Discussion
Main findings:
Our review of cases in last 5 years included a spectra of obstetric and gynaecological cases encountered routinely and some uncommon ones that benefited due to interventional radiology in terms of avoiding a surgical procedure and also reduced blood loss in the need of a surgical intervention. All nine cases of PAS disorders had a prophylactic balloon catheter placement that were inflated intraoperatively and were instrumental in reducing the blood loss significantly. Almost all patients of AVM who underwent embolisation were symptomatically relieved avoiding a surgical intervention except in one with a complication of rectal ischemia who required an exenteration procedure. Patients with fibroid complicating pregnancy had a prophylactic balloon placement in the event of uncontrolled hemorrhage during caesarean myomectomy which was useful in one case. All cases of fibroid who underwent UFE had symptomatic relief with complete resolution of myoma in all cases.
Interpretation:
1. Transarterial embolization is considered the alternative treatment for PPH, with urgent hysterectomy considered the standard treatment. Hysterectomy guarantees no future fertility, whereas embolization offers the chance of future fertility.
2. Transcatheter embolization of uterine AVM and UFE are minimally invasive alternative options which obviate the need for hysterectomy and related complications and preserve reproductive capability.
3. Proper protocol based selection of cases and multidisciplinary team management helps in reducing failure of procedure and management of complications preventing morbidity.
A literature review of these case scenarios and role of interventional radiology in their management is presented below.
Placenta accreta spectrum (PAS) disorders, comprising placenta accreta, increta, and percreta, are associated with serious maternal morbidity and mortality in both the developed and the developing world and are major contributors to the group of anticipated obstetric hemorrhages.
Placenta accreta  complications of placenta accreta include massive haemorrhage, damage to the uterus, bladder, ureters, and bowel.1
Cesarean hysterectomy is currently the definitive treatment method for PAS disorders2,4 ,5. Arterial embolisation is highly effective in treating bleeding associated with PASD.2,3 The Royal College of Obstetricians and Gynaecologists recommends the early involvement of IR in the management of PPH and use of IR in women at high risk of PPH.3
Brown and Heaston et al 4,5 first described the use of embolization in the treatment of PPH in 1979. Mathe et al4,5 concluded that the severity of hemodynamic instability and need for transfusion associated with PPH was reduced with early angiography and intervention4,5. Review of studies by Eriksson et al. Salomon et al. and Ornan et al.4 suggest that overall embolization for PPH appears to have little effect on resumption of menstruation and future fertility as was also seen in our study 4,5.
Uterine arteriovenous malformation although a rare entity can represent a life-threatening condition because of severe hemorrhage, requiring blood transfusion in up to 30% of the cases 6.
The first case of uterine arteriovenous fistula (AV fistula) has been described back in 1926 by Dubreuil and Loubat6. The incidence of acquired AVM (termed as AV fistula) has witnessed a gradual rise in recent years owing to an increase in uterine interventions (those following pregnancy, caesarean section, curettage and abortion).
Traditionally, uterine AVMs have been managed by hysterectomy with or without internal iliac artery ligation. Transcatheter embolization of uterine AVM was first described by Forssman et al in 19824,7. Since then all studies have reported an overall success rate with transcatheter uterine AVM embolization of over 95% with minimal complications of <4% which include transient paraesthesia /paralysis of the left arm and persistent blue coloration of the cervical os. For those with intractable vaginal bleeding, persistent evidence of AVM, or poor compliance with regular follow-up, surgical intervention should still be undertaken 6,7.Chronic pelvic pain (CPP) accounts for 10–40% of all gynaecological referrals and up to 30% of patients with CPP have pelvic congestion syndrome (PCS) as a sole cause of their pain7,10. The aetiology however is poorly understood and is likely to be multifactorial. 7,8,9,10.
Since its introduction in 1993 by Edward et al 9,10transcatheter embolotherapy (TCE) has transformed the treatment of PCS9. Complications of TCE are rare (<4%), and include recurrence of varices, ovarian vein thrombophlebitis, migration of embolic material and irradiation of ovaries8,9. A prospective study comparing ovarian vein embolizations to hysterectomy with oophorectomy (unilateral/bilateral) concluded that ovarian vein embolization was a safe, well tolerated, and effective treatment for chronic pelvic congestion syndrome that did not respond to medical treatment and its therapeutic efficacy compared favourably with traditional surgical treatment.7.8,9 ,10,15
Uterine leiomyoma (fibroid) is the commonest benign tumour of the female genital tract affecting 25% of women of reproductive age11. The most common presenting symptom is uterine bleeding although patients may also be referred for pelvic pain, urinary or bowel obstructive symptoms, infertility and miscarriage7,11,15.
The first attempt at percutaneous transcatheter artery embolization for the treatment of uterine fibroids was made by Jean Jacques Merland et al in 1989 and was subsequently published in 19957. Currently embolization has become a first line treatment for symptomatic uterine fibroid tumours in pre-menopausal women and is offered as an alternative to hysterectomy and myomectomy in certain indications11,15.
Fibroids naturally regress after menopause and so the procedure is rarely indicated in post-menopausal women. Because the risk of leiomyosarcoma increases with age, the procedure should not be performed in menopausal women with new onset or worsening symptoms related to presumed leiomyomas7. Before contemplating UFE, factors such as current use of gonadotropin releasing hormone (GnRH) agonists that reduce uterine artery calibre, extensive adenomyosis, previous internal iliac artery ligation, the presence of numerous fibroids, and plans for future pregnancy should be borne in mind. Absolute contraindications include pregnancy, malignancy, active genitourinary tract infection, diseased arteries limiting vascular access and high risk of contrast-induced nephropathy. Pedunculated subserosal fibroids are a relative contraindication due to a potential risk of stalk ischemic necrosis and torsion7,11,15.
The REST trial7,11 (Randomized Trial of Embolization versus Surgical Treatment for Fibroids) , the embolization versus hysterectomy (EMMY) 7,12 trial and HOPEFUL study ( a recent multicentre retrospective cohort study) all reported that the embolization patients had a shorter hospital stay, less pain, less adverse effects during hospitalization and a faster return to daily activities and the procedural failures were mainly due to difficult anatomy and absence of a uterine artery 7,11,12,13,14.
Strengths:
The strengths of this study include meticulous data collection with all records derived from a real-time updated electronic database, thereby minimising the possibility of bias. Nonetheless, the present study has several caveats:
Lack of long term follow up data
Prospective, multicentre, larger trials are necessary to consider the safety of UFE in patients desirous of fertility an aspect which wasn’t evaluated in our study.