Subsequent pregnancy after two uterine artery embolizations

Abstract

Uterine artery embolization (UAE) was first described in 1995 as an effective alternative in the treatment of symptomatic uterine leiomyomas [1]. This procedure has remained a popular option for women wishing to avoid surgery (myomectomy or hysterectomy) and preserve the uterus [2]. For women wishing to maintain fertility, the safety of this procedure remains controversial. There have been a limited number of reports describing the surveillance and outcome of pregnancy after embolization. Complications such as fetal malpresentation, small for gestational age, premature delivery, cesarean delivery, and postpartum hemorrhage have been previously reported in pregnancies occurring after a single UAE [3]. Here, we describe the first reported case of pregnancy after undergoing two prior uterine artery embolizations. A 34-year-old G2P0010 was referred to our practice for a perinatal consultation at 16 weeks due to a history of two prior uterine artery embolizations. The patient experienced menometrorrhagia with severe anemia secondary to extensive uterine leiomyomas 2 years prior to conception. Treatment options were offered including a myomectomy to preserve fertility. She ultimately chose UAE to avoid a laparotomy. 1 year after her initial uterine artery embolization procedure, she continued to experience menometrorrhagia with anemia and was found to have persistent leiomyomas. After extensive counseling, she chose a second uterine artery embolization procedure. An MRI obtained 3 months following the second procedure revealed significantly smaller, devascularized leiomyomas. 6 months later, she underwent a hysteroscopic resection of a submucosal fibroid. She spontaneously conceived an intrauterine pregnancy about 1 year after the second UAE procedure. The patient was extensively counseled regarding the potential risks including small for gestational age, premature delivery, cesarean delivery, and postpartum hemorrhage, which have been previously described with pregnancy following a single uterine artery embolization procedure. She elected to continue her pregnancy. She underwent close follow-up with monthly serial growth ultrasounds, and twice weekly fetal testing beginning at 32 weeks. Biometry and growth were appropriate for gestational age throughout the pregnancy and her antepartum course remained uncomplicated. At 40 weeks and 6 days, the patient presented for a scheduled induction of labor. She subsequently underwent a primary low transverse cesarean section for arrest of dilatation and delivered a healthy male infant, weighing 3,288 g. Her postpartum course was uncomplicated. Uterine artery embolization is a treatment option that is increasingly used for women who experience symptoms of menorrhagia and/or pelvic pressure due to uterine leiomyoma [4, 5]. The effectiveness of this minimally invasive and uterine preserving procedure makes UAE an attractive option. Currently, myomectomy is the only recommended surgical option for women with leiomyomas who desire future fertility [4]. However, one study found that 30% of patients who underwent UAE desired future fertility [6]. Embolization has also been employed in the management of postpartum hemorrhage and uterine arteriovenous S. F. Ravangard (&) Department of Obstetrics and Gynecology, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030, USA e-mail: Sravangard@resident.uchc.edu