An effective, minimal invasive but “vastly underutilized” treatment option for fibroids: Uterine Fibroid Embolization

Statistics by National Institute of Health (NIH) indicate that nearly 3 in 4 women will develop fibroid by the time they reach age 50, but more than half of these women have never heard of Uterine Fibroid Embolization and 11% think that hysterectomy is the only treatment option available to them says the results of a Nationwide survey conducted by Harris Poll between June 23 and 27, 2017.

The survey was conducted on behalf of the Society of Interventional Radiology (SIR) and results were presented at the Society of Interventional Radiology’s 2017 Annual Scientific Meeting.

The survey of almost 1,200 women found that about one third of women did not know what fibroids are, 37% did not know anybody else with the diagnosis of fibroid, and nearly 60% did not think that they are at risk of developing fibroid.

Courtesy: Linkedin.com 

One in 5 women thought fibroids are cancerous and surgery is the only treatment option they have.

A majority of women (62%)have never heard of Uterine Fibroid Embolization, and 73% of women who knew about UFE reported that they got the information elsewhere, other than their Ob/Gyn.

As per National Uterine Foundation, nearly 600,000 hysterectomies performed annually in the United States out of which ~170,000 - ~300,000 are due to uterine fibroids. A review of published studies has shown that nearly 1 in 5 hysterectomy is unindicated and 40% of patient who have hysterectomy do not receive full information about other medical or less invasive procedures available to them. It appears that it was presented to them as the best treatment option available, says the SIR report.

James Spies, MD, MPH, a professor of radiology at Georgetown University Medical Center, Washington, DC, and the president-elect of SIR said, "Misperceptions about uterine fibroids and the treatments available often lead women to undergo invasive and potentially unnecessary surgery for their fibroids, despite more than 20 years of clinical use supporting uterine fibroid embolization.”

"Unfortunately, still many health care professionals start and end with hysterectomy as the recommendation for patients," he further added.

An NIH study showed that 165,000 more hysterectomies were performed than UFEs (167,650 vs. 2,470) nationwide, a difference of whopping 67% between the two procedures.

The study also reported that nine out of 10 women who have uterine fibroid embolization have significant improvement. Many women report their symptoms disappear completely.

UFE also helps women in getting back to normal lives quickly after the procedure, with no residual effects of early menopause and sexual dysfunction, as often experienced after hysterectomies.

It is also minimally invasive with a hospital stay of one day or less, cost effective, low rate of complications and few women require follow up treatment. If the fibroids recur, they can be again be treated: A second UFE is not contraindicated, said Dr Spies.

It’s also a great option for women desiring future pregnancies.  A study published in Radiology Journal showed a 41.5 percent pregnancy rate after an average follow-up of almost six years.

The ACOG has included UAE in its FAQs on Uterine Fibroids. The procedure was included as one of the treatment option in its 2008 bulletin, reaffirmed again in 2016. The bulletin concludes, "Based on long- and short-term outcomes, uterine artery embolization is a safe and effective option for appropriately selected women who wish to retain their uteri." 

Courtesy: SIR

UFE is performed by an interventional radiologist who inserts a thin catheter into the artery at the groin or wrist. The doctor guides the catheter to the fibroid’s blood supply where small particles, about the size of grains of sand, are released to float downstream and block the small blood vessels and deprive the fibroid of nutrients. This results in the fibroid softening, bleeding less, and shrinking in size.

Does  the push to promote UFE by SIR means promoting self-interest? No, it only means that women diagnosed with fibroids deserve to know about all the options they have and the clinicians should be able to inform them about it. 

Executive summary of survey, Full PDF, SIR news release
RCOG recommendations for UAE for Fibroids

Guidelines revised for preventing thromboembolism in pregnancy.

Obstetric Venous thromboembolism (VTE) is a leading cause for maternal morbidity and mortality. Venous thromboembolism encompasses deep vein thrombosis(DVT) and pulmonary embolism (PE) complicates 0.5 to 3.0 per 1,000 pregnancies.[1] PE is the seventh leading cause of maternal mortality and contributes to 9% of maternal deaths.[2]

Maternal deaths due to VTE are preventable by forming and implementing comprehensive guidelines for prophylaxis of thromboembolism. But, presently sufficient clinical trial data remains unavailable to formulate VTE prophylaxis guidelines in pregnancy.

In US only women who are at high risk for VTE receive pharmacologic prophylaxis, thereby increasing the rate of obstetric VTE in the last decade.

On the contrary, RCOG guidelines in U.K recommend screening and assessment of antepartum and postpartum women for at risk for VTE. Due to regular assessment many women receive pharmacologic thromboprophylaxis, bringing down the rates of VTE since the release of the guidelines.

Observational data support risk-factor-based prophylaxis in bringing down the incidence of VTE, hence the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care developed safety bundle. Safety bundle supports routine risk evaluation for obstetric patients with pharmacological and mechanical thromboprophylaxis when needed. [3] It outlines simple practices that can be implemented in every maternal units, adapting according to the healthcare resources available in each community.

The article was published in October issue of Obstetrics and Gynecology journal.[4] The bundle is grouped into 4 domains: Readiness, Recognition, Response, and Reporting and Systems Learning. 

Readiness: Every Unit should use standard VTE risk assessment tool during prenatal outpatient visits, antepartum admissions to hospital, post labor and post cesarean stay in hospitals and 6 weeks postpartum.

Recognition and Response: Once the risk assessment is done, physicians should use patients Caprini[5] or Padua score[6] to identify those patients who will need thromboprophylaxis according to clinical situation and risk score. The thromboprophylaxis guidelines are as advocated by ACOG, American College of Chest Physicians and RCOG.

• Antepartum outpatient prophylaxis: women with a history of multiple VTE or thrombophilia episodes low-molecular-weight (LMW) heparin or unfractionated heparin (UFH) is recommended.
• Antepartum Inpatients for more than 3 days: Women who are not at risk for bleeding or imminent childbirth, prophylaxis with daily LMW heparin or twice-daily UFH is advocated.
• Women with a history of VTE who are undergoing a trial of vaginal birth are given intrapartum mechanical thromboprophylaxis using pneumatic compression devices while in bed. After the delivery, LMW heparin or UFH can be for those at high risk for VTE based on RCOG criteria or a Padua score of 4 or greater.
• Those women undergoing an operative delivery are prescribed mechanical thromboprophylaxis using pneumatic compression. Once the surgery is over, they can also be given LMW heparin or UFH, based on RCOG criteria or modified Caprini scores.
• RCOG criteria also advocates that all women who are undergoing operative delivery may be routinely prescribed LMW heparin or UFH due to complications with mechanical prophylaxis.
• Women with repeated history of VTE, high-risk thrombophilia, or VTE with acquired thrombophilia can be put on extended 6-week treatment-dose of LMW heparin or UFH postpartum.

Reporting and Systems Learning: All centers should meticulously keep records of patients receiving prophylaxis for VTE, adverse reactions and complications.  Routine audits should be performed to check whether physicians are evaluating, assessing the risk factors for VTE and planning the treatment accordingly.

However, in an accompanying editorial Baha M. Sibai, MD, from the University of Texas Medical School at Houston, and Dwight J. Rouse, MD, MSPH, associate editor for Obstetrics & Gynecology, have expressed concern that the widespread use pharmacological prophylaxis may do more harm than good. 

The authors are specially concerned with 3 days’ prophylaxis for antepartum hospitalized patients and women at high risk for VTE and have undergone vaginal birth.

They were especially worried about following the RCOG criteria of pharmacological prophylaxis after cesarean delivery, which would apply to more than half of the C.S. patients in the US. 

According to the editorial analysis” approximately 1 million women would require pharmacologic prophylaxis to prevent even one maternal death from cesarean delivery–associated pulmonary embolism."

Nevertheless, they advocate the use of mechanical prophylaxis in all obstetrics units’ post-cesarean and building a database of huge obstetric patients in whom the mechanical method was used. In the future, this large data base created can be used to assess the pros and cons of using pharmacological prophylaxis in obstetrics patients.

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[1] Snow V, Qaseem A, Barry P, et al., for the American College of Physicians, American Academy of Family Physicians Panel on Deep Venous Thrombosis/Pulmonary Embolism. Management of venous thrombo-embolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2007;146(3):204–210....

[2] The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer — 2003–2005: the seventh report on confidential enquiries into maternal deaths in the United Kingdom. London: CEMACH, 2007

[3] http://www.safehealthcareforeverywoman.org/secure/vte-prevention-patient-safety-bundle.php

[4] http://journals.lww.com/greenjournal/Citation/2016/10000/National_Partnership_for_Maternal_Safety_.3.aspx

[5] http://www.wikidoc.org/index.php/Caprini_risk_assessment_model

[6] http://www.mdcalc.com/padua-prediction-score-for-risk-of-vte/