Uterine artery embolization for postpartum hemorrhage

An increasing amount of evidence supports the use of interventional radiology, which can be used electively in cases of placenta previa/accreta in which large blood loss is anticipated or in the emergency situation, typically secondary to atonic uterus.Although a lot of single-case studies and short series have been reported, as well as some case-control studies and several systematic reviews, no randomized controlled trials have been identified.There are difficulties with the transfer of unstable patients and not all centers have access to an interventional radiology unit or a senior radiologist.Interventional radiology as an elective and prophylactic measure for hemostatic control of the pelvis is an option if hysterectomy is planned. Ideally, it should be subject to prospective, randomized analysis. If used, intense vascular surveillance is mandatory and catheters and sheaths should be removed at the first opportunity.The primary idea of conservative management is to leave the entire placenta or just the part that is adherent to the myometrium in situ to preserve the uterus. Conservative management should be considered only in highly selective cases when blood loss is minimal and there is desire for fertility preservation. It is not clear whether adjuvant methotrexate or selective arterial embolization is beneficial.Occlusion of the distal uterine artery bed with absorbable gelatine preparations lasts for about 4 weeks, whereupon it recanalizes, thus preserving fertility and reproductive potential if conservative treatment is possible.Resuscitation and stabilization are the initial focus of intervention in patients who are hemorrhaging after a vaginal birth. If temporizing measures are ineffective, arterial embolization can be performed before laparotomy if the woman is hemodynamically stable and facilities for interventional vascular radiology are available or close by.If failure of management occurs during cesarean section, compressive sutures, and stepwise devascularization, which are quick, relatively easy, and effective, should be tried first.For persistent uterine atony, the success rate of emergency arterial embolization varies from 70–100%.

• Elective and prophylactic embolization should ideally be submitted to prospective, randomized analysis.

• Research is needed into how to minimize vascular complications.

• More experience with early embolization for conservative approach in placenta accreta is necessary.

• The timing and place of emergency embolization after vaginal delivery and cesarean section requires investigation.

Uterine artery embolization in the treatment and prevention of postpartum hemorrhage.

OBJECTIVES: The study was conducted to evaluate the efficacy of superselective transcatheter uterine artery embolization for control of obstetric hemorrhage. METHODS: Between January 2002 and December 2005, 14 consecutive patients underwent uterine artery embolization to control postpartum hemorrhage, and two to prevent hemorrhage before second-trimester therapeutic abortion. RESULTS: Embolization was performed by transfemoral arterial catheterization. Pieces of absorbable gelatin sponge were used in all cases, with the addition of platinum coils in two cases for complete vessel occlusion. Optimal bleeding control was achieved in all cases but one--a patient who underwent hysterectomy due to embolization failure. No severe complications were observed. CONCLUSIONS: The high success rate, low morbidity rate, and possibility of preserving reproductive function have made superselective uterine artery embolization the technique of choice to control life-threatening, intractable postpartum hemorrhage in hemodynamically stable patients, provided multidisciplinary medical teams are promptly available.     

子宫动脉栓塞术治疗子宫肌瘤

子宫动脉栓塞术治疗子宫肌瘤不但能使肌瘤坏死、缩小甚至消失,从而改善临床症状,同时可以保留子宫的生理功能,已经成为一种有效的、保留子宫的微创治疗方法。但在临床应用中也出现一些严重的并发症,甚至出现死亡病例。获得良好疗效和避免并发症的关键是处理好以下问题：选择合适的病例、使用合适的栓塞剂和栓塞颗粒、准确栓塞肌瘤的靶动脉、控制好栓塞程度、及时发现并处理并发症。     

Uterine artery embolization in an undiagnosed uterine sarcoma

Background: Uterine sarcomas are rare malignancies that resemble benign uterine leiomyomata. Uterine artery embolization is offered increasingly for treatment of uterine leiomyomata, which might lead to embolization of undiagnosed uterine sarcoma.Case: A 52-year-old woman, gravida 7, para 6, with perimenopausal menometrorrhagia was diagnosed with uterine leiomyomata after physical examination and transvaginal ultrasound. An endometrial biopsy was negative for malignancy. After medical treatment was unsuccessful, she had uterine artery embolization. She then passed a piece of tissue from her vagina, the pathology report of which was necrotic high-grade sarcoma. During surgery we confirmed that the tumor was confined to the uterus.Conclusion: Uterine sarcoma cannot be diagnosed except by pathologic examination of a resected specimen. Women considering uterine artery embolization for treatment of apparent leiomyomata should be counseled on the risk of decreased survival by delaying diagnosis and treatment of uterine sarcoma.     

Uterine artery embolization for symptomatic fibroids.

OBJECTIVES: The aim of this study was to introduce uterine artery embolization (UAE) as an effective and safe treatment option in patients with symptomatic fibroids. METHODS: Sixty-one patients underwent UAE with a 3- and 12-month follow-up. RESULTS: The procedure was well tolerated in all patients with the following symptoms improving: heavy bleeding [90% (95% CI 80.21%; 95.4%)]; dysmenorrhea [median -4 (95% CI -5; -4)]; feeling of a mass [74% (95% CI 57.9%; 85.8%)]; abdomino-pelvic discomfort [88% (95% CI 75.5%; 94.9%)]; and deep dyspareunia [90% (95% CI 71.1%; 97.3%)]. Uterine volume decreased by a median difference of 188 cm(3) (95% CI 146.5; 236), which related to a median % reduction of 37.7% (95% CI 32.4%; 45%) at 12-month follow-up. Most (91%) patients were satisfied with the procedure and only minor complications occurred. CONCLUSIONS: Uterine artery embolization can be performed effectively and safely at centers with the necessary expertise and can be used with success in Africa.     

ACOG Committee Opinion. Uterine artery embolization

Uterine artery embolization for the treatment of symptomatic uterine leiomyomata has become increasingly popular. Based on current evidence, it appears that uterine artery embolization, when performed by experienced physicians, provides good short-term relief of bulk-related symptoms and a reduction in menstrual flow. Complication rates associated with the procedure are low, but in rare cases can include hysterectomy and death. There is insufficient evidence to ensure its safety in women desiring to retain their fertility, and pregnancy-related outcomes remain understudied. The American College of Obstetricians and Gynecologists' Committee on Gynecologic Practice considers the procedure investigational or relatively contra-indicated in women wishing to retain fertility. The use of uterine artery embolization in postmenopausal women is rarely, if ever, indicated. The Committee strongly recommends that women who wish to undergo uterine artery embolization have a thorough evaluation with an obstetrician-gynecologist to help facilitate optimal collaboration with interventional radiologists and to ensure the appropriateness of this therapy, taking into account the reproductive wishes of the patient. It is also recommended that all patients considering uterine artery embolization be adequately informed about potential complications.     

Uterine artery embolization for symptomatic uterine myomas

OBJECTIVE: To evaluate the role of uterine artery embolization as treatment for symptomatic uterine myomas. DESIGN: Medline literature review, cross-reference of published data, and review of selected meeting abstracts. RESULT(S): Results from clinical series have shown a consistent short-term reduction in uterine size, subjective improvement in uterine bleeding, and reduced pain following treatment. Posttreatment hospitalization and recovery tend to be shorter after uterine artery embolization compared with hysterectomy. Randomized controlled trials have not been conducted, and long-term efficacy has not been studied. A limited number of deliveries have been reported following uterine artery embolization for uterine myomas. CONCLUSION(S): Uterine artery embolization is a unique new treatment for symptomatic uterine myomas. Even without controlled studies, demand for this procedure has increased rapidly. Uterine artery embolization may be considered an alternative to hysterectomy, or perhaps myomectomy, in well-selected cases. At the present time, however, uterine artery embolization should not be routinely recommended for women who desire future fertility.     

Uterine artery embolization immediately preceding laparoscopic myomectomy

ObjectiveTo determine whether performing uterine artery embolization (UAE) immediately before laparoscopic myomectomy can facilitate a minimally invasive surgical approach for larger uterine fibroids.MethodsIn a retrospective case–control study, laparoscopic myomectomy with and without preoperative UAE was examined. Data were analyzed from 26 laparoscopic myomectomies performed by a single surgeon at Northwestern University Feinberg School of Medicine between 2004 and 2010. Controls were matched for age, calendar year, surgeon, and number of fibroids removed. Surgical outcomes included preoperative clinical uterine size, operative time, operative blood loss, and postoperative myoma specimen weight. Data were analyzed via 2-tailed Student t test.ResultsTwelve women underwent laparoscopic myomectomy within 169 ± 16 minutes (mean ± SEM) of preoperative UAE. Fourteen control patients underwent laparoscopic myomectomy alone. The UAE group had a greater mean preoperative clinical uterine size (19.7 versus 12.4 weeks, P < 0.001) and a greater mean myoma specimen weight measured postoperatively (595.3 versus 153.6 grams, P < 0.05). There were no significant differences in operative time or blood loss, and there were no intra-operative complications.ConclusionUAE performed immediately before laparoscopic myomectomy facilitated minimally invasive surgery for larger uteri and larger uterine myomas, with no differences in operative time or blood loss.     

Uterine artery ligation to control postpartum hemorrhage

Bilateral uterine artery ligation was performed for 32 patients in order to control intractable postpartum hemorrhage in 25 of them (currative ligation) and as prophylaxis against postpartum hemorrhage in seven (elective ligation). Mass ligation was used for 29 patients and isolation ligation for three. Among the 25 patients for whom curative ligation was performed, successful hemostasis was achieved in 20 patients (80%) and the technique failed in five (20%). This failure was due to a clotting defect in three and placenta previa accreta in two patients. Twenty-four patients (96%) survived and one died as a result of a clotting defect. Among five patients followed up, normal menstruation occurred with pregnancy in three of them.     

Uterine artery ligation for postabortal hemorrhage.

A case is presented that demonstrates that bilateral ligation of the ascending branches of the uterine artery to control uterine hemorrhage is as effective in the first trimester as it is in the last trimester.     

Uterine artery embolization: a pilot study in a rabbit model

Eight female adult ex-breeder New Zealand white rabbits underwent bilateral, unilateral, or superselective unilateral uterine artery embolization. The histopathologic changes after embolization in New Zealand white rabbits resemble those in humans, making rabbits an appropriate model for experimental uterine artery embolization.     

Uterine artery embolization as a treatment option for uterine myomas

Information is still being collected on the long-term clinical responses and appropriate patient selection for UAE. Prospective RCTs have not been performed to compare the clinical results from UAE with more conventional therapies for symptomatic uterine leiomyomata. At least three attempts at conducting such RCTs have been unsuccessful because of poor patient accrual that related to differing patient expectation and desires, clinical bias, insurance coverage, and the tendency that patients who have exhausted other treatment options may be disposed more favorably to less invasive treatments. Other comparative studies have serious limitations. For example, the retrospective study that compared outcomes after abdominal myomectomy with UAE suggested that patients who received UAE were more likely to require further invasive treatment by 3 years than were recipients of myomectomy. Lack of randomization introduced a selection bias because women in the group that underwent UAEwere older and were more likely to have had previous surgeries. A prospective study of "contemporaneous cohorts," which excluded patients who had sub-mucosal and pedunculated subserosal myomas, sought to compare quality of life measures and adverse events in patients who underwent UAE or hysterectomy. The investigators concluded that both treatments resulted in marked improvement in symptoms and quality of life scores, but complications were higher in the group that underwent hysterectomy over 1 year. In this study,however, a greater proportion of patients who underwent hysterectomy had improved pelvic pain scores. Furthermore, hysterectomy eliminates uterine bleeding and the risk for recurrence of myomas. Despite the lack of controlled studies that compared UAE with conventional surgery, and despite limited extended outcome data, UAE has gained rapid acceptance, primarily because the procedure preserves the uterus, is less invasive, and has less short-term morbidity than do most surgical options.The cost of UAE varies by region, but is comparable to the charges for hysterectomy and is less expensive than abdominal myomectomy. The evaluation before UAE may entail additional fees for diagnostic testing, such as MRI, to assess the uterine size and screen for adenomyosis. Other centers have recommended pretreatment ultrasonography, laparoscopy, hysteroscopy, endometrial biopsy, and biopsy of large fibroids to evaluate sarcoma. Generally,after UAE the recovery time and time lost from work are less; however, the potential need for subsequent surgery may be greater when compared with abdominal myomectomy. Any center that offers UAE should adhere to published clinical guidelines,maintain ongoing assessment of quality improvements measures, and observe strict criteria for obtaining procedural privileges. After McLucas advocated that gynecologists learn the skill to perform UAE for managing symptomatic myomas, the Society of Interventional Radiology responded with a precautionary commentary on the level of technical proficiency that is necessary to maintain optimum results from UAE. The complexity of pelvic arterial anatomy, the skill that is required to master modern coaxial microcatheters, and the hazards of significant patient radiation exposure were cited as reasons why sound training and demonstration of expertise be obtained before clinicians are credentialed to perform UAE.A collaboration between the gynecologist and the interventional radiologist is necessary to optimize the safety and efficacy of UAE. The primary candidates for this procedure include women who have symptomatic uterine fibroids who no longer desire fertility, but wish to avoid surgery or are poor surgical risks. The gynecologist is likely to be the primary initial consultant to patients who present with complaints of symptomatic myomas. Therefore, they must be familiar with the indications, exclusions, outcome expectations, and complications of UAE in their particular center. When hysterectomy is the only option, UAE should be considered. Appropriate diagnostic testing should aid in the exclusion of most, but not all, gynecologic cancers and pregnancy. Other contraindications include severe contrast medium allergy, renal insufficiency, and coagulopathy. MRI may be used to screen women before treatment in an attempt to detect those who have adenomyosis; patients should be aware that UAE is less effective in the presence of solitary or coexistent adenomyosis. Because some women may experience ovarian failure after UAE, additional studies to determine basal follicle-stimulating hormone and estradiol before and after the procedure may provide insight into UAE-induced follicle depletion.UAE is a unique new treatment for uterine myomas, and is no longer considered investigational for symptomatic uterine fibroids. There is international recognition that data are needed from RCTs that compare UAE with surgical alternatives. Current efforts to provide prospective objective assessment of treatment outcomes and complications after UAE will help to optimize patient selection and clinical guidelines. FIBROID should provide critical data for the assessment of safety and outcomes measures for women who receive UAE for symptomatic uterine myomas.