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Fernandez MG, Coutinho de Carvalho SF, Martins BA, Santos FDSM, Neto FAFP, Medeiros MODA, Bastos Metzger P. Uterine Artery Embolization Versus Hysterectomy in Postpartum Hemorrhage: A Systematic Review With Meta-Analysis. J Endovasc Ther 2024:15266028241252730. [PMID: 38733296 DOI: 10.1177/15266028241252730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
PURPOSE The objective of this study is to perform a meta-analysis comparing the effectiveness of uterine artery embolization (UAE) versus peripartum hysterectomy for acute refractory postpartum hemorrhage (PPH) control. MATERIALS AND METHODS We systematically searched 6 medical databases for studies comparing UAE and hysterectomy in PPH. Outcomes examined were mortality, hospitalization duration (HD) in days, and red blood cells (RBC) units utilization. Statistical analysis used RevMan 5.1.7 and random-effects models. Odds ratios (OR) and mean differences (MDs) with 95% confidence intervals (CIs) were used for dichotomous and continuous outcomes, respectively. RESULTS We included 833 patients from 4 cohort studies, with 583 (70%) undergoing UAE. The UAE population required fewer RBC units (MD: -7.39; 95% CI: -14.73 to -0.04; p=0.05) and had shorter HD (MD: -3.22; 95% CI: -5.42 to -1.02; p=0.004). Lower mortality rates were noted for UAE in the pooled analysis, but no statistical significance. Uterine artery embolization demonstrated lower procedural complications (16.45% vs. 28.8%), in which UAE had less ureter and bladder lesions (OR: 0.05; 95% CI: 0.01-0.38; p=0.004 and OR: 0.02; 95% CI: 0.00-0.15; p<0.001, respectively). Only 35 (6%) required conversion to hysterectomy, while 27 (4.6%) underwent re-embolization with 100% bleeding control. Uterine artery embolization did not hinder fertility, with normal menstruation restored in 19 patients with postoligomenorrhea. CONCLUSION Uterine artery embolization for the control of PPH is associated with lower use of RBC units and HD, but similar rates of mortality are noted when compared to hysterectomy. These results associated with uterine preservation could support its importance for refractory PPH management. CLINICAL IMPACT Uterine Artery Embolization is associated with a shorter hospitalization duration and reduced use of red blood cell units when compared with hysterectomy in refractory postpartum hemorrhage. Although demonstrating similar mortality rates, these findings, together with fertility preservation, support the method incorporation as a valuable option in obstetric services.
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Zhang W, Cui S, Mao Z, Hao Y, Tan Y, Ban Y, Cui B. Effect of direct surgical treatment in pregnancy-related uterine arteriovenous malformation. BMC Pregnancy Childbirth 2023; 23:673. [PMID: 37726661 PMCID: PMC10507977 DOI: 10.1186/s12884-023-05961-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 08/28/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Uterine arteriovenous malformation (UAVM) is a relatively rare but potentially life-threatening situations abnormal vascular connections between the uterine arterial and venous systems. Lack of recognized guidelines and clinic experience, there is a lot of clinic problems about diagnosis and treatment. By analyzing the clinical data of patients with pregnancy-related UAVM, we aim to confirm the safety of direct surgeries and the benefit of pretreatment (uterine artery embolization or medical therapy) before surgery, and to explore more optimal therapies for patients with pregnancy-related UAVM. METHODS A total of 106 patients in Qilu Hospital of Shandong University from January 2011 to December 2021 diagnosed of pregnancy-related UAVM were involved in this study. Depending on whether preoperative intervention was performed, the patients were divided into direct surgery group and pretreatment group (uterine artery embolization or medical management). Clinical characteristics, operative related factors and prognosis were analyzed. RESULTS The most common symptom of pregnancy-related UAVM was vaginal bleeding (82.5%), which could also be accompanied by abdominal pain. Pretreatments (uterine artery embolization or medical therapy) had no obvious benefit to the subsequent surgeries, but increased the hospital stay and hospital cost. Direct surgery group had satisfactory success rate and prognosis compared to pretreatment group. CONCLUSION For pregnancy-related UAVM, direct surgery has good effects and high safety with shorter hospital stays and less hospital cost. What is more, without uterine artery embolization and other medical therapy, patients could remain better fertility in future.
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Affiliation(s)
- Wenjing Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China
| | - Suhua Cui
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China
| | - Zhonghao Mao
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China
| | - Yiping Hao
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China
| | - Yilin Tan
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Qingdao, Shandong, 266011, China
| | - Yanli Ban
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China.
| | - Baoxia Cui
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China.
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Algeri P, Spazzini MD, Seca M, Garbo S, Villa A. About uterine enhanced myometrial vascularity: Doppler ultrasound could reduce misdiagnosed life-threatening vaginal bleeding after pregnancy and guide the management. J Ultrasound 2023; 26:695-701. [PMID: 36284049 PMCID: PMC10468474 DOI: 10.1007/s40477-022-00734-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/18/2022] [Indexed: 11/29/2022] Open
Abstract
Enhanced myometrial vascularity is a rare entity in which an abnormal communication between vessels of the myometrial wall, potentially derived from all pregnancies, increases bleeding risk. Spontaneous regression is possible, but often, it is not foreseeable in which cases it's better to adopt a waiting behaviour and in which others a treatment is required. We reported three cases of enhanced myometrial vascularity: two occurring after vaginal delivery, and the third one after a scar pregnancy. The first case was successfully treated by embolization, the second one was subjected to curettage complicated by uterine perforation; the third one underwent embolization as well, but subsequently required hysterctomy for persistent methrorragia. As we treated these similar cases in three different ways, we decided to perform a mini review of the literature in the aftermath. Considering literature data, we strongly believe that the detection of peak systolic speed by colour-Doppler ultrasound together with a careful evaluation of clinical symptoms, could be a good guide to the best treatment of each patient.
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Affiliation(s)
- Paola Algeri
- Department of Obstetrics and Gynaecology, Bolognini Hospital, ASST Bergamo Est, Seriate, Bergamo, Italy.
| | - Maria Donata Spazzini
- Department of Obstetrics and Gynaecology, Treviglio Hospital, ASST Bergamo Ovest, Treviglio, Bergamo, Italy
| | - Marta Seca
- Department of Obstetrics and Gynaecology, San Gerardo Hospital, University of Milano-Bicocca, Monza, Monza e Brianza, Italy
| | - Stefano Garbo
- Department of Obstetrics and Gynaecology, Treviglio Hospital, ASST Bergamo Ovest, Treviglio, Bergamo, Italy
| | - Antonella Villa
- Department of Obstetrics and Gynaecology, Treviglio Hospital, ASST Bergamo Ovest, Treviglio, Bergamo, Italy
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Matsumoto MM, Caridi TM. Uterine Vascular Anomalies: Management and Treatment Overview. Semin Intervent Radiol 2023; 40:342-348. [PMID: 37575348 PMCID: PMC10415054 DOI: 10.1055/s-0043-1770714] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Uterine vascular anomalies (UVAs), while rare, can result in severe, life-threatening hemorrhage. An understanding of the presentation and management options for UVAs is important for interventional radiologists to appropriately evaluate and care for these patients. The authors propose a standardized terminology for UVAs to avoid confusion and conflating congenital from acquired vascular lesions, which have a different pathophysiology. Limited high-level evidence and no definitive guidelines for UVA management exist, although endovascular treatment with uterine artery embolization has generally become the first-line approach for symptomatic or persistent UVAs with high technical and clinical success rates. There is also no consensus on the optimal embolization technique; the authors propose an initial approach to first embolize the dominant uterine artery supplying the UVA with gelatin sponge, with the option to embolize the contralateral side at the time of initial embolization if there is persistent supply (avoiding bilateral empiric embolization). Repeat embolization is feasible and recommended in the setting of recurrence, and both clinical and imaging follow-up is important. Ultimately, a multidisciplinary approach with individualized patient management is needed, particularly in the face of a lack of consensus guidelines for the management of symptomatic UVAs.
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Affiliation(s)
- Monica M. Matsumoto
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Theresa M. Caridi
- Department of Radiology, University of Alabama-Birmingham, Birmingham, Alabama
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Xie Z, Wang Y, Chen R. Persistent cornual pregnancy mimicking uterine arteriovenous malformation: a case report. BMC Womens Health 2023; 23:314. [PMID: 37328873 PMCID: PMC10276523 DOI: 10.1186/s12905-023-02450-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/24/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Uterine arteriovenous malformation(AVM) refers to the abnormal direct traffic between uterine arteries and veins, which can be characterized by the imaging examination, showing increased uterine vascularity and arteriovenous shunting. However, similar imaging manifestations can also be seen in a variety of conditions including retained production of conception, gestational trophoblastic disease, placental polyp, and vascular neoplasm. CASE PRESENTATION Here we present a case of a 42-year-old woman who was suspected of suffering uterine AVM indicated by Doppler sonography and magnetic resonance imaging but was finally diagnosed with a persistent ectopic pregnancy located on the right uterine corner by pathology after laparoscopy. She recovered well after surgery. CONCLUSION Uterine AVM is a rare and serious condition. In general, it presents special radiological manifestations. However, when complicated with other diseases it can also be distorting. Standardized diagnosis and management are important.
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Affiliation(s)
- Zhuolin Xie
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, National Clinical Research Center for Obstetric & Gynecologic Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Yang Wang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, National Clinical Research Center for Obstetric & Gynecologic Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Rong Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, National Clinical Research Center for Obstetric & Gynecologic Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
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Chen H, Tan X, Xiong W, Wang X. High-intensity-focused ultrasound for uterine arteriovenous malformation associated with retained products of conception: A case report. Asian J Surg 2023; 46:653-654. [PMID: 35871967 DOI: 10.1016/j.asjsur.2022.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/06/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Hengxi Chen
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Xin Tan
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Wei Xiong
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Xiaoli Wang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.
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Mathieu E, Riethmuller D, Delouche A, Sicot M, Teyssier Y, Finas M, Guillaume B, Thony F, Ferretti G, Ghelfi J. Management of Symptomatic Vascularized Retained Products of Conception by Proximal Uterine Artery Embolization with Gelatin Sponge Torpedoes. J Vasc Interv Radiol 2022; 33:1313-1320. [PMID: 35868595 DOI: 10.1016/j.jvir.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 06/02/2022] [Accepted: 07/12/2022] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To evaluate the effectiveness and safety of temporary proximal uterine artery embolization (UAE) for the treatment of highly vascularized retained products of conception (RPOCs). MATERIALS AND METHODS This retrospective analysis included women who underwent treatment for vaginal bleeding after abortion, miscarriage, or delivery, with highly vascularized RPOCs detected by Doppler ultrasound (US) (ie, presence of an enhanced myometrial vascularity, a low resistance index of <0.5, and a peak systolic velocity of ≥0.7 m/s). A unilateral or bilateral embolization with torpedoes of gelatin foam was performed. From November 2017 to January 2021, 24 women with a median age of 30 years (interquartile range, 26.0-34.5 years) with symptomatic highly vascularized RPOCs were included. Clinical success was defined as bleeding arrest between the UAE and 1-month follow-up. Technical success was defined as the complete obstruction of at least 1 uterine artery supplying vascular abnormalities. The safety of the procedure according to the classification of the Society of Interventional Radiology and evolution of lesions on US were also reported. RESULTS Technical success was achieved in all 24 (100%) patients, with bilateral arterial embolization in 19 (79%) patients and unilateral embolization in 5 (21%) patients. Clinical success was achieved in all 24 (100%) patients. Five patients still had uterine retention at the 1-month follow-up, including 2 patients with highly vascularized RPOCs. Two patients benefited from hysteroscopy, and 3 had noninvasive management. Four minor adverse events were reported (1 patient had infectious endometritis and 3 patients had a postembolization syndrome). CONCLUSIONS Proximal UAE with torpedoes of gelatin foam is safe and effective for the management of symptomatic highly vascularized RPOCs.
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Affiliation(s)
- Eliott Mathieu
- University of Grenoble Alpes, Grenoble, France; Department of Radiology, Grenoble Alpes University Hospital, Grenoble, France
| | - Didier Riethmuller
- University of Grenoble Alpes, Grenoble, France; Department of Obstetrics and Gynecology, Grenoble Alpes University Hospital, Grenoble, France
| | - Aurélie Delouche
- Department of Radiology, Grenoble Alpes University Hospital, Grenoble, France
| | - Marie Sicot
- Department of Obstetrics and Gynecology, Grenoble Alpes University Hospital, Grenoble, France
| | - Yann Teyssier
- Department of Radiology, Grenoble Alpes University Hospital, Grenoble, France
| | - Mathieu Finas
- Department of Radiology, Grenoble Alpes University Hospital, Grenoble, France
| | - Bénédicte Guillaume
- Department of Radiology, Grenoble Alpes University Hospital, Grenoble, France
| | - Frederic Thony
- Department of Radiology, Grenoble Alpes University Hospital, Grenoble, France
| | - Gilbert Ferretti
- University of Grenoble Alpes, Grenoble, France; Department of Radiology, Grenoble Alpes University Hospital, Grenoble, France
| | - Julien Ghelfi
- University of Grenoble Alpes, Grenoble, France; Department of Radiology, Grenoble Alpes University Hospital, Grenoble, France; INSERM U1209/CNRS UMR 5309, Institute for Advanced Biosciences, University of Grenoble Alpes, Grenoble, France.
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