Case Report: Uterine artery embolization after dysfunctional uterine bleeding due to incomplete abortion in female

Introduction

The most typical application of uterine artery embolization in females is a minimally invasive technique that relieves vaginal bleeding caused by uterine fibroids (non-cancerous tumors inside the uterus).¹ Uterine artery embolization (UAE) can treat excessive bleeding in emergency cases caused by trauma, malignant (cancerous) gynecological tumors, or postpartum hemorrhage, in addition to fibroids. With over 25 years of supporting data, uterine artery embolization has been demonstrated to be a safe and efficient treatment for symptomatic uterine fibroid.² UAE is a well-known form of treatment, but there are a few misconceptions that may make it less accessible to some patients. However, there are difficulties that can make it more difficult for interventional radiologists to provide the best care and treatment for specific patients. This paper will overcome these misconceptions and difficulties, offering opportunities for future development and innovation to help interventional radiologists better serve this patient population.³

Abortion is common practice. Although inaccurate, data on abortion rates can be used to examine the trends. Worldwide, the rate was 35 abortions per 1000 women aged 15–44 years in 2010–2014, which is almost five points less than that of 40 abortions for years between 1990 and 1994.⁴ Although there are different abortion regulations around the world, they are typically stricter in developing nations. However, limiting the regulations frequently results in risky procedures. Despite high rates of death and morbidity, they do not always stop women from getting abortions. Accessibility necessitates a legal framework for abortion, yet numerous regulations are not supported by evidence of restricted accessibility and delayed access.⁵ Abortion is a frequent practice, and data on abortion rates could be utilized to look at patterns despite being erroneous. From 2010 to 2014, there were 35 abortions per 1000 women worldwide (aged 15–44 years), which is a five-point decrease. For the sake of public health, abortion should be accessible, and any legal framework should also be as tolerant as feasible to promote access. Strategies for harm reduction are necessary to lower abortion-related mortality and morbidity in the absence of legal access.⁶ Both medical and surgical methods of abortion are effective and safe (in the first trimester, via manual or electric vacuum aspiration). Cervical priming made surgery easier, and the chances of unsuccessful abortion were lower. Septic abortions are a common and typically preventable cause of maternal deaths that almost invariably follow botched abortions. All women should be given access to a type of contraception as soon as feasible, even though normal post-abortion follow-up is not required. Together with improved education and other efforts, this may minimize unintended pregnancies.⁷

Case presentation

This case study focuses on an Indian woman from the Vidarbha region in Maharashtra who chose Shalini Tai Meghe Hospital, Nagpur, for treatment. A 27 year old woman was diagnosed as having dysfunctional uterine bleeding. She was counselled about all the procedures, merits, and demerits, and informed consent was obtained.

Clinical findings

On general examination pulse was 76 bpm, respiratory rate of 18 per/min BP: 100/72 mmHg.

Patient was a febrile on touch, on systemic examination RS-air entry bilateral equal on CVS-S1 S2 heard, no murmur, CNS: conscious and oriented, per abdominal examination: soft non-tender, per vaginal examination: OS admits tip of finger, bleeding++, patient was immediately advice for USG abdomen +pelvis and blood investigation.

USG done on 05/11/2022, suggestive of retained products of conception.

An immediate decision to check for curettage was made. All blood tests were performed and were within normal limits.

Procedure was completed and was uneventful, patient was admitted in ward for observation.

The patient continued to bleed, and passage of blood clots was observed in the valvar pads even after successful check curettage. A repeat USG was suggested to check for any RPOC in the uterus. USG was performed on 7/11/22, suggestive of blood clots in the uterus, and the patient was counselled.

Regarding the current condition and was given the option of either hysterectomy or uterine artery embolization, considering the patient’s age. The decision to perform uterine artery embolization was made, the patient was referred for uterine artery embolization, as shown in Figure 1.

Figure 1. Uterine blood supply before uterine artery embolization.

Treatment plan

During the procedure, there was a nidus of multiple tortuous vessels with feeders from the uterine artery, and super selective cannulation was performed with a progreat microcatheter and embolization was performed using PA particles of size 5 mm, as shown in Figure 2. Post-embolization reduced the contrast blush arising from the uterine artery, and the procedure was uneventful, as shown in Figure 3.

Figure 2. Embolization with polyvinyl alcohol particle.

Figure 3. Uterine artery blood supply after uterine artery embolization.

Regarding postoperative medications, patient was advised for the injection. Tranexa 8 hourly, injection Cefotaxim 12 hourly, Injection Pantoprazole 24 hourly, Injection Diclofenac 12 hourly, Tablet methergin 0.25 mg 8 hourly.

The patient complained of pain after the procedure for 2 days, for which she was administered an injection. Tramadol, which relieved the patient’s pain tremendously.

Discussion

Pados G. et al. reported that acute dysfunctional uterine bleeding (DUB) in female is treated medically with hormones, NSAIDs, and antifibrinolytic drugs. Hormonal therapy is regarded as the standard medical treatment for acute DUB. Conjugated equine estrogen administered intravenously, COCs, and oral and intramuscular progestins are among the available treatments. A randomized double-blind study including 34 women demonstrated the effectiveness of intravenous conjugated equine estrogen in DUB therapy. According to the study, uterine hemorrhage decreased by 72% in comparison to 38% in the placebo group 8 h after intravenous premarin was administered.⁸ According to a theory, the endometrium heals itself as a result of the induced growth caused by growing oestradiol levels during the primary follicular phase of a typical menstrual cycles. Estrogen also has an impact on the endometrium by reducing capillary permeability, increasing fibrinogen levels, clotting factors, and platelet aggregation, which in turn encourages coagulation and decreases capillary permeability. COCs and oral progestins are among the additional types of hormonal therapies. Progestogens unaccompanied or in combination with estrogen have the same therapeutic effect when used to treat anovulatory DUB, according to a recent Cochrane study.⁹

NSAIDs and antifibrinolytics can be used in ovulatory DUB patients on days when there is significant uterine bleeding. In comparison to single-agent therapy, the use of these drugs in combination with other agents can result in a larger decrease in uterine bleeding. It has been discovered that antifibrinolytics reduce uterine hemorrhage by 40–50% from baseline in comparison with placebo. They have also been reported to be higher than NSAIDs, with a 25–50% decrease in menstrual blood loss from the baseline.¹⁰

Surgery is only used for hysterectomy, UAE, and endometrial ablation in patients with acute DUB. Currently, only women with fibroids have been found to benefit from the use of UAE for menorrhagia. After five years of follow-up, the EMMY trial revealed that 70% of the patients who were randomly assigned to the UAE group did not require hysterectomy. To date, only one instance illustrating the use of UAE in the treatment of acute DUB has been documented in the literature. For example, a 12 years girl with first-onset menorrhagia, which was life threatening, was treated with UAE after traditional medical or gynecological procedures had failed to work.¹¹

UAE has been demonstrated to be effective in treating postpartum hemorrhage, with reported success rates of >90%, in addition to its involvement in menorrhagia. In one of the registers, it was discovered that 2% of the patients experienced uterine infection after UAE. One patient in the case series of these 21 individuals experienced multiple organ failure and septic shock leading to death following UAE, according to a systematic evaluation of 36 articles. Additional issues include intestinal perforation, groyne hemorrhage or pseudoaneurysm, femoral artery blockage, and arterial dissection or perforation.¹² However, only 4.8% of the total number of women enlisted belonged to the category of women with three or more previous sections. After using impedance-controlled endometrial ablation in a patient who had previously undergone three transverse caesarean sections, the patient developed a vesicouterine fistula, raising concerns about the safety of endometrial ablation. Endometrial ablation was not seen to be the best course of treatment for our patient because there is conflicting evidence on its safety in women who had three previous caesarean sections and because our hospital offers only microwave endometrial ablation, which is performed in the dark.¹³

In this case, UAE was attempted because the patient did not respond to medical treatment of DUB and expressed no interest in undergoing hysterectomy. Both times after the UAE, her monthly bleeding was controlled. Angiographic evidence of a convoluted right uterine artery indicates an increase in the caliber and flow of the right uterine artery. However, research on monkeys has revealed that convoluted uterine arteries are the only anatomical variance. In conclusion, we hypothesized that UAE might have a role in treating acute DUB in women whose fertility must be preserved. However, further research is needed to determine the efficacy of UAE in the treatment of acute DUB.¹⁴

Conclusion

UAE is an effective and safe treatment option for DUB associated with incomplete abortion. The procedure can provide quick and lasting relief of symptoms with a low risk of complications. UAE should be considered an alternative to a more invasive surgical option for the administration of DUB related to incomplete abortion. However, patient selection, careful evaluation of the jeopardies, and benefits of the procedure are important factors to consider.

Consent

The patient provided written informed consent for the publication of this manuscript.