Synonym/Acronym
UFE; uterine artery embolization.
Rationale
A less-invasive modality used to assist in treating fibroid tumors found in the uterine lining, heavy menstrual bleeding, and pelvic pain.
Patient Preparation
There are no activity restrictions unless by medical direction. Instruct the patient to fast and restrict fluids for 8 hr, or as ordered, prior to the procedure. Fasting may be ordered as a precaution against aspiration related to possible nausea and vomiting. The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org.
Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken.
Patients on beta blockers before the surgical procedure should be instructed to take their medication as ordered during the perioperative period. Protocols may vary among facilities.
Normal Findings
- Decrease in uterine bleeding
- Decrease of pelvic pain or fullness.
Study type: X-ray Special/Contrast; related body system: Reproductive system.
Uterine fibroid embolization (UFE) is a way of treating fibroid tumors of the uterus. Fibroid tumors, also known as myomas, are masses of fibrous and muscle tissue in the uterine wall that are benign but that may cause heavy menstrual bleeding, pain in the pelvic region, or pressure on the bladder or bowel. Using angiographic methods with a contrast medium for visualization and fluoroscopic guidance, a catheter is placed in each of the two uterine arteries, and small embolizing particles are injected to block the arterial branches that supply blood to the fibroids. The fibroid tissue dies, the mass shrinks, and the symptoms are relieved. This procedure, which is done under local anesthesia, is less invasive than open surgery done to remove uterine fibroids. Because the effects of uterine fibroid embolization on fertility are not yet known, the ideal candidate is a premenopausal woman with symptoms from fibroid tumors who no longer wishes to become pregnant. This technique is an alternative for women who do not want to receive blood transfusions or do not wish to receive general anesthesia. This procedure may be used to halt severe bleeding following childbirth or caused by gynecological tumors.
Contraindications
Pregnancy is a general contraindication to procedures involving radiation.
Conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
Patients with bleeding disorders, because the puncture site may not stop bleeding.
Patients in whom cancer is a possibility or who have inflammation or infection in the pelvis.
Factors That May Alter the Results of the Study
- Gas or feces in the gastrointestinal tract resulting from inadequate cleansing or failure to restrict food intake before the study.
- Retained barium from a previous radiological procedure.
- Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
Other Considerations
- A small percentage of women may pass a small piece of fibroid tissue after the procedure. Women with this problem may require a procedure called a D&C (dilatation and curettage).
- Some women may experience menopause shortly after the procedure.
Abnormal Findings Related to
- No reduction in size of fibroid
Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Discuss how this procedure can assist in assessing and treating the uterus.
- Explain that the procedure takes about 90 min depending on the location and number of fibroids and is performed in a cath lab or operating room.
- Review the procedure with the patient.
- Explain that pregnancy testing may be required.
- Explain that prior to the procedure, laboratory testing may be required to determine the possibility of bleeding risk (coagulation testing).
- Review the type of anesthetic (local or general) to be used.
- Discuss how there may be moments of discomfort or pain when the IV line or catheter is inserted, allowing for infusion of fluids such as saline, anesthetics, sedatives, medications used in the procedure, or emergency medications.
- Discuss that a sedative and/or anesthetic may be administered before the procedure to promote relaxation.
- Explain that the contrast material and the embolizing material will be injected, by catheter, at a separate site from the IV line.
- Discuss how the contrast is used to aid in fluoroscopic guidance for identification of the fibroids.
- Explain that embolizing particles are injected to block the blood flow to the fibroids. The particles include polyvinyl alcohol, gelatin sponge (Gelfoam), and micospheres.
- Explain that a warm and flushing sensation may be felt throughout the body during the injection of the contrast medium.
Procedural Information
- Baseline vital signs are recorded and monitored throughout the procedure.
- Positioning for this procedure is in the supine position on an examination table. The selected areas are cleansed and covered with a sterile drape.
- Electrocardiographic electrodes are placed for cardiac monitoring, to establish baseline rhythm, and to determine the presence of any ventricular dysrhythmias.
- Peripheral pulses are marked with a pen before the angiography, allowing for a quicker and more consistent assessment of the pulses after the procedure.
- A small incision is made at the catheter insertion site (femoral artery).
- Once the contrast medium is injected in the catheter to provide guidance for embolization, the catheter is moved further into the uterine arteries, the embolizing material is administered through the same catheter, and a rapid series of images is taken during and after the filling of the vessels to be examined.
- The patient is advised to take slow, deep breaths if nausea occurs during the procedure.
- An ordered antiemetic drug is administered, as needed. An emesis basin is ready for use, as needed.
- Delayed images may be taken to examine the target vessels after the embolizing material is administered and to monitor the resulting reduction in blood flow.
- Once the needle or catheter is removed, a pressure dressing is applied over the puncture site and a closure device may be placed over the incision site to quickly stop any bleeding.
Potential Nursing Actions
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
Safety Considerations
- Anticoagulants, aspirin, and other salicylates should be discontinued by medical direction for the appropriate number of days prior to a procedure where bleeding is a potential complication.
After the Study: Implementation & Evaluation Potential Nursing Actions
Avoiding Complications
- Monitor the patient for complications related to the procedure.
- Establishing an IV site and injection of contrast medium are invasive procedures that can cause rare complications. For additional information see Appendix A: Patient Preparation and Specimen CollectionPatient Preparation and Specimen Collection, subsection: Potential Contraindications and Complications Associated With Diagnostic Procedures.
- Additional potential complications include blood clot formation (related to thrombus formation on the tip of the catheter sheath surface or in the lumen of the catheter; the use of a heparinized saline flush during the procedure decreases the risk of emboli); cardiac dysrhythmias; detachment of small pieces of fibroid tissue during UFE, which will pass, but a D&C may be required to verify that all material is removed to prevent further bleeding or infection; the occurrence of menopause following UFE, which is generally experienced in women older than 45 yr of age; damage to other organs (related to unintended embolization); postembolization fertility issues (the possibility of decreased fertility and complications during pregnancy.
- Explain the importance of immediately reporting symptoms such as difficulty breathing, chest pain, fever, hyperpnea, hypertension, nausea, palpitations, pruritus, rash, tachycardia, urticaria, or vomiting.
- Administer ordered antihistamines or prophylactic steroids if the patient has an allergic reaction.
- Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation.
- The patient will be placed in a flat, supine position for a specified period of time to avoid pooling of blood at the femoral artery insertion site.
Treatment Considerations
- Follow postprocedure vital sign and assessment protocol.
- Resume usual diet, fluids, medications, or activity, as directed by the HCP.
- Explain that pain is the most frequent post-procedural side effect experienced during the first 24 hr, related to changes in blood flow to the uterine tissue. Pelvic cramps, fatigue, fever, nausea, and vomiting may be experienced for several days after the procedure.
- Assess extremities for signs of ischemia or absence of distal pulse caused by a catheter-induced thrombus.
- Instruct the patient in the care and assessment of the injection site.
- Instruct the patient to apply cold compresses to the puncture site as needed, to reduce discomfort or edema.
- Explain that a watery or mucus-like discharge from the vagina may occur for several weeks following the procedure; the discharge should stop without requiring treatment.
- Explain the importance of immediately reporting signs and symptoms of infection (e.g., chills, fever, continuing pain).
Clinical Judgement
- Consider which social service providers can provide the best support to cope with the outcome of this procedure.
Follow-Up and Desired Outcomes
- Acknowledges the importance of adhering to the therapy regimen.
- Acknowledges the importance of returning for the follow-up examination as requested by the health-care provide.
- Understands the significant adverse effects associated with the prescribed medication and agrees to review corresponding literature provided by a pharmacist.