Emergency Uterine Artery Embolization Research Articles

Short-term outcomes of uterine artery embolization for urgent or emergent abnormal uterine bleeding.

To evaluate the outcomes of uterine artery embolization (UAE) for patients with urgent or emergent abnormal uterine bleeding (AUB). Retrospective review of all patients from 1/2009-12/2020 who were treated urgently or emergentlywith UAE for AUB. Urgent and emergent cases were defined as those requiring inpatient admissions. Demographic data were collected for each patient including hospitalizations related to bleeding and length of stay (LOS) for each hospitalization. Hemostatic interventions other than UAE were collected. Hematologic data were collected before and after UAE including hemoglobin, hematocrit, and transfusion products. Data specific to the UAE procedure included complication rates, 30-day readmission, 30-day mortality, embolic agent, site of embolization, radiation dose, and procedure time. 52 patients (median age: 39) underwent 54 urgent or emergent UAE procedures. The most common indications for UAE were malignancy (28.8%), post-partum hemorrhage (21.2%), fibroids (15.4%), vascular anomalies (15.4%), and post-operative bleeding (9.6%). There were no procedure-related complications. Following UAE, 44 patients (84.6%) achieved clinical success and required no additional intervention. Packed red blood cell transfusion decreased from a mean of 5.7 to 1.7 units (p < 0.0001). Fresh frozen plasma transfusion decreased from a mean of 1.8 to 0.48 units (p = 0.012). 50% of patients received a transfusion prior to UAE, while only 15.4% were transfused post-procedure (p = 0.0001). Emergent or urgent UAE is a safe and effective procedure to control AUB hemorrhage secondary to a variety of etiologies.

The method for termination of mid-trimester pregnancy with placenta previa: A case study.

Background:Prenatal bleeding is very dangerous for pregnant women with placenta previa during termination of pregnancy in the mid-trimester. Traditionally, cesarean section or hysterectomy is used to stop bleeding. This study aims to investigate the method for termination of mid-trimester pregnancy with placenta previa, especially emergency uterine artery embolization (UAE) combined with cervical double balloon (CDB).Methods:A retrospective study was conducted based on 261 cases of mid-pregnancy termination in our hospital, where 34 cases with placenta previa were set as the observation group, and the remaining 227 cases were set as control group. At first, the termination method of Mifepristone combined with Misoprostol/Ethacridine Lactate was adopted. If the volume of prenatal bleeding was up to 400 mL, emergency uterine artery embolization (UAE) was implemented to stop bleeding, then cervical double balloon (CDB) was used to promote cervical ripening. Receiver operating characteristic (ROC) curves analysis was performed to assess the accuracy in predicting the length of placental edge crossed the cervical os for prenatal bleeding.Results:The number of gravidity/parities, the rate of cesarean section, the medical cost, the rate of previous cesarean section were all higher in the observation group than in the control group (P < .05). The volume of prenatal hemorrhage, postpartum hemorrhage, the rate of puerperal morbidity, emergency UAE rate and ICU rate were higher in the observation group than in the control group (P < .05). There were 4 cases showing prenatal hemorrhage up to 400 mL and undergoing emergency UAE + CDB in the observation group, while there were no such cases in the control group (P < .05). An optimal cut-off value of 1.7cm for the length of placental edge crossed the cervical os in diagnosing prenatal hemorrhage demonstrated sensitivity and specificity of 75.0% and 86.7%, respectively (area under the ROC curve, 0.858).Conclusion:The combined therapy of mifepristone and Misoprostol/Ethacridine Lactate was useful for termination of mid-trimester pregnancy with placenta previa, and attention needs to be attached to prenatal hemorrhage during labor induction. Emergency UAE + CDB is a good combination method to treat prenatal hemorrhage and promote cervical ripening during the induction.

Use of Barbed Suture in Laparoscopic Myomectomy with Large Posterior Myoma

To assess the safety and efficacy of barbed suture laparoscopic myomectomy for large posterior myoma compared to conventional suture. Descriptive study. Department of Gynecology, Affiliated Women and Children's Hospital of Ningbo University, Ningbo, Zhejiang, China between July 2019 and June 2020. All cases of laparoscopic myomectomy for large posterior myoma (≥8cm in the largest diametre) were retrospectively reviewed. The surgical technique was identical except the selection of suture material. A comparison between the barbed suture and conventional suture was performed in terms of clinical characteristics and surgical outcomes such as total operative time, suture time, intraoperative blood loss, and changes in hemoglobin concentration. A total of 48 eligible cases, 24 cases with barbed sutures and 24 cases with conventional sutures were included in the final analysis. Patients' clinical characteristics such as age, body mass index, number, and size of myomas were similar between the two groups. In patients with barbed sutures, the time for suturing, the total operative time, intraoperative blood loss, and the changes in hemoglobin concentration were significantly lower than in conventional sutures (all p<0.05). No significant differences in time for enucleation, time for morcellation, and postoperative complications were found between the two groups. Two patients with conventional sutures received postoperative emergent uterine artery embolization and three patients received a blood transfusion. The use of barbed sutures could reduce the difficulty and enhance safety in laparoscopic myomectomy for large posterior myoma. Barbed suture, Laparoscopy, Myomectomy, Posterior.

Emergency Uterine Artery Embolization Used for Managing Profuse Intra-Abdominal Bleeding and Uterine Rupture in a Patient with Advanced Cervical Cancer.

Advanced cervical cancer can lead to life-threatening vaginal bleeding. Emergency uterine artery embolization (UAE) has been successfully used in such cases to achieve hemostasis. Our case demonstrates the unusual emergency use of this procedure to cease heavy hemorrhage, which led to hematometra, uterine rupture and hemoperitoneum in a patient with a large tumor in the cervical region. Vaginal bleeding was minimal in this case. The emergency UAE controlled the bleeding, and the patient was scheduled for laparotomy soon after the procedure, where a supracervical hysterectomy with bilateral salpingo-oophorectomy and the removal of blood and blood clots was performed. Since the tumor primarily involved the parametria, a sample was taken for histopathology examination with the following result: squamocellular HPV-associated cervical carcinoma. The postoperative management of the patient consisted of combined chemotherapy and radiotherapy, with no complications related to the UAE. Four months after the procedure the patient is reasonably well. Urgent surgery was not the optimal decision because of the alteration of the pelvic anatomy by the tumor, and thus the UAE enabled us to manage this life-threatening condition quickly, allowing us to best prepare the patient for further therapeutic modalities.

Management of Acquired Uterine Arteriovenous Malformations Associated with Retained Products of Conception

PurposeTo evaluate the efficacy and safety of different treatments for acquired uterine arteriovenous malformations associated with retained products of conception (UAVM-RPOC) and to investigate the role of uterine artery embolization (UAE) in acquired UAVM-RPOC. Materials and MethodsThis was a retrospective study of consecutive patients who were diagnosed with uterine arteriovenous malformation by ultrasound after recently terminated pregnancy. Forty-eight patients were included in this study and were divided into 2 groups (major and minor bleeding groups) according to vaginal bleeding. The treatments were analyzed between groups. Technical and clinical success rates of UAE were analyzed. ResultsOf the 48 patients, 11 patients were in the massive bleeding group and 37 were in the minor bleeding group. Five patients were referred for UAE in each group and UAE was a priority for patients with unstable hemodynamics (chi-square value = 5.524, P =.022). Conservative management, dilation and curettage (D&C), operative hysteroscopy, and UAE were performed in 16 (33%), 18 (38%), 7 (15%), and 13 (27%) patients, respectively. Two patients with ectopic pregnancies suffered uncontrollable bleeding during D&C and required emergent UAE. Three patients underwent UAE before surgery to prevent hemorrhage. The technical and clinical success rates of UAE were 100%. No complications or recurrences occurred. ConclusionsUAE is a safe and effective treatment for UAVM-RPOC and a priority for patients with unstable hemodynamics. Conservative management, D&C, and hysteroscopy are safe and effective for patients with UAVM-RPOC with stable hemodynamics. However, UAVM-RPOC following ectopic pregnancy may have high risks of massive hemorrhage during procedures.

The Management of Scar Ectopic: A Single-Center Experience.

Purpose: This study aimed to highlight the clinical features, diagnosis, and different modalities of the treatment of cesarean scar pregnancy (CSP).Methods: This study was done in the tertiary referral hospital of India for one year. A total of 11 cases were enrolled prospectively. In each case, the diagnostic ultrasonography and measurement of baseline beta-human chorionic gonadotropin (β-HCG) levels were done. The treatment was given based on the hemodynamic status of the patient and desire for future fertility. Various treatment modalities used were medical, surgical, or interventional digital subtraction angiography to control hemorrhage. Also, in some cases, ultrasound-guided methotrexate was injected into the scar ectopic. Medically treated cases were followed up until their β-HCG levels became normal.Results: Out of 11 patients, six had a history of two cesarean sections in the past, four patients had a history of one cesarean section and one patient with a previous three low segments cesarean section (LSCS). Seven out of 11 patients underwent medical management with either methotrexate with potassium chloride (KCl) or methotrexate alone. The success of the medical management was monitored by serial β- HCG values. The mean time for the resolution of these 10 patients was 86.7 ± 53.6 days. Three patients underwent emergency uterine artery embolization due to uncontrolled bleeding and one patient required laparotomy.Conclusion: CSP is a life-threatening condition that can be diagnosed with the help of transvaginal ultrasonography. The treatment, however, depends on the hemodynamic status of the patient and desire for future fertility. Well-defined diagnostic criteria coupled with structured management and follow-up protocol can help in treating this challenging form of ectopic pregnancy.

How to minimize bleeding in laparoscopic myomectomy.

Laparoscopic myomectomy is a common surgical procedure for symptomatic myomas. However, bleeding control during surgery may pose a challenge. Therefore, the aim of this study was to review recent evidence regarding interventions to control bleeding during laparoscopic myomectomy. The use of vasopressin resulted in less blood loss compared to placebo. Barbed sutures reduced blood loss compared to conventional sutures. Intravenous infusion of tranexamic acid (TXA) in the intraoperative period of large myomectomies showed no significant difference compared to placebo. Uterine artery occlusion (UAO) and emergency uterine artery embolization were reported to be feasible and may reduce and treat bleeding before conversion to laparotomy. Several methods can control bleeding during laparoscopic myomectomy. Vasopressin and barbed sutures resulted in decreased blood loss, and TXA did not have an impact on bleeding control. The use of UAO and emergency embolization techniques can contribute to the control of bleeding; however, further studies are needed to prove the efficacy of these and other agents.

Abstract No. 43 Evaluation of urgent and emergent uterine artery embolization in hospitalized patients for vaginal bleeding

Abstract No. 43 Evaluation of urgent and emergent uterine artery embolization in hospitalized patients for vaginal bleeding

Clinical investigation in the methods for complete placenta previa labor induction in the second trimester

Objective: To investigate the appropriate method of labor induction in the second trimester for complete placenta previa patients. Methods: The labor induction outcomes of 85 cases with complete placenta previa in the second trimester were retrospectively analyzed. Twenty patients in group A were treated with cesarean section, 30 patients in group B were treated with ethacridine and mifepristone combined with uterine artery embolization (UAE), and 35 patients in group C were induced by using ethacridine and mifepristone. The clinical features and induction outcomes of three groups were compared. Results: The total duration of labor in group B [(28.7±30.1) hours] was significantly longer than that of group C [(24.3±21.9) hours; P<0.05]. The total amount of blood loss during induction and labor in group B [(302±271) ml] was significantly lower than those of group C [(393±523) ml] and group A [(626±487) ml; P<0.05]. The incidence of fever in group B (13%, 4/30) was significantly higher than those of group C (11%, 4/35) and group A (10%, 2/20; P<0.05). In group C, 13 patients (37%, 13/35) underwent emergency UAE, and 2 patients (6%, 2/35) underwent emergency cesarean section. As to average hemoglobin level and blood transfusion rate, there were no difference among the three groups (all P>0.05). Conclusion: Prophylactic UAE combined with drug induction in patients with complete placenta previa in the second trimester could significantly reduce the amount of bleeding during induction and reduce the risk of emergency procedures.

Successful conservative treatment of cervical pregnancy with uterine artery embolization followed by curettage: a report of 19 cases.

The purpose of this retrospective study was to evaluate the safety and efficacy of uterine artery embolization (UAE) followed by curettage for conservative management of cervical pregnancy. Retrospective review. Peking University First Hospital. Patients with cervical pregnancy diagnosed by trans-vaginal ultrasound at Peking University First Hospital between January 2003 and December 2014. We retrospectively reviewed the clinical background and outcomes of patients with cervical pregnancy who underwent UAE followed by curettage for prevention of massive vaginal bleeding and removal of gestational tissue from the cervix. We also reviewed the literature on the role of UAE in the treatment of cervical pregnancy. Clinical assessments included gestational age, gravidity, endocervical canal mass, serum beta-human chorionic gonadotrophin (β-HCG) level, blood loss, hospitalisation stay and expenses, time of resumption of menstruation and subsequent pregnancy outcomes. A total of 19 patients with cervical pregnancy treated with UAE followed by curettage were identified. Curettage was performed 24-72hours after UAE in 16 patients, within 24hours after UAE in three patients. None of the patients underwent a hysterectomy as a result of cervical pregnancy. Of the nine patients with available follow-up information (median follow-up time 59months), eight resumed normal menstruation and one had a term pregnancy with a normal vaginal delivery. Quick regression of serum β-HCG level, low blood loss and short hospital stay were observed. UAE combined with curettage is a safe, effective and fertility-sparing choice for treatment of patients with cervical pregnancy. A serial of 19 patients with cervical pregnancy treated with UAE followed by curettage showed a good prognosis.

Curettage after uterine artery embolization combined with methotrexate treatment for caesarean scar pregnancy.

In the present study, we evaluated the diagnosis and management modalities of caesarean scar pregnancy (CSP). Thirty patients diagnosed with CSP were retrospectively studied between February, 2010 and February, 2012. Twenty-five patients were offered prophylactic uterine artery embolization (UAE) and methotrexate (MTX) prior to uterine suction curettage. Five cases were referred from other hospitals where the initial management with uterine suction curettage had resulted in uncontrollable massive haemorrhage, 4 of the cases had UAE and one proceeded immediately to hysterectomy. In the 25 patients treated with prophylactic UAE and MTX, 12 had laparoscopy-guided curettage and 13 had ultrasound-guided curettage without complication. The results showed that the 25 patients with CSP, who received prophylactic UAE and MTX prior to uterine curettage, recovered without complications. Five patients referred from other hospitals, where uterine curettage was the primary procedure, had severe complications including uncontrolled vaginal bleeding and uterine rupture. Four of the five patients were treated successfully with emergency UAE and the remaining patient underwent emergency hysterectomy as ultrasound examination detected significant haemorrhage between the uterus and the bladder. Of the 25 patients who received prophylactic UAE combined with MTX, there were no reports of irregular menstruation or serious adverse effects. Notably, the decrease in serum human chorionic gonadotropin (HCG) levels 3 days post-surgery was greater with ultrasound-guided curettage (84.3±5.5%) than with laparoscopy-guided curettage (76.3±10.2%). In summary, the data suggested that prophylactic UAE with MTX followed by ultrasound-guided curettage is the most effective therapeutic approach in CSP.

Uterine necrosis and hysterectomy in a postpartum hemorrhage patient who underwent repeated uterine artery embolization

A 19-year-old nulliparous female in the 28th week of her first pregnancy, a monoamniotic monochorial twin pregnancy, was transferred to our hospital after she presented with watery vaginal discharge and lower abdominal pain. Soon after admission to our hospital, the patient was managed conservatively; her condition stabilized without significant clinical events. Approximately 1 month later, she developed vaginal bleeding with fresh blood, suggesting premature membrane rupture requiring emergency cesarean delivery. The estimated blood loss during cesarean delivery was approximately 1000 mL. The patient showed continued vaginal bleeding after cesarean delivery in the operating room. Vital signs and laboratory data were: blood pressure 1⁄4 122/ 73 mmHg, pulse rate 1⁄4 111 times/minute, hemoglobin 1⁄4 8.5 g/dL, and hematocrit 1⁄4 25.3%. The patient was managed by conservative methods including uterine massage, fluid loading, intravenous administration of oxytocin, and vaginal packing. Uterine atony was considered as the cause of postpartum bleeding because the patient had no abnormal findings of the placenta and no particular event occurred during cesarean delivery. Emergency uterine artery embolization (UAE) was performed for massive postpartum hemorrhage (PPH). The anterior divisions of both the right and left internal iliac arteries were embolized using gelfoam particles (Cutanplast, Mascia Brunelli, Milan, Italy). The next morning, massive vaginal bleeding was again evident. The vital signs were blood pressure 1⁄4 80/60 mmHg and pulse rate 1⁄4 125 times/minute. The hemoglobin level was 6.6 g/dL. Emergency UAE was performed once more. A pelvic angiogram showed active bleeding in the

Management of Cesarean Scar Pregnancy: A Case Series.

To survey effective treatment strategies for cesarean scar pregnancy (CSP). The clinical data of 78 patients diagnosed with CSP from January 2010 to December 2013 were reviewed. Among these patients, 17 patients were first treated at our hospital; of them, 2 were misdiagnosed. The other 61 patients were referred from other hospitals; of them, 21 were initially misdiagnosed. There were 9 patients who were treated with laparotomy, 50 patients with curettage after uterine artery embolization (UAE) with or without local methotrexate (MTX) infusion, 10 patients with dilatation and curettage, 6 patients with transvaginal sonographic guided local intragestational MTX injection, and 3 patients with systemic MTX injection. All patients finally recovered. Patients with excessive vaginal hemorrhage underwent either emergency UAE treatment or laparotomy. These two treatments had similar success rates (81.82% vs. 100%, χ2 =0.289, P>0.05). The accurate diagnosis of CSP is important. Curettage after UAE with or without local MTX infusion is a safe and effective method.

Conservative management of uterine artery pseudoaneurysm after laparoscopic-assisted myomectomy and subsequent pregnancy outcome: case series and review of the literature

ObjectiveUterine artery pseudoaneurysm is a rare potentially life-threatening complication after myomectomy. Its clinical characteristics and management, and the outcomes of subsequent pregnancy, are not well understood. The purpose of this study was to clarify these important issues. Study designRetrospective analysis of a case series of uterine artery pseudoaneurysm detected after laparoscopic-assisted myomectomy (LAM) in a single center over a 13-year period. During the early postoperative course, gray scale ultrasonographic evaluation was carried out routinely by searching for an anechoic or hypoechoic well-defined cystic structure in the post-myomectomy scar. In suspicious cases, further evaluation was performed by color Doppler flow analysis and three-dimensional computerized tomographic angiography. After finally confirming the diagnosis by digital subtraction angiography, uterine artery pseudoaneurysm was conservatively managed by angiographic intervention. In cases achieving successful conception, cesarean delivery was chosen and the uterine scar was evaluated. ResultsUterine artery pseudoaneurysm was diagnosed in 9 out of 854 cases of LAM. One case was undiagnosed until massive uterine hemorrhage occurred in the late postoperative period, while the other eight cases were diagnosed in the early postoperative course without hemorrhagic complication. Eight cases were managed by uterine artery embolization, but spontaneous resolution of pseudoaneurysm was observed in one case during a difficult prolonged attempt to superselect the offending branch of the uterine artery. Postembolization course was uneventful, except in a 41-year-old woman who developed oligomenorrhea. Among five women desiring preserved fertility, three women including one after spontaneous miscarriage achieved live birth by cesarean section. One woman experienced spontaneous miscarriage and one did not become pregnant by fertility treatment. In a case with elective cesarean delivery, severe early postpartum hemorrhage occurred from the placental bed and was conservatively managed by emergency uterine artery embolization. ConclusionThe development of uterine artery pseudoaneurysm after myomectomy may be more common than previously considered, and should be carefully monitored to avoid potentially life-threatening hemorrhage and loss of fertility. Although spontaneous resolution may occur, conservative management by angiographic intervention could be a feasible management option for future fertility preservation, once a diagnosis has been made.

Conservative management of cervical pregnancy: The utility of methotrexate treatment and uterine artery embolization

The aim of this retrospective case series report is to evaluate systemic methotrexate therapy in conjunction with uterine artery embolization (UAE) in the conservative management of cervical pregnancy. We examined clinical presentations, treatments, and therapeutic outcomes in fifteen patients with a cervical pregnancy who wished for preservation of fertility, treated at Okayama University Hospital between 1998 and 2012. Twelve patients received systemic methotrexate including five treated with UAE. One was treated with UAE alone. Two patients received neither UAE nor methotrexate because of a low human chorionic gonadotropin (hCG) level and poor blood flow around the gestational sac (GS). An increased GS size and the elevated hCG level during methotrexate therapy might be risk factors for emergent UAE. Two of six patients treated with UAE had subsequent confirmed viable pregnancies. In patients with a cervical pregnancy, methotrexate therapy in combination with UAE can be considered as an option before performing a hysterectomy with suitable counseling about the risk of loss of fertility. Careful observation of the GS size and hCG level during methotrexate therapy might be important for management.

Uterine Artery Embolization Combined with Methotrexate in the Treatment of Cesarean Scar Pregnancy: Results of a Case Series and Review of the Literature

PurposeTo explore the clinical value of uterine artery embolization (UAE) combined with methotrexate in the treatment of cesarean scar pregnancy (CSP) before and after uterine curettage. Materials and MethodsFrom August 2009 to April 2012, 15 patients with CSP treated with UAE (before or after uterine curettage) were analyzed retrospectively. Eleven subjects with a definite diagnosis of CSP were offered preventive UAE combined with methotrexate before uterine curettage. The other four patients, who were misdiagnosed as having an intrauterine pregnancy, were treated with emergency UAE for uncontrollable massive hemorrhage after uterine curettage. Clinical data, treatment sequence, and outcome were analyzed, and a brief review of the published literature summarizing UAE in the treatment of CSP was performed. ResultsEleven patients with definite CSP received preventive UAE combined with methotrexate followed by uterine curettage, and CSP was resolved successfully without hysterectomy. In the four misdiagnosed patients, three were treated successfully with emergency UAE. The other patient underwent uterine curettage and emergency UAE followed by repeat curettage, but hysterectomy was performed because of continued severe hemorrhage. ConclusionsBased on a small number of patients, it appears that UAE may be an effective means of treating CSP, including treatment in an emergency setting. Further study is required before the safety and effectiveness of UAE can be confirmed.

Postpartum Hemorrhage in Coagulopathic Patients: Preliminary Experience with Uterine Arterial Embolization with N-Butyl Cyanoacrylate

The present report describes uterine artery embolization (UAE) with N-butyl cyanoacrylate (NBCA) in four patients with postpartum hemorrhage (PPH) in a coagulopathic condition. Initial UAE with gelatin sponge particles and/or fibered platinum microcoils had failed in these patients. Subsequently, a mixture of NBCA and iodinated poppy seed oil (Lipiodol) was used as embolic material, and hemostasis was achieved immediately in all patients. No vaginal bleeding recurred thereafter, and all patients were discharged within 3 weeks of UAE. One patient resumed menstruation in 6 months. NBCA may be a promising embolic material for emergent UAE in patients with PH, especially for patients with a coagulopathic condition.

Uterine artery embolization for emergent management of postpartum hemorrhage associated with placenta accreta

Although uterine artery embolization (UAE) is a well-recognized alternative treatment for postpartum hemorrhage (PPH) with a high clinical efficacy, the reported success rate of UAE for PPH associated with placenta accreta (PA) is lower. Recently, with advances in techniques and expertise, a few studies have reported favorable results of UAE in controlling PPH in the setting of PA. To evaluate the efficacy of UAE in the emergent management of intractable PPH associated with PA. Seventeen consecutive patients who underwent emergent UAE for the management of PPH associated with PA were included in this retrospective study. Medical records were reviewed regarding the delivery and UAE procedure. Follow-up gynecologic outcomes after UAE were obtained by telephone interview. UAE successfully controlled PPH in 14 patients (82.4%). Three patients underwent hysterectomy after UAE failed to stop the bleeding. All hysterectomy cases were accompanied by uterine atony or total placenta previa. Relevant gynecologic findings were obtained from 10 patients; three patients were breastfeeding and seven patients resumed normal menstruation, including one pregnancy. UAE appears to be a safe and effective means by which to control PPH associated with PA. PA complicated by uterine atony or placenta previa may be at increased risk of UAE failure.

Placental polyp with prominent neovascularization

Placental polyp is a potentially life-threatening disorder that develops after abortion or parturition. Evaluation of neovascularization by multimodal imaging is potentially useful in management of placental polyp in a woman who wishes to preserve fertility.

Emergency Uterine Artery Embolization

Emergency uterine artery embolization for serious obstetrical hemorrhage has proved to be a useful technique. Protocols between obstetricians and interventional radiologists that have been established allow the effective management of these young women in what may be life-threatening situations.