Keywords : uterine artery embolization ● fibroids ● postpartum hemhorrage.The use of uterine artery embolization (UAE) as a therapeutic alternative for symptomatic uterine fibroids and acute uterine bleeding in those patients who would prefer uterine preservation needs to be highlighted. We report three cases of uterine artery embolization done for the treatment of uterine fibroid in two cases and for controlling acute uterine bleeding in a case of choriocarcinoma. The advantages of the procedure include restoration of the physiological menstrual cycle, a great psychological benefit and significantly low complication rates as compared to surgery. UAE is also valuable for controlling severe postpartum uterine bleeding.
The use of uterine artery embolization (UAE) as a therapeutic alternative for symptomatic uterine fibroids and acute uterine bleeding in those patients who would prefer uterine preservation needs to be highlighted. We report three cases of uterine artery embolization done for the treatment of uterine fibroid in two cases and for controlling acute uterine bleeding in a case of choriocarcinoma. The advantages of the procedure include restoration of the physiological menstrual cycle, a great psychological benefit and significantly low complication rates as compared to surgery. UAE is also valuable for controlling severe postpartum uterine bleeding.
A 43 year old, para 3 had polymenorrhoea since 8 months and on examination revealed a 8 week size uterus. On ultrasound examination, the uterus measured 11.5 x 10.2 x
9.5 cm and showed a 10 x 9.2 x 8.4 cm size well defined hypoechoic intramural fibroid in the anterior wall. Vaginal bleeding did not reduce inspite of medical therapy and so hysterectomy was advised. The patient had an appendectomy, two cesarean sections and an exploratory laparotomy for adhesive small bowel obstruction in the past, and hence was reluctant to go for one more surgery. Considering the technical difficulties that would have been encountered during hysterectomy due to adhesions, she was explained about the alternative of UAE.
Selective pre-embolization bilateral uterine artery angiogram showed dilated tortuous hypertrophied bilateral main uterine arterial trunks with extensive intramural tortuous arcuate and radial branches supplying the fibroid with tumor blush during the arteriodocapillary phase (Figure 1A, 1B) and washout with the venous phase. Both uterine arteries were then embolized using a mixture of 500-750 micron polyvinyl alcohol particles and gelfoam particles. Post-embolization angiogram showed complete lack of tumor blush on both sides (Figure 2A, 2B). Elective ovarian arterial study showed no supply to the fibroid from either side.
The patient was kept under observation overnight and discharged on the next day. She had mild lower abdominal pain for the next two days which was very well taken care of by oral analgesics. She developed amenorrhea for 3 months but regained normal menstrual cycles thereafter. At follow up after 6 months, she had normal menstrual cycles, was totally asymptomatic, and on ultrasound examination showed reduction in the size of the uterus and fibroid. Uterus measured 8.5x 7.0 x 6.5 cm and the fibroid measured 6.0 x 5.5 x 5.2 cm.
A 42 year old, P4A1, presented with polymenorrhagia for 6 months. Examination revealed a 6 week size uterus and bleeding from the cervical os. Ultrasound examination showed a bulky uterus measuring 9.5 x 7.5x 6.2 cm with a large, well defined, intramural hypoechoic fibroid measuring 7.5 x 6.0 x 5.0 cm, in the posterior wall of the uterus. The symptoms did not improve in spite of medical therapy. Hysterectomy was advised but since the patient did not want surgery, UAE was performed as in the previous case. Immediate postprocedural period showed a mild postembolization syndrome comprising pain, nausea and fever which was well controlled by symptomatic treatment. Postprocedure noncontrast CT scan of the pelvis showed retention of contrast by the tumor suggesting totally successful embolization (Figure 3).
Eight weeks later, the patient was readmitted with amenorrhea, hot flushes, sweating and insomnia. She was treated symptomatically. Follow up showed that the symptoms reduced and menstrual bleeding resumed three months later. It was considered that the symptoms were due to trasient ovarian failure which is known to occur in association with uterine artery embolization. On follow up after 7 months, the patient is asymptomatic and has regular periods.
A 20 year old, primigravida presented with 10 weeks of amenorrhea, hyperemesis, rapidly enlarging lower abdominal swelling, severe weakness, breathlessness, and spotting since 2 days. On examination she was pale and had a 24 week size lower abdominal swelling from the cervical os. At speculum examination about one liter of frank blood gushed out with expulsion of few grape like vesicles. Ultrasound examination showed a bulky uterus completely filled with a large heterogenous mass with multiple anechoic cystic spaces (Figure 4A). There was no evidence of any intra - or extra-uterine gestational sac or fetal parts. Chest radiograph revealed multiple well defined, round, nodular opacities suggestive of metastases in both the lung fileds distributed predominantly in the lower zone. Laboratory investigations revealed a positive urine pregnancy test, 3.5 g/dL hemoglobin and 109 IU serum
bhCG. She was diagnosed as a case of choriocarcinoma. Uterine artery ligation was mandatory for controlling severe uterine bleeding but considering the anesthetic risks, an emergency bilateral UAE was performed which successfully controlled the uterine bleeding. She was later put on combination chemotherapy including etoposide, methotrexate. D-actinomycin, cyclophosphamide and vincristine (EMACO regime) for 6 cycles, and followed up clinically and with serum bhCG levels. The follow up chest radiograph after 2 weeks showed reduction in the size of the metastases which completely resolved after 4 weeks.
At 6 months follow up she was having regular periods. Her bhCG level was normal and ultrasound exmmination showed an absolutely normal uterus (Figure 4b).
For decades, hysterectomy has been the standard surgical therapy for uterine leiomyomata for women who have completed their fertility, and myomectomy for those who wish to conceive. In recent years, alternative surgical and medical treatments have been developed, including laparoscopic / hysteroscopic resection and GnRHa. For those patients who are candidates for hysterectomy but prefer uterine preservation and are unwilling to go for surgery and, for young women who desire pregnancy, UAE represents a promising alternative method of treating refractory symptoms related to uterine leiomyomas 1. Use of UAE for treatment of fibroids was first reported from France by Ravina et al 2 in 1995.
This procedure involves occluding the vessels using polyvinyl alcohol particles, gelfoam, or coils. The normal myometrium rapidly develops a new blood supply from collateral circulation, whereas the fibroids do not. The procedure leads to fibroid shrinkage of approximately 30-50% and appears to lead to relief of fibroid-associated symptoms 1.
Embolization appears to be a good alternative to surgery even for very large fibroids 3. It takes weeks to months for noticeable symptomatic improvement, which occurs through a combination of size reduction and alteration in the internal architecture of the fibroids as they undergo hyaline degeneration, rendering them softer and more pliable. They begin to exert less mass effect on the uterus and surrounding structures. The presenting symptoms such as increased urinary frequency, pelvic pain and/or pressure, and constipation improve dramatically during the first several months after UAE, even with only a modest reduction in fibroid size. Most fibroids shrink between 40 and 60% of their volume on an average. Based on the geometry of a sphere, a volume reduction of 50% only amounts to a 20% diameter reduction of the diameter. 4.
Complications of UAE have been extremely uncommon but fall into three general categories – complications of angiography, pelvic infection, and ischemic phenomena 5,6. The major adverse effect following fibroid embolization is pain 7. Most patients experience considerable uterine cramping after the procedure and require overnight hospitalization for pain control. The other serious postembolization problem is the development of amenorrhea associated with transient ovarian failure. Non-targeted embolization of ovarian arteries has always been considered a possible complication of UAE 8. UAE is both safe and effective when performed as an outpatient procedure 9. Smaller baseline leiomyoma size and submucosal location are more likely to result in a positive imaging outcome 10.
Transcatheter UAE is of significant value in treating certain hemorrhagic conditions in obstetrics and gynecology including postpartum hemorrhage. In our case of choriocarcinoma, UAE was performed to control severe uterine bleeding as an emergency procedure, as emergency hysterectomy was not feasible due to anesthetic risks. However chemotherapy was given later as a definitive treatment.
