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Venous thromboembolic event in pregnancy is a rare but dreaded complication. When it occurs in labour, it presents with sudden severe fetal distress and maternal haemodynamic compromise. We present to you a case where in patient was taken up for emergency caesarean section for severe fetal distress. Intraoperative ECG showed right heart strain. Hence, an immediate bedside echocardiography was done in medical intensive care unit and it picked up a swirling thrombus in right atrium which immediately got dislodged to pulmonary vessels. Postcaesarean, we faced challenge of controlling active bleeding from atonic uterus with non-surgical techniques (Bakri balloon tamponade and uterine artery embolisation) before considering anticoagulation therapy for pulmonary embolism. The patient recovered well after anticoagulation treatment.

To assess the role of Uterine Artery Embolization (UAE) to treat cesarean scar pregnancy (CSP) using different embolic materials, focusing on its clinical and technical success rates; the association of UAE with methotrexate (MTX) and/or dilatationcurettage (DC) was evaluated also.A retrospective analysis 33 patients (mean age 35 years) affected by CSP and treated with UAE from March 2012 to 2020 was performed. Dynamic levels of serum β-HCG have been collected until they decreased to normal values after procedures. For the statistical analysis the sample was divided into 2 groups: UAE versus UAE + MTX.The gestational sac age ranged between 5 and 13 weeks (mean 7 weeks). According to operator's preference, 11 patients (33.33%) were treated with sponge injection, 2 patients (6.06%) with a combination of sponge and microsphere the remaining 20 patients (60.60%) with microspheres alone. No major complications occurred after UAE and DC, neither side effects related to the MTX administration. Technical and clinical success rates were 97% and 85%, respectively. Mean percentage of β-HCG reduction was 90% (range - 99.92 to + 7.98%). Statistical analysis with linear regression shows a RIn this series UAE has been found to be safe and effective for the treatment of CSP.

Leiomyomata, or fibroids, are a common gynecological problem affecting many women of reproductive age. Historically, myomectomy is offered to women with symptomatic fibroids who desire to preserve fertility. More recently, uterine artery embolization (UAE) has been explored as another fertility-sparing option.This review aims to provide an in-depth summary of the effects on fertility and reproductive outcomes following myomectomy and UAE for the treatment of symptomatic fibroids.Articles were obtained from PubMed using search termsWhile myomectomy and UAE are both fertility-sparing options for women with fibroids, reproductive outcomes following myomectomy are superior to UAE with higher rates of clinical pregnancy and live births and lower rates of spontaneous abortion, abnormal placentation, preterm labor, and malpresentation.Myomectomy should be offered to women with symptomatic submucosal or cavity-distorting fibroids who have a strong desire for a future pregnancy. For women who are not appropriate surgical candidates, UAE can be offered, although detrimental effects on future fertility should be disclosed.A thorough understanding of the efficacy of both myomectomy and UAE, as well as their impact on future fertility, allows for improved counseling when deciding the optimal intervention for women with fibroids who desire future fertility.

To compare the efficacies between ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin and hysteroscopic electro-resection after methotrexate chemotherapy in the treatment of caesarean scar pregnancy (CSP). 60 patients with CSP admitted to our hospital were selected as the study subjects, and divided into observation group (

Uterine artery embolisation (UAE) is a safe and effective procedure for symptomatic uterine fibroids with an estimated rate of post-operative intra-uterine infection of 0.9–2.5%. While rates of infection have remained low over the past two decades, there is variation in infection prevention practices. Intra-uterine infection after UAE may occur via access site haematogenous spread or ascension of vaginal flora through the cervical canal. Although the evidence base is immature, risk factors for infection including previous pelvic infection, hydrosalpinx, endocervical incompetence, diabetes, smoking, obesity, respiratory disease, and immunosuppression should be assessed during the pre-operative consultation with the interventional radiologist to tailor a plan for minimising infection, which may include optimisation of any modifiable risk facts and prophylactic antibiotics.

Ten women with a mean body mass index of 31.5 kg/m

Objective. To investigate the efficacy of uterine artery ligation (UAL) and uterine artery embolization (UAE) in the treatment of uterine asthenia postpartum hemorrhage (PPH) after cesarean section and its effect on uterine and ovarian artery blood flow and function. Methods. 100 patients with uterine asthenia PPH after cesarean section in our hospital from January 2018 to November 2020 were randomly divided into 50 cases in the UAL group and 50 cases in the UAE group. They were followed up for 12 months. The bleeding volume, operation time, immediate hemostasis rate, and hemostasis effective rate; lochia clearance time and menstrual rehydration time; RI and S/D; and serum FSH, E2, and LH levels were compared between the two groups. Results. Compared with the UAL group, the amount of bleeding in the UAE group was significantly increased and the operation time was significantly shortened (p<0.05). There was no significant difference in the immediate hemostatic rate and hemostatic effective rate between the two groups (p>0.05). There was no significant difference in lochia clearance time and menstrual rehydration time between the two groups (p>0.05). There was no significant difference in RI and S/D between the two groups (p>0.05). Compared with before the operation, the levels of FSH and LH in the two groups decreased significantly, and the level of E2 increased significantly (p<0.05). There was no significant difference between the two groups (p>0.05). Conclusion. The efficacy of UAL and UAE in the treatment of PPH with uterine asthenia after cesarean section and its effect on the blood flow and function of uterine and ovarian arteries are equivalent, but the amount of bleeding in UAL is less and the operation time of UAE is shorter. The appropriate operation method can be selected according to the actual situation.

To describe the clinical and fertility outcomes after uterine artery embolization (UAE) for symptomatic uterine arteriovenous malformations (AVMs).This single-center retrospective study included 33 patients with uterine AVMs who underwent UAE at our institution between May 2013 and May 2021. The inclusion criteria were diagnostic features of uterine AVM as detection of the nidus and early venous drainage on angiography. The exclusion criteria were high levels of beta-human chorionic gonadotropin indicative of gestational trophoblastic neoplasia. Polyvinyl alcohol (PVA) with a diameter of 500-700 µm (with or without Gelfoam/Glue) was used in 32 procedures and, Glue (with lipiodol) was used in one. The patients were followed up for 31 months (range, 6-90 months). Angiograms, medical records, and phone interviews were used to describe the technical and clinical success, complications, and pregnancy outcomes.Thirty-three patients with a mean age of 31.2 ± 5.4 years (range, 21-42 years) were included in this case series. Technical success was reported in all patients (100%). Bleeding control was also achieved in 32 (96%) patients. Pelvic and puncture site pain and groin hematoma were reported as minor complications (grade 1 according to CIRSE classification). Six pregnancies (33%) occurred after uterine artery embolization. Four women had full-term pregnancies without complications and delivered healthy newborns. Another two women were in the second trimester of pregnancy with a favorable fetal condition. No post-embolization miscarriage was reported.The UAE is safe and effective in controlling vaginal bleeding caused by uterine AVMs, allowing successful future pregnancies.

Uterine arteriovenous malformations (UAVM) are rare vascular lesions characterized by an abnormal arteriovenous communication between the branches of uterine artery and the myometrial venous plexus. UAVM can be a serious cause of massive post-partum hemorrhage (PPH) leading to potentially life-threatening anemic shock. This review aims to summarize main experiences on clinical presentation and management of UAVM in the setting of unexplained PPH.A systematic review of the literature in Scopus, PubMed and MEDLINE was conducted. A case report of a PPH UAVM-related in a patient managed at the authors' center is also provided.Eleven studies met the inclusion criteria. The mean age of cases was 30. In 3/11 cases, previous uterine surgeries were reported and 72.7% cases gave birth by cesarean section. Nine cases had a secondary PPH (24 h up to 12 week post-partum), whereas only one case had a primary PPH. Our case report had both a primary and a secondary PPH. Reported vaginal bleedings were profuse and blood loss entity ranged from 1000 to 2000 ml. In all cases a color Doppler ultrasound was performed first to suspect UAVM and in 10/11 cases a subsequent pelvic angiography confirmed the diagnosis of UAVM as leading cause of the unexplained PPH. In 81.8% cases a conservative management by uterine artery embolization (UAE) was adopted: bilateral UAE was always successful; in 1 out of 2 cases treated by unilateral UEA, emergency total hysterectomy was performed for a sudden hemodynamic instability.Maternal mortality pregnancy-correlated is a major health concern worldwide, mostly due by PPH. UAVM should be considered in clinical practice among possible causes of unexplained PPH.

Uterine artery embolization (UAE) is a common minimally invasive treatment of different uterine pathologies, such as fibroids, adenomyosis, and menorrhagia. The procedure involves the injection of embolic agents into the uterine arteries, whereby various particles can be used, such as polyvinyl alcohol (PVA). Complication of UAE is the dispersion of polyvinyl alcohol (PVA) microsphere particles in the uterine body which can lead to a granular vaginal discharge. We report the management of complications of PVA microspheres dispersed from the uterine body causing postprocedural discomfort due to the vaginal passage of microspheres or because of an induced fibroid-size enlargement. The dispersion of the PVA microspheres is one example of a minor UAE complication, which nevertheless causes significant distress to the patient and eventfully requires further surgical interventions.

To explore the efficacy of uterine artery embolization (UAE) in the treatment of uterine fibroid and share the experience of transvaginal fibroid expulsion (FE) after UAE.We retrospectively analyzed the changes in uterine and fibroid volume in 152 patients with symptomatic uterine fibroid after UAE at Fujian Provincial Hospital and Fujian Longyan People Hospital from March 2014 to March 2020. After a 12-month follow-up, the improvement in postoperative clinical symptoms and the incidence of complications were evaluated. We also shared the clinical features and imaging findings of four patients with FE after UAE.All 152 patients successfully underwent UAE. After a 12-month follow-up, the postoperative volumes of the uterus and fibroid at 3, 6, and 12 months were significantly reduced or disappeared compared to those before surgery (P 0.05). Clinical symptoms, such as menorrhagia, dysmenorrhea, prolonged menstrual period, anemia, increased leucorrhea, pelvic discomfort, and urinary tract compression, were significantly improved after UAE. Among the 152 patients, the incidences of postoperative fever, nausea, vomiting, lower abdominal pain, and increased vaginal secretion were 7.89%, 7.24%, 3.95%, 19.08%, and 4.61%, respectively. Additionally, there were six cases of FE, with an incidence of 3.95%. Three cases of fibroid specimens and pathological images of fibroid biopsy, which were expelled through the vagina, were also provided.UAE is a satisfactory alternative surgical method for symptomatic uterine fibroid with definitive efficacy and high safety. However, it is necessary to guard against the occurrence of postoperative complications such as FE.

Uterine fibroids are the most common cause of solid pelvic tumours, occurring in 20-30% of fertile women and presenting clinical complications that seriously affect women's health. They commonly cause severe symptoms, such as heavy, prolonged menstrual bleeding and anaemia. The study of microscopic and macroscopic vascular aspects of uterine fibroids is important for understanding the clinical manifestations of uterine fibroids, for predicting the effectiveness of alternative treatments to surgery, i.e. uterine artery embolization, for improving surgery outcomes and for carrying out a differential diagnosis with other benign conditions, e.g. adenomyosis, or malignancy, e.g. leiomyosarcoma, and to develop new therapeutic approaches. In this review, current knowledge of how the vascular network and angiogenesis are implied in the formation of uterine fibroids and in the pathogenesis of related symptoms is explored, and evidence on the role of ultrasound in evaluating fibroid vascularization is summarized. This review combines anatomical, morphological and biomolecular information related to angiogenic mechanisms with diagnostic and clinical information, highlighting the various interconnections. Uterine and fibroid vascularization need further investigation to gain a deeper understanding of the pathogenetic elements that lead to the formation of uterine fibroids and their clinical manifestations.

PURPOSE To prospectively determine the rate of radial artery occlusion (RAO) in patients undergoing transradial access for intra-arterial interventions. MATERIALS AND METHODS Seventy-seven patients undergoing transradial access from August 2019 to March 2021 for 120 intra-arterial procedures (yttrium-90 mapping [n = 39] and radioembolization [n = 38], uterine artery embolization [n = 19], transarterial chemoembolization [n = 10], active bleed embolization [n = 8], angiomyolipoma embolization [n = 4], and other [n = 2]) were enrolled. The average patient age was 59 years ± 13.1 (range, 30-90 years), and 43 (55.8%) of the 77 patients were men. The patients underwent radial artery (RA) palpation, ultrasound evaluation, the Barbeau test, and the reverse Barbeau test prior to and following the intervention. Verapamil, nitroglycerin, and heparin were administered in a total of 114 (95%) of the 120 procedures prior to starting the procedure. The incidence of RAO and radial artery spasm (RAS) was calculated, and univariate logistic regression was performed to analyze the predictors of RAS. RESULTS The preprocedural RA diameter (3.0 mm ± 0.67) was not significantly different from the postprocedural RA diameter (3.0 mm ± 0.65, P = .904). The RAO rate was determined to be 0.8% (1/120), and this artery recanalized within 1 week. Due to the small number of occlusions, statistical analysis of predictors of RAO was not performed. The rate of RAS was 22.7% (27/119). None of the variables tested-including age, sex, RA diameter, initial versus repeat access, operator experience, and artery puncture technique-showed significant prediction for RAS. Patients were seen for follow-up after 111 (92.5%) of the 120 procedures. CONCLUSIONS Transradial access resulted in a

The aim was to compare a protocol of uterine artery embolization (UAE) consisting in three digital subtraction angiographies (DSAs)-Group A, with a protocol based on a single DSA-Group B.This is a single-center prospective randomized study enrolling 20 women (mean age 41 years, range 22-55 years) with uterine fibroids treated with UAE, from January 2015 to February 2016. All UAEs were performed by two interventional radiologists using the same angiography machine. Protocol of Group A consisted in three DSA runs (non-selective pelvic view and selective uterine views before and after embolization). Protocol of Group B consisted in 1 DSA run: selective UA angiography before embolization. (Fluoroscopic roadmap was used for UA catheterization; fluoroscopy storage was used as control after embolization.) Each patient was randomized to receive Protocol A in one pelvic side and Protocol B on the other.All patients received bilateral UAE. Mean fluoroscopy time for UA catheterization was 11.3 ± 3.7 s. (Protocol A) and 9.93 ± 2.99 s. (Protocol B) (p = 0.19). Fluoroscopy dose for catheterization and embolization was not different between both protocols (p = 0.14). Identification of the UA origin score was similar in both protocols (median error = 0, p = 0.79). Mean dose area product (DAP) was 40859 mGy/cmReducing the number of DSA runs from 3 to 1 during UAE allows at least a 30% reduction on radiation exposure, without compromising technical outcomes.

Objectives: The aim of this study was to determine if a long versus short interval between preoperative uterine artery embolization (PUAE) and subsequent myomectomy impact perioperative blood loss and the complication rate in cases of enlarged multi-fibroid uterus. Design: In cases of an enlarged multi-fibroid uterus, operative myomectomy can lead to heavy blood loss and consequently increases the risk for transfusion and hysterectomy. PUAE can possibly contribute to a reduction of these risks. Our study was designed to determine if a long versus short interval between PUAE and subsequent surgery impacts perioperative blood loss and complication rate. Participants and Methods: PUAE was performed 24 h before the planned myoma enucleation in 21 patients between January 2011 and March 2016 (group 1) or 19 days before the operation in 23 patients from March 2016 to May 2018 (group 2). A comparison was made to a historical sample of 57 patients with large myomas (>10 cm) without PUAE (group 3). Perioperative blood loss, need for postoperative blood transfusion, and postoperative complications were recorded. Subjective improvement of myoma-related symptoms was assessed for each group by a questionnaire. Results: PUAE was carried out successfully without complications in all patients. Conversion to hysterectomy was not needed in any of the PUAE patients but was necessary in one of the control patients. In the three groups’ comparison, there was a significant lower risk for high blood loss (≥500 mL) in group 1 and a lower but not significant lower risk in group 2 compared to group 3 without an embolization preoperatively. Also, a significant lower risk for postoperative blood transfusion for group 1 (OR 0.02; 0.001–0.328; p = 0.01) and 2 (OR 0.02; 0.001–0.277; p = 0.01) compared to group 3 was observed. The postoperative complication risk was lower in group 2 (model 1: OR 0.12; 0.016–0.848; p = 0.03; model 2 OR 0.07; 0.009–0.588; p = 0.01) compared to group 3. In the context of the postoperative questionnaire, 10 of 11 patients in group 1, 12 of 12 patients in group 2, and 31 of 36 patients from the control group reported an improvement of their complaints. Conclusion: PUAE is beneficial for uterus-preserving removal of myomas from patients with a substantially enlarged uterus. There is a significant reduction of high blood loss (≥500 mL), need for postoperative blood transfusion, and postoperative complications in patients with extensive fibroid disease after PUAE compared to no intervention before myoma enucleation.

Objective Uterine artery embolization is an attractive option for the management of postpartum haemorrhage, however it is not available in every hospital. We compared the clinical characteristics and haemodynamic state of patients with postpartum haemorrhage, before and after helicopter transfer to a tertiary hospital for possible uterine artery embolization. We also analysed whether the type of treatment could modify the outcome. Study design: Between 1999 and 2019 in Switzerland, we retrospectively found 82 consecutive patients with postpartum haemorrhage who were transferred by a physician-staffed helicopter emergency medical service to the tertiary hospital for potential uterine artery embolization. The collected data included the type of delivery, estimated blood loss, shock index and blood lactate levels before transfer and at destination, uterine artery embolization rate and hospital mortality rate. Our primary outcome was to describe the clinical characteristics, outcomes and haemodynamic state of the patients with postpartum haemorrhage before and after helicopter transfer. Our secondary outcome was to report the treatments performed at the tertiary hospital. The collected data were analysed with Stata version 14 (Stata Corporation, College Station, TX, USA). Continuous data are compared by using the Student's t-test or the Mann-Whitney U test, as appropriate. Results We included 69 patients. Postpartum haemorrhage occurred after vaginal delivery in 38 cases (55%). Blood loss prior to transfer exceeded 2 L in 34% of cases. The median shock index was 1 (IQR 0.8 to 1.1) before transfer and 0.9 (IQR 0.8 to 1.1) after transfer (p=0.41). The median lactate level was 2.9 mmol/L (IQR 2.1 to 6.8) before, and 2.1 mmol/L (IQR 1.55 to 3.5) after transfer (p=0.90). Forty-four patients underwent uterine artery embolization (64%), with an overall success rate of 93%. One patient died (1.4%), from a haemorrhagic shock of abdominal origin. Conclusions Interhospital helicopter transfer of patients with postpartum haemorrhage to a tertiary hospital seems to be safe in our setting, despite a significant proportion of patients exhibiting signs of haemodynamic instability. Decision criteria would be helpful to better guide choices regarding the transfer of patients with postpartum haemorrhage.

Purpose: Transradial arterial access has become more popular in body interventional procedures but has not been ubiquitously adapted. This retrospective study assesses the efficacy of this approach in uterine artery embolization. Aim of the study was to compare transradial to transfemoral arterial access in patients undergoing uterine artery embolization for the treatment of fibroids. Material and methods: A total of 172 patients underwent uterine artery embolization procedures at our institute from October 2014 to June 2020. Of these, 76 patients had their operations performed via transfemoral access while 96 underwent transradial access. The peak radiation dose, fluoroscopy time, procedure time, total contrast volume, and equipment cost for each procedure were all reviewed to evaluate for statistical differences between the 2 groups. Results: All cases were technically successful without major complications. The average peak skin dose was 2281 mGy, with no statistical difference between the transradial or transfemoral cohorts. Average fluoroscopy time was 25 minutes, also with no statistical difference between the subsets. Mean procedure time was 100 min, and mean contrast volume usage was 138 mL with no statistical differences. Similarly, the average equipment cost was $2204, with no significant differences found between transradial and transfemoral access. Conclusions: With respect to many pertinent radiation parameters, transradial access was evaluated as being an equally efficacious alternative to transfemoral access in uterine artery embolization procedures. The results of this study suggest that transradial access should be considered more often, whenever viable, as an option in the uterine artery embolization treatment of fibroids.

Проведен поиск информации по базам данных PubMed, Scopus, Webof-science, РИНЦ по следующим ключевым словам: post-embolization syndrome, uterine artery embolization, uterine myoma, без языковых ограничений. Для анализа выбрали 50 источников с полным доступом к тексту, 90 % которых были опубликованы в течение последних пяти лет, а 50 % – в течение последних трех лет. Критерием исключения источников служили малая информативность и устаревшие данные. Постэмболизационный синдром (ПЭС) после эмболизации маточных артерий (ЭМА) при миоме матки является ранним послеоперационным осложнением, развивается в первые 24-48 часов после проведения процедуры и обычно спонтанно разрешается в течение 10-14 суток. Частота ПЭС сегодня точно не установлена, поэтому находится в широком диапазоне: от 0,2 % до 96 %. Профилактика и лечение ПЭС заключается в интраоперационной и послеоперационной симптоматической терапии симптомов осложнения. Используются разные стратегии – внутриартериальное интраоперационное введение анестетиков, назначение нестероидных противовоспалительных препаратов, парацетамола и опиоидов. Следует отметить, что рекомендации, касающиеся профилактики тяжелого ПЭС и его лечения при ЭМА, основаны на исследованиях низкого качества с недостаточным количество наблюдений. В стратегии борьбы с ПЭС для создания единых подходов, основанных на доказательной медицине, необходимы дальнейшие крупные рандомизированные клинические исследования., The search for information was carried out in the PubMed, Scopus, Webof-science, RSCI databases using the following keywords: post-embolization syndrome, uterine artery embolization, uterine myoma, without language restrictions. For analysis, 50 sources with full access to the text were selected, 90 % of which were published within the last five years, and 50 % within the last three years. The criteria for excluding sources were low information content and outdated data. Post-embolization syndrome (PES) after uterine artery embolization (UAE) in uterine myoma is an early postoperative complication that develops in the first 24-48 hours after the procedure and usually resolves spontaneously within 10-14 days. The frequency of PES has not been precisely established today, therefore it is in a wide range: from 0.2 % to 96 %. Prevention and treatment of PES consists of intraoperative and postoperative symptomatic treatment of the symptoms of the complication. Different strategies are used – intra-arterial intraoperative administration of anesthetics, the appointment of non-steroidal anti-inflammatory drugs, paracetamol and opioids. It should be noted that recommendations regarding the prevention and treatment of severe PES in UAE are based on low-quality studies with insufficient follow-up. In the strategy to combat PES, further large randomized clinical trials are needed to create unified approaches based on evidence-based medicine.

Проведен поиск информации по базам данных PubMed, Scopus, Web of Science, РИНЦ по следующим ключевым словам: infection prevention, uterine artery embolization, uterine myoma, etiology, pathogenesis, diagnosis, treatment, без языковых ограничений. Для анализа выбрали 34 источника с полным доступом к тексту, 90 % которых были опубликованы в течение последних пяти лет, а 50 % – в течение последних трех лет. Критерием исключения источников служили малая информативность и устаревшие данные. Эмболизация маточной артерии (ЭМА) – эффективная и безопасная процедура с низкой общей частотой послеоперационных инфекций матки (< 2,5 %), аналогичная миомэктомии. Входными воротами инфекции при ЭМА вероятнее всего является процедурный артериальный доступ или цервикальный канал для вагинальной микрофлоры. Для профилактики послеоперационных инфекционных осложнений рекомендуется в течение часа перед разрезом на коже внутривенное введение антибиотиков. Следует отметить, что многие выводы и рекомендации, касающиеся подходов к профилактике инфекций после эмболизации маточных артерий при миоме матки основаны на исследованиях низкого качества с недостаточным количеством наблюдений. В стратегии борьбы с инфекционными осложнениями при ЭМА для создания единых подходов, основанных на доказательной медицине, необходимы дальнейшие крупные рандомизированные клинические исследования., Information was searched for PubMed, Scopus, Webof-science, RSCI databases using the following keywords: infection prevention, uterine artery embolization, uterine myoma, etiology, pathogenesis, diagnosis, treatment, without language restrictions. For the analysis, 34 sources with full access to the text were selected, 50 % of which were published within the last five years, and 90 % within the last three years. The criteria for excluding sources were low information content and outdated data. Uterine artery embolization (UAE) is an effective and safe procedure with a low overall incidence of postoperative uterine infections (< 2.5 %), similar to myomectomy. The entrance gate of infection in UAE is most likely a procedural arterial access or cervical canal for vaginal microflora. For the prevention of postoperative infectious complications, intravenous antibiotics are recommended within an hour before the incision on the skin. It should be noted that many of the conclusions and recommendations regarding approaches to infection prevention after uterine artery embolization for uterine fibroids are based on low-quality studies with insufficient follow-up. In the strategy of combating infectious complications in UAE, further large randomized clinical trials are needed to create unified approaches based on evidence-based medicine.

Objective To study the risk factors leading to type II/III cesarean scar pregnancy and evaluate the efficacy of hysteroscopic treatment and subsequent reproductive outcomes. Design Retrospective study from 2013 to 2018. Setting Inpatient samples. Patient(s) A total of 439 patients with cesarean scar pregnancy received hysteroscopic treatment. They were grouped according to the type of surgery as hysteroscopy combined with dilation and curettage, systemic methotrexate followed by hysteroscopy combined with dilation and curettage, and uterine artery embolization or laparoscopic ligation of bilateral uterine arteries followed by hysteroscopy combined with dilation and curettage. Cesarean scar pregnancy was classified as types I, II, and III on the basis of the relationship between the gestational sac and myometrial thickness by ultrasound. Intervention(s) Not applicable. Main Outcome Measure(s) Risk factors leading to type II/III cesarean scar pregnancy. The success of hysteroscopic treatment as well as favorable reproductive outcomes. Result(s) The significant variables were multiple parity, prior cesarean section (CS), hysteroscopic therapy, and dilation and curettage after the last CS between type I and type II/III. There were significant differences among the three groups in symptoms, largest diameter of the gestational sac, presence of fetal heartbeat, myometrial thickness, type of cesarean scar pregnancy, blood loss, length of hospital stay, and expense. The rates of complications and success were 8.2% and 93.6%, respectively. Thirty-seven women conceived again, and 22 women completed a term pregnancy with no uterine rupture. The recurrence rate of cesarean scar pregnancy was 10.8%. Conclusions The type of cesarean scar pregnancy is related to the rates of multiple parity, cesarean deliveries, and dilation and curettage procedures after the last CS. Hysteroscopic therapy is a safe and effective surgical approach with a low risk of subsequent ectopic pregnancy.

PURPOSE This study aimed to investigate the effect of prophylactic uterine artery embolization (UAE) on reproductive outcomes in patients with cesarean scar pregnancy (CSP). METHODS A retrospective case-control study was conducted using the hospital records of all women diagnosed with CSP during a period of 6 years, between January 2014 and December 2019, at Shengjing Hospital of China Medical University. The clinical characteristics and different treatment modalities were analyzed. According to the inclusion and exclusion criteria, 181 patients with reproductive needs were selected and divided into a UAE group (n = 51) and a non-UAE group (n = 130) according to whether they received preventive UAE before their hysteroscopic or laparoscopic operation. The basic characteristics and pregnancy outcomes of patients in each group were compared, and a propensity score-matched (PSM) analysis was used to produce 37 matched pairs. RESULTS Before PSM, the UAE group had a thinner muscle layer, larger mass size, and higher serum human chorionic gonadotropin level than the non-UAE group. The pregnancy rate and live birth rate of the UAE group were 54.9% and 61.9%, respectively, which were lower than those of the non-UAE group (61.5% and 66.7%), but no statistical differences were observed. Post-PSM, no significant differences between basic characteristics of the groups were observed. The pregnancy rate of the UAE group was 51.4%, which was lower than that of the non-UAE group (73.0%); the live birth rate of the UAE group was 64.3%, which was also lower than that of the non-UAE group (72.7%); however, the differences were not statistically significant with the P value of 0.077 and 0.716. CONCLUSION Prophylactic UAE did not induce a significant difference in pregnancy rate and live birth rate between the UAE group and the non-UAE group.

Objective: To investigate the association between magnetic resonance imaging (MRI) classification and symptom relief after uterine artery embolization (UAE) in patients with adenomyosis. Methods: Totally, 73 patients with symptomatic adenomyosis who underwent UAE were retrospectively analyzed. Preoperative MRI classification was defined as: type I, high signal on both T2-weighted images (T2WI) and T1-weighted images (T1WI); type III, high signal only on T2WI, and type II, high signal on neither T1WI nor T2WI. Dysmenorrhea was measured with the visual-analog scales and the degree of menorrhagia was measured according to the number of sanitary pads used in one menstrual cycle. Dysmenorrhea and menorrhagia were measured before UAE and 12 months after UAE. Results: The number of the type I, II, III cases was 23, 37, and 13, respectively. The baseline characteristics of the three groups exhibited no significant difference. The alleviation rates of dysmenorrhea among type I, II, III cases were 73.9%, 89.2%, and 84.6%, respectively (P=0.455). The alleviation rates of menorrhagia for type I, II, III were 69.6%, 78.4%, and 92.3%, respectively (P=0.714). Conclusion: Pre-procedure MRI classification and symptom relief after UAE exhibited no significant association. UAE has a favorable mid-term control on dysmenorrhea and menorrhagia among patients with adenomyosis. Preoperative MRI classification might not indicate symptom relief. More research is needed before changing clinical practice.

Aim To introduce the novel use of lauromacrogol for cesarean scar pregnancy (CSP), and to compare the clinical efficacy and safety of curettage combined with ultrasound-guided sclerosant injection (USI) and curettage following uterine artery embolization (UAE) in the treatment of CSP. Methods CSP patients undergoing curettage combined with USI (n = 72) from December 2014 to May 2020 were compared to patient with curettage following UAE (n = 72).The basic clinical findings and clinical outcomes were reviewed between the two groups. Results For USI group, 69 patients underwent successful treatment (95.8% success rate), while the number of cured patients for the UAE group was 70 (97.2% success rate). Differences between USI group and UAE group in intraoperative blood loss (10.0 [10.0-20.0] vs. 10.0 [10.0-20.0] mL) and time for serum β human chorionic gonadotropin (β-hCG) to reduce to normal (28.0 [21.0-40.0] vs. 28.0 [21.0-35.0] days) were not statistically significant. The hospital stay for USI group was significantly shorter than that for UAE group (4.0 [4.0-6.0] vs. 6.0 [5.0-7.0] days, respectively). Statistically significant decreases were noted in hospitalization expenses and adverse events in USI group, compared to UAE group. There was no difference in live birth rate between the two groups with fertility intentions during the follow-up. Conclusion For treatment of CSP, curettage combined with USI yielded clinical results comparable to those of curettage following UAE. Curettage combined with USI was associated with lower hospitalization expenses, shorter hospital stay and less complications, and it merited an effective and safe treatment for CSP.

To study the efficacy and safety of uterine artery embolization in treatment of obstetric hemorrhage. This ethically approved prospective study was conducted between November 2017 and October 2019, and written informed consent was obtained from all patients. Consecutive patients presenting with uncontrolled obstetric hemorrhage were evaluated. Fifty-three patients with uncontrolled bleeding underwent uterine artery embolization (UAE) and were followed up. Spectrum of patients encountered in this study was arteriovenous malformations (AVMs) (n = 25), retained products of conception (RPOC) (n = 16), RPOC with secondary AVMs (n = 5), ectopic pregnancy (n = 5) and iatrogenic trauma to cervix or vagina (n = 2). A total of 57 UAE procedures were performed in these 53 patients as repeat sessions were required in four patients. Most common embolic agent used was polyvinyl alcohol (PVA) particles with gelfoam followed by cyanoacrylate glue as second most common agent. Technical success was achieved in 57 (100%) of 57 UAE procedures. Primary clinical success was achieved in 49 (92%) of 53 patients and secondary clinical success in 52 (98%) patients. Clinical failure was observed in one patient who underwent hysterectomy. Uterine artery embolization is a safe and effective procedure in the management of uncontrolled obstetric hemorrhage.

Objective Our study seeks to assess the value of transvaginal two-dimensional ultrasound combined with color Doppler in evaluating ovarian function and reproductive function after uterine artery embolization (UAE). Methods Totally 64 cases with cesarean scar pregnancy (CSP) were collected. Their information was recorded, including baseline information, intraoperative and postoperative information, preoperative and postoperative uterine receptivity, and preoperative and postoperative levels of sex hormones in serum. Finally, the patients were followed up to observe whether they were pregnant after treatment. Results In comparison with 24 hours after UAE, decreases were found in endometrial blood flow pulsatility index (PI), endometrial thickness, ovarian artery peak end-systolic velocity (Vs), ovarian artery resistance index (RI), and the ratio of Vs to peak end-diastolic velocity (S/D) 1 and 3 months after embolization, while Vd increased markedly 3 months after embolization. In addition, in terms of sex hormones, a significant increase was revealed in the level of follicle-stimulating hormone, while the reduction in the levels of luteinizing hormone (LH), estrogen (E2), prolactin (PRL), and progesterone (P) in the first month and the third month of menstrual resumption compared with those before treatment. From the follow-up data, there were 50 cases of pregnancy, including 45 cases of intrauterine pregnancy, 2 cases of tubal pregnancy, and 3 cases of recurrent CSP. Conclusion UAE is a safe and effective method to prevent massive hemorrhage of CSP. Transvaginal two-dimensional ultrasound combined with color Doppler can more accurately evaluate its therapeutic effect and provide a basis for effective treatment.

Objective To quantify the efficacy of medical management of uterine arteriovenous malformation (AVM) and compare efficacy between different classes of medication. In addition, we evaluated for factors associated with treatment success and pregnancy outcomes after medical management. Design Systematic review and meta-analysis. Setting Not applicable. Patient(s) Thirty-two studies representing 121 premenopausal women with medically-treated uterine AVM were identified via database searches of MEDLINE, Embase, Web of Science, and cited references. Intervention(s) Medical treatment with progestins, gonadotropin-releasing hormone agonists (GnRH-a), methotrexate, combined hormonal contraception , uterotonics, danazol, or combination of the above. Main Outcome Measure(s) Primary outcome of treatment success was defined as AVM resolution without subsequent procedural interventions. Secondary outcome was treatment complication (readmission or transfusion). Result(s) The overall success rate of medical management was 88% (106/121). After adjusting for clustering effects, success rates for progestin (82.5%; 95% confidence interval [CI], 70.1%–90.4%), GnRH-a (89.3%; 99% CI, 71.4%–96.5%) and methotrexate (90.0%; 99% CI, 55.8%–98.8%) were significantly different from the null hypothesis of 50% success. The agents with the lowest adjusted proportion of complications were progestins (10.0%; 99% CI, 3.3%–26.8%) and GnRH-a (10.7%; 99% CI, 3.5%–28.4%). No clinical factors were found to predict treatment success. Twenty-six subsequent pregnancies are described, with no reported recurrences of AVM. Conclusion(s) Medical management for uterine AVM is a reasonable approach in a well selected patient. These data should be interpreted in the context of significant publication bias.

Objective Adenomyosis usually causes dysmenorrhea and anemia. Clinically, it is difficult to be treated with medicine or by traditional surgery, however, hysterectomy is always performed for radical treatment. In this article, we introduce a new method that could control the dysmenorrhea and the anemia through laparoscopic uterine artery occlusion (LUAO) combined with uterine-sparing pelvic plexus block and partial adenomyomectomy for uterus preservation. Design Surgical video article. Local institutional review board approval for the video reproduction was obtained. Setting A 42-year-old patient, who had a history of a previous cesarean delivery, was admitted to our department with complaints of progressive dysmenorrhea for more than 5 years and aggravated with anemia for 1 year. The patient had failed treatment with traditional Chinese medicine and gonadotropin-releasing hormone and had to take painkillers for nearly half a year. The patient had no desire for another pregnancy. After careful consideration, the patient strongly rejected hysterectomy and demanded the preservation of the uterus, insisting on the integrity of the organs. A gynecologic examination showed that the uterus was hard and enlarged similar to one that is more than 8 gestational weeks, without tender nodules in the rectouterine pouch. The visual analog scale pain score was 7, and her hemoglobin was 93 g/L (after correction). The preoperative magnetic resonance imaging implied that there was 1 lesion in the posterior wall and the maximum diameter of the lesion was 7.8 cm. Interventions We performed laparoscopic partial adenomyomectomy combined with occlusion of uterine artery to limit the amount of intraoperative bleeding, dissected the uterine branch of pelvic plexus nerve, and performed electrocoagulation blocking to relieve the dysmenorrhea. The specific operation procedures are as follows ( Video ): Firstly, we opened the peritoneum through Cheng's triangle, which contained the external iliac blood vessels, the round ligament, and the infundibulopelvic ligament ( Fig. 1 ). Secondly, we separated the lateral rectal space and exposed the ureter, the internal iliac artery, the uterine artery, and the deep uterine vein. Thirdly, we found that the pelvic plexus was located on the outside of the sacral ligament and was approximately 2 to 3 cm below the ureter, going against the sacral ligament and passing through below the deep uterine vein ( Supplemental Video 1 ). Fourthly, we separated the 4 layers of the paracervix [1] . The first layer included the internal iliac artery and the uterine artery. The second layer was the ureter. The third layer was the deep uterine vein. The last layer was the pelvic plexus, which involved the forward-going bladder branch, the inward-going uterine branch, and the downward-going rectal branch ( Supplemental Video 2 ). These anatomic structures are similar to the complex architecture of an overpass called the Cheng's Cross [2] ( Fig. 2 ). In this operation, only the uterine artery and the uterine branch would be blocked. Finally, we performed the partial adenomyomectomy. The endometrium, the myometrial tissues, and the serosa were repaired in some layers with continuous suture, depending on the depth of incision. The operation time was 92 minutes, and the intraoperative hemorrhage was approximately 50 mL. The patient was able to get out of bed on the first day after the operation and urinate after removing the catheter. On the second day after the surgery, the patient had exhaustion and defecation. From the third day after the surgery, gonadotropin-releasing hormone (Goserelin Acetate Sustained-Release Depot,3.6mg each, subcutaneous injection, name of the enterprise: AstraZeneca UK Limited) was used every 4 weeks, with a total of 3 times. Menstruation began on the 67th day after withdrawal of the drug. The results of postoperative condition of the patient followed up at 6 months after surgery were collected as follows: dysmenorrhea was significantly relieved (visual analog scale score was 2), hemoglobin was 123 g/L, and uterine volume was reduced to 43% of preoperative volume. The comparison of the patient's preoperative and postoperative magnetic resonance imaging showed that the uterus was approximately the same size as that of a woman of the same age, and the incision healed well ( Fig. 3 ). Conclusion Adenomyosis is a common gynecologic disease, mainly occurring in women of childbearing age. Adenomyosis is defined as endometrial glands and stroma that invade the myometrium and is surrounded by chronical inflammation in the endometrium [3] . Secondary dysmenorrhea and menorrhagia are the most common chief complaints in patients with adenomyosis, among which dysmenorrhea is the most unbearable symptom [2] . In the past, we had always treated adenomyosis by hysterectomy [4] . With the continuous pursuit of quality of life, it is difficult to meet clinical needs through drugs and traditional surgical methods. Uterine sparing surgery is a current trend in the treatment of adenomyosis, which enables women to maintain fertility and avoid the effects of hysterectomy on sexual function and mental discomfort. Dysmenorrhea can be divided into peripheral dysmenorrhea and central dysmenorrhea. According to our previous studies on dysmenorrhea, the uterine branch nerve has a controlling effect on dysmenorrhea [2] . The purpose of pelvic plexus uterine branch ablation is to further relieve dysmenorrhea by blocking nerve conduction pathways. Therefore, we selectively blocked the uterine branch nerve to alleviate the dysmenorrhea of adenomyosis. The uterine artery controls 90% of uterine blood flow. According to our team research, LUAO is an effective method to treat symptomatic uterine myomas and adenomyosis. We investigated the morphologic change and apoptosis occurring in myomal and adjacent myometrial tissues after LUAO. We concluded that apoptosis through mitochondrial pathways may lead to reduction of the volume of myoma and myometrium and eventually relief of symptoms [ 5 , 6 ]. We speculated “single organ shock uterine” to explain uterine artery occlusion (UAO) mechanism, which was different from uterine artery embolization. The single organ shock theory of UAO can still inhibit the growth of myomas effectively. It is difficult to completely remove adenomyosis lesions during surgery, especially for diffuse adenomyosis. Therefore, in our team, we performed UAO combined with resection of focal lesions in key areas for patients with diffuse adenomyosis, instead of pursuing radical resection [ 7 , 8 ]. The purpose of UAO is to reduce the amount of bleeding during surgery and further atrophy of residual and scattered adenomyosis lesions in utero [ 5 , 6 ]. The intraoperative blocking of the uterine artery can reduce intraoperative bleeding and operation time, improve operation quality, and decrease recurrence rate. In our team, this technique has been used in clinic for more than 10 years. Our previous studies have shown that LUAO combined with pelvic plexus uterine branch nerve block and resection of most of the adenomyosis has achieved satisfactory clinical efficacy as a treatment for adenomyosis [ 2 , 3 ]. With this procedure, we can help patients with adenomyosis retain their uterus and relieve the anxiety caused by hysterectomy. In conclusion, UAO and uterine branch ablation in uterine sparing laparoscopic treatment is a safe and effective method, which may be considered as a good choice for symptomatic adenomyosis.

The purpose of this study was to introduce a continuous quality improvement (CQI) program for radiation dose optimisation during uterine artery embolisation (UAE) and assess its impact on dose reduction and image quality. The CQI program investigated the effects of optimising radiation dose parameters on the kerma-area product (KAP) and image quality when comparing a ‘CQI intervention’ group (n = 50) and ‘Control’ group (n = 50). Visual grading characteristics (VGC) analysis was used to assess image quality, using the ‘Control’ group as a reference. A significant reduction in KAP by 17% (P = 0.041, d = 0.2) and reference air kerma (Ka, r) by 20% (P = 0.027, d = 0.2) was shown between the two groups. The VGC analysis resulted in an area under the VGC curve (AUCVGC) of 0.54, indicating no significant difference in image quality between the two groups (P = 0.670). The implementation of the CQI program and optimisation of radiation dose parameters improved the UAE radiation dose practices at our centre. The dose reduction demonstrated no detrimental effects on image quality.

This review will examine the use of uterine artery embolization (UAE) for the management of adenomyosis (AUB-A) and evaluate its advantages and disadvantages. In the last 5 years, 8 articles have described UAE for the management of AUB-A. These include 2 prospective and 5 retrospective studies and 1 systematic review and meta-analysis. There are no randomised controlled trials for UAE as a treatment of adenomyosis. Recent data report a reduction in heavy menstrual bleeding (HMB) in 80–88% of patients and a reduction in dysmenorrhoea in 76–80% of those undergoing UAE. Quality of life is reported to be significantly improved and uterine volumes reduced following treatment. Disadvantages of UAE include post-procedural pain, adenomyoma extrusion, pyomyoma, Asherman syndrome, and requirement for further intervention including subsequent hysterectomy for management of pain or bleeding. Initial non-randomised data support uterine artery embolization as an effective modality for the conservative management of AUB-A. The advantages of UAE include avoidance of abdominal surgery, significant improvement in symptoms, and quality of life scores and preservation of reproductive potential. To date, most data are retrospective with no randomised controlled studies and a few prospective analyses. Randomised controlled data are needed to comprehensively evaluate UAE as conservative treatment for AUB-A and to compare efficacy, cost, and durability of both medical and surgical treatments.

Introduction. Uterine leiomyomas are the most common benign pelvic tumors in women over 35 years and can be symptomatic or asymptomatic. Among the main treatment strategies, there are hormone therapy, hysterectomy, myomectomy, and uterine artery embolization (UAE), a recent and promising treatment for patients who wish to avoid hysterectomy. Ideal candidates for UAE are women with symptomatic uterine leiomyomas that present no desire for pregnancy, premenopausal and heavy menstrual bleeding, or dysmenorrhea caused by intramural fibroids. Case Presentation. A 36-year-old female diagnosed with leiomyomas and an extensive history of failed previous treatments who, in order to preserve her uterus, underwent UAE and had tumor expulsion 15 days after the procedure. The patient remained eight months in amenorrhea and, currently, presents normal hormone levels and irregular periods. Conclusion. UAE presents itself as a minimally invasive procedure and as an efficient alternative for those patients who wish to preserve their uteri and also improve their symptoms and quality of life.

Uterine vascular abnormalities though are not very common but are potentially life threatening as can lead to torrential vaginal bleeding. Although they are considered relatively rare, with fewer than 150 cases reported in the literature, a true incidence of the uterine AVM may be much higher. We are reporting a case which was diagnosed as molar pregnancy and suction curettage was done, at the time of the evacuation there was excessive bleeding which was immediately dealt with the tamponade by the Foleys catheter and the vaginal packs till the arrangements for the uterine artery embolization were done. At the time of embolization right uterine artery arteriovenous malformation was detected incidentally and embolized along with the uterine arteries. The post op recovery of the patient was uneventful. Retrospectively when the Doppler ultrasound was reassessed hypoechoic lesions and dilated veins were seen in the myometrium which were misdiagnosed as molar. In any patient if the myometrium shows dilated veins and on Doppler if abnormal active vessel flow with a coloured mosaic pattern is detected uterine AVM should be suspected and should be investigated further with the computed tomography (CT) for proper treatment of the patient and prevention of the life-threatening haemorrhage. Key words: Uterine artery embolization, haemorrhage, dilatation and curettage. Uterine AVM.

Background: Uterine artery embolization is now evolving to be the first-line therapy for symptomatic uterine leiomyoma alongside elder conventional alternatives comprising hysterectomy and myomectomy whether surgical or endoscopic. Many clinical trials have confronted UAE and surgical therapies as regard safety and efficacy in treatment of symptomatic leiomyomas where UAE exhibited comparable short and mid-term clinical outcomes, encompassing symptomatic amelioration, better quality of life and psychological satisfaction benefiting from uterine preservation.Aim of the Work: to emphasize the role of the trans-catheter uterine artery embolization as an effective stand-alone technique in treating the symptoms attributable to uterine leiomyomata.Patients and Methods: This study included 30 patients with uterine fibroids referred from gynecology clinic to interventional radiology unit to be counseled for UAE.Results: Follow-up symptomatic assessment was done for all patients at 1 and 3 months. Most patients confirmed symptomatic amelioration at 1 months persisting or continue at 3-month follow-up visit. Among 21 patients presented with bleeding, 90.5% of patients reported symptomatic improvement at 1 month post-procedurally continued to increase to reach 95.2% at 3 months follow-up visit, however, no significant symptomatic change was noted between 3, 6 months follow up. Fourteen patients complained from pressure symptoms. At 1-month follow-up, 71.44% of patients stated improvement, 14.29% had stationary course with similar percentage exhibited slightly worse response. Contrariwise, 85.71% of patients reported symptomatic amelioration at 3 month and 14.3% had no change. Indifferent from bleeding, a highly statistically significant time improvement between 1, 3 months follow up is notable. Of 13 patients admitted with pelvic pain, 53.9% get improved, 30.77% showed no change, 15.38 % gave slightly worse response in comparison to 84.7%, 7.69%, 7.69% at 1, 3 months follow-up clinical assessment visits. There is clinical reduction of pain between 1, 3 months however it didn’t reach clinical significance. Among three patients presented with infertility, one gets pregnant at 3 months follow up with no significant change between 1, 3 months follow up. On MRI, the mean uterine volume was reduced by 30% 6 months after treatment. Similarly, mean dominant leiomyoma volume was reduced by 44 % after 6 months. There was highly statistically reduction of volume between 1 and 6 months follow up. Conclusion: Although limited by small sample size however we might conclude that UAE is associated with considerable cumulative reduction of leiomyoma volume that parallels patients’ symptomatic amelioration and psychological satisfaction and should be considered among first lines of management of symptomatic leiomyoma particularly in child-bearing age.

BACKGROUND: To systematic review the safety and effectiveness between uterine artery embolization (UAE), surgery and high intensity focused ultrasound (HIFU) in the treatment of uterine fibroids. METHODS: The PubMed, EMbase, The Cochrane Library, Web of Science, Wanfang Data, and CNKI were electronically searched to collect relevant studies on comparing the safety and effectiveness of UAE, surgery and HIFU in the treatment of uterine fibroids from January 2000 to August 2019. After two reviewers independently screened the literature, extracted the data and evaluated the risk of bias of included studies, network meta-analysis was performed by ADDIS 1.16.8 and Stata 14 software. RESULTS: A total of 11 studies (22 articles) involving 3,646 patients were included. Compared with surgery, UAE and HIFU patients had higher quality of life (1-year follow-up) improvement, and UAE was higher than HIFU. Network meta-analysis show that patients treated with HIFU had the lowest incidence of major complications within 1 year, followed by UAE, and the highest surgery. Patients treated with HIFU and UAE have shorter hospital stays and quicker recovery time than surgery. The rate of further intervention after surgery treatment might be lower than that of UAE and HIFU. CONCLUSIONS: UAE has the highest quality of life improvement (1-year follow-up) for uterine fibroids. HIFU and UAE are safer with shorter hospital stays and quicker recovery time compared with surgery. However, both UAE and HIFU have the risks of re-treatment. However, limited by the number and quality of included studies, the above conclusions need to be verified through more high-quality studies.

The incidence of postpartum hemorrhage is rising and may lead to severe maternal morbidity and maternal mortality. In this manuscript we investigated women in need of massive blood transfusion because of postpartum hemorrhage in order to improve our understanding of postpartum hemorrhage associated with severe maternal outcome and to compare management strategies and maternal outcome between different settings. Furthermore, we evaluated maternity care at different stages of bleeding following childbirth, i.e.: onset of hemorrhage (timely recognition of women at risk of progression of hemorrhage), persistent hemorrhage (evaluation of obstetric interventions to cease persistent hemorrhage), and end of hemorrhage (learn lessons once a maternal death from obstetric hemorrhage has occurred).

In patients with persisting symptoms after uterine arteries embolization (UAE), ovarian arteries embolization (OAE) may play a role to improve symptoms and decrease subsequent surgery rates. In a retrospective cohort, we aimed to investigate the efficacy and safety of OAE in females with recurrent or persistent symptoms following UAE. We performed a retrospective analysis of prospectively collected cases at a single reference academic hospital; we identified patients who benefited from OAE for persisting symptoms following UAE from 2008 to 2021. Outcome variables included the rates of subsequent surgery, a quality-of-life questionnaire with the UFS-QOL tool, the MRI reduction in uterine and fibroids volumes and the fibroid devascularization rate. Among 1300 women treated with UAE during the study period, 18 eventually received OAE and were included (mean age 44 ± 4.3 SD). There was no OAE procedural complication. There was a decrease in uterine volume and a complete devascularization of the dominant fibroid in 10/11 (90.9%) patients who underwent 12 months MRI. Three women underwent subsequent hysterectomy. Among 10/18 patients who answered the quality-of-life questionnaire after a mean follow-up of 70 months, eight reported an improvement or stability of symptoms. OAE for persisting symptoms after UAE was associated with improvement or stability of quality-of-life in most study subjects and less than a fifth of the cohort underwent hysterectomy after OAE. This study highlights the role of OAE as an adjunct to UAE.

Choosing a treatment option for uterine fibroids is today one of the most relevant problems in gynecological practice. Thanks to the success of modern medicine and the increased level of the population’s culture, female patients seek medical help without waiting for the tumor to acquire significant sizes. However, in practice, there are cases when fibroids reach gigantic sizes. Hysterectomy is a traditional approach to treating uterine fibroids of these sizes according to the current clinical guidelines. The introduction of new high-tech treatments, such as uterine artery embolization, has led to a revision of radical surgery, by giving preference to alternative approaches especially in cases where the patient desires to preserve the reproductive organ. The paper describes a clinical case that confirms an individual approach to choosing a treatment option towards organ-sparing surgery for giant uterine fibroids. The use of endovascular embolization of the uterine arteries as a treatment for giant uterine fibroids is shown to be justified as an organ-sparing surgery if the patient desires to preserve reproductive function.

OBJECTIVES To evaluate uterine tamponade devices' effectiveness for atonic refractory postpartum haemorrhage (PPH) after vaginal birth and the effect of including them in institutional protocols. SEARCH STRATEGY PubMed, EMBASE, CINAHL, LILACS, POPLINE, from inception to January 2021. STUDY SELECTION Randomised and non-randomised comparative studies. OUTCOMES Composite outcome including surgical interventions (artery ligations, compressive sutures or hysterectomy) or maternal death, and hysterectomy. RESULTS All included studies were at high risk of bias. The certainty of the evidence was rated as very low to low. One randomised study measured the effect of the condom-catheter balloon compared with standard care and found unclear results for the composite outcome (relative risk [RR] 2.33, 95% CI 0.76-7.14) and hysterectomy (RR 4.14, 95% CI 0.48-35.93). Three comparative studies assessed the effect of including uterine balloon tamponade in institutional protocols. A stepped wedge cluster randomised controlled trial suggested an increase in the composite outcome (RR 4.08, 95% CI 1.07-15.58) and unclear results for hysterectomy (RR 4.38, 95% CI 0.47-41.09) with the use of the condom-catheter or surgical glove balloon. One non-randomised study showed unclear effects on the composite outcome (RR 0.33, 95% CI 0.11-1.03) and hysterectomy (RR 0.49, 95% CI 0.04-5.38) after the inclusion of the Bakri balloon. The second non-randomised study found unclear effects on the composite outcome (RR 0.95, 95% CI 0.32-2.81) and hysterectomy (RR 1.84, 95% CI 0.44-7.69) after the inclusion of Ebb or Bakri balloon. CONCLUSIONS The effect of uterine tamponade devices for the management of atonic refractory PPH after vaginal delivery is unclear, as is the role of the type of device and the setting. TWEETABLE ABSTRACT Unclear effects of uterine tamponade devices and their inclusion in institutional protocols for atonic refractory PPH after vaginal delivery.

Objectives To assess the cost-effectiveness of uterine artery embolisation (UAE) and myomectomy for women with symptomatic uterine fibroids wishing to avoid hysterectomy. Design Economic evaluation alongside the FEMME randomised controlled trial. Setting 29 UK hospitals. Population Premenopausal women who had symptomatic uterine fibroids amenable to UAE or myomectomy wishing to avoid hysterectomy. 254 women were randomised to UAE (127) and myomectomy (127). Methods A within-trial cost-utility analysis was conducted from the perspective of the UK NHS. Main outcome measures Quality-adjusted life years (QALYs) measured using the EuroQoL EQ-5D-3L, combined with costs to estimate cost-effectiveness over 2 and 4 years of follow-up. Results Over a 2-year time horizon, UAE was associated with higher mean costs (difference £645; 95% CI -1381 to 2580) and lower QALYs (difference -0.09; 95% CI -0.11 to -0.04) when compared with myomectomy. Similar results were observed over the 4-year time horizon. Thus, UAE was dominated by myomectomy. Results of the sensitivity analyses were consistent with the base case results for both years. Over 2 years, UAE was associated with higher costs (difference £456; 95% CI -1823 to 3164) and lower QALYs (difference -0.06; 95% CI -0.11 to -0.02). Conclusions Myomectomy is a cost-effective option for the treatment of uterine fibroids. The differences in costs and QALYs are small. Women should be fully informed and have the option to choose between the two procedures. Tweetable abstract Fully informed women with uterine fibroids should have a choice between uterine artery embolisation or myomectomy.

Background: Uterine fibroids are the most common benign gynecologic tumors, with a lifetime incidence of approximately 70%. They are associated with multiple symptoms, including heavy uterine bleeding and pelvic pain. Currently used treatments include contraceptive steroids, Gonadotropin-releasing hormone agonist (GnRHa), progesterone modulators, uterine artery embolization (UAE), magnetic resonance imaging-guided focused ultrasound surgery (MRgFUS), and radiofrequency ablation (RFA). Objective: To evaluate the effect of atorvastatin on decreasing fibroid related symptoms and fibroid size, endometrial thickness and cholesterol level in perimenopausal women. Patients and methods: Prospective randomized controlled trial that was conducted over a period of 12 months during 2019 and 2021 on 105 patients with symptomatic uterine fibroid in perimenopausal age, admitted to emergency unit and gynecology outpatient clinic at Mansoura University Hospital and after obtaining acceptance from institutional research board faculty of medicine then patients were prospectively recruited and randomized by computer program. Results: All groups at presentation demonstrated insignificant differences concerning demographic characteristics, gravidity and symptoms of uterine fibroid. Uterine fibroid demonstrated significant reduction in size as well as significant changes following the atorvastatin treatment after 6 months in a dose dependent manner, while endometrial thickness demonstrated insignificant differences as measured by transvaginal ultrasound (TVS). Cholesterol level demonstrated highly statistically significant decrease following atorvastatin treatment in a dose dependent manner. Conclusion: The current study demonstrated that atorvastatin has promising effects in cases with uterine fibroids as it was associated with a reduction of fibroid size with reduction of fibroid related symptom (menorrhagia, dysmenorrhea).

Kai Yuan,1,2 Jin Long Zhang,2 Jie Yu Yan,2 Bing Yuan,1 Jin Xin Fu,2 Yan Wang,2 Xue Dong Sun,3 Yang Guan,2 Feng Duan,2 Mao Qiang Wang1,2 1Medical School of Chinese PLA, Beijing, 100853, People’s Republic of China; 2Department of Interventional Radiology, The Fifth Medical Center, Chinese PLA General Hospital, Beijing, 100853, People’s Republic of China; 3School of Medicine, Nankai University, Tianjin, 300071, People’s Republic of ChinaCorrespondence: Mao Qiang WangDepartment of Interventional Radiology, The Fifth Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Beijing, 100853, People’s Republic of ChinaTel +86 10-66937190Email wangmq@vip.sina.comPurpose: To assess the long-term outcome of performing uterine artery embolization (UAE) using small particles in women with symptomatic adenomyosis (AD).Methods: Twenty-seven consecutive women (median age 42 years, range 29– 53 years) with AD, in eight cases AD combined with fibroids, who underwent UAE between February 2015 and January 2019, were retrospectively analyzed. The embolization was performed using small-sized polyvinyl alcohol particles (100 μm and 300 μm). The patients completed the Uterine Fibroid Symptom and Quality of Life questionnaire at baseline and at a 42-month follow-up (range 24– 71). The junction zone (JZ) thickness and uterine volume were also calculated at baseline and at a three-month follow-up.Results: The total symptom severity score (SSS) decreased from a median of 59 (range 34– 78) at baseline to a median of 9 (range 3– 47) at the end of this study; the health-related quality of life score (HRQOL) increased from a median of 38 (range 23– 49) at baseline to a median of 84 (range 46– 97) at 42 months. Twenty of the 27 patients were asymptomatic. The clinical response of the remaining seven women was little improvement in their symptoms, and one of the seven women underwent a hysterectomy at 35 months. Twenty-six of the 27 (96%) patients had a preserved uterus at the 42-month follow-up. There was no difference after UAE in SSS, HRQOL, junction zone (JZ) thickness, and uterus volume between patients with pure AD and those with AD combined with fibroids (p = 0.729, 0.710, 0.973, and > 0.99). There was no difference in the JZ thickness and uterus volume at baseline between the asymptomatic women and the women with an insufficient response (p = 0.854 and 0.253), and there were no major complications afterwards.Conclusion: From the long-term follow-ups, it could be seen that UAE using small particles is safe and effective in treating AD, especially in preserving the uterus. There is no relationship between the clinical outcomes and the initial presence of AD, with or without fibroids, and the JZ thickness at baseline does not seem to be a predictor for the long-term outcome of UAE.Keywords: adenomyosis, uterine artery embolization, UFS–QoL, interventional radiology

A 39-year-old woman presented with bleeding 4 months after a surgical termination of pregnancy. Persistent beta-human chorionic gonadotropin levels were suggestive of retained products of conception (RPOC). However, multimodal imaging revealed a concurrent uterine arteriovenous malformation (AVM). Although most stable AVMs can be managed conservatively, the need for surgical management of chronic RPOC and consequential hemorrhage risk complicates this approach. Patient-determined management prioritized blood conservation while minimizing risks to fertility. This case is discussed with respect to the rare concurrent existence of RPOC and AVM. Little is known regarding the optimal tandem therapeutic approach. As depicted, successful treatment requires careful diagnostic workup and a multidisciplinary approach.

Background:Abnormal uterine bleeding is a common presenting symptom in the family practice setting. The most common causes are uterine fibroids, dysfunctional uterine bleeding and adenomyosis. All conditions were accompanied by chronic blood loss disabling normal lifestyle with variable degrees of morbidity. Objectives: This study is aiming to evaluate the safety, efficacy, and complications of uterine artery embolization(UAE) in the management of abnormal uterine bleeding (AUB)in different age groups. Patients and Methods: This a prospective randomized clinical trial prospective study included 20 patients referred for UAE. Twelve patients had uterine fibroids, 4 patients had adenomyosis and other 4 patients were diagnosed as dysfunctional uterine bleeding. The embolizing materials were used includingPolyvinyl alcohol, Tris- acryl gelatin microspheresand gelatin sponge. All patients had AUB. Results: Most patients showed good therapeutic responses through the follow up period (6-12 months). Complete control of bleeding was achieved in 90% of patients and recurrence occurred only in 10%. There was complete improvement of the pelvic pain and bulk related symptoms. Reduction of uterine and fibroid size occurred with average uterine and dominant fibroid volumes loss of 39%, and 57% respectively. However, the reduction in the Junctional zone thickness was 5.6 %. Conclusion: UAE is considered minimally invasive, safe, and effective method that plays an important role in treatment of variable types of AUB causes, aiming for uterine preservation and avoiding hysterectomy giving the chance for future fertility. It has high success rate with obvious low morbidity and mortality rates.

This study aimed to compare the performance of non-contrast-enhanced magnetic resonance angiography (NCE-MRA) at 1.5 T and 3 T for the visualization of uterine and ovarian arteries (OAs) before uterine artery embolization (UAE). Preprocedural pelvic NCE-MRA images of 85 symptomatic patients undergoing UAE for the treatment of uterine leiomyomas were reviewed by two specialists in pelvic MRI. Left and right uterine arteries (UAs) were judged separately and scored on a 5-point scale. Score 5 was the highest, in which the UA could be visualized inside the musculature, forming a peritumoral plexus. Score 1 was the lowest, where visualization was limited to the descending segment. The detection of enlarged OAs was also compared. The Mann–Whitney U and Fisher exact tests were used for statistical analysis. p < 0.05 was considered to be statistically significant. Of the 170 UAs, 110 were classified at 1.5 T and 60 were classified at 3 T. Median (interquartile range [IQR]) score was 3 (IQR: 2–4) for visualization at 1.5 T vs 5 (IQR: 4–5) for 3 T. The scores for UA visualization were significantly higher at 3 T (p < 0.05). For enlarged OAs, NCE-MRA at 1.5 T and 3 T visualized 7 and 5 enlarged OAs, respectively; there was no significant difference between the two field strengths (p = 0.36). NCE-MRA performed at 3 T can visualize UAs over a greater range than at 1.5 T. No difference was found regarding the detection of enlarged OAs. • Preprocedural MRA can provide interventional radiologists with valuable information, including the origin and course of the uterine arteries and the existence of collateral feeders to the tumor. • This study demonstrates the superiority of non-contrast-enhanced MRA performed at 3 T over that performed at 1.5 T in the visualization of the uterine arteries in patients undergoing uterine artery embolization for the treatment of uterine leiomyomas. • Non-contrast-enhanced MRA is a useful imaging modality for patients with symptomatic leiomyoma undergoing uterine artery embolization in whom contrast administration is unfeasible. If available, it is preferable to perform the examination with a 3 T MR unit rather than a 1.5 T MR unit.

BACKGROUND It was reported that high-intensity focused ultrasound (HIFU) of cesarean scar pregnancy (CSP) can locally inactivate pregnancy tissue. Uterine artery embolization (UAE) can achieve good results for CSP too. To investigate the clinical efficacy and safety of HIFU and UAE in the treatment of cesarean scar pregnancy (CSP), we conducted this research. METHODS Multiple databases were used to search for relevant studies and articles related to HIFU, UAE, and CSP. The selected literature were retrospectively evaluated using Review Manager 5.2. In addition, forest plots, sensitivity analysis, and bias analysis were conducted for the included literature. RESULTS Finally, 8 related studies met the inclusion criteria. There were no significant differences in postoperative adverse reactions and hospitalization time between the HIFU group and the UAE group. However, the normalization time of serum beta human chorionic gonadotropin (B-HCG) in the HIFU group was higher than that in the UAE group [MD =1.16, 95% confidence interval (CI), 0.09, 2.22, P=0.03, I2=93%], and the hospitalization cost in the HIFU group was significantly lower than that in the UAE group (MD =-8.81, 95% CI, -12.64, -4.97, P

Study Objective To characterize the short-term incidence of gynecologic cancer after undergoing uterine artery embolization (UAE). Design Retrospective cohort study. Setting Commercial insurance claims database. Patients Total of 15 393 United States women aged 18 to 64 years who underwent UAE between 2007 and 2017. Interventions We used the IBM MarketScan (Armonk, NY) claims to identify adult women without previous gynecologic cancer diagnoses undergoing UAE between 2007 and 2017. Database queries identified women with any diagnostic or procedure codes related to gynecologic malignancies occurring in the first 3 years after UAE. A malignancy diagnosis was suggested by recurrent malignancy-related claims not linked exclusively to diagnostic testing (e.g., transvaginal ultrasound) and malignancy codes linked to tissue pathology claims. Incidence of malignancy diagnosis was calculated. Rates of endometrial sampling in the year before UAE were identified. Measurements and Main Results Thirty-one women undergoing UAE had gynecologic cancer diagnoses within 3 years of the procedure (22 of 31, 71% uterine cancers; 7 of 31, 23% ovarian cancers; and 2 of 31, 6% cervical cancers). On average, cancer diagnoses were made 1.1 ± 0.9 years after UAE. One in 497 women undergoing UAE was diagnosed with a gynecologic malignancy within 3 years, with an incidence of 1.1 malignancies per 1000 person-years. Cancer incidence increased with age at the time of UAE: short-term malignancy diagnoses were made in 1 in 377 women aged 45 to 54 years, and 1 in 79 women aged 55 to 64 years. In the year before UAE, 28% (4311 of 15 362) of women without cancer, and 23% (5 of 22) of women diagnosed with uterine cancer had preprocedural endometrial sampling. Conclusion These data can inform risk/benefit counseling and shared decision-making regarding UAE and its alternatives. Short-term malignancies after UAE highlight the importance of preprocedure evaluation in symptomatic women and women with age-related risk.

Objective. To compare the efficacy of uterine artery embolization (UAE) with traditional methods for treating endometriosis. Methods. The randomized controlled trials of uterine artery embolization and other medical treatments for endometriosis in PubMed, Embase, Web of Science, Cochrane Library, China Journal Full-Text Database, Wanfang Database, VIP Database, and China Biomedical Literature Database were retrieved by computer. The search time was up to June 2022. The quality of articles was evaluated by Cochrane ROB 2.0, and meta-analysis was performed by Stata15.1 software. Results. 7 studies were finally included. Meta-analysis showed that the serum CA125 level after uterine artery embolization was significantly lower than that in the control group (SMD = −0.85, 95%CI (−1.12, −0.59)], and the postoperative visual analogue scale (VAS) of dysmenorrhea was significantly lower than that in the control group (SMD = −1.86, 95%CI (−2.21, −1.50)) There was no significant difference in the effective rate, FSH level, E2 level, and LH level between the two groups. Conclusion. UAE can effectively reduce the VAS score of dysmenorrhea and serum CA125 level for treating endometriosis. However, due to the limitation of the quality of included articles, more large sample size and high quality RCTs are needed to provide stronger evidence-based medicine evidence for clinical practice.