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Uterine necrosis after uterine artery embolization for leiomyoma
Uterine Necrosis After Uterine Artery Embolization for Leiomyoma To the Editor: May I add my reply to that of Doctor Pelage,1 concerning the above case report by Godfrey and Zbella.2 Dr. Godfrey has described a case of infection after embolization, not necrosis. Studies have shown the uterus to reperfuse within days, when examined with magnetic resonance imaging. We have often performed laparoscopic myomectomy immediately after uterine fibroid embolization.3 The uterus appears cyanotic at the beginning of the case, but the uterus inevitably returns to its normal color upon completion. The patient seemed to do well immediately postoperatively and 2 months after the procedure. She then developed signs of infection, interpreted as pelvic inflammatory disease (PID). Pyometrium is a well-recognized although rare complication of uterine artery embolization. Cultures were drawn on this patient after she had been on antibiotic therapy. Antibiotics are well known to sterilize cultures. The pathology specimen is described in indefinite terms, but is consistent with a patient suffering
from acute endometritis possibly caused by an anaerobic organism. We notice a history of cocaine use by this patient. Cocaine’s ischemic effect is well known and will lower the body’s ability to withstand a serious infection. Cocaine use may have contributed to the “poor collateral circulation” described, and might be considered a relative contraindication to embolization. Infection after embolization has been reported as a small but serious complication in several well-known journals, including The Lancet, as referenced by Dr. Godfrey. This complication is thought to arise either from embolizing patients with acute, undiagnosed PID or by using a large particle load in a large uterus.4 In our series of 667 patients, only one has undergone hysterectomy because of an infection after uterine fibroid embolization4 (Figure 1). We must also respectfully disagree with Dr. Pelage’s comment on the risks associated with submucous myomas. Submucous myomas are a risk for prolapse, but not for infection. They can be treated effectively with a simple vaginal myomectomy.4 In short, infection, a well-documented but rare complication of embolization, likely caused the condition described in the case report. Gynecologists may continue to recommend embolization to their patients suffering
Figure 1. Abscess seen on magnetic resonance imaging in patient who ultimately underwent a hysterectomy for infection after uterine fibroid embolization. McLucas. Uterine Necrosis. Obstet Gynecol 2002.
VOL. 100, NO. 6, DECEMBER 2002
Letters to the Editor
1357
from myomata as a much less morbid alternative to myomectomy. Bruce McLucas, MD Department of Obstetrics and Gynecology UCLA School of Medicine Box 957034, Suite 310, 100 UCLA Medical Plaza Los Angeles, CA 90095-7034 Stuart Sostrin, MD Department of Pathology Century City Hospital Los Angeles, California REFERENCES 1. Pelage JP, Walker WJ, Dref OL. Uterine necrosis after uterine artery embolization for leiomyoma. Obstet Gynecol 2002;99:676–7. 2. Godfrey CD, Zbella EA. Uterine necrosis after uterine artery embolization for leiomyoma. Obstet Gynecol 2001; 98:950–2. 3. Schwartz ML, Klein A, McLucas B. Using uterine artery embolization to treat fibroids. Contemp Obstet Gynecol 46:14 –37. 4. McLucas B, Adler L, Perrella R. Uterine fibroid embolization: Nonsurgical treatment for symptomatic fibroids. J Am Coll Surg 2001;192:95–105.
Chronic Hypertension In Pregnancy To the Editor: The Expert’s Review by Dr. Sibai1 was an excellent article that I appreciated immensely. In the section about the safety of antihypertensive drugs in pregnancy, Dr. Sibai cautioned about the use of atenolol during pregnancy. There are certainly anecdotal and retrospective data to suggest that atenolol use in early pregnancy is associated with smaller fetal birth weights. However, caution must be exercised when interpreting the results of the trial involving atenolol reported in 1990 by Butters et al.2 This was a small, randomized, placebo-controlled trial with 15 patients enrolled in the atenolol arm and 14 patients randomized to a placebo. Furthermore, those women randomized to atenolol were started at a dose of 50 mg daily, and the dose was increased at each visit until the blood pressure was less than 140/90 or a maximum dose of 200 mg daily was reached. Although this trial found that fetuses treated
1358
Letters to the Editor
with atenolol had significantly lower birth weights, the results must be interpreted in light of the dosing regimen. The standard initial dose for atenolol is 50 mg daily, with 100 mg daily considered the upper limit of efficacy for hypertension. The significance of the lower birth weight in this study is highly questionable, given the high-dose protocol of up to 200 mg daily. There are two randomized trials that suggest that atenolol use during the third trimester may be safe. A randomized, prospective, double-blind study of 85 women with pregnancy-induced hypertension was performed by Rubin et al.3 Women who developed hypertension in the third trimester were randomized to 100 mg of atenolol daily or a placebo. There was no difference in fetal growth between the two groups. Another study, by Tuimala and Hartikainen-Sorri,4 compared atenolol use with pindolol, a beta blocker. Patients with pregnancyinduced hypertension were randomized to 50 mg of atenolol or 10 mg of pindolol daily. There were 24 patients in the atenolol group and 27 patients in the pindolol group. No differences in gestational age or newborn weight were seen. Dana P. Damron, MD University of Vermont Burlington, VT 05401
REFERENCES 1. Sibai BM. Chronic hypertension in pregnancy. Obstet Gynecol 2002;100:369–77. 2. Butters L, Kennedy S, Rubin PC. Atenolol in essential hypertension during pregnancy. BMJ 1990;301(6752):587–9. 3. Rubin PC, Butters L, Clark DM, Reynolds B, Sumner DJ, Steedman D, et al. Placebo-controlled trial of atenolol in treatment of pregnancy-associated hypertension. Lancet 1983;1(8322):431–4. 4. Tuimala R, Hartikainen-Sorri AL. Randomized comparison of atenolol and pindolol for treatment of hypertension in pregnancy. Curr Ther Res 1988;44:579–84.
In Reply: I thank Dr. Damron for the information and thoughtful comments. I agree with Dr. Damron regarding the lack of effects of atenolol on fetal weight when used in women with pregnancy-induced hypertension during the third trimester. In these cases, atenolol is only used for an average of 2 to 3 weeks. In contrast, in women with chronic hypertension its use will be throughout gestation. Indeed, every study in which atenolol was started before 20 weeks and continued beyond
OBSTETRICS & GYNECOLOGY
from acute endometritis possibly caused by an anaerobic organism. We notice a history of cocaine use by this patient. Cocaine’s ischemic effect is well known and will lower the body’s ability to withstand a serious infection. Cocaine use may have contributed to the “poor collateral circulation” described, and might be considered a relative contraindication to embolization. Infection after embolization has been reported as a small but serious complication in several well-known journals, including The Lancet, as referenced by Dr. Godfrey. This complication is thought to arise either from embolizing patients with acute, undiagnosed PID or by using a large particle load in a large uterus.4 In our series of 667 patients, only one has undergone hysterectomy because of an infection after uterine fibroid embolization4 (Figure 1). We must also respectfully disagree with Dr. Pelage’s comment on the risks associated with submucous myomas. Submucous myomas are a risk for prolapse, but not for infection. They can be treated effectively with a simple vaginal myomectomy.4 In short, infection, a well-documented but rare complication of embolization, likely caused the condition described in the case report. Gynecologists may continue to recommend embolization to their patients suffering
Figure 1. Abscess seen on magnetic resonance imaging in patient who ultimately underwent a hysterectomy for infection after uterine fibroid embolization. McLucas. Uterine Necrosis. Obstet Gynecol 2002.
VOL. 100, NO. 6, DECEMBER 2002
Letters to the Editor
1357
from myomata as a much less morbid alternative to myomectomy. Bruce McLucas, MD Department of Obstetrics and Gynecology UCLA School of Medicine Box 957034, Suite 310, 100 UCLA Medical Plaza Los Angeles, CA 90095-7034 Stuart Sostrin, MD Department of Pathology Century City Hospital Los Angeles, California REFERENCES 1. Pelage JP, Walker WJ, Dref OL. Uterine necrosis after uterine artery embolization for leiomyoma. Obstet Gynecol 2002;99:676–7. 2. Godfrey CD, Zbella EA. Uterine necrosis after uterine artery embolization for leiomyoma. Obstet Gynecol 2001; 98:950–2. 3. Schwartz ML, Klein A, McLucas B. Using uterine artery embolization to treat fibroids. Contemp Obstet Gynecol 46:14 –37. 4. McLucas B, Adler L, Perrella R. Uterine fibroid embolization: Nonsurgical treatment for symptomatic fibroids. J Am Coll Surg 2001;192:95–105.
Chronic Hypertension In Pregnancy To the Editor: The Expert’s Review by Dr. Sibai1 was an excellent article that I appreciated immensely. In the section about the safety of antihypertensive drugs in pregnancy, Dr. Sibai cautioned about the use of atenolol during pregnancy. There are certainly anecdotal and retrospective data to suggest that atenolol use in early pregnancy is associated with smaller fetal birth weights. However, caution must be exercised when interpreting the results of the trial involving atenolol reported in 1990 by Butters et al.2 This was a small, randomized, placebo-controlled trial with 15 patients enrolled in the atenolol arm and 14 patients randomized to a placebo. Furthermore, those women randomized to atenolol were started at a dose of 50 mg daily, and the dose was increased at each visit until the blood pressure was less than 140/90 or a maximum dose of 200 mg daily was reached. Although this trial found that fetuses treated
1358
Letters to the Editor
with atenolol had significantly lower birth weights, the results must be interpreted in light of the dosing regimen. The standard initial dose for atenolol is 50 mg daily, with 100 mg daily considered the upper limit of efficacy for hypertension. The significance of the lower birth weight in this study is highly questionable, given the high-dose protocol of up to 200 mg daily. There are two randomized trials that suggest that atenolol use during the third trimester may be safe. A randomized, prospective, double-blind study of 85 women with pregnancy-induced hypertension was performed by Rubin et al.3 Women who developed hypertension in the third trimester were randomized to 100 mg of atenolol daily or a placebo. There was no difference in fetal growth between the two groups. Another study, by Tuimala and Hartikainen-Sorri,4 compared atenolol use with pindolol, a beta blocker. Patients with pregnancyinduced hypertension were randomized to 50 mg of atenolol or 10 mg of pindolol daily. There were 24 patients in the atenolol group and 27 patients in the pindolol group. No differences in gestational age or newborn weight were seen. Dana P. Damron, MD University of Vermont Burlington, VT 05401
REFERENCES 1. Sibai BM. Chronic hypertension in pregnancy. Obstet Gynecol 2002;100:369–77. 2. Butters L, Kennedy S, Rubin PC. Atenolol in essential hypertension during pregnancy. BMJ 1990;301(6752):587–9. 3. Rubin PC, Butters L, Clark DM, Reynolds B, Sumner DJ, Steedman D, et al. Placebo-controlled trial of atenolol in treatment of pregnancy-associated hypertension. Lancet 1983;1(8322):431–4. 4. Tuimala R, Hartikainen-Sorri AL. Randomized comparison of atenolol and pindolol for treatment of hypertension in pregnancy. Curr Ther Res 1988;44:579–84.
In Reply: I thank Dr. Damron for the information and thoughtful comments. I agree with Dr. Damron regarding the lack of effects of atenolol on fetal weight when used in women with pregnancy-induced hypertension during the third trimester. In these cases, atenolol is only used for an average of 2 to 3 weeks. In contrast, in women with chronic hypertension its use will be throughout gestation. Indeed, every study in which atenolol was started before 20 weeks and continued beyond
OBSTETRICS & GYNECOLOGY