| Abstract|| |
Purpose: To evaluate the safety and short-term efficacy of uterine artery embolization (UAE) in treating uncontrolled vaginal bleeding in a group of gynecologic and obstetric patients. Methods: Eighteen symptomatic patients were treated by this method. These included 11 patients with an advanced carcinoma of the cervix, three patients with uterine fibroid, three patients with a uterine arterio-venous malformation (AVM) and one patient with placenta accreta. All procedures were done by transfemoral route. Polyvinyl alcohol foam particles, 300-500 microns in size, were used for embolization. Imaging by duplex sonography was performed before the procedure and at one week and one-month follow-up. Result: Eight patient (six with carcinoma of the cervix and one each with a uterine AVM and placenta accreta) underwent unilateral and 10 patients underwent a bilateral UAE. All procedures were technically and clinically successful. Four patients developed a self-limiting post-embolization syndrome, characterized by mild fever and leucocytosis. They responded well to analgesic therapy. One patient developed a groin hematoma that resolved with conservative management. All patients reported mild to moderate pelvic pain in the post-embolization period which lasted for 24-72 hours and responded well to medication. There were no permanent sequelae of UAE. The follow-up period was 2-17 months (mean, 7 months). During follow-up, vaginal bleeding was controlled in all of them. It stopped completely in 8 and was significantly reduced in 10 patients. The size of the tumor regressed in all patients. The AVM was completely blocked in one and showed a substantially reduced flow in two patients. Conclusion: UAE is used in treating vaginal bleeding, irrespective of its etiology. The procedure is safe, produces no permanent sequelae and provides an effective control of hemorrhage. The overall complication rate is low.
Keywords: Vaginal bleeding, Uterine artery embolisation
|How to cite this article:|
Sharma S, Mohanthy B K, Chopra S, Mohapatra M, Deka D, Rajani M. Acute and short term results transcatheter management of vaginal bleeding in gynecological and obstetric disorders. Indian J Radiol Imaging 2002;12:59-65
|How to cite this URL:|
Sharma S, Mohanthy B K, Chopra S, Mohapatra M, Deka D, Rajani M. Acute and short term results transcatheter management of vaginal bleeding in gynecological and obstetric disorders. Indian J Radiol Imaging [serial online] 2002 [cited 2020 Jul 9];12:59-65. Available from: http://www.ijri.org/text.asp?2002/12/1/59/28418
| Introduction|| |
Genital tract hemorrhage is a major cause of morbidity and mortality in many disorders of the female reproductive tract ,,.,. Its management represents an issue of critical concern to the involved sub-specialists. It is caused by a variety of gynecologic and obstetric conditions and is usually insidious, chronic and intractable [1-8]. If conservative local measures fail to control this hemorrhage, the patients are traditionally managed by radical surgery and/or bilateral internal iliac artery ligation. These treatment approaches have significant morbidity and mortality, are mutilating and often not effective in the control of hemorrhage ,,.
Angiographic localization of the bleeding vessel and their transcatheter occlusion by embolic material has been successfully used to control bleeding in various anatomic locations and etiologies. Recent evidence suggests that this treatment-method may be safe and effective in treating selected patients with vaginal bleeding ,,,. Many advanced cases of carcinoma of the cervix develop profuse vaginal bleeding during the course of illness. It often remains intractable to hemostatic radiotherapy .
Transcatheter embolization may be a viable management alternative in patients who are sick, have coexisting debilitating medical illness, in whom surgery is contra-indicated or high risk, and in emergency situations where quick control of life-threatening hemorrhage is vital in a hemodynamically unstable patient. In order to validate the above issues, we have studied the efficacy , safety and short-term result of uterine artery embolization (UAE) in treating a group of patients with vaginal bleeding in elective and emergency situations.
| Materials and Methods|| |
Eighteen patients with an uncontrolled, vaginal bleeding due to an organic gynecologic or obstetric cause were included in this study. The underlying clinical indications included an advanced carcinoma of the cervix in 11 (Group 1), uterine fibroid in three, (Group 2), uterine AVM in three (Group 3) and placenta accrete in one patient (Group 4). The neab age of the patients was 40 (range, 18 to 62) years. The pre-procedure work-up included an obstetric and gynecologic history and physical examination, as well as a duplex sonographic examination of the uterus in elective cases. An informed, written consent was obtained in each patient.
All the procedures were performed under local anesthesia. We used the transfemoral approach in all patients. At the beginning of the procedure, a 6-French sheath with an indwelling valve was placed in the femoral artery in the groin by percutaneous technique. Heparin, 100 IU/kg body weight, was given parenterally at this stage. A contreol pelvic IA-DSA was obtained by injecting a 25 ml bolus of sn iodinated contrast medium (Omnipaque, Nycomed) at 14 ml/sec from a pigtail catheter positioned above the aortic bifurcation. This helped to identify the uterine arteries and vascular supply to the target area. The target uterine artery was cannulated from contralateral route via anterior division of the internal iliac artery by pre-shaped catheters. We used a Picard, Cobra or a UAE catheter (Cook, USA) for this purpose. In addition, a micro catheter (Tracker 18, Boston-Scientific, USA) was used for super-selective catherization of the uterine artery in three patients. This was introduced through a diagnostic 5-French catheter.
Based on the clinical indication, the need for unilateral or bilateral UAE was decided. We used the contralateral femoral approach for selective cannulation of the uterine artery in all patients. As a result, the patients who underwent bilateral UAE had an arterial sheath inserted in each groin before the injection of heparin. The decision on which side to embolize first was based on the review of the control IA-DSA. We treated the side with dominant supply to the target area first. We used polyvinyl alcohol foam particles, 300-500 microns in size, for embolization. At the end of the procedure, a check IA-DSA was obtained to asses the adequacy of embolization.
At the end of the procedure, the sheath was removed and hemostasis was obtained by manual compression. These patients were treated by medication by analgesic and anti-inflammatory drugs in the 24-72 hour period after embolization. Care was taken to exclude any evidence of infection in the post-operative period.
The follow-up was done by clinical and duplex sonographic evaluation at one week and month, and then once every three months.
| Results|| |
A total of 20 procedures were performed in 18 patients. Among them, 32 vessels were embolized. Two patients with a uterine AVM underwent two procedures each. All procedures were technically and clinically successful. No major complications were encountered. Four patients developed a self-limiting post-embolization syndrome, characterized by mild fever and leucocytosis. They responded well to analgesic therapy. One patient developed a groin hematoma that resolved with conservative management. All patients had mild to moderate pelvic pain in the post-embolization period which lasted for 24-72 hours and responded well to medication. There were no permanent sequale of UAE. The overall follow-up period ranged between 2-17 (mean, 7) months.
Group 1 included 11 patients with an advanced carcinoma of the cervix. Among them, three patients underwent UAE in presence of gross active bleeding and systemic hypotension. Abnormal angiographic abnormalities included arterial hypertrophy, contrast extravasation, pseudoaneurysm formation, arteriovenous shunting, tumore vasculature and encasement [Figure - 1]. Six patients underwent a unilateral UAE because the angiographic findings were predominantly located on one side, on the right in five and on the left in two of them. The remaining five patients underwent bilateral UAE because the angiographic signs were seen on both sides. The embolization was successful in controlling the hemorrhage in all of them. These patients were subsequently treated with radiotherapy as per their original treatment protocol.
Group 2 included three patients with uterine fibroids [Figure - 2]. Among them, two patients had co-existing hypertension and an impaired renal function. One patient had gross, active bleeding and had a systolic pressure of 70-80 mm Hg at the time of UAE. All of them underwent successful bilateral UAE. All these patients had menorrhagia. In addition, two of them also had pressure symptoms. After UAE, bleeding was controlled in all and the pressure symptoms also showed an improvement in both patients. Two patients, in whom follow-up duplex sonogram was available, showed an appreciable decrease in the size of the fibroids during follow-up. We did not perform quantitative assessment of the size and volume of the fibroids due to non-uniformity of the images and small sample size.
Group 3 included three patients with a uterine AVM. Among them, one patient was treated in hemodynamic unstable condition with persistent hypotension, despite multiple blood transfusions and intravenous fluid and drug
support, secondary to persistent severe bleeding following an invasive gynecologic instrumentation elsewhere. The other two patients were underwent elective procedures. In one patient, the AVM was fed by a single artery and had a single draining vein. This was successfully occluded with particles with complete obliteration of the nidus [Figure - 3]. The remaining two patients had a diffuse AVM with multiple feeders and involving the entire uterus. Both of them underwent bilateral UAE. During follow-up, both patients had recurrence of menorrhagia at four and seven months respectively. Repeat successful bilateral UAE was performed in both of them. Despite the presence of a small residual AVM, the bleeding stopped and the patients remained free of bleeding on follow-up at three and six months respectively. The latter patient developed amenorrhea after UAE for six months when she was lost to follow-up. The other two patients had normal menstrual cycles at two and three months respectively after UAE.
Group 4 included one patient of placenta accrete [Figure - 4]. She had prolonged vaginal bleeding after delivery. She was successfully treated with UAE. The abnormal vasculature was angiographically localized and occluded selectively. The bleeding stopped completely after the procedure.
| Discussion|| |
Our results confirm that UAE is safe and effective in the control of vaginal hemorrhage, irrespective of its etiology, the hemodynamic status of the patient and the timing of the procedure. The utility of UAE in treating vaginal bleeding in various gynecologic and obstetric conditions has not been previously reported in India. We have observed that UAE is feasible in emergency situations and is time-efficient. It has many advantages, including rapid control of bleeding, less invasiveness, reduced morbidity, mortality and hospital stay, lower incidence of re-bleed and reduced morbidity, mortality and hospital stay, lower incidence of re-bleed and reduced overall cost. In addition, it has the ability to preserve fertility.
Infiltrating neoplasms of the genital tract can cause intractable, hemorrhage, refractory to management by conventional methods ,,,,10]. At angiography, the bleeding sites can be difficult to localize because these tumors recruit supply from various branches of the internal iliac artery. Direct angiographic sign of bleeding is manifested as contrast extravasation and is not commonly seen. Indirect signs are more common and include tumor vascularity, pseudoaneurysm and A-V shunts. These lesions are best treated by particulate embolization. The results are often dramatic, provided that care is taken to identify all the tumor supply and a selective distal embolization of the target vessels is performed.
Yamashita et al  reported the results of UAE in 17 patients with vaginal bleeding caused by malignant neoplasms. Among them, 12 patients had a primary carcinoma of the cervix and five had a recurrent malignant lesion in the cervix. The bleeding was temporarily controlled in all but recurred in seven patients. Re-embolization was done in three patients. There were two complications. In our study, the hemorrhage was effectively controlled in all the patients, without complication. There was no recurrence of bleeding. We feel that the reason for continued control of bleeding after embolization in our patients was related to the choice of the embolizing agent. We used polyvinyl alcohol foam particles for embolization that produce a quasi-permanent result. The higher incidence of recurrence of bleeding in the study by Yamashita et al  was probably related to their selection of absorbable gelatin sponge as the embolization material. The latter causes a temporary occlusion and is prone to early recanalization.
Some patients in the present study complained of pelvic pain after embolization and had a transient post-embolization syndrome, characterized by fever and leucocytosis. This usually lasts for 24-72 hours and is relieved by analgesic therapy. Despite control of bleeding, further medical treatment for the underlying malignant lesion must be continued, as required. Embolization may also have an anti-tumor effect. This concept has been validated in renal cell carcinoma but has not been assessed in the setting of carcinoma of the cervix. Further studies to assess the immune response to tumor embolization in genital tract malignancies are necessary to define its role in the management of these patients.
Uterine myomata are the most common benign tumors of the female genital tract. Hemorrhage is the most frequent complication and is usually associated with submucosal and interstitial myomata. The resultant increase in the size of the uterus also causes pain, heaviness and discomfort. A number of therapies are available for the treatment of these patients, including the traditional surgical hysterectomy, myomectomy and newer less invasive techniques, such as hysteroscopic resection of intramural and subserol fibroids , ,,,. The utilization of UAE as a primary therapy for the treatment of fibroids was first reported by Ravina et al in 1995 . These authors treated 16 patients. At a mean follow-up of 20 months, symptoms resolved in 11 of the 16, three patients had a partial improvement and there were two failures. Goodwin et al  subsequently reported on the results of this treatment in 11 patients. Bilateral embolization was successful in 10 and unilateral embolization was successful in the remaining one patient. One patient developed endometritis and pyometrium within three weeks, and required hysterectomy. Of the remaining 10 patients, symptomatic improvement was seen in eight. The mean decrease in uterine volume was 40% and dominant fibroid volume decreased by 60-65%. Bradley and colleagues  reported the results of this therapy in eight patients with large fibroids. Menorrhagia was controlled in 4/5 patients and pressure symptoms improved in all. They reported that all patients experienced an intermittent, non-purulent vaginal discharge, presumed to be necrotic fibroid tissue debris. One patient reported a transcervical passage of a substantial portion of a submucosal fibroid six weeks after the procedure. Spies et al  reported 61 patients who were treated by UAE in a 16-month period. Of them, 60 procedures were technically successful. Menstrual bleeding was improved in 89% while pain and pressure symptoms were improved in 96% patients. Minor complications were seen in five patients. The impact of UAE on the resumption of menses and ovarian function, and also on health-related quality of life before and after therapy has been evaluated ,,.
In patients with uterine fibroids, UAE avoids surgery and also helps to preserve the reproductive function. This treatment helps to control the bleeding in most patients. However, a small number of patients do not improve with this treatment. The reasons for the failure of UAE to control hemorrhage are not well understood in such patients. It has been reported that the presence of fibroid blood supply from other sources, such as the ovarian artery or blood supply parasitized from other pelvic branches may be responsible for the continued bleeding . It has been observed that there is an appreciable reduction in the volume of the tumor within the first three months of embolization in over half the patients who are treated by this method. The procedure is generally safe in expert hands. The most common complication is the pelvic pain after successful embolization. This is probably caused by ischemia, is usually self-limiting and subsidies in 24-72 hours. It may require analgesic and anti-inflammatory therapy and can occasionally be intense.
Uterine AVM is rare but an extremely dangerous cause of vaginal bleeding ,. Attempts to surgically ligate it are generally unsuccessful because of rapid recruitment of collateral vessels. The original use of transcatheter embolization in this condition was described in the intraoperative setting. In this case, Gelfoam was used in conjunction with arterial ligation to successfully stop the hemorrhage. Of the nine successful cases reported cases in the iterature, as many as four have conceived during follow-up, proving the efficacy and superiority of this treatment ,. The goal of therapy should be superselective occlusion of the nidus of the feeder vessels by particulate material. Among the reported cases, there was no major complication. In this study, we treated three such patients with technical and clinical success, without complication. It must be remembered that embolization in presence of AVM is usually a palliative treatment-method and may need multiple sittings for effective control of the abnormality, as demonstrated in our cases.
Obstetric hemorrhage is a significant cause of maternal morbidity and mortality. Potential causes include birth canal laceration, abnormal placentation, retained products of conception, uterine atony and uterine rupture . The primary management involves manual exploration and curettage for the retained products, uterine massage, local and parenteral medications, suturing of lacerations, drainage of hematoma and vaginal packing. Bilateral internal iliac artery ligation has been advocated in patients who fail to respond to the above-mentioned means. But, this is generally ineffective in controlling the hemorrhage in this clinical setting . Abnormal placentation is an uncommon cause of this hemorrhage . Placenta accrete is an abnormally firm attachment of placental villi to the uterine wall with absence of the normal intervening deciduas basalis and fibrinoid layer of Nitabuch. Three variants of this condition are recognized. The reported incidence varies widely, from 1 in 540 to 1 in 70,000 deliveries, with an average incidence of approximately 1 in 7,000. The incidence is highest among women with placenta previa or a previous caesarean section. Other risk factors include an advanced maternal age, multiparity and previous uterine curettage . It is possible to demonstrate the abnormal vascular supply by angiography. Our case demonstrates that UAE can be used as an effective management alternative in this rare cause of vaginal hemorrhage.
Complications of UAE are generally uncommon and can be related to the puncture site, embolization site and general ,,,,,,,,,,,. Pelvic pain, probably caused by ischemia, is the most common compliant after embolization. This is usually self-limiting and disappears within 24-72 hours. It can occasionally be intense. Pelvic infection can occur after successful embolization and should be looked for in suspected cases. Those who have been previously treated by radiotherapy or elderly patients with atherosclerosis are at a higher risk to develop ischemic complications. Vesico-vaginal fistula formation after embolization has been reported in this setting.
We conclude that transcatheter embolization is safe and effective in treating vaginal hemorrhage, irrespective of the etiology. It is fast emerging as the preferred treatment method in this group of patients. Further refinements in the techniques and hardware will help in minimizing non-target embolization and wider acceptance among the concerned sub-specialists. Further studies are warranted to assess the issue of tumor immunity after transcatheter embolization of genital tract neoplasms.
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Department of cardiovascular Radiology, All India Institute of Medical Sciences, New Delhi-110029
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]