UTERINE ARTERY EMBOLISATION (UAE) OR UTERINE FIBROID EMBOLISATION (UFE)

Transcription

1 UTERINE ARTERY EMBOLISATION (UAE) OR UTERINE FIBROID EMBOLISATION (UFE) A Step-by-Step Guide fr Patients This page and its cntents are Cpyright 2010 the British Fibrid Trust Dr Nicki On. PhD, MRPharmS. Pharmacist Dr Rbert Kaikini. MA, MRCP, FRCR. Cnsultant Interventinal Radilgist. Website address: What is UAE/UFE prcedure? Uterine Artery Emblisatin (UAE), als knwn as Uterine Fibrid Emblisatin (UFE), is an image-guided, minimally invasive prcedure used t treat patients with symptmatic uterine fibrids. An interventinal radilgist, a specialist in perfrming these prcedures, uses a highdefinitin x-ray camera t guide a catheter with a diameter f abut 2 mm int the uterine arteries t deliver particles f an emblic material. The particles ldge in the small vessels supplying the fibrids reducing their bld supply and causing them t shrink Currently, several different types f emblic materials are used fr UAE. They functin in the same way, but differ in their cmpsitin, fr examples: Plyvinyl alchl, a plastic material resembling carse sand. Gelfam, a gelatin spnge material. Micrspheres, plyacrylamide spheres with a gelatin cating. Diagram f the UAE/UFE prcedure Key Features f UAE/UFE prcedure It requires nly lcal anaesthetic. Shrt hspital stay r vernight. Quick recvery time: 1-2 weeks. Minimal bld lss. It shrinks the fibrids and des NOT remve them. UAE/UFE is suitable fr wmen wh What situatins prevent me frm having UAE/UFE fr fibrids? Situatins that prevent yu frm having UAE include pelvic infectin, severe allergy t the cntrast material t be used in the prcedure, arterivenus shunting, an undiagnsed pelvic mass, cagulpathy (cltting disrder and bleeding disrder), inefficient kidney functin, a histry f pelvic radiatin and genital tract malignancy. N lnger want t have children. Want t avid hysterectmy. Have fibrids that cause heavy bleeding. Have fibrids that cause pain r pressing n the bladder r rectum. NOT all fibrids are suitable fr UAE. This ften depends n their psitin within yur wmb: Intracavity r submucsal fibrids may be mre apprpriate fr hysterscpic resectin than UAE. This is because there is a risk f delayed and pssibly painful transcervical passage f the fibrid. Pedunculated (attached t the wmb by a stalk) fibrids prjecting int the abdminal cavity may becme detached fllwing UAE and lead t infectin within the abdmen. Date f preparatin: 01 September 2010

2 Page 2 What are the risks r cmplicatins ns f UAE/UFE prcedure? As with any prcedure, there are risks and ptential cmplicatins assciated with it which include: Ovarian failure (induced early menpause). Despite all measures being taken, the injected particles may travel t the varies. This may cause the varies t stp wrking temprarily r permanently. Infectin. Nt cmmn but can be ptentially serius. This may ccur in the degenerating (dying) fibrids, anything up t several mnths after the prcedure. Serius infectin f the uterus can lead t emergency hysterectmy. Signs f uterus infectin are: severe pain, sweating and a high fever. Pst Emblisatin Syndrme. Mild flu-like symptms, smetimes with a lw temperature, which is caused by the fibrids dying away. This typically ccurs within 4 days after the prcedure and shuld nt last mre than a week. Simple pain killers may help. Vaginal Discharge. May happen fr sme weeks up t several mnths. Discharge is a result f dead fibrid tissue being expelled frm the wmb. Smetimes, this appears as whitish stringy material mixed with bld clt at the time f a perid. This is nt a cause fr cncern. Emblism. Bld clts in the lungs and arteries may rarely ccur. Grin haematma. Bruises at the site f entry f catheter. Perfratins ratins. Puncture f the majr arteries due t the guide-wire. Am I the right candidate fr UAE/UFE prcedure? The radilgist carries ut a MRI scan t determine the size and lcatin f the fibrids and t exclude ther cnditins that can mimic fibrids. This helps t determine whether yu are suitable fr UAE treatment. UAE Step-by-Step Guide I am n Zladex, what shuld I d befre starting UAE/UFE prcedure? With regards t Zladex r any GnRHa, the fibrids return quickly t their riginal size after cessatin. Hwever, it is prbably advantageus t the interventinal radilgist that the fibrids d becme vascular again s that the emblisatin particles can adequately penetrate the fibrids. There is n advantage t 'capitalising' n the size reductin as ne may have thught. We recmmend stpping Zladex at least 2 weeks prir t UFE. Hw d I prepare fr the prcedure? Yur preparatin fr the day includes: Yu must stp bld-thinning medicine starting 5 days befre the prcedure. Yu are als advised t stp taking aspirin, nnsteridal anti-inflammatry drugs (NSAIDs) fr examples ibuprfen (Nurfen), naprxen, diclfenac. Yu must infrm the hspital if yu have any allergies, especially t lcal anaesthetic medicatins r t cntrast materials (als knwn as "dye" r "x-ray dye"). If yu have a cil fitted fr cntraceptin, infrm the hspital r yur GP abut it. It is best t remve the cil befre the UAE prcedure in rder t reduce the risk f infectin. Yu are required t have 4 hurs f fasting (n fd) befre the prcedure, althugh it is alright t drink sme water. If yu are diabetic, n the day f the prcedure, yu shuld stp Metfrmin if yu use this medicatin but yu can cntinue yur regular insulin. On the day f the prcedure, yu are asked t shave the skin arund the grin area where the artery is. Date f preparatin: 01 September 2010

3 UAE Step-by-Step Guide What happens BEFORE the UAE/UFE prcedure? Yu may expect the fllwing: Bld sample is taken t measure FSH hrmne as a baseline fr varian functin. Pregnancy test is carried ut. Yu will lie flat n yur back n the X-ray table. A bladder catheter may be fitted. An IV (intravenus) line in ne f yur arms is inserted thrugh which sedative r pain killers will be given. Yu will be sedated lightly fr the prcedure s that yu are awake but nt actively s. A mnitring device is attached t yur chest and finger and yu may be given xygen thrugh small tubes in yur nse. Antibitic injectins and suppsitries may be given t help t prevent infectin. What happens DURING the UAE prcedure? Lcal anaesthetic is injected in the grin t numb the skin. The injectin can cause sme stinging initially but the area will then g numb. Thrughut the prcedure, a nurse will be with yu t mnitr yur pulse and bld pressure and may give yu xygen if apprpriate. The interventinal radilgist places a catheter int an artery in the leg (femral artery) thrugh a nick in the skin and dye (cntrast material) will be injected t btain the "radmap" fr the catheter. Yu may get a ht feeling in the pelvis as the dye ges in. Using x-ray imaging, he/she steers the catheter twards the bld vessels f the wmb feeding the fibrids. Once in a safe psitin, the radilgist slwly injects tiny emblic particles t blck ff these bld vessels. The result is the starvatin f the fibrid leading t its shrinkage. Events DURING the prcedure (Cntinued) Bth arteries feeding the wmb are Page 3 emblised even if the fibrids are cnfined t ne side. This is necessary t prevent the "unemblised" artery frm taking ver the bld supply t the fibrids. Once x-ray cnfirms successful emblisatin, the catheter is remved and pressure is applied ver the grin area fr apprximately 5-10 minutes t stp any bleeding. N sutures/stitches are needed. Yur intravenus line is remved. The whle prcedure usually takes apprximately 1-2 hurs. What happens AFTER the UAE prcedure? Yu return t the ward, yur bld pressure and pulse are mnitred as rutine bservatins and frequent checks are made fr signs f bleeding frm the skin entry pint. Yu are required t lay flat fr a few hurs (at least 4 hurs) t reduce the risk f bleeding frm the puncture sites in the grins. The ward starts yur pst-perative analgesic pain regimen as yu may experience mild pain t severe crampy, perid-like pain during the first 24 hurs which tends t be wrst in the first 12 hurs. Expect sme pain t still be there by the time yu are being discharged hme. It is nrmal fr yu t spend a night in hspital and yu are ready t g hme by lunchtime the next day. Hspital stay may in sme cases extend t 2 nights. On discharge, yu are given pain relieving tablets t take hme. Yu will have a fllw up ultrasund scan in 3, 6 mnths and MRI scan in 12 mnths. Date f preparatin: 01 September 2010

4 Page 4 Care at hme guide Yu may feel very tired fr up t 2 weeks. Rest fr 3-4 days. Mst wmen return t wrk within ne r tw weeks. D nt drive fr 48 hurs. Keep the puncture site cleaned t prevent infectin and help healing. Mild zing frm wund site may appear which is nrmal. Tenderness may last fr a week, bruising may g n t 2 weeks and a small lump may appear which can last up t 6 weeks. If yu have a slight fever after the prcedure, d nt wrry, it is a sign that the fibrid is breaking dwn. It is cmmn fr yu t see bldy vaginal discharge fr 2 weeks but this can last up t several mnths. Use sanitary twels fr at least 4 weeks in rder t reduce the risk f infectin. Yu can resume nrmal activities when yu feel yu are able t. Allw yurself 10 days ff fr cmplete recvery. It is advisable t use cndms r a diaphragm fr at least 4 weeks if yu are sexually active. When shuld I seek emergency medical attentin? Seek immediate medical attentin if any f the fllwings ccurs: Feel very unwell. Intense pain. High fever & sweating. Pelvic tenderness. Bad smelling r ffensive vaginal discharge. Hw shuld I expect my perids t change after the prcedure? Yur perid shuld gradually return t a mre nrmal frequency with reduced flw. Occasinally, yu may miss a cycle r tw r even rarely stp having perids altgether. Date f preparatin: 01 September 2010 UAE Step-by-Step Guide What is the risk f early (premature) menpause? Abut 1-5% f wmen becme menpausal after UAE prcedure, prbably due t sme emblic particles reaching the varies. The risk f develping premature menpause is higher in wmen aged ver 45 years. Hw sn will I ntice an imprvement in symptms after the prcedure? It usually takes 2 t 3 weeks t ntice the relief f bulk-related symptms and imprvement ccurs ver a perid f mnths as the fibrids cntinue t shrink and sften. By six mnths, the prcess has usually finished and the amunt f symptm imprvement will stabilise. What happens t my fibrid(s) after UAE/UFE? Fibrids within the wmb cavity may be expelled thrugh the vagina as whle r pieces f tissue. Expulsin usually ccurs 6 weeks t 3 mnths afterwards. When this happens, yu are likely t feel perid-like pain and have sme bleeding. Shuld I be cncerned abut the effect f x-ray expsure during UAE n my uterus? Yu are expsed t x-rays during UAE, but the expsure levels usually are well belw thse levels where adverse effects n the patient r future childbearing wuld be a cncern. Hw des UAE affect my fertility There is n clear answer t this questin, althugh a number f healthy pregnancies have been reprted in wmen wh have had the UAE prcedure. Because f this uncertainty, it is recmmended that a wman wh wishes t have mre children shuld cnsider surgical remval f the individual fibrids. This ptin, hwever is nt always pssible and nt withut its wn risks. Scar frmatin after surgical remval may als reduce fertility.

5 UAE Step-by-Step Guide Hw sn can I plan fr pregnancy and what is the advice fr bstetric care? It is nt knwn whether the wall f yur wmb is in anyway weakened by an UAE prcedure. A weakened uterine wall might result in uterine rupture during labur. Yu are advised t use cntraceptin fr 6 mnths after UAE and cnsider caesarean delivery. What is the recurrence rate f UAE? Apprximately 10-20% f wmen underging UAE will need t have either a repeat UAE r a hysterectmy in the future. Is a third UAE/UFE pssible and des this third time prcedure depend d n the wman's age? Third repeat emblisatin is typically rare. As lng as the diagnsis is crrect, the fibrids have regrwn and the uterine arteries are still patent, there shuld be n reasn why they cannt be re-emblised. This is nt based n age but ther cnditins shuld clearly be excluded first and an MRA (Magnetic Resnance Angigram) wuld be useful t assess the state f the uterine arteries. Page 5 I have experienced sme leg pain after UAE prcedure. Shuld I be cncerned and hw can ne exclude the pssibility f DVT? Leg pain is recgnised and may be caused by referred pain. The iliinguinal nerve supplies the inner thigh and the same nerve rt (L1) supplies the varies and part f the uterus. Inflamed fibrids may be pressing n a pelvic nerve causing pain in hip, buttck, r dwn the leg. This will settle in time with simple analgesia (e.g. NSAIDs). DVT shuld be cnsidered if there is leg swelling as well as pain and is easily excluded with a Dppler examinatin. DVT is nt cnnected with nn-target emblisatin but culd be due t immbility fllwing the prcedure (much higher risk with surgery). FURTHER INFORMATION Ryal Cllege f Obstetricians & Gynaeclgists and Ryal Cllege f Radilgists. Clinical recmendatins n the use f uterine artery emblisatin in the management f fibrids (Secnd editin). Natinal Institute fr Health and Clinical Excellence. NICE Guidance n UAE fr fibrids. DVT. Deep Vein Thrmbsis. Medical Terms Arterivenus Shunting. Abnrmal cmmunicatin between arteries and veins. Emblisatin. A prcess that clgs bld vessels and blcks the flw f bld. MRI (Magnetic Resnance Imaging). Use f nuclear magnetic resnance t prduce images f the human rgans. Hysterscpic Resectin. Remval f fibrids inside f the wmb via the vagina using an instrument called hysterscpe. Disclaimer This FACTFILE prvides primarily infrmatin which is intended fr educatinal purpse nly. All cntents within this factfile shuld nt be treated as a substitute fr the medical advice f yur wn interventinal radilgist, dctr r gynaeclgist r any ther health care prfessinal. British Fibrid Trust is nt respnsible r liable fr any diagnsis made by a user based n the cntent f ur factfile. c/ 141 Brkmill Rad Lndn SE8 4JH [email protected] Date f preparatin: 01 September 2010 Cpyright BFT 2010