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    • Uterine Fibroid...

    Uterine Fibroid Embolisation-Standard Treatment Guidelines

    Written by supriya kashyap kashyap Published On 2017-02-25T09:54:11+05:30  |  Updated On 16 Aug 2021 4:23 PM IST
    Whenever a woman of child bearing age presents with menorrhagia (excessive bleeding during menstruation), dysmenorrhea (painful menses), or recurrent abortion.

    Introduction


    Uterine fibroid is a common benign tumour smooth muscle cells and fibrous connective tissue that develop within the walls of the uterus. It generally affects the middle-aged women and present with menorrhagia and pressure effects on the urinary bladder and or the rectum. Women with fibroids may also have dysmenorrhea. When occurring in the child bearing age, these fibroids may interfere with pregnancy and the lady is either unable to conceive or unable to carry the pregnancy till completion. Uterine fibroid embolisation (UFE) is a minimally invasive, percutaneous, endovascular (interventional radiological) therapy to treat the fibroids, by blocking the arteries supplying the fibroid.


    Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Uterine Fibroid Embolisation.


    Following are the major recommendations :


    Indications
    It is indicated for treatment of symptomatic uterine fibroids, causing menorrhagia /dysmenorrhea / pressure effects on rectum or urinary bladder.


    INCIDENCE OF THE CONDITION IN OUR COUNTRY
    Fibroids is a common ailment of the middle aged women, occurring in up to 20%.


    DIFFERENTIAL DIAGNOSIS


    Other causes of uterine masses could be cancer cervix, endometrial cancer. Occasionally ovarian cancer may mimic a uterine fibroid. Imaging with Ultrasound / MRI and histopathological studies can give the correct diagnosis.


    PREVENTION AND COUNSELING


    Menorrhagia / lower abdominal masses should be evaluated by imaging and histopathology, to arrive at the correct diagnosis, and early appropriate treatment should be implemented. The middle aged women should be always evaluated with a PAP smear to rule out any malignancy of uterine cervix.


    OPTIMAL DIAGNOSTIC CRITERIA, INVESTIGATIONS, TREATMENT & REFERRAL CRITERIA / FOLLOW UP


    Diagnostic Criteria




    • Ultrasound: Reveals a spherical mass with heterogeneous middle level echoes. Most fibroids are intramural. Occasionally they may be pedunculated and apparently detached from the uterus or they could be subendometrial There is always an accompanied displacement of the endometrial echo, which also serves an indirect indicator for the isoehoic fibroids.

    • MRI: Reveals a uterine mass that is heterogeneously hyperintense on T2 and isointense on T1 images. There is hypertrophy of the uterine arteries.


    Investigations




    • Ultrasound Pelvis

    • MRI Pelvis

    • PAP smear from Cervix

    • Endometrial biopsy, if there is suspicion of endometrial Ca

    • Blood - Hb, TLC, DLC, ESR

    • Blood – Platelets count

    • Blood – PT(INR) and APTT

    • Blood Creatinine


    Treatment

    Uterine fibroid embolisation – The uterine artery is accessed endovascularly and the tip of the catheter / microcatheter is placed distal to the ovarian / cystic / cervical branch, and embolised with Poly Vinyl alcohol particles, till the flow becomes very sluggish.


    Referral criteria


    Patients meeting the criteria for UFE should be referred to centers equipped with capability to perform UFE.


    Follow up


    Patient would be admitted a day prior to the embolisation and managed as inpatient till 2-3 days till the pain and nausea gets tolerable. There after Clinical follow up is done at 2 week, 6 weeks, 3 months and 6 months. During these follow up ultrasound could be done to assess the size of the fibroid.


    Situation 1: At Secondary Hospital/ Non-Metro situation: Optimal Standards of Treatment in Situations where technology and resources are limited


    Clinical Diagnosis: As above


    Investigations: As above


    Treatment


    Standard Operating procedure


    Patient would be assessed and evaluated by the primary gynecologist to rule out any other gynecological problems. Thereafter patient will be assessed by the interventional radiologist for the feasibility of embolisation. Most of the times the procedure would be done under local anesthesia and if required the anesthesiologist's consultation can be taken. The patient's uterine artery would then be accessed by endovascular approach; the catheter tip will be placed beyond the branches to the ovary, urinary bladder and uterine cervix. Then polyvinyl alcohol particle would be injected for embolisation of the artery till the flow becomes sluggish.


    a. In Patient: UFE is to be done as inpatient.
    b. Out Patient: no.
    c. Day Care: no
    e) Referral criteria: As above


    Situation 2: At Super Specialty Facility in Metro location where higher-end technology is available


    Clinical Diagnosis: As above
    Investigations: As above
    Treatment: As above


    Standard Operating procedure: As above.
    a. In Patient-The procedure will be done as an inpatient therapy
    b. Out Patient - No
    c. Day Care - No
    Referral criteria: As above.






























































    DesignationClinical RoleTimeline
    GynecologistClinical Evaluation and assessment of the gynecologic status of the patient. To rule out any other malignancy by PAP smear. Pharmacological control of bleeding and symptomatic management of pain till the embolisation is done. Patient to be informed about option of UFE and referred to interventional radiologist. Following this the patient should decide between hysterectomy / myomectomy / UFEScreening on presentation to

    OP till the embolisation is

    performed.

    Post embolisation, to be

    followed up by gynecologist

    and interventional

    radiologist
    PathologistTo assess the PAP smear or any other histopathology examination

    As soon as possible
    Diagnostic RadiologistImaging of the uterine pathology by USG or MRIAs soon as possible.
    Interventional RadiologistAssessment for feasibility for uterine fibroid embolisationAs soon as possible.
    BiochemistBiochemical evaluationAs soon as possible
    CardiologistCardiac evaluationAfter consultation by and on the request of interventional radiologist for patients who are high risk for cardiac status
    Interventional RadiologistPerforms the uterine fibroid embolisationAfter the patient is declared fit for the procedure by the above timelines
    Nursing StaffAssist in managing the patient as Inpatient in ward and in Interventional Radiology SuiteNA
    TechnicianAssist in Imaging the patient, assist the IR specialist in the IR suite, and manage the DSA images also.NA

    RESOURCES REQUIRED FOR ONE PATIENT / PROCEDURE (PATIENT WEIGHT 60 KGS)

    (Units to be specified for human resources, investigations, drugs and consumables and equipment. Quantity to also be specified)


























    SITUATIONHUMAN RESOURCESINVESTIGATIONSDRUGS & CONSUMABLESEQUIPMENT
    1.Doctors – (Gynaecologist– 1, Interventional Radiologist – 1, Diagnostic Radiologist -1, Technician(s) – 1, Nursing - 1Hemoglobin, Random Blood Sugar, PT, APTT or INR, Platelet Count, Se. Creatinine, HBsAg, HIV

    1. Drugs: MRI contrast media, Lignocaine, Nitroglycerine, , Heparin, Non Ionic radiographic contrast media 2. Consumables: Angiographic catheters – pigtail - 1, Cobra / sim2/uterine -1, Guidewire 0.035"– 1 Vascular sheath – 1 PVA particles – 2 vials
    Ultrasound (1) MRI Digital Subtraction Angiography
    2.Doctors – (Gynaecologist– 1, Interventional Radiologist – 1, Diagnostic Radiologist -1, Technician(s) – 1, Nursing - 1Hemoglobin, Random Blood Sugar, PT, APTT or INR, Platelet Count, Se. Creatinine, HBsAg, HIV1. Drugs: Lignocaine, Nitroglycerine, , Heparin, Non Ionic radiographic contrast media 2. Consumables: Angiographic catheters – pigtail - 1, Cobra / sim2/uterine -1, Guidewire 0.035"– 1 Vascular sheath – 1 Microcatheter and guidewire – 1 each, PVA particles – 2 vialsUltrasound (1) MRI Digital Subtraction Angiography System (1) Sterile Suite Multichannel invasive monitor (1) Resuscitation equipment (1) Crash Trolley (1)

    Guidelines by The Ministry of Health and Family Welfare :

    Dr. Chander Mohan
    Dr. B.L. Kapur Hospital
    New Delhi
    Dr Chander MohandysmenorrheaendovascularlyguidelinesMRI Pelvistreatment guidelinesUltrasound PelvisUterine Fibroid Embolisation

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    supriya kashyap kashyap
    supriya kashyap kashyap
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