1. 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

2. 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

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

4. UF - What are they? b Common growths in female population (20 - 50%) b Smooth muscle in origin b Predominantly benign b May be associated with reproductive disorders b Asymptomatic fibroid do not require treatment

5. 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

6. UF - Population affected b Increased incidence between the ages of 35 - 49 b Afro-Caribbean women higher risk b Generic and hormonal factors

7. 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

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

9. Ultrasound UF – Diagnosis (Con’t)

10. Magnetic Resonance Imaging UF – Diagnosis (Con’t)

11. Hystersalpingogram

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

13. Hysterectomy UF - Treatment options (cont)

14. 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)

15. 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

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

17. 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

18. 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

19. UFE THE ROLE OF THE IMAGING NURSE

20. UFE - Patient preparation l

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

22. Nursing documentation

23. 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

24. 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

25. UFE - Arteriogram

26. 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

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

28. UFE - Nursing documentation.

29. 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

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

31. 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

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

33. UFE - Post Procedure Syndromes b Pyrexia, nausea and vomiting b Pelvic pain b Could last up to 24 - 48 hours and up to 7 days 7 days b Worse with large and multiple fibroids

34. UFE - Complications b Groin haematoma b Pelvic pain b Uterine infection leading to hysterectomy 0.5 - 2% b Fibroid impaction b Premature ovarian failure (menopause) 1 - 5% b Non-target organ ischaemia b 2 reported deaths related to infection

35. 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)

36. 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

37. UFE - Benefits (cont) b Clinical success 80 - 94% b Average reduction of fibroid volume 41 - 64% b Reported pregnancy post UFE

38. 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

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

40. 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 11:305-311 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;224:610-613