Pii: s0029-7844(02)02347-5

CASE REPORT
A 33-year-old primigravida at 24 weeks’ gestation expe- rienced premature rupture of membranes. Her antenatal course was complicated by uterine leiomyomata. She Jay Goldberg, MD, Leonardo Pereira, MD, and had undergone an abdominal myomectomy 6 years prior because of pain and menometrorrhagia. With con- tinued symptoms and additional leiomyomata docu- Department of Obstetrics and Gynecology, Jefferson Medical College, Thomas mented on ultrasound, a uterine artery embolization was Jefferson University, Philadelphia, Pennsylvania performed the following year, 5 years before the de- scribed pregnancy. Her symptoms resolved after the BACKGROUND: Uterine artery embolization is an increas-
ingly popular alternative to hysterectomy and myomec- At the time of the present admission, with no evidence tomy as a treatment for uterine leiomyoma. Whether this of infection, the patient received two doses of betametha- procedure is safe for women desiring future fertility is sone (12 mg intramuscularly). Intravenous ampicillin and erythromycin were administered for 48 hours, fol- CASES: A primigravida who had previously undergone
lowed by oral amoxicillin and erythromycin for 7 days.
uterine artery embolization had premature rupture of She was managed expectantly as an inpatient for 4 membranes at 24 weeks. She had a cesarean delivery at 28 weeks, until she developed evidence of chorioamnionitis weeks, which was followed by uterine atony requiring at 28 weeks’ gestation. Because of her history of myo- hysterectomy. A primigravida who had previously under- mectomy, as well as a breech presentation, a cesarean gone uterine artery embolization delivered appropriately grown dichorionic twins at 36 weeks. An analysis of the 50 delivery was performed. No residual leiomyomata were published cases of pregnancy after uterine artery emboli- noted. A 1673-g male fetus was delivered, with Apgar zation revealed the following complications: malpresenta- scores of 7 and 8 at 1 and 5 minutes, respectively. The tion (17%), small for gestational age (7%), premature deliv- placenta was delivered manually and noted to be slightly ery (28%), cesarean delivery (58%), and postpartum adherent. We noted significant bleeding from the endo- metrial lining, which appeared necrotic and ragged.
Uterine atony developed and did not respond to vigor- CONCLUSION: Women who become pregnant after uterine
artery embolization are at risk for malpresentation, pre- ous uterine massage, oxytocin, methylergonovine, pros- term birth, cesarean delivery, and postpartum hemor- taglandin F2␣, or misoprostol per the rectum. A supra- rhage. (Obstet Gynecol 2002;100:869–72. 2002 by cervical hysterectomy was performed. Estimated blood The American College of Obstetricians and Gynecolo- loss was 8000 mL. In treating the disseminated intravas- cular coagulopathy that developed, the patient was trans- fused 15 U of fresh frozen plasma, 14 U of packed red blood cells, and 8 U of platelets. Pathology of the uterus and placenta showed residual necrotic placental tissue Uterine artery embolization is an increasingly popular with acute inflammation extending into the myometrium alternative to hysterectomy and myomectomy as a treat- and acute chorioamnionitis with funisitis. The patient ment for uterine leiomyomata. It was first reported as an did well postoperatively and was discharged home on effective primary treatment for symptomatic leiyomyo- postoperative day 8. The infant also did well and was mata in 1995.1 Whether this procedure is safe for women desiring future fertility is controversial. There are very few data regarding the outcomes of pregnancies after embolization. We present two cases of pregnancy in women who had previously undergone uterine artery A 42-year-old primigravida with dichorionic twins pre- sented at 26 weeks with preterm labor and cervical dilation of 2 cm. Her antenatal course was complicated Address reprint requests to: Jay Goldberg, MD, Thomas Jefferson by uterine leiomyomata and infertility. Three years be- University, Jefferson Medical College, Department of Obstetrics and Gynecology, 834 Chestnut Street, Suite 400, Philadelphia, PA 19107; fore conception she had undergone uterine artery embo- lization for symptoms of pain and menometrorrhagia.
2002 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
Table 1. Published Cases of Pregnancy After Uterine Artery Embolization
Goldberg (2002) (current case) Leiomyomata Goldberg (2002) (current case) Leiomyomata AVM ϭ uterine arteriovenous malformation; CD ϭ cesarean delivery; AGA ϭ adequate for gestational age; GTD ϭ gestational trophoblastic disease; PTL ϭ preterm labor; SVD ϭ spontaneous vaginal delivery; IVF ϭ in vitro fertilization; NA ϭ not available; AIDS ϭ acquired immunodeficiency syndrome; SAB ϭ spontaneous abortion; AMA ϭ advanced maternal age (Ͼ35 y); SGA ϭ small for gestational age; TAB ϭ therapeutic abortion; CPD ϭ cephalopelvic disproportion; PPROM ϭ preterm premature rupture of membranes.
Table 2. Pregnancy Complication Rates After Uterine Artery Embolization
Later that same year she underwent a myomectomy Our case 2 is the second reported twin gestation after secondary to persistent symptomatic leiomyomata.
uterine artery embolization. Although she experienced The patient then underwent in vitro fertilization, preterm labor, the patient did not ultimately deliver until which resulted in the dichorionic twin gestation. She was admitted to the hospital for magnesium sulfate tocolysis Table 1 summarizes all published cases of pregnancies and a course of betamethasone. After successful tocoly- after uterine artery embolization.3–16 We used the MeSH sis, she was placed on prolonged bedrest. At 36 weeks terms “uterine artery embolization” and “embolization.” labor began and an uncomplicated cesarean delivery was All articles were checked also for related references. A performed for breech/vertex presentation. Her twins compilation and analysis of the 48 previously published were appropriately grown at 2359 g and 2469 g. The cases, plus our two cases, shows a 22% (11 of 49) rate of patient had an uncomplicated recovery, and she and the spontaneous abortion, a 17% (five of 29) rate of malpre- twins were discharged from the hospital on postopera- sentation, a 7% (two of 29) rate of small for gestational age infants, a 28% (nine of 32) rate of premature deliv-ery, a 58% (18 of 31) cesarean delivery rate, and a 13%(four of 31) rate of postpartum hemorrhage. If the anal- ysis is limited to only women whose indication for Uterine artery embolization has been shown to be an embolization was symptomatic leiomyomata (eliminat- effective treatment for symptomatic uterine leiomyo- ing those with procedures performed for uterine arterio- mata, although no long-term studies have been pub- venous malformation, gestational trophoblastic disease, lished. Spies2 reported improvement in heavy bleeding cervical pregnancy, placenta previa, placenta accreta, or in 90% (95% confidence interval [CI] 86%, 95%) and abruptio placentae), there is a 32% (11 of 34) rate of bulk symptoms in 91% (95% CI 86%, 95%) at 1 year.
spontaneous abortion, a 22% (five of 23) rate of malpre- Outcomes data regarding women who desire future fertility are less clear and very limited.
sentation, a 9% (two of 22) rate of small for gestational In our case 1, because of contributing factors, such as age infants, a 22% (five of 23) rate of premature delivery, chorioamnionitis, prior myomectomy, and nonvisual- a 65% (15 of 23) cesarean delivery rate, and a 9% (two of ized residual leiomyomata, neither the premature rup- 23) rate of postpartum hemorrhage. Reported rates in ture of membranes nor the uterine atony requiring hys- the general population for these events are 10–15% for terectomy can be definitively attributed to the prior spontaneous abortion, 5% for malpresentation, 10% for uterine artery embolization. Nonetheless, it is important smallness for gestational age, 5–10% for premature de- to be aware of the possible relationship between these livery, 22% for cesarean delivery, and 4–6% for postpar- complications and prior uterine artery embolization be- tum hemorrhage.17,18 Table 2 compares these three cause of the increasing number of women desiring future groups. In interpreting these rates, it should be taken into fertility who are electing to undergo this therapy. Theo- consideration that the cesarean delivery rate was affected retically, devascularization of the myometrium resulting by elective cases as well as two patients whose prior from the embolization procedure could affect its ability myomectomies necessitated operative delivery. The in- to successfully contract following delivery.
creased rate for malpresentations was possibly influ- Goldberg et al
enced by the presence of residual leiomyomata. Addi- subsequent successful intrauterine pregnancy. Aust N Z J tionally, information was not complete for each pub- lished pregnancy. The limited number of pregnancies 8. Chow TWP, Nwosu EC, Gould DA, Richmond DH.
after uterine artery embolization reported in the litera- Pregnancy following successful embolisation of a uterine ture may reflect a reporting bias. Because many women vascular malformation. Br J Obstet Gynaecol 1995;102: have already undergone this procedure, it would seem logical that many other unreported conceptions have 9. Gaens J, Desnyder L, Raat H, Stockx L, Wilms G, Baert AL. Selective transcatheter embolization of a uterine arte- Before uterine artery embolization can be regarded as riovenous malformation with preservation of the repro- a safe procedure for women desiring future fertility, ductive capacity. J Belge Radiol 1996;79:210–1.
additional studies must be performed. Based on the few 10. McIvor J, Cameron EW. Pregnancy after uterine artery available data, women becoming pregnant after uterine embolization to control haemorrhage from gestational tro- artery embolization may be at significantly increased risk phoblastic tumour. Br J Radiol 1996;69:624–9.
for postpartum hemorrhage, preterm delivery, cesarean 11. Stancato-Pasik A, Mitty HA, Richard HM, Eshkar N.
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OBSTETRICS & GYNECOLOGY

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