Diagnosis of uterine arteriovenous malformation by color and pulsed Doppler ultrasonography

Ultrasound diagnosis and management of acquired uterine enhanced myometrial vascularity/arteriovenous malformations

BACKGROUND

Arteriovenous malformation is a short circuit between an organ's arterial and venous circulation. Arteriovenous malformations are classified as congenital and acquired. In the uterus, they may appear after curettage, cesarean delivery, and myomectomy among others. Their clinical feature is usually vaginal bleeding, which may be severe, if curettage is performed in unrecognized cases. Sonographically on 2-dimensional grayscale ultrasound scanning, the pathologic evidence appears as irregular, anechoic, tortuous, tubular structures that show evidence of increased vascularity when color Doppler is applied. Most of the time they resolve spontaneously; however, if left untreated, they may require involved treatments such as uterine artery embolization or hysterectomy. In the past, uterine artery angiography was the gold standard for the diagnosis; however, ultrasound scanning has diagnosed successfully and helped in the clinical management. Recently, arteriovenous malformations have been referred to as enhanced myometrial vascularities.

OBJECTIVES

The purpose of this study was to evaluate the role of transvaginal ultrasound scanning in the diagnosis and treatment of acquired enhanced myometrial vascularity/arteriovenous malformations to outline the natural history of conservatively followed vs treated lesions.

METHODS

This was a retrospective study to assess the presentation, treatment, and clinical pictures of patients with uterine Enhanced myometrial vascularity/arteriovenous malformations that were diagnosed with transvaginal ultrasound scanning. We reviewed both (1) ultrasound data (images, measured dimensions, and Doppler blood flow that were defined by its peak systolic velocity and (2) clinical data (age, reproductive status, clinical presentation, inciting event or procedure, surgical history, clinical course, time intervals that included detection to resolution or detection to treatment, and treatment rendered). The diagnostic criteria were "subjective" with a rich vascular network in the myometrium with the use of color Doppler images and "objective" with a high peak systolic velocity of ≥20 cm/sec in the vascular web. Statistical analysis was performed and coded with statistical software where necessary.

RESULTS

Twenty-seven patients met the diagnostic criteria of uterine enhanced myometrial vascularity/arteriovenous malformation. Mean age was 31.8 years (range, 18-42 years). Clinical diagnoses of the patients included 10 incomplete abortions, 6 missed abortions, 5 spontaneous complete abortions, 5 cesarean scar pregnancies, and 1 molar pregnancy. Eighty-nine percent of patients had bleeding (n = 24/27), although 1 patient was febrile, and 2 patients were asymptomatic. Recent surgical procedures were performed in 55.5% patients (15/27) that included curettage (n = 10), cesarean deliveries (n = 5), or both (n = 1); 4 patients had a remote history of uterine surgery that included myomectomy. Treatment was varied and included expectant treatment alone in 48% of the patients with serial ultrasound scans and serum human chorionic gonadotropin until resolution (n = 13/27 patients), uterine artery embolization (29.6%; 8/27 patients), methotrexate administration (22.2%; 6/27 patients), hysterectomy (7.4%; 2/27 patients), and curettage (3.7%; 1/27 patients). Three patients required a blood transfusion. Of the 9 patients whose condition required embolization, the conditions of 7 patients resolved after the procedure although 1 patient's condition required operative hysteroscopy and 1 patient's condition required hysterectomy for intractable bleeding. Average peak systolic velocity after embolization in the 9 patients was 85.2 cm/sec (range, 35-170 cm/sec); the average peak systolic velocity of the 16 patients with spontaneous resolution was 58.5 cm/sec (range, 23-90 cm/sec).

CONCLUSIONS

Acquired enhanced myometrial vascularity/arteriovenous malformations occurred after unsuccessful pregnancies or treatment procedures that included uterine curettage, cesarean delivery, or cesarean scar pregnancy. Triage of patients for expectant treatment vs intervention with uterine artery embolization based on their clinical status, which was supplemented by objective measurements of blood velocity measurement in the arteriovenous malformation, appears to be a good predictor of outcome. Ultrasound evaluation of patients with early pregnancy failure and persistent bleeding should be considered for evaluation of a possible enhanced myometrial vascularity/arteriovenous malformation.

Use of three-dimensional power Doppler sonography in the diagnosis of uterine arteriovenous malformation and follow-up after uterine artery embolization: Case report and brief review of literature

Arteriovenous malformations (AVM) of the uterus can cause life-threatening hemorrhage. Unexplained, heavy vaginal bleeding in a reproductive age woman should raise suspicion for an AVM. Here a 37-year-old woman had increasingly severe vaginal bleeding for 15 days. Serum β-hCG was elevated. Two-dimensional transvaginal ultrasound suggested retained products of conception. Before dilation and curettage (D&C), color Doppler and three-dimensional (3D) power Doppler demonstrated findings indicative of uterine AVM. A bilateral uterine artery embolization was performed without complications. Three months after uterine artery embolization, 3D power Doppler ultrasonography found complete resolution of the AVM. This case illustrates the importance of assessing both gray-scale and 3D power Doppler, and the ability of postprocedure Doppler to assess resolution.

Ultrasonographic indications for conservative treatment in pregnancy-related uterine arteriovenous malformations

BACKGROUND

Uterine arteriovenous malformations (AVMs) are known to spontaneously regress.

PURPOSE

To assess the predictive value of ultrasonography for patients requiring conservative treatment for pregnancy related to AVMs.

MATERIAL AND METHODS

Our prospective study included 75 patients (conservative management:therapeutic management = 45:30) with vaginal bleeding from pregnancy-related AVM. Clinical and ultrasonography examinations were reviewed, and the following information was gathered: complete blood count, AVM maximal diameter, AVM echogenicity, retained product of conception, number of blood vessels, and spectral Doppler (pulsatility index [PI], resistance index [RI], peak systolic velocity [PSV], time-averaged maximum velocity [TAMXV]). The Doppler criteria by Timmerman (mean PSV >70 cm/s: therapeutic management, mean PSV < 52 cm/s: conservative management) were used for the initial management selection. The association between experimental variables and outcomes was assessed to determine their usefulness for predicting conservative management.

RESULTS

Features strongly associated with conservative management and their accuracy were PSV 89.6%, hemoglobin 84.7%, RI 83.1%, TAMXV 79.3%, and PI 78.6%. The overall accuracy for correct outcome classification was 64 (85.3%) of 75 patients. Most patients with conservative management had quicker improvement of symptoms and spontaneous regression at follow-up.

CONCLUSION

Ultrasonography can accurately predict selection of conservative management.

Uterine arteriovenous malformation caused by intrauterine instrumentation for laparoscopic surgery due to left tubal pregnancy

Uterine arteriovenous malformation (AVM) is a rare entity in gynecology with fewer than 100 cases reported in the literature. Due to abnormal connection between arteries and veins without an intervening capillary system, recurrent and profuse vaginal bleeding is the most common symptom which can be potentially life-threatening. Uterine AVM can be either congenital or acquired. Acquired AVM is reported as a consequence of previous uterine trauma such as curettage procedures, caesarean section or pelvic surgery. It is also associated with infection, retained product of conception, gestational trophoblastic disease, malignancy and exposure to diethlystilboestrol. We herein report a case of acquired uterine AVM located on the right lateral wall after intrauterine instrumentation for laparoscopic left salpingectomy due to left tubal pregnancy. The patient was successfully treated with embolization.

Increased endometrial vascularity and intraoperative haemorrhage among women undergoing surgical evacuation for retained product of conception

The aim of this study was to ascertain the incidence of “increased endometrial vascularity” recorded in the ultrasound scan reports, in the context of RPOC and correlate this finding with the incidence of life threatening intra‐operative bleeding.

Ultrasound scan reports sometimes mention the presence of increased endometrial / sub‐endometrial vascularity in the context of retained products of conception or secondary post partum haemorrhage. This raises the possibility of serious intra‐operative haemorrhage in the minds of the junior doctors because of the possibility of arterio‐venous malformation. This retrospective case series was designed to find the incidences of increased endometrial vascularity and severe intra‐operative haemorrhage in the patients with RPOC in the south eastern part of Melbourne population. The study found that the incidence of increased endometrial vascularity was 7.57% and none of these patients suffered severe intra‐operative haemorrhage. A literature survey revealed that there were few studies on this topic.

Sonography in first trimester bleeding

Vaginal bleeding is the most common cause of presentation to the emergency department in the first trimester. Approximately half of patients with first trimester vaginal bleeding will lose the pregnancy. Clinical assessment is difficult, and sonography is necessary to determine if a normal fetus is present and alive and to exclude other causes of bleeding (eg, ectopic or molar pregnancy). Diagnosis of a normal intrauterine pregnancy not only helps the physician in terms of management but also gives psychologic relief to the patient. Improved ultrasound technology and high-frequency endovaginal transducers have enabled early diagnosis of abnormal and ectopic pregnancies, decreasing maternal morbidity and mortality. The main differential considerations of first trimester bleeding are spontaneous abortion, ectopic pregnancy, or gestational trophoblastic disease. This article reviews the causes of first trimester bleeding and the sonographic findings, including normal features of first trimester pregnancy.

Diagnóstico de malformação arteriovenosa uterina por meio da ultra-sonografia com doppler colorido e achados à angiorressonância magnética: relato de caso

As malformações arteriovenosas do útero são entidades raras. Sua forma de apresentação clínica é muito diversa, devendo o ginecologista e o imaginologista estar atentos para esta possibilidade diagnóstica, para estabelecer o tratamento de forma precisa e rápida. O presente artigo visa mostrar um caso de malformação arteriovenosa uterina adquirida após doença trofoblástica gestacional, cujo diagnóstico foi bem estabelecido por meio da ultra-sonografia com Doppler colorido e correlação com angiorressonância magnética.

Uterine arteriovenous malformation

INTRODUCTION

Uterine arteriovenous malformations are very rare and potentially life-threatening. They can present with menorrhagia, postpartum bleeding, postmenopausal bleeding, an asymptomatic mass, or congestive heart failure.

CASE REPORT

We present a 37-year-old woman with massive uterine bleeding that started abruptly 3 weeks after D and C and was found to be due to arteriovenous malformations.

Sonographic evaluation of first-trimester bleeding

Vaginal bleeding is a leading cause of presentation for emergency care during the first trimester of the pregnancy. Clinical assessment of the pregnancy outcome at this stage is less reliable. US examination is crucial in establishing IUP and early pregnancy failure and to exclude other causes of bleeding, such as ectopic pregnancy and molar pregnancy. Diagnosis of a normal IUP at this stage not only assists the physician in an expectant management, but also gives a psychologic boost to the patient. With recent advances in US technology and the availability of high-frequency transvaginal transducers, reliable diagnosis of early pregnancy failure can be made even before the embryo is visible.

Uterine arteriovenous malformation: a rare cause of uterine bleeding. Diagnosis and treatment

A case of uterine arteriovenous malformation following a dilatation and curettage is presented. Initial diagnosis with colour and pulsed Doppler ultrasound and treatment with transcatheter arterial embolization are described.

Color Doppler imaging is a valuable tool for the diagnosis and management of uterine vascular malformations

OBJECTIVE

The aim of this study was to assess the spontaneous outcome of uterine vascular malformations detected with ultrasonography and color Doppler, and to investigate the predictive value of color Doppler imaging as to which patients require invasive treatment.

METHODS

This was a prospective observational study conducted between January 1999 and February 2001 comprising all consecutive patients diagnosed with a uterine vascular malformation by ultrasonography and color Doppler imaging. Spectral analysis included measurement of flow velocities, pulsatility index (PI) and resistance index (RI). Close follow-up was arranged in all cases and the outcomes were recorded.

RESULTS

A total of 30 consecutive patients with uterine vascular malformations were included in the study. Spectral analysis of the vessels in the vascular malformations within the myometrium and endometrium revealed the presence of a low-impedance and high-velocity flow. The average values for PI, RI, peak systolic velocity (PSV) and time-averaged maximum velocity (TAMXV) were 0.50, 0.38, 0.63 m/s and 0.46 m/s, respectively. Eight patients (27%) eventually required embolization of the uterine arteries and three of them had true arteriovenous malformations confirmed at angiography. PSV values of >/= 0.83 m/s were associated with higher probabilities of further treatment, such as an embolization, whereas no vascular malformation with a PSV value < 0.39 m/s required embolization.

CONCLUSION

Conservative management is possible in more than two-thirds of patients presenting with uterine vascular malformations diagnosed by color Doppler sonography. Despite considerable overlap, PSV values appear to be useful in distinguishing between low- and high-risk patients.

Color Doppler US in the evaluation of uterine vascular abnormalities

Uterine vascular lesions are rare but potentially life-threatening lesions that should be suspected in women of reproductive age with unexplained vaginal bleeding and in postmenopausal women in whom anechoic structures are detected at ultrasonography (US). This is especially true in patients with a history of infection, curettage, therapeutic abortion, pelvic surgery, endometrial carcinoma, or gestational trophoblastic disease. Color Doppler US is valuable in the detection and characterization of many uterine vascular lesions, including arteriovenous malformations (AVMs) (especially arteriovenous fistulas), true aneurysms, pseudoaneurysms, and chorioangioma of the placenta. Arteriovenous fistulas demonstrate a mosaic pattern representing turbulent flow. Spectral analysis of intralesional arterial flow demonstrates high-velocity flow with a low resistive index, and spectral analysis of intralesional venous flow shows high peak systolic velocities consistent with an arterial flow pattern. Spectral analysis of a true aneurysm demonstrates arterial signals, whereas a to-and-fro or swirling pattern of flow is seen at the neck of a pseudoaneurysm. Chorioangioma is a benign hypervascular lesion with arterial and venous flow that, like AVMs, contains numerous cystic spaces that produce color signals. Color Doppler US is useful in the early diagnosis and treatment of these potentially clinically significant disorders of the uterus and placenta. Response to treatment can also be assessed with this technique.

Vascular malformations in the uterus: ultrasonographic diagnosis and conservative management

OBJECTIVE

To investigate the presence and outcome of uterine vascular malformations in women with abnormal premenopausal bleeding.

STUDY DESIGN

In this observational study 265 consecutive patients with abnormal premenopausal bleeding were examined by the same ultrasonographer with transvaginal gray-scale ultrasonography and color Doppler imaging. A final diagnosis of uterine vascular malformation was based on ultrasonographic findings, hysteroscopy or histological findings. Patients suspected of uterine vascular malformations at ultrasonography were closely monitored.

RESULTS

In nine patients (3.4%) we found ultrasonographic features of uterine vascular malformations. Color Doppler imaging showed hypervascularity, marked turbulence, and low-impedance, high-velocity flow. In six patients the condition resolved spontaneously. Two patients with hydatiform mole needed chemotherapy and their condition normalized. One patient underwent a selective embolization of the uterine artery. Subsequently, five patients had uncomplicated pregnancies after resolution of the vascular malformation.

CONCLUSION

Uterine vascular malformations are more common than previously thought. We conclude that conservative management is a valuable option in many of the acquired pregnancy-related cases that are diagnosed with color Doppler imaging.