Emergency embolization of a massive life-threatening placenta percreta bleeding following delivery by Cesarean section.

The rise in the number of Cesarean sections (CS) worldwide has increased the incidence of the placenta accreta spectrum disorders in the past years. About 5% of patients undergoing a CS develop placenta percreta. A 30-year-old woman, G2P1 with previous uncomplicated CS delivery had an elective CS delivery at 37w6d. The delivery was complicated by a substantial hemorrhage. On emergency laparotomy a placenta percreta was seen in the broad ligament, which could not be removed surgically. Embolization was performed with Gelfoam particles until stasis in the right uterine artery with placement of a coil. Patient discharge was 12 days after intervention. Emergency embolization is an effective treatment in bleeding complications due to placenta percreta at partus.

Selective Embolisation of a Heavily Bleeding Cervical Fibroid in a Pregnant Woman.

We report a case of a 20-week pregnant woman, who underwent embolisation of a cervical fibroid to end a life-threatening massive bleeding. This is the first reported case in the literature of a super-selective uterine fibroid embolisation (UFE) in a pregnant woman, even though pregnancy is considered an absolute contraindication for UFE. This rare case demonstrates that UFE can be safely performed during pregnancy providing an excellent short- and long-term clinical outcome for both mother and child.

Women's Attitudes towards the Option to Choose between Karyotyping and Rapid Targeted Testing during Pregnancy.

Objectives. Pregnant women, referred because of an increased risk of fetal Down syndrome, who underwent an invasive prenatal procedure were offered a choice between karyotyping and rapid targeted testing. This study aims to assess women's attitudes and experiences towards what option to choose. Methods. A retrospective multicentre survey (2008-2010) was conducted among 1370 women. General questions were asked about decision making issues, followed by personal questions about their experiences in choice making, test preference, influence of others, and possible regrets. Results. In total, 90.1% of the respondents (N = 825) indicated that pregnant women are able to choose, although 33.1% stated that the choice can best be made by a professional. 18.4% indicated that making a choice places a burden on women. In 96.4%, respondents preferred to have the option to choose again in case of a next pregnancy, whereas 2.7% preferred the choice to be made by a professional. Regret was indicated by 1.2%. Decision making was influenced by others in 64.9%. A slightly higher preference for karyotyping was indicated by 52.7% of the respondents. Conclusions. Positive attitudes and experiences were expressed towards the option to choose. Respondents took decisions freely, although sometimes influenced by a partner or a professional, to follow their individual perspectives.

Why do parents prefer to know the fetal sex as part of invasive prenatal testing?

Objectives. The aim of this study was to determine whether prospective parents, primarily referred for prenatal diagnosis to exclude Down syndrome, prefer to know the fetal sex as part of invasive testing. Methods. In this prospective study 400 pregnant women undergoing amniocentesis were invited to answer a questionnaire, including information about demographic factors, current pregnancy, and previous children. In two open-ended questions they were asked why they wanted to know the fetal sex after amniocentesis or ultrasound investigation. Scores were given for reasons that could have played a role in the wish whether or not to know the sex of their unborn child. Results. A total of 210 (52.5%) questionnaires were completed. Overall, 69.0% was interested to know the fetal sex as part of the diagnostic test result. The most important reasons were curiosity (77.8%), "just want to know" (68.0%), and "because it is possible" (66.8%). The overall knowledge of sex chromosomal disorders appeared low and did not seem to affect the parent's wish to know the fetal sex. Almost all women (96.6%) planned to have a 20-week ultrasound scan and 96.2% thought the scan to be reliable in detecting the fetal sex. A minority (28%) was willing to learn the fetal sex by ultrasound examination, whereas 65% preferred to learn the fetal sex only after the amniocentesis. Conclusion. Personal values affect the parental desire to know or not to know the fetal sex. This does not appear to be affected by invasive prenatal testing and/or genetic knowledge of sex chromosomal disorders.

Embolization of uterine leiomyomas with polyzene F-coated hydrogel microspheres: initial experience.

PURPOSE: To evaluate effectiveness and safety of Polyzene F-coated hydrogel microspheres for uterine artery embolization (UAE) in women with symptomatic uterine leiomyomas. MATERIALS AND METHODS: Between August 2006 and August 2008, 86 nonconsecutive premenopausal women (mean age, 43.9 years; median, 44 y; range, 28-54 y) were treated with UAE. Calibrated microspheres of 500, 700, and 900 µm, alone or in combination, were used as embolic agents. Change in uterine and tumor volume and tumor infarction rate during follow-up were assessed with magnetic resonance imaging. Clinical follow-up was evaluated by the Uterine Fibroid Severity and Quality Of Life (UFS-QOL) questionnaire at baseline, 3 months, and last follow-up in November 2008. RESULTS: At 3 months, mean volume reductions of the dominant leiomyoma and uterus were 45% and 42%, respectively, and complete infarction of the dominant leiomyoma was achieved in 69 patients (80%). Complete infarction of the overall tumor burden was achieved in 52 patients (60%). Infarction rates of the dominant tumor and overall tumor burden were more than 90% in 81 patients (94%) and 79 patients (91%), respectively. During follow-up, permanent amenorrhea developed in seven women (8.1%). Four women (4.7%) had additional therapy after UAE; three had a hysterectomy and one had a second embolization. The UFS-QOL showed significant improvement in symptom severity and quality of life after 3 months that continued to improve at last follow-up (mean, 12.8 months). CONCLUSIONS: In this preliminary study, Polyzene F-coated hydrogel microspheres for UAE resulted in good dominant and overall tumor infarction in most patients, with corresponding improvement of symptoms. Determining optimal sizing of the material and comparing outcomes versus those of other embolic agents requires additional study.

Uterine artery embolization in patients with a large fibroid burden: long-term clinical and MR follow-up.

Uterine artery embolization (UAE) in patients with a large fibroid burden is controversial. Anecdotal reports describe serious complications and limited clinical results. We report the long-term clinical and magnetic resonance (MR) results in a large series of women with a dominant fibroid of >10 cm and/or an uterine volume of >700 cm(3). Seventy-one consecutive patients (mean age, 42.5 years; median, 40 years; range, 25-52 years) with a large fibroid burden were treated by UAE between August 2000 and April 2005. Volume reduction and infarction rate of dominant fibroid and uterus were assessed by comparing the baseline and latest follow-up MRIs. Patients were clinically followed at various time intervals after UAE with standardized questionnaires. There were no serious complications of UAE. During a mean follow-up of 48 months (median, 59 months; range, 6-106 months), 10 of 71 patients (14%) had a hysterectomy. Mean volume reduction of the fibroid and uterus was 44 and 43%. Mean infarction rate of the fibroid and overall fibroid infarction rate was 86 and 87%. In the vast majority of patients there was a substantial improvement of symptoms. Clinical results were similar in patients with a dominant fibroid >10 cm and in patients with large uterine volumes by diffuse fibroid disease. In conclusion, our results indicate that the risk of serious complications after UAE in patients with a large fibroid burden is not increased. Moreover, clinical long-term results are as good as in other patients who are treated with UAE. Therefore, a large fibroid burden should not be considered a contraindication for UAE.

Is an intrauterine device a contraindication for uterine artery embolization? A study of 20 patients.

The presence of an intrauterine device (IUD) has been traditionally considered a risk factor for postprocedural infection in patients undergoing uterine artery embolization (UAE). The authors retrospectively evaluated the occurrence of infectious complications following embolization in 20 women with IUDs. After a mean follow-up of 20.5 months, none of the patients developed an infectious complication. One patient required hysterectomy following embolization for persistent pain. Pathologic evaluation of the hysterectomy specimen demonstrated ischemia without evidence of inflammation. This experience suggests that the presence of an IUD might not be considered a contraindication for UAE.

Safety and effectiveness of uterine artery embolization in patients with pedunculated fibroids.

PURPOSE: To assess complications and outcomes of uterine artery embolization (UAE) in women with pedunculated fibroids in a large single-center patient cohort. MATERIALS AND METHODS: From a database with prospectively collected data from 716 women treated with UAE between 1996 and 2008, 29 women were identified with 31 pedunculated fibroids. Magnetic resonance images obtained before and 3 months after UAE were used to calculate stalk diameter change and volume reduction of both the pedunculated fibroid and uterus. Two observers assessed the overall percentage infarction and infarction of pedunculated fibroid. Complications were recorded and long-term clinical follow-up (mean, 33 months; range, 10-78 months) assessed with use of a questionnaire. RESULTS: The mean reduction in uterine and pedunculated fibroid volume was 37% and 33%, respectively. The mean reduction in stalk diameter was 0.3 cm (95% confidence interval [CI]: 0.18, 0.52 cm) or 13% from initial mean diameter. Stalk enhancement was not affected by UAE. The mean pedunculated fibroid infarction and mean overall infarction rates were 87% and 92%, respectively, for observer 1 and 88% and 92% for observer 2, with good interobserver variability. All women returned the questionnaire and no early or late complications of UAE were reported (0%; 95% CI: 0.0%-13.9%). CONCLUSIONS: In this small series of pedunculated subserosal fibroids treated with UAE, no complications occurred. The findings suggest that the use of UAE to treat pedunculated subserosal fibroids may be safe and effective.

Sexual functioning and psychological well-being after uterine artery embolization in women with symptomatic uterine fibroids.

OBJECTIVE: To assess the effects of uterine artery embolization (UAE) on psychological and sexual well-being 3 months after treatment. DESIGN: Prospective study. SETTING: Large teaching hospital in Tilburg, the Netherlands. PATIENT(S): 141 Premenopausal women with symptomatic uterine fibroids. INTERVENTION(S): UAE for symptomatic fibroids. MAIN OUTCOME MEASURE(S): Changes in scores on a questionnaire concerning sexual well-being (ranging from 0 to 32, a higher score indicating better functioning) and a questionnaire concerning psychological well-being (SCL-90, ranging from 0 to 360, a higher score indicating more emotional and somatic concerns). RESULT(S): The total score for sexual functioning showed a statistically significant increase from 20.3 to 22.7, 3 months after UAE, indicating that sexual functioning improved. Thirty-four percent and 37% of women reported an increase in sexual activity and desire. The percentage of women reporting sexual problems of lubrication, orgasm, or pain decreased 7%, 36%, and 14%, respectively. The total SCL-90 score showed a statistically significant decrease from 133 to 116, 3 months after UAE, indicating a decrease in emotional and somatic concerns. CONCLUSION(S): Sexual and psychological well-being improved significantly 3 months after UAE in women with symptomatic uterine fibroids. Sixty-eight percent had an increase in the total score for sexual functioning. Problems with sexual functioning were statistically significantly decreased.

Detection of chromosome aneuploidies in chorionic villus samples by multiplex ligation-dependent probe amplification.

The objective of this study was to examine the suitability of multiplex ligation-dependent probe amplification (MLPA) in chorionic villus samples as a replacement for traditional karyotyping for the detection of (an)euploidies of chromosomes 21, 18, 13, X, and Y. Chorionic villus samples were diagnosed by traditional karyotyping using short-term cultures (STC) and long-term cultures (LTC), and by MLPA using kit P095. DNA was extracted after digestion of whole villi with proteinase K and/or trypsin and collagenase. Different cell-dissociation procedures were tested to obtain MLPA results representative of the cytotrophoblast layer and the mesenchymal core. Over 95% of the MLPA results were in concordance with the traditional karyotyping of STC and LTC. Traditional karyotyping revealed seven mosaics. After digestion of whole villi with proteinase K, only abnormal cell lines confined to the STC gave rise to abnormal MLPA results. In one sample, the complete discrepancy between STC and LTC was resolved after enzymatic dissociation of cells from the cytotrophoblast layer and the mesenchymal core. MLPA in chorionic villus samples was found to be a reliable test for the detection of (an)euploidies of chromosomes 21, 18, 13, X, and Y. Whole villi digestion with proteinase K resulted in the over-representation of cytotrophoblasts in the DNA pool. To obtain MLPA results representative for STC and LTC, enzymatic dissociation of cells from the cytotrophoblast layer and mesenchymal core is required.

Long-term outcome of uterine artery embolization for symptomatic uterine leiomyomas.

PURPOSE: To evaluate long-term outcomes and factors associated with treatment failure after uterine artery embolization (UAE) in women with symptomatic uterine leiomyomas. MATERIALS AND METHODS: One hundred consecutive women treated with UAE for symptomatic uterine leiomyomas participated. Clinical outcome data (ie, changes in symptoms, menstrual status, subsequent therapies) and satisfaction data were collected. Treatment failure was defined by subsequent major surgery (ie, hysterectomy or myomectomy), a second embolization, or a lack of symptom improvement at the patient's final follow-up interval. Possible predictors of failure were age, clinical baseline characteristics (ie, bleeding, pain, and bulk), and imaging results (eg, percent volume reduction of the dominant tumor). Cox proportional-hazards analysis was used to determine factors associated with failure. RESULTS: Follow-up was available in 93 women (median follow-up, 54 months; range, 45-87 y). Continued symptom relief was observed in 72% of patients (n = 67). Among the 26 women with treatment failure (28%), 11 (42%) underwent hysterectomy, four (15%) myomectomy, and eight (31%) repeat embolization. Three (12%) reported no improvement. In women without any additional surgery (n = 70), heavy menstrual bleeding, pain, and bulk-related symptoms improved in 97%, 93%, and 92%. Ninety percent of all women (n = 93) were satisfied or very satisfied at final follow-up. Predictors of failure were a lack of improvement in bleeding (hazard ratio [HR], 9.0; 95% CI, 3.1-26.3; P < .001) or pain (HR, 7.4; 95% CI, 2.2-24.4; P < .001) at 1 year after UAE and the percent reduction in dominant tumor volume (HR, 0.97; 95% CI, 0.95-0.99; P = .007). CONCLUSIONS: UAE in women with symptomatic leiomyomas leads to long-term symptom improvement. Predictors of failure were a lack of improvement in bleeding or pain at 1 year and the percent reduction in dominant tumor volume.

Acrylamido polyvinyl alcohol microspheres for uterine artery embolization: 12-month clinical and MR imaging results.

PURPOSE: To report the 12-month clinical and magnetic resonance (MR) imaging results of an ongoing two-center registry involving acrylamido polyvinyl alcohol (PVA) microspheres for uterine artery embolization (UAE) for leiomyomas. MATERIALS AND METHODS: A total of 69 patients underwent UAE with 500-700-microm, 700-900-microm, and 900-1,200-mum acrylamido PVA microspheres (BeadBlock). Thirty-three patients underwent UAE with a limited embolization (protocol A) and 36 patients underwent UAE with stasis as the angiographic endpoint (protocol B). Primary objectives were clinical efficacy measured by a leiomyoma-specific quality of life (QOL) questionnaire and infarction rate of leiomyomas on early contrast agent-enhanced MR imaging. Secondary objectives were in-hospital complications, patient satisfaction, and frequency of clinical failure. RESULTS: Bilateral embolization was technically successful in 68 of 69 patients. A significant decrease (P < .001) in symptom severity and increase in health-related QOL was observed at 3 and 12 months with no significant differences between embolization protocols. However, contrast agent-enhanced MR imaging showed a significantly lower rate of completely infarcted leiomyomas in protocol A compared with protocol B (P < .05). Early clinical failures in patients treated according to protocol A were caused by incomplete tumor infarction. Minor complications occurred in five of 69 patients. Patient satisfaction was similar between protocols. CONCLUSIONS: Acrylamido PVA microspheres are a clinically effective and safe embolic agent for UAE. The use of 500-700-microm spheres and a limited embolization results in an unacceptably high rate of failed tumor infarction. Superior imaging results and fewer repeat interventions can be achieved with use of 700-900-microm spheres and stasis as the angiographic endpoint.

Uterine artery embolization for symptomatic adenomyosis with or without uterine leiomyomas with the use of calibrated tris-acryl gelatin microspheres: midterm clinical and MR imaging follow-up.

PURPOSE: To evaluate clinical and magnetic resonance (MR) imaging results after uterine artery embolization (UAE) in women with symptomatic adenomyosis with or without uterine leiomyomas. MATERIALS AND METHODS: Thirty-eight women with symptomatic adenomyosis with or without uterine leiomyomas were treated with UAE with calibrated tris-acryl gelatin microspheres. Based on MR findings, women were categorized as having pure adenomyosis (group A; n = 15), adenomyosis dominance with fibroid tumors (group B; n = 14), or fibroid tumor dominance with adenomyosis (group C; n = 9). RESULTS: Heavy menstrual bleeding, pain, and bulk-related symptoms at last follow-up at a median of 16.5 months (range, 3-38 months) were compared with baseline symptoms. With follow-up MR imaging at a median of 12 months (range, 3-36 months), changes in uterine volume, leiomyoma volume, junctional zone thickness, and contrast enhancement of adenomyosis were assessed. After embolization, adenomyosis infarction could be depicted on contrast medium-enhanced MR in 44.1% of cases. Median reductions of uterine volume, fibroid tumor volume, and junctional zone thickness were 44.8%, 77.1%, and 23.9%, respectively. In group A, three patients needed additional surgery after UAE, in addition to two in group B and one in group C. In the remaining 32 patients, except for one patient in group C, all preexisting symptoms (eg, bleeding, pain, bulk-related symptoms) improved or resolved after UAE. Overall, 84.2% of women were satisfied with the results of UAE. CONCLUSION: In this study, midterm results (at a median of 16.5 months) showed that UAE in symptomatic adenomyosis with or without uterine leiomyomas is effective. Hysterectomy was avoided in the vast majority of patients. MR imaging showed reduction of uterine volume and junctional zone thickness.