Uterine Artery Embolisation for the Treatment of Large Submucosal Fibroid (Clinical Case)

C l i n M e d International Library Citation: Dobrokhotova J, Grishin I, Khachatryan A, Causeva O, Zlatovratsky A, et al. (2015) Uterine Artery Embolisation for the Treatment of Large Submucosal Fibroid (Clinical Case). Obstet Gynecol Cases Rev 2:023 Received: November 04, 2014: Accepted: February 06, 2015: Published: February 09, 2015 Copyright: © 2015 Dobrokhotova J. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Dobrokhotova et al. Obstet Gynecol cases Rev 2015, 2:1


Introduction and Background
Uterine Artery Embolization (UAE) is a uterine-sparing procedure that is used for the treatment of uterine fibroids.The indications for UAE include all symptomatic fibroids i.e. fibroids accompanied with menometrorrhagia, pain, heaviness, frequent urination, dyspareunia, etc., as well as rapidly growing fibroids, and large fibroids [1][2][3][4][5].Spies say that the indications for UAE include virtually all the indications for the surgical treatment for the uterine fibroids [6].
The narrow-stalked, pedunculated subserous and submucosal fibroids come under the contraindications for UAE as in the former case the risk of fibroid expulsion into the abdominal cavity after endovascular intervention is high; whereas an alternative of minimally invasive hysteroscopic resection is available in the latter case 1 .It is sensible to carry out UAE with a subsequent myomectomy for the treatment of most uterine fibroids, when one of the tumours has a subserous or submucosal position [7].
Based on the above-stated case, UAE is proved clinically appealing and effective procedure for the treatment of large submucosal uterine fibroids.

ISSN: 2377-9004
The diagnosis of submucous leiomyoma of uterus with anemia of moderate degree was established based on the anamnesis data, clinical blood analysis, ultrasound investigation, and the clinical picture.Despite the large size of the fibroid, its submucosal position, a bright clinical picture, and taking into consideration patient's reproductive age, it was decided to refrain from hysterectomy.Carrying out its resection through a resectoscope was not an option as the fibroid was large.Thus, a decision was made to perform uterine artery embolization.
Arteriography and uterine artery embolization were performed in the radio-endovascular surgery department of N.I.Pirogov City Clinical Hospital No.1.Blood transfusion with 323mLs of erythrocyte suspension was carried out to the patient.Antibacterial, antiinflammatory, and analgesic medicines were administered along with the infusion therapy.An ultrasound investigation was carried out after UAE.It showed increased size of the body of the uterus, relatively corresponding to 15-16 weeks of pregnancy (13.5cm×9.3cm×10.9cm)and was shown as avascular on the Color Doppler scan.
Under our observation, the patient was discharged from the hospital on the 8 th day.The patient was provided with directions regarding the further continuation of treatment of her anemia by keeping the blood hemoglobin level under control.She was asked to carry out planned ultrasound investigations in the period of 1, 3, 6, and 12 months.
Three months later a recurrent hospitalization in N.I.Pirogov City Clinical Hospital No.1 was followed due to a heavy bloody discharge from the genital tract.The patient complained of two heavy menstrual periods after UAE.According to the ultrasound investigation of the organs of lesser pelvis, the submucosal fibroid was descended to the lower third of the uterus.This time it was 10.5cm×6.5cm×7.9cm in size.Intranodular and perinodular blood flow were well pronounced on the Colour Doppler scan (Figure 1).Gynecological Investigations: the cervix was round in shape, narrow with no hypertrophy.External os of the cervix measured between 3 and 4cm.There was observed a bloody discharge through the cervical canal.Bimanual vaginal examination with abdominal palpation revealed the uterus to be in the anteflexed position.The body of the uterus was balloon shaped.It was increased in size, relatively corresponding to 11-12 weeks of pregnancy.It was slightly dense and painless on palpation.Fornices of the vagina were deep and empty.There was no infiltration to the parametrium.
After taking into consideration the clinical picture and ultrasound investigation of the lesser pelvis, including the Colour Doppler scan that marked well pronounced intranodular and perinodular blood flow, a decision was made to perform UAE for the second time.Arteriography and uterine artery embolization were performed in the radio-endovascular surgery department of N.I.Pirogov City Clinical Hospital No.1.An ultrasound investigation showed the uterus to be 6.2cm×3.8cm×5.9cm in size.A wide-stalked tumour mass of heterogeneous echogenicity (12.0cm×7.0cm×8.6cm)had Gynecological Investigations revealed narrow cervix.External os of the cervix measured between 3 and 4cm.The lower edge of the fibroid was soft on palpation.There was observed a bloody discharge through the cervical canal.Bimanual vaginal examination with abdominal palpation revealed the uterus to be increased in size, relatively corresponding to 11-12 weeks of pregnancy.
After taking into consideration the large size of the fibroid and its soft consistency, a decision was made to carry out transcervical myomectomy.Transcervical myomectomy with hysteroscopy was performed on the 7 th day after UAE.Blood loss was about 50mLs (Figure 2).
According to the postoperative ultrasound investigation, the uterus measured 6.0cm×4.4cm×4.8cm.Its borders were regular with no evidence of myomata.Endometrium was 0.8 cm thick with regular and clear borders.
The condition of the patient was satisfactory.Under our observation, the patient was discharged from the hospital on the 10 th day.The patient was provided with directions regarding the further continuation of treatment of her anemia by keeping the blood hemoglobin level under control.She was asked to carry out planned ultrasound investigations in the period of 1, 3, 6, and 12 months.
One month after the transcervical myomectomy, an ultrasound investigation of the organs of lesser pelvis was carried out as it had been planned.The uterus measured 6.7cm×4.2cm×5.6cm.Its borders were regular, but the myometrium was heterogeneous.No evidence of myomata.A hypoechoic tumour bed (2.3cm×0.8cm×1.2cm)was revealed on the middle third of posterior wall of the uterus.Thickness of endometrium was 0.5cm on the upper third and 0.2cm on the lower third (Figure 3).

Discussion
UAE is successfully used in the treatment of most uterine fibroids [1].A number of researches do not promote to use UAE technique when the uterine fibroid has submucosal position, considering the conservative transcervical myomectomy to be more accessible [8].As the authors mention [8][9][10], 5% of the patients with submucosal uterine fibroid may face both early as well as late transvaginal expulsion.In most cases, the detaching fibroid expulses in the early days once the symptoms appear.
In some observations noted the myometrial migration of submucosal fibroids to be accompanied by their subsequent volume reduction or fibrosis and followed by their volume retention in absence of clinical manifestations of the uterine fibroid [3,7].In these cases it becomes possible to perform resectoscopy, however early it was impossible because of the size of fibroids.
However, the indications for UAE are considerably more in number than those for the surgical treatment for the uterine fibroids; besides the endovascular intervention eliminates the need of a hysterectomy in patient, avoiding the use of anaesthesia, surgical trauma, as well as severe early and late postoperative complications in case of surgical treatment [2,11].Thus UAE can be carried out among women with submucosal uterine fibroid of type 0, I, and II [12] as an alternative to hysterectomy, as well as when the transcervical myomectomy cannot be carried out immediately [13,14].UAE is the method of choice unlike the surgical interventions especially among patients with high surgical and anesthesiological risk [5,12].
According to the literature in recent years, UAE doesn't effect significant on menstrual function and fertility among women.Тrореаnо et al. [15,16] established no effect UAE on the level of follicle-stimulating hormone (FSH), estradiol, the number of antral follicles and ovarian volume within 1 year of observation for women after UAE [15,16].Kim et al. evaluated the effectiveness of UAE in young women taking into account peculiarities of blood supply to the uterus and ovaries describe three clinical cases of amenorrhea in patients with uterus-ovarian anastomoses [17].
Most researchers noted a significant success in the treatment of UAE of uterine fibroids in patients interested in the reproductive function [18][19][20].Walker et al published data on 56 pregnancies that ended in the birth of 33 (58,9%) cases [21].

Conclusion
According to Marret et al. such complications as endometritis and pyometra may occur due to a late fibroid expulsion [10].
Although in this particular case, the fibroid was trapped in the uterus; and we do not count it as a complication.UAE can be used as a part of the overall treatment that a patient needs for the uterine fibroids, thereby called as UAE-assisted transcervical myomectomy.This case illustrates the uterine-sparing importance of UAE in patients with large and submucosal uterine fibroid.Thus, as an alternative to a hysterectomy, it is sensible and effective to perform uterine artery embolisation for the treatment of large submucosal fibroid among women that are still in their reproductive age with subsequent myomectomy possible.

Figure 1 :
Figure 1: Ultrasound investigation of the uterus and uterine fibroid after using UAE for the first time

Figure 2 :
Figure 2: Gross appearance of the submucosal fibroid

Figure 3 :
Figure 3: Ultrasound investigation of the uterus myomectomy (The arrow points to the tumour bed)