Uterine artery embolisation for massive uterine fibroids in the presence of submassive pulmonary emboli

Abstract

A 46-year-old woman was admitted to our hospital with acute shortness of breath and pre-syncope. She had known massive uterine fibroids with a history of menorrhagia and dysmenorrhoea, and had been awaiting total abdominal hysterectomy and bilateral salpingo-oophorectomy. She had no past or family history of venous thromboembolism (VTE). She was an ex-smoker with a 16-pack/year smoking history. On examination, she looked unwell, was sweaty and clammy, but apyrexial. Her heart rate was 130 per minute and her blood pressure was 140/95 mmHg. She was tachypnoeic with a respiratory rate of 28 breaths per minute; however, her chest was clear. Abdominal examination revealed an enormous uterus, equivalent to the size of a 30-week pregnancy. There was no clinical evidence of deep vein thrombosis (DVT). She was hypoxic: oxygen saturation on air was 88%; arterial blood gas measurement on 100% oxygen—pH 7.4, PO2 29.0mmHg, PCO2 3.5mmHg, bicarbonate 18.5mmol/L, base excess of 7.5 mol/L. Her full blood count revealed a microcytic anaemia with a mean cellular volume of 67.9 fl (normal: 81–99 fl) and haemoglobin of 9.4 g/dL (normal: 12.0–15.0 g/L). Her D-dimer was significantly elevated at 1.7 Ag/mL (normal: <0.5 Ag/mL). Other blood tests including renal profile, liver function, thyroid function, C-reactive protein and clotting profile were all within normal limits. Her 12 lead electrocardiogram demonstrated sinus rhythm with right bundle branch block and T wave inversion in V1-3 with classic ‘S1QIIITIII’ changes. Her Chest X-ray showed blunting of the basal pulmonary arteries particularly on the right. Transthoracic echocardiography findings were consistent with submassive pulmonary embolism: the left ventricular size and function was normal; the right ventricle was dilated with moderately impaired systolic function; the right atrium was also dilated; the inferior vena cava was distended and failed to collapsewith inspiration; the estimated right ventricular systolic pressure was 50 mmHg. A contrast CT pulmonary angiogram revealed occlusive thrombus in the proximal basal left and mid and basal right pulmonary arteries. She was initially managed with aggressive fluid resuscitation and was commenced on intravenous unfractionated heparin (target APTT ratio of 2.0–3.0). On day 3 she began to heavily menstruate and required a total of nine units of blood over the ensuing 10 days. She was given subcutaneous Zoladex and 30 mg TDS provera to reduce her menstrual blood loss. On day 13 she underwent iliac venography and inferior cavography with insertion of a temporary IVC filter. No free intravascular thrombus was seen in either common iliac vein or within the IVC. There was however significant compression on all three of these veins. Immediately following this, she underwent uterine artery embolisation (UAE). At the time of UAE, her uterus and dominant fibroid measured 3800 and 3220 mL, respectively. Two weeks post-UAE her caval filter was removed, via a jugular route, without complication. A follow up pelvic MRI, one month later, confirmed complete fibroid degeneration with migration of the fibroid into the endometrial cavity (Fig. 1). The uterus measured 2200 mL and the fibroid 1000 mL, correlating with a 42% and 69% respective relative reduction in size. At six weeks she passed a large ‘steak-sized’ degenerate fibroid. At three months pelvic ultrasound showed that the uterus had reduced to 315 mL and the fibroid volume was 1.5 mL. The patient has made a complete recovery and has been given life-long warfarin.