Saxena N*, Deshmukh P**, Chauhan AR***
(* Ex- Registrar, ** Third Year Resident, *** Professor, Department of Obstetrics and Gynecology, Seth G. S. Medical College and K.E.M. Hospital, Mumbai, India)
Amongst the various nonsurgical techniques used for the conservative management of retained products of conception, uterine artery embolization (UAE) has shown promising results. It is an effective outpatient nonsurgical radiologic treatment. We report a case of a 23 year old P2 L2 MTP1; previous 2 LSCS who underwent dilatation and curettage (D & C) twice for persistent findings of retained products of conception with continuous vaginal bleeding. Successful conservative management of the retained products was done using uterine artery embolization and serial monitoring of β hCG levels; patient subsequently recovered with negligible β hCG levels.
Uterine artery embolization (UAE) is a noninvasive radiological modality useful as an outpatient nonsurgical treatment of uterine leiomyomas. This technique was first reported by Ravina et al in 1995 where it was used as an effective pre-hysterectomy treatment which had a significant clinical improvement and averted many hysterectomies.
We observed gradual reduction in the volume of uterine contents (retained blood clots) after undergoing uterine artery embolization (UAE) eventually resulting in disappearance of the entire products and clinical improvement of the patient.
A 23 year old woman with two previous cesarean sections and two medical terminations of pregnancy was referred to our emergency department on day 28 post curettage with ultrasound suggestive of retained products of conception. MTP pills were consumed 4 months back when she had a viable intrauterine pregnancy of 8 weeks on ultrasound. Dilatation and curettage (D & C) was done after she bled continuously for 20 days. The bleeding continued after D & C and the patient was referred to a tertiary care in view of repeat ultrasound suggestive of retained products, with possible differential diagnoses of gestational trophoblasatic disease or arterio-venous malformation. Magnetic resonance imaging (MRI) was done which confirmed the diagnosis of retained products.
On admission, her general condition was fair, vital parameters were normal, there was no tachycardia or pallor. Abdominal examination revealed uterus just palpable. On speculum examination, the cervical os was partially open with active bleeding. Per vaginal examination revealed uterus 12-14 weeks, mobile with slight irregularity on right wall and ballooned up lower segment.
All routine blood investigations and coagulation profile were normal (hemoglobin was 9.1 g/dL, INR was 1.08), β hCG was 481 mIU/ml, and liver and renal function tests were normal. Ultrasound of pelvis revealed a well-defined heterogenous collection of approximately 7 x 6 x 5.5 cm in lower uterine segment with multiple vascular channels suggestive of retained products of conception. MRI confirmed the findings of retained products of conception with stretched and thinned out myometrium.
In view of two previous unsuccessful surgical attempts to evacuate her twice- scarred uterus, the patient was unwilling to undergo a third surgical procedure. As she was stable a decision to manage her conservatively was taken, and she underwent uterine artery embolization (UAE). The patient was followed up regularly with serial ultrasonography and β hCG, which fell rapidly initially and gradually disappeared to < 2 mIU/ml.
UAE is a noninvasive radiologic modality that was first reported by Ravina et al in 1995 where it was used as an effective pre-hysterectomy treatment. This technique resulted in significant clinical improvement and averted many hysterectomies. The procedure is of short duration performed usually under conscious sedation where the branches of uterine artery are occluded using a variety of embolization substances. The most common embolization substances used for the management of post partum hemorrhage or vaginal bleeding include gelfoam particles, coils or glue like n-butyl-cyanoacrylate.
The common indications for which UAE is used are the management of intramural fibroids (causing menorrhagia, pelvic pain and pressure symptoms, infertility, or as a pre-operative measure for large fibroids), dysfunction uterine bleeding and adenomyosis. Other less common indications include uterine AV malformations and pseudoaneurysms. UAE is used in obstetric cases for morbid adherent placenta and postpartum hemorrhage; its role in retained products of conception is limited and there are very few reports for this indication.
There was a significant clinical improvement and effective control of vaginal bleeding after UAE in our case. Cravello et al report a similar case where severe hemorrhage following abortion at 12 weeks gestation was successfully managed by UAE after ruling out cervical trauma and perforation. However, persistent symptoms after UAE occur in approximately 20 % of patients who may require other procedures such as repeat embolization, myomectomy or hysterectomy.
The pre procedural care includes administration of IV fluids, analgesics, anti-emetics and antibiotics which should be continued post procedure as well. A few complications include angiography complications, post-embolization syndrome and uterine artery dissection or rupture.
The important outcomes for the management of vaginal bleeding that are achieved with UAE are alleviation for the need for emergency hysterectomy, gradual resumption of menstruation, simultaneous treatment of unsuspected abnormalities and successful pregnancy outcomes post procedure.
Amongst a variety of treatment options available now days for refractory cases, conservative line of management helps to preserve future fertility in younger women. Methotrexate has emerged with promising results to treat persistent retained placental tissue. It action on the dividing trophoblastic cells of the placental tissue reduces the neovascularisation; resorption of retained placental tissue occurs over course of time. Other standard treatments include internal iliac artery ligation and emergency hysterectomy.
In conclusion, UAE has a role to play in cases of retained products where there is hemorrhage, previous surgical attempts have failed to evacuate the uterus or in patients who are medically high risk or unfit for surgery. Where facilities are available, it may be tried for newer indications like retained products of conception.
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Saxena N, Deshmukh P, Chauhan AR. Uterine Artery Embolization In The Management Of Retained Products Of Conception. JPGO 2016. Volume 3 No. 9. Available from: http://www.jpgo.org/2016/09/uterine-artery-embolization-in.html