AJR 2004; 183:1025-1028
© American Roentgen Ray Society
Emergency Selective Arterial Embolization for Control of Life-Threatening Hemorrhage from Uterine Fibroids
Ronan F. J. Browne1,2,
Jeffrey McCann1,
Ciaran Johnston1,
Martin Molloy1,
Hugh O'Connor3 and
Niall McEniff1
1 Department of Diagnostic Imaging, St. James's Hospital, James's St., Dublin 8,
Ireland.
2 Present address: Department of Radiology, Abdominal Division, Vancouver
General Hospital, 899 W 12th Ave., Vancouver V5Z 1M9, BC, Canada.
3 Department of Gynecology, St. James's Hospital, Dublin 8, Ireland.
Received September 25, 2003;
accepted after revision April 29, 2004.
Address correspondence to R. F. J. Browne
(ronanbrowne{at}hotmail.com).
Introduction
Uterine leiomyomata, commonly known as fibroids, occur in up to 40% of
women of childbearing age [1,
2]. Menorrhagia is the most
frequent manifestation of these lesions and can occasionally be acute and
severe, warranting emergency treatment. Treatment options have traditionally
been medical (using specific hormone antagonists) or surgical (hysterectomy)
[3]. Percutaneous embolization
techniques have proven to be effective in the emergency treatment of
nonmalignant pelvic hemorrhage in many clinical settings
[4–6]
and have recently become established as one of the techniques used in the
elective treatment of fibroid-related menorrhagia
[1,
7,
8]. We report our experience
with the technique of emergency uterine artery embolization in the treatment
of patients with acute intractable menorrhagia secondary to uterine fibroid
disease.
Subjects and Methods
Three patients with known uterine fibroid disease were admitted over a
7-month period with severe acute menorrhagia and underwent emergency selective
embolization of the uterine arteries. The patients were 37, 44, and 48 years
old (mean age, 43 years). At admission, all had symptoms (dyspnea [n
= 2], palpitations [n = 2], and diaphoresis [n = 1]) in
addition to changes in vital signs (tachycardia [n = 3] and
hypotension [n = 3]) that indicated grade 3 acute hypovolemic shock.
The patients' blood pressures on arrival were 70/30, 80/42, and 86/48 mm Hg,
and their hemoglobin levels were 4.4, 4.6, and 5.7 g/dL (mean, 4.9 g/dL). The
patients' hematocrit levels were 0.180, 0.199, and 0.192 (mean, 0.190). The
patients were resuscitated with fluids and blood transfusion (4–5 U of
packed RBCs) before undergoing embolization. The time from admission to
embolization was 4–15 hr (mean, 8 hr). All patients had been seen in the
gynecology service for chronic fibroid-related menorrhagia. All had uterine
fibroid disease that had been revealed on MR images obtained as part of the
routine workup for elective uterine artery embolization within the 6 months
before the emergency admission. In all cases, findings at physical examination
and results of laboratory investigations were normal before the acute
admission. Hemoglobin levels were 12.1, 11.9, and 12.5 g/dL (mean, 12.1 g/dL)
in the 6 months before the acute presentation.
Procedures were performed by an interventional radiologist in the
interventional radiology suite under fluoroscopic guidance. Prophylactic IV
antibiotic (Rocephin [ceftriaxone], 1 gm, Roche Pharmaceuticals) and rectal
analgesia (Difene [diclofenac sodium], 100 mg, Fujisawa Pharma) were
administered to all patients 1 hr before the procedure. Conscious sedation was
maintained throughout the procedure using IV midazolam (Hypnovel, Roche
Pharmaceuticals) and morphine tartrate–cyclizine tartrate (Cyclimorph,
Amdipharm).
With the patient under local anesthesia, we performed angiography via a
unilateral femoral artery approach using a 5-French vascular sheath. A
5-French pigtail catheter (Omniflush, AngioDynamics) was used to obtain a
nonselective pelvic arteriogram to identify the uterine arteries
(Fig. 1A). A hydrophilic
polymer-coated 0.035-inch angled guidewire (Radifocus, Terumo) was used to
position a 4-French Cobra catheter (Cobra Radifocus, Terumo) in the
contralateral internal iliac artery, and selective arteriography was
performed. After superselective catheterization of the uterine artery (Figs.
1B and
1C), particles (Embospheres,
Biosphere Medical) with a 500- to 700-µ m diameter were introduced
under fluoroscopy. The particles were mixed with iodinated contrast medium,
and infusion was continued until occlusion of the uterine vascular bed and a
marked reduction of flow in the main uterine artery occurred. Lignocaine
hydrochloride (4 mg composed of 2 mL of 0.2%, weight/volume) was injected
directly into the uterine artery before embolization. This procedure was then
repeated in the ipsilateral internal iliac and uterine arteries using a new
4-French Cobra catheter.
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Fig. 1B. —44-year-old woman with acute severe menorrhagia. Left uterine
arteriogram shows uterine artery (arrow) and vascular fibroids. Note
retrograde filling of left ovarian artery. Fibroids are vascular, but no
active contrast material extravasation is seen. Embolization was performed
with 500- to 700-µm particles (Embospheres, Biosphere Medical),
and complete occlusion of uterine artery was confirmed under fluoroscopy.
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Fig. 1C. —44-year-old woman with acute severe menorrhagia. Selective right
uterine arteriogram shows hypervascular fibroids. No active contrast material
extravasation is seen. Uterine artery (arrow) was embolized with
Embospheres. Bleeding subsequently stopped and has not recurred for 12
months.
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All patients were closely monitored after embolization and were evaluated
for procedure-related complications. Analgesia was administered as required
using a standard postprocedural pain management regimen. All patients
underwent gynecologic assessment 6 weeks after the procedure. All patients
were imaged 6 weeks after the procedure with transabdominal sonography and at
6 months with MRI.
Results
Bilateral uterine artery embolization was performed in all patients. No
patient experienced procedure-related complications. In all patients,
embolization resulted in immediate cessation or reduction of hemorrhage,
obviating further treatment. All patients required between 6 and 10 hr of
narcotic analgesia after the procedure. The mean hospital stay was 3 days
(range, 2–4 days). All patients were found to have had complete
cessation of menorrhagia at 6-week outpatient follow-up, and sonography
performed at this time showed that the size of the fibroids in all patients
had decreased, with no Doppler flow seen. One patient passed a 3.5-cm fibroid
per vaginum 3 weeks after the procedure and also underwent MRI at 6-week
follow-up (Fig. 2A,
2B,
2C,
2D) that revealed a significant
decrease in the size of remaining fibroids. Six-month follow-up MRI showed
further decrease in fibroid size in two patients (Figs.
1D,
1E, and
3A,
3B,
3C,
3D). One patient is awaiting
6-month follow-up. All remained free of symptoms at mean follow-up of 6.3
months (range, 3–12 months).
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Fig. 2A. —37-year-old woman with acute severe menorrhagia. Sagittal
T2-weighted image obtained 3 months before current episode of bleeding reveals
multiple fibroids in uterine body, largest (arrow) of which is in
anterior wall with significant submucosal extension to endometrial cavity.
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Fig. 2B. —37-year-old woman with acute severe menorrhagia. Sagittal
T2-weighted image obtained 6 months after embolization shows decrease in size
of all fibroids. Note partial expulsion of submucosal lesion.
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Fig. 2D. —37-year-old woman with acute severe menorrhagia. Selective
right uterine arteriogram shows dilated uterine arteries (arrow) and
hypervascular fibroids. No active contrast material extravasation is seen.
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Fig. 1D. —44-year-old woman with acute severe menorrhagia. Sagittal
T2-weighted images obtained before (D) and after (E)
embolization show enlarged uterus with multiple fibroids that are
significantly reduced in size on postembolization image (E).
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Fig. 1E. —44-year-old woman with acute severe menorrhagia. Sagittal
T2-weighted images obtained before (D) and after (E)
embolization show enlarged uterus with multiple fibroids that are
significantly reduced in size on postembolization image (E).
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Fig. 3A. —48-year-old woman with acute severe menorrhagia. Sagittal
T2-weighted image obtained 4 months before current episode of bleeding shows
enlarged uterus with multiple fibroids. Largest (arrow) of fibroids
is posteriorly placed in uterine body.
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Fig. 3D. —48-year-old woman with acute severe menorrhagia. Selective
right uterine arteriogram obtained arteries (arrow) and hypervascular
fibroids. Shows no active contrast material extravasation is seen.
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Discussion
Uterine fibroids are the most common solid tumors of the female genital
tract [1]. They are benign,
hypervascular tumors originating in the intramural portion of the myometrium
as an abnormal proliferation of smooth-muscle cells
[9]. Although up to 50% of
patients with uterine fibroids are asymptomatic, referable symptoms include
menorrhagia, pelvic pain, backache, and reproductive dysfunction
[1]. Abnormal uterine bleeding
and menorrhagia are usually chronic
[2,
10], but occasionally patients
may present acutely with intractable profuse uterine hemorrhage, necessitating
immediate resuscitation and treatment of the underlying cause.
Surgical hysterectomy has been the mainstay of treatment for severe fibroid
disease [2,
3,
7]. This technique, however, is
associated with a significant risk profile, including those involving general
anesthesia and surgical complications including infection, bleeding, and
ureteral injury [2,
5]. When compounded by
hemodynamic instability, these risks are even greater. Hysterectomy also
eliminates any potential for future childbearing
[5,
9]. Recently, minimally
invasive techniques, including laparoscopic myomectomy, endometrial ablation,
hysteroscopic endometrial resection, thermocoagulation, and myolysis, have
been used so that reproductive function can be preserved
[2,
11]. However, recurrence rates
of up to 50% after these procedures remain a substantial problem, and these
techniques may be less suitable for the emergency setting
[2,
3]. Medical treatment options,
including tranexamic acid and manipulation of steroid hormone concentrations
using specific hormone antagonists, are often temporary measures or may be
unsuccessful in the acute setting.
During the past 10 years, uterine artery embolization has become
established as an alternative to hysterectomy for the treatment of nonacute
uterine hemorrhage caused by fibroids
[1,
7,
8]. This technique has been
shown to be highly effective in controlling menorrhagia and triggering tumor
degeneration [2,
10], with significantly fewer
complications than surgery [1,
2,
7,
9]. In addition, percutaneous
embolization of internal iliac arterial branches has proven effectiveness in
the emergency treatment of pelvic hemorrhage resulting from trauma and other
causes [2,
4–6,
8]. This technique offers
significant advantages over surgery with regard to hemorrhage-related
morbidity and mortality and also maintains patient fertility
[5]. We used the technique of
uterine artery embolization as a therapeutic measure in acute severe
fibroid-related menorrhagia. Embolization has the added potential benefit of
maintaining fertility in these women who are usually of childbearing age
[1]. We believe this technique
offers a successful outcome both in the initial control and subsequent
treatment of these patients.
The only complication encountered in our experience of uterine artery
embolization in this group of patients was postprocedural pain in two patients
that was well controlled with standard pain management regimens.
Postprocedural pain is thought to be related to particle size
[8]. Smaller particles cause
more shrinkage of the lesion by occluding small distal vessels but also cause
more pain and may be associated with an increased risk of ischemic
complications [2,
5,
8]. We used 500- to
700-µ m particles with satisfactory results in all patients. The
small risk of uterine necrosis and infection makes it prudent to administer
prophylactic antibiotics before the procedure
[5].
Correctly diagnosing the cause of uterine hemorrhage is essential, allowing
treatment to be directed to the specific cause of the problem. In our series,
all patients were undergoing workup for uterine fibroid disease, including
MRI, and two were awaiting elective embolization. MRI provided more accurate
diagnosis and assessment of fibroids than other techniques and excluded the
possibility of malignant causes of hemorrhage
[2,
9].
Radiologic follow-up consisted of sonography at 6 weeks after the procedure
to give an early assessment of initial response to treatment. A more detailed
assessment was made with MRI 6 months after the procedure when a significant
response would have been expected. Pedunculated and mainly subserous fibroids
are believed to be unsuitable for embolization
[2]. One of our patients had a
fibroid with a significant submucosal component; nonetheless, a decision was
made to proceed with this treatment, and the patient was warned of possible
expulsion of the fibroid per vaginum. This patient had complete cessation of
symptoms after 2 days and passed a 3.5-cm fibroid per vaginum 3 weeks after
embolization. Follow-up MRI has shown a further decrease in size of residual
fibroids.
Uterine fibroid disease remains the single most common indication for
hysterectomy [3]. In our
series, emergency uterine artery embolization proved to be an effective means
of controlling and treating acute severe menorrhagia resulting from uterine
fibroids. Embolization in this clinical setting offers a safe and viable
alternative to surgery and maintains potential reproductive ability.
References
- Pinto I, Chimeno P, Romo A, et al. Uterine fibroids: uterine artery
embolization versus abdominal hysterectomy for treatment—a prospective,
randomized, and controlled clinical trial. Radiology2003; 226:425
–431[Abstract/Free Full Text]
- Walker WJ, Pelage JP, Sutton C. Fibroid embolization.
Clin Radiol2002; 57:325
–331[Medline]
- Stewart EA. Uterine fibroids. Lancet2001; 357:293
–298[Medline]
- Ben Menachem Y, Coldwell DM, Young JWR, Burgess AR. Hemorrhage
associated with pelvic fractures: causes, diagnosis, and emergent management.
AJR 1991;157:1005
–1014[Abstract/Free Full Text]
- Vedantham S, Goodwin SC, McLucas B, Mohr G. Uterine artery
embolization: an underused method of controlling pelvic hemorrhage.
Am J Obstet Gynecol1997; 176:938
–948[Medline]
- Pelage JP, Le Dref O, Mateo J, et al. Life-threatening primary
postpartum hemorrhage: treatment with emergency selective arterial
embolization. Radiology1998; 208:359
–362[Abstract/Free Full Text]
- Floridon C, Lund N, Thomsen SG. Alternative treatment for
symptomatic fibroids. Curr Opin Obstet Gynecol2001; 13:491
–495[Medline]
- Pelage JP, Le Dref O, Soyer P, et al. Fibroid-related menorrhagia:
treatment with superselective embolization of the uterine arteries and midterm
follow-up. Radiology2000; 215:428
–431[Abstract/Free Full Text]
- Sasadeusz KJ, Andrews RT. Uterine fibroid embolization.
Semin Roentgenol2002; 37:361
–370[Medline]
- Hutchins FL Jr, Worthington-Kirsch R. Embolotherapy for
myoma-induced menorrhagia. Obstet Gynecol Clin North
Am 2000;27:397
–405[Medline]
- Franchini M, Cianferoni L. Emergency endometrial resection in women
with acute, severe uterine bleeding. J Am Assoc Gynecol
Laparosc 2000;7:347
–350[Medline]
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Introduction
Subjects and Methods
