Fibroids and Pregnancy
The trial at the Royal Surrey County Hospital and London Clinic represents the largest world series of pregnancies following Uterine Artery Embolization (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 embolization||105|
|Miscarriages||27 - Rate 25%|
|Abortion (unwanted pregnancy)||8|
|Baby died through knot in cord||1|
|Still birth 37 weeks||1|
Pregnancy after uterine artery embolization for leiomyomata: a series of 56 completed pregnanciesAmerican Journal of Obstetrics and Gynaecology (2006) 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.
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 embolization 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.
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 (less than 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.
Table III Caesarean sections
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.
Acknowledgments and References
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