Nursing care for women undergoing Uterine Fibroid Embolisation Jan Jackson BSc (Hons), DMS, CMS, RN, SEN (UK) Head Nurse, Imaging Directorate, Hammersmith Hospitals NHS Trust, London, UK Hammersmith Hospitals NHS Trust

UFE - Background b First used in late 1970s to control post- partum bleed b Ravina et al (1995) published results on treatment for UF disease - effective in controlling symptoms 80-94% - effective in controlling symptoms 80-94% - fewer complications - fewer complications - over 7,000 women treated - over 7,000 women treated

UFE - Reputation b Reputation of being ‘quick and safe’

UF - What are they? b Common growths in female population ( %) b Smooth muscle in origin b Predominantly benign b May be associated with reproductive disorders b Asymptomatic fibroid do not require treatment

UF - Type of Fibroid b Intramural - common and develops in the wall of uterus b Subserosal - develops under outside covering of uterus b Submucosal - develops under the inner lining of the uterus and is lease common and problematic

UF - Population affected b Increased incidence between the ages of b Afro-Caribbean women higher risk b Generic and hormonal factors

UF - Symptoms b Abnormal vaginal bleeding (menorrhagia) b Pelvic pain b Pelvic pressure (large fibroid) on bladder, bowel, kidneys causing increases urination, constipation b Infertility, recurrent spontaneous abortion, pre-term labour

UF - Diagnosis b Physical exam (bimanual-abdomen) b Ultrasound b MRI b Hysterosalpingogram b CT b Hysteroscopy

Ultrasound UF – Diagnosis (Con’t)

Magnetic Resonance Imaging UF – Diagnosis (Con’t)

Hystersalpingogram

UF - Treatment options b Symptoms management b Surgery - NSAID - Hormone Therapy - Hysterectomy - Myomectomy

Hysterectomy UF - Treatment options (cont)

b Endometrial ablation b Thermal ablation of uterus fibroid - percutaneous insertion of laser fibres - percutaneous insertion of laser fibres - focussed US - focussed US b Uterine Fibroid Embolisation (UFE)

Uterine Fibroid Embolisation (UFE) b Less invasive b Non-surgical b Performed by Interventional Radiologists b Blood flow in the right and left uterine arteries is occluded and the fibroids are deprived of their blood supply b Occlusion leads to necrosis and death of the fibroids

UFE - Indications b Referred by gynaecologist b Symptomatic patients who have failed other therapy or do not wish to have surgery

UFE – Contraindications b Coagulation disorder or other contraindication to angiography b Infection b Other uterine pathology e.g. endometriosis, adenomyosis, cancer b Patients who desire fertility and have exhausted other alternatives

UFE – Before Procedure b Pelvic US TA/TV or MRI b Excluding malignancy b Gynaecological examination - reviewed b Discuss with interventional radiologist b Procedure explained b Patient information leaflet b Consent

UFE THE ROLE OF THE IMAGING NURSE

UFE - Patient preparation l

b Imaging nurse visits patient prior to procedure b Assessment b Patient preparation instruction b Analgesia b Antibiotic

Nursing documentation

UFE - Hammersmith Hospital Pre -procedure b Patient admits to ward b Seen by radiologist - consent b Prepare for procedure e.g. NBM, shaved b Collected by IA to Imaging b Imaging nurse received patient and hand over from ward nurse b Check patient b Medication - Diclofenac suppository 100 mg

UFE - Hammersmith Hospital Procedure Technique b Conscious sedation b Local anaesthesia b Femoral puncture b Pelvic arteriogram performed b Use of microcatheters and guidewires to select uterine arteries b PVA b Final uterine arteriogram

UFE - Arteriogram

UFE - conscious sedation b Adult b Sedation policy b To allow gastric emptying: - Solid food up to 4 hours prior to procedure. - Solid food up to 4 hours prior to procedure. - Clear fluids up to 2 hours prior to - Clear fluids up to 2 hours prior to procedure. procedure. - Nil by mouth. - Nil by mouth. American Society of Anaesthesiologists Task Force on Sedation and Analgesia by non-anaesthesiologists (1996) Practice guidelines for sedation and analgesia by non-anaesthesiologists

UFE - Peri-procedure b Conscious sedation b Pain management - pain assessment - pain assessment b Monitor vital signs b Comfort and reassuring patient b Documentation

UFE - Nursing documentation.

UFE – Pain Management During Procedure b Pain assessment b Medications - Hypnovel IV (Midazolam) - Hypnovel IV (Midazolam) - Diamorphine IV - Diamorphine IV - Zofran IV (Ondansetron) - Zofran IV (Ondansetron) - Paracetamol infusion - Paracetamol infusion

UFE - Post procedure b Recovery b Pain management b Anti-nausea medication b Activities - bed rest b Education - patients, ward nurse

UFE - Post procedure pain b Start shortly after 2nd uterine is occluded b Worsen for 2 hours then plateau for 6-8 hours b Improvement over next 12 hours b Improve over next several days

UFE - Post procedure Pain Management b Diclofenac 50mg oral 8 hrly b Tramadol 50mg oral 6 hrly b Anti-emetic. Zofran or Cyclizine

UFE - Post Procedure Syndromes b Pyrexia, nausea and vomiting b Pelvic pain b Could last up to hours and up to 7 days 7 days b Worse with large and multiple fibroids

UFE - Complications b Groin haematoma b Pelvic pain b Uterine infection leading to hysterectomy % b Fibroid impaction b Premature ovarian failure (menopause) 1 - 5% b Non-target organ ischaemia b 2 reported deaths related to infection

UFE - Discharge instructions b Femoral instruction site care b Contact number b Follow-up appointment b Pain control b Anti-emetic b Shower b Nothing in vagina for 2-3 weeks (no sexual intercourse, no tampon)

UFE - Benefits b Treats all fibroid simultaneously b Permanent infarction without regrowth b Minimally invasive b Preserve options for other therapies b Effective in controlling bleeding b Significant uterine volume reduction b Shorter recovery times

UFE - Benefits (cont) b Clinical success % b Average reduction of fibroid volume % b Reported pregnancy post UFE

UFE - NICE Guidelines b July 2003 b Remains uncertain over safety and effectiveness b Both gynaecologists and radiologists are involved in the decision to carry out procedure b BSIR Registry b Systemic review

UFE - Conclusion b Good short term results b Require long term follow-up b Need to carry out RCT b Effect on pregnancy

References Walker, WJ – Uterine Artery Embolisation for Symptomatic Fibroids: Clinical Result in 400 Women with Imaging Follow-up Siskin, GP et al (2000) – Outpatient Uterine Artery Emblisation for Symptomatic Uterine Fibroids: Experience in 49 patients, JVIR 11: National Institute of Clinical Excellence (NICE) – Uterine artery embolisation for fibroids, 2003 Ryan, JM et al (2002) – Simplified Pain-Control Protocol after Uterine Artery embolisation, Radiology 2002;224: