The trial at the Royal Surrey County Hospital and London Clinic represents the largest world series of pregnancies following Uterine Artery Embolisation (UAE) (1,3,7). It is important to remember the population group in our trial is atypical i.e. older and with other additional risk factors compared with the general obstetric population. Most of our patients had been rejected for surgery, many had very large fibroid masses and they were an older age group, 37.2 years average (Walker Bratby 2007(1)). 14 patients with successful pregnancies had only been offered hysterectomy.
In the series of 2,000 patients we have had 105 pregnancies and the results of these pregnancies are summarised in Table 1. As of February 2010
Pregnancies post fibroid embolisation | 105 |
Successful deliveries | 65 |
Ongoing pregnancies | 2 |
Miscarriages | 27 - Rate 25% |
Ectopic pregnancy | 1 |
Abortion (unwanted pregnancy) | 8 |
Baby died through knot in cord | 1 |
Still birth 37 weeks | 1 |
However, further to the above the total is now 76 successful completed pregnancies after UAE. Data under current analysis.
Miscarriage and complication rates: The spontaneous miscarriage rate and other complications outlined in Table 1 are no higher than would be expected allowing for age and fibroid status.
Subsequently we updated our results(1) analysing 67 pregnancies (our miscarriage rate was 22%). With regard to miscarriage there has been some controversy about rates following UAE.
Some concerns have been expressed with regard to pregnancy and miscarriage rates following fibroid embolisation. The problem is that early reviews of pregnancy outcomes were based on old data when the technique was evolving. There has only been one randomised control trial with myomectomy versus embolisatiom (Mara et al) from the Czech Republic but the numbers were very small and in addition it is obvious from the results that radiologists inexperienced in the technique of embolisation were performing the embolisations. This is evinced by the fact that there is an unacceptably high rate of failure to infarct the dominant fibroid at 30% i.e. nearly one third of patients. You would expect this percentage to be ½-1% at most. In addition there were a very high number of unilateral embolisations which usually do not work. They changed the particle size during the series (obviously believing that they wre using the wrong sized particles and, in addition, they used a type of particle which we would not recommend). The FEMME Study which looked at this trial reported 'borderline significant and the study was not powered for any outcomes' but even that study did not take into account the obvious lack of experience of the radiologists performing the procedure and the poor technical embolisation results.
There has been one other article by Homer and Saridogan which also suggested higher rates. However the article is again flawed; for example they quote our miscarriage rate as as being 34% whereas in reality if they had read the article from 2007 they would see that we were reporting a miscarriage rate of 22%. In other words the results are misquoted. In addition, our early series were performing embolisations on patients with very difficult fibroids referred when gynaecologists did not wish to perform myomectomy because the cases were too difficult; for example 14 of our patients who has successful pregnancies had only been offered hysterectomy. We had an average age which was high i.e. 37.5(1) years and we know that miscarriage rates and obstetric problems increase with age. We were treating often very large fibroids. Despite this our results were acceptable and not above matched groups. We have now had 76 successful completed pregnancies and we are currently analysing our pregnancy data and, in particular, our more recent results when our patients have been less extreme in terms of their fibroid disease and in a situation where there has been an increase in experience, expertise and an improvement in technique. If we look at recent publications on pregnancy rates (McLucas; Firovznia at al; Pisco et al) the results have been good (see as an example table below).
Pisco et al: Fertility and Sterility 2010
74 women
The fact is that pregnancy rates and miscarriage rates will be hugely influenced by age and severity of fibroid disease. There is no doubt that patients with more difficult disease tend to get referred for fibroid embolisation.
Thus our research shows that it is scientifically invalid as is often stated by various bodies and in areas of the literature to claim that no patient wishing to become pregnant should have fibroid embolisation. It should be noted that a number of our patients who had had failed myomectomies had successful pregnancies following UFE and some patients who had UFE required myomectomy.
1. Walker WJ, Bratby . Magnetic Resonance Imaging (MRI) Analysis of Fibroid Location in Women Achieving Pregnancy After Uterine Artery Embolisation. Cardiovascular interventional Radiology - August 2007
3. Walker WJ, McDowell SJ. Pregnancy after uterine artery embolisation for leiomyomata: at series of 56 completed pregnancies. American Journal of Gynecology & Obstetrics November 2006 195(5) 1266-71
7. TT Carpenter, WJ Walker. Pregnancy following uterine artery embolisation for symptomatic fibroids: a series of 26 completed pregnancies. British Journal of Obstetrics and Gynaecology, 112, pp321-325 March 2005.
Our results in 56 pregnancies published July 2006 in the American Journal of Obstetrics and Gynecology can be downloaded from the menu link to the left: 'Pregnancy-Paper'
Our subsequently updated series Walker & Bratby(1) can be accessed on the internet.
Pregnancy after uterine artery
embolization for leiomyomata: A series of 56
completed pregnancies Woodruff 3. Walker,
FRCR,a,* Simon 3. McDowell, MBCHBb
Departments of Radiology and Obstetrics and
Gynaecology, The Royal Surrey County
Hospital, Guildford, UK Received for
publication November 4, 2005; revised April
5, 2006; accepted April 17, 2006
Uterine artery embolization. Uterine fibroid
embolization. Fibroids. Leiomyomata
Pregnancy Objective:
This study was undertaken to evaluate the incidence and outcome of pregnancies after uterine artery embolization (UAE) for symptomatic uterine fibroids.
Study design: A retrospective analysis of all pregnancies after UAE by a single interventional radiologist.
Results: 56 completed pregnancies were
identified in approximately 1200 women after
UAE. 108 patients were attempting to become
pregnant and 33 of these became pregnant.
33 (58.9%) of the 56 pregnancies had
successful outcomes.
6 (18.2%) of these were premature.
17 (30.4%) pregnancies miscarried.
There were 3 terminations, 2 stillbirths,
and 1 ectopic pregnancy. Of the 33
deliveries, 24 (72.7%) were delivered by
caesarean section. There were 13 elective
sections and the indication for nine was
fibroids.
There were 6 cases of postpartum haemorrhage
(18.2%).
Conclusion: Compared with the general
obstetric population, there is a significant
increase in delivery by caesarean section
and an increase in pre-term delivery,
postpartum haemorrhage, miscarriage, and
lower pregnancy rates. When taking into
account the demographics of the study
population, these results can be partly
explained. There were no other obstetric
risk identified.
© 2006 Mosby, Inc. All rights reserved.
Uterine
artery embolization (UAE) is a recognized
treatment for symptomatic uterine fibroids,
as described in numerous reports since 1995.1-5
Information on its effects on fertility and
infertility, however, is limited. Advice
often given to women with uterine fibroids
who desire to retain fertility is to avoid
UAE.
Pregnancy after fibroids embolization has been described in
the literature in the form of case reports,
and a review article.6 Some retrospective
series7-9, and one retrospective cohort study
comparing UAE with laparoscopic myomectomy.10
In December 1996, a prospective
observational study was established to
evaluate UAE in the management of
symptomatic uterine fibroids.4 Most of the
cases have been carried out at the Royal
Surrey County Hospital with a minority
performed privately at The London Clinic.
All procedures were performed by a single
interventional radiologist (Woodruff J.
Walker).
Pregnancy after embolisation has been reported previously from this ongoing study, with a smaller population.11 To our knowledge 60 women have successfully achieved pregnancy after UAE. This article describes the outcomes of those pregnancies.
During the period December 1996 to May 2005 approximately 1200 women underwent bilateral UAE as described in our previous publication.4 Ethical committee approval was obtained before December 1996. All patients after embolization were sent a screening questionnaire. Information requested included: actively or previously attempted conception, not attempting conception, use of contraceptives, fertility problems before or after embolization, and other treatments offered by their primary gynecologist. If no reply was forthcoming an additional questionnaire was sent out at 2 months and if still no response, the patients were telephoned and the form filled out by a research assistant. All these initial forms were either returned or discussed over the telephone if incomplete or unreturned. An additional questionnaire was sent to these women seeking information on pregnancy outcome, age at delivery, complications of antenatal, intrapartum and postpartum periods, mode of delivery, reason for assisted delivery, other surgical procedures, birth weight, and length of lochia. Of these, 3 forms remained incomplete from the miscarriage group. Sixty pregnancies were identified in 48 women. Four of these pregnancies were ongoing, therefore excluded from further evaluation. Several women had been pregnant twice, one 3 times, and one 4 times. The women were from multiple locations throughout the United Kingdom. In complicated cases, reference wasmade to the patients' medical records after their consent.
Complication | No. | (% Rate) |
Rate from literature (General obstetric population) |
Miscarriage | 17 | (30.4%) | 10% - 15% 21 |
Morning Sickness | 20 | (60.6%) | 50% - 70% 22 |
First-trimester bleeding | 8 | (24.2%) | 25% 23 |
Second-trimester bleeding | 5 | (15.2%) | NA |
Third-trimester bleeding | 4 | (12.1%) | 17.6% 24 |
Placenta previa | 1 | (3.0%) | 0.4% 25 |
Proteinuric hypertension | 2 | (6.1%) | 8% - 18% 26 |
Premature rupture of membranes |
3 | (9.1%) | 2% - 3.5% |
IUGR | 1 | (3.0%) | 5% |
Preterm delivery | 6 | (18.2%) | 5% - 10% 28 |
Postpartum haemorrhage | 6 | (18.2%) | 5.4% - 13% 19,29 |
From the approximately 1,200 responses, 108 women had been seeking at some time to become pregnant, and 33 of these 108 women became pregnant at least once regardless of outcome. Eighteen women had unintentionally become pregnant; 30.5% of women wishing to become pregnant were successful regardless of outcome, and at least once after embolization. Of the 60 pregnancies, 19 had prior subfertility or infertility investigation, ranging from 18 months to 8 years. Twelve of these went on to have successful pregnancies. There was 1 successful in vitro fertilization (IVF) pregnancy. One other woman postembolization failed to become pregnant with IVF, but was successful later without IVF. 35 pregnancies were first conceptions. There were 33 (58.9%) successful live births in 27 women. Twenty-seven (81.8%) of the 56 pregnancies delivered at term ( greater than or equal to R37 weeks’ gestation), and 6 18.2%) premature (<37 weeks). There were 17 (30.4%) miscarriages, 3 (5.4%) terminations, 2 (3.6%) stillbirths, and 1 (1.8%) tubal ectopic.
Many of the patients had treatment for fibroids before and/or after embolization. Preembolization, 2 had previous open myomectomy, 2 had hysteroscopic resections, and 3 had laser ablation. Two had undergone 'combined' procedures. This consisted of UAE before myomectomy in the same day and which aimed to virtually eliminate blood loss and kill any fibroids that would be diffcult to remove surgically. Post embolization, 5 required hysteroscopic resection and 1 required a laparoscopic myomectomy. Of the 27 women with successful pregnancies, 14 had been previously offered hysterectomy as the only treatment option.
The mean age at cessation of all pregnancies was 37.44 (SD 3.90). The mean for the miscarriage group was 38.75 (SD 4.43), and for the successful pregnancies 36.30 (SD 3.34).
Of the miscarriages, 13 were early, or first trimester. One was second trimester (19 weeks), and for 3 cases the gestation at miscarriage was unavailable. In the first trimester miscarriages, 5 had a spontaneous miscarriage and 7 underwent evacuation for retained products of conception (ERPC). One required a second ERPC after developing infection for retained products of conception and a second required syntocinon for abnormal blood loss. The second trimester miscarriage was a 19-week missed miscarriage, which was revealed on ultrasound scan after a cessation in fetal movements. No cause was found for the miscarriage and post mortem examination was normal. This patient required a curettage for excessive vaginal bleeding after delivery.
There were 3 terminations, 2 for social reasons, and 1 at 25 weeks’ gestation for trisomy. 21 The 1 case of ectopic pregnancy was managed by salpingectomy at 6 weeks.
There were 2 stillbirths. The first was at 33 weeks gestation, and was found to have a true knot in the cord. The second was at 37 weeks gestation in a woman who had had a previous successful pregnancy after embolization, delivered by a cesarean. During this subsequent pregnancy she had severe abdominal pain develop at 35 weeks but was not seen by an obsterician until 37 weeks. At emergency cesarean she was found to have a ruptured uterus through her previous cesarian scar.
20 (60.6%) of the successful pregnancies had morning sickness. 8 (24.2%) of the 33 successful pregnancies had first-trimester bleeding, and 5 (15.2%) had second-trimester bleeding. There were 4 cases of third-trimester bleeding. Of these, 2 had major bleeds; one required admission from 29 weeks, and the other had an emergency cesarean for placental abruption.
One woman was found to have a placenta previa. Another 5 had low-lying placentas. These migrated upward before 20 weeks’ gestation.
There were 2 cases of proteinuric hypertension. The first was at 26 weeks gestation.
Treatment was commenced for the HELLP syndrome and the patient had an emergency cesarean section at 27 weeks. The second was at 29 weeks’ gestation and required cesarean section at 33 weeks. There were 4 cases of pregnancy-induced hypertension, none of which required admission to hospital.
There were 3 cases of premature rupture of membranes. The first was at 32 weeks gestation in a patient who had undergone 2 intrauterine fetal blood transfusions, and was subsequently found to have chorioamnioitis. The second was at 33 weeks gestation in a patient who had a septate uterus and activated protein C resistance caused by factor V leiden coagulopathy. She had been treated with low molecular weight heparin. The third occurred at 31 weeks gestation in a first conception. No cause was found and there were no associated factors identified.
There was 1 case of intrauterine growth retardation IUGR) requiring a cesarean section at 33 weeks gestation for impaired uterine artery blood flow. Data for all pregnancy complications are shown in Table I.
Six infants were born prematurely, 2 before 30 weeks gestation. The average premature gestation was 32.17 (SD 3.06) weeks. These cases are described in Table II.
Gestation (weeks) |
Wtkg) | Indication for delivery |
Complications/ treatment |
Mode of Delivery |
34 | 1.86 | SROM, activated protein C resistance |
Jaundice, antibodies | Cesarian |
27 | 0.99 | HELLP | Ventilation, PDA, No ongoing problems |
Cesarian |
32 | 2.18 | Parvovirus/SROM/ Chorioamnioitis |
Hepatosplenomegaly, infection, antibiotics |
Cesarian |
31 | 1.51 | SROM | Oxygen, no ongoing problems |
Vaginal |
33 | 1.65 | PET | Oxygen, feeding tubes | Cesarian |
36 | 1.96 | Abruption | Reuscitation, oxygen | Cesarian |
SROM, Spontaneous rupture of membrane; PET, pre-eclamptic toxaemia.
The mean birth weight for term infants was 3.53 kg (SD 0.63). The mean maternal age at delivery for premature deliveries was 36.83 (SD 4.07).
Gestation (weeks) | Em LSCS/El LSCS | Indication |
38 | EL | Placenta previa |
37 | EL | Fibroids |
37 | EL |
Fibroids/previous
cervical cone biopsy |
39 | EL | Fibroids |
39 | EL | Fibroids |
38 | EL | Fibroids/previous cesarian |
39 | EL | Fibroids |
38 | EL | Fibroids/previous cesarian |
39 | EL | Breech |
39 | EL | Cephalopelvic disproportion |
37 | EL | Fibroids |
40 | EL | Previous cesarian |
38 | EL | Fibroids |
41 | Em | Poor CTG secondary
to true knot in cord |
36 | Em | Placental abruption |
41 | Em | FTP past 2 cm |
42 | Em | FTP past 3 cm |
42 | Em | Face
presentation/obstructed labour |
38 | Em | Malpresentation/fibroids |
33 | Em | PET |
27 | Em | PET |
38 | Em | Fibroids |
34 | Em |
Previous cesarian,
SROM uterine septum, activated protein c resistance |
32 | Em |
Chorioamnionitis,
SROM parvovirus infection |
Em, Emergency; LSCS, Lower segment caesarean section; El, elective; CTG, cardiotocography;
Nine (27.3%) of women with successful outcomes
delivered vaginally and 24 (72.7%) by cesarean section.
Five of the 6 premature deliveries were by
caesarean, therefore of those deliveries at
term (~37 weeks), 19 (70.4%) of 27 were by
cesarean section.
Thirteen (54.2%) of the caesarean sections were
elective, and 11(45.8%) were as an
emergency. Fibroids were the indication for
9 of the 13 elective caesareans. The
emergency caesareans had a variety of
indications.
Of the emergency caesarean sections, 5
attempted vaginal deliveries. One of the
vaginal deliveries required ventouse for
poor maternal effort. Indications for all
caesarean sections are shown in Table III.
There were 5 cases of postpartum
haemorrhage, 2 requiring blood transfusion.
There were no cases of abnormal placentation
other than the previa described previously.
The mean length of lochia was 4.63 weeks.
Two women did not provide details and for 5
women lochia was not yet completed.
There were 2 cases of presumed endometritis
and 1 of postnatal depression.
Pregnancy after uterine artery embolisation
is well documented. There are valid concerns
regarding the effect of fibroids
embolisation on those women wishing to
retain fertility, and on the pregnant
uterus.
The numbers of patients who have become
pregnant after uterine embolisation remains
relatively small, meaning information for
medical staff to convey to prospective
uterine artery embolisation candidates is
limited or incomplete.
A review in 2004 advised that until further
data are available, laparoscopic myomectomy,
open myomectomy, or hysteroscopic resection
constitutes the standard of care in patients
desiring future fertility.6
However, such cases may be difficult,
particularly where there are numerous
interstitial and/or sub mucous fibroids, and
recurrence rates may be higher than 60%.12
Fibroid embolization has the advantage
over myomectomy pre pregancy after
embolisation in that it kills all the
fibroids in one procedure, which then shrink
or, in some cases, are passed vaginally.
Our current series is the largest series to
date of pregnancies after fibroid
embolisation for uterine fibroids. In this
article we do not attempt to compare uterine
artery embolisation with myomectomy, its
object is to present the incidence of
pregnancy after embolisation, outcomes, and
complication rates.
The population in this series is
approximately double of that in the previous
series. 11
The demographics of the population have
remained similar, but with higher numbers of
normal, uncomplicated pregnancies. It is
important to emphasise that the population
involved is not a cohort typical of the
general obstetric population. The mean age
for all pregnancies at cessation was
extremely high at 37.44 years. There are
known associations between fibroids, sub
fertility, pregnancy loss, and pregnancy
complications.
The information for this study was primarily
obtained from patient questionnaires.
Patients had pregnancy care from all over
the United Kingdom, making it difficult to
obtain medical records in all cases. Only in
complicated cases were the medical records
sought out. Optimally, all records should be
perused. If there was confusion in the
questionnaire, patients were telephoned by
an obstetrically trained medical
practitioner.
Also, in the initial questionnaire, women
were not asked if they had a history of sub
fertility, only if they had been attempting
pregnancy or intending to attempt pregnancy.
The reason for this was that most patients
were advised other treatment regimens if
desiring to keep their fertility. Only those
who achieved pregnancy after fibroids
embolisation were sent a second
questionnaire detailing any history of sub
fertility.
From our study other comments relating to
previous infertility, treatment and cause,
cannot be made.
Overall, most pregnancy
complications were within normal ranges for
the general obstetric population. The rate
of miscarriage was high at 30.4%.
The Royal College of Obstetrics and
Gynaecology gives a 10% to 15% risk of
spontaneous miscarriage. Rates of
miscarriage increase 2- to 3-fold over the
age of 40 years.14
The mean age in the miscarriage group was
38.75 years, and the ages ranged from 30 to
50 years. Of our patients who miscarried, 7
were older than 40 years, and all but 2 were
older than 35 years. The rates of
miscarriage in our study are higher;
however, this may be explained, or partly
explained, by the increased maternal age.
The rates of first-trimester vaginal
bleeding for successful pregnancies was also
at the upper limit for the normal obstetric
population; however, this has reduced since
our previous series 11 from 40% to 24.2%. The
continued moderately higher rate may again
be due to the older age group in our study
population with corresponding higher risk
factors. It could also be due to differences
in embolization technique, as in the initial
400 patients who were embolized with
polyvinyl alcohol particles to the branch
vessels of the uterine arteries and coils
blocking or restricting flow in the main
uterine arteries.
Subsequent patients were embolized with
particles only and without occlusion of the
main uterine arteries. Thus, there may have
been a possibility of ischemia to the normal
uterus and this may have contributed to the
slightly increased complication rate in the
earlier cases. Also, increasing technical
experience led to progressive improvement in
the reliability and efficiency.
There were 6 (10.7%) cases of low-lying
placenta; however, only 1 failed to migrate.
Fibroids and abnormal uterine shape can be
associated with placenta previa, therefore
theoretically one might expect the rates of
placenta previa to be
higher than the general obstetric
population. The Ontario multicenter trial 9
had 3 cases of placenta previa (14.3%), 2 of
which had antepartum haemorrhage that
required delivery.
The relevance or our increased rate of
placenta previa is debatable with only a
single case identified.
Abnormal placentation can be a contributory factor to
proteinuric hypertension and IUGR. The rate
of proteinuric hypertension and IUGR in our
series are below the general obstetric
population. Of the 3 cases of premature
rupture of membranes, 2 are likely to be
associated with other factors (an
intrauterine septum and intrauterine blood
transfusions). Therefore, the adjusted rate
is 3.0%. This is within the normal range.
The rate of premature delivery (18.2%) is
higher than the rates for the general
obstetric population (5%- 10%). 15,16
It has been documented that women
older than 35 years have approximately
double the risk of premature delivery.16
The mean maternal age for the pre-term
group was 36.8 years. The pre-term delivery
rate is similar to the Ontario trial 9 4 of
18 (22.2%) and the Goldberg study 10 5 of 32
(16%).
The laparoscopic myomectomy group in
the Goldberg study had a much lower rate of
pre-term delivery at 3%. Although the
numbers are still small, it appears that
rates of pre-term delivery are higher than
the general obstetric population. This may
well be explained by increased maternal age.
The rate of caesarean section was extremely
high at 72.7%. The rate of elective
caesarean is also high at 39.4%. The
indication in 9 of the elective sections was
either partly or solely caused by fibroids,
whereas in the emergency group, only 1 had
fibroids as the indication. This may
demonstrate that of those who elect to
attempt a normal vaginal delivery following
pregnancy after embolisation will not
necessarily then need an emergency section
with fibroids as the indication.
Understandably, obstetricians take a
conservative approach to managing labour in
these patients because of limited
information on pregnancy after uterine
fibroids embolisation. However, the rate of
caesarean sections in those going to term
and planning a normal vaginal delivery
remains well above normal rates at 42.9%
(6/14). The overall rate of caesarean
sections for England and Wales was 21.9% in
2001 and 2002. This demonstrates that this
conservatism is not without reason. The
Goldberg study10 found rates of caesarean
high in both the UAE group (63%) and the
laparoscopic myomectomy group (59%). The
Ontario multicenter trial9 found cesarean
rates of 50%.
The Goldberg study 10 also
found high rates of mal-presentation in 4 of
35 cases (11%).
Fibroids are linked with both
malpresenation17 and preterm labor,18
probably by distorting the uterine cavity.
Our study identified 2 of 33 (6.1%) mal
presentations, and 1 face presentation, a
rate that is not increased.
Postpartum
haemorrhage was increased at 18.2%. Current
evidence linking fibroids with postpartum
haemorrhage is inconsistent.17
One
large multicenter study has concluded
fibroids are an independent risk factor for
increased postpartum blood loss.19
There
was 1 case of abnormal placentation, a
placenta previa. The Ontario trial9
identified 3 cases of abnormal placentation,
all of which had postpartum haemorrhage and
the Goldberg study found a low rate of
postpartum haemorrhage at 6%.
We have
not been able to find evidence that
adequately corrects for age and the presence
of fibroids.
Our study found an increased
risk of postpartum haemorrhage that has not
been replicated in other studies, but this
may be explained by age and the presence of
fibroids.
The
overall pregnancy rate for women wishing to
become pregnant is 30.5% (33/108). This is
much lower than that reported for pregnancy
rate after laparoscopic myomectomy.
A review
by Poncelet et al20 in 2002 of myoma and
infertility showed that within 24 months of
surgery almost 60% of patients spontaneously
conceived. It should be noted, however, that
many of our patients would have been
unsuitable for laparoscopic myomectomy, (ie,
with 1 or 2 suitably positioned fibroids
less than 8 cm), and most of our patients
were only offered embolisation if they had
fibroids that were considered not amenable
to laparoscopic or hysteroscopic resection.
Many of
our patients had difficult multiple complex
fibroids and had been rejected by referring
gynaecologists for other procedures.
Fourteen, in fact, had been offered
hysterectomy.
The object of this study was
not to compare myomectomy with the efficacy
of myomectomy versus fibroid embolization.
The latter would require a randomised
controlled trial, in which patients were
very accurately matched particularly with
regard to the magnetic resonance imaging
evaluation of the number and types and size
of fibroids involved.
The main purpose of this article is to
present the outcome of pregnancy after
embolization and the complication rates. The
cases in which other fibroid treatment
procedures were performed are therefore
included, as these patients were still
exposed to the ‘‘risk’’ of embolization of
the uterine arteries.
From our
results, it is evident women can become
pregnant after fibroid embolisation, and a
successful pregnancy outcome is possible.
Successful pregnancy outcome was finally
achieved in some patients having previous
failed myomectomies and in 14 patients only
offered hysterectomy.
Two patients with virtually untreatable
fibroids achieved pregnancy after combined
procedure(s). Rates of miscarriage, preterm
delivery, and postpartum haemorrhage were
higher than the general obstetric
population; however, this population of
patients is not typical and has additional
risk factors.
From our
data, it appears that there is an increase
in miscarriage, preterm deliveries, and
postpartum haemorrhage, which may be
explained by the increased age of the study
population and the history of a fibroid
uterus. There is a significantly increased
rate of caesarean section compared with the
national average.
Taking
the demographics of
the study population into account, we did
not identify any other major obstetric
risks. We believe that our results have
influenced the way in which patients with
fibroids wanting to become pregnant should
be counselled. For those patients with large
and/or multiple sub mucous or interstitial
fibroids where resection would be difficult
and likely to recur and in those with failed
previous fibroid surgery, embolisation
should be considered as an option for
treatment with advice that a successful
pregnancy outcome is possible after UAE.
A
randomized controlled trial of myomectomy
versus UAE is required to optimally evaluate
pregnancy rates after fibroid embolisation
but such a trial would be an enormously
complex undertaking to accurately match
patients in the two groups.
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Condensation:
Pregnancy after uterine artery embolisation
for symptomatic fibroids has higher rates of
caesarean section, miscarriage, preterm
delivery, and postpartum haemorrhage but
without other major obstetric risks.
For additional information
Please Call 07795 643019