1
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Saleem HA, Albalwi N, Ba'Abbad L. Uterine rupture in a term pregnancy after a previous uterine artery embolization to manage a large fibroid. A case report. Case Rep Womens Health 2023; 39:e00551. [PMID: 37829161 PMCID: PMC10565681 DOI: 10.1016/j.crwh.2023.e00551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 09/28/2023] [Accepted: 09/28/2023] [Indexed: 10/14/2023] Open
Abstract
Uterine artery embolization (UAE) is an effective minimally invasive alternative to surgery for the treatment of symptomatic uterine fibroids. Uterine rupture is an obstetrical emergency that requires early diagnosis and prompt management to improve perinatal and maternal outcomes. A 33-year-old woman at 37 weeks of gestation who had had previous two uncomplicated vaginal deliveries at term presented with abdominal pain and rupture of membranes. The patient had undergone UAE for the management of a large anterior wall uterine fibroid three years prior to conception. Vaginal examination revealed cord prolapse and ultrasound showed negative fetal heart. Intrauterine fetal demise with cord prolapse was diagnosed. After admission the patient developed vaginal bleeding and features of hypovolemic shock. Urgent laparotomy revealed a ruptured uterus with a large hemoperitoneum and dead fetus in the abdominal cavity. Obstetricians should be attentive to the possibility of a spontaneous uterine rupture in pregnant women who have previously undergone UAE for the management of a uterine fibroid.
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Affiliation(s)
- Heba Abu Saleem
- Department of Obstetrics and Gynaecology, King Abdullah Bin Abdulaziz University Hospital, Saudi Arabia
| | - Nouf Albalwi
- Department of Obstetrics and Gynaecology, King Abdullah Bin Abdulaziz University Hospital, Saudi Arabia
| | - Lina Ba'Abbad
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Princess Nourah Bint Abdulrahman University, Saudi Arabia
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2
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Yammine K, Osman D, Daher J, Salha M, Mouawad S. Acquired uterine arteriovenous malformation treated with superselective embolization: Case report. Radiol Case Rep 2023; 18:2204-2208. [PMID: 37101894 PMCID: PMC10123316 DOI: 10.1016/j.radcr.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/05/2023] [Accepted: 03/07/2023] [Indexed: 04/28/2023] Open
Abstract
Acquired uterine arteriovenous malformation is a rare condition, sometimes provoking abnormal life-threatening uterine hemorrhage. Here, we present the case of a 30-year-old healthy woman who developed heavy vaginal bleeding after dilatation and suctioning of the placenta 1 month after the delivery of a nonviable fetus. An ultrasound was performed which showed the appearance of a large exacerbation of a vessel with positive fetal sounds, normal cardiac movement, and normal morphological analysis. The patient was successfully treated with unilateral superselective embolization, distal to the ovarian supply, maintaining normal supply to the uterus and ovaries restoring normal menstruation, and showed complete resolution of the arteriovenous malformation.
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Affiliation(s)
- Kabalane Yammine
- Department of Diagnostic and interventional radiology, Clemenceau Medical Center, Beirut, Lebanon
- Corresponding author.
| | - Dani Osman
- Department of Surgery, University of LAU, Beirut, Lebanon
| | - Jihad Daher
- Department of Radiology, Clemenceau Medical Center, Beirut, Lebanon
| | - Makram Salha
- Department of Radiology, University of Balamand, Beirut, Lebanon
| | - Sabine Mouawad
- Department of Radiology, University of Balamand, Beirut, Lebanon
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3
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Li F, Chen J, Yin L, Zeng D, Wang L, Tao H, Wu X, Wei F, Xu F, Shi Q, Lin Z, Wang Z. HIFU as an alternative modality for patients with uterine fibroids who require fertility-sparing treatment. Int J Hyperthermia 2023; 40:2155077. [PMID: 36603842 DOI: 10.1080/02656736.2022.2155077] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES To compare pregnancy outcomes after high-intensity focused ultrasound ablation (HIFU), myomectomy and uterine artery embolization (UAE) for fertility-sparing patients with uterine fibroids and to investigate the possible mechanism of improving pregnancy by HIFU. MATERIALS AND METHODS A meta-analysis of 54 studies containing 12,367 patients was conducted to compare the pregnancy outcomes of three fertility-sparing therapies. And a retrospective self-control study of 26 patients with uterine fibroids from May 2019 to December 2020 was performed to assess the blood flow impedance of bilateral uterine arteries before and after HIFU. RESULTS In the analysis by treatment option, the pregnancy rate after myomectomy was 0.43 (95% CI 0.36-0.49), which was higher than 0.18 (95% CI 0.10-0.26) after HIFU, the latter was significantly higher than that after UAE (ratio 0.08, 95% CI 0.06-0.10). The miscarriage rate after HIFU was 0.08 (95% CI 0.04-0.12), which was similar to 0.15 (95% CI 0.09-0.21) after myomectomy and also similar to 0.16 after UAE (95% CI 0.01-0.30). In the subgroup analysis, women who received ultrasound guided HIFU (USgHIFU) were more likely to have ideal pregnancy outcomes than that after magnetic resonance imaging-guided HIFU. The pulsatility index and resistance index on the right side were significantly higher 3 months after HIFU than before (1.637 ± 0.435 vs. 1.845 ± 0.469; p = 0.033; 0.729 ± 0.141 vs. 0.784 ± 0.081, p = 0.039). CONCLUSIONS HIFU, especially USgHIFU, may be an alternative fertility-sparing modality for patients with uterine fibroids over 40 years old. HIFU may contribute to improving pregnancy rates by elevating uterine blood flow impedance.
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Affiliation(s)
- Fang Li
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China.,Liuzhou Maternity and Child Healthcare Hospital, Affiliated Women and Children's Hospital of Guangxi University of Science and Technology, Liuzhou, China
| | - Jing Chen
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China.,Liuzhou Maternity and Child Healthcare Hospital, Affiliated Women and Children's Hospital of Guangxi University of Science and Technology, Liuzhou, China
| | - Li Yin
- Xiamen Maluan Bay Hospital, Xiamen, China
| | - Dingyuan Zeng
- Liuzhou Maternity and Child Healthcare Hospital, Affiliated Women and Children's Hospital of Guangxi University of Science and Technology, Liuzhou, China
| | - Li Wang
- Liuzhou Maternity and Child Healthcare Hospital, Affiliated Women and Children's Hospital of Guangxi University of Science and Technology, Liuzhou, China
| | - Hua Tao
- Liuzhou Maternity and Child Healthcare Hospital, Affiliated Women and Children's Hospital of Guangxi University of Science and Technology, Liuzhou, China
| | - Xiajuan Wu
- Liuzhou Maternity and Child Healthcare Hospital, Affiliated Women and Children's Hospital of Guangxi University of Science and Technology, Liuzhou, China
| | - Feng Wei
- Liuzhou Maternity and Child Healthcare Hospital, Affiliated Women and Children's Hospital of Guangxi University of Science and Technology, Liuzhou, China
| | - Fan Xu
- Nanchong Central Hospital, North Sichuan Medical University, Nanchong, China
| | - Qiuling Shi
- State Key Laboratory of Ultrasound Engineering in Medicine, School of Public Health, Chongqing Medical University, Chongqing, China
| | - Zhong Lin
- The Reproductive Hospital of Guangxi Zhuang Autonomous Region, China
| | - Zhibiao Wang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
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4
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Liu Y, Huang J, Du C, Jiang J, Zhou H, Qu D. High-intensity focused ultrasound as a pretreatment combined with hysteroscopic resection for gestational trophoblastic neoplasia with chemotherapy intolerance: a case report. Int J Hyperthermia 2023; 40:2192448. [PMID: 36966804 DOI: 10.1080/02656736.2023.2192448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Due to resistance and intolerance to chemotherapy, localized lesion resection may be required in some patients with Gestational trophoblastic neoplasia (GTN), which may lead to massive bleeding. In this case report, we describe the successful use of high-intensity focused ultrasound (HIFU) as an effective pretreatment method for surgical procedure in a patient with GTN to reduce the perioperative risk and the impact on fertility. CASE PRESENTATION A 26-year-old woman was diagnosed with high-risk GTN (FIGO Stage III: 12 prognostic scores) after a hydatidiform mole. The fifth chemotherapy cycle was interrupted due to severe chemotherapy toxicity. However, the uterine lesion was still present and the beta-human chorionic gonadotropin (β-hCG) level was not restored to normal. Therefore, ultrasound-guided HIFU was performed as a pretreatment method to shrink the lesion and prevent massive bleeding during localized lesion resection. The effectiveness of ablation was evaluated immediately using contrast-enhanced ultrasound and Color Flow Doppler ultrasonography. One month after HIFU treatment, the uterine lesion was completely resected under hysteroscopic surgery. During the surgery, HIFU was found to have shrunk the lesion and there was minimal bleeding (5 mL). The uterine cavity morphology and menstruation returned to normal after surgery. The patient has showed no signs of recurrence as of one-year follow-up. CONCLUSION Ultrasound-guided HIFU ablation may be a new choice for high-risk GTN patients with chemoresistance or chemo-intolerance. As a noninvasive pretreatment method, HIFU can shrink the uterine lesion, and reduce the risk of bleeding with no obvious effect on fertility.
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Affiliation(s)
- Yue Liu
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Jing Huang
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Chengchao Du
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Jing Jiang
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Honggui Zhou
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
- Non-invasive and Microinvasive Laboratory of Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Dacheng Qu
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
- Non-invasive and Microinvasive Laboratory of Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
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5
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Spontaneous Uterine Vessel Rupture During Pregnancy or in the Puerperium: A Review of the Literature. Obstet Gynecol Surv 2022; 77:227-233. [PMID: 35395092 DOI: 10.1097/ogx.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Importance Spontaneous perinatal rupture of a uterine vessel is a rare occurrence that may lead to severe hemorrhage and requires prompt identification and management. Objective The aim of this study was to examine the etiologies, locations, diagnostic tools, treatment options, and risks in subsequent pregnancies when spontaneous rupture of a uterine vessel occurs in pregnancy. Evidence Acquisition A literature search was performed by university research librarians using the PubMed, CINAHL, and Web of Science search engines. Identified were 78 cases of perinatal spontaneous uterine vessel rupture and formed the basis for this review. Results Increased uterine blood flow during pregnancy may alter the integrity of pelvic vessels leading to increased risk of spontaneous rupture. The uterine artery is the most common site of vessel rupture; the second most common site is the uterine-ovarian plexus. The most common presentation is abdominal or pelvic pain, maternal vital sign abnormalities, and an absence of vaginal bleeding. Exploratory laparotomy and embolization (interventional radiology) have been reported as management options. Conclusions Spontaneous rupture of uterine vessels is a rare but potentially life-threatening complication of pregnancy that should be included in the differential diagnosis of pregnant patients presenting with an acute abdomen. Relevance Our aim is to increase the awareness of spontaneous vessel rupture during pregnancy to improve detection, management, and perinatal outcomes.
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6
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Kakinuma T, Kakinuma K, Matsuda Y, Yanagida K, Kaijima H, Ohwada M. Successful Conservative Treatment of Cesarean Scar Ectopic Pregnancy with Local Injections of Absolute Ethanol. Gynecol Minim Invasive Ther 2021; 10:132-134. [PMID: 34040976 PMCID: PMC8140540 DOI: 10.4103/gmit.gmit_125_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/15/2020] [Accepted: 09/04/2020] [Indexed: 11/18/2022] Open
Abstract
Cesarean scar ectopic pregnancy (CSEP) is becoming more common worldwide. Here, we report a case of cesarean scar pregnancy successfully treated using transvaginal ethanol injection. A 31-year-old female (gravida 3, para 2) with two prior cesarean sections presented at 9 weeks and 3 days of pregnancy. Her serum human chorionic gonadotropin level was 91,798 mIU/mL. CSEP was confirmed by transvaginal ultrasonography, pelvic magnetic resonance imaging, and color Doppler ultrasonography. Transvaginal absolute ethanol local injection under transvaginal ultrasound guidance was performed. She was discharged 7 days after treatment with no complications and resumed normal menses 1 month after treatment. We describe a safe and successful treatment option for CSEP.
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Affiliation(s)
- Toshiyuki Kakinuma
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, Japan
| | - Kaoru Kakinuma
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, Japan
| | - Yoshio Matsuda
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, Japan
| | - Kaoru Yanagida
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, Japan
| | | | - Michitaka Ohwada
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, Japan
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7
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Estelle AO, Bonfils K, Lynda GB, Eric KK, Sadio DA, N'Dri Simon D, Paul YY, Paulette Y. [Pregnancy after the first uterine fribrom embolization procedures in sub-saharian Africa in Côte d'Ivoire]. ACTA ACUST UNITED AC 2021; 49:587-592. [PMID: 33677123 DOI: 10.1016/j.gofs.2021.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To report the obstetrical outcome of patients wishing to conceive after embolization of uterine fibroids in Côte d'Ivoire. MATERIALS AND METHOD Over a 72-month period from February 2012 to February 2018, a prospective observational and descriptive longitudinal study focused on 181 non menopausal patients who had symptomatic uterine fibroids for which they had benefited from embolization of the uterine arteries. Among them, some were selected taking into account the inclusion criteria and were regularly monitored by their obstetrician-gynecologist. RESULTS The mean age of the 65 patients was 40.7 years and 16.3% of them had a history of myomectomy. The mean uterine volume and size of dominant myomas before and six months after embolization were 849.5cm3, respectively; 67.7cm and 584cm3; 45.4cm (all these measurements are in centimeters), i.e. a reduction rate of 33% and 43%. Of the 65 patients, eleven of them with an average age of 36.7 years were able to conceive, a rate of 16.9%. Among these 11 patients, 8 had had one pregnancy and three had had two each, for a total number of 14 pregnancies. The mean time from uterine fibroid embolization to pregnancy was 34 months with extremes ranging from 06 to 60 months. Among the obstetric complications, there was one case of placenta accreta which required hysterectomy and two cases of placenta previa which had progressed well after cesarean delivery. CONCLUSION The onset of pregnancy is possible after embolization of uterine fibroids. This less invasive procedure than myomectomy can also be offered to patients with a desire for motherhood. However, there is little agreement on fertility status after UFE and fertility rates after UFE have not yet been effectively quantified. Also, the decision to favor EFU over myomectomy in women wishing to maintain their fertility remains limited by the small size of our sample. We should analyze more patients who are trying to conceive after UFE and use longer follow-up.
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Affiliation(s)
- A-O Estelle
- Service de radiodiagnostic et imagerie médicale du CHU de Treichville, Abidjan, Côte d'Ivoire.
| | - K Bonfils
- Service de radiodiagnostic et imagerie médicale du CHU de Bouaké, Abidjan, Côte d'Ivoire
| | - G-B Lynda
- Service de radiodiagnostic et imagerie médicale du CHU de Treichville, Abidjan, Côte d'Ivoire
| | - K K Eric
- Service de radiodiagnostic et imagerie médicale du CHU de Treichville, Abidjan, Côte d'Ivoire
| | - D A Sadio
- Service de gynécologie-obstétrique du CHU de Treichville, Abidjan, Côte d'Ivoire
| | - D N'Dri Simon
- Service de radiodiagnostic et imagerie médicale du CHU de Treichville, Abidjan, Côte d'Ivoire
| | - Y Y Paul
- Institut de Cardiologie, Abidjan, Côte d'Ivoire
| | - Y Paulette
- Service de radiodiagnostic et imagerie médicale du CHU de Treichville, Abidjan, Côte d'Ivoire
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8
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Seyama R, Makino S, Shinohara M, Takahashi M, Sato A, Takeda J, Takeda S, Itakura A. Advantages of contrast-enhanced ultrasonography and uterine balloon tamponade during intrauterine evacuation of retained products of conception. HYPERTENSION RESEARCH IN PREGNANCY 2021. [DOI: 10.14390/jsshp.hrp2020-004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rie Seyama
- The Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine
| | - Shintaro Makino
- The Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine
| | - Mitsuko Shinohara
- The Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine
| | - Masaya Takahashi
- The Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine
| | - Anna Sato
- The Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine
| | - Jun Takeda
- The Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine
| | - Satoru Takeda
- The Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine
| | - Atsuo Itakura
- The Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine
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9
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Esther LSY, Chew KT, Rahman RA, Zainuddin AA, Hing EY, Kampan N. Uterine-conserving approach in ruptured intramyometrial ectopic pregnancy. Horm Mol Biol Clin Investig 2020; 41:hmbci-2020-0001. [PMID: 32167930 DOI: 10.1515/hmbci-2020-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/05/2020] [Indexed: 11/15/2022]
Abstract
Intramyometrial ectopic pregnancy (IMEP) is a rare form of ectopic pregnancy. It is defined as a conceptus implanted within the myometrium and is completely surrounded by myometrium with clear separation from both the uterine cavity and tubes. IMEP possesses not only diagnostic but also therapeutic challenge. The majority of reported cases were managed by hysterectomy. Early management of unruptured IMEP using methotrexate may help to preserve fertility. We, for the first time, report a case of ruptured IMEP managed successfully using suction and curettage followed by Bakri balloon tamponade and avoiding hysterectomy. Post-procedure, the patient received two doses of intramuscular methotrexate 50 mg/m2 due to plateauing serial beta human chorionic gonadotropin (β-hCG) levels and subsequently achieved undetectable level 10 weeks post-methotrexate. She also had complete resolution of the ectopic intramyometrial mass.
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Affiliation(s)
- Loh Sweet Yi Esther
- Department of Obstetrics and Gynaecology, Faculty of Medicine, UKM Medical Centre, Cheras 56000 Kuala Lumpur, Malaysia
| | - Kah Teik Chew
- Department of Obstetrics and Gynaecology, Faculty of Medicine, UKM Medical Centre, Cheras 56000 Kuala Lumpur, Malaysia, Phone: +60391455949, Fax: +60391455672
| | - Rahana Abd Rahman
- Department of Obstetrics and Gynaecology, Faculty of Medicine, UKM Medical Centre, Cheras 56000 Kuala Lumpur, Malaysia
| | - Ani Amelia Zainuddin
- Department of Obstetrics and Gynaecology, Faculty of Medicine, UKM Medical Centre, Cheras 56000 Kuala Lumpur, Malaysia
| | - Erica Yee Hing
- Department of Radiology, Faculty of Medicine, UKM Medical Centre, Cheras 56000, Kuala Lumpur, Malaysia
| | - Nirmala Kampan
- Department of Obstetrics and Gynaecology, Faculty of Medicine, UKM Medical Centre, Cheras 56000 Kuala Lumpur, Malaysia
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10
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Khaw SC, Anderson RA, Lui MW. Systematic review of pregnancy outcomes after fertility-preserving treatment of uterine fibroids. Reprod Biomed Online 2020; 40:429-444. [DOI: 10.1016/j.rbmo.2020.01.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/17/2019] [Accepted: 01/02/2020] [Indexed: 02/08/2023]
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11
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A Novel Approach for Treatment of Uterine Fibroids: Stereotactic Radiosurgery as a Proposed Treatment Modality. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020. [DOI: 10.1007/s13669-020-00277-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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12
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Ludwig PE, Huff TJ, Shanahan MM, Stavas JM. Pregnancy success and outcomes after uterine fibroid embolization: updated review of published literature. Br J Radiol 2019; 93:20190551. [PMID: 31573326 DOI: 10.1259/bjr.20190551] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Females with symptomatic leiomyomas (fibroids) wishing to maintain fertility are faced with difficult treatment choices. These include uterine fibroid embolization (UFE), myomectomy, hormonal therapy, MRI high intensity focused ultrasound, and myolysis. This review focuses on UFE, one of the most commonly accepted minimally invasive procedural choices among patients with symptomatic fibroids wishing to retain the option of becoming pregnant in the future, and makes comparisons to myomectomy which has historically been the surgical choice for fertility-preserving fibroid treatment. Pubmed and Google Scholar searches using keywords such as: uterine artery embolization, uterine fibroid embolization, pregnancy, complications, infertility were performed between Jan 1, 2019 and May 10, 2019. Publications were chosen based on their inclusion of information pertaining to fertility or pregnancy after UFE without being limited to single case reports.Randomized controlled trials comparing myomectomy and UFE are limited due to study size and confounding variables, but through registry data and familiarity with referring clinicians, UFE has gained wide acceptance. Healthy pregnancies following UFE have been sporadically reported but the actual fertility rate after UFE remains uncertain. Conversely, low birth weight, miscarriage and prematurity have been associated with UFE. Despite inherent risks of possible fertility issues after UFE, the procedure remains an option for females with clinically symptomatic fibroids who desire pregnancy. However, additional research regarding rates of conception and obstetrical risks of infertility following UFE is necessary.
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Affiliation(s)
- Parker E Ludwig
- Creighton University School of Medicine, Omaha, United States
| | - Trevor J Huff
- Creighton University School of Medicine, Omaha, United States
| | - Meaghan M Shanahan
- Creighton University School of Medicine, Omaha, United States.,Creighton University School of Medicine, Department of Obstetrics and Gynecology, Omaha, United States
| | - Joseph M Stavas
- Creighton University School of Medicine, Omaha, United States.,Creighton University School of Medicine, Department of Radiology, Omaha, United States
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13
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Knuttinen MG, Stark G, Hohenwalter EJ, Bradley LD, Braun AR, Gipson MG, Kim CY, Pinchot JW, Scheidt MJ, Sella DM, Weiss CR, Lorenz JM. ACR Appropriateness Criteria ® Radiologic Management of Uterine Leiomyomas. J Am Coll Radiol 2018; 15:S160-S170. [PMID: 29724419 DOI: 10.1016/j.jacr.2018.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/04/2018] [Indexed: 10/17/2022]
Abstract
Uterine fibroids, also known as leiomyomas, are the most common benign tumor in women of reproductive age. When symptomatic, these patients can present with bleeding and/or bulk-related symptoms. Treatment options for symptomatic uterine leiomyomas include medical management, minimally invasive treatment such as uterine artery embolization, and surgical options, such as myomectomy. It is important to understand the role of these treatment options in various clinical scenarios so that appropriate consultation is performed. Furthermore, patients should be presented with the outcomes and complications of each of these treatment options. A summary of the data and clinical trials of the treatment options for symptomatic uterine leiomyomas is outlined in this article. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Gregory Stark
- Research Author, University of Illinois at Chicago, Chicago, Illinois
| | - Eric J Hohenwalter
- Panel Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Linda D Bradley
- Cleveland Clinic, Cleveland, Ohio; American Congress of Obstetricians and Gynecologists
| | - Aaron R Braun
- St. Elizabeth Regional Medical Center, Lincoln, Nebraska
| | | | - Charles Y Kim
- Duke University Medical Center, Durham, North Carolina
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14
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Chen H, Athreya S. Systematic review of uterine artery embolisation practice guidelines: are all the guidelines on the same page? Clin Radiol 2018; 73:507.e9-507.e15. [DOI: 10.1016/j.crad.2017.12.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 12/06/2017] [Indexed: 11/15/2022]
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15
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Karlsen K, Hrobjartsson A, Korsholm M, Mogensen O, Humaidan P, Ravn P. Fertility after uterine artery embolization of fibroids: a systematic review. Arch Gynecol Obstet 2017; 297:13-25. [PMID: 29052017 DOI: 10.1007/s00404-017-4566-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 10/11/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE The impact of uterine artery embolization (UAE) for the purpose of diminishing the effect of uterine fibroids on fertility is unclear. We have investigated the reported rates of pregnancy and miscarriage after treatment of uterine fibroids with UAE. MATERIALS AND METHODS We searched for relevant information in PubMed and Embase for randomized controlled trials (RCT), controlled clinical trials, comparative before-after trials, cohort studies, case-control studies and case series where UAE treatment of premenopausal women was performed for uterine fibroids with and where a control intervention was included. The PRISMA guideline was used to do a systematic review using the main outcomes pregnancy rate and miscarriage rate. Risk of bias was assessed by the Cochrane risk of bias tool or by ROBINS-I. The quality of evidence was assessed by the GRADE approach. RESULTS We included 17 studies (989 patients): 1 RCT, 2 cohort studies, and 14 case series. Pregnancy rates after UAE were 50% in the RCT and 51 and 69% in the cohort studies. Among the case series median pregnancy rate was 29%. Miscarriage rates were 64% in the RCT. Miscarriage rates at 56 and 34% were found in the cohort studies after UAE. The median miscarriage rate was 25% in the case series. CONCLUSION Pregnancy rate was found to be lower and miscarriage rate higher after UAE than after myomectomy. However, we found very low quality of evidence regarding the assessed outcomes and the reported proportions are uncertain. There is a need for improved prospective randomized studies to improve the evidence base. Systematic review registration number: CRD42016036661.
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Affiliation(s)
- K Karlsen
- Department of Gynaecology and Obstetrics, Odense University Hospital, University of Southern Denmark, Kløvervænget 10, 10.sal, 5000, Odense C, Denmark.
| | - A Hrobjartsson
- Center for Evidence-Based Medicine, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - M Korsholm
- Department of Gynaecology and Obstetrics, Odense University Hospital, University of Southern Denmark, Kløvervænget 10, 10.sal, 5000, Odense C, Denmark
| | - O Mogensen
- Department of Gynaecology, Karolinska Institute Stockholm and the University of Southern Denmark, Karolinska University Hospital Stockholm, Stockholm, Sweden
| | - P Humaidan
- Faculty of Health, The Fertility Clinic, Skive Regional Hospital, Aarhus University, Skive, Denmark
| | - P Ravn
- Department of Gynaecology and Obstetrics, Odense University Hospital, University of Southern Denmark, Kløvervænget 10, 10.sal, 5000, Odense C, Denmark
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Pisco JM, Duarte M, Bilhim T, Branco J, Cirurgião F, Forjaz M, Fernandes L, Pereira J, Costa N, Pisco JBM, Oliveira AG. Spontaneous Pregnancy with a Live Birth after Conventional and Partial Uterine Fibroid Embolization. Radiology 2017; 285:302-310. [DOI: 10.1148/radiol.2017161495] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- João M. Pisco
- From the Department of Interventional Radiology, Saint Louis Hospital, Lisbon, Portugal (J.M.P., M.D., T.B., L.F., J.P., N.C., J.B.M.P.); University Department of Radiology (T.B., L.F., J.P., N.C.) and Department of Obstetrics and Gynecology (J.B.), Faculty of Medical Sciences, Universidade Nova de Lisboa, Lisbon, Portugal; Department of Obstetrics and Gynecology, S. Francisco Xavier Hospital, Lisbon, Portugal
| | - Marisa Duarte
- From the Department of Interventional Radiology, Saint Louis Hospital, Lisbon, Portugal (J.M.P., M.D., T.B., L.F., J.P., N.C., J.B.M.P.); University Department of Radiology (T.B., L.F., J.P., N.C.) and Department of Obstetrics and Gynecology (J.B.), Faculty of Medical Sciences, Universidade Nova de Lisboa, Lisbon, Portugal; Department of Obstetrics and Gynecology, S. Francisco Xavier Hospital, Lisbon, Portugal
| | - Tiago Bilhim
- From the Department of Interventional Radiology, Saint Louis Hospital, Lisbon, Portugal (J.M.P., M.D., T.B., L.F., J.P., N.C., J.B.M.P.); University Department of Radiology (T.B., L.F., J.P., N.C.) and Department of Obstetrics and Gynecology (J.B.), Faculty of Medical Sciences, Universidade Nova de Lisboa, Lisbon, Portugal; Department of Obstetrics and Gynecology, S. Francisco Xavier Hospital, Lisbon, Portugal
| | - Jorge Branco
- From the Department of Interventional Radiology, Saint Louis Hospital, Lisbon, Portugal (J.M.P., M.D., T.B., L.F., J.P., N.C., J.B.M.P.); University Department of Radiology (T.B., L.F., J.P., N.C.) and Department of Obstetrics and Gynecology (J.B.), Faculty of Medical Sciences, Universidade Nova de Lisboa, Lisbon, Portugal; Department of Obstetrics and Gynecology, S. Francisco Xavier Hospital, Lisbon, Portugal
| | - Fernando Cirurgião
- From the Department of Interventional Radiology, Saint Louis Hospital, Lisbon, Portugal (J.M.P., M.D., T.B., L.F., J.P., N.C., J.B.M.P.); University Department of Radiology (T.B., L.F., J.P., N.C.) and Department of Obstetrics and Gynecology (J.B.), Faculty of Medical Sciences, Universidade Nova de Lisboa, Lisbon, Portugal; Department of Obstetrics and Gynecology, S. Francisco Xavier Hospital, Lisbon, Portugal
| | - Marcela Forjaz
- From the Department of Interventional Radiology, Saint Louis Hospital, Lisbon, Portugal (J.M.P., M.D., T.B., L.F., J.P., N.C., J.B.M.P.); University Department of Radiology (T.B., L.F., J.P., N.C.) and Department of Obstetrics and Gynecology (J.B.), Faculty of Medical Sciences, Universidade Nova de Lisboa, Lisbon, Portugal; Department of Obstetrics and Gynecology, S. Francisco Xavier Hospital, Lisbon, Portugal
| | - Lúcia Fernandes
- From the Department of Interventional Radiology, Saint Louis Hospital, Lisbon, Portugal (J.M.P., M.D., T.B., L.F., J.P., N.C., J.B.M.P.); University Department of Radiology (T.B., L.F., J.P., N.C.) and Department of Obstetrics and Gynecology (J.B.), Faculty of Medical Sciences, Universidade Nova de Lisboa, Lisbon, Portugal; Department of Obstetrics and Gynecology, S. Francisco Xavier Hospital, Lisbon, Portugal
| | - José Pereira
- From the Department of Interventional Radiology, Saint Louis Hospital, Lisbon, Portugal (J.M.P., M.D., T.B., L.F., J.P., N.C., J.B.M.P.); University Department of Radiology (T.B., L.F., J.P., N.C.) and Department of Obstetrics and Gynecology (J.B.), Faculty of Medical Sciences, Universidade Nova de Lisboa, Lisbon, Portugal; Department of Obstetrics and Gynecology, S. Francisco Xavier Hospital, Lisbon, Portugal
| | - Nuno Costa
- From the Department of Interventional Radiology, Saint Louis Hospital, Lisbon, Portugal (J.M.P., M.D., T.B., L.F., J.P., N.C., J.B.M.P.); University Department of Radiology (T.B., L.F., J.P., N.C.) and Department of Obstetrics and Gynecology (J.B.), Faculty of Medical Sciences, Universidade Nova de Lisboa, Lisbon, Portugal; Department of Obstetrics and Gynecology, S. Francisco Xavier Hospital, Lisbon, Portugal
| | - Joana B. M. Pisco
- From the Department of Interventional Radiology, Saint Louis Hospital, Lisbon, Portugal (J.M.P., M.D., T.B., L.F., J.P., N.C., J.B.M.P.); University Department of Radiology (T.B., L.F., J.P., N.C.) and Department of Obstetrics and Gynecology (J.B.), Faculty of Medical Sciences, Universidade Nova de Lisboa, Lisbon, Portugal; Department of Obstetrics and Gynecology, S. Francisco Xavier Hospital, Lisbon, Portugal
| | - António G. Oliveira
- From the Department of Interventional Radiology, Saint Louis Hospital, Lisbon, Portugal (J.M.P., M.D., T.B., L.F., J.P., N.C., J.B.M.P.); University Department of Radiology (T.B., L.F., J.P., N.C.) and Department of Obstetrics and Gynecology (J.B.), Faculty of Medical Sciences, Universidade Nova de Lisboa, Lisbon, Portugal; Department of Obstetrics and Gynecology, S. Francisco Xavier Hospital, Lisbon, Portugal
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Abstract
Postpartum haemorrhage (PPH) remains one of the leading causes of maternal death worldwide and can be classified as either immediate (primary) or delayed (secondary) according to the onset time - before or after 24 hours postpartum. Uterine pseudoaneurysm is a rare cause of PPH that has been suggested to arise from abnormal vascular regression and a recurrent vascular healing state, such as a vascular stricture and relaxation with thrombin deposits after placental expulsion. With advances in multidetector computed tomography, 3D-computed tomography with angiography can aid in identifying the location and originating vessels of the pseudoaneurysm via fast and clear 3D images. Once a bleeding pseudoaneurysm is diagnosed as the cause of PPH, conservative management is frequently unsuccessful in controlling bleeding. Transcatheter uterine arterial embolisation appears to be the treatment of choice in haemodynamically stable women.
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Affiliation(s)
- Sang Wook Yi
- a Department of Obstetrics and Gynecology , Gangneung Asan Hospital, University of Ulsan College of Medicine , Gangneung , Korea
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18
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Ma Y, Yang C, Shao X. Efficacy comparison of transcatheter arterial embolization with gelatin sponge and polyvinyl alcohol particles for the management of cesarean scar pregnancy and follow-up study. J Obstet Gynaecol Res 2017; 43:682-688. [PMID: 28133896 DOI: 10.1111/jog.13256] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 10/21/2016] [Accepted: 11/13/2016] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study was to compare the therapeutic efficacy of transcatheter arterial embolization (TAE) with gelatin sponge (GS) and polyvinyl alcohol (PVA) particles for cesarean scar pregnancy (CSP). METHODS A total of 35 patients with CSP, who were classified into either the GS group (n = 22) or the PVA group (n = 13), underwent TAE and postoperative ultrasound-guided curettage. Their hospital stay, first-scheme success rate, intra-curettage blood loss, serum β-human chorionic gonadotropin (hCG) level, and other indicators were simultaneously recorded. During the follow-up period, time for the serum β-hCG level to return to normal, time for the return of menstrual cycle, and menstrual blood volume were recorded. RESULTS Compared with the GS group, patients in the PVA group: (i) were older; (ii) had greater number of abortions or curettages, and had longer times since last cesarean (P < 0.05); (iii) had similar hospital stay and first-scheme success rate (P > 0.05); (iv) had lower, but not significantly different, hemorrhage rate (7.7% vs 36.4%, P = 0.066); (v) had a significantly higher serum β-hCG level at discharge and a smaller drop in serum β-hCG level from admission to discharge (P < 0.05); (vi) had a similar time for the serum β-hCG level to return to normal (P > 0.05); (vii) had a shorter time for the return of menstrual cycle (P = 0.012); and (viii) had a significantly higher incidence of abnormal menstrual blood volume reduction (50.0% vs 8.3%, P = 0.034). CONCLUSION TAE with either GS or PVA particles for CSP treatment had relatively good efficacy. During the selection of the ideal embolic agent, the patient's age, hemorrhage risk, and requirement for protecting ovarian function and reserving fertility should be comprehensively considered.
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Affiliation(s)
- Yan Ma
- Departments of Gynecology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Chao Yang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaonan Shao
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, China
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19
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McLucas B, Voorhees III WD, Elliott S. Fertility after uterine artery embolization: a review. MINIM INVASIV THER 2015; 25:1-7. [DOI: 10.3109/13645706.2015.1074082] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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20
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Pregnancy after uterine artery embolization: a case report in a woman with leiomyomata. Case Rep Obstet Gynecol 2015; 2015:235312. [PMID: 25705532 PMCID: PMC4325223 DOI: 10.1155/2015/235312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 01/21/2015] [Indexed: 11/22/2022] Open
Abstract
Background. Several pregnancies have been reported after embolization of uterine artery. This procedure is an accepted nonsurgical treatment for symptomatic uterine fibroids but its safety in women desiring future childbearing is not well established. Case Report. We present a 40-year-old woman with leiomyomata who became pregnant after previously undergone uterine artery embolization for three times. The placenta was previa and the fetus was in transverse position. She had a cesarean delivery of an appropriately grown fetus at 37 weeks, which was followed by uterine atony requiring hysterectomy. Conclusion. Although pregnancy-related outcomes remain understudied, the available reports evidence that pregnancies after uterine artery embolization may be at significantly increased risk for postpartum hemorrhage, cesarean delivery, abnormal placentation, and malpresentation. In patients who are undergoing this type of treatment and contemplating pregnancy, the possibility of adverse complications should be taken in consideration and women should be appropriately advised.
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21
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Mara M, Kubinova K. Embolization of uterine fibroids from the point of view of the gynecologist: pros and cons. Int J Womens Health 2014; 6:623-9. [PMID: 25018653 PMCID: PMC4074023 DOI: 10.2147/ijwh.s43591] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Uterine artery embolization (UAE) is a minimally invasive procedure with large symptomatic potential in treatment of women with uterine leiomyomas. Due to specificities of this method and possible complications the appropriate indication is crucial. Patient’ symptoms, age, plans for pregnancy, and surgical and reproductive history play a major role in decision-making regarding appropriate subjects for UAE. Close cooperation between the gynecologist and the interventional radiologist is necessary. UAE is usually offered as an alternative to surgical treatment. In patients with no fertility plans, it is a less invasive option than abdominal hysterectomy, with a comparable effect on fibroid-related symptoms and quality of life. The need for reintervention is markedly greater in patients after UAE (up to 35% within 5 years) than after hysterectomy. Women with large symptomatic fibroids wishing to retain the uterus and ineligible for minimally invasive (laparoscopic or vaginal) hysterectomy are good candidates for UAE. However, studies comparing UAE with minimally invasive hysterectomy are lacking. Use of UAE in younger women desiring pregnancy is more controversial, mainly because of the significant risk of miscarriage (as high as 64% in some studies) as well as the increased risk of other complications of pregnancy, such as preterm delivery, abnormal placentation, and post-partum hemorrhage. The risk of infertility or subfertility following UAE is unknown. Even poor candidates for myomectomy should be carefully selected for UAE after counseling about all possible adverse effects on fertility. Good prospective studies focused on fertility comparing UAE with no treatment or with myomectomy are needed but would be ethically questionable. This review summarizes the current knowledge regarding the benefits and potential risks of UAE from the point of view of the gynecologist, who should be responsible for proper indication of this treatment.
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Affiliation(s)
- Michal Mara
- Department of Obstetrics and Gynecology, General Faculty Hospital and First Medical Faculty of Charles University, Prague, Czech Republic
| | - Kristyna Kubinova
- Department of Obstetrics and Gynecology, General Faculty Hospital and First Medical Faculty of Charles University, Prague, Czech Republic
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22
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23
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A uterus ruptured and a cerclage extruded. Obstet Gynecol 2014; 123:415-417. [PMID: 24413248 DOI: 10.1097/aog.0000000000000108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Abstract
BACKGROUND There are few data regarding safety of pregnancy after uterine artery embolization. However, numerous women desire future fertility after this procedure. Uterine rupture without a history of cesarean delivery or uterine scarring is an exceedingly rare complication in pregnancy. CASE We report a case of uterine rupture in a primigravid woman after uterine artery embolization. Her pregnancy was also complicated by placenta previa with placenta increta, resulting in a favorable neonatal outcome in an otherwise life-threatening situation for mother and fetus. CONCLUSION Uterine artery embolization is a risk factor for abnormal placentation and uterine rupture in subsequent pregnancies.
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25
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Torre A, Paillusson B, Fain V, Labauge P, Pelage JP, Fauconnier A. Uterine artery embolization for severe symptomatic fibroids: effects on fertility and symptoms. Hum Reprod 2014; 29:490-501. [DOI: 10.1093/humrep/det459] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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26
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Goldberg J. Current thinking on the role of interventional radiology in women’s health. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.2.5.621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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27
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Segars JH, Parrott EC, Nagel JD, Guo XC, Gao X, Birnbaum LS, Pinn VW, Dixon D. Proceedings from the Third National Institutes of Health International Congress on Advances in Uterine Leiomyoma Research: comprehensive review, conference summary and future recommendations. Hum Reprod Update 2014; 20:309-33. [PMID: 24401287 DOI: 10.1093/humupd/dmt058] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Uterine fibroids are the most common gynecologic tumors in women of reproductive age yet the etiology and pathogenesis of these lesions remain poorly understood. Age, African ancestry, nulliparity and obesity have been identified as predisposing factors for uterine fibroids. Symptomatic tumors can cause excessive uterine bleeding, bladder dysfunction and pelvic pain, as well as associated reproductive disorders such as infertility, miscarriage and other adverse pregnancy outcomes. Currently, there are limited noninvasive therapies for fibroids and no early intervention or prevention strategies are readily available. This review summarizes the advances in basic, applied and translational uterine fibroid research, in addition to current and proposed approaches to clinical management as presented at the 'Advances in Uterine Leiomyoma Research: 3rd NIH International Congress'. Congress recommendations and a review of the fibroid literature are also reported. METHODS This review is a report of meeting proceedings, the resulting recommendations and a literature review of the subject. RESULTS The research data presented highlights the complexity of uterine fibroids and the convergence of ethnicity, race, genetics, epigenetics and environmental factors, including lifestyle and possible socioeconomic parameters on disease manifestation. The data presented suggest it is likely that the majority of women with uterine fibroids will have normal pregnancy outcomes; however, additional research is warranted. As an alternative to surgery, an effective long-term medical treatment for uterine fibroids should reduce heavy uterine bleeding and fibroid/uterine volume without excessive side effects. This goal has not been achieved and current treatments reduce symptoms only temporarily; however, a multi-disciplined approach to understanding the molecular origins and pathogenesis of uterine fibroids, as presented in this report, makes our quest for identifying novel targets for noninvasive, possibly nonsystemic and effective long-term treatment very promising. CONCLUSIONS The Congress facilitated the exchange of scientific information among members of the uterine leiomyoma research and health-care communities. While advances in research have deepened our knowledge of the pathobiology of fibroids, their etiology still remains incompletely understood. Further needs exist for determination of risk factors and initiation of preventive measures for fibroids, in addition to continued development of new medical and minimally invasive options for treatment.
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Affiliation(s)
- James H Segars
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Bethesda, MD 20892, USA
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Firouznia K, Ghanaati H, Jalali AH, Shakiba M. Uterine artery embolization for treatment of symptomatic fibroids: a review of the evidence. IRANIAN RED CRESCENT MEDICAL JOURNAL 2013; 15:e16699. [PMID: 24693405 PMCID: PMC3955520 DOI: 10.5812/ircmj.16699] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 06/25/2013] [Accepted: 08/27/2013] [Indexed: 12/17/2022]
Abstract
Fibroids are the most common benign tumors of the uterus during female reproductive age. Uterine artery embolization (UAE) using embolic particles (PVA, Gelfoam) to occlude the uterine arteries, have been reported as a relatively safe, effective, and durable nonsurgical alternative to hysterectomy in diminishing fibroid-related symptoms. To block the arterial blood supply to the fibroid completely, UAE is typically performed in both uterine arteries by an experienced interventional radiologist. Reduction in menorrhagia has been reported as 80-93 percent and the mean decrease in fibroid size varies from 50-78% in the literature. In our center improvement in menstrual bleeding after 6 months was 80.3%, and uterine fibroids underwent shrinkage of 63.7±33.7% after12 months. Complication rate including amenorrhea ranges from 1% - 7% in the literature. UAE may be followed by menopause in 1% of cases. Nevertheless, it is usually encountered in women in their late 40s. It seems that the future of UAE depends on optimal selection of patients according to volume-shrinkage prediction and fertility outcome. Although pregnancy is possible after embolization, however neither fertility preservation nor improvement can be guaranteed following UAE. Indeed, Women who desire to become pregnant should be cautioned about potential complications during pregnancy. The aim of this review is to discuss about the efficacy, safety, technique, and choice of embolic agent. Also we present the effects of this technique on fertility and pregnancy outcome and also methods for dose reduction during this procedure.
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Affiliation(s)
- Kavous Firouznia
- Advanced Diagnostic and Interventional Radiology Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
- Corresponding Author: Kavous Firouznia, Advanced Diagnostic and Interventional Radiology Research Center, Tehran University of Medical Sciences, Tehran, IR Iran. Tel: +98-2166581579, Fax: +98-2166581578, E-mail:
| | - Hossein Ghanaati
- Advanced Diagnostic and Interventional Radiology Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | | | - Madjid Shakiba
- Advanced Diagnostic and Interventional Radiology Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
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Guo XC, Segars JH. The impact and management of fibroids for fertility: an evidence-based approach. Obstet Gynecol Clin North Am 2013. [PMID: 23182558 DOI: 10.1016/j.ogc.2012.09.005] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Fibroids affect 35% to 77% of reproductive-age women. When selecting a treatment plan for symptomatic fibroids, the fibroid location, size, and number must be considered. Myomectomy remains the preferred method for women with fibroid-related infertility who wish to have children or maintain fertility. Currently available medical therapies reduce symptoms in the short term but may involve side effects when used long term. Initial fertility studies are encouraging but trials are needed. Recent medical advances have led to minimally invasive approaches for women with fibroid disease, but there is a strong demand for additional treatment options.
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Affiliation(s)
- Xiaoxiao Catherine Guo
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 10 Center Drive, Building 10 CRC 1-3140, MSC 1109, Bethesda, MD 20892-1109, USA
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31
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Pregnancy after uterine artery embolization for the treatment of myomas: a case series. Arch Gynecol Obstet 2012; 287:71-6. [DOI: 10.1007/s00404-012-2512-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 07/31/2012] [Indexed: 10/28/2022]
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Talaulikar VS, Manyonda I. Progesterone and progesterone receptor modulators in the management of symptomatic uterine fibroids. Eur J Obstet Gynecol Reprod Biol 2012; 165:135-40. [PMID: 22901974 DOI: 10.1016/j.ejogrb.2012.07.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 06/03/2012] [Accepted: 07/25/2012] [Indexed: 10/28/2022]
Abstract
The majority of symptomatic uterine fibroids are currently treated by surgical interventions (myomectomy or hysterectomy) or radiological treatments (uterine artery embolisation or focussed ultrasound surgery). None of these treatments is a panacea, and what is conspicuous is the lack of an effective long-term medical therapy for a disorder so common among women of reproductive age. It has been known for some time that progesterone and its receptors enhance proliferative activity in fibroids and this has raised the possibility that anti-progestins and (PRMs) could be useful in the medical management of fibroids. Some of the compounds which have produced promising results in recent clinical trials or research studies include mifepristone, CDB-4124 (telapristone), CP-8947, J-867 (asoprisnil) and CDB-2914 (ulipristal acetate or UA). UA has recently completed Phase III clinical trials with very encouraging results, and has now acquired a licence for clinical use in Europe. While considerable research has yet to be done on the long-term safety and efficacy of UA there is nevertheless good reason for optimism on the emergence of effective medical therapy in the form of UA and possibly other PRMs.
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Affiliation(s)
- Vikram Sinai Talaulikar
- Department of Obstetrics & Gynaecology, St. George's Hospital and University of London, Cranmer Terrace, Tooting, London SW17 0RE, United Kingdom.
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Talaulikar VS, Manyonda IT. Ulipristal acetate: a novel option for the medical management of symptomatic uterine fibroids. Adv Ther 2012; 29:655-63. [PMID: 22903240 DOI: 10.1007/s12325-012-0042-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Indexed: 11/26/2022]
Abstract
Fibroids, the most common tumor in women of reproductive age, impact negatively on women's health and quality of life, and have significant cost implications for their management. The current mainstay treatments are surgical (myomectomy and hysterectomy) and more recently radiological (UAE and focused ultrasound surgery). Hysterectomy is curative but precludes future fertility, whereas the impact of the other treatments on reproduction is uncertain. With women in Western societies deferring childbearing to their 30s and 40s, when fibroids are most symptomatic, there is a pressing need for a uterus-sparing medical therapy that is cheap, effective, and enhances reproductive potential. Serendipity and meticulous translational research has shown that progesterone augments fibroid proliferation, raising the possibility that progesterone receptor modulators could inhibit fibroid growth; this research has culminated in the emergence of ulipristal acetate (UA), a first-in-class, oral selective progesterone receptor modulator (SPRM) that has successfully completed phase III clinical trials. It has been licensed in Western Europe for short-term clinical use prior to surgery, and has shown efficacy with a significant reduction in uterine bleeding, fibroid volume, and improved quality of life, without the side effects associated with other medications such as gonadotropin-releasing hormone (GnRH) agonists. As with all new medicines, there are concerns surrounding UA, not least its effect on the endometrium and the long-term impact on general health and reproduction. Research to date has tended to be industry led, and therefore, there is a need for researcher/clinician-led studies to address the wider issues concerning SPRMs. UA may not turn out to be the "Holy Grail" of medical therapy in the treatment of symptomatic uterine fibroids, but it has rightly given cause for a huge optimism. Further laboratory and clinical research into PRMs and related compounds will no doubt lead to more refined medications.
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Affiliation(s)
- Vikram S Talaulikar
- Department of Obstetrics & Gynaecology, St. George's Hospital and University of London, Cranmer Terrace, London, SW17 0RE, UK
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Uterine Artery Embolization Versus Laparoscopic Uterine Artery Occlusion: The Outcomes of a Prospective, Nonrandomized Clinical Trial. Cardiovasc Intervent Radiol 2012; 35:1041-52. [DOI: 10.1007/s00270-012-0388-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 03/25/2012] [Indexed: 11/25/2022]
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35
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O'Driscoll D, Malone DE, Johnston C. Your Patient Has Symptomatic Fibroids and Would like to Have a Baby: What Treatment Should you Advise? Can Assoc Radiol J 2012; 63:2-4. [DOI: 10.1016/j.carj.2010.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 08/02/2010] [Accepted: 08/03/2010] [Indexed: 10/19/2022] Open
Affiliation(s)
| | - Dermot E. Malone
- University College Dublin, St Vincent's University Hospital, Elm Park, Dublin, Ireland
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36
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Munro MG. Uterine Leiomyomas, Current Concepts: Pathogenesis, Impact on Reproductive Health, and Medical, Procedural, and Surgical Management. Obstet Gynecol Clin North Am 2011; 38:703-31. [DOI: 10.1016/j.ogc.2011.09.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Schirf BE, Vogelzang RL, Chrisman HB. Complications of uterine fibroid embolization. Semin Intervent Radiol 2011; 23:143-9. [PMID: 21326757 DOI: 10.1055/s-2006-941444] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Uterine fibroid embolization (UFE) is an increasingly popular, minimally invasive treatment option for women with symptomatic fibroid disease. UFE therapy in qualified hands is an effective, well-tolerated procedure that offers relief of fibroid symptoms with a low risk of complications. In the acute postprocedural period, immediate complications may relate to vascular access, thromboembolic events, infection, and pain management. Reported major complications include but are not limited to pulmonary embolus, uterine ischemia, necrosis, sepsis, and death. Non-life-threatening complications include altered ovarian and sexual function, subcutaneous tissue necrosis, expulsion of fibroid tissue, and treatment failure. Awareness of the known complications of UFE may allow more rapid diagnosis and effective therapeutic responses to complications when they occur.
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Affiliation(s)
- Brian E Schirf
- Department of Radiology, Northwestern University, Chicago, Illinois
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Burke CT, Funaki BS, Ray CE, Kinney TB, Kostelic JK, Loesberg A, Lorenz JM, Millward SF, Nemcek AA, Owens CA, Shaw H, Silberzweig JE, Vatakencherry G. ACR Appropriateness Criteria ® on Treatment of Uterine Leiomyomas. J Am Coll Radiol 2011; 8:228-34. [DOI: 10.1016/j.jacr.2010.12.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 12/21/2010] [Indexed: 11/25/2022]
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Transcatheter arterial chemoembolization versus systemic methotrexate for the management of cesarean scar pregnancy. Int J Gynaecol Obstet 2011; 113:178-82. [DOI: 10.1016/j.ijgo.2010.11.027] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2010] [Revised: 11/29/2010] [Accepted: 02/24/2011] [Indexed: 11/21/2022]
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Uterine Artery Embolization for Symptomatic Adenomyosis: A New Technical Development of the 1-2-3 Protocol and Predictive Factors of MR Imaging Affecting Outcomes. J Vasc Interv Radiol 2011; 22:497-502. [DOI: 10.1016/j.jvir.2011.01.426] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Revised: 12/16/2010] [Accepted: 01/02/2011] [Indexed: 11/23/2022] Open
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Balghari Z, Chow N, Comi N, Antoniou A. Successful spontaneous pregnancy and delivery following myomectomy and uterine artery embolization (UAE) – A case report. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2011. [DOI: 10.1016/j.mefs.2010.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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42
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Pregnancy after uterine fibroid embolization. Fertil Steril 2011; 95:1121.e5-8. [DOI: 10.1016/j.fertnstert.2010.08.032] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 07/10/2010] [Accepted: 08/13/2010] [Indexed: 11/18/2022]
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43
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Bonduki CE, Feldner PC, Silva JD, Castro RA, Sartori MGF, Girão MJBC. Pregnancy after uterine arterial embolization. Clinics (Sao Paulo) 2011; 66:807-10. [PMID: 21789384 PMCID: PMC3109379 DOI: 10.1590/s1807-59322011000500016] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Accepted: 02/11/2011] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE To evaluate pregnancy outcomes, complications and neonatal outcomes in women who had previously undergone uterine arterial embolization. METHODS A retrospective study of 187 patients treated with uterine arterial embolization for symptomatic uterine fibroids between 2005-2008 was performed. Uterine arterial embolization was performed using polyvinyl alcohol particles (500-900 mm in diameter). Pregnancies were identified using screening questionnaires and the study database. RESULTS There were 15 spontaneous pregnancies. Of these, 12.5% were miscarriages (n = 2), and 87.5% were successful live births (n = 14). The gestation time for the pregnancies with successful live births ranged from 36 to 39.2 weeks. The mean time between embolization and conception was 23.8 months (range, 5-54). One of the pregnancies resulted in twins. The newborn weights (n = 14) ranged from 2.260 to 3.605 kg (mean, 3.072 kg). One (7.1%) was considered to have a low birth weight (2.260 kg). There were two cases of placenta accreta (12.5%, treated with hysterectomy in one case [6.3%]), one case of premature rupture of the membranes (PRM) (6.3%), and one case of preeclampsia (6.3%). All of the patients were delivered via Cesarean section. CONCLUSION In this study, there was an increased risk of Cesarean delivery. There were no other major obstetric risks, suggesting that pregnancy after uterine arterial embolization is possible without significant morbidity or mortality.
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Affiliation(s)
- Cláudio E Bonduki
- Department of Gynecology, Federal University of São Paulo, São Paulo, SP, Brazil
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44
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Stokes LS, Wallace MJ, Godwin RB, Kundu S, Cardella JF. Quality Improvement Guidelines for Uterine Artery Embolization for Symptomatic Leiomyomas. J Vasc Interv Radiol 2010; 21:1153-63. [DOI: 10.1016/j.jvir.2010.03.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2010] [Revised: 03/01/2010] [Accepted: 03/13/2010] [Indexed: 11/26/2022] Open
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Uterine artery embolization for fibroids is associated with an increased risk of miscarriage. Fertil Steril 2010; 94:324-30. [DOI: 10.1016/j.fertnstert.2009.02.069] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2008] [Revised: 01/21/2009] [Accepted: 02/25/2009] [Indexed: 10/20/2022]
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47
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Intramyometrial ectopic pregnancy in an ICSI patient following uterine artery embolization. Reprod Biomed Online 2010; 20:831-5. [PMID: 20382082 DOI: 10.1016/j.rbmo.2010.02.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Revised: 07/29/2009] [Accepted: 01/25/2010] [Indexed: 12/26/2022]
Abstract
Myometrial pregnancy represents a rare subtype of ectopic pregnancy. A history of uterine artery embolization (UAE) because of symptomatic uterine fibroids, and assisted reproductive treatment may predispose to this unusual implantation site. A 40-year-old woman with a history of uterine fibroids underwent a transfer of two embryos after intracytoplasmic sperm injection treatment. The combined findings on transvaginal ultrasound scan, pelvic magnetic resonance imaging scan, suction curettage, diagnostic hysteroscopy and laparoscopy were compatible with a diagnosis of ectopic pregnancy within the myometrium, at the site of a necrotized intramyometrial fibroid following UAE. Treatment with systemic methotrexate resulted in successful resolution of this ectopic pregnancy. In conclusion, this study reports a pregnancy within a previously necrotized fibroid. Findings suggest that in patients with a history of UAE for the treatment of uterine fibroids and who subsequently undergo assisted reproductive treatment, the risk of an ectopic pregnancy within the myometrium has to be considered.
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Lucot JP, Coutty N, Lions C. Impact sur la fertilité des traitements conservateurs d’un utérus fibromateux : traitements chirurgicaux et non chirurgicaux. IMAGERIE DE LA FEMME 2009. [DOI: 10.1016/j.femme.2009.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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49
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Bradley LD. Uterine fibroid embolization: a viable alternative to hysterectomy. Am J Obstet Gynecol 2009; 201:127-35. [PMID: 19646564 DOI: 10.1016/j.ajog.2009.01.031] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Revised: 12/18/2008] [Accepted: 01/16/2009] [Indexed: 11/30/2022]
Abstract
Benign uterine fibroids, or leiomyomas, are the most common tumors found in gynecologic practice. Symptomatic fibroids present with menorrhagia, pelvic pain, leukorrhea, pressure and bloating, increased abdominal girth, and severe dysmenorrhea. Traditional treatment has relied on surgery because long-term medical therapies have demonstrated only minimal response. Uterine fibroid embolization (UFE) using particulate emboli to occlude the uterine arteries, thereby disrupting the blood supply to fibroids and leading to devascularization and infarction, has been reported to be effective in alleviating fibroid-related symptoms. UFE is a safe, effective, and durable nonsurgical alternative to hysterectomy.
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Affiliation(s)
- Linda D Bradley
- Department Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH, USA
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50
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Ezzati M, Norian JM, Segars JH. Management of uterine fibroids in the patient pursuing assisted reproductive technologies. WOMEN'S HEALTH (LONDON, ENGLAND) 2009; 5:413-21. [PMID: 19586433 PMCID: PMC3444289 DOI: 10.2217/whe.09.29] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Uterine leiomyomas are present in 30-70% of women of reproductive age. In addition to causing menstrual disorders and pain, uterine fibroids negatively affect fertility and pregnancy outcome for patients pursuing assisted reproduction. The two questions that have to be addressed are: which fibroids should be treated and how should they be treated? Submucosal fibroids are associated with a 70% reduction in delivery rate. Intramural fibroids had a lesser effect and reduced the delivery rate by approximately 30%. By contrast, studies have demonstrated that subserosal fibroids did not negatively impact fertility. Furthermore, both submucosal and intramural fibroids were associated with an increased risk of spontaneous miscarriage. Myomectomy is considered the treatment of choice to alleviate these detrimental effects. Further research is needed before alternative treatments can be recommended.
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Affiliation(s)
- Mohammad Ezzati
- Department of Obstetrics & Gynecology, Washington Hospital Center, Washington, DC, USA.
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