Is pregnancy safe after uterine artery embolisation?

Abstract

Uterine artery embolisation (UAE) was first described as a treatment for symptomatic leiomyomas in 1995 by Ravina et al. 1 and has since become established as a valid nonsurgical management option for a woman wishing to conserve her uterus. It involves targeted disruption to the blood supply of the uterus using embolic material such as polyvinyl alcohol particles and subsequent necrosis of the fibroids. However, although there has been great interest in the use of this technique in women wishing to preserve their fertility, it is unclear whether subsequent pregnancy is safe. This uncertainty relates to the relative dearth of published data compounded by the lack of adequate controls; women undergoing UAE tend to have larger, more symptomatic fibroids in comparison with the usual control groups, who are frequently derived from series of women with infertility. 2 To date, over 200 pregnancies following UAE have been reported in the literature. 3 Early pregnancy, in particular, appears to be adversely affected with an increased spontaneous miscarriage rate over the general population (38.5 versus 10-15%) 3 and over other women with uterine fibroids matched for age and fibroid location (35.2 versus 16.5%). 2 A recent systematic review compared pregnancies after UAE with pregnancies in women with untreated fibroids, data informing the review were generally from small retrospective, uncontrolled series. The meta-analysis reported that women who had previously had UAE were more likely to be delivered by caesarean section (66 versus 48.5%; odds ratio [OR] 2.1; 95% CI 1.4-2.9) and were six times more likely to experience postpartum haemorrhage (PPH) (13.9 versus 2.5%; OR 6.4; 95% CI 3.5-11.7). Rates of preterm delivery (14 versus 16%; OR 0.9; 95% CI 0.5-1.5), fetal growth restriction (7.3 versus 11.7%; OR 0.6; 95% CI 0.3-1.3) and malpresentation (10.4 versus 13%; OR 0.8; 95% CI 0.4-1.5) were similar. 2 Despite the lack of large, controlled prospective series or randomised studies, the observed increase in caesarean delivery and, more notably, in PPH raises concerns over the safety of pregnancy after UAE.The cause of increased blood loss after delivery is unclear from the reported data. However, it has been suggested that this is related to the higher caesarean section rate or to inherent impaired contraction of the fibroid uterus. 2 Of note, however, are the increasing number of case reports in the literature of placenta accreta complicating these pregnancies. [4][5][6][7] We have recently experienced an incident of placenta accreta in a 34-year-old general practitioner who underwent UAE of a 15 · 6-cm posterior wall leiomyoma in 2007, which was subsequently passed per vaginam. At hysteroscopy, performed for the investigation of primary infertility, a large crater was noted in the posterior uterine wall. It was felt that this was likely to prevent spontaneous conception. She later presented with a positive pregnancy test and ultrasound showed a singleton intrauterine pregnancy. She was monitored closely throughout the pr...

Uterine Artery Embolization for Uterine Arteriovenous Malformation Is Associated With Placental Abnormalities in the Subsequent Pregnancy: Two Cases Report

“…The mechanism of placental abnormalities has not been reported in detail but it may be due to damage of the endometrium by UAE for leiomyoma. The potential explanation for abnormal placentation following UAE for leiomyoma is the endometrial ischaemia which would adversely affect the quality of the endometrium and the myometrial deficit left after the expulsion of the infarcted leiomyoma, which occurs in up to 10% of women undergoing UAE for symptomatic uterine leiomyoma 16) . Implantation at such a site could be assumed to be associated with a higher incidence of placenta accreta, particularly if minimal myometrium remains 16) .…”

“…The potential explanation for abnormal placentation following UAE for leiomyoma is the endometrial ischaemia which would adversely affect the quality of the endometrium and the myometrial deficit left after the expulsion of the infarcted leiomyoma, which occurs in up to 10% of women undergoing UAE for symptomatic uterine leiomyoma 16) . Implantation at such a site could be assumed to be associated with a higher incidence of placenta accreta, particularly if minimal myometrium remains 16) . Direct implantation of a placenta onto a leiomyoma or focal myometrial deficit has been described by two groups in published case reports both of which were diagnosed after unexpected complications occurred during delivery 16) .…”

“…Implantation at such a site could be assumed to be associated with a higher incidence of placenta accreta, particularly if minimal myometrium remains 16) . Direct implantation of a placenta onto a leiomyoma or focal myometrial deficit has been described by two groups in published case reports both of which were diagnosed after unexpected complications occurred during delivery 16) . Hystero scopy revealed that the endometrium after UAE for symptomatic leiomyoma had a necrotic area, and histological analysis during hysteroscopy showed that about 5% of the endometrium after UAE was hypoproliferative 19) .…”

“…C. Transabdominal ultrasound shows the site of placentation was on the posterior wall and was the different site to the area of AVM. PREGNANCY AFTER UAE FOR SYMPTOMATIC AVM ery 16) . On the other hand among the patients who underwent UAE for AVM, the evidences of pregnancy after UAE for AVM are much less than those after UAE for leiomyoma.…”

A comparative study between the efficacy of local intra-myometrial injection of vasopressin and octreotide acetate, in reducing blood loss during myomectomy

“…Although uterine artery embolization is now an effective way for managing symptomatic uterine myomas but its effect on future conception remains unclear. 3 Myomectomy is an invasive surgical procedure, may be performed abdominally, laparoscopically or by robotic method. It can be associated with many intraoperative and postoperative complications including excessive haemorrhage, pyrexia, visceral damage, thromboembolism, conversion to hysterectomy, blood transfusions, scar dehiscence in future pregnancy and many others.…”