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Kennedy A, Debbink M, Griffith A, Kaiser J, Woodward P. Cesarean Scar Ectopic Pregnancy: A Do-Not-Miss Diagnosis. Radiographics 2024; 44:e230199. [PMID: 38843098 DOI: 10.1148/rg.230199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
The rate of cesarean section (CS) for delivery has increased internationally, reaching 50% in some countries. Abnormal implantation of a new pregnancy at the site of the prior hysterotomy is an important complication because of the risks of hemorrhage, uterine rupture, and progression to placenta accreta spectrum (PAS), a condition with high morbidity with potential for catastrophic obstetric hemorrhage, maternal and fetal mortality, and loss of fertility. Cesarean scar ectopic pregnancy (CSEP) is the recommended term to describe these pregnancies, which are recognized on the basis of the sac implantation site, growth pattern, and associated abnormal perfusion. The true incidence of CSEP is unknown because the condition is likely underdiagnosed and underreported. The 2022 Society for Maternal-Fetal Medicine consult series notes that severe maternal morbidity and mortality are linked to difficulty in making the diagnosis of CSEP. The authors review the signs of CSEP at imaging, some pitfalls that may lead to delayed or missed diagnosis, and the consequences thereof. CSEPs must be differentiated from low implantation of a normal pregnancy, cervical ectopic pregnancy, and evolving pregnancy loss. Early recognition allows prompt and safe treatment that is usually surgical. Early treatment results in decreased health care costs, a shorter hospital stay, preservation of fertility, and prevention of iatrogenic preterm delivery, which is typical in cases that progress to PAS. Hysterectomy has serious negative psychologic consequences for patients of childbearing age; early diagnosis and prompt treatment of CSEP can prevent this often-ignored complication. ©RSNA, 2024 Supplemental material is available for this article.
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Affiliation(s)
- Anne Kennedy
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
| | - Michelle Debbink
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
| | - April Griffith
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
| | - Jennifer Kaiser
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
| | - Paula Woodward
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
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García-Lima L, Diaz BP, Bermúdez Rodríguez A, Palacios Macedo Chavolla A, Malfavon M. The Management of Uterine Arteriovenous Malformations in Obstetrics. Cureus 2024; 16:e60425. [PMID: 38882955 PMCID: PMC11179488 DOI: 10.7759/cureus.60425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/18/2024] Open
Abstract
Uterine arteriovenous malformation (AVM) is a rare but serious condition that can cause heavy uterine bleeding. It occurs when abnormal connections form between the arteries and veins in the uterus, leading to significant health complications. Accurate identification and diagnosis are crucial because overlooking or mishandling them can lead to severe, life-threatening bleeding. We present the case of a 30-year-old patient presenting with abnormal uterine bleeding 15 days after she gave birth to her second child. The ultrasound examination showed images suggestive of retained ovuloplacental remnants, so a uterine aspiration was performed, but the patient presented severe vaginal bleeding. Subsequently, magnetic resonance imaging (MRI) was performed, demonstrating the presence of a prominent lesion in the posterior wall of the uterine body with multiple serpentine-like pathways and a signal void suggestive of aberrant vessels corresponding to AVMs. Ergotrate and misoprostol were administered to control the bleeding, and a Bakri balloon was inserted and maintained until the bleeding stopped. We are highlighting this case to emphasize the importance of considering uterine AVM (UAVM) when dealing with abnormal uterine bleeding, even in the postpartum period. Due to its rarity, there is a lack of substantial evidence to guide clinicians in managing this condition.
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Affiliation(s)
- Linda García-Lima
- Gynecology, American British Cowdray Medical Center, Mexico City, MEX
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Xholli A, Scovazzi U, Londero AP, Paudice M, Vacca I, Schiaffino MG, Kratochwila C, Cavalli E, Perugi I, Cagnacci A. Clinical and ultrasonographic characteristics of pregnancy-related enhanced myometrial vascularity: prospective cohort study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:672-682. [PMID: 37984401 DOI: 10.1002/uog.27537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 11/04/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE To assess the ultrasonographic, epidemiological, clinical and evolutive characteristics of enhanced myometrial vascularity (EMV) following a first-trimester termination of pregnancy (TOP) or management of non-viable pregnancy. METHODS This prospective study included women who underwent follow-up ultrasound examination 5-6 weeks after a first-trimester TOP or after management of a first-trimester non-viable pregnancy at the University Hospital Polyclinic San Martino of Genoa between March 2021 and March 2022. EMV was characterized using two- and three-dimensional ultrasound and Virtual Organ Computer-aided Analysis. Ultrasonographic diagnosis of EMV was made when an unusual, tortuous myometrial vessel structure, with high-velocity blood flow, protruding towards the endometrium was observed, while an abnormal junctional zone, absent endometrial midline and heterogeneous endometrium supported the diagnosis. Patients with EMV underwent expectant management with planned ultrasonographic follow-up every 2 weeks until resolution. RESULTS During the study period, 305 women underwent TOP, of whom 132 attended the initial follow-up 5-6 weeks later, at which 52 were diagnosed with EMV. Ninety-six women were managed for a non-viable pregnancy, of whom 32 presented for follow-up, at which six had a diagnosis of EMV. Thus, overall, 164 of 401 women were included in the study and EMV was identified in 58 (35%) of these. The prevalence of EMV 5-6 weeks after a TOP was therefore between 52/305 (17%) and 52/132 (39%), and that after management of a non-viable pregnancy was between 6/96 (6%) and 6/32 (19%). Bleeding/pelvic pain was present in half (29/58) of the women with EMV, and serum human chorionic gonadotropin was detectable in 29% (17/58) at the first follow-up examination. At ultrasound assessment, all cases with EMV presented abundant tortuous myometrial vessels with high-velocity flow projecting from the myometrium towards the endometrium, along with non-uniform heterogeneous endometrium in 97% of cases, which often (67% of these) contained cystic areas, absence of the endometrial midline in 98% of cases and an abnormal junctional zone in 97% of cases (64% interrupted, 33% irregular). Most (67%) women with EMV were parous and 90% of them had undergone TOP rather than management for a non-viable pregnancy. Medical management of the TOP or non-viable pregnancy was more frequent in women with than those without EMV (93% vs 77%, P = 0.023). Multiple regression analysis showed the risk of EMV to be increased following TOP vs non-viable pregnancy (odds ratio (OR), 3.67 (95% CI, 1.16-11.56), P = 0.026) and in parous compared with nulliparous women (OR, 2.95 (95% CI, 1.45-6.01), P = 0.002). All women with EMV underwent expectant management. Eleven women did not return for subsequent follow-up examinations and did not present to our outpatient or emergency facilities, so were lost to further follow-up. Spontaneous resolution of the lesion was observed within 7-16 weeks after the procedure in 96% (45/47) of the remaining cases. Two women chose to undergo surgery for pelvic discomfort, and histology showed the presence of neovessels mixed with retained chorionic villi. CONCLUSIONS EMV is a transient and common finding 5-6 weeks following first-trimester TOP or management of non-viable pregnancy. TOP and being parous are risk factors for EMV. Expectant management of EMV is appropriate, because, in almost all cases, this resolves spontaneously, without complications, within 2-4 months. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A Xholli
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - U Scovazzi
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DINOGMI), Genoa, Italy
| | - A P Londero
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DINOGMI), Genoa, Italy
| | - M Paudice
- Department of Pathology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- University of Genoa, Genoa, Italy
| | - I Vacca
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DINOGMI), Genoa, Italy
| | - M G Schiaffino
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DINOGMI), Genoa, Italy
| | - C Kratochwila
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DINOGMI), Genoa, Italy
| | - E Cavalli
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DINOGMI), Genoa, Italy
| | - I Perugi
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DINOGMI), Genoa, Italy
| | - A Cagnacci
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DINOGMI), Genoa, Italy
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Kamil H, Aboulkher MG, Anbarji A, Martini N, Adwan D. Modified compression sutures for treatment of asymptomatic uterine arteriovenous malformation in a low-resource setting: A case report. Int J Surg Case Rep 2024; 118:109678. [PMID: 38663286 PMCID: PMC11064609 DOI: 10.1016/j.ijscr.2024.109678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/18/2024] [Accepted: 04/21/2024] [Indexed: 05/05/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Uterine arteriovenous malformation (UAVM) can be present at birth or acquired later, often after trauma like cesarean delivery. It can cause severe vaginal bleeding but may have no symptoms. What makes our case special, other than being a rare condition, is the surgical technique used. CASE PRESENTATION A 24-year-old woman came in with abdominal pain at 38 weeks pregnant. She had a cesarean delivery 13 months before. She had an uncomplicated repeat cesarean but bled heavily after from uterine atony. A 5 × 7 cm asymptomatic uterine AVM was found incidentally in the right uterine horn. After the transfusion, B-Lynch sutures were used to treat the atony and AVM. The patient recovered well after the sutures. Follow-up ultrasound showed the AVM got much smaller and no more bleeding. CLINICAL DISCUSSION While conventional approaches advocate hysterectomy or uterine artery embolization (UAE), our case, situated in a low-income setting, necessitated innovative strategies. With embolization unavailable, and surgery carrying inherent risks, the B-lynch Procedure emerged as a pragmatic choice. CONCLUSION Uterine AVM with no symptoms can happen after cesarean delivery. In low-resource settings, modified compression sutures can effectively treat heavy bleeding after delivery and shrink AVM size, avoiding hysterectomy.
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Affiliation(s)
- Hazem Kamil
- Damascus University, Faculty of Medicine, Damascus, Syrian Arab Republic; Stemosis for Scientific Research, Damascus, Syrian Arab Republic.
| | - Mhd Ghazi Aboulkher
- Damascus University, Faculty of Medicine, Damascus, Syrian Arab Republic; Stemosis for Scientific Research, Damascus, Syrian Arab Republic
| | - Abdullah Anbarji
- Damascus University, Faculty of Medicine, Damascus, Syrian Arab Republic; Stemosis for Scientific Research, Damascus, Syrian Arab Republic
| | - Nafiza Martini
- Damascus University, Faculty of Medicine, Damascus, Syrian Arab Republic; Stemosis for Scientific Research, Damascus, Syrian Arab Republic
| | - Dema Adwan
- Obstetrics and Gynecology Hospital, Damascus University, Damascus, Syria
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Jeerakornpassawat D, Tantipalakorn C, Sirilert S, Tongsong T. Sonographic Features of Uterine Arteriovenous Malformation: A Case Series. Diagnostics (Basel) 2024; 14:873. [PMID: 38732288 PMCID: PMC11083442 DOI: 10.3390/diagnostics14090873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/18/2024] [Accepted: 04/20/2024] [Indexed: 05/13/2024] Open
Abstract
Uterine arteriovenous malformation (AVM) is very rare but potentially life-threatening. Early and accurate diagnosis is the cornerstone of its management. The objective of this study is to encourage sonographers to become familiar with a variety of grayscale sonographic features, facilitating rapid recognition of the patterns and prompting them to apply color flow Doppler for a diagnosis of uterine AVM and possible further investigations or interventions. We present six cases of uterine AVM presenting with abnormal uterine bleeding at varying degrees of severity, from abnormal menstruation to life-threatening bleeding following curettage. All initially provided some clues of uterine AVM upon grayscale ultrasound, leading to the application of color Doppler flow to support a diagnosis, with confirmation using abdominal computer tomography angiography (CTA) in most cases, resulting in definitive treatment using uterine artery embolization or other interventions. Most importantly, this study provides various sonographic features of uterine AVM, such as appearances of small tubular structures, spongy patterns, a conceptive-product-like appearance, and spaghetti-like patterns. Hopefully, familiarity with these sonographic features can facilitate practitioners to make an early diagnosis, leading to proper further investigation and intervention, and to prevent serious complications from potentially being caused by this subtle but very serious disorder.
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Affiliation(s)
| | | | | | - Theera Tongsong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
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Melamud K, Wahab SA, Smereka PN, Dighe MK, Glanc P, Kamath A, Maheshwari E, Scoutt LM, Hindman NM. Imaging of Antepartum and Postpartum Hemorrhage. Radiographics 2024; 44:e230164. [PMID: 38547034 DOI: 10.1148/rg.230164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Severe obstetric hemorrhage is a leading cause of maternal mortality and morbidity worldwide. Major hemorrhage in the antepartum period presents potential risks for both the mother and the fetus. Similarly, postpartum hemorrhage (PPH) accounts for up to a quarter of maternal deaths worldwide. Potential causes of severe antepartum hemorrhage that radiologists should be familiar with include placental abruption, placenta previa, placenta accreta spectrum disorders, and vasa previa. Common causes of PPH that the authors discuss include uterine atony, puerperal genital hematomas, uterine rupture and dehiscence, retained products of conception, and vascular anomalies. Bleeding complications unique to or most frequently encountered after cesarean delivery are also enumerated, including entities such as bladder flap hematomas, rectus sheath and subfascial hemorrhage, and infectious complications of endometritis and uterine dehiscence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Javitt and Madrazo in this issue.
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Affiliation(s)
- Kira Melamud
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Shaun A Wahab
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Paul N Smereka
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Manjiri K Dighe
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Phyllis Glanc
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Amita Kamath
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Ekta Maheshwari
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Leslie M Scoutt
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Nicole M Hindman
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
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7
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Kurakazu M, Kurakazu M, Kiyoshima C, Shigekawa K, Hirakawa T, Yoshikawa K, Ito T, Urushiyama D, Miyata K, Yotsumoto F. Clinical Prediction of Retained Products of Conception: Combining Obstetric History and Ultrasound for Improved Accuracy in Severe Postpartum Hemorrhage. Cureus 2024; 16:e53651. [PMID: 38449994 PMCID: PMC10917468 DOI: 10.7759/cureus.53651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 03/08/2024] Open
Abstract
Background The current challenge is how to improve the management of postpartum hemorrhage (PPH) to reduce the maternal mortality rate further. This study aimed to investigate whether a combined specific obstetric history and ultrasonographic findings can improve the predictive accuracy of retained products of conception (RPOC) with severe PPH. Methods This retrospective study included 56 patients who were diagnosed with RPOC. We extracted the following clinical data: obstetric history of second-trimester miscarriage, the time at which there was clinical suspicion of RPOC after the previous pregnancy (TIME), grayscale ultrasonographic finding (RPOC long-axis length [SIZE]), and color Doppler ultrasonographic finding based on the Gutenberg classification (RPOC hypervascularity). In this study, we defined cases requiring blood transfusion therapy or transcatheter arterial embolization as severe PPH. The patients were divided into two groups according to the presence or absence of severe PPH. The predictors of severe PPH were evaluated using logistic regression models. Model A comprised a combination of second-trimester miscarriage and TIME, Model B comprised a combination of Model A and long-axis SIZE, and Model C comprised a combination of Model B and RPOC hypervascularity. Results The multivariable analysis showed that long-axis SIZE was the only significant predictor of severe PPH (odds ratio [OR], 10.38; 95% confidence interval [CI], 2.06-63.86) independent of second-trimester miscarriage, TIME, and RPOC hypervascularity. The c-statistic was higher in Model C (OR, 0.863; 95% CI, 0.731-0.936) than in Model A (OR, 0.723; 95% CI, 0.551-0.847) and Model B (OR, 0.834; 95% CI, 0.677-0.923). Conclusion Combining a specific obstetric history (second-trimester miscarriage and TIME) and ultrasonographic findings (long-axis SIZE and RPOC hypervascularity) improves the predictive accuracy of RPOC with severe PPH. This prediction model may be a useful clinical screening tool for RPOC with severe PPH.
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Affiliation(s)
- Mariko Kurakazu
- Department of Obstetrics and Gynecology, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Masamitsu Kurakazu
- Department of Obstetrics and Gynecology, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Chihiro Kiyoshima
- Department of Obstetrics and Gynecology, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Koichiro Shigekawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Toyofumi Hirakawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Kenichi Yoshikawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Tomohiro Ito
- Department of Obstetrics and Gynecology, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Daichi Urushiyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Kohei Miyata
- Department of Obstetrics and Gynecology, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Fusanori Yotsumoto
- Department of Obstetrics and Gynecology, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
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Timor-Tritsch IE, Kaelin Agten A, Monteagudo A, Calỉ G, D'Antonio F. The use of pressure balloons in the treatment of first trimester cesarean scar pregnancy. Best Pract Res Clin Obstet Gynaecol 2023; 91:102409. [PMID: 37716338 DOI: 10.1016/j.bpobgyn.2023.102409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 08/02/2023] [Accepted: 08/17/2023] [Indexed: 09/18/2023]
Abstract
Cesarean scar pregnancy (CSP) is among the most severe complications of cesarean delivery. CSP refers to the abnormal implantation of the gestational sac in the area of the prior cesarean delivery (CD), potentially leading to severe hemorrhage, uterine rupture, or development of placenta accreta spectrum disorders (PAS). The management of women with CSP has not been standardized yet. In women who opted for termination, discussion about the treatments should consider maternal symptoms, gestational age at intervention, and the future reproductive risk. A multitude of treatments, either medical or surgical, for CSP has been reported in the published literature. The present review aims to provide up-to-date information on a recently introduced minimally invasive treatments for CSP, including the single and double balloon catheter. The methodology of using the single or double catheter is described in a step-by-step fashion illustrated by pictures as well as video recordings. Both catheters have their deserved place to be used as a primary method for terminating scar pregnancies as well as using them as adjuncts to other treatments. They were successfully used by multiple individual practitioners and institutions due to their simplicity and low complication rates. The rare, but possible post-procedure complications such as recurrent CSP and enhanced myometrial vascularity are also mentioned.
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Affiliation(s)
| | - Andrea Kaelin Agten
- Liverpool Women's Hospital NHS Foundation Trust, Liverpool, L8 7SS, United Kingdom
| | - Ana Monteagudo
- Icahn School of Medicine. Carnegie Maternal Fetal Associates New York, USA
| | - Giuseppe Calỉ
- Maternal Fetal Medicine Unit AO Villa Sofia-Cervello, Italy
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9
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Agrawal S, Dave A, Shukla S. Postabortal Bleeding: A Diagnostic Dilemma Resolved As Arteriovenous Malformation and Successfully Managed With Uterine Artery Embolization. Cureus 2023; 15:e49666. [PMID: 38161858 PMCID: PMC10756586 DOI: 10.7759/cureus.49666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Uterine arteriovenous malformations (AVM) are rare and may be missed in routine clinical practice, often concealing their existence until dire consequences emerge. This potentially lethal condition can manifest abruptly, with torrential postabortal bleeding, as a grim reminder of its risky nature. Here, we present a rare case of para 1, living 1, abortion 2, initially subjected to dilatation and evacuation due to a missed abortion at a peripheral healthcare facility, subsequently developing torrential bleeding despite all the conservative measures. So she was referred to our hospital in view of heavy vaginal bleeding following the earlier instrumentation; the differential diagnosis of molar pregnancy and AVM was made clinically. As per speculum examination, the presence of remnants of abortion was seen, and the possibility of an invasive mole was suspected. Ultrasonography with color Doppler showed uterine AVM, which was further confirmed by magnetic resonance imaging (MRI). In order to save her life while preserving the uterus, a multidisciplinary approach was involved in managing this patient, consisting of interventional radiologists to perform uterine artery embolization (UAE).
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Affiliation(s)
- Shreya Agrawal
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Apoorva Dave
- Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Samarth Shukla
- Pathology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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10
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Zhang W, Cui S, Mao Z, Hao Y, Tan Y, Ban Y, Cui B. Effect of direct surgical treatment in pregnancy-related uterine arteriovenous malformation. BMC Pregnancy Childbirth 2023; 23:673. [PMID: 37726661 PMCID: PMC10507977 DOI: 10.1186/s12884-023-05961-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 08/28/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Uterine arteriovenous malformation (UAVM) is a relatively rare but potentially life-threatening situations abnormal vascular connections between the uterine arterial and venous systems. Lack of recognized guidelines and clinic experience, there is a lot of clinic problems about diagnosis and treatment. By analyzing the clinical data of patients with pregnancy-related UAVM, we aim to confirm the safety of direct surgeries and the benefit of pretreatment (uterine artery embolization or medical therapy) before surgery, and to explore more optimal therapies for patients with pregnancy-related UAVM. METHODS A total of 106 patients in Qilu Hospital of Shandong University from January 2011 to December 2021 diagnosed of pregnancy-related UAVM were involved in this study. Depending on whether preoperative intervention was performed, the patients were divided into direct surgery group and pretreatment group (uterine artery embolization or medical management). Clinical characteristics, operative related factors and prognosis were analyzed. RESULTS The most common symptom of pregnancy-related UAVM was vaginal bleeding (82.5%), which could also be accompanied by abdominal pain. Pretreatments (uterine artery embolization or medical therapy) had no obvious benefit to the subsequent surgeries, but increased the hospital stay and hospital cost. Direct surgery group had satisfactory success rate and prognosis compared to pretreatment group. CONCLUSION For pregnancy-related UAVM, direct surgery has good effects and high safety with shorter hospital stays and less hospital cost. What is more, without uterine artery embolization and other medical therapy, patients could remain better fertility in future.
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Affiliation(s)
- Wenjing Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China
| | - Suhua Cui
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China
| | - Zhonghao Mao
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China
| | - Yiping Hao
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China
| | - Yilin Tan
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Qingdao, Shandong, 266011, China
| | - Yanli Ban
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China.
| | - Baoxia Cui
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China.
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11
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Matsumoto MM, Caridi TM. Uterine Vascular Anomalies: Management and Treatment Overview. Semin Intervent Radiol 2023; 40:342-348. [PMID: 37575348 PMCID: PMC10415054 DOI: 10.1055/s-0043-1770714] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Uterine vascular anomalies (UVAs), while rare, can result in severe, life-threatening hemorrhage. An understanding of the presentation and management options for UVAs is important for interventional radiologists to appropriately evaluate and care for these patients. The authors propose a standardized terminology for UVAs to avoid confusion and conflating congenital from acquired vascular lesions, which have a different pathophysiology. Limited high-level evidence and no definitive guidelines for UVA management exist, although endovascular treatment with uterine artery embolization has generally become the first-line approach for symptomatic or persistent UVAs with high technical and clinical success rates. There is also no consensus on the optimal embolization technique; the authors propose an initial approach to first embolize the dominant uterine artery supplying the UVA with gelatin sponge, with the option to embolize the contralateral side at the time of initial embolization if there is persistent supply (avoiding bilateral empiric embolization). Repeat embolization is feasible and recommended in the setting of recurrence, and both clinical and imaging follow-up is important. Ultimately, a multidisciplinary approach with individualized patient management is needed, particularly in the face of a lack of consensus guidelines for the management of symptomatic UVAs.
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Affiliation(s)
- Monica M. Matsumoto
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Theresa M. Caridi
- Department of Radiology, University of Alabama-Birmingham, Birmingham, Alabama
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12
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Zenati N, Seinturier C, Blaise S. [Can retained products of conception be considered as an unclassified acquired vascular malformation?]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:387-389. [PMID: 36924926 DOI: 10.1016/j.gofs.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 03/15/2023]
Affiliation(s)
- Nora Zenati
- Department of Vascular Medicine, Grenoble-Alpes University Hospital, 38000 Grenoble, France
| | - Christophe Seinturier
- Department of Vascular Medicine, Grenoble-Alpes University Hospital, 38000 Grenoble, France
| | - Sophie Blaise
- Department of Vascular Medicine, Grenoble-Alpes University Hospital, 38000 Grenoble, France; HP2 Laboratory, University Grenoble-Alpes, 38000 Grenoble, France.
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13
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Xie Z, Wang Y, Chen R. Persistent cornual pregnancy mimicking uterine arteriovenous malformation: a case report. BMC Womens Health 2023; 23:314. [PMID: 37328873 PMCID: PMC10276523 DOI: 10.1186/s12905-023-02450-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/24/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Uterine arteriovenous malformation(AVM) refers to the abnormal direct traffic between uterine arteries and veins, which can be characterized by the imaging examination, showing increased uterine vascularity and arteriovenous shunting. However, similar imaging manifestations can also be seen in a variety of conditions including retained production of conception, gestational trophoblastic disease, placental polyp, and vascular neoplasm. CASE PRESENTATION Here we present a case of a 42-year-old woman who was suspected of suffering uterine AVM indicated by Doppler sonography and magnetic resonance imaging but was finally diagnosed with a persistent ectopic pregnancy located on the right uterine corner by pathology after laparoscopy. She recovered well after surgery. CONCLUSION Uterine AVM is a rare and serious condition. In general, it presents special radiological manifestations. However, when complicated with other diseases it can also be distorting. Standardized diagnosis and management are important.
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Affiliation(s)
- Zhuolin Xie
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, National Clinical Research Center for Obstetric & Gynecologic Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Yang Wang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, National Clinical Research Center for Obstetric & Gynecologic Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Rong Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, National Clinical Research Center for Obstetric & Gynecologic Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
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14
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Bartels HC, Brennan DJ, Timor-Tritsch IE, Agten AK. Global variation and outcomes of expectant management of CSP. Best Pract Res Clin Obstet Gynaecol 2023; 89:102353. [PMID: 37329645 DOI: 10.1016/j.bpobgyn.2023.102353] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/14/2023] [Accepted: 05/02/2023] [Indexed: 06/19/2023]
Abstract
The incidence of Cesarean scar pregnancies (CSPs) is rising globally. Ultrasound criteria for the diagnosis of CSPs have been described by the International Society of Ultrasound in obstetrics and gynecology and appear to be well used in various centers around the world. There is no guidance on best practices for expectant management of CSP, and there is considerable variation in how this is offered globally. Many studies have reported significant maternal morbidity in cases of CSP with fetal cardiac activity managed expectantly, largely relating to hemorrhage and cesarean hysterectomy from placenta accreta spectrum. However, high live birth rates are also reported. Literature describing the diagnosis and expectant management of CSP in low-resource settings is lacking. Expectant management in selected cases where no fetal cardiac activity is present is a reasonable option and can be associated with good maternal outcomes. Standardization in reporting different types of CSPs and correlating these with pregnancy outcomes will be an important next step in developing guidance for expectant management of this high-risk pregnancy with a high burden of complications.
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Affiliation(s)
- Helena C Bartels
- Dept of UCD Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Holles Street, Dublin 2, Ireland.
| | - Donal J Brennan
- University College Dublin Gynaecological Oncology Group (UCD-GOG), Mater Misericordiae University Hospital and St Vincent's University Hospital, Dublin, Ireland.
| | | | - Andrea Kaelin Agten
- Liverpool Women's Hospital NHS Foundation Trust, Liverpool, L8 7SS, United Kingdom.
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15
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Ban Y, Shen J, Wang X, Zhang T, Lu X, Qu W, Hao Y, Mao Z, Li S, Tao G, Wang F, Zhao Y, Zhang X, Zhang Y, Zhang G, Cui B. Cesarean Scar Ectopic Pregnancy Clinical Classification System With Recommended Surgical Strategy. Obstet Gynecol 2023; 141:927-936. [PMID: 37023450 PMCID: PMC10108840 DOI: 10.1097/aog.0000000000005113] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/15/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE To establish a new cesarean scar ectopic pregnancy clinical classification system with recommended individual surgical strategy and to evaluate its clinical efficacy in treatment of cesarean scar ectopic pregnancy. METHODS This retrospective cohort study included patients with cesarean scar ectopic pregnancy in Qilu Hospital in Shandong, China. From 2008 to 2015, patients with cesarean scar ectopic pregnancy were included to determine risk factors for intraoperative hemorrhage during cesarean scar ectopic pregnancy treatment. Univariable analysis and multivariable logistic regression analyses were used to explore the independent risk factors for hemorrhage (300 mL or greater) during a cesarean scar ectopic pregnancy surgical procedure. The model was internally validated with a separate cohort. Receiver operating characteristic curve methodology was used to identify optimal thresholds for the identified risk factors to further classify cesarean scar ectopic pregnancy risk, and the recommended operative treatment was established for each classification group by expert consensus. A final cohort of patients from 2014 to 2022 were classified according to the new classification system, and the recommended surgical procedure and clinical outcomes were abstracted from the medical record. RESULTS Overall, 955 patients with first-trimester cesarean scar ectopic pregnancy were included; 273 were used to develop a model to predict intraoperative hemorrhage with cesarean scar ectopic pregnancy, and 118 served as an internal validation group for the model. Anterior myometrium thickness at the scar (adjusted odds ratio [aOR] 0.51, 95% CI 0.36-0.73) and average diameter of the gestational sac or mass (aOR 1.10, 95% CI 1.07-1.14) were independent risk factors for intraoperative hemorrhage of cesarean scar ectopic pregnancy. Five clinical classifications of cesarean scar ectopic pregnancy were established on the basis of the thickness and gestational sac diameter, and the optimal surgical option for each type was recommended by clinical experts. When the classification system was applied to a separate cohort of 564 patients with cesarean scar ectopic pregnancy, the overall success rate of recommended first-line treatment with the new classification grouping was 97.5% (550/564). No patients needed to undergo hysterectomy. Eighty-five percent of patients had a negative serum β-hCG level within 3 weeks after the surgical procedure; 95.2% of patients resumed their menstrual cycles within 8 weeks. CONCLUSION Anterior myometrium thickness at the scar and the diameter of the gestational sac were confirmed to be independent risk factors for intraoperative hemorrhage during cesarean scar ectopic pregnancy treatment. A new clinical classification system based on these factors with recommended surgical strategy resulted in high treatment success rates with minimal complications.
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Affiliation(s)
- Yanli Ban
- Department of Obstetrics and Gynaecology, the Department of Ultrasound, the Department of Radiology, and the Clinical Epidemiology Unit, Qilu Hospital of Shandong University, Jinan, China
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16
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Adwan D, Taifour W, Reslan FH. A successful bilateral iliac arteries ligation as an emergency management to a life-threatening AVM bleeding: A case report and literature review. Int J Surg Case Rep 2023; 106:108022. [PMID: 37084555 PMCID: PMC10154729 DOI: 10.1016/j.ijscr.2023.108022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/01/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Uterine arteriovenous malformation (AVM) is a defect due to direct connection between uterine arteries and veins, it has wide range of symptoms and severity, usually causes vaginal bleeding which may be mild or severe and may cause death in some rare cases. Diagnostic methods may include ultrasound, MRI, CT and/or angiography which reveal a high blood flow hypoechoic mass. Many options have been applied as management procedures, including invasive and noninvasive procedures, aiming to save patient life and stop bleeding or preserve fertility in the less severe cases. CASE PRESENTATION 21 years old primigravida patient developed episodes of severe vaginal bleeding due to AVM after complete molar pregnancy evacuation and chemotherapy, managed successfully by bilateral internal iliac artery ligation and applying compression sutures on the uterus and continuing with compound medical treatment, trying to preserve fertility and ability to get pregnant in the future. CLINICAL DISCUSSION We point out AVM types, its sings, symptoms and the diagnostic procedures. We discuss the bilateral iliac artery ligation and applying modified compression sutures on uterus as possible emergency managements to AVM when there is a threatening on life due to huge bleeding. We also mentioned the other surgical and medical treatments. CONCLUSION We confirm the importance of keeping AVM in mind as a possible diagnose when there is unknown cause vaginal bleeding. Consider doing bilateral iliac artery ligation and applying the modified compression sutures as emergency procedures to stop or reduce AVM bleeding.
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Affiliation(s)
- Dema Adwan
- Obstetrics and Gynecology Hospital, Damascus University, Damascus, Syria
| | - Wessam Taifour
- Obstetrics and Gynecology Hospital, Damascus University, Damascus, Syria.
| | - Fatima Haj Reslan
- Obstetrics and Gynecology Hospital, Damascus University, Damascus, Syria
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Blavier F, Grobet D, Duflos C, Rayssiguier R, Ranisavljevic N, Duport Percier M, Rodriguez A, Blockeel C, Santos-Ribeiro S, Faron G, Gucciardo L, Fuchs F. Usability, accuracy, and cost-effectiveness of a medical software for early pregnancies: a retrospective study. Hum Reprod 2023; 38:549-559. [PMID: 36762880 DOI: 10.1093/humrep/dead025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/13/2023] [Indexed: 02/11/2023] Open
Abstract
STUDY QUESTION Can early pregnancies be accurately and cost-effectively diagnosed and managed using a new medical computerized tool? SUMMARY ANSWER Compared to the standard clinical approach, retrospective implementation of the new medical software in a gynaecological emergency unit was correlated with more accurate diagnosis and more cost-effective management. WHAT IS KNOWN ALREADY Early pregnancy complications are responsible for a large percentage of consultations, mostly in emergency units, with guidelines becoming complex and poorly known/misunderstood by practitioners. STUDY DESIGN, SIZE, DURATION A total of 780 gynaecological emergency consultations (446 patients), recorded between November 2018 and June 2019 in a tertiary university hospital, were retrospectively encoded in a new medical computerized tool. The inclusion criteria were a positive hCG test result, ultrasonographical visualization of gestational sac, and/or embryo corresponding to a gestational age of 14 weeks or less. Diagnosis and management suggested by the new computerized tool are named eDiagnoses, while those provided by a gynaecologist member of the emergency department staff are called medDiagnoses. PARTICIPANTS/MATERIALS, SETTING, METHODS Usability was the primary endpoint, with accuracy and cost reduction, respectively, as secondary and tertiary endpoints. Identical eDiagnoses/medDiagnoses were considered as accurate. During follow-up visits, if the updated eDiagnoses and medDiagnoses became both identical to a previously discrepant eDiagnosis or medDiagnosis, this previous eDiagnosis or medDiagnosis was also considered as correct. Four double-blinded experts reviewed persistent discrepancies, determining the accurate diagnoses. eDiagnoses/medDiagnoses accuracies were compared using McNemar's Chi square test, sensitivity, specificity, and predictive values. MAIN RESULTS AND THE ROLE OF CHANCE Only 1 (0.1%) from 780 registered medical records lacked data for full encoding. Out of the 779 remaining consultations, 675 eDiagnoses were identical to the medDiagnoses (86.6%) and 104 were discrepant (13.4%). From these 104, 60 reached an agreement during follow-up consultations, with 59 medDiagnoses ultimately changing into the initial eDiagnoses (98%) and only one discrepant eDiagnosis turning later into the initial medDiagnosis (2%). Finally, 24 remained discrepant at all subsequent checks and 20 were not re-evaluated. Out of these 44, the majority of experts agreed on 38 eDiagnoses (86%) and 5 medDiagnoses (11%, including four twin pregnancies whose twinness was the only discrepancy). No majority was reached for one discrepant eDiagnosis/medDiagnosis (2%). In total, the accuracy of eDiagnoses was 99.1% (675 + 59 + 38 = 772 eDiagnoses out of 779), versus 87.4% (675 + 1 + 5 = 681) for medDiagnoses (P < 0.0001). Calculating all basic costs of extra consultations, extra-medications, extra-surgeries, and extra-hospitalizations induced by incorrect medDiagnoses versus eDiagnoses, the new medical computerized tool would have saved 3623.75 Euros per month. Retrospectively, the medical computerized tool was usable in almost all the recorded cases (99.9%), globally more accurate (99.1% versus 87.4%), and for all diagnoses except twinning reports, and it was more cost-effective than the standard clinical approach. LIMITATIONS, REASONS FOR CAUTION The retrospective study design is a limitation. Some observed improvements with the medical software could derive from the encoding by a rested and/or more experienced physician who had a better ultrasound interpretation. This software cannot replace clinical and ultrasonographical skills but may improve the compliance to published guidelines. WIDER IMPLICATIONS OF THE FINDINGS This medical computerized tool is improving. A new version considers diagnosis and management of multiple pregnancies with their specificities (potentially multiple locations, chorioamnionicity). Prospective evaluations will be required. Further developmental steps are planned, including software incorporation into ultrasound devices and integration of previously published predictive/prognostic factors (e.g. serum progesterone, corpus luteum scoring). STUDY FUNDING/COMPETING INTEREST(S) No external funding was obtained for this study. F.B. and D.G. created the new medical software. TRIAL REGISTRATION NUMBER NCT03993015.
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Affiliation(s)
- F Blavier
- Department of Obstetrics and Prenatal Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, Montpellier, France.,Department of Obstetrics and Prenatal Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.,Department of Obstetrics and Gynecology, Hospital Center of Orange, Orange, France
| | - D Grobet
- Lecturer Computer Science, Brussels Engineering School (ISIB), Brussels, Belgium
| | - C Duflos
- Clinical Research and Epidemiology Unit, CHU Montpellier, Université Montpellier, Montpellier, France
| | - R Rayssiguier
- Department of Obstetrics and Prenatal Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, Montpellier, France
| | - N Ranisavljevic
- ART-PGD Department, Arnaud de Villeneuve Hospital, CHU Montpellier, Montpellier, France
| | - M Duport Percier
- Department of Obstetrics and Prenatal Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, Montpellier, France
| | - A Rodriguez
- Department of Obstetrics and Prenatal Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, Montpellier, France
| | - C Blockeel
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | - G Faron
- Department of Obstetrics and Prenatal Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - L Gucciardo
- Department of Obstetrics and Prenatal Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - F Fuchs
- Department of Obstetrics and Prenatal Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, Montpellier, France.,Inserm, CESP Center for Research in Epidemiology and Population Health, U1018, Reproduction and Child Development, Villejuif, France.,Desbret Institute of Epidemiology and Public Health, University of Montpellier, Montpellier, France
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Mappa I, Patrizi L, Maruotti GM, Carbone L, D'Antonio F, Rizzo G. The role of ultrasound in the diagnosis and management of postpartum hemorrhage. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:362-372. [PMID: 36785506 DOI: 10.1002/jcu.23343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/05/2022] [Indexed: 06/18/2023]
Abstract
Postpartum hemorrhage (PPH) is the leading cause of death or severe morbidity for the mother after delivery. As a consequence healthcare staff working in the delivery room should be trained to perform a prompt diagnosis and adequate management of PPH. Uneventful outcome is induced correct identification of the underlying cause of hemorrhage. Ultrasound is a promising technique for the prompt diagnosis of PPH etiology. Indeed, it is easily available, with relatively low cost, not using ionizing radiation, and can be used in different settings including the labor room, the operating theater and at the bedside of an affected women. In order to be effective Obstetricians should have an adequate knowledge of postpartum ultrasonography. In this article, we will review the sonographic findings occurring in PPH, in the differential diagnosis of the underlying cause of hemorrhage, that include retained placenta, morbidly adherent placenta, rupture of the uterus uterine, vascular anomalies of the uterine arteries and uterine inversion. We will also provide an algorithm to manage PPH according to the ultrasonographic findings.
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Affiliation(s)
- Ilenia Mappa
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata Roma, Università di Roma Tor Vergata, Rome, Italy
| | - Lodovico Patrizi
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata Roma, Università di Roma Tor Vergata, Rome, Italy
| | | | - Luigi Carbone
- Department of Obstetrics and Gynecology, Università di Napoli Federico II, Naples, Italy
| | - Francesco D'Antonio
- Department of Obstetrics and Gynecology, Università di Chieti, Chieti, Italy
| | - Giuseppe Rizzo
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata Roma, Università di Roma Tor Vergata, Rome, Italy
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19
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Mandava A, Kandati M, Koppula V. Gestational Trophoblastic Neoplasia in a Uterus with Müllerian Duct Anomaly Complicated by Arteriovenous Malformation. Radiol Imaging Cancer 2023; 5:e220133. [PMID: 36705557 PMCID: PMC9896220 DOI: 10.1148/rycan.220133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Anitha Mandava
- From the Department of Radiodiagnosis, Basavatarakam Indo American Cancer Hospital & Research Institute, Road No 10, Banjara Hills, Hyderabad, Telangana, India 500034
| | - Meghana Kandati
- From the Department of Radiodiagnosis, Basavatarakam Indo American Cancer Hospital & Research Institute, Road No 10, Banjara Hills, Hyderabad, Telangana, India 500034
| | - Veeraiah Koppula
- From the Department of Radiodiagnosis, Basavatarakam Indo American Cancer Hospital & Research Institute, Road No 10, Banjara Hills, Hyderabad, Telangana, India 500034
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20
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Chueca G, Illescas T, Sotillo L, Rodríguez R, Álvarez C, Hernández A, Bartha J, Antolín E. Malformación arteriovenosa uterina. Un reto diagnóstico y terapéutico. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2023. [DOI: 10.1016/j.gine.2022.100813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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21
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Yan Y, Jia Y, Lategan B, Alexander Z, Awadalla A, Goubran A. Acquired uterine arteriovenous malformation in a patient with cornual pregnancy: A case report. Medicine (Baltimore) 2022; 101:e31629. [PMID: 36451408 PMCID: PMC9704990 DOI: 10.1097/md.0000000000031629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Acquired uterine arteriovenous malformation (uAVM) is a rare disease and could occur after dilation and curettage, cesarean section, or neoplastic processes. PATIENT CONCERNS A 29-year-old female presented with acute right lower abdominal pain and positive beta human chorionic gonadotropin (β-hCG). DIAGNOSIS A 6 cm ectopic right cornual pregnancy was found on ultrasound examination. INTERVENTIONS She underwent a laparoscopic resection of the cornual ectopic pregnancy. She returned with extensive vaginal bleeding 6-month post surgery, and eventually diagnosed with arteriovenous malformation at the previous surgical site by Color Dopplor endovaginal ultrasound. Percutaneous transcatheter uterine artery embolization (UAE) was attempted, however, vaginal bleeding continued. She was taken to the operation room for a hysteroscopic ablation of uAVM. OUTCOMES Complete cessation of the bleeding was achieved without hysterectomy. CONCLUSION We report an extremely unusual case of acquired uAVM after a wedge resection of cornual pregnancy. Ultrasound evaluation of patients with post-operative persistent bleeding should be considered for evaluation of a possible arteriovenous malformation.
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Affiliation(s)
- Yi Yan
- Department of Radiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Yong Jia
- Department of Pathology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Belinda Lategan
- Department of Pathology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Zarine Alexander
- International Medical Graduate Programs, Room 260 Brodie Centre 727 McDermot Avenue, University of Manitoba, Winnipeg, MB, Canada
| | - Alaa Awadalla
- Obstetrics, Gynecology and Reproductive Sciences 260 Brodie Centre, 727 McDermot Avenue University of Manitoba, Bannatyne Campus Winnipeg, MB, Canada
| | - Ashraf Goubran
- Department of Radiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Ultrasound Department, Radiology & Diagnostic Imaging, St. Boniface General Hospital, Winnipeg, MB, Canada
- *Correspondence: Ashraf Goubran, Ultrasound Department, Radiology & Diagnostic Imaging, St. Boniface General Hospital, 409 Taché Ave, Winnipeg, MB R2H2A6, Canada (e-mail: )
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Mathieu E, Riethmuller D, Delouche A, Sicot M, Teyssier Y, Finas M, Guillaume B, Thony F, Ferretti G, Ghelfi J. Management of Symptomatic Vascularized Retained Products of Conception by Proximal Uterine Artery Embolization with Gelatin Sponge Torpedoes. J Vasc Interv Radiol 2022; 33:1313-1320. [PMID: 35868595 DOI: 10.1016/j.jvir.2022.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 06/02/2022] [Accepted: 07/12/2022] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To evaluate the effectiveness and safety of temporary proximal uterine artery embolization (UAE) for the treatment of highly vascularized retained products of conception (RPOCs). MATERIALS AND METHODS This retrospective analysis included women who underwent treatment for vaginal bleeding after abortion, miscarriage, or delivery, with highly vascularized RPOCs detected by Doppler ultrasound (US) (ie, presence of an enhanced myometrial vascularity, a low resistance index of <0.5, and a peak systolic velocity of ≥0.7 m/s). A unilateral or bilateral embolization with torpedoes of gelatin foam was performed. From November 2017 to January 2021, 24 women with a median age of 30 years (interquartile range, 26.0-34.5 years) with symptomatic highly vascularized RPOCs were included. Clinical success was defined as bleeding arrest between the UAE and 1-month follow-up. Technical success was defined as the complete obstruction of at least 1 uterine artery supplying vascular abnormalities. The safety of the procedure according to the classification of the Society of Interventional Radiology and evolution of lesions on US were also reported. RESULTS Technical success was achieved in all 24 (100%) patients, with bilateral arterial embolization in 19 (79%) patients and unilateral embolization in 5 (21%) patients. Clinical success was achieved in all 24 (100%) patients. Five patients still had uterine retention at the 1-month follow-up, including 2 patients with highly vascularized RPOCs. Two patients benefited from hysteroscopy, and 3 had noninvasive management. Four minor adverse events were reported (1 patient had infectious endometritis and 3 patients had a postembolization syndrome). CONCLUSIONS Proximal UAE with torpedoes of gelatin foam is safe and effective for the management of symptomatic highly vascularized RPOCs.
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Affiliation(s)
- Eliott Mathieu
- University of Grenoble Alpes, Grenoble, France; Department of Radiology, Grenoble Alpes University Hospital, Grenoble, France
| | - Didier Riethmuller
- University of Grenoble Alpes, Grenoble, France; Department of Obstetrics and Gynecology, Grenoble Alpes University Hospital, Grenoble, France
| | - Aurélie Delouche
- Department of Radiology, Grenoble Alpes University Hospital, Grenoble, France
| | - Marie Sicot
- Department of Obstetrics and Gynecology, Grenoble Alpes University Hospital, Grenoble, France
| | - Yann Teyssier
- Department of Radiology, Grenoble Alpes University Hospital, Grenoble, France
| | - Mathieu Finas
- Department of Radiology, Grenoble Alpes University Hospital, Grenoble, France
| | - Bénédicte Guillaume
- Department of Radiology, Grenoble Alpes University Hospital, Grenoble, France
| | - Frederic Thony
- Department of Radiology, Grenoble Alpes University Hospital, Grenoble, France
| | - Gilbert Ferretti
- University of Grenoble Alpes, Grenoble, France; Department of Radiology, Grenoble Alpes University Hospital, Grenoble, France
| | - Julien Ghelfi
- University of Grenoble Alpes, Grenoble, France; Department of Radiology, Grenoble Alpes University Hospital, Grenoble, France; INSERM U1209/CNRS UMR 5309, Institute for Advanced Biosciences, University of Grenoble Alpes, Grenoble, France.
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23
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Uterine disorders and iron deficiency anemia. Fertil Steril 2022; 118:615-624. [PMID: 36182260 DOI: 10.1016/j.fertnstert.2022.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/18/2022] [Accepted: 08/08/2022] [Indexed: 02/07/2023]
Abstract
Abnormal uterine bleeding (AUB) is a clinical entity which can lead to iron deficiency anemia. Classification according to the acronym PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy, and hyperplasia; coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not otherwise classified) provides a structured approach to establish the cause of AUB. The goal of this review is to discuss the different mechanisms and the relationship between uterine disorders and AUB. Heavy menstrual bleeding, a subgroup of AUB, is more closely related to the presence of uterine fibroids. The relationship between heavy menstrual bleeding and uterine fibroids remains poorly characterized, particularly the understanding of endometrial function in women with structural myometrial features such as leiomyomas. A number of theories have been proposed in the literature and are discussed in this review. Uterine adenomyosis is also a frequent cause of AUB, and its pathogenesis is still far from being fully elucidated. The mechanisms contributing to its development are multifactorial. Many theories lean toward invasion of the myometrium by endometrial cells. Both clinical and basic studies favor the theory of direct invasion, although de novo development of adenomyosis from Müllerian rests or stem cells has not been ruled out. Development of adenomyotic lesions involves repeated tissue injury and repair. In addition, this review describes the other causes of AUB such as endometrial polyps, cesarean scar defects, and uterine vascular abnormalities. Endometrial polyps are often asymptomatic, but approximately 68% of women have concomitant AUB. Histologic alterations in the lower uterine segment in patients who had undergone cesarean sections were identified and may explain the cause of AUB.
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24
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Habte R, Yosef A, Bedaiwy M. Medical Management of Uterine Arteriovenous Malformation: A Case Series. Eur J Obstet Gynecol Reprod Biol 2022; 274:48-55. [PMID: 35580531 DOI: 10.1016/j.ejogrb.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/29/2022] [Accepted: 05/08/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND There has been increasing interest in medical management of uterine Arteriovenous Malformations (AVMs) in hemodynamically stable patients as a means of decreasing the need for invasive treatment that may impact fertility. CASES Amongst six cases of sonographically diagnosed uterine AVM managed medically with combined oral contraceptive pills or medroxyprogesterone acetate, three experienced complete resolution and three experienced partial resolution. Amongst those with complete resolution, all had a subsequent pregnancy that had no complication attributable to previous AVM or medical therapy. Amongst those with partial resolution, one is currently pregnant, one remains on therapy, and one has discontinued treatment with resumption of normal menses. CONCLUSION Medical management is effective in completely or partially resolving uterine AVMs. Subsequent pregnancies in this population are feasible and are not at higher risk for perinatal complications.
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Affiliation(s)
- Ruth Habte
- Department of Obstetrics and Gynecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada
| | - Ali Yosef
- Assiut University, Postal 71111, Egypt
| | - Mohamed Bedaiwy
- Department of Obstetrics and Gynecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada; Women's Health Research Institute (WHRI), H214 - 4500 Oak Street, Vancouver, BC V6H 3N1, Canada; Division of Reproductive Endocrinology & Infertility, Department of Obstetrics and Gynecology, University of British Columbia, BC Women's Hospital, C420 -4500 Oak Street, Vancouver, BC V6H 3N1, Canada.
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25
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Takahashi H, Tanaka H, Osuga Y, Miura K, Saito S, Sato S, Sugawara J, Ide S, Koh I, Yamauchi K, Okuyama A, Okuno K, Kuwata T, Fujieda S, Ikeda T. Retained products of conception (RPOC) following delivery without placenta previa: Which patients with RPOC show postpartum hemorrhage? Placenta 2022; 124:12-17. [DOI: 10.1016/j.placenta.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 11/30/2022]
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26
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Lamrissi A, Mabengui A, Mourabbih M, Jalal M, Fichtali K, Bouhya S. Acquired uterine arterio-venous malformation post molar pregnancy suction-curettage: 2 case reports. Int J Surg Case Rep 2022; 94:107105. [PMID: 35658284 PMCID: PMC9062665 DOI: 10.1016/j.ijscr.2022.107105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 04/13/2022] [Accepted: 04/15/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction Acquired uterine AVM is an abnormal and non-functional connection between uterine arteries and veins. It is reported as a consequence of uterine trauma as curettage procedures, pelvic surgery. Cases presentation The authors report 2 cases of uterine AVM post suction-curettage procedure on molar pregnancy incidentally discovered in ultrasound screening in the usual follow-up of this disease, diagnosed in the Department of Maternity of Mother and Child University Hospital Abderrahim Harouchi of Casablanca. Clinical discussion Uterine AVMs are extremely rare and should be considered in cases of heavy and persistent uterine bleeding. Uterine AVMs are either acquired or, more rarely, congenital, due to abnormal differentiation of the primary vascular structures during embryogenesis. The invasive technique allows confirmation of the diagnosis and identification of the major feeding vessels when embolization may be indicated as a treatment option. Conclusion Acquired uterine arteriovenous malformation is the result of uterine trauma; it presents as uterine bleeding through the vagina that can be life threatening, the rarity of the condition makes it difficult to diagnose, however the evolution of investigative techniques helps in the diagnostic process. Arteriovenous malformation (AVM) also called arteriovenous fistula is a short circuit between an organ’s arterial and venous circulation. Acquired arteriovenous malformations are often consequences of uterine trauma They are also associated with infection, retained product of conception, gestational trophoblastic disease Uterine artery embolization remains the treatment of choice for AVMs for patients who wish to preserve their fertility.
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27
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Sharpless KE, Pappas II, Dobrow EM, Moccia M, Bates A, Pinette MG, Paul M. Severe hemorrhage due to acquired uterine arteriovenous malformation/fistula following first-trimester aspiration abortion: A case report. Case Rep Womens Health 2022; 34:e00410. [PMID: 35479418 PMCID: PMC9035398 DOI: 10.1016/j.crwh.2022.e00410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 11/17/2022] Open
Abstract
Uterine arteriovenous malformation/arteriovenous fistula is a rare, but potentially life-threatening, cause of severe hemorrhage. A case of uterine arteriovenous malformation/fistula causing severe hemorrhage following a first-trimester aspiration abortion procedure in a patient with a history of prior cesarean sections is presented. In this case, the patient was promptly diagnosed and effectively treated with uterine artery embolization. Consideration of uterine arteriovenous malformation/fistula in the differential diagnosis of severe hemorrhage following first-trimester aspiration abortion, especially in women with risk factors, can lead to timely recognition and appropriate treatment. Uterine arteriovenous malformation/arteriovenous fistula is a vascular anomaly that can cause life-threatening hemorrhage. Acquired uterine arteriovenous malformation/arteriovenous fistula is a rare cause of hemorrhage following aspiration abortion. The diagnosis should be considered when hemorrhage fails to resolve with additional suction curettage and uterotonic administration. Uterine artery embolization is the treatment of choice for hemodynamically stable patients who want to preserve fertility.
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Affiliation(s)
- Kathryn E. Sharpless
- Maine Medical Center, 22 Bramhall St, Portland, ME 04102, USA
- Planned Parenthood of Northern New England, 443 Congress St., Portland, ME 04101, USA
- Corresponding author at: Department of Obstetrics and Gynecology, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA.
| | - India I. Pappas
- Maine Medical Center, 22 Bramhall St, Portland, ME 04102, USA
| | - Ethan M. Dobrow
- Maine Medical Center, 22 Bramhall St, Portland, ME 04102, USA
- VA Maine Healthcare System, 1 VA Ctr., Augusta, ME 04330, USA
| | - Matthew Moccia
- Maine Medical Center, 22 Bramhall St, Portland, ME 04102, USA
| | - Alison Bates
- Planned Parenthood of Northern New England, 443 Congress St., Portland, ME 04101, USA
| | | | - Maureen Paul
- Planned Parenthood of Northern New England, 443 Congress St., Portland, ME 04101, USA
- Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215, USA
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Keller CA, Antil N, Jeffrey RB, Kamaya A. Color Doppler Imaging of Vascular Abnormalities of the Uterus. Ultrasound Q 2022; 38:72-82. [PMID: 35239631 DOI: 10.1097/ruq.0000000000000578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Many uterine abnormalities present clinically with bleeding encompassing a broad spectrum of patients from postmenopausal spotting to life-threatening hemorrhage. Color and spectral Doppler imaging of the pelvis is often the first crucial investigation used to quickly establish the correct etiology of the uterine bleeding and guide clinical decision making and patient management.
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Affiliation(s)
- Cody A Keller
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
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29
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Gao F, Ma X, Xu Y, Fu L, Guo X. Management of acquired uterine arteriovenous malformation associated with retained products of conception. J Vasc Interv Radiol 2022; 33:547-553. [PMID: 35093540 DOI: 10.1016/j.jvir.2022.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/09/2021] [Accepted: 01/18/2022] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To evaluate the efficacy and safety of different treatments for acquired uterine arteriovenous malformation associated with retained products of conception (UAVM-RPOC) and investigate the role of uterine artery embolization (UAE) in acquired UAVM-RPOC. MATERIALS AND METHODS This was a retrospective study of consecutive patients who presented with UAVM by ultrasound after recent termination pregnancy. 48 patients were included in this study, divided into two groups (massive and minor bleeding groups) according to vaginal bleeding. The treatments were analyzed between groups. Technical and clinical success of UAE was analyzed. RESULTS Of the 48 patients, 11 patients were in the massive bleeding group, and 37 were in the minor bleeding group. 5 patients were referred for UAE in each group, and UAE was a priority for patients with unstable hemodynamics (chi-square value=5.524, p=0.022). Conservative management, dilation and curettage (D&C), operative hysteroscopy, and UAE were performed in 16 (33%), 18 (38%), 7 (15%) and 13 (27%) patients, respectively. Two patients following ectopic pregnancy suffered uncontrollable bleeding during D&C and required UAE. Three patients underwent UAE before surgery to prevent hemorrhage. The technical and clinical success rate of UAE was 100%. No complications or recurrence occurred. CONCLUSION UAE is a safe and effective treatment for UAVM-RPOC and a priority for patients with unstable hemodynamics. Conservative management, D&C and hysteroscopy are safe and effective for UAVM-RPOC patients with stable hemodynamics. However, UAVM-RPOC following ectopic pregnancy may have high risks of massive hemorrhage during procedures.
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Affiliation(s)
- Feng Gao
- Department of Radiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xinwen Ma
- Department of Oncology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yali Xu
- Department of Radiology, Shanghai Tenth People's Hospital, Shanghai, China
| | - Le Fu
- Department of Radiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaoqing Guo
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China.
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Symptomatic Enhanced Myometrial Vascularity After Medically Managed Early Miscarriage or Abortion. A Case Series. Contraception 2021; 108:80-82. [PMID: 34973208 DOI: 10.1016/j.contraception.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/13/2021] [Accepted: 12/15/2021] [Indexed: 11/24/2022]
Abstract
This case series evaluates clinical outcomes and sonographic features of symptomatic enhanced myometrial vascularity (EMV) developed after either first trimester medical abortion or miscarriage management. All cases were followed until spontaneous resolution. Ultrasonography alongside persistent low serum β-HCG supports EMV diagnosis and expectant management is a feasible approach.
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31
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Jha S, Singh A. Arteriovenous Malformation Complicating Cesarean Scar Pregnancy: A Rare Case of Vaginal Bleeding Managed Successfully by Uterine Artery Embolization. J Family Reprod Health 2021; 15:210-214. [PMID: 34721613 PMCID: PMC8536824 DOI: 10.18502/jfrh.v15i3.7140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective: Arteriovenous malformation (AVM) can occur in cesarean scar ectopic pregnancy. The presence of retained product of conception can pose a diagnostic dilemma and clinical presentation could be similar. Case report: A 27 year old female presented with continuous vaginal bleeding for two and half months following dilatation and evacuation (D&E) done for cesarean scar pregnancy (CSP) of 10 weeks 4days period of gestation. Sonography with color Doppler revealed dilated tortuous vessels around the mass in lower uterine segment suggesting CSP with AVM. Digital subtraction angiography confirmed the diagnosis. Bilateral uterine artery embolization achieved complete devascularisation as confirmed on post intervention angiogram. Patient became symptom free since then. Conclusion: Uterine artery embolization is an effective mode of treatment of AVM complicating CSP if future fertility is desired.
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Affiliation(s)
- Sangam Jha
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences Patna, Bihar, India
| | - Akanksha Singh
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences Patna, Bihar, India
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Accuracy of flow-void diameters on MR images in diagnosing uterine arteriovenous malformations in patients with pregnancy-related diseases. Sci Rep 2021; 11:19806. [PMID: 34615908 PMCID: PMC8494937 DOI: 10.1038/s41598-021-99209-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/21/2021] [Indexed: 11/30/2022] Open
Abstract
To evaluate the “flow void” diameter in patients with pregnancy-related diseases with and without uterine AVMs and assess the diagnostic performance of unenhanced MRI for uterine AVMs. From May 2014 to April 2019, 79 patients with pregnancy-related diseases were included, including 36 with and 43 without uterine AVMs confirmed by DSA. On MRI, the diameter of the most prominent “flow void” (hereinafter referred to as fv-D) was measured and compared between patients with and without uterine AVMs. The diagnostic performance of fv-D was estimated with receiver operating characteristic curves. The “flow void” sign was observed in patients with and without uterine AVMs (P > 0.05). The fv-D was significantly larger in patients with uterine AVMs in the myometrium and parametrium than in patients without uterine AVMs (P < 0.0001). The fv-D achieved a reliable diagnostic performance in the myometrium (sensitivity 80.6%, specificity 60.5%, negative predictive value 78.8%, positive predictive value 63%, AUC 0.727, cut-off: > 1.33 mm) and parametrium (sensitivity 97.2%, specificity 67.4%, negative predictive value 96.7%, positive predictive value 71.4%, AUC 0.881, cut-off > 2.6 mm). On MRI, fv-D could diagnose uterine AVMs. The fv-D had a much higher diagnostic efficiency in the parametrium than in the myometrium. The parametrium fv-D greatly improved the diagnostic sensitivity and provides a more accurate, noninvasive method of investigating possible uterine AVMs.
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Moynihan HV, Richardson J, Loveridge K. Fertility-Preserving Management of Uterine Arteriovenous Malformation in a 16-Year-Old Female. Cureus 2021; 13:e18162. [PMID: 34584814 PMCID: PMC8457299 DOI: 10.7759/cureus.18162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 11/21/2022] Open
Abstract
Arteriovenous malformations (AVM) are abnormal connections between arteries and veins without a capillary bed, creating high- and low-flow areas that are prone to bleeding. Uterine AVMs can be congenital or acquired with an incidence of 0.1%. Acquired cases are usually caused by uterine instrumentation, trauma, infection, or gestational trophoblastic disease. Patients typically present with sudden onset of heavy vaginal bleeding. Diagnosis is made using angiography, ultrasound, computerized tomography, or magnetic resonance imaging. After patients are stabilized, management depends on their desire for future fertility and may include hysterectomy or endovascular embolization. We present the case of a 16-year-old G1P0010 female with recurrent vaginal bleeding caused by a uterine AVM. To preserve the patient’s fertility, a selective embolization approach was employed using microcoils and gel foam. This case highlights a unique treatment option for uterine AVMs in patients who desire fertility preservation. Additionally, we review the diagnostic imaging and treatment options for uterine AVMs.
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Affiliation(s)
| | - Jordan Richardson
- Emergency Medicine, Detroit Medical Center Children's Hospital of Michigan, Detroit, USA
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34
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Goda M, Suzuki T, Adachi H. Placental polyp with arteriovenous malformation treated with a gonadotoropin-releasing hormone antagonist. BMJ Case Rep 2021; 14:14/9/e244664. [PMID: 34497058 PMCID: PMC8438750 DOI: 10.1136/bcr-2021-244664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 35-year-old woman (gravida 1, para 0) underwent termination of pregnancy (ToP) at 12 weeks of gestation. One month after ToP, she experienced significant vaginal bleeding and the mass with blood flow was identified on imaging. The presence of a placental polyp with arteriovenous malformation (AVM) was suspected on transvaginal sonography and MRI. Since the bleeding had ceased when she visited our hospital, we decided to treat the placental polyp with AVM with gonadotropin-releasing hormone (GnRH) antagonist therapy instead of surgery. Two months after GnRH antagonist treatment, the mass and blood flow in the uterus disappeared. Menstruation resumed 1 month after the completion of treatment. In our case, we were able to successfully treat placental polyps with AVM using GnRH antagonist therapy.
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Affiliation(s)
- Mayuko Goda
- Obstetrics and gynaecology, Seirei Hamamatsu Hospital, Hamamatsu, Shizuoka, Japan
| | - Takashi Suzuki
- Obstetrics and gynaecology, Seirei Hamamatsu Hospital, Hamamatsu, Shizuoka, Japan
| | - Hiroshi Adachi
- Obstetrics and gynaecology, Seirei Hamamatsu Hospital, Hamamatsu, Shizuoka, Japan
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Campos CI, Kujundzic W, Vergara-Galliadi LM, Ávila F, Nieto-Calvache AJ. Diffuse Uterine Arteriovenous Malformations as an Unusual Cause of Secondary Postpartum Hemorrhage. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 45:177-178. [PMID: 35589526 DOI: 10.1016/j.jogc.2021.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/15/2021] [Accepted: 01/18/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Clara Ivette Campos
- Fundación Valle del Lili, Pathology and Blood Bank Department, Cali, Colombia 760032
| | - Winy Kujundzic
- Universidad Icesi, Medicine Program, Cali, Colombia, 760032
| | | | - Fernando Ávila
- Fundación Valle del Lili, Tertiary Obstetric Care Unit, Cali, Colombia, 760032
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Ultrasound features help identify patients who can undergo noninvasive management for suspected retained products of conception: a single institutional experience. Abdom Radiol (NY) 2021; 46:2729-2739. [PMID: 33459841 PMCID: PMC8206055 DOI: 10.1007/s00261-020-02948-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/20/2020] [Accepted: 12/31/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To evaluate ultrasound (US) features associated with successful noninvasive management for suspected retained products of conception (RPOC). METHODS In this IRB-approved retrospective study, the radiology report database was queried for pelvic US with keywords of postpartum hemorrhage (PPH) and/or RPOC over a 2-year period. Follow-up exams, US exams without clinical follow-up, suboptimal image quality, and > 1 year from delivery or pregnancy termination were excluded. Charts were reviewed for clinical presentation and management. Two radiologists reviewed images for endometrial thickness, endometrial echogenicity, endometrial vascularity, and enhanced myometrial vascularity (EMV), as well as inner myometrial peak systolic velocity (PSV) and resistive index (RI) where available. Features were assessed for associations with management approach, and test characteristics were calculated. RESULTS Initial query yielded 196 exams, and 48 were excluded. A total of 148 patients were included. Mean age was 34.2 years (21-47), and mean time from delivery or pregnancy termination was 40.4 days (0-223). 81 (55%) underwent noninvasive management: 72 (48%) expectant and 9 (6%) medical. 67 (45%) underwent invasive management: 60 (41%) surgical and 7 (5%) uterine artery embolization. There was substantial inter-reader agreement for assessment of EMV (K = 0.78) and endometrial vascularity (K = 0.72). Thin endometrial stripe, avascular endometrium, and absence of EMV were associated with successful noninvasive management (p < 0.05). Thin endometrium (< 10 mm) had specificity (90%), PPV (88%), and likelihood ratio (5.91) in predicting successful noninvasive management. CONCLUSION Endometrial thickness < 10 mm, avascular endometrium, and absence of EMV are the sonographic features associated with successful noninvasive management for PPH or suspected RPOC.
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Nakashololo T, Khan N, Dunn Z, Snyman L, Mh Ismail S. Uterine arteriovenous malformations, clinical and radiological considerations: A report of two cases. Radiol Case Rep 2021; 16:1924-1929. [PMID: 34149976 PMCID: PMC8189875 DOI: 10.1016/j.radcr.2021.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/07/2021] [Accepted: 02/10/2021] [Indexed: 11/17/2022] Open
Abstract
Uterine arteriovenous malformations (AVMs) are rare, with approximately 100 described cases. They can be either congenital or acquired, with acquired AVMs mainly being associated with pregnancy related iatrogenic uterine trauma. Congenital AVMs are rarer, they originate from anomalous differentiation in the primitive capillary network, resulting in anomalous communication between the arteries and veins. In this article, we present and discuss 2 cases of uterine AVMs aged 21 and 22 with P0G2M2 and P0G1M1 respectively. Both cases presented with repeated episodes of profuse vaginal bleeding. Ultrasound (US) examination revealed classical signs of uterine arteriovenous malformation (AVM) confirmed on computerized tomography angiography (CTA) and digital subtraction angiography (DSA). The present case report highlights on the type of uterine malformations with their clinical presentation, imaging findings and management. Uterine AVM's are either congenital or acquired, clinically they are suspected if a pulsatile mass or bruit is felt in the pelvis. They may be confused with gestational related pathologies (retained products of conception, gestational trophoblastic disease), other vascular anomalies (hemangiomas), or malignancies of the uterus. In a case of suspected uterine AVM, clinical examination and diagnostic imaging, particularly quantitative ultrasound blood flow measurements, plays an important role.
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Affiliation(s)
- Tertu Nakashololo
- Department of Diagnostic Radiology, Faculty of Health Sciences, University of Pretoria, South Africa
| | - Nausheen Khan
- Department of Diagnostic Radiology, Faculty of Health Sciences, University of Pretoria, South Africa
| | - Zandile Dunn
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Pretoria, South Africa
| | - Leon Snyman
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Pretoria, South Africa
| | - Shaakera Mh Ismail
- Department of Diagnostic Radiology, Faculty of Health Sciences, University of Pretoria, South Africa
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Rudaitis V, Maldutytė G. Uterine Arteriovenous Malformation Treated with Selective Embolisation of Uterine Arteries: A Case Report. Acta Med Litu 2021; 28:153-158. [PMID: 34393638 PMCID: PMC8311842 DOI: 10.15388/amed.2021.28.1.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 11/22/2022] Open
Abstract
Uterine arteriovenous malformation (AVM) is a very rare gynaecological condition, which can potentially lead to life-threatening abnormal uterine bleeding. In most cases uterine AVM is associated with prior pregnancy or pelvic surgery. We present the case of young woman seven weeks after medical termination of pregnancy diagnosed with heavy uterine bleeding due to uterine AVM, which was successfully treated with selective embolisation of uterine arteries.
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Affiliation(s)
- Vilius Rudaitis
- Clinic of Obstetrics and Gynaecology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania Department of Gynaecology, Center of Obstetrics and Gynaecology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Gailė Maldutytė
- Faculty of Medicine, Vilnius University, Vilnius, LithuaniaDepartment of Gynaecology, Center of Obstetrics and Gynaecology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
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39
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Lokossou MS, Akouala G, Aganahi A, Vodouhe M, Lokossou AL, Tramier A, Ayhan G, Janky E. [Uterine arteriovenous malformation: about two cases at the University Hospital of Guadeloupe]. Pan Afr Med J 2021; 38:307. [PMID: 34178225 PMCID: PMC8197057 DOI: 10.11604/pamj.2021.38.307.24924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 02/24/2021] [Indexed: 11/11/2022] Open
Abstract
Uterine arteriovenous malformations are possible causes of persistent metrorrhagia, in particular in patients with a history of abortion and trophoblast diseases. We here report the diagnostic and therapeutic features of two patients with uterine arteriovenous malformations complicating post-abortion in the Maternity Ward of the University Hospital of Pointe-a-Pitre in Guadeloupe. Patients had metrorrhagias after abortion with curettage. Arteriovenous malformation was suspected based on ultrasound combined with Doppler. Arteriography confirmed the diagnosis and allowed, in the same time, for conservative treatment by arterial embolization. No complication was reported. The lack of knowledge about uterine arteriovenous malformations can lead to deleterious consequences ranging from haemostatic hysterectomy due to cataclysmic hemorrhage to death.
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Affiliation(s)
- Mègnissè Sèna Lokossou
- Département de Gynécologie et d'Obstétrique, Centre Hospitalier Universitaire de Pointe à Pitre, Pointe à Pitre, Guadeloupe
| | - Gelly Akouala
- Département de Gynécologie et d'Obstétrique, Centre Hospitalier Universitaire de Pointe à Pitre, Pointe à Pitre, Guadeloupe
| | - Allyriane Aganahi
- Département de Gynécologie et d'Obstétrique, Centre Hospitalier Universitaire de Pointe à Pitre, Pointe à Pitre, Guadeloupe
| | | | - Andrea Larissa Lokossou
- Service de Radiologie, Centre Hospitalier de Blois, Mail Pierre Charlot, 41000 Blois, France
| | - Ambre Tramier
- Département de Gynécologie et d'Obstétrique, Centre Hospitalier Universitaire de Pointe à Pitre, Pointe à Pitre, Guadeloupe
| | - Gülen Ayhan
- Département de Gynécologie et d'Obstétrique, Centre Hospitalier Universitaire de Pointe à Pitre, Pointe à Pitre, Guadeloupe
| | - Eustache Janky
- Département de Gynécologie et d'Obstétrique, Centre Hospitalier Universitaire de Pointe à Pitre, Pointe à Pitre, Guadeloupe.,Centre Hospitalier Universitaire Borgou-Alibori, Parakou, Bénin.,Service de Radiologie, Centre Hospitalier de Blois, Mail Pierre Charlot, 41000 Blois, France
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40
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Timor-Tritsch IE, McDermott WM, Monteagudo A, Calί G, Kreines F, Hernandez S, Stephenson C, Bryk H, D'Antonio F. Extreme enhanced myometrial vascularity following cesarean scar pregnancy: a new diagnostic entity. J Matern Fetal Neonatal Med 2021; 35:5846-5857. [PMID: 33730990 DOI: 10.1080/14767058.2021.1897564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To define, illustrate and to follow-up the diagnosis, pathophysiology and treatment of a subset of the known enhanced myometrial vascularity (EMV): its extreme form, associated with cesarean scar pregnancies (CSP) and with some cases pf placenta accreta spectrum being at increased risk of significant bleeding complications. We also aim to provide guidance to the management of such cases. MATERIAL AND METHODS This is an IRB-approved retrospective observational study of thirteen patients with an extreme form of EMV complicating CSPs. Patient's age, parity, number of cesarean deliveries, initial and time to negative serum hCG levels, primary and secondary diagnoses, blood flow peak systolic velocities, primary and secondary treatments, uterine artery embolization and outcomes were recorded. RESULTS Gestational ages ranged 6-11 weeks at initial presentation. Initial serum hCG was 20.0-102.48 mIU/L (mean 44.4 mIU/L). Diameter of EMV reached 20-75 mm (mean 46.8 mm). The mean peak systolic velocity (PSV) was 84.2 cm/s (range 46.7-118.0). Primary treatments were: systemic methotrexate (MTX) alone; D&C alone; MTX and D&C; local and systemic intra-gestational MTX injection; double cervical ripening balloon with systemic MTX; misoprostol and D&C; emergent UAE. UAE and hysterectomy were the two main secondary treatments in 10 women except 1 having a D&C after UAE, and in 1 the lesion regressed without secondary treatment. Mean time to nonpregnant hCG levels was 21-122 days (mean 67.2). Mean follow-up was 110.2 days (range 26-160). Ten women were treated with UAE, 6 had one, 3 had two embolizations. Two women had hysterectomies, one of these for persistent bleeding. Based upon the common denominators of the clinical and the US pictures, our definition of extreme EMV is sustained form of EMV associated with treated or untreated CSP, with peak systolic velocities of blood flow over 50 cm/s, slow return or plateauing serum hCG, with or without clinically significant vaginal bleeding, unresponsive to initial or secondary treatment requiring uterine artery embolization or hysterectomy. CONCLUSION The EMV developing in the background of retained placental tissue associated with CSP differs following the normal regression of the physiologically re-modelled, dilated vascular bed from the faulty "disrepair" of the vessel wall in in treated or untreated CSPs. The "threatening" appearance of the above EMVs warranted the term "extreme", creating their separate new sub-category." Extreme forms of CSP-related EMV pose significant diagnostic and management challenges. Prompt recognition and intervention, the proactive use of UAE, can maximize the outcome of women affected by this "extreme" form of EMV enabling to preserve reproductive potential. Obstetricians, gynecologists and interventional radiologists should be aware of this form of severe vascular complication.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, NYU Langone Health, NYU School of Medicine, New York, NY, USA
| | | | - Ana Monteagudo
- Department of Obstetrics, Gynecology and Reproductive Science, Carnegie Imaging for Women, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Giuseppe Calί
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - Fabiana Kreines
- Department of Obstetrics and Gynecology, NYU Langone Health, NYU School of Medicine, New York, NY, USA
| | - Sasha Hernandez
- Department of Obstetrics and Gynecology, NYU Langone Health, NYU School of Medicine, New York, NY, USA
| | | | - Hillel Bryk
- Department of Radiology, NYU School of Medicine, New York, NY, USA
| | - Francesco D'Antonio
- Department of Obstetrics and Gynaecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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Shiina Y. Overview of Neo-Vascular Lesions after Delivery or Miscarriage. J Clin Med 2021; 10:jcm10051084. [PMID: 33807766 PMCID: PMC7961487 DOI: 10.3390/jcm10051084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/06/2021] [Accepted: 03/01/2021] [Indexed: 11/16/2022] Open
Abstract
The concept of intrauterine neo-vascular lesions after pregnancy, initially called placental polyps, has changed gradually. Now, based on diagnostic imaging, such lesions are defined as retained products of conception (RPOC) with vascularization. The lesions appear after delivery or miscarriage, and they are accompanied by frequent abundant vascularization in the myometrium attached to the remnant. Many of these vascular lesions have been reported to resolve spontaneously within a few months. Acquired arteriovenous malformations (AVMs) must be considered in the differential diagnosis of RPOC with vascularization. AVMs are errors of morphogenesis. The lesions start to be constructed at the time of placenta formation. These lesions do not show spontaneous regression. Although these two lesions are recognized as neo-vascular lesions, neo-vascular lesions on imaging may represent conditions other than these two lesions (e.g., peritrophoblastic flow, uterine artery pseudoaneurysm, and villous-derived malignancies). Detecting vasculature at the placenta-myometrium interface and classifying vascular diseases according to hemodynamics in the remnant would facilitate the development of specific treatments.
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Affiliation(s)
- Yuji Shiina
- Department of Obstetrics and Gynecology, Yamagata Prefectural Shinjo Hospital, Shinjo, 12-55 Wakabacho, Yamagata 996-0025, Japan
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Ultrasonographic technique to differentiate enhanced myometrial vascularity/arteriovenous malformation from retained products of conception. J Ultrasound 2021; 25:379-386. [PMID: 33651329 DOI: 10.1007/s40477-021-00574-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/13/2021] [Indexed: 10/22/2022] Open
Abstract
PURPOSE To objective of this study is to discuss the ultrasonographic technique to diagnose uterine enhanced myometrial vascularity/arteriovenous malformation (EMV/AVM) and differentiate it from retained products of conception. The study also reviews the management and outcome of EMV/AVM. METHODS We present a series of three women who developed EMV after early pregnancy loss and a control case of incomplete abortion, where colour Doppler ultrasound was used to distinguish retained products of conception from features of EMV. Clinical status and imaging findings, including peak systolic velocity (PSV), were used for the initial risk stratification of the patients. All cases with EMV/AVM were managed expectantly with serial ultrasound imaging and trending human chorionic gonadotropin levels. The patient with retained products of conception was managed by hysteroscopy and curettage. RESULTS In all cases, presentation was suggestive of incomplete abortion with retained products of conception. However, colour Doppler ultrasound demonstrated hypoechoic areas within the endometrium extending into the myometrium with a high maximum PSV. In the control case, colour Doppler ultrasound noted a heterogeneous area in the left uterine cavity; however, vascular flow in this area was distinct from the endometrium, suggesting retained products of conception. All three women with EMV were managed expectantly with close monitoring and good outcomes. CONCLUSION In patients with early pregnancy loss and bleeding or persistently elevated human chorionic gonadotropin levels, clinical status and appropriate use of ultrasound imaging with colour Doppler, including PSV measurement, can assist in recognition of EMV/AVM. Expectant management with serial ultrasound evaluation is a safe treatment option for EMV/AVM with low PSV and can minimise complications such as need for blood transfusion, uterine artery embolization, and hysterectomy.
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43
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Timor-Tritsch IE. Cesarean scar pregnancy: a therapeutic dilemma. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:32-33. [PMID: 33387410 DOI: 10.1002/uog.23549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 06/12/2023]
Affiliation(s)
- I E Timor-Tritsch
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
- Department of Obstetrics and Gynecology, Division of Ob/Gyn Ultrasound, New York University Langone Health, New York, NY, USA
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Gilbert A, Thubert T, Dochez V, Riteau AS, Ducloyer M, Ragot P, Frampas E, Douane F, David A. Angiographic findings and outcomes after embolization of patients with suspected postabortion uterine arteriovenous fistula. J Gynecol Obstet Hum Reprod 2020; 50:102033. [PMID: 33301980 DOI: 10.1016/j.jogoh.2020.102033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 12/03/2020] [Accepted: 12/06/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The purpose of this study is to assess the angiographic incidence of uterine arteriovenous fistula (UAVF) in women referred for a high ultrasonographic suspicion in a postabortion setting and to evaluate the safety, efficacy and impact on further fertility of uterine artery embolization (UAE) in this indication. MATERIALS AND METHODS A monocentric retrospective study of 31patients managed by uterine artery embolization for suspected UAVF after spontaneous or induced first trimester abortion. The diagnosis of UAVF was confirmed when an early venous drainage was identified on the angiogram. Technical success was defined as complete exclusion of the vascular lesion. Clinical success was defined as the absence of bleeding during the clinical follow-up and during the surgery in case of hysteroscopic resection. Information about further fertility was gathered by phone calls to the patients. RESULTS The mean age of the patients was 30.8 (±6.0) years. The diagnosis of UAVF was angiographically confirmed in 6 patients (19.4 %). Angiographic findings of retained product of conception (RPOC) with varying degrees of vascularity were observed in remaining patients. The technical success rate of UAE was 100 %, mostly through a proximal and bilateral embolization using a resorbable agent (27/31 patients, 87.1 %). The clinical success rate of UAE was 100 % in the group treated by a single UAE. We did not notice any bleeding during the surgery in the group of patients who needed a further hysteroscopic resection. 14 patients led at least one subsequent pregnancy to term without any difficulty. CONCLUSION UAVF is a rare condition. We supposed it may constitute the ultimate stage in the natural history of the retained products of conception with "marked vascularity". UAE seems to be an effective and safe first-line treatment.
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Affiliation(s)
- Alizé Gilbert
- Department of Radiology, Nantes University Hospital, 9 Quai Moncousu, 44093, Nantes, France
| | - Thibault Thubert
- Department of Obstetrics and Gynecology, Nantes University Hospital, 38 Boulevard Jean Monnet, 44000, Nantes, France
| | - Vincent Dochez
- Department of Obstetrics and Gynecology, Nantes University Hospital, 38 Boulevard Jean Monnet, 44000, Nantes, France
| | - Anne-Sophie Riteau
- Department of Obstetrics and Gynecology, Jules Verne Medical Center, 2 - 4 Route de Paris, 44300, Nantes, France
| | - Mathilde Ducloyer
- Department of Radiology, Nantes University Hospital, 9 Quai Moncousu, 44093, Nantes, France
| | - Paul Ragot
- Department of Obstetrics and Gynecology, Nantes University Hospital, 38 Boulevard Jean Monnet, 44000, Nantes, France
| | - Eric Frampas
- Department of Radiology, Nantes University Hospital, 9 Quai Moncousu, 44093, Nantes, France
| | - Frédéric Douane
- Department of Radiology, Nantes University Hospital, 9 Quai Moncousu, 44093, Nantes, France
| | - Arthur David
- Department of Radiology, Nantes University Hospital, 9 Quai Moncousu, 44093, Nantes, France.
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Lin T, Jago CA, Singh SS. Letter: Uterine Arteriovenous Malformation. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:1319-1320. [DOI: 10.1016/j.jogc.2020.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 05/27/2020] [Indexed: 11/15/2022]
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O'Rourke-Suchoff D, Benitez S, Higgins MCCS, Stier EA. Diagnosis and treatment of women with radiologic findings suspicious for uterine arteriovenous malformations. J OBSTET GYNAECOL 2020; 41:769-773. [PMID: 33054446 DOI: 10.1080/01443615.2020.1798905] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This study investigated the clinical outcomes for patients with pelvic ultrasound findings suspicious for uterine arteriovenous malformations (AVMs) at a single institution. We reviewed the electronic medical record to identify women with pelvic ultrasound reports read as possible uterine AVM, and used medical records to determine clinical outcomes. Among the 39 women with ultrasounds suspicious for AVM, 14 had subsequent MRIs, 10 had additional ultrasounds, and 10 underwent pelvic angiography. Five of the 39 women were ultimately diagnosed with AVMs. Of the 34 women who did not have an AVM, 12 were diagnosed with retained products of conception. Women may be receiving overtreatment for possible uterine AVMs; careful clinical consideration is warranted as the most common clinical diagnosis for women with radiologic findings suspicious of uterine AVM is retained products of conception.Impact statementWhat is already known on the subject: An acquired uterine arteriovenous malformation (AVM) is an abnormal arterio-venous connection in the myometrium that may cause life-threatening haemorrhage. Over the past decade, it has been noted that the characteristic ultrasound findings of uterine AVM may represent other causes of uterine hypervascularity including retained products of conception.What the results of this study add: As there is no consensus on the management of highly vascular myometrial lesions suspicious for uterine AVMs, this study reports our institution's experience with pelvic ultrasound findings suspicious for uterine AVMs. We found that further diagnostic workup, including MRI and angiography were common, but that the most frequent final diagnosis was retained products of conception.What the implications are of these findings for future clinical practice: This study contributes to the growing body of work noting spectrum of conditions with similar vascular ultrasound findings, and suggests that at least in this sample, women may be receiving overtreatment for these presumed uterine AVMs. Close collaboration among gynaecologists and radiologists is needed to interpret the significance of these radiographic images and to determine the appropriate intervention, as women with radiologic findings suspicious of uterine AVM will frequently have retained products of conception.
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Affiliation(s)
| | - Susana Benitez
- Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA, USA
| | - Mikhail C C S Higgins
- Division of Interventional Radiology, Department of Radiology, Boston Medical Center, Boston, MA, USA
| | - Elizabeth A Stier
- Department of Obstetrics and Gynecology, Boston Medical Center, Boston, MA, USA.,Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA, USA
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Yapar Eyi EG, Halıcı Öztürk F, Alkan M. Placenta percreta-induced uterine rupture with right ovarian vein thrombus protracting into the inferior vena cava. JOURNAL OF CLINICAL ULTRASOUND : JCU 2020; 48:493-497. [PMID: 32783208 DOI: 10.1002/jcu.22903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 07/16/2020] [Accepted: 07/19/2020] [Indexed: 06/11/2023]
Abstract
In Turkey, the triad of prior cesarean section (CS), placenta previa, and placenta accreta spectrum is worth of concern. Here, we present an unpublished complication of placenta percreta-induced uterine rupture: ovarian vein thrombosis (OVT) protracting into the inferior vena cava (IVC) in a woman with a previous CS and placenta previa. We propose the integration of the sub-xiphoid transabdominal long axis of the IVC into the point-of-care ultrasound practice with color Doppler to establish the diagnosis of complicated OVT. To prevent placenta accreta spectrum-related complications, there is an urgent need to lower CS rate both globally and in Turkey.
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Affiliation(s)
| | | | - Mihriban Alkan
- Ministry of Health Ankara City Hospital, Bilkent, Ankara, 06800, Turkey
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48
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Giurazza F, Corvino F, Silvestre M, Cavaglià E, Amodio F, Cangiano G, De Magistris G, Niola R. Uterine Arteriovenous Malformations. Semin Ultrasound CT MR 2020; 42:37-45. [PMID: 33541588 DOI: 10.1053/j.sult.2020.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Uterine arteriovenous malformations are rare but may represent a life-threatening cause of vaginal bleeding. The typical patient affected is a multiparous woman during her thirties. The origin can be congenital or acquired, with the latter being more common after uterine surgery and presenting mainly as arteriovenous fistulous connections into the myometrium supplied by uterine arteries. The correct diagnosis of uterine arteriovenous malformations requires imaging findings of tubular and tortuous structures with mixed signal from arterial and venous flows; transvaginal color-Doppler ultrasound is the initial technique applied, then integrated with contrast-enhanced magnetic resonance or computed tomography. Multiple treatment approaches are available, including conservative-medical, endovascular embolization and surgery. Transarterial embolization represents the most applied, preserving childbearing capacity with negligible procedural complications; clinical and technical success rates are elevated, up to 90%. The goal of embolization is to occlude the point of fistula or the nidus and the application of multiple embolizing agents has been reported: despite there is no clear superiority of one over the others, liquids, especially those related to the dymethil-sulfoxide family, present relevant technical advantages. Surgery is nowadays to be considered when the endovascular approach fails and in these cases hysterectomy remains the common recommendation.
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Affiliation(s)
- Francesco Giurazza
- Vascular and Interventional Radiology Department, Cardarelli Hospital, Naples, Italy.
| | - Fabio Corvino
- Vascular and Interventional Radiology Department, Cardarelli Hospital, Naples, Italy
| | - Mattia Silvestre
- Vascular and Interventional Radiology Department, Cardarelli Hospital, Naples, Italy
| | - Enrico Cavaglià
- Vascular and Interventional Radiology Department, Cardarelli Hospital, Naples, Italy
| | - Francesco Amodio
- Vascular and Interventional Radiology Department, Cardarelli Hospital, Naples, Italy
| | - Gianluca Cangiano
- Vascular and Interventional Radiology Department, Cardarelli Hospital, Naples, Italy
| | - Giuseppe De Magistris
- Vascular and Interventional Radiology Department, Cardarelli Hospital, Naples, Italy
| | - Raffaella Niola
- Vascular and Interventional Radiology Department, Cardarelli Hospital, Naples, Italy
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Sonographic findings after induced medical abortion at 12–21 weeks of gestation: Retrospective cohort study. Contraception 2020; 102:87-90. [DOI: 10.1016/j.contraception.2020.04.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 04/16/2020] [Accepted: 04/19/2020] [Indexed: 11/16/2022]
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50
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Li X, Sun W, Chen L, Jin M, Zhang Z, Gao J, Fei X. Cesarean scar pregnancy combined with arteriovenous malformation successfully treated with transvaginal fertility-sparing surgery: A case report and literature review. Medicine (Baltimore) 2020; 99:e21432. [PMID: 32756152 PMCID: PMC7402736 DOI: 10.1097/md.0000000000021432] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION A cesarean scar pregnancy (CSP), when combined with an arteriovenous malformation (AVM), is a rare, but potentially life-threatening condition that may be associated with uncontrolled hemorrhage. Hysterectomy is indicated when conservative treatment fails. Preservation of fertility is challenging. PATIENT CONCERNS We reported a 33-year-old woman with a CSP combined with an AVM who failed methotrexate administration as conservative treatment. DIAGNOSES A CSP combined with an AVM was diagnosed via three-dimensional color Doppler angiogram and magnetic resonance imaging. INTERVENTIONS Transvaginal removal of the ectopic gestation and repair of the uterine defect was performed without incident. OUTCOMES The fertility of the patient was preserved and hysterectomy was avoided. CONCLUSION Transvaginal fertility-sparing surgery may be successfully performed to prevent hysterectomy when conservative treatment fails in patients with a CSP combined with an AVM.
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Affiliation(s)
- Xiangjuan Li
- Department of Female Pelvic Medicine and Reconstructive Surgery
| | | | | | - Mei Jin
- Department of Female Pelvic Medicine and Reconstructive Surgery
| | | | - Jiansong Gao
- Department of Ultrasonography, Hangzhou Women's Hospital, Hangzhou, China
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