea for 4 years before visiting the clinic. She underwent UAE for suspected symptomatic leiomyoma. Two months later, dilatation and curettage was performed because of genital bleeding and a necrotic mass was submitted for pathological examination. Three months after curettage, with renewed symptoms, endometrial biopsy was done, which confirmed pleomorphic sarcoma. Metastatic nodes to the lung were also found at that time. Multiple leiomyosarcomas and a leiomyosarcoma showing dedifferentiation of the uterine body were found on pathological examination. The patient had metastatic nodes to the brain later and died of metastatic disease 20 months in total after UAE. This is a rare case of leiomyosarcoma with dedifferentiation and multiple metastases occurring after UAE, suggesting that dedifferentiation could be derived from ordinary leiomyosarcoma and that the traumatic effect of curettage might cause early metastasis. The present case is a warning that careful and detailed evaluation of the uterine tumor are needed before UEA.     

Treatment of uterine leiomyomas with luteinizing hormone-releasing hormone antagonist Cetrorelix

The efficacy of the luteinizing hormone-releasing hormone antagonist Cetrorelix (SB-75) in the medical management of uterine leiomyomas (fibromas) was evaluated. Cetrorelix was administered to 18 pre- menopausal women with myomas with a mean age of 33.3 years, who had been candidates for hysterectomy. The initial dose of Cetrorelix was 5 mg twice daily s.c. for the first 2 days and thereafter 0.8 mg was given twice daily s.c. for at least 3 months. The mean duration of the treatment was 4.4 months. Before the therapy with Cetrorelix, the mean uterine volume, measured by ultrasonography, was 395.4 +/- 69.2 ml (range 89-1166). Sixteen patients showed a progressive reduction in uterine volume from 410.4 +/- 77.1 to a mean of 230.8 +/- 52.6 ml at 3 months. All patients became amenorrhoeic and had hot flushes. After treatment with Cetrorelix, a surgical myomectomy was performed in 12 women. One of the patients subjected to myomectomy after therapy with Cetrorelix became pregnant. These patients have been followed for up to 25 months and only in one case has the uterine volume increased after therapy. Three patients had good responses to therapy with Cetrorelix and it was decided to follow them only by observation. One patient became pregnant 2 months later. In the other patient, the uterine volume remained unchanged for the duration of the follow-up of 2 years and the third patient showed an increase after 21 months. In three patients, it was necessary to perform total hysterectomy. In 14 patients, serum concentrations of luteinizing hormone, follicle stimulating hormone and oestradiol decreased after the administration of the first dose of Cetrorelix and continued at subnormal values throughout therapy. In 15 patients who were not subjected to total hysterectomy, menstrual function returned at 1 month after cessation of treatment. Overall results support the use of Cetrorelix for the management of uterine leiomyomas.      

Sonographic assessment of pregnancy co-existing with uterine leiomyoma in Owerri,Nigeria

Background

Uterine myomas co-existing with pregnancy could cause obstetric complications.

Objectives

To assess sonographically the frequency of occurrence and effect of uterine myomas co-existing with pregnancy.

Methods

A longitudinal study was conducted during a period of 23 months. A convenience sample of 816 consecutive consenting pregnant women who met the inclusion criteria was evaluated during routine prenatal ultrasound scan. The women were referred for prenatal sonography. One hundred of the subjects who had myoma co-existing with pregnancy and another 100 subjects without myoma were selected for follow-up. These groups were followed up till delivery and obstetric complications and outcomes were documented. Any changes in size and growth rate of myoma were documented.

Results

Subjects with myoma co-existing with pregnancy were 12.3%. This was commoner with increasing maternal age. An increase was observed in myoma mean size from 60mm to 63mm from the 1^st scan sequence to the 2^nd scan sequence and a reduction from 63mm to 59mm in the 3^rd scan sequence. Myoma growth rate was 0.667mm per week. Myomas in pregnancy especially large ones caused more complications during delivery when compared to pregnancies without myomas.

Conclusion

Routine sonography is important in pregnancy management of uterine myomas co-existing with pregnancy.     

Uterine artery embolization for management of interstitial twin ectopic pregnancy: case report

Interstitial pregnancy is rare and dangerous variation of ectopic pregnancy. We describe a case of unilateral interstitial viable twin pregnancy treated by selective uterine artery embolization. A 23-year-old women with clinical and ultrasonic diagnosis of viable twin interstitial pregnancy was treated by selective uterine artery embolization after failure of systemic methotrexate treatment. Her serum beta-HCG was undetectable 2 months after the procedure and the ultrasound scan 70 days after embolization showed only multiple echogenic spots in the right uterine cornua. This therapeutic modality seems to be effective for conservative management of interstitial ectopic pregnancy, and as a prophylactic measure before surgical intervention to prevent major bleeding.     

Alternatives to hysterectomy: focus on global endometrial ablation, uterine fibroid embolization, and magnetic resonance-guided focused ultrasound

The aim of this study was to inform the clinician of alternatives to hysterectomy through a critical evaluation of three treatment options: global endometrial ablation, uterine fibroid embolization, and magnetic resonance-guided focused ultrasound. Studies published in English-language, peer-reviewed journals were systematically searched using Cochrane and Medline. Keywords used included "alternatives to hysterectomy," "endometrial ablation," "uterine fibroid embolization," "uterine artery embolization," and "focused ultrasound." Articles meeting the inclusion criteria were reviewed and analyzed for themes and similarities. All three alternative methods of treatment reviewed are currently approved for use in the United States and abroad. In fact, five different global endometrial ablation devices are approved by the Food and Drug Administration for treatment of menorrhagia. Patient satisfaction scores after endometrial ablation are high (90%-95%), but amenorrhea rates are much lower (15%-60%). Data from randomized trials demonstrate that uterine fibroid embolization results in a shorter hospital stay and quicker return to work as compared with abdominal hysterectomy for leiomyomas, but after embolization, up to 20% of women need a second procedure. Ex-ablative therapy of leiomyomas with focused ultrasound is the newest of the three methods. It has a special set of patient selection criteria and is only available at less than 20 medical centers in the United States. Leiomyoma symptom relief after focused ultrasound therapy at 1 year post-procedure is high (85%-95%). There are many effective alternatives to hysterectomy in women with menorrhagia and/or symptomatic leiomyomas. However, because these procedures are performed by individuals from different subspecialists, primarily gynecologists and interventional radiologists, clinicians must consider using a multidisciplinary approach to find the best procedure for a given patient. There are no randomized trials comparing uterine fibroid embolization to vaginal hysterectomy, laparoscopic hysterectomy, or laparoscopic myomectomy.