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Uterine necrosis is a rare complication of uterine artery embolization for postpartum hemorrhage and most patients end up having a hysterectomy. Here we report a case in which the patient experienced a recurrent fever 28 days after uterine artery embolization as treatment for postpartum hemorrhage and had no response to antibiotics. Magnetic resonance imaging of the pelvis revealed a mass which was approximately 12‐cm in size with air bubbles in the uterus, suggesting necrosis with infection. Transvaginal clamping of the uterine mass was performed and necrotic tissue removed under laparoscopic monitoring, which successfully spared the necessity for a hysterectomy. The patient's subsequent progress was favorable. In the present study we review the high‐risk factors of uterine necrosis following uterine artery embolization and summarize the key points of early diagnosis. In addition, we propose a strategy to successfully spare the necessity for a hysterectomy without the spread of infection or uterine perforation. Synopsis: Uterine necrosis should be considered when consistent fever appears after uterine artery embolization. Earlier diagnosis and timely removal of necrotic tissue could be helpful for hysterectomy sparing. [ABSTRACT FROM AUTHOR]

Background: Cesarean scar pregnancy (CSP), a distinct form of ectopic pregnancy, presents challenges in effective management. It is categorized into three subtypes according to the location of placental implantation and the thickness of the myometrium at the uterine scar. Nevertheless, the optimal choice of treatment modalities for these subtypes remains largely unexamined. Methods: In this retrospective analysis, we investigated the cases of 130 patients diagnosed with CSP who underwent diverse treatment approaches, namely ultrasound-guided dilation and curettage (D&C), hysteroscopic surgery alone or in combination with laparoscopic surgery (HCoLC), or uterine artery embolization (UAE) followed by curettage. Clinical data were meticulously retrieved from medical records and follow-up data, and a comparative analysis of relevant indicators was carried out across the different CSP subtypes. Results: From January 2017 to December 2021, 35 patients underwent D&C, 85 underwent HCoLC, and 10 received UAE as a pretreatment. In the D&C group, the success rates for Type I and Type II CSP were 64.29% (18/28) and 14.28% (1/7), respectively. Significant differences were observed between the success and failure groups in terms of gestational sac size and clinical classification. Compared to Type I CSP, Type II CSP exhibited significantly longer surgical durations and higher hospitalization costs (P < 0.05). Three patients classified as Type III underwent simultaneous hysteroscopic evacuation of cesarean scar pregnancy and laparoscopic repair of the cesarean scar defect, achieving a 100% success rate in their initial treatment. HCoLC showed no significant differences in surgical duration and hospitalization costs but had higher success rates and shorter hospital stays compared to the D&C and UAE groups (P < 0.05). The UAE group had significantly longer surgical durations, higher hospitalization costs, and a higher incidence of postoperative complications (P < 0.05). However, these factors did not result in improved surgical success rates. Conclusion: The classification of CSP and the measurement of gestational sac are of crucial importance in determining the most appropriate surgical intervention strategy. For patients diagnosed with Type I CSP, D&C and hysteroscopy are reliable treatment choices. In cases with larger gestational sacs or Type II CSP, hysteroscopy, either alone or in combination with laparoscopy, is regarded as a reliable and effective treatment approach. In patients with type III CSP, lesion excision with uterine repair is the recommended treatment. [ABSTRACT FROM AUTHOR]

Uterine arteriovenous malformation (UAM) is a rare medical condition. Even though UAM can cause abnormal and life-threatening uterine hemorrhage, there is no consensus on the clinical guideline on its treatments, most likely due to its low incidence, unknown etiology, and distinct fertility demands by different patients. Here, we present one elderly woman with uncommon UAM. We first discuss our experience regarding the diagnoses and treatments of UAM and then propose a hypothesis for the pathogenesis of UAM. [ABSTRACT FROM AUTHOR]

OBJECTIVE: In uterine artery embolization (UAE) for the treatment of fibroids, nondegradable particles permanently occlude the uterine artery (UA). These particles remain in the vessels and can cause secondary undesirable effects, such as severe pain after embolization and fertility issues. In this prospective experimental study, we aimed to evaluate the angiographic recanalization, local and systemic reactions, and uterine damage occurring after performing UAE with newly developed degradable starch microspheres (DSMs) in sheep. MATERIALS AND METHODS: Under general anesthesia, eight nonpregnant sheep underwent bilateral UAE using DSMs to achieve stasis. Angiographic evaluation was performed on days 1, 3 and 7 after embolization to assess in vivo recanalization. In addition, the angiographic series were scored via a modified embolization score. A postmortem tissue examination was performed to determine whether DSMs and foreign body inflammatory reactions were present and to assess uterine necrosis. RESULTS: Complete bilateral embolization of the UA and cervicovaginal branches was achieved in all treated animals. Recanalization of the occluded arteries was evident in 25 of 27 arteries during the angiographic evaluation. In all sheep, there were multifocal areas of uterine necrosis, and some uterine vessels contained intraluminal material consistent with DSMs. The average weight of both uterine horns was significantly correlated with both the number of microspheres needed for complete embolization (r = 0.69, ρ<0.01) and the average percentage of necrosis in both uterine horns (r = 0.64, ρ<0.05). CONCLUSIONS: Our findings demonstrated the efficacy of vascular embolization with DSM by inducing ischemic changes in the uterus and subsequent recanalization of previously occluded arteries. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the safety and efficacy of emergency and prophylactic uterine artery embolization (UAE) in our clinical practice, including technical success, clinical success, and associated complications. In this retrospective study, we analyzed 64 women who underwent emergency (n =18) and prophylactic (n = 46) UAE. Indications for emergency UAE included postpartum hemorrhage or severe hemorrhage during pregnancy termination, while prophylactic UAE was performed prior to surgical removal of retained products of conception (RPOC), delivery with abnormal placental implantation, or pregnancy termination (cervical pregnancy or fetal anomalies accompanied by abnormal placental implantation). Technical success of UAE was defined as complete exclusion of the vascular lesion and contrast stasis on the final angiogram, while clinical success was defined as cessation of bleeding after UAE Termination without a hysterectomy. The overall clinical success of UAE in our study was 97% (62/64). All embolization procedures were technically and clinically successful in the prophylactic group without life-threatening hemorrhages or hysterectomies (100% success rate, 46/46). However, while 100% technical success was similarly attained in the emergency group, bleeding was successfully controlled in 89% of cases (16/18). In two patients with significant blood loss (over 2000 mL), embolization failed to achieve hemostasis, resulting in persistent bleeding and subsequent hysterectomy. UAE is a safe and effective procedure for managing primary postpartum hemorrhage or severe hemorrhage during pregnancy termination and for decreasing the risk of severe hemorrhage during surgical removal of RPOC, delivery with abnormal placental implantation, or pregnancy [ABSTRACT FROM AUTHOR]

Abstract Background Cesarean scar pregnancy (CSP), a distinct form of ectopic pregnancy, presents challenges in effective management. It is categorized into three subtypes according to the location of placental implantation and the thickness of the myometrium at the uterine scar. Nevertheless, the optimal choice of treatment modalities for these subtypes remains largely unexamined. Methods In this retrospective analysis, we investigated the cases of 130 patients diagnosed with CSP who underwent diverse treatment approaches, namely ultrasound-guided dilation and curettage (D&C), hysteroscopic surgery alone or in combination with laparoscopic surgery (HCoLC), or uterine artery embolization (UAE) followed by curettage. Clinical data were meticulously retrieved from medical records and follow-up data, and a comparative analysis of relevant indicators was carried out across the different CSP subtypes. Results From January 2017 to December 2021, 35 patients underwent D&C, 85 underwent HCoLC, and 10 received UAE as a pretreatment. In the D&C group, the success rates for Type I and Type II CSP were 64.29% (18/28) and 14.28% (1/7), respectively. Significant differences were observed between the success and failure groups in terms of gestational sac size and clinical classification. Compared to Type I CSP, Type II CSP exhibited significantly longer surgical durations and higher hospitalization costs (P

Abstract Uterine arteriovenous malformation (UAM) is a rare medical condition. Even though UAM can cause abnormal and life-threatening uterine hemorrhage, there is no consensus on the clinical guideline on its treatments, most likely due to its low incidence, unknown etiology, and distinct fertility demands by different patients. Here, we present one elderly woman with uncommon UAM. We first discuss our experience regarding the diagnoses and treatments of UAM and then propose a hypothesis for the pathogenesis of UAM.

Abstract This review compares the efficacy of Uterine Artery Embolization (UAE) and Myomectomy (MYO) in managing symptomatic Uterine Fibroids (UFs) in women who do not want hysterectomy. A meta-analysis was performed on all available studies that evaluated the relative benefits and harms of MYO and UEA for the management of patients suffering from UFs. Outcomes evaluated reintervention, UFs scores for quality of life (QOL) and symptom severity, and other complications. To determine mean differences (MDs) or odds ratios (ORs) with 95% confidence intervals (CIs), a random or fixed-effects model was utilized. A meta-analysis of 13 studies (9 observational and 4 randomized controlled trials) was conducted. The results indicated that UAE had a higher reintervention rate (OR 1.84; 95% CI 1.62–2.10; P

Kun-Kun Qiang,1,2 Qing-Yun Song1,2 1Department of Diagnostic Ultrasound, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China; 2Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Chengdu, People’s Republic of ChinaCorrespondence: Qing-Yun Song, Department of Diagnostic Ultrasound, West China Second University Hospital, Sichuan University, Chengdu, Sichuan Province, 610041, People’s Republic of China, Email huaxi2chaoshengsqy@163.comIntroduction: Uterine artery pseudoaneurysm (UAP) is a rare cause of late postpartum hemorrhage. Insufficient understanding of this condition among clinicians may result in delayed diagnosis and treatment, potentially leading to incorrect interventions and poor prognosis, including fatal hemorrhage and even necessitating hysterectomy in severe cases.Case Report: The patient, a 41-year-old woman with a history of three pregnancies and two deliveries, underwent cesarean section and subsequently experienced persistent small amounts of vaginal bleeding for a duration of two months. Transvaginal ultrasonography revealed a hypoechoic mass in the cervix that was initially misdiagnosed as a cervical fibroid. Approximately 12 h prior to admission, she experienced an episode of acute vaginal bleeding of significant intensity. Emergency transvaginal ultrasound demonstrated an intrauterine mass located in the posterior wall of the cervix with swirling blood flow, exhibiting a to-and-fro pattern. The mass was connected to the left uterine artery adjacent to the cervix through a tear measuring approximately 0.5 cm in diameter. Emergency bilateral uterine artery embolization was performed. After a follow-up period of ten months, there was no recurrence of abnormal vaginal bleeding, and subsequent ultrasound examination confirmed the complete resolution of the cervical lesions.Conclusion: The findings of this case suggest that the UAP undergoes a dynamic process. In the early stages, the lesion may manifest as a small hypoechoic or anechoic area within the myometrium. Color Doppler imaging might not reveal blood flow signals within the lesion, potentially leading to misdiagnosis as other common uterine lesions such as fibroids or cysts. However, considering the close association between UAP and the uterine artery, meticulous observation of the relationship between the uterine artery and its branches is crucial for identifying myometrial lesions to facilitate early detection of UAP and minimize misdiagnosis.Keywords: uterine artery, pseudoaneurysm, postpartum hemorrhage, ultrasound, uterine artery embolization

Introduction: Uterine artery embolization is performed in pre‐menopausal women. Understanding the contribution of radiation dose at each stage of the procedure is important for potential dose reduction. The aim was to retrospectively analyse radiation dose on a per‐procedural‐stage basis, comparing digital subtraction angiography (DSA) and conventional roadmap (CRM). Methods: Group A consisted of 50 patients where DSA was used for road mapping at all stages: (I) Aortogram, (II) Left internal iliac artery (IIA) DSA, (III) Left uterine artery (UA) DSA, (IV) Right IIA DSA and (V) Right UA DSA. Group B included 50 patients, where CRM was used for road mapping at stages (II) and (IV). Results: For Group A, mean total dose‐area product (DAP) was 39.7 Gy·cm2; mean DAP for each stage were (I) Aortogram = 3.4 Gy·cm2, (II) Left IIA DSA = 5.9 Gy·cm2, (III) Left UA DSA = 3.2 Gy·cm2, (IV) Right IIA DSA = 5.5 Gy·cm2 and (V) Right UA DSA = 3.0 Gy·cm2. For Group B, mean total DAP was 33.6 Gy·cm2, mean DAP for each stage were (I) Aortogram = 3.3 Gy·cm2, (II) Left IIA CRM = 1.5 Gy·cm2, (III) Left UA DSA = 3.3 Gy·cm2, (IV) Right IIA CRM = 1.5 Gy·cm2 and (V) Right UA DSA = 3.3 Gy·cm2. Fluoroscopy time was 10 and 9.4 min for Groups A and B, respectively. Conclusion: The highest road‐mapping radiation dose contribution was from bilateral IIA DSA. The use of CRM, intermittent fluoroscopy and elimination of the aortogram is recommended to further reduce procedural radiation dose. [ABSTRACT FROM AUTHOR]

Background: No standard treatment guidelines have been established for postpartum hemorrhage (PPH). We aimed to assess the differences in outcomes and prognoses between patients with PPH who underwent surgical and non-surgical treatment. Methods: This retrospective study included 230 patients diagnosed with PPH at two referral hospitals between August 2013 and October 2023. The patients were divided into non-surgical (group 1, n = 159) and surgical intervention groups (group 2, n = 71). A subgroup analysis was performed by dividing the surgical intervention group into immediate (n = 45) and delayed surgical intervention groups (n = 26). Results: Initial lactic acid levels and shock index were significantly higher in group 2 (2.85 ± 1.37 vs. 4.54 ± 3.63 mmol/L, p = 0.001, and 0.83 ± 0.26 vs. 1.10 ± 0.51, p < 0.001, respectively). Conversely, initial heart rate and body temperature were significantly lower in group 2 (92.5 ± 21.0 vs. 109.0 ± 28.1 beat/min, p < 0.001, and 37.3 ± 0.8 °C vs. 37.0 ± 0.9 °C, p = 0.011, respectively). Logistic regression analysis identified low initial body temperature, high lactic acid level, and shock index as independent predictors of surgical intervention (p = 0.029, p = 0.027, and p = 0.049, respectively). Regarding the causes of PPH, tone was significantly more prevalent in group 1 (57.2% vs. 35.2%, p = 0.002), whereas trauma was significantly more prevalent in group 2 (24.5% vs. 39.4%, p = 0.030). Group 2 had worse overall outcomes and prognoses than group 1. The subgroup analysis showed significantly higher rates of uterine atony combined with other causes, hysterectomy, and disseminated intravascular coagulopathy in the delayed surgical intervention group than the immediate surgical intervention group (42.2% vs. 69.2%, p = 0.027; 51.1% vs. 73.1%, p = 0.049; and 17.8% vs. 46.2%, p = 0.018, respectively). Conclusions: Patients with PPH presenting with increased lactic acid levels and shock index and decreased body temperature may be surgical candidates. Additionally, immediate surgical intervention in patients with uterine atony combined with other causes of PPH could improve prognosis and reduce postoperative complications. [ABSTRACT FROM AUTHOR]

Background/Objectives: Our objective was to evaluate changes in the management of symptomatic fibroids after establishing a multidisciplinary fibroid center with minimally invasive gynecologic surgery (MIGS) and interventional radiology (IR). Methods: A retrospective cohort study was conducted at the fibroid center created in September 2020. Patients were offered same-day consults with both MIGS and IR providers. Data were collected for patients with initial consultations from January to June 2019 (pre-fibroid center) and from January to June 2021 (post-fibroid center). Results: Among 615 patients meeting inclusion criteria, 273 had consultations pre-center and 342 post-center. More patients seen post-center had previously attempted medical management (30.1% vs. 20.2%), with a significant proportion having no prior medical or surgical treatment (53.2% vs. 61.5%). Post-center, there were more MIGS consultations (65.5% vs. 53.1%) and a decrease in general gynecology (GYN) consultations (19.0% vs. 25.6%). More patients sought additional opinions post-center (83.6% vs. 67.0%), particularly with MIGS (58.8% vs. 37.0%). General GYNs referred to MIGS (79.3% vs. 73.1%) and IR specialists (16.0% vs. 13.0%) more often in 2021. In 2021, use of MRI increased (66.5% vs. 52.4%), and more patients underwent uterine artery embolization (UAE) within 1 year of consultation compared to the pre-center period (13.8% vs. 6.9%). Conclusions: Patients with symptomatic fibroids often seek the expertise of specialists to explore treatment options. A multidisciplinary fibroid center that integrates efforts of MIGS and IR enables thorough counseling and a rise in the utilization of minimally invasive procedures, including UAE. [ABSTRACT FROM AUTHOR]

STUDY QUESTION What are the maternal and neonatal outcomes of second delivery in women who underwent uterine artery embolization (UAE) during their first delivery? SUMMARY ANSWER Women who underwent UAE during their first delivery exhibited higher risks of placental problems, preterm births, and postpartum hemorrhage (PPH) in second delivery and the second offspring also showed increased risk of major congenital malformations, admission to the neonatal intensive care units (NICU), necrotizing enterocolitis, intraventricular hemorrhage, and bronchopulmonary dysplasia. WHAT IS KNOWN ALREADY UAE is a minimally invasive procedure used as an alternative to hysterectomy for managing severe PPH. However, recent studies have raised concerns about potential obstetric complications, including recurrent PPH, placenta accreta spectrum (PAS), and fetal growth restriction in subsequent delivery following UAE. STUDY DESIGN, SIZE, DURATION This was a nationwide retrospective cohort study using the Korean National Health Insurance Service (K-NHIS) database, covering 50 million individuals from 2004 to 2020. The cohort included 3 616 923 women with live births between 1 January 2005 and 31 December 2019 with follow-up data extending to 31 December 2020. PARTICIPANTS/MATERIALS, SETTING, METHODS The study included women who had their first live birth between 2005 and 2019, excluding those who underwent hysterectomy (without UAE = 3 612 389, UAE = 4534). Among them, we selected women who had single gestation secondary delivery (without UAE = 1 694 600, UAE = 1146). Propensity score matching was used to control for confounding factors, resulting in 11 184 women without UAE and 1119 women with UAE for subsequent analysis. MAIN RESULTS AND THE ROLE OF CHANCE Women in the UAE group had significantly higher risks of PAS (odds ratio (OR) = 38.91, 95% CI = 18.61–81.34), placenta previa (OR = 6.98, 95% CI = 5.57–8.75), and preterm birth (OR = 2.23, 95% CI = 1.71–2.90) during their second delivery. The risk of recurrent PPH was also significantly higher (OR = 8.94, 95% CI = 7.19–11.12). Their second offspring were more likely to have major congenital malformations (OR = 1.62, 95% CI = 1.25–2.11) and adverse neonatal outcomes, including NICU admissions (OR = 1.83, 95% CI = 1.48–2.25). Long-term outcomes showed a higher risk of attention-deficit/hyperactivity disorder (hazard ratio = 1.64, 95% CI = 1.03–2.63) but were otherwise comparable to those in the without UAE group. LIMITATIONS, REASONS FOR CAUTION Retrospective nature of the study may have introduced exposure and outcome misclassifications, despite the reliability of the K-NHIS database. Unmeasured confounders and selection bias due to only including live births could also have influenced the results. WIDER IMPLICATIONS OF THE FINDINGS Women with a history of UAE require meticulous prenatal care and close monitoring during subsequent deliveries due to increased risks of complications. Counseling and referral to high-risk medical centers may improve outcomes. Further research is needed to understand the mechanisms of complications in both mothers and offspring at sequential delivery, as well as to refine UAE procedures. STUDY FUNDING/COMPETING INTEREST(S) This study supported by Patient-Centered Clinical Research Coordinating Center (PACEN) funded by the Ministry of Health & Welfare, Republic of Korea (HC21C0123). This study was funded by S.-Y.O. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. TRIAL REGISTRATION NUMBER N/A. [ABSTRACT FROM AUTHOR]

Introduction: Cesarean scar ectopic pregnancies (CSEPs) are associated with significant maternal morbidity and termination is often recommended in the early first trimester. Management of more advanced cases is challenging due to higher risks of major intraoperative hemorrhage. Hysterectomy is currently the intervention of choice for advanced cases. This study aimed to investigate if advanced live CSEPs could be managed effectively conservatively using suction curettage and interventional radiology. Material and methods: A retrospective single‐center cohort study was performed. A total of 371 women diagnosed with CSEP were identified between January 2008 and January 2023. A total of 6% (22/371) women had an advanced live CSEP with crown‐rump length (CRL) of ≥40 mm (≥10 weeks' gestation). Of these, 77% (17/22) opted for surgical intervention, whilst the remaining five continued their pregnancies. A preoperative ultrasound was performed in each patient. All women underwent suction curettage under ultrasound guidance and insertion of Shirodkar cervical suture as a primary hemostatic measure combined with uterine artery embolization (UAE) if required. The primary outcome was rate of blood transfusion. Secondary outcomes were estimated intraoperative blood loss, UAE, intensive care unit admission, reintervention, hysterectomy, hospitalization duration and rate of retained products of conception. Descriptive statistics were used to describe these variables. Results: Median CRL of the 17 patients included was 54.1 mm (range: 40.0–85.7) and median gestational age based on CRL was 12 + 3 weeks (range: 10 + 6–15 + 0). On preoperative ultrasound scan placental lacunae were recorded in 76% (13/17) of patients and color Doppler score was ≥3 in 67% (10/15) of patients. At surgery, Shirodkar cervical suture was used in all cases. It was successful in achieving hemostasis by tamponade in 76% (13/17) of patients. In the remaining 24% (4/17) patients tamponade failed to achieve complete hemostasis and UAE was performed to stop persistent arterial bleeding into the uterine cavity. Median intraoperative blood loss was 800 mL (range: 250–2500) and 41% (7/17) women lost >1000 mL. 35% (6/17) needed blood transfusion. No women required hysterectomy. Conclusions: Surgical evacuation with Shirodkar cervical suture and selective UAE is an effective treatment for advanced live CSEPs. [ABSTRACT FROM AUTHOR]

Background: Postpartum hemorrhage (PPH) and post-abortion hemorrhage (PAH) are life-threatening conditions. Purpose: To evaluate the efficacy and safety of uterine arterial embolization (UAE) for PPH and PAH and to investigate future fertility after UAE. Material and Methods: This study included 57 consecutive patients (mean age = 34 years) who underwent UAE for PPH (n = 46) and PAH (n = 11) at our institution between January 2011 and December 2022. Technical success, non-visualization of the peripheral portion of bilateral uterine arteries on angiography, and clinical success, complete hemostasis after UAE, were assessed. UAE-associated complications and factors related to clinical success were analyzed. Pregnancy outcomes after UAE and complications during subsequent pregnancy were investigated in 16 patients who desired fertility and were followed up for >1 year. Results: The technical and clinical success rates were 100% and 84.2%, respectively. Sepsis (n = 1) and uterine empyema (n = 1) were observed as severe complications. Placental disorder, bleeding within 24 h after delivery or abortion, ≥1.5 shock index, ≥6 units of transfusion erythrocytes, and ≥8 obstetrical disseminated intravascular coagulation score were significantly associated with unfavorable clinical outcomes. In total, 16 pregnancies were observed in 12 patients after UAE, three of which were miscarriages and 13 were successful live births. During pregnancy, uterine rupture (n = 1) and accreta (n = 1) were observed. Conclusion: UAE is an effective treatment for PPH and PAH. Although UAE could preserve future fertility, careful attention should be paid to perinatal management for unusual complications. [ABSTRACT FROM AUTHOR]

Introduction: Uterine artery embolization (UAE) and hysterectomy are often used to treat uterine myoma. Nevertheless, the impact of these two treatments on postoperative ovarian function remains uncertain. Aim: To compare the postoperative ovarian function in individuals with uterine myoma who had UAE against hysterectomy. Material and methods: Searches were conducted in the Wanfang, Web of Science, and PubMed databases to find qualifying studies. The data were combined and analyzed. Results: Seven publications were included in this meta-analysis. Uterus and uterine myoma volume were dramatically decreased by UAE (p < 0.00001 for both). The combined preoperative levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) were similar in both groups. Three months postoperatively, the combined FSH (p = 0.28) and LH (p = 0.64) levels were similar in both groups, while the combined E2 level was notably higher in the UAE group compared to the hysterectomy group (p < 0.00001). Six months postoperatively, the combined postoperative FSH and LH levels were considerably lower in the UAE group compared to the hysterectomy group (p = 0.002 for both). However, the combined E2 levels were similar between the two groups (p = 0.07). Also, 12 months after surgery, the combined postoperative FSH and LH levels were remarkably lower in the UAE group compared to the hysterectomy group (p = 0.02 and p < 0.00001, respectively). However, the combined E2 levels were similar in both groups (p = 0.15). Conclusions: UAE may provide superior preservation of postoperative ovarian function compared to hysterectomy in individuals with uterine myoma. [ABSTRACT FROM AUTHOR]

Uterine fibroids are the most common benign tumor in women of reproductive age and can present with symptoms including bleeding, bulk related symptoms, and infertility. Several treatment options are available for the management of uterine fibroids, including medical management, minimally invasive therapies such as uterine artery embolization and MR-guided focused ultrasound ablation, and surgical interventions ranging from laparoscopic myomectomy to open hysterectomy. Given this wide range of therapeutic interventions, it is important to understand the data supporting these interventions and to be able to apply it in different clinical settings. This document provides a summary of recent trials supporting various therapies for uterine fibroids, including recent evidence for MR-guided focused ultrasound ablation and a detailed discussion of fertility outcomes in myomectomy and uterine fibroid embolization. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation. [ABSTRACT FROM AUTHOR]

In an 8-year period at two medical center, 138 patients underwent uterine artery embolization, and 11 of them were diagnosed with uterine necrosis. Among them, three were successfully conceived. However, one of them developed an arteriovenous malformation after an artificial abortion, and another experienced complications, including placenta previa and placenta accreta spectrum, which resulted in early preterm delivery and recurrent postpartum hemorrhage, necessitating subtotal hysterectomy. Therefore, it is crucial to prepare for potential adverse pregnancy outcomes in subsequent pregnancies for patients with a history of uterine necrosis.

The aim of this study is to uncover potential areas for cost savings in uterine artery embolization (UAE) using time-driven activity-based costing, the most accurate costing methodology for direct health care system costs. One hundred twenty-three patients who underwent outpatient UAE for fibroids or adenomyosis between January 2020 and December 2022 were retrospectively reviewed. Utilization times were captured from electronic health record time stamps and staff interviews using validated techniques. Capacity cost rates were estimated using institutional data and manufacturer proxy prices. Costs were calculated using time-driven activity-based costing for personnel, equipment, and consumables. Differences in time utilization and costs between procedures by an interventional radiology attending physician only versus an interventional radiology attending physician and trainee were additionally performed. The mean total cost of UAE was $4,267 ± $1,770, the greatest contributor being consumables (51%; $2,162 ± $811), followed by personnel (33%; $1,388 ± $340) and equipment (7%; $309 ± $96). Embolic agents accounted for the greatest proportion of consumable costs, accounting for 51% ($1,273 ± $789), followed by vascular devices (15%; $630 ± $143). The cost of embolic agents was highly variable, driven mainly by the number of vials (range 1-19) of tris-acryl gelatin particles used. Interventional radiology attending physician only cases had significantly lower personnel costs ($1,091 versus $1,425, P =.007) and equipment costs ($268 versus $317, P =.007) compared with interventional radiology attending physician and trainee cases, although there was no significant difference in mean overall costs ($3,640 versus $4,386; P =.061). Consumables accounted for the majority of total cost of UAE, driven by the cost of embolic agents and vascular devices. [ABSTRACT FROM AUTHOR]

Black and underinsured women in the United States are more likely than their counterparts to develop uterine fibroids (UFs) and experience more severe symptoms. Uterine artery embolization (UAE), a uterine-sparing therapeutic procedure, is less invasive than the common alternative, open hysterectomy. To determine whether demographic disparities persist in UF treatment utilization, we reviewed patient characteristics associated with UAE versus hysterectomy for UF among studies of US clinical practices. A systematic literature review was conducted via PubMed, Embase, and CINAHL (PROSPERO CRD42023455051), yielding 1,350 articles (January 1, 1995, to July 15, 2023) that outlined demographic characteristics of UAE compared with hysterectomy. Two readers screened for inclusion criteria, yielding 13 full-text US-based comparative studies specifying at least one common demographic characteristic. Random effects meta-analysis was performed on the data (STATA v18.0). Egger's regression test was used to quantify publication bias. Nine (138,960 patients), four (183,643 patients), and seven (312,270 patients) studies were analyzed for race, insurance status, and age as predictors of treatment modality, respectively. Black race (odds ratio = 3.35, P <.01) and young age (P <.05) were associated with UAE, whereas private insurance (relative to Medicare and/or Medicaid) was not (odds ratio = 1.06, P =.52). Between-study heterogeneity (I 2 > 50%) was detected in all three meta-analyses. Small-study bias was detected for age but not race or insurance. Knowledge of demographic characteristics of patients with UFs receiving UAE versus hysterectomy is sparse (n = 13 studies). Among these studies, which seem to be racially well distributed, Black and younger women are more likely to receive UAE than their counterparts. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: Management of cesarean scar pregnancy (CSP) is challenging as there are no specific treatment guidelines and management ought to be individualized. Aim: This study aims to analyze the various treatment modalities done for CSP. Materials and methods: This single-center retrospective study was done between 2017 and 2021 in a tertiary care hospital in South India. Data of all patients with a diagnosis of CSP between 2017 and 2021 were taken from the hospital database, and the cases were analyzed. The patients were divided into the following two groups based on gestational age at diagnosis: Group I, below 8 weeks at diagnosis and group II more than 8 weeks at diagnosis. Statistical analysis was performed, and the results were analyzed and compared between the two groups using Fisher’s exact test for categorical variables and analysis of variance (ANOVA) for continuous variables, and p-value significance was considered as below 0.05. Results: During the 5-year period, there were a total of 23 cases of CSP. The mean age of the women in the study was 30.8 years; 14 belonged to group I and 9 women were in group II; 2.60% had vaginal bleeding; and 30.4% were asymptomatic. Transvaginal ultrasound is used as a diagnostic modality. Most of our patients had combined treatment modalities. Systemic methotrexate (MTX) or uterine artery embolization (UAE) was done prior to the procedure which was followed by either suction and evacuation or excision of scar pregnancy by laparotomy. Suction and evacuation under ultrasound guidance were performed on 12 of 14 patients in group I. The procedure was uneventful in all patients, without any complications during the procedure or post-procedure. There was no significant blood loss requiring a blood transfusion. In group II, laparotomy with excision of scar pregnancy was done in seven out of nine patients. Among them, in two patients suction and evacuation was done initially and proceeded to laparotomy because of increased bleeding. Patients were followed up with day 7 beta-human chorionic gonadotropin (β-HCG). Mean pre- and posttreatment β-HCG levels were calculated. The percentage decrease in β-HCG in group I was 87.66% and in group II was 80.56%. Conclusion: Early diagnosis is very important not only in catastrophic in reducing complications but also in successful management. Patients with early gestational age can be managed successfully with suction and evacuation and for those with higher gestational age and higher beta HCG level, laparotomy and scar pregnancy excision can be done. [ABSTRACT FROM AUTHOR]

Background: There have been conflicting outcomes regarding the use of lidocaine to reduce pain after uterine artery embolization (UAE). Purpose: To investigate the efficacy of intra-arterial lidocaine injection for pain and inflammatory response control within 24 h of UAE for symptomatic uterine fibroids. Material and Methods: Of 1530 patients who underwent UAE for uterine fibroids in 2007–2021, 5 mL of 1% lidocaine was injected into each uterine artery immediately after UAE in 23 patients. A disease-matched control group (n = 23) who did not receive intra-arterial lidocaine was generated from the same registry. The pain score, white blood cell (WBC) count, C-reactive protein (CRP), neutrophil/lymphocyte ratio (NLR), and fentanyl consumption were compared before and after UAE. Complete infarction of the dominant fibroid was assessed using magnetic resonance imaging. Results: Significantly lower WBC count, CRP level, and NLR were noted 24 h after UAE in the lidocaine group. No statistically significant difference was noted in the pain score between groups at 0–24 h. The cumulative fentanyl dose administered during the first 24 h after UAE was not significantly different. After embolization, fibroid-related symptoms resolved in all patients. No significant difference was observed in the rate of complete infarction of the dominant fibroid. Conclusion: Lidocaine administration immediately after UAE resulted in a significant reduction in the inflammatory response. However, such a difference in the inflammatory reaction did not contribute to significant reductions in pain scores or fentanyl consumption. [ABSTRACT FROM AUTHOR]

Background and Objectives: Cesarean scar pregnancy (CSP) represents a type of ectopic pregnancy in which the embryo implants inside the scar of a previous cesarean section. This condition can lead to maternal morbidity and mortality. The best therapeutic approach in terms of clinical effectiveness and patient safety for CSP has not been described yet, although different therapeutic strategies are currently available. The purpose of the present study was to analyze the success rate of two different treatments in a single institution. Materials and Methods: A retrospective study was performed among patients diagnosed with CSP at the Gynecology and Obstetrics Department of the "Cannizzaro" Hospital in Catania (University of Enna—Italy) from January 2016 to December 2022. The diagnosis was made by 2D/3D transvaginal ultrasound, following Timor-Tritsch criteria. Two treatment strategies were performed: local and systemic methotrexate (MTX) injection and uterine artery embolization (UAE) with subsequent dilatation and curettage (D&C). All treated women underwent subsequent clinical and sonographic follow-up. Complete recovery was defined as the reduction of β-HCG values until it was undetectable and the disappearance of the mass in the uterine scar on ultrasound. Results: Nineteen patients were included; nine were in the MTX group and ten were in the UAE + D&C group. No significant differences were found between the two groups in terms of clinical parameters. Treatment was successful in 4 of 10 (44%) patients in the MTX group and 10 of 10 (100%) in the UAE + D&C group (p = 0.01); the length of hospital stay was significantly shorter in the latter group (p < 0.0001). Conclusions: In our experience, administration of MTX is not recommended as the primary treatment or pre-treatment. Dilatation and curettage after uterine artery embolization are better than methotrexate injection for the treatment of cesarean scar pregnancy in a single-institution series in terms of complete recovery and length of hospital stay. [ABSTRACT FROM AUTHOR]

Background/Aims: Demonstration of possible utero-ovarian anastomoses (UOA) before or during uterine artery embolization (UAE) is important to preserve ovarian reserve. This study aimed to evaluate the incidence and risk factors for the presence of type 1b or type 3 UOA in patients undergoing UAE for the treatment of uterine myomas. Methods: Procedural angiographies of patients who underwent UAE were evaluated in a single academic center. Patients’ demographics, indication for UAE, presence and type of UOA, presence of adnexal pathology at preprocedural MRI, history of pelvic surgery, and total uterine volume at preprocedural MRI were retrospectively evaluated. Analysis of the aforementioned variables between patients with and without UOA was performed. Results: This study included 30 patients with a mean age of 41.97±5.72 years (range 32 - 56). UOA was found in 17 (56.6%) patients, 10 (33.3%) of them were type 1b, and 7 (23.3%) of them were type 3. Five patients (17.2%) had adnexal pathology at pre-procedural MRI and 12 patients (40%) had a history of pelvic surgery. The mean total uterine volume was 607.1 cm3. In the analysis of variables between patients with and without UOA, UOA presence was significantly higher in patients with a history of pelvic surgery (p=0.005). All of the patients with a history of myomectomy were found to have type 1b or type 3 UOA. No significant relation between UOA and age, the presence of adnexal pathology, and uterine volume were detected. Conclusion: Utero-ovarian anastomoses are commonly encountered during UAE. A history of pelvic surgery was found to be a risk factor for the presence of type 1b and type 3 UOA.

Background: The objective of this study is to assess the effectiveness of ultrasound-guided suction curettage (UGSC) in conjunction with or without high-intensity focused ultrasound (HIFU) or uterine artery embolization (UAE) for the treatment of three distinct types of cesarean scar pregnancy (CSP). Methods: This was a retrospective study that included subjects diagnosed with CSP in a single tertiary referral centre from January 2015 to December 2020. UGSC associated with/without pretreatment was offered to CSP patients according to the location of pregnancy sac, the depth of implantation and the surrounding blood flowing. The data about baseline characteristics and outcome parameters were analyzed across the three groups. Results: The present study included 434 patients diagnosed with CSP. The majority were cured without severe complication except one case accepted blood transfusion. The baseline data from the three groups did not differ statistically. The UGSC group had the same successful rate of treating type I CSP with a shorter hospital stay (χ2 = 51.771, p = 0.000) compared to the HIFU or UAE groups. Type II CSP presented marked less blood loss (Z = –2.464, p = 0.014) and higher decline ration of beta-human chorionic gonadotropin (β-HCG) (Z = –4.728, p = 0.000) in HIFU group. Treatment success was high in patients with type III CSP in both the HIFU and UAE groups, but the rate of β-HCG decline was higher in the HIFU group (Z = –2.255, p = 0.024). Conclusions: This study suggests that UGSC is an effective and safe option for patients with low-risk CSP. HIFU or UAE combined with UGSC has higher efficacy in high-risk CSP. And HIFU may be superior in reducing bleeding and increasing the rate of β-HCG decline.

Background: Placenta accreta spectrum (PAS) disorders are a continuum of placental pathologies with increased risk for hemorrhage, blood transfusion and maternal morbidity. Uterine artery embolization (UAE) is a safe approach to the standardization of complex PAS cases. The aim of this study is to analyze anemia and transfusion rate, outcome and anesthesiological management of women who underwent caesarean delivery with subsequent UAE for the management of PAS. Material and Methods: This retrospective observational study included all pregnant women admitted to the University Hospital Frankfurt between January 2012 and September 2023, with a diagnosis of PAS who underwent a two-step surgical approach for delivery and placenta removal. Primary procedure included cesarean delivery with subsequent UAE, secondary procedure included placenta removal after a minim of five weeks via curettage or HE. Maternal characteristics, anesthesiological management, complications, anemia rate, blood loss and administration of blood products were analyzed. Results: In total, 17 women with PAS were included in this study. Of these, 5.9% had placenta increta and 94.1% had placenta percreta. Median blood loss was 300 (200–600) mL during primary procedure and 3600 (450–5500) mL during secondary procedure. In total, 11.8% and 62.5% of women received red blood cell transfusion during the primary and secondary procedures, respectively. After primary procedure, postpartum anemia rate was 76.5%. The HE rate was 64.7%. Regional anesthesia was used in 88.2% during primary procedure. Conclusion: The embolization of the uterine artery for women diagnosed with PAS is safe. Anemia management and the implementation of blood conservation strategies are crucial in women undergoing UAE for the management of PAS. [ABSTRACT FROM AUTHOR]

uterine artery embolization (UAE) is important to preserve ovarian reserve. This study aimed to evaluate the incidence and risk factors for the presence of type 1b or type 3 UOA in patients undergoing UAE for the treatment of uterine myomas. Methods: Procedural angiographies of patients who underwent UAE were evaluated in a single academic center. Patients' demographics, indication for UAE, presence and type of UOA, presence of adnexal pathology at preprocedural MRI, history of pelvic surgery, and total uterine volume at preprocedural MRI were retrospectively evaluated. Analysis of the aforementioned variables between patients with and without UOA was performed. Results: This study included 30 patients with a mean age of 41.97±5.72 years (range 32 - 56). UOA was found in 17 (56.6%) patients, 10 (33.3%) of them were type 1b, and 7 (23.3%) of them were type 3. Five patients (17.2%) had adnexal pathology at pre-procedural MRI and 12 patients (40%) had a history of pelvic surgery. The mean total uterine volume was 607.1 cm3. In the analysis of variables between patients with and without UOA, UOA presence was significantly higher in patients with a history of pelvic surgery (p=0.005). All of the patients with a history of myomectomy were found to have type 1b or type 3 UOA. No significant relation between UOA and age, the presence of adnexal pathology, and uterine volume were detected. Conclusion: Utero-ovarian anastomoses are commonly encountered during UAE. A history of pelvic surgery was found to be a risk factor for the presence of type 1b and type 3 UOA. [ABSTRACT FROM AUTHOR]

Objective: This study aims to retrospectively evaluate the outcomes of uterine artery embolization (UAE) for uterine fibroids (UFs), specifically submucosal UFs, according to the International Federation of Gynecology and Obstetrics (FIGO) classification of UFs. Materials and methods: Forty-two patients with symptomatic UFs underwent UAE with Embosphere® between July 2016 and November 2021. MRI was performed before, at 3 and 6 months after the UAE. At each examination, the volume of UF was measured, and the percentage volume reduction rate (VRR) was calculated. The technical success rate (TSR), symptom improvement rate (SIR), regrowth rate (RR) after 6 months, and adverse events (AEs) were examined; VRR was compared between patients with submucosal UFs (FIGO types 0–2, group A), those with submucosal contacts (FIGO type 3, group B), and those without submucosal UFs (FIGO types 4–7, group C). Statistical analysis was performed on the difference in VRR between groups A, B, and C at 3 and 6 months after UAE. The relationship with hormone levels before UAE and VRR was evaluated. Results: Thirty-seven of the 42 patients were evaluated. Overall, VRR was 37.0% at 3 months and 52.1% at 6 months; TSR, SIR, and RR were 100%, 95.2%, and 5.4%, respectively; VRR at 6 months was 80.7% for group A (n = 7), 57.8% for group B (n = 13), and 37.1% for group C (n = 17). Significant differences were found between A and C (p < 0.001) and B and C (p = 0.023). Hormone levels before UAE had no effect on VRR. There was no significant AEs other than grade 3 pulmonary embolism in one patient. Conclusion: UAE was effective for submucosal FIGO types 0–3. UAE was especially useful as an option for FIGO type 3 with a low protrusion rate that is difficult to treat with transcervical resection. [ABSTRACT FROM AUTHOR]

Aims: Owing to the continuous debate and dilemma regarding the appropriate approach for managing fibroids with pregnancy, this review aims to synthesize, analyze and build up evidence from the published studies, especially the recent ones, about the changing trends in the last decade regarding the management of uterine fibroids with pregnancy and the feasibility as well as safety of cesarean myomectomy in comparison to the traditional conservative approach of deferring removal of the fibroids 3--6 months post-partum. Materials and methods: This is a review of the literature, and all the co-authors searched for, gathered, and filtered the most recent publications on the subject through PubMed, Medline, Google search, and others. Findings: The prevalence of fibroids with pregnancy ranges between 0.1 and 3.9% however, the true rate may be higher than this presently reported incidence. Discussion: An increasing trend in diagnosing fibroids with pregnancy is currently clearly obvious, mainly due to the concept of delaying child-bearing as well as the steady increase in the rate of cesarean delivery which leads to more incidental findings of asymptomatic fibroids. Conclusions: Uterine fibroids in pregnancy represent a dilemma in both diagnosis and treatment. Ultrasonography remains the main diagnostic modality for fibroids during pregnancy despite its reduced sensitivity and specificity during pregnancy. Treatment of fibroids with pregnancy continues to be a matter of debate and controversy, where traditionally myomectomy used to be deferred until after delivery and maybe after puerperium. At present both caesarean myomectomy and also, myomectomy during pregnancy have places in modern obstetrics. Statement of significance: • The problem regarding the association of fibroids with pregnancy arises mainly from the challenges in both the diagnosis, where ultrasonography has a reduced sensitivity and specificity during pregnancy, as well as the controversy and debate in the treatment strategies of the condition. • The traditional known practice of managing fibroids in association with pregnancy, is to postpone the removal of fibroids until postnatal and even after puerperium to allow a time for uterine involution and shrinkage of the fibroid hence, minimizing the operative time and the associated blood loss with the potential risks of spontaneous miscarriage, placental dysfunction, fetal malpresentations and preterm birth especially with submucous and intramural fibroids. • This article highlighted the newly introduced interventions in the context of the management of fibroids with pregnancy including, techniques to prevent preterm delivery and achieve term birth in case of treatment delay until post-delivery, or the implementation of cesarean myomectomy as well as myomectomy during pregnancy. [ABSTRACT FROM AUTHOR]

Aim and background: The incidence of cesarean scar pregnancy (CSP) varies from 1/1,800 to 1/2,500 of all pregnancies, which comprises almost six percent of all ectopic pregnancies, in patients with at least one previous cesarean section, and it has increased due to a rise in the number of cesarean deliveries and early detection due to better imaging modalities. Case description: In this case series, three women with early pregnancy presented to the emergency room at our hospital with complaints of lower abdominal pain and spotting or bleeding per vaginum. Diagnosis of CSP was made after performing a transvaginal ultrasound (TVUS) and CSP was successfully managed using systemic methotrexate (MTX) and uterine artery embolization (UAE) in one case and instillation of intracardiac potassium chloride (KCl) along with injecting MTX in the gestational sac in two cases. Beta human Chorionic Gonadotrophin (β-hCG) was measured every week for follow-up until negative. Conclusion: Cesarean scar pregnancy was managed using different modalities depending on the presenting complaints of the woman, clinical features, imaging, and the presence of cardiac activity. Clinical significance: Early detection and timely interventions in CSP are associated with reduced maternal morbidity and mortality. [ABSTRACT FROM AUTHOR]

This study aimed to assess the association of menstrual blood volumes (MBV) and reproductive outcomes in patients after uterine artery embolization (UAE) combined with curettage for caesarean scar pregnancy (CSP). This retrospective observational study enrolled women who underwent UAE plus curettage for CSP at the Interventional Department of Henan Provincial People's Hospital between December 2012 and December 2017. The primary outcome was pregnancy rate and the secondary outcomes were live birth rate (LBR) and interpregnancy interval. This study finally included 37 women (16 women with normal MBV and 21 women with decreased MBV) with pregnancy intention after UAE plus curettage for CSP. The pregnancy rate in women with normal MBV was higher than those with decreased MBV (81.3% vs. 47.6%; P = 0.048). There were no differences between the two groups regarding the interpregnancy interval (18.4 ± 8.7 vs. 22.2 ± 10.0 months, P = 0.233), and LBR (63% vs. 38%, P = 0.191). In conclusion, Women with normal MBV after UAE combined with curettage for CSP management might have a higher pregnancy rate compared with patients with decreased MBV, but there were no differences in LBR between the two groups. [ABSTRACT FROM AUTHOR]

Background: Uterine arterial pseudoaneurysm (UAP) is a rare cause of vaginal bleeding. Usually, UAP follows cesarean section, uterine curettage, vaginal delivery, or cervical conization and must be considered in the differential diagnosis. Here we report a very unusual case of UAP causing intra-abdominal and vaginal bleeding after cervical cerclage and its successful management through the endovascular route. Case Presentation: This 30-year-old P2L1A2 woman presented with vaginal bleeding after 7 days following hysterotomy for termination of pregnancy. At 16 weeks of her index pregnancy, she underwent cervical cerclage for cervical insufficiency, followed by an emergency hysterotomy at 20 weeks for profuse vaginal bleeding after failed medical management. On ultrasound and contrast-enhanced computed tomography (CECT), uterine dehiscence and a cervical pseudoaneurysm were detected. Dehiscence was repaired surgically, and pseudoaneurysm was successfully managed by uterine artery embolization. Conclusion: UAP is an uncommon cause of vaginal bleeding; however, it should be considered in the differential diagnosis of a woman with unusual vaginal bleeding, particularly in the postpartum or postoperative setting like cesarean section, uterine curettage, cervical conization, or cerclage. Endovascular uterine artery embolization is a minimally invasive, effective, preferred, and safe method for managing UAP. [ABSTRACT FROM AUTHOR]

Uterine artery embolization (UAE), a minimally invasive procedure used for controlling and managing profuse bleeding in conditions like uterine fibroids, and uterine hemorrhage, in cases of intractable postpartum hemorrhage (PPH). A wide array of complications due to UAE includes pulmonary embolism, uterine ischemia, necrosis, sepsis, and death. A 27 years old married woman (parity 1+2) presented with complaints of a mass protruding of the vagina with dirty brown vaginal discharge. Following UAE was done for postpartum hemorrhage (PPH) she had developed fever and burning micturition on which ultrasound was done to show an anteverted, enlarged, bulky uterus, with multiple endogenic foci, with endometrial canal and adjacent myometrium suggestive of infective pathology. In this case report complications of UAE for the management of PPH were discussed, however, research is required to comprehend the causes of uterine necrosis following uterine artery embolization and its management. Keywords: Uterine Artery Embolization; Postpartum Hemorrhage; Uterine Necrosis; Pathology.

ObjectiveTo assess the impact of an evidence-informed protocol for management of placenta accreta spectrum (PAS).MethodsThis was a retrospective cohort study of patients who underwent cesarean hysterectomy (c-hyst) for suspected PAS from 2012 to 2022 at a single tertiary care center. Perioperative outcomes were compared pre- and post-implementation of a standardized Multidisciplinary Approach to the Placenta Service (MAPS) protocol, which incorporates evidence-informed perioperative interventions including preoperative imaging and group case review. Intraoperatively, the MAPS protocol includes placement of ureteral stents, possible placental mapping with ultrasound, and uterine artery embolization by interventional radiology. Patients suspected to have PAS on prenatal imaging who underwent c-hyst were included in the analysis. Primary outcomes were intraoperative complications and postoperative complications. Secondary outcomes were blood loss, need for ICU, and length of stay. Proportions were compared using Fisher's exact test, and continuous variables were compared used t-tests and Mood's Median test.ResultsThere were no differences in baseline demographics between the pre- (n = 38) and post-MAPS (n = 34) groups. The pre-MAPS group had more placenta previa (95% pre- vs. 74% post-MAPS, p = 0.013) and prior cesarean sections (2 prior pre- vs. 1 prior post-MAPS, p = 0.012). The post-MAPS group had more severe pathology (PAS Grade 3 8% pre- vs. 47% post-MAPS, p = 0.001). There were fewer intraoperative complications (39% pre- vs.3% post-MAPS, p 1l (95% pre- vs.65% post-MAPS, p = 0.001), ICU admissions (59% pre- vs.35% post-MAPS, p = 0.04) and shorter hospital stays (10 days pre- vs.7 days post-MAPS, p = 0.02) in the post-MAPS compared to pre-MAPS patients. Neonatal length of stay was 8 days longer in the post-MAPS group (9 days pre- vs. 17 days post-MAPS, p = 0.03). Subgroup analyses demonstrated that ureteral stent placement and uterine artery embolization (UAE) may be important steps to reduce complications and ICU admissions. When comparing just those who underwent UAE, patients in the post-MAPS group experienced fewer hemorrhages greater five liters (EBL >5l 43% pre- vs.4% post-MAPS, p = 0.007).ConclusionAn evidence-informed approach to management of PAS was associated with decreased complication rate, EBL >1l, ICU admission and length of hospitalization, particularly for patients with severe pathology.

Enhanced myometrial vascularity (EMV) is a rare disorder associated with various obstetrical and gynecological pathologies. We describe a unique case of interstitial ectopic pregnancy associated with EMV successfully managed with bilateral uterine artery embolization.

Abstract Background Caesarean scar pregnancy (CSP) is a special type of ectopic pregnancy with a high risk of massive haemorrhage. Few studies have focused on the efficacy of prophylactic abdominal aortic balloon occlusion as a minimally invasive method in caesarean section. This study aimed to evaluate the effectiveness and safety of prophylactic abdominal aortic balloon occlusion for patients with type III CSP. Methods This was a prospective cohort study. Patients with type III CSP in the First Affiliated Hospital of Zhengzhou University from January 2020 to June 2022 were enrolled. Eligible patients received prophylactic abdominal aortic balloon occlusion (defined as the AABO group) or uterine artery embolization (defined as the UAE group) before laparoscopic surgery. Clinical outcomes included intraoperative blood loss, body surface radiation dose, hospitalization expenses, and time to serum β-hCG normalization, and safety were also assessed. Results A total of 68 patients met the criteria for the study, of whom 34 patients were in the AABO group and 34 patients were in the UAE group. The median intraoperative blood loss in the AABO and UAE groups was 17.5 (interquartile ranges [IQR]: 10, 45) and 10 (IQR: 6.25, 20) mL, respectively (P = 0.264). The body surface radiation dose of the AABO group was much lower than that of the UAE group (5.22 ± 0.44 vs. 1441.85 ± 11.59 mGy, P

Uterine artery embolization (UAE) is a technique for management of various obstetrical and gynecological problems. Transfemoral approach (TFA) is preferred which can be unilateral or bilateral; however, unilateral puncture is preferred due to lesser chances of puncture-related complications as compared to bilateral puncture. UAE through unilateral TFA is possible with use of reverse loop catheters (Roberts uterine catheter [RUC] or Gandras catheter) to access ipsilateral uterine artery. Other way of cannulating the ipsilateral uterine artery is by maneuvering catheters to form Waltman's loop/Simmon's reverse loop. With advent of RUC, unilateral TFA became standard of care. In the recent past, RUC was retracted from Indian market and its nonavailability had mandated use of either bilateral TFA or use of catheters and techniques used in the past for unilateral TFA. Herein, we describe a technique of doing UAE by unilateral TFA using simple gentle curve catheter (Picard) by making a reverse curve loop.

Hysterectomy is the most common gynecologic procedure performed all over the world and various complications may appear depending on the surgical route. Delayed postoperative hemorrhage is a rare, life threatening complication. It requires timely management and recently the surgical reinterventions tend to be replaced by minimally invasive techniques. Transcatheter arterial embolization shows good results as a treatment strategy for massive vaginal bleeding post hysterectomy, when vaginal vault suturing fails to achieve hemostasis. We report a case of right uterine artery bleeding occurring 30 days after vaginal hysterectomy that was successfully treated by transcatheter arterial embolization.

Abstract Background Uterine arteriovenous malformation (UAVM) is a relatively rare but potentially life-threatening situations abnormal vascular connections between the uterine arterial and venous systems. Lack of recognized guidelines and clinic experience, there is a lot of clinic problems about diagnosis and treatment. By analyzing the clinical data of patients with pregnancy-related UAVM, we aim to confirm the safety of direct surgeries and the benefit of pretreatment (uterine artery embolization or medical therapy) before surgery, and to explore more optimal therapies for patients with pregnancy-related UAVM. Methods A total of 106 patients in Qilu Hospital of Shandong University from January 2011 to December 2021 diagnosed of pregnancy-related UAVM were involved in this study. Depending on whether preoperative intervention was performed, the patients were divided into direct surgery group and pretreatment group (uterine artery embolization or medical management). Clinical characteristics, operative related factors and prognosis were analyzed. Results The most common symptom of pregnancy-related UAVM was vaginal bleeding (82.5%), which could also be accompanied by abdominal pain. Pretreatments (uterine artery embolization or medical therapy) had no obvious benefit to the subsequent surgeries, but increased the hospital stay and hospital cost. Direct surgery group had satisfactory success rate and prognosis compared to pretreatment group. Conclusion For pregnancy-related UAVM, direct surgery has good effects and high safety with shorter hospital stays and less hospital cost. What is more, without uterine artery embolization and other medical therapy, patients could remain better fertility in future.

Abstract A 37-old III gravida II para with two previous cesarean sections (CS) presented in 7 + 3 weeks of pregnancy with cervical ectopic pregnancy (CEP). At 12th week of pregnancy, a cerclage was performed to avoid cervical distention by the expanding placenta. Due to missing experience in CEP management and to avoid emergency operation, we recommended CS in 30th week of pregnancy due to unspecific pain of the patient. Vaginal bleeding never occured. After transverse laparotomy, the urinary bladder was sharply dissected from the anterior uterine and cervical wall. The baby was delivered by transverse cervicotomy caudally of the placenta. The placenta was left in situ. The patient then got prophylactic embolization of the uterine arteries to prevent further severe hemorrhage. 48 h later, ultrasound showed a floating, avascular placenta within a poor echogenic fluid-filled cervical space as well as macrohematuria. After re-laparotomy and cervicotomy at the same day, the placenta was completely and easily evacuated. A bladder injury was recognized and closed. We performed a cervical internal os plasty by inverting the cervical lips and suturing their distal ends on the proximal cervical tissue, resulting in complete bleeding cessation. Although, the patient got 8 erythrocyte concentrates at all, she was always in a stable condition without hemorrhagic shock. This case demonstrates for the first time a live-birth with uterus-conserving management in CEP.

Aim and background: Uterine arteriovenous malformation (AVM) is a rare cause of abnormal uterine bleeding (AUB) in young patients. The condition could be congenital or acquired following uterine trauma due to curettage, or uterine surgeries like myomectomy or cesarean section. Case description: Here we report a 29-year-old lady with previous two therapeutic curettages for missed abortions, who presented with recurrent AUB requiring multiple blood transfusions. Ultrasound and Doppler studies of the pelvis showed features consistent with AVM. The patient underwent angiography of the internal iliac and uterine arteries confirming the AVM on the right side. Successful embolization was performed using n-butyl cyanoacrylate and lipiodol mixture. The patient was discharged after 24 hours of the procedure and the bleeding was effectively controlled. Conclusion and clinical significance: Uterine AVM should be a differential in all young patients with AUB who have a history of uterine instrumentation and a negative pregnancy test. A high degree of clinical suspicion should be maintained to diagnose the condition. Uterine artery embolization is a viable option for acquired AVM in young patients with AUB. [ABSTRACT FROM AUTHOR]

Background: This study aimed to evaluate the effectiveness of different treatments for cesarean scar pregnancy (CSP) and to identify key factors influencing treatment selection, in order to help standardize CSP management. Methods: We retrospectively analyzed data from 220 CSP patients at the Family Planning Department of the Women’s Hospital, School of Medicine, Zhejiang University, from January 2019 to December 2019, adhering to the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines. Treatment methods included dilation and curettage (D&C), curettage after uterine artery embolization (UAE+C), hysteroscopy plus curettage (H/S+C), H/S+C following UAE (UAE+H/S+C), and hysteroscopy combined with laparoscopic resection (L/S+H/S). We assessed treatment outcomes by evaluating the normalization of serum β-human chorionic gonadotropin (β-hCG) levels, disappearance of the isthmic mass, and the occurrence of complications. Results: No significant difference in treatment success rates was found among the groups (p > 0.05). Larger gestational sac diameter (GSD) and thinner myometrial thickness were significant factors in choosing uterine artery embolization (UAE) (p < 0.05), while thinner myometrial thickness alone was a predictor for selecting H/S+C (p < 0.05). The presence of a fetal heartbeat and the subtype of CSP also influenced the choice of UAE and surgical treatment (p < 0.05). Conclusions: This study highlights the need for personalized treatment plans for CSP, considering factors like GSD, myometrial thickness, heartbeat, and CSP subtype. Although no treatment method proved superior, the study identifies important considerations for treatment selection, emphasizing the importance of individualized care in CSP management. The use of STROBE guidelines ensured comprehensive reporting and analysis, offering valuable insights for CSP treatment.

Abstract Background The burden of uterine fibroids is substantial in sub-Saharan Africa (SSA), with up to 80% of black women harboring them in their lifetime. While uterine artery embolization (UAE) has emerged as an effective alternative to surgery to manage this condition, the procedure is not available to the vast majority of women living in SSA due to limited access to interventional radiology (IR) in the region. One of the few countries in SSA now offering UAE in a public hospital setting is Tanzania. This study aims to assess the safety and effectiveness of UAE in this new environment. Methods From June 2019 to July 2022, a single-center, retrospective cohort study was conducted at Tanzania’s first IR service on all patients who underwent UAE for the management of symptomatic fibroids or adenomyosis. Patients were selected for the procedure based on symptom severity, imaging findings, and medical management failure. Procedural technical success and adverse events were recorded for all UAEs. Self-reported symptom severity and volumetric response on imaging were compared between baseline and six-months post-procedure using paired sample t-tests. Results During the study period, 92.1% (n = 35/38) of patients underwent UAE for the management of symptomatic fibroids and 7.9% (n = 3/38) for adenomyosis. All (n = 38/38) were considered technically successful and one minor adverse event occurred (2.7%). Self-reported symptom-severity scores at six-months post-procedure decreased in all categories: abnormal uterine bleeding from 8.8 to 3.1 (-5.7), pain from 6.7 to 3.2 (-3.5), and bulk symptoms from 2.8 to 1 (-1.8) (p

Abstract Objective: To determine the efficacy of Uterine Artery Embolization in patients with bleeding acquired uterine arteriovenous malformations (AVMs). Methods: A prospective review of all patients who underwent Uterine Artery Embolization at our institution between July 2015 and April 2022 was performed. 225 patients were diagnosed with a uterine vascular malformation on doppler and corresponding MRI imaging. All patients underwent transcatheter embolization of the uterine arteries. Embolic agents in the 375 procedures included Histoacryl glue only (n = 326), polyvinyl alcohol (PVA) particles and Histoacryl glue (n = 29), PVA particles (n = 5), Gelfoam (n = 5), coils (n = 4), PVA particles and coils (n = 3), Histoacryl glue and Gelfoam (n = 2), and Histoacryl glue and coils (n = 1). Results: A total of 375 embolization procedures were performed in 225 patients. 90 patients required repeat embolization for recurrence of bleeding. The technical success rate of embolization was 100%. The clinical success rate was 92%: bleeding was controlled in 222 of 225 patients and three patients underwent a hysterectomy. 60 of the 225 patients had uneventful intrauterine pregnancies carried to term. The 210 patients who underwent successful embolization had no recurrence of bleeding at a median follow-up of 53 months (range, 5-122 months) after treatment. 15 patients were eventually lost to follow-up. One minor complication (0.4%) of non-flow-limiting dissection of the internal iliac artery occurred. Conclusion: Uterine Artery Embolization is a safe, effective, minimally invasive method to treat uterine AVMs with long-term efficacy, which can provide the preservation of fertility.

Uterine artery embolization is an established minimally invasive therapy for symptomatic fibroids. It has also been used for other diseases of the uterus, including adenomyosis, uterine arteriovenous malformation, ectopic pregnancy, abnormal invasive placenta, and postpartum hemorrhage. In this review, we provide an updated and comprehensive review of uterine artery embolization based on the evidence published. We review the indications, the role of MRI, technical aspects, and complications of the procedure. The issues with a future pregnancy, risk of infertility, and fetal radiation are discussed as well.