PREGNANCY AFTER PREGNANCY AFTER UTERINE UTERINE FIBROID EMBOLIZATION FIBROID EMBOLIZATION

((UFE)UFE)João Martins Pisco, MD, PhD

Interventional Radiologist

• Marisa Duarte, MD– Interventional Radiologist

• Tiago Bilhim, MD– Interventional Radiologist

Saint Louis Hospital – Interventional Radiology

Lisbon, Portugalwww.hospstlouis.com

St. Louis HospitalSt. Louis Hospital

Faculty of Medical Sciences New University of Lisbon

Faculty of Medical Sciences New University of Lisbon

UTERINE FIBROIDSUTERINE FIBROIDS

• UTERINE FIBROIDS OR MYOMAS ARE THE MOST FREQUENT BENIGN TUMOURS IN FERTILE AGE WOMEN

• 30% OF WOMEN OLDER THAN 35 YEARS OF AGE

• 50% OF AFRICANS SAME AGE

UTERINE FIBROIDSUTERINE FIBROIDS CLINICAL PRESENTATIONCLINICAL PRESENTATION

• HEAVY MENSTRUAL BLEEDING

• PELVIC PAIN

• A CAUSE OF INFERTILITY OR SPONTANEOUS ABORTION

• ASYMPTOMATIC

HOW TO TREAT UTERINE HOW TO TREAT UTERINE FIBROIDS?FIBROIDS?

• MEDICINE DRUGS: – PILL – ANTI - INFLAMMATORY– HORMONES

• SURGERY:– MYOMECTOMY– HYSTERECTOMY

• UFE

DESIRE FOR FUTURE PREGNANCY, IS A RELATIVE CONTRAINDICATION TO UTERINE FIBROID EMBOLIZATION (UFE)

MIOMECTOMY INDICATED

SOME REPORTED PREGNANCIES

HIGH COMPLICATION RATES

SOME OBSTETRIC RISKS

INTRODUCTIONINTRODUCTION

PREGNANCY AFTER UFE

A.C.O.G. (2004) – UFE CONTRAINDICATED IF

PT WISHES CONCEPTION

LIMITED DATA ON FERTILITY RATE AND

PREGNANCY OUTCOMES AFTER UFE

82 – PRESERVE FERTILITY

74 WANTED PREGNANCY

NONE COULD GET A SUCCESSFUL

PREGNANCY

WOMEN INFORMED OF THE UNCERTAIN

EFFECT OF UFE ON FERTILITY AND

PREGNANCY

AT LEAST 6 MONTHS BEFORE CONCEPTION

MATERIAL – 743 PATIENTSMATERIAL – 743 PATIENTS

AGE – 27 – 43 YEARS

(MEAN 36.2)

UTERUS SIZE – 69 - 1450 CC

(MEAN 343)

DOMINANT FIBROID SIZE – 39 - 1280 CC

(MEAN 151)

SPONTANEOUS ABORTION BEFORE UFE – 11 (5

PATIENTS)

CLINICAL DATA OF SUCCESSFUL CLINICAL DATA OF SUCCESSFUL LIVE BIRTH PREGNANCIES LIVE BIRTH PREGNANCIES (N=30)(N=30)

UFE (UTERINE FIBROID UFE (UTERINE FIBROID EMBOLIZATION)EMBOLIZATION)

• MAY BE THE UNIQUE EFFECTIVE TREATMENT FOR INFERTILE PATIENTS WITH UTERINE FIBROIDS

• IN THE FUTURE, UFE MAY BE A FIRST LINE TREATMENT OPTION FOR THESE PATIENTS

UFE 1ST - CASEUFE 1ST - CASE• SC, 33 YEARS OLD, WANTED TO GET PREGNANT

• SEVERAL UTERINE MYOMAS (THE LARGEST 2 HAD 10 AND 9 CM)

• HEAVY BLEEDING (MENSTRUATION 2 - 3 WEEKS), EXTREME ANEMIA (NEEDED PERIODICALLY IRON TRANSFUSION), PAIN AND LARGE BELLY

• SHE HAD 2 UNSUCCESSFUL MYOMECTOMIES AND 3 IN VITRO FERTILIZATION

• HYSTERECTOMY BOOKED!

UFE 1ST - CASEUFE 1ST - CASE

• UFE: JUNE 24, 2004

– BLEEDING AND PAIN FINISHED

– THE ANEMIA WAS CURED

– HER HUGE BELLY DECREASED

• MAY 2006 - PREGNANCY

• FEBRUARY 2007 - CESAREAN DELIVERY (38 WEEKS OF PREGNANCY); DAUGHTER CATARINA WITH 2.800KG

• “EMBOLIZATION CHANGED MY LIFE, THE BLEEDING IS FINISHED, I KEEP PART OF MY BODY THAT GYNECOLOGIST WANTED TO BE REMOVED.

• SINCE EMBOLIZATION I HAVE A COMPLETELY HEALTHY LIFE.

• THE EMBOLIZATION GAVE ME THE BEST PRIZE, MY DEAR DAUGHTER CATARINA”

UFE 1ST - CASEUFE 1ST - CASE

WHAT IS UFE?WHAT IS UFE?• UTERINE FIBROID

EMBOLIZATION (UFE) IS A MINIMALLY INVASIVE PROCEDURE

• TINY NICK IN THE SKIN, THE CATHETER IS GUIDED BY X-RAYS TO THE UTERINE ARTERY AND BLOCKS BLOOD SUPPLY TO UTERINE FIBROIDS

• WITHOUT BLOOD THE MYOMA WILL SHRINK AND DIE

• CAN BE PERFORMED AS OUTPATIENT PROCEDURE

WHO PERFORMS UFE?WHO PERFORMS UFE?

• AN INTERVENTIONAL RADIOLOGIST

• PERFORMS THE MOST ADVANCED AND LEAST INVASIVE TREATMENTS THAT REPLACE SURGERY

• LESS RISK, LESS PAIN, LESS RECOVERY TIME

• NO SCAR JUST A BANDAID

• www.sirweb.org

WHAT IS AN INTERVENTIONAL WHAT IS AN INTERVENTIONAL RADIOLOGISTRADIOLOGIST

• ARE BOARD CERTIFIED PHYSICIANS WHO SPECIALIZE IN MINIMALLY INVASIVE TARGETED TREATMENTS

• USING CATHETERS GUIDED BY IMAGING EQUIPAMENT

HOW TO PERFORM UFE IF PATIENT HOW TO PERFORM UFE IF PATIENT WANTS TO GET PREGNANT?WANTS TO GET PREGNANT?

• LOW X-RAY TIME

• EMBOLIZE THE LEAST POSSIBLE (ONLY TUMOR VESSELS)

• KEEP THE UTERINE ARTERIES PERMEABLE– POLYVINYL ALCOHOL (PVA)

– EMBOZENE MICROSPHERES

IF I DON’T WANT TO DO A SURGERY IF I DON’T WANT TO DO A SURGERY PROPOSED BY GYNECOLOGIST WHAT PROPOSED BY GYNECOLOGIST WHAT

TO DO?TO DO?

• GET A 2ND OPINION WITH AN INTERVENTIONAL RADIOLOGIST

• INTERVENTIONAL RADIOLOGISTS ARE WIDELY AVAILABLE THROUGHOUT THE USA

• WWW.SIRWEB.ORG

WHY TO TREAT FIBROIDS BEFORE WHY TO TREAT FIBROIDS BEFORE PREGNANCY PREGNANCY

• UTERINE FIBROIDS:

– MAY BE A CAUSE OF INFERTILITY

– MAY INDUCE SPONTANEOUS ABORTION

– INCREASE IN SIZE DURING PREGNANCY

• HOWEVER, AFTER UFE, IN CASE OF PREGNANCY, THE FIBROIDS CONTINUE TO DECREASE IN SIZE

• AFTER UNSUCCESSFUL MYOMECTOMY OR IN VITRO FERTILIZATION

• HUGE OR MULTIPLE FIBROIDS

• HYSTERECTOMY (UTERUS REMOVAL) THE ONLY OFFERED TREATMENT

• MYOMECTOMY BUT EVENTUAL HISTERECTOMY CAN NOT BE RULED OUT

UFE MAY BE THE SINGLE UFE MAY BE THE SINGLE EFFECTIVE TREATMENT EFFECTIVE TREATMENT

OUR RESULTS OF PREGNANCY OUR RESULTS OF PREGNANCY AFTER UFEAFTER UFE

PREGNANCIES – SPONTANEOUS (WITHOUT ASSISTED REPRODUCTION TECHNIQUES) IN 43 OF 74 WOMEN WHO WANT TO CONCEIVE (58.1%)

• 36 FINISHED PREGNANCIES (83.7%)

– 30 SUCCESSFUL LIFE BIRTHS (83.3%)

– PRE TERM (36 WEEKS) 2 (6.6%)

– 5 ABORTIONS (13.8%)

• 1 INDUCED

• 4 SPONTANEOUS (13.3%)

– 1 STILLBIRTH (AFTER 5 MIOMECTOMIES, + 1 IVF CESAREAN AT 36 WEEKS)

• 7 ONGOING PREGNANCIES (16.3%)

TREATMENT PERFORMED OR TREATMENT PERFORMED OR OFFERED TO OUR PREGNANT OFFERED TO OUR PREGNANT

WOMEN WOMEN • PERFORMED:

– MYOMECTOMY 16 (1-4) – 6 PATIENTS – FIV 7 (1-3) – 3 PATIENTS

• OFFERED: – HISTERECTOMY – 9 PATIENTS– MIOMECTOMY – 11

HISTERECTOMY COULD NOT BE EXCLUDED IN 5 PATIENTS

5 PREGNANT WOMEN. WHOSE PREGNANCY WAS POSSIBLE ONLY AFTER UFE

PREGNANCY AFTER UFE PREGNANCY AFTER UFE –– CONCLUSIONCONCLUSION

• UFE IS NOT A CONTRAINDICATION TO PATIENTS WHO WANT TO CONCEIVE

• UFE MAY BE THE SINGLE EFFECTIVE TREATMENT FOR SUCCESSFUL PREGNANCIES IN SOME PATIENTS WITH UTERINE FIBROIDS

• OUR RESULTS OF SUCCESSFUL PREGNANCIES AFTER UFE ARE COMPARABLE TO THOSE OF MIOMECTOMY

• PATIENTS SHOULD BE ABLE TO CHOOSE BETWEEN SURGICAL OPTIONS AND UFE