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JANET CLARK, 42, consults with her gynecologist about signs and symptoms she's had for the past several months: heavy and prolonged menstrual bleeding, urinary frequency, pelvic pain, and increasing abdominal bloating. Ms. Clark remembers her mother having similar symptoms from uterine fibroids and worries that she'll need a hysterectomy. After a thorough exam and diagnostic studies, including a pelvic ultrasound to rule out other conditions, Ms. Clark's gynecologist confirms the diagnosis of uterine leiomyomas, commonly called uterine fibroids.
In this article, I'll discuss uterine fibroid embolization (UFE), which is sometimes called uterine artery embolization. This minimally invasive alternative to traditional surgery may be a good option for Ms. Clark. First, let's review some facts about fibroids.
Uterine fibroids are benign pelvic tumors that affect approximately 20% to 40% of women age 35 or older. From 10% to 20% of women with fibroids experience symptoms.1 African-American women and women with a family history are especially susceptible to uterine fibroids.
Some women with mild symptoms are successfully treated with oral contraceptives or other hormonal agents to decrease bleeding. Ms. Clark's symptoms, however, are interfering with her activities. Her gynecologist tells her that she may be a candidate for UFE, a less invasive alternative to hysterectomy.
Until recently, hysterectomy (surgical removal of the uterus) or myomectomy (surgical removal of fibroids) were the only options for women with severe symptoms. Both surgeries require general anesthesia and at least 2 days in the hospital. In contrast, UFE is performed with moderate sedation and analgesia, requires no more than one night in the hospital, and doesn't require a surgical incision. Recovery time at home is also shorter.
Now let's look at the patient-selection process.
After ruling out other conditions that can cause similar symptoms, such as cancer or infection, the gynecologist considers the patient's symptoms, findings of the physical exam and imaging studies, and the patient's preferences.
He'll also ask the patient if she's planning a future pregnancy. Most health care providers recommend a myomectomy for these patients because no reliable data is available about UFE's effect on fertility and fetal growth. However, some patients who've had a UFE have later had successful pregnancies.
The gynecologist decides that Ms. Clark may be a candidate for UFE and refers her to an interventional radiologist, who will make sure she doesn't have any contraindications, explain this procedure and other treatment options, obtain informed consent, and perform the procedure (see An inside look at UFE).
The interventional radiology nurse tells Ms. Clark to fast before the procedure because she'll be having moderate sedation and analgesia. Generally, patients should fast for 6 hours after a light meal (toast and clear liquids) and for 2 hours after clear liquids.2 She'll also take a thorough allergy history to make sure that Ms. Clark isn't sensitive to contrast media or any medications used in the procedure. A patient who's considered to be at risk for a contrast media reaction would undergo a premedication regimen to prevent or reduce the severity of contrast media reactions (corticosteroids alone or with antihistamines). Also, she'd receive a nonionic, low-osmolality contrast medium.
A patient with diabetes would be instructed to alter her insulin or oral diabetes agent regimens as directed by her health care provider. Metformin would be discontinued at the time of the procedure, withheld for 48 hours after the procedure, and restarted only after renal function had been reevaluated.
If you'll be caring for Ms. Clark, make sure she's prepared to stay overnight and has a ride home. Also make sure she's given informed consent according to facility protocol.
Before the procedure starts, review her lab results and report any abnormal results to the interventionalist. Then review postprocedure pain control with Ms. Clark. Our institution uses a patient-controlled analgesia pump to deliver either fentanyl (Sublimaze) or hydromorphone (Dilaudid).
Because the procedure takes 1 to 2 hours and one of her symptoms is frequent urination, you may need to insert an indwelling urinary catheter. Discuss this with the interventional radiologist.
Ms. Clark may be apprehensive about the procedure. Help put her at ease by showing concern for her comfort and welfare, providing explanations, and answering questions.
After an I.V. catheter is inserted, Ms. Clark may receive a corticosteroid as an anti-inflammatory and antibiotic prophylaxis, depending on the facility's protocols.
Remind Ms. Clark that she'll be receiving sedation and analgesia during the procedure, but that she'll be conscious and able to ask questions.
Encourage her to alert the team if she has any discomfort and reassure her that everyone is committed to keeping her comfortable.
During the procedure, follow your institution's policies for monitoring the patient. At our facility, patients undergo continuous cardiac and pulse oximetry monitoring and their vital signs are checked every 5 minutes.
Emotional support and adequate sedation and analgesia are the keys to making the procedure a positive experience.
When the procedure is over, Ms. Clark may experience intense cramping because of the decreased blood supply to the uterus and fibroids. If hemostasis is obtained by manual compression, the extremity used for vascular access (for example, the right leg for the right femoral artery) will be immobilized for 4 hours. If a vascular closure device is used, you may be able to raise the head of her bed right away and help her ambulate in 2 hours. Assess her with a pain-rating scale and check her for signs of infection, such as tachycardia and elevated temperature. Make sure her pain is well controlled before she's transferred out of the interventional radiology unit. Also observe the arterial access site for hematoma or active bleeding and continue to give her emotional support.
Ms. Clark will be hospitalized overnight. In the morning, she'll be switched over to oral pain medications and observed for another few hours to ensure that she remains comfortable on the oral regimen.
Before she's discharged, explain to her that her pain and cramping should subside in 2 to 4 days. Tell her that some patients have flulike symptoms (postembolization syndrome) for the first week after the procedure. Because her job is sedentary, she can resume work in 5 to 7 days. Review her medications with her, give her phone numbers for questions, and make sure she knows when to return for follow-up exams.
To perform UFE, an interventional radiologist numbs the patient's groin area with a local anesthetic after the area's been prepared and draped. After she makes a small nick in the skin, she'll insert a catheter into the femoral artery. Contrast media and fluoroscopy (X-ray imaging) are used to advance the catheter to the right and left uterine arteries. After locating the arteries to be embolized, she'll inject tiny beadlike particles, which block the arteries supplying blood to the tumor. Deprived of oxygen and nutrients, the tumor shrinks over time and symptoms diminish.
Six months after UFE, fibroids are typically about 50% smaller in most women, and in 80% to 90% of women, the symptoms are considerably lessened or gone. About 5% of patients experience complications from the procedure, such as infection or permanent cessation of menstrual periods.
1. Society of Interventional Radiology. Uterine fibroid symptoms and diagnosis. http://www.sirweb.org/patPub/uterine.shtml. Accessed March 23, 2007. [Context Link]
2. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures. Anesthesiology. 90(3):896-905, March 1999. [Context Link]
Mueller GC, et al. Diagnostic imaging and vascular embolization for uterine leiomyomas. Seminars in Reproductive Medicine. 22(2):131-142, May 2004.
Wolanske KA, Gordon, RL. Uterine artery embolization: Where does it stand in the management of uterine leiomyomas? Part 1. Applied Radiology. 33(10):22-29, October 2004.
BioSphere Medical. What you should know about fibroids. http://www.ask4ufe.com.
Phalen K. Uterine fibroid embolization: Tiny beads can save a uterus. http://www.healthsystem.virginia.edu/internet/radiology/angio/tiny-beads.cfm.
University of Virginia Health System. http://www.healthsystem.virginia.edu/internet/radiology/angio/angio-pted-uterine.
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