Sławomir Woźniak

Predicting the results of uterine artery embolization: correlation between initial intramural fibroid volume and percentage volume decrease

Introduction and objective Uterine artery embolization (UAE) is a minimally invasive treatment option for symptomatic fibroids. Long-term follow-up studies have shown that at five-year follow-up after UAE, up to 30% of patients required a hysterectomy. Therefore, it seems of utmost importance to identify patients, who are unlikely to benefit from UAE. It has been postulated that the percentage volume reduction of fibroids may predict long-term UAE outcome. The results of available studies are equivocal, therefore it seemed of interest to investigate the correlation between the preinterventional intramural fibroid volume and imaging outcome of UAE in premenopausal patients. Material and methods Uterine artery embolization was performed in 65 premenopausal patients with symptomatic, intramural fibroids. Dominant fibroid volume was assessed using an integrated VOCAL (Virtual Organ Computer-aided AnaLysis) imaging program at baseline and 3 months after UAE. The percentage reduction of fibroid volume was calculated. The association between preinterventional fibroid volumes and percentage volume reductions was determined with the Spearman rank correlation test. Results Before UAE, the median dominant fibroid volume was 101 cm3 (range 23.6-610). At three-month follow-up the median dominant leiomyoma volume decreased to 50.4 cm3 (range 6.9-193.9). Median percentage reduction of fibroid volume three months after UAE was calculated at 50.1% (range 2.7-93.5). The Spearman correlation test between the preinterventional dominant fibroid volume and percentage volume reduction showed a statistically significant, positive correlation (R = 0.33; p = 0.006). Conclusions The percentage volume reduction of intramural leiomyomas after UAE seems to be more pronounced in the case of larger tumors.

Prenatal diagnosis of persistent right umbilical vein – Incidence and clinical impact. A prospective study

Persistent right umbilical vein (PRUV) is usually an isolated finding but it may be accompanied by other fetal malformations.

The influence of uterine artery embolisation on ovarian reserve, fertility, and pregnancy outcomes – a review of literature

Uterine fibroids are considered to be the most frequent female benign tumours. Fibroids affect mainly women of reproductive age. The most frequently reported signs and symptoms of fibroids include disturbances of the menstrual cycle such as heavy bleeding and painful menstruation, pelvic masses associated with pelvic pain, urinary problems or constipation, as well as infertility and recurrent pregnancy loss. The mainstay of fibroid treatment is still surgery. However, many patients seek alternative treatment options for fibroids, to preserve their uterus and fertility. One of the most important alternative treatment options for fibroids is uterine artery embolisation (UAE). However, there are some concerns that UAE may negatively influence ovarian function and even result in premature menopause. Moreover, the use of UAE in patients with future reproductive plans is still controversial, due to the possible pregnancy complications. The purpose of this review is to summarise the current knowledge regarding the possible influence of UAE on fertility, pregnancy outcome, and ovarian reserve.

The effect of ulipristal acetate treatment on symptomatic uterine fibroids within 12-months follow-up

Aim of the study The purpose of the study was to monitor the effect of ulipristal acetate treatment on symptomatic uterine fibroids within 12-months follow-up. Material and methods Fifty six patients with symptomatic uterine fibroids qualified for surgical treatment were included in the prospective observational study. All patients received preoperative oral UPA treatment for 3 months (1 × 5 mg). Patients that refused surgical treatment after UPA therapy were followed-up for the next 9 months. The volume of the intramural fibroid was estimated by TV-US using and integrated VOCAL 3D imaging program at baseline, after 3 months of UPA treatment and further at 3-months intervals. Results Before UPA mean dominant fibroid volume was estimated to be 216.0 cm3 (38.4-768.2 cm3) and decreased to 117.6 cm3 (12.6-668.0 cm3) after 3 months of UPA therapy. Mean percentage volume reduction was 45.6%. Mean hemoglobin level increased from an initial 10.1 g/dL (6.8-12.9 g/dL) to 12.6 g/dL (10.1-14.8) after 3 months of UPA therapy. At 12 months after initiating UPA treatment mean dominant fibroid volume decreased by 43.9%. In one third of followed-up patients the effect of 3 month UPA therapy persisted for the next 9 months. Conclusions Three month UPA therapy decreases fibroid volume and improves hemoglobin level before planned surgical treatment. In one third of followed-up patients the effect of 3 month UPA therapy persisted for the next 9 months.

Ascites Index — a novel technique to evaluate ascites in ovarian hyperstimulation syndrome: a concept-proof study

OBJECTIVES Controlled ovarian hyperstimulation is an important step in infertility treatment. In some cases, however, ovar-ian hyperstimulation syndrome (OHSS) can occur. In its severe forms, ascites is likely to develop, associated with dyspnea. The aim of this study was to explore the usefulness of Ascites Index (AsI), a new tool for quantitative determination of ascites in patients with OHSS, to obtain data for planning further trials. MATERIAL AND METHODS Twelve patients with OHSS and ascites were included in the study. All patients were admitted to the hospital because of abdominal pain and dyspnea due to increasing ascites. Ultrasound measurements of ascites extent were performed in four external quadrants of the abdomen. Pockets of free fluid were measured. The obtained values were totaled, forming the Ascites Index (AsI), similarly to the amniotic fluid index. Because of dyspnea, paracentesis was performed in all cases. RESULTS Median AsI at which patients reported dyspnea was 29.0 cm (range 21.6-38.6 cm). At AsI values less than 21.6 cm, no dyspnea was observed in any of the 12 studied patients. To avoid complications, 2000 mL of ascitic fluid was collected in each patient. After paracentesis, range of AsI decreased to 12.1-14.5 cm. CONCLUSIONS The proposed AsI seems to be a promising tool for estimating and monitoring the ascites extent in OHSS. It can be estimated using basic ultrasound equipment. AsI requires further studies for standardization and transferability to other causes of ascites.

Acute urticaria: an extremely rare adverse effect of levonorgestrel-releasing intrauterine system as a possible manifestation of progestogen hypersensitivity syndrome

Address for correspondence: Justyna Emeryk-Maksymiuk, MD, PhD, Chair of Internal Medicine and Department of Internal Medicine in Nursing, Medical University of Lublin, 8 Jaczewskiego St, 20-954 Lublin, Poland, phone: +48 81 724 47 02, e-mail: justynaemeryk@poczta.onet.pl Received: 6.03.2017, accepted: 9.07.2017. Acute urticaria: an extremely rare adverse effect of levonorgestrel-releasing intrauterine system as a possible manifestation of progestogen hypersensitivity syndrome

Ultrasonography of uterine leiomyomas

Uterine leiomyomas or uterine fibroids are the most common gynaecological tumours and occur in about 20-50% of women around the world. Ultrasonography (USG) is the first-line imaging examination in suspected fibroids and shows high sensitivity and specificity in diagnosing this condition. Ultrasound scans can be performed transvaginally (transvaginal scan – TVS) or transabdominally (transabdominal scan – TAS); both scans have advantages and limitations, but, in general, transvaginal sonography is superior to transabdominal sonography in most cases of pelvic pathology. Whether a leiomyoma is symptomatic or not depends primarily on its size and location. During ultrasound examination, leiomyomas usually appear as well-defined, solid, concentric, hypoechoic masses that cause a variable amount of acoustic shadowing. During the examination of leiomyomas differential diagnosis is important. Some of the most common misdiagnosed pathologies are adenomyosis, solid tumours of adnexa, and endometrial polyps. Misdiagnosis of a leiomyosarcoma has the most negative consequences, presenting symptoms are very similar to benign leiomyoma, and there is no pelvic imaging technique that can reliably differentiate between those pathologies. Magnetic resonance and computer tomography might be helpful in the diagnostics of uterine leiomyoma; however, ultrasound examination is the basic imaging test confirming the existence of leiomyomas, allowing the differentiation of myomas with adenomyosis, endometrial polyps, ovarian tumours, and pregnant uterus.

Fertility impairment associated with uterine fibroids – a review of literature

Uterine fibroids (also known as leiomyomas or myomas) are the most common benign tumors affecting reproductive organs in women. They are monoclonal tumors of the uterine smooth muscle, which spring from myometrium. It is estimated that they occur in 50-60% of the female population and rise to 70% by the age of 50. While mostly asymptomatic, myomas can be connected with several conditions, including abnormal bleeding with subsequent anemia, pelvic masses, pelvic pain, bulk symptoms, unfavorable impact on fertility and obstetric complications. Factors, which predispose the emergence of fibroids are: hormones, Afro-American ethnicity, age, obesity, adverse pregnancy outcome history, early menarche, genetic factors, alcohol, caffeine or eating too much red meat. On the other hand, there are factors, which can decrease this risk: pregnancy, early menopause and tobacco smoking. There are several mechanisms of fertility impairment in females with fibroids: alternations in uterus function (flawed blood supply, increased contractility), changes in the normal uterus anatomy, local hormonal changes induced by fibroids. In this review the connection between fibroids and infertility is analyzed.

The safety and tolerance of phytotherapies in menopausal medicine – a review of the literature

Phytoestrogens are polyphenol, non-steroidal substances of plant origin, resembling 17β-estradiol in structure. These substances can act as either agonists or antagonists of oestrogen receptors α and β. Phytoestrogens are widely used to alleviate menopausal symptoms, such as hot flushes and night sweats. Most of the currently available products of plant origin registered to soften climacteric symptoms consist of extracts obtained from soy, red clover, or black cohosh. Non-hormonal phytotherapy is a new alternative for patients suffering from menopausal symptoms. Active ingredients such as PI 82-GC FEM extract do not show any direct hormonal mechanisms of action typical for oestrogens and phytoestrogens. There are concerns about the safety and tolerability of phytoestrogens. In this review we summarise the current literature regarding the clinical aspect of safety and tolerance of different phytotherapies used to relieve menopausal symptoms.

Pelvic congestion syndrome initially misdiagnosed as a hydrosalpinx — a diagnostic challenge

Pelvic congestion syndrome (PCS) is characterized by abnormalities of ovarian, internal iliac or parametrial veins such as: dilation, varices, valvular insufficiency, obstruction or local inflammatory process. Chronic pelvic pain (CPP) is the typical symptom of PCS. PCS is one of the most frequently underdiagnosed or misdiagnosed gynecological conditions. The differential diagnosis, including gynaecological, gastrointestinal, urological and neurologic disorders, plays an important role in the adequate recognition and further treatment. We report a case of a 41-year-old patient of Caucasian racial origin, gravida 3, para 3, admitted to the hospital due to deterioration of CPP. The patient was previously diagnosed with a hydrosalpinx in the outpatient setting and was awaiting laparoscopic treatment. CPP, with a year and a half duration, was the only complaint reported. Transvaginal ultrasound examination was performed using a UGEO WS80A ultrasound system (Samsung Medison, Seoul, Korea). The uterus appeared normal except for the presence of multiple tortuous arcuate veins in the myometrium (Fig. 1), the ovaries were bilaterally unremarkable, the suspicion of hydrosalpinx was not confirmed. A dilated (up to 10.4 mm) left parametrial venous plexus, which was probably mistakenly interpreted as a hydrosalpinx, was also seen (Fig. 2). Some ultrasound features of the dilated plexus, such as an anechoic mass with incomplete septa, separated from the ovary may have led to the initial outpatient misdiagnosis of a hydrosalpinx. Slow and retrograde blood flow was noted in the dilated plexus (Fig. 3). Valsalva manoeuver was performed during the examination to show the enhanced reversed blood flow. Basing on the ultrasound image of the pelvic veins the diagnosis of PCS was made. The patient was qualified for phlebography and embolization of the left ovarian vein using the femoral approach. During the procedure the diagnosis was confirmed by visualizing reflux in the abnormal left ovarian vein and left parametrial venous plexus. The abnormal veins were closed with the use of detachable coils and aethoxysclerol (Fig. 4). Immediately after the procedure and during 3 months follow-up the patient did not report any pain. Moreover, the ultrasound findings tended to regress, the dilated pelvic veins were not visualized at 3 months follow-up. PCS is often an overlooked condition, that can mimic other gynecological diseases, and can be effectively treated by minimally invasive techniques. Transvaginal ultrasound is the first line imaging modality to confirm the suspicion of PCS. Ultrasound diagnostic criteria for PCS are dilated pelvic or ovarian veins > 6 mm, reversed blood flow in the pelvic or ovarian veins, polycystic changes in the ovaries and dilated veins in the myometrium. The awareness of PCS is low. In our case, despite the fact that 3 out of 4 diagnostic criteria for PCS were met, the initial outpatient diagnosis was false. The diagnosis of PCS is challenging and PCS should not be omitted in the diagnostic investigation of CPP. Figure 1. Transvaginal ultrasound image of the uterus. Multiple tortuous arcuate veins (arrows) were seen in the myometrium