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.