Uterine Fibroid Embolization


Uterine Fibroid Embolization

 

Definition

Uterine fibroids are growths in the muscular tissue of the womb (uterus). Uterine fibroid embolization is non-surgical removal of the growths through the use of a tubular device called a catheter.

Purpose

It is estimated that between 20% and 40% of women over age 35 years have fibroids. These noncancerous tumors of the uterus, also called myomas, fibromyomas, or leiomyomas, can be as tiny as a pea or grow to as large as a cantaloupe. They grow along the muscular wall of the uterus and are made of both muscle and fiber-like tissue. Although they are not cancerous, they can cause uncomfortable symptoms in women, particularly pain and a feeling of pressure in the area between the hip bones (the lower pelvic area). Some women experience a feeling that they constantly need to urinate. Others may feel pressure in the bowel, and experience bloating or constipation. Sometimes, fibroids cause heavy menstrual bleeding and lengthier menstrual periods.In some cases, women need no treatment for fibroids, since the growths may cause no symptoms or may stop causing symptoms when a woman reaches menopause. However, when the fibroids cause heavy bleeding that can lead to anemia, pelvic pain, and create pressure on other organs, the physician and patient may discuss treatment options. A woman still planning to have children may need to have fibroids removed to ensure they do not interfere with the ability of a fertilized egg to implant on her uterine lining. In rare cases, fibroids cause such severe and sharp pelvic pain that emergency treatment is required.Although some medications may help ease the symptoms of fibroids or even slow their growth, they are not long-term solutions to the fibroid growths. Surgery also can remove the fibroids. Myomectomy is the most common surgery option still used to treat fibroids because it does not involve removing the uterus. In severe cases, women may have a hysterectomy and have their uterus removed.The development of uterine fibroid embolization has offered women a non-surgical alternative to treating fibroids that are causing symptoms. It also is effective for treating multiple fibroids.

Precautions

Although uterine fibroid embolization has been shown in many studies to be effective, some physicians say it is a relatively new procedure that lacks long-term data on its effectiveness. Estimates show that at least 90% of women who have the procedure will have relief of symptoms and no return of fibroids. Some women have reportedly stopped having menstrual periods following the procedure. Since the long-term effects of uterine fibroid embolization on future pregnancies has not been studied extensively, patients still wanting to have children should discuss the latest research and fibroid treatment options with their physicians. Overall, however, the treatment is a safer and less invasive alternative than surgery.

Description

Uterine fibroid embolization usually is performed in a hospital, but sometimes in an outpatient imaging center. An interventional radiologist normally performs the procedure. Interventional radiologists are physicians who are specially trained to use x rays to see inside the body while guiding narrow tubes called catheters through blood vessels to diagnose or treat various diseases.Uterine fibroid embolization also may be called uterine artery embolization. This is because the procedure injects tiny particles, called embolic agents, into the artery that supplies blood to the fibroid tumor, blocking off the tumor's blood supply. The radiologist reaches the uterine artery by first making a small nick (about one-quarter of an inch) in the patient's skin in the groin area. From this incision, the radiologist can inset the catheter into the femoral artery and then guide the catheter toward the area of the uterus. Patients do not feel the catheter as it moves along the artery and a nurse or anesthesiologist will provide drugs for pain relief at the insertion site. The nurse or a technologist also will insert a Foley catheter into the patient s bladder. This keeps the bladder emptied so that the radiologist can have a better picture of the uterus and the anatomy that surrounds the uterus during the procedure.The radiologist can view the progress of the catheter using a moving x-ray technique called fluoroscopy. When the catheter reaches the artery supplying blood to the fibroid tumor, the radiologist injects the embolic agents, which are only about the size of grains of sand. When they gather together, they form a clot and since no more blood can reach the fibroids, they eventually will shrink and disappear. If a woman has fibroids on both sides, the radiologist will guide the catheter around to repeat the procedure on the other side of the uterus. After removing the catheter, the medical team will clean the puncture area and cover it with a bandage. They also remove the Foley catheter. The entire procedure takes about one hour and should cost less than hysterectomy or other surgical treatments. Most insurance companies will pay for uterine fibroid embolization.

Preparation

When the embolization is scheduled, the hospital or facility should provide instructions regarding medications or food and drink to avoid prior to the procedure. Once a patient checks in, a nurse or technician may draw blood for routine tests and a nurse or radiologic technologist who specializes in vascular procedures will start an intravenous (IV) line through which the patient will receive antibiotics to prevent infection.

Aftercare

Although uterine fibroid embolization is an outpatient procedure, patients may stay in a recovery area for up to 23 hours. When patients are discharged, they will receive specific instructions about follow-up care and medication for relief of pain and swelling. Uterine fibroid embolization rarely requires stitches. Patients may be advised to use a stool softener while taking some of the aftercare medications to avoid constipation. They will be instructed to drink plenty of fluids for the first week following the procedure. Normally, the patient should avoid soaking in hot baths for the first three days and should not drive a car for about three days following uterine fibroid embolization.Strenuous activity, such as climbing stairs, squatting, or lifting heavy objects should be avoided for about one week. Patients also should not stand in one position for long periods of time in the first week following the procedure. It is usually best to avoid heavy exercise routines, athletic activity and sexual relations for about up to month. Women also may be advised to avoid using tampons for menstrual periods for up to three months following uterine fibroid embolization, substituting sanitary pads.

Risks

Most patients experience moderate to severe pain and cramping for several hours after the procedure and some will have nausea and fever. There is a risk of infection from uterine fibroid embolization, but the risk is small and the infection usually can be controlled by antibiotics. A small percentage (about one percent) of women may experience an injury to the uterus or an infection that may lead to a later hysterectomy. There also is a small risk that a woman will stop having periods after uterine fibroid embolization. Overall, these risks are relatively low compared to surgical removal of fibroids.

Key terms

Anemia — A condition in which the blood has a low number of red blood cells, low hemoglobin, or low total blood volume.Artery — One of several tubular branches of muscular and elastic walled vessels that carry blood from the heart through the body.Femoral artery — The chief artery of the thigh.Groin — The fold that marks the meeting of the lower abdomen and the inner thigh.

Normal results

About 90% of women who have the procedure experience significant or complete relief of heavy bleeding, pain, and other symptoms. Patients usually will follow up with their gynecologist about two weeks following the procedure. Recurrence of fibroids is rare, though long-term studies of 10 years or more have shown that about 10% of patients may need additional treatment after 10 years. Additional studies continue on the procedure's long-term effectiveness.

Resources

Periodicals

Johnson, Kate. "Inform Patients of Long-term UFE Outcomes." Family Practice News (Dec. 15, 2004):40-41.Johnson, Kate. "Recovery Fast in Uterine Fibroid Embolization: Most Patients Recover Within Two Weeks." Family Practice News (Aug. 15, 2002):40-41."Uterine Fibroid Embolization Is Minimally Invasive Alternative to Hysterectomy." Women s Health Weekly (Dec. 23, 2004):181.

Organizations

National Uterine Fibroids Foundation. 1132 Lucero Street, Camarillo, CA 93010. 805-482-2698. http://www.nuff.org.Society of Interventional Radiology. 10201 Lee Highway, Suite 500, Fairfax, VA 22030. 703-691-1805. http://www.sirweb.org.

Other

Brown, Linda. Alternatives to Hysterectomy: New Technologies, More Options. U.S. Food and Drug Administration website, 2001. http://www.fda.gov/fdac/features/2001/601_tech.html.Uterine Artery Fibroid Embolization. Georgetown University Hospital website, 2003. http://www.fibroidoptions.com/embol.htm.

Uterine Fibroid Embolization

Synonym/acronym: UFE; uterine artery embolization.

Common use

A less invasive modality used to assist in treating fibroid tumors found in the uterine lining, heavy menstrual bleeding, and pelvic pain.

Area of application

Uterus.

Contrast

IV iodine based.

Description

Uterine fibroid embolization (UFE) is a way of treating fibroid tumors of the uterus. Fibroid tumors, also known as myomas, are masses of fibrous and muscle tissue in the uterine wall that are benign but that may cause heavy menstrual bleeding, pain in the pelvic region, or pressure on the bladder or bowel. Using angiographic methods, a catheter is placed in each of the two uterine arteries, and small particles are injected to block the arterial branches that supply blood to the fibroids. The fibroid tissue dies, the mass shrinks, and the symptoms are relieved. This procedure, which is done under local anesthesia, is less invasive than open surgery done to remove uterine fibroids. Because the effects of uterine fibroid embolization on fertility are not yet known, the ideal candidate is a premenopausal woman with symptoms from fibroid tumors who no longer wishes to become pregnant. This technique is an alternative for women who do not want to receive blood transfusions or do not wish to receive general anesthesia. This procedure may be used to halt severe bleeding following childbirth or caused by gynecological tumors.

This procedure is contraindicated for

  • high alert Patients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far outweigh the risk of radiation exposure to the fetus and mother.
  • high alert Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Although patients are still asked specifically if they have a known allergy to iodine or shellfish, it has been well established that the reaction is not to iodine, in fact an actual iodine allergy would be very problematic because iodine is required for the production of thyroid hormones. In the case of shellfish, the reaction is to a muscle protein called tropomyosin; in the case of iodinated contrast medium, the reaction is to the noniodinated part of the contrast molecule. Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
  • high alert Patients with conditions associated with preexisting renal insufficiency (e.g., renal failure, single kidney transplant, nephrectomy, diabetes, multiple myeloma, treatment with aminoglycosides and NSAIDs) because iodinated contrast is nephrotoxic.
  • high alert Elderly and compromised patients who are chronically dehydrated before the test because of their risk of contrast-induced renal failure.
  • high alert Patients with bleeding disorders because the puncture site may not stop bleeding.
  • high alert Patients in whom cancer is a possibility or who have inflammation or infection in the pelvis.

Indications

  • Treatment for anemia from chronic blood loss
  • Treatment of fibroid tumors and tumor vascularity, for both single and multiple tumors
  • Treatment of tumors in lieu of surgical resection

Potential diagnosis

Normal findings

  • Decrease in uterine bleeding
  • Decrease of pelvic pain or fullness

Abnormal findings related to

  • No reduction in size of fibroid

Critical findings

    N/A

Interfering factors

  • Factors that may impair clear imaging

    • Gas or feces in the gastrointestinal tract resulting from inadequate cleansing or failure to restrict food intake before the study.
    • Retained barium from a previous radiological procedure.
    • Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.

  • Other considerations

    • The procedure may be terminated if chest pain or severe cardiac arrhythmias occur.
    • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status, may interfere with the test results.
    • Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.
    • Consultation with a health-care provider (HCP) should occur before the procedure for radiation safety concerns regarding younger patients or patients who are lactating. Pediatric & Geriatric Imaging Children and geriatric patients are at risk for receiving a higher radiation dose than necessary if settings are not adjusted for their small size. Pediatric Imaging Information on the Image Gently Campaign can be found at the Alliance for Radiation Safety in Pediatric Imaging (www.pedrad.org/associations/5364/ig/).
    • Risks associated with radiation overexposure can result from frequent x-ray procedures. Personnel in the room with the patient should wear a protective lead apron, stand behind a shield, or leave the area while the examination is being done. Personnel working in the examination area should wear badges to record their level of radiation exposure.
    • A small percentage of women may pass a small piece of fibroid tissue after the procedure. Women with this problem may require a procedure called a D & C (dilatation and curettage).
    • Some women may experience menopause shortly after the procedure.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in assessing and treating the uterus.
  • Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, anesthetics, contrast medium, or sedatives.
  • Obtain a history of the patient’s reproductive system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Note any recent procedures that can interfere with test results; include examinations utilizing barium- or iodine-based contrast medium.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Obtain a list of the patient’s current medications, including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals, especially those known to affect coagulation (see Effects of Natural Products on Laboratory Values online at DavisPlus). Such products should be discontinued by medical direction for the appropriate number of days prior to a surgical procedure. Note the last time and dose of medication taken.
  • Note that if iodinated contrast medium is scheduled to be used in patients receiving metformin (Glucophage) for non-insulin-dependent (type 2) diabetes, the drug should be discontinued on the day of the test and continue to be withheld for 48 hr after the test. Iodinated contrast can temporarily impair kidney function, and failure to withhold metformin may indirectly result in drug-induced lactic acidosis, a dangerous and sometimes fatal side effect of metformin related to renal impairment that does not support sufficient excretion of metformin.
  • Review the procedure with the patient. Address concerns about pain and explain that there may be moments of discomfort and some pain experienced during the test. Explain that a sedative and/or anesthetic may be administered before the procedure to promote relaxation. Inform the patient that the procedure is performed in a radiology or vascular department by an HCP, with support staff, and takes approximately 30 to 120 min.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Explain that an IV line may be inserted to allow infusion of IV fluids such as normal saline, anesthetics, sedatives, or emergency medications. Explain that the contrast medium will be injected, by catheter, at a separate site from the IV line.
  • Inform the patient that a burning and flushing sensation may be felt throughout the body during injection of the contrast medium. After injection of the contrast medium, the patient may experience an urge to cough, flushing, nausea, or a salty or metallic taste.
  • Instruct the patient to remove jewelry and other metallic objects from the area to be examined prior to the procedure.
  • Instruct the patient to fast and restrict fluids for 8 hr prior to the procedure. Instruct the patient to avoid taking anticoagulant medication or to reduce dosage as ordered prior to the procedure. Protocols may vary among facilities.
  • Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
  • This procedure may be terminated if chest pain, severe cardiac arrhythmias, or signs of a cerebrovascular accident occur.

Intratest

  • Potential complications:

  • Establishing an IV site and injecting contrast medium by catheter are invasive procedures. Complications are rare but do include risk for allergic reaction (related to contrast reaction); bleeding (related to a bleeding disorder, or the effects of natural products and medications known to act as blood thinners; postprocedural bleeding from the site is rare because at the conclusion of the procedure a resorbable device, composed of non-latex-containing arterial anchor, collagen plug, and suture, is deployed to seal the puncture site); blood clot formation (related to thrombus formation on the tip of the catheter sheath surface or in the lumen of the catheter; the use of a heparinized saline flush during the procedure decreases the risk of emboli); cardiac arrhythmias; hematoma (related to blood leakage into the tissue following insertion of the catheter); infection (which might occur if bacteria from the skin surface is introduced during catheter insertion); tissue damage (related to extravasation of the contrast during injection); nerve injury or damage to a nearby organ (which might occur if the catheter strikes a nerve or perforates an organ); detachment of small pieces of fibroid tissue during UFE which will pass, but a D & C may be required to verify that all material is removed to prevent further bleeding or infection; and the occurrence of menopause following UFE, which is generally experienced in women older than 45 yr of age.

  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
  • Ensure the patient has complied with dietary, fluid, and medication restrictions for 8 hr prior to the procedure.
  • Ensure the patient has removed all external metallic objects from the area to be examined prior to the procedure.
  • Administer ordered prophylactic steroids or antihistamines before the procedure if the patient has a history of allergic reactions to any substance or drug. Use nonionic contrast medium for the procedure.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Have emergency equipment readily available.
  • Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided.
  • Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure because movement produces unreliable results.
  • Record baseline vital signs and assess neurological status. Protocols may vary among facilities.
  • Establish an IV fluid line for the injection of saline, sedatives, or emergency medications.
  • Administer an antianxiety agent, as ordered, if the patient has claustrophobia. Administer a sedative to an uncooperative adult, as ordered.
  • Place electrocardiographic electrodes on the patient for cardiac monitoring. Establish baseline rhythm; determine if the patient has ventricular arrhythmias.
  • Using a pen, mark the site of the patient’s peripheral pulses before angiography; this allows for quicker and more consistent assessment of the pulses after the procedure.
  • Place the patient in the supine position on an examination table. Cleanse the selected area, and cover with a sterile drape.
  • The contrast medium is injected, and a rapid series of images is taken during and after the filling of the vessels to be examined. Delayed images may be taken to examine the vessels after a time and to monitor the venous phase of the procedure.
  • Ask the patient to inhale deeply and hold her breath while the x-ray images are taken, and then to exhale after the images are taken.
  • Instruct the patient to take slow, deep breaths if nausea occurs during the procedure. Monitor and administer an antiemetic agent if ordered. Ready an emesis basin for use.
  • Particles are injected through the catheter to block the blood flow to the fibroids. The particles include polyvinyl alcohol, gelatin sponge (Gelfoam), and micospheres.
  • The needle or catheter is removed, and a pressure dressing is applied over the puncture site.
  • Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis, bronchospasm).
  • Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Instruct the patient to resume usual diet, fluids, medications, or activity, as directed by the HCP. Renal function should be assessed before metformin is resumed.
  • Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered by the HCP. Take temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Protocols may vary among facilities.
  • Observe for delayed allergic reactions, such as rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.
  • Instruct the patient to immediately report symptoms such as fast heart rate, difficulty breathing, skin rash, itching, chest pain, persistent right shoulder pain, or abdominal pain. Immediately report symptoms to the appropriate HCP.
  • Inform the patient that she may experience pelvic cramps for several days after the procedure and possible mild nausea and fever.
  • Assess extremities for signs of ischemia or absence of distal pulse caused by a catheter-induced thrombus.
  • Instruct the patient in the care and assessment of the injection site.
  • Instruct the patient to apply cold compresses to the puncture site as needed, to reduce discomfort or edema.
  • Recognize anxiety related to test results, and be supportive of impaired activity related to genitourinary system. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Educate the patient regarding access to counseling services.
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
  • Instruct the patient in the use of any ordered medications. Explain the importance of adhering to the therapy regimen. As appropriate, instruct the patient in significant side effects and systemic reactions associated with the prescribed medication. Encourage her to review corresponding literature provided by a pharmacist.
  • Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include CBC, CT angiography, CT pelvis, hysterosalpingography, laparoscopy, MRA, MRI pelvis, PT/INR, and US pelvis.
  • Refer to the Reproductive System table at the end of the book for related tests by body system.