Mandibular gingival arteriovenous malformation in pregnancy

Massive maternal haemorrhage due to a mandibular arteriovenous malformation in a term pregnancy: A case report

Mandibular arteriovenous malformations (AVMs) are vascular lesions that are rare in pregnancy but that can be life threatening due to the potential for massive haemorrhage when ruptured.

This report describes a 30-year-old woman who presented at 39 weeks of gestation with hypovolemic shock secondary to a massive haemorrhage from her oral cavity. After resuscitation, she underwent an emergency caesarean section indicated for fetal distress. A live infant was born who required neonatal intensive care support. An angiogram was performed post-operatively which demonstrated a mandibular AVM that was selectively embolised. The patient and her newborn ultimately recovered with no further bleeding or complications.

This report describes the fourth case of a mandibular AVM in pregnancy published in the literature, that was managed with selective embolisation. More research is required to determine the effect of pregnancy on AVM manifestation and rupture. Antenatal management should be on a case-by-case basis with multi-disciplinary team involvement.

•

AVMs of the oral cavity are a rare but life-threatening differential diagnosis of oral bleeding.

•

The physiological changes of pregnancy may increase risk of vascular malformations

•

Amulti-disciplinary approach is essential to manage cases of maternal hypovolemic shock to achieve good outcomes for the patient

Major haemorrhage from oral arteriovenous malformation during pregnancy: a case report

This case report describes the presentation of a pregnant woman, a periodontist, at 39 weeks gestation to The Royal Prince Alfred Hospital emergency department (Sydney, NSW) with major haemorrhage from an oral arteriovenous malformation (AVM) and foetal distress. The lesion had grown rapidly during her pregnancy and she had presented to multiple hospitals and dental practitioners who had failed to diagnose her condition and recognize the potential for major complications for the patient and her baby. Bleeding was controlled with manual pressure while she underwent an emergency Caesarean section followed by emergency angiography and partial embolization of the lesion. The bleeding did not recur, and the lesion continued to regress post-partum. This paper illustrates the diagnostic dilemma of recognizing an AVM and also the potentially disastrous consequences that could occur if a dentist was to embark on extractions or other surgical treatment in the vicinity of such a lesion without realizing its significance.

Clinical, Radiographic and Histological Assessments of a Rare Case of Intraosseous Arteriovenous Malformation in Maxilla Occurred During Pregnancy: A Case Report

Objective: Intraosseous Arteriovenous malformation (AVM) is a vascular hamartoma with almost 50% of cases occurring in the head and neck. These lesions are of great importance as they may cause massive bleeding during tooth extraction and surgeries.

Case report: A 33 year old female complained of swelling and gingival bleeding on the right side of the maxilla and hard palate. The swelling was noticed during pregnancy and the patient underwent a surgical excision 6 months after labor. The specimen was submitted for histological examination. An intraosseous AVM presenting in maxilla was diagnosed.

Conclusion: Although rare, intraosseous AVM may occur. The role of pregnancy and hormonal changes is still controversial. Clinical, radiographic and histological characteristics of AVM should be thoroughly assessed before surgical excision.

Pregnancy With Large Arteriovenous Malformation of Tongue: Anesthetic Challenges and Conduct

A pregnant woman with large intraoral arteriovenous malformation of tongue obliterating the oral cavity presented for elective cesarean delivery shortly after experiencing spontaneous, large-volume, oral bleeding. This case report describes the unconventional method of securing the airway for ensuring perioperative airway protection and the anesthetic management of the case.

Primary free fibula reconstruction in life-threatening haemorrhage from high flow arteriovenous malformation of mandible

Background:

High flow arteriovenous malformation (AVM) of the mandible is rare, but it can present as a life-threatening emergency with severe intraoral bleeding for the first time. The gold standard of treatment for an AVM of the mandible is selective embolisation combined with resection and subsequent reconstructions. With the advent of advanced multidisciplinary techniques aimed at definitive therapy, surgical resection and primary reconstruction can provide an ideal anatomical and functional cure. There are no previous reports on primary resection and reconstruction for life-threatening haemorrhage from high flow AVM of the mandible.

Aim:

We discuss our approach aimed at definitive therapy in life-threatening intraoral bleeding from large high flow AVM of the mandible.

Subjects and Methods:

Four patients were managed for life-threatening intraoral bleeding during 2015–2017. Compression was applied over the bleeding point before the airway could be secured by endotracheal tube. Under general anaesthesia, the external carotid artery (ECA) was temporarily occluded using an umbilical tape loop ligature to control the bleeding. Emergency selective embolisation was done, followed by curative resection and primary mandible reconstruction using free fibula flap. Outcome assessed.

Results:

Temporary occlusion of the ECA successfully controlled the bleeding immediately and facilitated selective embolisation and definitive therapy. All the four cases were successfully reconstructed with a good outcome. There was no recurrence during the follow-up period.

Conclusion:

In life-threatening intraoral bleeding from large high flow AVM of the mandible, emergency selective embolisation followed by curative resection and primary reconstruction is safe in achieving an ideal cure.

Arteriovenous malformations in the differential diagnosis of palatal swellings

An arteriovenous malformation (AVM) is composed of abnormal communications between arteries and veins without the normal intervening capillary bed. AVM of the head and neck is a rare vascular anomaly. We present here an unusual case of AVM with the size of 4x3 cm at the left posterior palatal area. Incisionel biopsy revealed AVM. Resection of the lesion following angiography was suggested to the patient however, he refused the treatment. The patient was considered to be under control. AVM should always be kept in mind in the differential diagnosis of palatal swellings.

Large arteriovenous malformation of the oromaxillofacial region with multiple phleboliths

Vascular tumors are the most common benign tumors of the head and neck in infancy and childhood. Vascular anomalies of the head and neck were divided into 2 categories including hemangiomas and vascular malformations. Oral and maxillofacial hemangiomas and vascular malformations are congenital lesions with various clinical characteristics, manifestations, indications, and possibilities for treatment. This paper reports a case of large arteriovenous malformations including a description of the features demonstrated by panoramic radiography, cone beam computed tomography, and magnetic resonance imaging. The differential diagnosis and treatment modalities (including embolization with N-butylcyanoacrylate in this case) are also discussed following the case presentation, along with the available literature review.

Life-threatening arteriovenous malformation of the maxillomandibular region and treatment outcomes

We report on cases of life-threatening maxillomandibular arteriovenous malformations (AVM) whereby patients had successful endovascular treatment with good outcomes. Out of a total 93 facial AVMs treated endovascularly between 1991 and 2009, five patients (5.4%) had maxillomandibular AVMs. All presented with uncontrolled dental bleeding. Endovascular procedure was the primary treatment of choice in all cases, either transfemoral approach with arterial feeder embolization or transosseous puncture, depending on the accessible route in each patient. NBCA (glue) was the only embolic agent used. Tooth extraction and dental care were performed after bleeding was controlled. All five patients (8-18 years) with a mean age of 12.4 years presented with massive dental bleeding following loosening of teeth, dental extraction and/or cheek trauma. The plain films and CT scans of four patients with AVMs of mandibles and one of maxilla, revealed expansile osteolytic lesions. The mean follow-up period was 6.6 years (ranging between one and 19 years). Three cases developed recurrent bleeding between two weeks to three months after first embolization, resulting from residual AVM and infection. Late complications occurred in two patients from chronic localized infection and osteonecrosis, which were successfully eradicated with antibiotic therapy and bony curettage. Complications occurring in two patients which included soft tissue infection, osteomyelitis and osteonecrosis were successfully treated with antibiotics, curettage and bone resection. No patient had a recurrence of bleeding after the disease had cured Initial glue embolization is recommended as the effective treatment of dental AVMs for emergent bleeding control, with the aim to complete eradicate the intraosseous venous pouches either by means of transarterial superselection or direct transosseous puncture. Patient care by a multidisciplinary team approach is important for sustained treatment results.