Linda D. Bradley, MD
Vice Chairman of Obstetrics, Gynecology
and Women’s Health Institute
Director, Center for Menstrual Disorders,
Fibroids and Hysteroscopic Services
Cleveland Clinic
Cleveland, Ohio
Teresa Dews, MD, FIPP
Medical Director, Pain Management Center
Hillcrest Hospital
Mayfield Heights, Ohio
supplement to
Free
1.0 CME
credit
Gary P. Siskin, MD
Professor and Chairman
Department of Radiology
Albany Medical College
Albany, New York
Learning Objectives
• List the 3 most common symptoms associated with the postembolization
syndrome
• Formulate the 4 most important home-going medications and instructions
that should be relayed to the patient
• List the most common symptoms associated with fibroids
• Determine the success rate for relief of menorrhagia, bulk symptoms, and size
reduction after uterine fibroid embolization
Target Audience
This course is designed to meet the continuing medical education needs of the
practicing obstetrician and gynecologist, primary care physician, clinical nurse
practitioner, and physician assistant.
Accreditation
Omnia Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Credit Designation
Omnia Education, Inc., designates this educational activity
for a maximum of 1 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the
extent of their participation in the activity.
Release Date: September 1, 2008 Expiration Date: August 31, 2009
Acknowledgement of Commercial Support
This activity is supported by an independent educational grant from BioSphere
Medical, Inc.
Disclosure of Conflicts of Interest
To provide the highest quality of CME programming in compliance with the
ACCME Standards for Commercial Support, Omnia Education requires that all
faculty and planning committee members disclose relevant financial relationships with any commercial interest that produces health care goods or services.
Omnia Education assesses conflict of interest with its faculty, planners, authors,
and reviewers of CME activities. Identified conflicts of interest are thoroughly
reviewed and resolved by independent reviewers for fair balance, scientific objectivity of studies utilized in the activity, and patient care recommendations.
Omnia Education is committed to providing its learners with high-quality,
unbiased, and state-of-the-art education.
The following faculty have reported real or apparent conflicts of interest that
have been resolved:
Linda D. Bradley, MD, reports that she is a consultant for American Medical
Systems, Bayer Heathcare Pharmaceuticals, BioSphere Medical, Inc., Ethicon
Inc., and Gyrus ACMI. She has research grants from Conceptus, Inc., and Microsulis. She is on a commercial interest speakers bureau for Bayer Healthcare
Pharmaceuticals, BioSphere Medical, Inc., Novo Nordisk, and Wyeth-Ayerst
Laboratories.
Teresa Dews, MD, FIPP, reports that she is a consultant for Abbott Laboratories.
Gary P. Siskin, MD, reports that he is a consultant for BioSphere Medical, Inc.,
and has a research grant from Teruma Medical Corporation.
Disclaimer
Participants have an implied responsibility to use newly acquired information
to enhance patient outcomes and their own professional development. The
information presented in this activity is not meant to serve as a guideline for
patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by
clinicians without evaluation of their patients’ conditions and possible contraindications or dangers in use, review of any applicable manufacturer’s product
information, and comparison with recommendations of other authorities.
The views and opinions expressed in this educational activity are those of
the authors and do not necessarily represent the views of Omnia Education,
BioSphere Medical, Inc., OBG Management, or Dowden Health Media. Please
refer to the official prescribing information for each product for discussion of
approved indications, contraindications, and warnings.
This material has been submitted by Omnia Education. It has been edited and
peer reviewed by OBG Management.
September 2008
Available at www.obgmanagement.com
UTERINE FIBROID
EMBOLIZATION:
A roundtable discussion describing
effective protocols for pain management
Uterine fibroid embolization (UFE) has become an increasingly popular
procedure in the past decade. Patients with symptomatic uterine fibroids
often seek alternatives to hysterectomy, and UFE represents a viable option
for many of these patients. Worldwide, an estimated 150,000 to 200,000
women have had the procedure. Approximately 25,000 women in the United
States choose to undergo UFE each year.1 It offers excellent outcomes across
the spectrum of fibroid-related symptoms, and improvement can be seen
in 85% to 92% of patients with heavy menstrual bleeding or menorrhagia,
dysmenorrhea, and bulk symptoms including pelvic pressure, constipation,
dyspareunia, and urinary symptoms (frequency, urgency, and retention).2-7
Other effects, such as decreased abdominal girth resulting from decreased
fibroid burden, may be less consistent. UFE is associated with a high level of
patient satisfaction and few complications for the correctly selected patient
who is interested in alleviating specific symptoms.
Recent reports in the medical literature have compared UFE with traditional treatments, such as hysterectomy and myomectomy. In observational
studies, this procedure has resulted in a significant reduction in uterine volume, a decrease in excessive uterine bleeding, a low rate of subsequent
hysterectomy, and a high rate of sustained symptom control (up to 80%) 5
years postprocedure.8-11
Additionally, the procedure can be performed on an outpatient basis,
thus inviting comparison—in terms of efficacy, patient satisfaction, and need
for pain control—with other minimally invasive gynecologic procedures. As
UFE enters the mainstream of minimally invasive gynecologic surgery, clinicians are looking at pain management strategies that have been effective in
other settings as well.
The UFE procedure has been adopted slowly, in large part because of
concerns about pain. Interestingly, as will be addressed in more detail in this
roundtable discussion, the procedure itself has been shown to be associated
with minimal pain and discomfort. In Pron’s evaluation of 555 women, tabulated pain scores demonstrated that the procedure itself (catheterizing the
femoral artery) is not uncomfortable, but that the discomfort resulted from
postprocedural dispersal of the embolic particles, a process that created an
ischemic event, which could be best characterized as a “heart attack of the
pelvis” with decreased blood flow to the fibroids.8,12
Copyright © 2008 Dowden Health Media and Omnia Education, Inc.
Supplement to OBG Management | September 2008
S
Uterine fibroid embolization
UFE in practice: As viable as other
gynecologic procedures?
Dr Bradley: As an early adopter of UFE, I have
been impressed by the reports of outcomes and
patient satisfaction in the medical literature. Additionally, my personal experience has now included
referring more than 500 patients for the procedure
and working closely with interventional radiologists
(IRs) to ensure appropriate patient selection and good
outcomes.13 However, as a practicing physician, I was
initially skeptical about the procedure’s viability and
whether an obstetrician/gynecologist (ObGyn) would
accept it, in part because of the need to refer patients
and partly because of the initial reports concerning
pain associated with the procedure.
Dr Siskin: Early on, I believed that pain management was a significant challenge for the IRs performing
this procedure. It is clear now that some patients may
have been under-medicated or discharged too early,
which led to many ObGyns receiving emergency calls
from these patients. This situation has changed significantly during the past several years. As experience has
been gained with this procedure, IRs have improved
the medication regimens used to address postprocedure pain. In addition, many radiologists have developed office-based practices, which have provided them
with the infrastructure necessary for optimal patient
follow-up. Finally, many have developed collaborative
practice arrangements with ObGyns in the community.
I believe that these changes have greatly reduced the
number of patients who require additional pain management and/or hospital readmission. As we continue
to collect more data and gain even more experience
with this procedure, I believe that we will continue to
see the readmission rates decline.
Dr Bradley: Yes, both pain control and the need to
work collaboratively with individuals in another specialty posed a significant clinical challenge that has
been addressed with the development of protocols
for effective pain management. Today, UFE is a widely
adopted procedure. It is consistently accomplished
with a 23-hour hospital stay. Some institutions are
piloting protocols that feature discharge 5 to 8 hours
postprocedure, accompanied by effective pain management. Patient experiences with pain, satisfaction
with the procedure, time required for return to work,
cost, and quality of life postprocedure have been well
documented and compare favorably with traditional
interventions.14,15
S
Certainly, advances in pain control for UFE have
resulted in a “kinder and gentler” procedure. Much
data are contained in the Fibroid Registry publications, as well as other reports.16 What about return to
normal activities? At our institution, we tell patients
that they will typically return to work in 10 to 14
days. Additionally, we inform them that one-third
of patients will have an abnormal vaginal discharge,
vasomotor symptoms, and lethargy with flu-like
symptoms. Most symptoms resolve within 1 to 4
weeks. We also instruct them to purchase a thermometer and to take their temperature several times daily
during the first 7 to 10 days at home. Since vasomotor symptoms are common and may mimic a febrile
response, we ask them also to take their temperature
when they “feel warm.”
Dr Siskin: That conforms to our approach. Someone who is highly motivated to return to work may be
able to return to work sooner, especially if their particular job requires little in terms of physical activity.
Do patient characteristics or UFE
technique correlate with pain?
Dr Bradley: Dr Siskin, as an IR, could you describe
the procedure, particularly in terms of pain and pain
management?
Dr Siskin: UFE is a percutaneously performed,
angiographic procedure that begins by gaining access
into the arterial circulation, usually by catheterizing
the common femoral artery. Using fluoroscopy for
guidance, a catheter is advanced into the contralateral
uterine artery. Once the catheter position has been
confirmed, embolic material is injected into the artery
until there is relative stasis of flow in that vessel. Ultimately, the goal is to leave some flow in the main uterine artery but to occlude flow in the distal branches.
Once embolization of the contralateral vessel is completed, the catheter is repositioned into the ipsilateral
uterine artery and the procedure is repeated. Typically, a final angiogram is performed after both vessels
are embolized to determine if there are any prominent
collateral vessels to the uterus that must be addressed
as well.
The goal of the UFE procedure is to successfully infarct the entire uterine fibroid burden by
occluding flow in the uterine arteries. Infarction is
important because recent findings have indicated
that patients who have uninfarcted or viable fibroid
tissue after UFE are at risk for fibroid recurrence.17
September 2008 | Supplement to OBG Management
UFE and quality of life
R
andomized trials that assess quality-of-life outcomes associated with UFE vs surgery have
provided outcomes of great interest to clinicians.
A 2007 publication described a randomized trial
comparing UFE and surgery in women with symptomatic uterine fibroids.1 The primary outcome was
quality of life at 1 year of follow-up, as measured
by the Medical Outcomes Study 36-Item ShortForm General Health Survey (SF-36). Patients were
randomly assigned: 106 patients to UFE and 51
to surgery (43 hysterectomies and 8 myomectomies). At 1 year, no significant differences between
groups were observed in any of the SF-36 score
components. The embolization group had a shorter
median duration of hospitalization than the surgical
group (1 day vs 5 days, P<.001) and a shorter time
before returning to work (P<.001). At 1 year, symptom scores were better in the surgical group (P=.03).
During the first year, there were 13 major adverse
events in the embolization group (12%) and 10 in
Conversely, when fibroids are completely infarcted,
there is evidence to suggest that they will always
remain infarcted. Recent studies have focused on the
type of embolic agent and other technical steps that
can be taken in order to optimize the infarction rate
after UFE. Currently, our patients are told that 90% of
patients will achieve 100% infarction of their entire
fibroid burden.
As has been noted, little or no pain occurs during
the procedure, as the uterus and fibroids maintain sufficient blood flow to avoid symptoms. Therefore, it is
unlikely that technical advances in the procedure will
modify pain that occurs subsequent to embolization.18
Dr Bradley: Does uterine size affect potential
pain? If a uterus is 14 to 16 weeks in size versus 25 to
30 weeks in size, is there a difference in the amount of
materials being used to embolize the uterine arteries?
Does that affect pain? Is the number of fibroids a factor? Is the size of the dominant fibroid of importance?
Dr Siskin: No one has shown convincingly that
uterine size plays a role in determining the amount
of pain a patient will experience after UFE. Nor does
fibroid size: we’ve treated patients with small, 1- to
2-cm submucosal fibroids who have more pain than
patients with much larger fibroids and found no consistency in terms of levels of postprocedure pain.
Anecdotally, the vascularity of fibroids differs
markedly, and that affects the amount of material that
Available at www.obgmanagement.com
the surgical group (20%) (P=.22), mostly related to
the intervention. A total of 10 patients in the embolization group (9%) required repeated embolization
or hysterectomy for inadequate symptom control.
After the first year of follow-up, 14 women in the
embolization group (13%) required hospitalization,
3 of them for major adverse events and 11 for reintervention for treatment failure. The investigators
noted that women who have UFE experience faster
recovery, although a small minority of patients may
need further treatment.
UFE is also associated with lower costs compared with surgery (mean difference, £951 [$1,712
at an exchange rate of £1=$1.80]; 95% confidence
interval, £329 to £1480 [$592 to $2,664]), suggesting
that at 1 year, UFE was more cost-effective than surgery for patients with symptomatic uterine fibroids.
Reference
1.The REST Investigators. Uterine-artery embolization versus surgery for
symptomatic uterine fibroids. N Engl J Med. 2007;356:360-370.
must be used to embolize the arteries. In general, I
do find that patients with extremely vascular fibroids
requiring a lot of material for embolization tend to be
more uncomfortable after the procedure, but there
are a lot of exceptions to that rule.
Proactive management for
postprocedure pain
Dr Siskin: As described by Dr Pron, the procedure
itself is not painful but the effects of the procedure are
painful. In general, the pain associated with UFE tends
to manifest itself within a half hour after the procedure. At that time, tissue necrosis begins to occur and
ischemic symptoms may be quite severe. This is characterized clinically by a postembolization syndrome
that manifests itself by pain, nausea, vomiting, fever,
leukocytosis, and malaise. Symptoms vary in distribution and intensity from patient to patient.18,19
Dr Bradley: Dr Dews, with this in mind, how
should a physician approach pain management?
Dr Dews: Certainly, the patient’s previous history
with pain will be an important factor. Predominantly,
if the patient has had exposure to pain medications
in the past, she has a perspective on medications that
work and are well tolerated versus those that are not
tolerated.
Supplement to OBG Management | September 2008
S
Uterine fibroid embolization
The patient’s preprocedure history is important
in evaluating the patient’s exposure to pain medications as well as pain tolerance. It is important to
ascertain if the patient is taking chronic pain medications. It is also helpful to know the patient’s previous history of pain related to surgical procedures and
interventions. Although not specifically studied for
the UFE procedure, patients taking significant doses
of pain medications or who have a history of severe
postprocedure or surgical pain in the past should
heighten one’s awareness of potential increased
postoperative pain.
Opioid medications are the mainstay in management of moderate to severe pain in the surgical and
postsurgical setting. This is true of minimally invasive
gynecologic procedures, including endometrial ablation. Although the opioids do have a beneficial profile for pain relief, they do pose risks of side effects,
including sedation, gastrointestinal side effects (nausea, vomiting, and constipation), and urinary retention. More severe complications relate to respiratory
depression or hypotension.
Opioids can be used in combination with nonsteroidal anti-inflammatory drugs (NSAIDs), thus
providing a synergistic effect and improving the side
effect profile.
Dr Siskin: In our experience—and much of the
literature describe protocols used after UFE—practitioners have had the most success in combining
opioids and NSAIDs agents for postprocedural pain
management.
Dr Bradley: Dr Siskin, how has your pain management protocol evolved in the last decade?
Dr Siskin: When we started performing UFE,
many of our initial procedures were done on an outpatient basis, largely because of patient demand and
the success of our pain management strategy. We
began with a dose of demerol 75 mg IV and supplemented that with 2 doses of 30 mg of ketorolac given
IV, with a dose given after each artery was embolized.
Both demerol and ketorolac could be repeated during
the immediate postprocedure recovery period. Using
that regimen, patients were sufficiently comfortable
to be discharged at the end of the day. We reported
our experience with outpatient UFE and found that
96% of patients could be discharged within 8 hours of
the procedure, with none of these patients requiring
hospital or ER care within the first 48 hours.20,21 Klein
et al also studied outpatient UFE and found that 83%
of their patients could be discharged within 10 hours
of UFE.22 At our institution, however, demerol was
S
taken off the formulary, which required us to modify our protocol and use morphine for pain control
along with ketorolac.
Protocol for pain management
Dr Bradley: What is your experience with the
need for pain medication after the procedure and
during the recovery? If you look at one of the welldocumented trials, the Pron study that was mentioned
earlier, the mean duration of pain medication in this
evaluation of 555 women was 6.8 days.8,12 That is why I
tell my patients that they will likely need to remain on
pain medication for 6 days. What’s been your clinical
experience?
Dr Siskin: I agree with that entirely. Currently, we
use routine conscious sedation with midazolam and
fentanyl citrate during the procedure, which are medications used for many outpatient procedures. As mentioned, we also provide a dose of ketorolac, 30 mg IV,
after we embolize the first artery and another 30 mg IV
after we embolize the second artery. Our goal is to activate the anti-inflammatory effects of this medication
in place at the conclusion of the procedure, when the
patient will start to experience pain. Midazolam has the
additional property of being an amnestic, so patients do
not recall details of the procedure. It is often helpful for
patients to be lightly sedated during the procedure so
that they can hold their breath at various times, which
can help with visualization of the arteries. They can also
help describe their need for pain control so that additional medications can be given as needed.
Following the procedure, we use a constant infusion of morphine together with an additional dose
given on demand to further control postprocedure
pain. Although this provides sufficient management,
it often leaves patients too fatigued to be discharged,
which is why many of our patients are observed overnight. By the next day, we discontinue morphine, put
patients on oxycodone and acetaminophen, 1 to 2
tablets every 4 to 6 hours, in combination with oral
ketorolac, 10 mg every 6 hours, for 3 days. After that
time, patients are instructed to switch to ibuprofen
and to continue the percocet as needed. We find that
most patients require only ibuprofen after the first 5
days.
It has been our experience that this protocol
maintains patient comfort and addresses the pain
that would otherwise be experienced over the first few
days after embolization.
September 2008 | Supplement to OBG Management
Pain control postprocedure:
A report from the literature
Dr Siskin: A small study of 71 patients assessed
the time course of pain after UFE.23 Sedation and pain
control during the procedure were achieved with IV
administration of midazolam, fentanyl citrate, and
ketorolac tromethamine. At the procedure completion, morphine sulfate, 5 mg, was administered IV.
Postprocedure, all patients received ibuprofen,
800 mg orally, followed by 600 mg orally every 4 hours.
Additionally, morphine sulfate was provided through
a patient-controlled analgesia (PCA) pump. The PCA
pump provided a dose of 1 mg, 6-minute lockout,
10 mg/hour maximum dose (no continuous dose) and
was discontinued the morning after UFE.
Patients’ PCA units were examined postdischarge
to reflect the hourly use of morphine sulfate. An average PCA dose for each hour after UFE was determined (95% confidence interval). Based on the hourly
PCA dose after UFE, it was observed that cramping
increased for approximately 2 hours, plateaued for 3
to 4 hours, and then decreased to a lower plateau over
4 to 5 hours, remaining relatively constant beyond
that point. Self-reported pain scores paralleled PCA
use. The author noted that the initial period of relatively high pain probably resulted from global uterine
ischemia caused by the sudden occlusion of the main
uterine arteries. Residual pain probably represented
ischemia of the fibroids themselves.
Dr Bradley: In our protocol for pain management,
we insist that patients comply with the scheduled
medication and dosages. We insist that—in addition
to a narcotic and an antiemetic—patients take NSAIDs
around the clock for the first 2 to 3 days at home.
Anecdotally, the most common complaint or
telephone call for our institution is constipation. We
make sure patients are informed about the use of laxatives; the importance of increasing fiber and adding
prunes, prune juice, and raisins to their diet; and,
most importantly, using milk of magnesia or Miralax.
Patients sometimes go home still taking stool softeners, but these are generally insufficient. Constipation
is sometimes the biggest complaint that we receive.
Since initiating this protocol, we have had no
readmissions for these problems.
Dr Siskin: I agree with that approach. We give
each of our patients a schedule so they know exactly
when to take the prescribed medications. We try to
alternate the opioid analgesic with the NSAID so that
they are taking something approximately every 2 to 3
Available at www.obgmanagement.com
hours, starting as early as 7 am and continuing until
midnight. This way, they receive medication around
the clock. I agree that the antiemetic is an extremely
important component of the medication regimen.
We, too, get calls about constipation. At that point, we
try to encourage our patients to ease off of the opioid
analgesic, if possible, since that is what is most likely
causing this problem.
New options for pain management
Dr Bradley: Given that we have characterized the
nature and source of pain associated with UFE, and
presented established protocols for management, are
there recent investigations or new techniques that
may be of importance to ObGyns and IRs?
Dr Siskin: One interesting approach that has
been recently described is the use of a superior hypogastric nerve block to control pain and reduce medication requirements.24 My only hesitation in using
this procedure is that adding another procedure to
a straightforward UFE procedure has the potential to
increase risk of the overall experience to the patient.
Still, any additional risk would be quite minimal. In
that report, the superior hypogastric nerve block is
performed during the embolization procedure with
fluoroscopy used for guidance. With the catheter in
place within the common iliac arteries, the aortic
bifurcation is very clearly seen. At that point, a needle can be placed anterior to the spine and just below
the bifurcation where medication can be administered for the nerve block.
Dr Dews: Certainly the visualization associated
with this procedure presents a good argument for its
selection. Because you can see the structures, use an
appropriate volume, and administer contrast, inadvertent vascular absorption is unlikely—although still
possible. Therefore, this pain management procedure
presents minimal risk of absorption of agents and subsequent systemic complications, which could include
seizure or cardiac arrest.
Dr Siskin: I agree. This technique is very interesting and is gaining attention among IRs, in large part
because of the move toward performing the procedure
in an outpatient setting. It offers an appealing option
for some patients and practitioners for pain control.
Dr Bradley: Do you have any experience with
epidurals?
Dr Siskin: I do not, although some IRs have used
this technique with success as well, and they have
Supplement to OBG Management | September 2008
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Uterine fibroid embolization
found that the medication requirements are reduced.
Dr Dews: Epidural anesthesia has been considered a safe alternative to general anesthesia for many
laparoscopic procedures, in general and specifically
for patients with respiratory issues. The respiratory
control mechanism remains intact and alveolar ventilation is not compromised, even in the Trendelenburg
position. Time to discharge is significantly reduced
with this modality, as compared with general anesthesia in typical gynecologic procedures.25
Dr Bradley: In addition to patients with respiratory
problems, is there another subset of patients for whom
an epidural or superior hypogastric nerve block might
warrant consideration?
Dr Dews: These modalities could certainly be
useful for a patient with a history of chronic pain who
is already tolerant of opioid medications. It may be
difficult to accurately identify these patients without
taking a careful history. As an example, a patient for
whom pain control may be a significant challenge may
be an individual who is being treated with oxycodone
in combination with acetaminophen for chronic back
pain. For this individual, tolerance to opioid analgesics may be present; therefore, adding medication will
likely be less effective, unless higher doses are used. A
superior hypogastric nerve block or an epidural may
be an appropriate intervention.
Dr Bradley: What are the potential complications
from each of these procedures?
Dr Dews: When epidurals are used, there is potential for spinal hematoma, nerve injury, or spinal cord
injury. Although these are severe, it should be noted
that the placement of epidurals is a very common procedure in anesthesiology and has a high safety record.
Complications rarely occur.26
The superior hypogastric nerve block is slightly
more invasive and, depending on the approach and
technique, may be associated with a slight additional
risk of nerve injury or intravascular injection. The anterior technique described by Rasuli also carries a risk of
infection.
Posterior paravertebral and transdiscal SHNB
approaches require an experienced anesthesiologist,
pain management specialist, or radiologist experienced in these procedures.
Dr Bradley: Thank you for the excellent discussion. To summarize, when we look at the early
“naysayers” who condemned UFE as a procedure
because of the potential for readmissions following
the procedure, we need to keep in mind that the pain
didn’t stem from the procedure per se. A number of
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prospective trials evaluated readmissions, commonly
categorized as being caused by: (1) pain, (2) nausea,
and (3) acute urinary retention. A key take-home message is that discharge should occur only if patients
can manage their pain, if they do not have nausea,
and when we are sure that urinary retention is not a
problem.
Dr Dews: Yes, I believe we have good protocols for
postprocedure pain management, but we might want
to look at “breakthrough” pain that might occur subsequently. In this light, it might be useful to consider the
role of acetaminophen, particularly for patients who
are not taking an opioid/acetaminophen combination. This agent is very appropriate for breakthrough
pain and offers a low side effect profile.
It is very important for patients to have specific
instructions on the pain medication recommendations, including medications that are prescribed
around-the-clock, versus how to use breakthrough
medications.
Potential advances in
future pain control
Dr Siskin: It’s important to note that, although we
have developed effective pain management protocols
for the post-UFE patient, there is a continuing need for
further investigation to identify the ideal medications
to use and the optimal dosing and administration
intervals. Since there is a growing trend to perform
this procedure outside the hospital setting, the need
for effective pain management will be magnified. You
will not have the option for obtaining a pain management consult in this setting.
Dr Dews: I agree with you. In anesthesiology, we
are always looking for opportunities for preemptive
algesias. And some of the protocols you discussed
in terms of patients receiving medication prior to
the initiation of the pain or the nociception—as you
described with ketorolac administration—are important. Research in this area is ongoing.
Some antiseizure medications, such as gabapentin and pregabalin, have demonstrated potential
utility in decreasing overall postoperative pain and in
reducing opioid administration. It would be an interesting opportunity to evaluate the use of these agents
in UFE.
Dr Bradley: In procedures such as endometrial
ablation that have transitioned from the OR to the
office, physicians have reported prescribing oral
September 2008 | Supplement to OBG Management
NSAIDs 24 hours prior to the procedure, adding an
IM injection of ketorolac in the office, and then following up with NSAIDs and narcotics within the first
24 to 48 hours postprocedure. Are NSAIDs used in
advance of UFE? Is there a concern about hematomas developing in the femoral artery when inserting
microcatheters?
Dr Siskin: I haven’t heard reports of medicating
patients so far in advance before a UFE procedure.
It would be interesting to learn if that might improve
patient outcomes. I believe that potential bleeding
risks associated with doing so would be minimal in
this patient population.
Dr Bradley: Dr Pron’s meticulous work demonstrates that among 555 patients, 26% used pain medication for 0 to 3 days, 44% required pain meds for 4
to 7 days, 26% from 8 to 14 days, and a total of 4% of
patients needed pain medication for 15 days or longer.
The median duration was about 6 days. That gives a
flavor for the readers: the procedure can be well tolerated, and it may be that we have not come up with
the best ways. Some of what we have talked about may
need to be studied, including steroid use and earlier
use of an NSAID.8,12
Would you have a problem if a patient had been
on an NSAID a day or two before?
Dr Siskin: No, it wouldn’t interfere with our
comfort level. Right now, if we are concerned about
patients who are potentially at risk for bleeding after
the catheter is removed, we will use a closure device
to seal the puncture site.
Dr Bradley: In many specialities, music therapy
and guided imagery have been well demonstrated to
decrease both pain and the amount of pain medication required. Could these strategies be helpful for
pain control in this context?
Dr Dews: Possibly. With pain, there is always an
anxiety component. Patients tend to do better if anxiety is reduced and they feel some autonomy. There
could be a role for such modalities, especially as UFE
moves increasingly into an outpatient setting.
We should also keep in mind that when we talk
about pain from UFE, we’re talking about ischemic
pain. It would be interesting to look at ischemic pain
in other scenarios and extrapolate that information
to UFE. n
References
1.Goldberg J. Current thinking on the role of interventional radiology in women’s health. Expert
Rev Obstet Gynecol. 2007;2:621-629.
2. Worthington-Kirsch R, Popky G, Hutchins F Jr.
Uterine arterial embolization for the management of leiomyomas: quality-of-life assessment
and clinical response. Radiology. 1998;208:625629.
3.Spies JB, Scialli AR, Jha R, et al. Initial results
from uterine fibroid embolization for symptomatic leiomyomata. J Vasc Interv Radiol.
1999;10:1149-1157.
4.Pelage JP, LeDref O, Soyer P, et al. Fibroid-related menorrhagia: treatment with superselective
embolization of the uterine arteries and midterm follow-up. Radiology. 2000;215:428-431.
5.Brunereau L, Herbreteau D, Gallas S, et al. Uterine artery embolization in the primary treatment of uterine leiomyomas: technical features
and prospective follow up with clinical and
sonographic examination in 58 patients. AJR.
2000;175:1267-1272.
6.Hutchins FL Jr, Worthington-Kirsch R, Berkowitz RP. Selective uterine artery embolization as
primary treatment for symptomatic leiomyomata uteri. J Am Assoc Gynecol Laparosc. 1999;6:
279-284.
7.Burn P, McCall J, Chinn R, et al. Embolization
of uterine fibroids. Brit J Radiology. 1999;72:
159-161.
8.Pron G, Bennett J, Common A, et al. The Ontario
Uterine Fibroid Embolization Trial. Part 2. Uterine fibroid reduction and symptom relief after
uterine artery embolization for fibroids. Fertil
Steril. 2003;79:120-127.
Available at www.obgmanagement.com
9.Tulandi T. Treatment of uterine fibroids—Is surgery obsolete? N Engl J Med. 2007;356:411-413.
10.Walker WJ, Barton-Smith P. Long-term followup of uterine artery embolisation—an effective
alternative in the treatment of fibroids. BJOG.
2006;113:464-468.
11.Spies JB, Bruno J, Czeyda-Pommersheim F, et
al. Long-term outcome of uterine artery embolization of leiomyomata. Obstet Gynecol.
2005;106:933-939.
12.Pron G, Mocarski E, Bennett J, et al. Tolerance,
hospital stay, and recovery after uterine artery
embolization for fibroids: the Ontario Uterine
Fibroid Embolization Trial. J Vasc Interv Radiol.
2003;14:1243-1250.
13.Park AJ, Bohrer JC, Bradley LD, et al. Complications after uterine artery embolization for
symptomatic uterine leiomyomas. Poster presented at: 34th Annual Meeting of the Society
of Gynecologic Surgeons; April 14-16, 2008;
Savannah, GA.
14. R
azavi MK, Hwang G, Jahed A, et al. Abdominal
myomectomy versus uterine fibroid embolization in the treatment of symptomatic uterine
leiomyomas. AJR. 2003;180:1571-1575.
15.Spies JB, Myers ER, Worthington-Kirsch R, et al.
The Fibroid Registry. Symptom and quality-oflife status 1 year after therapy. Obstet Gynecol.
2005;106:1309-1318.
16.Siskin GP, Stainken BF, Dowling K, et al. Outpatient uterine artery embolization for symptomatic uterine fibroids: experience in 49 patients
[abstract]. J Vasc Interv Radiol. 2000;11:3-5-311.
17.Pelage JP, Guaou Guaou N, Jha RC, et al. Uterine fibroid tumors: Long-term MR imaging
outcome after embolization. Radiology. 2004;
230:803-809.
18.Siskin GP, Bonn J, Worthington-Kirsch RL, et al.
III. Uterine fibroid embolization: pain management. Tech Vasc Interv Radiol. 2002;5:35-43.
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uterine artery embolization for leiomyomata:
can its severity be predicted and does severity predict outcome? J Vasc Interv Radiol.
2000;11:1047-1052.
20.Siskin GP, Stainken BF, Dowling K, et al. Outpatient uterine artery embolization for symptomatic uterine fibroids: experience in 49 patients.
J Vasc Interv Radiol. 2000;11:305-311.
21.Siskin GP, Stainken BF, Dowling K, et al. The
feasibility of performing uterine fibroid embolization as an outpatient procedure: Experience
in 73 patients [abstract]. J Vasc Interv Radiol.
2001;11:189.
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2001;184:1556-1560; discussion 1560-1563.
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24.Rasuli P, Jolly EE, Hammond I, et al. Superior hypogastric nerve block for pain control in outpatient uterine artery embolization. J Vasc Interv
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Supplement to OBG Management | September 2008
S
Self-Assessment and Activity Evaluation
Uterine fibroid embolization
Instructions for Credit
Read the article and complete the following self-assessment and the activity evaluation.
To receive CME credit and a certificate, fax or mail the completed form to the fax number/address below.
Your CME certificate will be sent via email. If an email address is not provided, your certificate will be sent via mail.
ARTICLE QUESTIONS
1. Uterine fibroid embolization should be offered to women
who are seeking fertility.
5. A quality-of-life study of UFE versus surgery for fibroid
management showed that:
True
False
2. The following are the most important types of medications that
should be given at discharge to prevent readmission: narcotics,
nonsteroidal anti-inflammatories, antiemetics, laxatives:
True
False
3. What are the most common complaints for patients within
the first month after undergoing uterine fibroid embolization?
Lethargy, discharge
Cramping
45%
60%
Vaginal discharge
All of the above
4. Sustained symptom control (up to 5 years after UFE) is seen
in what percentage of patients?
6. Infarction of the entire uterine fibroid burden by occluding
flow is important since patients who have uninfarcted or viable fibroid tissue after UFE are at risk for fibroid recurrence.
80%
90%
The embolization group had a shorter median duration of
hospitalization than the surgery group
At 1 year no significant differences were observed in any of
the Short-Form Survey (SF-36) core components
The embolization group had a shorter time before returning
to work
UFE was more cost-effective than surgery for patients with
symptomatic uterine fibroids
All of the above
True
False
ACTIVITY evaluation
Answer questions 1 and 2 using a scale of 1 to 5, where 5 = Strongly Agree, 3 = Agree, and 1 = Strongly Disagree.
1. The article met the stated objectives. 5
4
3
2
1
2. The article is relevant to my current clinical practice needs. 5
4
3
2
1
3. D
isclosure of faculty relationships with commercial organizations was
made available to me before the article. True
False
4. The commercial supporters were acknowledged in print. True
False
5. The article was balanced and free of commercial bias. True
False
6. If trade names were used, trade names of all products discussed were used.
True
False
7. A
ny off-label drug use and/or investigational drug use not yet approved by
the FDA was disclosed before or during the activity.
True
False
8. I f you answered “false” to any of the above questions, please provide details in the comments section below.
Your certificate for continuing education credit will be issued from the following information: (please print clearly)
today’s date
Degree
do
Resident
NP
Other_ __________________________
Home
Business
Specialty
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No. of Providers
street Address
Home phone
Omnia Education, ATTN: Fibroids
500 Office Center Drive, Ste 300
Fort Washington, PA 19034
Fax: 215.358.0556
Name
md
City, state, Zip
Mobile Phone
Office Phone
Office Fax
Email
Total time spent on this activity ___________________ Signature__________________________________________________________
Maximum of 1 AMA PRA Category 1 Credit(s)TM
Your CME certificate will be sent via email. If an email is not provided above, your certificate will be sent via mail.
Education, Inc., is a registered service mark of US HealthConnect, Inc. Printed in the USA.
SOmniaSeptember
2008 | Supplement to OBG Management
Return completed quiz and
evaluation form to:
Release Date:
September 1, 2008 Expiration Date: August 31, 2009