Correspondence
Uterine Fibroid Embolization
N Engl J Med 2009; 361:2292-2294December 3, 2009
- Article
To the Editor:
In their article on uterine fibroid embolization (Aug. 13 issue),1 Goodwin and Spies highlight few contraindications to the procedure; among them are “pregnancy, suspected cancer, active infection, or indeterminate endometrial or adnexal abnormalities.” They also cite the U.K. Hysterectomy or Percutaneous Embolisation for Uterine Leiomyomata (HOPEFUL) study, which showed a 2.6% incidence of septicemia after uterine fibroid embolization, with 1.1% of the women requiring emergency hysterectomy.2
Severe infection, often necessitating urgent hysterectomy, is a rare but well-established complication of uterine fibroid embolization.3 The FIBROID registry (Fibroid Registry for Outcomes Data) of 3160 patients showed an emergency hysterectomy rate of only 0.09% at 30 days.4 Emergency hysterectomy for bleeding has been described 4 months after uterine fibroid embolization.5
Clearly there are thousands of women for whom uterine fibroid embolization has obviated the need for hysterectomy. However, given that this is considered to be a “uterus-conserving” therapeutic approach, the small but appreciable risk of emergency hysterectomy inherent in performing uterine fibroid embolization may not be acceptable to all patients. As such, contraindications to this procedure must include women who refuse a hysterectomy under any circumstances.
5 ReferencesColin A. Walsh, M.R.C.O.G.
St. George Hospital, Sydney, NSW, Australia
colwalsh@hotmail.com 1
Goodwin SC ,Spies JB . Uterine fibroid embolization. N Engl J Med 2009;361:690-697
Full Text | Web of Science | Medline2
Dutton S ,Hirst A ,McPherson K ,Nicholson T ,Maresh M . A UK multicentre retrospective cohort study comparing hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids (HOPEFUL study): main results on medium-term safety and efficacy. BJOG 2007;114:1340-1351
CrossRef | Web of Science | Medline3
Payne JF ,Haney AF . Serious complications of uterine artery embolization for conservative treatment of fibroids. Fertil Steril 2003;79:128-131
CrossRef | Web of Science | Medline4
Worthington-Kirsch R ,Spies JB ,Myers ER , et al. The Fibroid Registry for Outcomes Data (FIBROID) for uterine embolization: short-term outcomes. Obstet Gynecol 2005;106:52-52[Erratum, Obstet Gynecol 2005;106:869.]
CrossRef | Web of Science | Medline5
Spies JB ,Spector A ,Roth AR ,Baker CM ,Mauro L ,Murphy-Skrynarz K . Complications after uterine artery embolization for leiomyomas. Obstet Gynecol 2002;100:873-880
CrossRef | Web of Science | Medline
To the Editor:
Serious infectious complications1-5 may occur more frequently after embolization of large fibroids and are probably not preventable with a short course of antibiotics, since the process of fibroid necrosis and elimination is ongoing for weeks. We report a case of endomyometritis and septic shock 14 days after uterine artery embolization, despite a 3-day prophylactic course of levofloxacin, in a 51-year-old patient with asymptomatic human immunodeficiency virus infection. Indications for the procedure were menometrorrhagia, with resulting iron-deficiency anemia, and pelvic pain; magnetic resonance imaging (MRI) had shown 17 submucosal and intramural uterine fibroids, the largest of which was 6.1 cm in diameter. After the procedure, the patient had persistent abdominal cramps and vaginal discharge of black, foul-smelling tissue. Fourteen days after the procedure, rigors and worsening abdominal cramps developed, and she presented with septic shock, with a hematocrit of 21% (baseline, 34%). The abdomen was tender over the uterus, and there was a vaginal discharge of dark blood. An abdominal computed tomographic (CT) scan was abnormal (Figure 1Figure 1
Computed Tomographic Scan of the Abdomen and Pelvis without Contrast, Showing an Enlarged and Distended Uterus.). Blood cultures grew Streptococcus bovis and Prevotella melaninogenica; a cervical culture grew S. bovis. The patient was successfully treated with a 14-day course of antibiotics.5 ReferencesMichele Halpern, M.D.
Stephen Jesmajian, M.D.
Michael Rubin, M.D.
Sound Shore Medical Center of Westchester, New Rochelle, NY
mhalmd@yahoo.com 1
Marshburn PB ,Matthews ML ,Hurst BS . Uterine artery embolization as a treatment option for uterine myomas. Obstet Gynecol Clin North Am 2006;33:125-144
CrossRef | Web of Science | Medline2
Godfrey CD ,Zbella EA . Uterine necrosis after uterine artery embolization for leiomyoma. Obstet Gynecol 2001;98:950-952
CrossRef | Web of Science | Medline3
Rajan DK ,Beecroft JR ,Clark TWI , et al. Risk of intrauterine infectious complications after uterine artery embolization. J Vasc Interv Radiol 2004;15:1415-1421
CrossRef | Web of Science | Medline4
Vashisht A ,Studd J ,Carey A ,Burn P . Fatal septicaemia after fibroid embolisation. Lancet 1999;354:307-308
CrossRef | Web of Science | Medline5
de Blok S ,de Vries C ,Prinssen HM ,Blaauwgeers HL ,Jorna-Meijer LB . Fatal sepsis after uterine artery embolization with microspheres. J Vasc Interv Radiol 2003;14:779-783
CrossRef | Web of Science | Medline
Author/Editor Response
We appreciate the comments of Walsh. We agree that a very small number of patients will require hysterectomy after uterine fibroid embolization because of complications. However, contraindicating uterine fibroid embolization in patients who desire a uterus-sparing option may leave some patients with no reasonable option once medical therapy has been exhausted. Myomectomy may rarely lead to hysterectomy, and the risk of conversion may be higher than it is with uterine fibroid embolization, thus excluding myomectomy as an option for these patients. Similarly, endometrial ablation1 and focused ultrasonography have more limited applicability2; in addition, both of these interventions also are likely to confer a small but real risk of hysterectomy due to a complication. The best approach is an informed-consent process in connection with any of these interventions that includes a discussion with the patient of the risks, including the risk of hysterectomy. With this knowledge, most patients can weigh the relative risks of their options and make an informed choice.
We also thank Halpern et al. for presenting their case. As they point out, some reports have correlated the size of fibroids with an increased risk of poor outcomes after uterine fibroid embolization. Another possible predictor of infection is location. Since presumably infection of a fibroid can result only from bacterial seeding from the endometrial cavity, the location of a fibroid has often been considered to be a more likely prognosticator of infection than has size. However, in a study involving a large series of patients, in which the effect of the size and location of fibroids on the rate of infection was specifically examined, no correlation with either size or location was found.3 The lack of consistency in the literature suggests that more research is needed. CT findings after uterine fibroid embolization can be misleading, since findings such as gas can occur in patients who do not have an infection.4 In general, MRI is viewed as a more powerful tool for evaluating patients after uterine fibroid embolization.5 We agree that a long course of antibiotics may be necessary. This case highlights the importance of surveillance of patients — and particularly immunocompromised patients — after any therapy. A similar level of increased risk might be anticipated with any intervention in an immunocompromised patient.
5 ReferencesScott C. Goodwin, M.D.
University of California at Irvine Medical Center, Orange, CA
sgoodwin@uci.edu James B. Spies, M.D., M.P.H.
Georgetown University, Washington, DC1
Practice Committee of American Society for Reproductive Medicine
Web of Science | Medline2
Taran FA, Hesley GK, Gorny KR, Stewart EA. What factors currently limit magnetic resonance-guided focused ultrasound of leiomyomas? A survey conducted at the first international symposium devoted to clinical magnetic resonance-guided focused ultrasound. Fertil Steril 2009 April 20 (Epub ahead of print).
3
Rajan DK ,Beecroft JR ,Clark TW , et al. Risk of intrauterine infectious complications after uterine artery embolization. J Vasc Interv Radiol 2004;15:1415-1421
CrossRef | Web of Science | Medline4
Vott S ,Bonilla SM ,Goodwin SC , et al. CT findings after uterine artery embolization. J Comput Assist Tomogr 2000;24:846-848
CrossRef | Web of Science | Medline5
Chrisman HB ,Rajeswaran S ,Dhand S , et al. Effect of postprocedural pelvic MR imaging on medical decision-making in women who have undergone uterine artery embolization. J Vasc Interv Radiol 2009;20:977-980
CrossRef | Web of Science | Medline
