Arteriovenous malformations of the uterus

An unsuspected case of uterine arteriovenous malformation with nidus aneurysm following vaginal delivery: Diagnostic challenges and management

Uterine arteriovenous malformations (AVMs) are rare but potentially life-threatening cause of postpartum hemorrhage (PPH). Accurate differentiation from other PPH causes, such as retained products of conception (RPOC) and gestational trophoblastic disease (GTD), is imperative, as inadvertent improper management such as uterine curettage may cause catastrophic bleeding with high mortality rates. We present the case of 35-year-old woman who presented with excessive vaginal bleeding 2 months postnormal vaginal delivery. Initial ultrasound findings raised suspicion of uterine AVM with a differential diagnosis of type 3 RPOC. Further imaging with computed tomography angiography (CTA) and digital subtraction angiography (DSA) confirmed an underlying uterine AVM with a nidus aneurysm. The patient subsequently was treated with successful embolization and was discharged in stable condition.

Imaging in Acute Obstetric Conditions: A Pictorial Essay

Acute abdominopelvic pain during pregnancy and the postpartum period is a diagnostic challenge owing to the overlapping symptoms of obstetric, gastrointestinal, and urinary conditions coupled with pregnancy-induced physiological changes. This pictorial essay reviews critical obstetric emergencies and categorizes cases into two phases: the first covers the preconception-to-pregnancy period, while the second focuses on the postpartum period. This essay covers key obstetric emergencies, such as ovarian hyperstimulation syndrome, hyperreactio luteinalis, ectopic pregnancy, red degeneration of fibroids, placenta accreta spectrum disorders, placental abruption, uterine rupture, retained products of conception, and uterine arteriovenous malformations, with an emphasis on their clinical and imaging characteristics. While ultrasound remains the first-line modality, MRI offers superior soft tissue contrast for more complex cases, and CT is reserved for critical scenarios in which the radiation risk is outweighed by diagnostic necessity. Timely and accurate imaging is essential for differentiating these conditions, guiding interventions, such as uterine arterial embolization and surgery, and minimizing maternal and fetal morbidity. This work aims to enhance the diagnostic precision and multidisciplinary management of obstetric emergencies, ensuring optimal clinical outcomes.

Uterine Arteriovenous Malformation: A Rare Cause of Postpartum Hemorrhage

Uterine arteriovenous malformation (AVM) is a rare but serious cause of secondary postpartum hemorrhage (PPH). Although its overall prevalence in the general population remains uncertain, uterine AVM is recognized as an underdiagnosed condition due to its nonspecific symptoms and variable presentation. It poses significant diagnostic and therapeutic challenges, especially when presenting in the delayed postpartum period. Uterine AVM can be acquired following uterine instrumentation or trauma, leading to abnormal vascular connections within the uterine wall. This study describes a unique instance of uterine AVM identified after a cesarean section in a patient with an in vitro fertilization (IVF)-conceived pregnancy, highlighting the potential implications of assisted reproductive techniques on uterine vascular remodeling. Early recognition and multidisciplinary management ensured successful treatment, preserving the patient's fertility and preventing severe complications.

Multimodal approach in distinguishing and managing uterine arteriovenous malformation: A case report

Arteriovenous malformations (AVMs) are abnormal vascular connections bypassing the capillary system, categorized as acquired or congenital. Acquired uterine AVMs, often resulting from uterine trauma due to procedures like dilatation and curettage, can be life threatening, necessitating prompt diagnosis and management. Here we present a 34-year-old woman with a history of missed abortion and dilatation and curettage presenting with abnormal uterine bleeding 2 months postprocedure. Although initial transvaginal ultrasound suggested retained products of conception, several modalities were required to accurately diagnose uterine AVM with invasive angiography revealing the culprit vessel. Multimodal imaging approaches are crucial for accurate diagnosis and treatment. This case highlights the importance of prompt and precise management to prevent severe outcomes and maintain fertility, emphasizing the need for continued research to improve treatment strategies.

A comprehensive diagnostic approach to differentiate intrauterine arteriovenous malformation in cases of enhanced myometrial vascularity

PURPOSE

The differentiation between conditions such as uterine arteriovenous malformation, pseudoaneurysm, gestational trophoblastic disease, and retained trophoblastic tissue can be challenging. Ultrasound imaging and Doppler interrogation are the primary diagnostic tools to assess cases of enhanced myometrial vascularity and differentiate intrauterine vascular anomalies. However, some cases remain of difficult differentiation. This study aims to analyze suspected cases and describe their diagnostic management and outcomes.

METHODS

We reviewed post-abortion cases that underwent pelvic transvaginal U/S imaging and Doppler examinations due to suspected uterine vascular anomalies. CT scans were performed in cases in which ultrasound did not reach a diagnosis. Simple follow-up, medical or surgical therapy, or embolization of uterine arteries were performed according to the final diagnosis.

RESULTS

From 2015 to 2022, we retrieved from electronic ultrasound records 22 cases of suspected vascular malformations. In eight cases, first-line U/S at admission excluded the suspected anomaly. In Five of the remaining 14 patients, uterine vascular anomalies were excluded upon a second-level  U/S based on angio-Doppler imaging and Doppler peak velocity interrogation. Nine cases underwent CT scan, and a digital angiography and embolization were performed in eight of these cases, of whom only two had a documented uterine arteriovenous malformation.

CONCLUSION

Our triage proved that only two out of 22 suspected cases had a uterine arteriovenous malformation. This diagnosis is frequently misused in clinical practice. Our data confirm that enhanced myometrial vascularity should be used to encompass the spectrum of possible differential diagnosis. A precise step-by-step diagnostic method is of paramount importance to prevent unnecessary interventions.

Minimally Invasive Endovascular Management of Uterine Arteriovenous Malformations: A Single Center Experience and Case Series

Uterine arteriovenous malformations (UAVMs) are rare and abnormal entanglements of uterine arteries and veins that are potentially fatal, requiring blood transfusions in about a third of cases. Although the optimal management of the condition is not well established in the literature, surgical hysterectomy is believed to be the only definitive treatment for arteriovenous malformations. We present three cases of UAVMs treated by a minimally invasive endovascular approach. Chief complaints were heavy menstrual bleeding and sudden onset heavy bleeding. The diagnosis was confirmed by computed tomography imaging and angiography of the pelvic vessels. Uterine artery embolization (UAE) was performed in all patients. The follow-up period was uneventful. In our experience, the UAE provides satisfactory results in terms of success rates, complications, and short hospital stays.

Uterine Arteriovenous Malformation: Diagnostic and Therapeutic Challenges

Uterine arteriovenous malformations are a rare cause of puerperal haemorrhage, but their incidence is increasing due to both improved diagnosis and the more frequent use of uterine surgery in recent years. The use of ultrasound, both B-mode and Doppler, is recommended for diagnosis and follow-up, as it has been shown to be the simplest and most cost-effective method. Endometrial thickening associated with an anechoic and vascular intramiometrial structure is very useful for diagnosis and can help to exclude other causes of dysfunctional bleeding. Pulsed Doppler shows low-resistance vessels and high pulsatility indices with a high peak systolic velocity (PSV). In a healthy myometrium, the vessels have a peak systolic velocity of 9-40 cm/s and a resistance index between 0.6 and 0.8, whereas in the case of AVMs, the systolic and diastolic velocities are 4-6 times higher (PSV 25-110 cm/s with a mean of 60 cm/s and a resistance index of 0.27-0.75 with a mean of 0.41). For treatment, we must individualise each case, taking into account haemodynamic stability, the patient's reproductive wishes, and the severity of the AVM as assessed by its size and PSV.

The Management of Uterine Arteriovenous Malformations in Obstetrics

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.

Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part I: Obstetric (Non-Fetal) Complications

Acute abdominopelvic pain in pregnant and postpartum patients presents clinical and therapeutic challenges, often requiring quick and accurate imaging diagnosis. Ultrasound remains the primary imaging investigation. Magnetic resonance imaging (MRI) has been shown to be a powerful diagnostic tool in the setting of acute abdominal pain during pregnancy and puerperium. MRI overcomes some drawbacks of US, avoiding the ionizing radiation exposure of a computed tomography (CT) scan. Although CT is not usually appropriate in pregnant patients, it is crucial in the emergency evaluation of postpartum complications. The aim of this article is to provide radiologists with a thorough familiarity with the common and uncommon pregnancy and puerperium abdominal emergencies by illustrating their imaging appearances. The present first section will review and discuss the imaging findings for acute abdominopelvic pain of obstetric (non-fetal) etiology.

Uterine venous malformations in the puerperium: 2 Atypical cases and literature review

Uterine arteriovenous malformations (AVMs) is a rare but high-risk cause of uterine bleeding. The clinical management of this condition is challenging, as the ultrasound picture can sometimes be unambiguously interpreted. Moreover, in the puerperium in which acquired AVMs are most frequently formed, it is necessary to discuss the correct management in a multidisciplinary and personalized manner. We present two cases of AVMs developing in the puerperium, both with a vaginal delivery and spontaneous and complete secondment. The symptom of onset was an episode of bright red blood loss in the puerperium, on the 14th and 21st postpartum days, respectively. Transvaginal ultrasound showed a hypervascularized lesion in the myometrium with turbulent vascular flow, confirmed by transabdominal ultrasound and angiography. To date, there are no guidelines on the management of MAVs. In our cases we opted for a conservative approach, in order to preserve the fertility of the patient. These experiences reported have the purpose of enriching a literature still sparse on the subject and in the future to be able to represent a fulcrum for official recommendations.

Acute pelvic pain: A pictorial review with magnetic resonance imaging

Acute uterine emergencies constitute both obstetric and gynecologic conditions. The superior image resolution, superior soft-tissue characterization, and lack of ionizing radiation make magnetic resonance imaging (MRI) preferable over ultrasonography (USG) and computed tomography (CT) in investigating uterine emergencies. Although USG is the first-line imaging modality and is easily accessible, it has limitations. USG is an operator dependent and limited by patient factors such as obesity and muscle atrophy. CT is limited by its risk of teratogenicity in pregnant females, poor tissue differentiation, and radiation effect. The non-specific findings on CT may lead to misinterpretation of the pathology. MRI overcomes all these limitations and is emerging as the most crucial imaging modality in the emergency room (ER). The evolving 3D MR sequences further reduce the acquisition times, expanding its ER role. Although MRI is not the first-line imaging modality, it is a problem-solving tool when the ultrasound and CT are inconclusive. This pictorial review discusses the various MRI techniques used in uterine imaging and the appearances of distinct etiologies of uterine emergencies across different MRI sequences.

Management of acquired uterine arteriovenous malformation associated with retained products of conception

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.

[Uterine vascular abnormalities]

Congenital and acquired vascular abnormalities of the uterus are quite rarely, but they are given much attention in the scientific literature due to the risk of life-threatening bleeding. In the uterus, as in any other organs, malformations can involve vessels of any caliber and type. The review summarizes the materials by clinical characteristics, pathogenesis, diagnostic methods, morphological features and management tactics of patients with uterine arteriovenous malformations. Enhanced myometrial vascularity in the puerperium due to retained placental tissue are also considered. The issues of terminology and differential diagnosis of these conditions are discussed, which is important in connection with significantly different approaches to treatment.

Fertility-Preserving Management of Uterine Arteriovenous Malformation in a 16-Year-Old Female

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.

Uterine Arteriovenous Malformation: A Pictorial Review of Diagnosis and Management

Uterine arteriovenous malformation (UAVM) is a rare condition and is classified as either congenital or acquired UAVM. Patients with UAVMs usually experience miscarriages or recurrent menorrhagia. Ultrasound is used for the initial estimation of UAVMs. Computed tomography and magnetic resonance imaging are noninvasive and valuable methods that provide good compatibility with digital subtraction angiography to support the diagnosis and treatment of UAVM. Timely diagnosis is crucial to provide appropriate treatment for alleviating complications. This article presents a pictorial and literature review of the current evidence of the diagnosis and management of UAVM.

Iatrogenic uterine injury leading to uterine arteriovenous malformation

The incidence of acquired uterine arteriovenous malformation has risen significantly because of increased instrumentation. Hysterectomy used to be the treatment of choice, but currently uterine artery embolisation is the preferred treatment. Here, the case of a 34-year-old woman who presented with uncontrolled uterine bleeding after iatrogenic uterine injury and who underwent successful management is described.

Uterine arteriovenous malformations, clinical and radiological considerations: A report of two cases

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.

Uterine Arteriovenous Malformation Treated with Selective Embolisation of Uterine Arteries: A Case Report

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.

Ultrasonographic technique to differentiate enhanced myometrial vascularity/arteriovenous malformation from retained products of conception

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.

Uterine Arteriovenous Malformations

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.

A Case Series on Uterine Arteriovenous Malformations: A Life-Threatening Emergency in Young Women

Uterine arteriovenous malformation (AVM) is a rare condition, with few cases reported in the literature. Despite being rare, it is a potentially life-threatening condition in women of child-bearing age. It should be considered in the differential diagnosis of prolonged or irregular vaginal bleeding, which, otherwise, can lead to critical complications ending up in severe morbidity and mortality. This case series describes four cases of young Asian women aged between 33 and 38 years who presented with irregular vaginal bleeding. Trans-abdominal ultrasound of the pelvis showed increased vascularity with multi-directional blood flow in the uterus. Magnetic resonance imaging (MRI) confirmed an arteriovenous malformation in all cases. All cases remained stable through the diagnostic journey. Embolization of the arteriovenous malformation was performed successfully in three cases and one case was managed conservatively on hormones. Later, two of them conceived within a year and had live births at term. The aim of reporting these cases is to share the common presentation of this condition and our experience in making the diagnosis and treatment of such patients. Although a few cases are reported world over, none was reported earlier from Pakistani Asian women.

Female Pelvic Vascular Malformations

Vascular malformations are classified primarily according to their flow characteristics, slow flow (lymphatic and venous) or fast flow (arteriovenous). They can occur anywhere in the body but have a unique presentation when affecting the female pelvis. With a detailed clinical history and the proper imaging studies, the correct diagnosis can be made and the best treatment can be initiated. Lymphatic and venous malformations are often treated with sclerotherapy while arteriovenous malformations usually require embolization. At times, surgical intervention of vascular malformations or medical management of lymphatic malformations has been implemented in a multidisciplinary approach to patient care. This review presents an overview of vascular malformations of the female pelvis, their clinical course, diagnostic studies, and treatment options.

Extensive uterine arteriovenous malformation with hemodynamic instability: Embolization for whole myometrium affection

Uterine arteriovenous malformation is abnormal and nonfunctional connections between the uterine arteries and veins. Patients typically present with vaginal bleeding which may be life-threatening. Treatment depends on the symptoms, age, desire for future fertility, localization and size of the lesion. Embolization of the uterine artery is the first choice in symptomatic AVM in patients in the reproductive age. We report a case of acquired AVM with an extensive lesion on ultrasound and MRI, which was successfully treated with uterine artery embolization for severe bleeding (UAE).

Multimodality imaging in secondary postpartum or postabortion hemorrhage: retained products of conception and related conditions

Secondary postpartum hemorrhage (PPH) and postabortion hemorrhage are rare complications. Retained products of conception (RPOC) is among the most common causes of both secondary PPH and postabortion hemorrhage. Other less common causes of secondary PPH are uterine vascular abnormalities such as arteriovenous malformations and pseudoaneurysms. These are usually related to a history of a procedure such as dilation and curettage or cesarean delivery. Subinvolution of the placental site is an idiopathic cause of secondary PPH; this condition may be underrecognized and therefore could have a higher incidence than currently reported. Gestational trophoblastic disease is rare but commonly presents as secondary PPH and resembles RPOC in radiologic appearance. The first-line imaging modality for secondary PPH is ultrasound, but computed tomography and magnetic resonance imaging may be used if the ultrasound findings are indeterminate. Angiography is an important tool for the definitive diagnosis of uterine vascular abnormalities. Appropriate management requires radiologists to be familiar with the multimodality imaging features of secondary PPH or postabortion hemorrhage.

Acquired uterine arteriovenous fistula following dilatation and curettage: an uncommon cause of vaginal bleeding

Dysfunctional uterine bleeding is a common presentation of women in the emergency department. We describe the case of a 33-year-old female who presented with intermittent spotting due to an acquired uterine AVF. The patient underwent a transvaginal pelvic ultrasound as well as a CT angiogram. The patient was treated conservatively and elected to undergo uterine artery embolization in an effort to preserve fertility. She successfully delivered a healthy baby boy at 39-week gestation via an emergent caesarian section due to a prolapsed umbilical cord 17 months after undergoing the uterine artery embolization.

Unexpected Findings During Evaluation of Acute Pelvic Pain With Transvaginal Sonography

Transvaginal sonography is the first-line imaging modality used to evaluate acute female pelvic pain in the emergency setting because of its accessibility, lack of ionizing radiation, and excellent ability to identify reproductive tract disorders. Although the intent of transvaginal sonography is to evaluate the reproductive organs, imaging of adjacent pelvic structures is an important part of every transvaginal sonographic examination. Gastrointestinal, urologic, and vascular disorders incidentally scanned on transvaginal sonography may explain the pain for which the examination is being performed. In such cases, transvaginal sonography may play an important role in the diagnostic process if the clinician is aware of the transvaginal sonographic appearance of these entities.

Successful Treatment of Uterine Arteriovenous Malformation due to Uterine Trauma

Uterine arteriovenous malformation (AVM) is defined as abnormal and nonfunctional connections between the uterine arteries and veins. Although the patients typically present with vaginal bleeding, some patients may experience life-threatening massive bleeding in some circumstances. The treatment of choice depends on the symptoms, age, desire for future fertility, and localization and size of the lesion; however, embolization of the uterine artery is the first choice in symptomatic AVM in patients at reproductive age with expectations of future fertility. We report a case of acquired AVM (after D/C) with an extensive lesion, which was successfully treated with bilateral uterine artery embolization (UAE).

Diagnosis of Acquired Uterine Arteriovenous Malformation by Doppler Ultrasound

BACKGROUND

Acquired uterine arteriovenous malformation (AVM) is a rare cause of postpartum vaginal bleeding and can often be confused with retained products of conception (RPOC). Certain findings on ultrasound (US) increase the likelihood for AVM, such as hypoechoic areas in the myometrium and high velocity, multidirectional blood flow. Recognizing these changes on bedside US can cue the physician to send the patient for further studying and lead to the correct diagnosis.

CASE REPORT

A 31-year-old, multigravida, multiparous female presented 5 weeks post-cesarean section with heavy, intermittent vaginal bleeding. Patient had multiple previous visits for similar bleeding, including an evaluation for RPOC. Upon current presentation, the patient underwent an US in the emergency department with color and pulse wave Doppler. US revealed a hypoechoic area within the myometrium, with high velocity, bidirectional blood flow, raising the clinical suspicion for uterine AVM. Following confirmatory studies, the patient underwent successful embolization of the AVM. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The proper diagnosis of AVM is crucial, because the primary treatment modality for the alternative diagnosis of RPOC (i.e., dilation and curettage) can worsen vaginal bleeding and lead to shock or death, and is therefore contraindicated for uterine AVM. US is a quick bedside tool that can be used for rapid diagnosis of uterine AVM.

Pregnancy after uterine arteriovenous malformation-case series and literature review

Purpose: To perform a retrospective audit of cases of uterine arteriovenous malformations (UAVM) at The Canberra Hospital and review of recent literature reporting pregnancies occurring after the diagnosis of UAVM aiming to devise a diagnostic and treatment protocol to optimise pregnancy post UAVM. Methods: A retrospective audit of cases of UAVM at the Canberra Hospital from a prospectively managed patient database was performed. A search of the electronic database PubMed, for articles between 2000-2011 relating to pregnancy post UAVM. Individual case studies were analysed separately to case series. Results: The study included 28 individual studies and five case series (61 women). Average age was 29.5 ± 6.7 (range 18-42). Most women (24, 85.7%, 100% in case series) presented with abnormal vaginal bleeding; 11 (41%) individuals presented post interruption of pregnancy. All women had had a previous pregnancy (mean gravidity 3.1 ± 3.1, range 1-15 for case studies) and only four women (14.2 %) had no history of uterine trauma. Only one woman (3.6 %) did not have any ultrasound and most women underwent colour Doppler ultrasonography (20, 71.4% in case studies; 61, 83.6% in case series). Of the women, 72 (53.6 % of case studies, 78.1 % of case series) were treated with uterine artery embolisation, seven (25%) were treated expectantly. A total of 63 pregnancies occurred post treatment, seven (13.9%) ending in miscarriage. Average time to conceive post diagnosis was 19 months ± 16.3 (range 2-72). A total of 54 healthy infants were born to mothers post AVM diagnosis. Conclusion: UAVM are likely to exist on a continuum with other pregnancy related pathologies, such as sub involution of the placental bed, making a single best diagnostic and treatment plan difficult. However, this study shows that successful uncomplicated pregnancy is achievable for women after the diagnosis of UAVM.

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.

Radiological findings of uterine arteriovenous malformation: a case report of an unusual and life-threatening cause of abnormal vaginal bleeding

Uterine arteriovenous malformations may cause life-threatening abnormal genital bleeding in women at childbearing age. Transvaginal Doppler ultrasonography is a widely available, noninvasive and excellent diagnostic method. The authors report the case of a patient with history of gestational trophoblastic disease and multiple curettage procedures who developed uterine arteriovenous malformations, with remission of the lesions after treatment with methotrexate.

Complications of minimally invasive procedures of the abdomen and pelvis: a comprehensive update on the clinical and imaging features

Minimally invasive gastrointestinal, genitourinary, and gynecological procedures are widely used in the clinical practice for diagnostic and therapeutic purposes. Complications both minor and major are not uncommon with these procedures. Imaging plays an important role in the detection and optimal management of these complications. Familiarity with the clinical and imaging features of these complications by radiologists can help in their timely detection.

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.

Fertility-preserving management of a uterine arteriovenous malformation: a case report of uterine artery embolization (UAE) followed by laparoscopic resection

Herein is presented a fertility-preserving approach in the management of a uterine arteriovenous malformation (AVM) resistant to endovascular management. The patient had a documented AVM and underwent 2 uterine artery embolization procedures, with subsequent recurrence of symptoms. Doppler ultrasound demonstrated recanalization of the AVM. Ultimately, laparoscopic resection of the AVM was performed after laparoscopic ligation of the uterine arteries. Postoperatively, the patient has remained asymptomatic. Laparoscopic resection of a uterine AVM may offer a fertility-preserving alternative to hysterectomy in patients in whom endovascular management has failed.

Management of bleeding uterine arteriovenous malformation with bilateral uterine artery embolization

PURPOSE

To evaluate the technical feasibility and clinical outcome of bilateral uterine artery embolization (UAE) as a first-line therapeutic option for bleeding uterine arteriovenous malformation (AVM).

MATERIALS AND METHODS

Between 2002 and 2012, 19 patients were diagnosed with acquired uterine AVM clinically and through imaging studies. The clinical characteristics, angiographic features, technical success rate of embolization, procedure-related complications, imaging, and clinical follow-up data were assessed. Clinical success was defined as immediate symptomatic resolution with disappearance of vascular abnormality on subsequent imaging studies.

RESULTS

A total of 20 bilateral UAE, with or without embolization of extra-uterine feeders, were performed as the first-line treatment. Technical and clinical success rate was 90.0% (18/20) and 89.5% (17/19), respectively. Embolization was incomplete in two patients who had residual extra-uterine fine feeders to the AVM or a procedure- related complication (ruptured uterine artery); the former showed slow regression of the vascular malformation during the observation period, while the latter underwent a successful second bilateral UAE. Immediate clinical success was achieved in the remaining 17 patients after a single session and no recurrence of bleeding was found. Recovery to normal menstrual cycle was seen in all 17 patients with clinical success within one or two months, two of whom subsequently had uneventful intrauterine pregnancies carried to term.

CONCLUSION

Bilateral UAE is a safe and effective first-line therapeutic option for the management of bleeding uterine AVMs. However, incomplete embolization due to unembolizable feeders or difficult access into the uterine artery may lead to suboptimal treatment.

The role of radical surgery in the management of acquired uterine arteriovenous malformation

BACKGROUND

Acquired arteriovenous malformations (AVMs) can develop after uterine instrumentation. The increased risks of vascular changes, including abnormal placentation, after repeated cesarean sections are well studied. Herein, we describe a patient with delayed hemorrhage from a uterine AVM, following dilation and curettage for a cesarean scar pregnancy.

CASE

A 32-year-old G3P2 presented with a cesarean scar ectopic pregnancy managed with dilation and curettage, which incurred a 1,500-ml blood loss. Within 6 weeks, she returned with 2 episodes of vaginal bleeding. Initial angiography demonstrated a high-flow arteriovenous fistula, which was coiled. Vaginal hemorrhage recurred; repeat angiography demonstrated a large AVM. Gelfoam embolization of the bilateral internal iliac arteries reduced the vascularity of the AVM. The AVM's location, starting at the left lateral apex of the cesarean scar and extending into the parametrium, necessitated a radical hysterectomy. Pathologic examination revealed a placenta percreta extending into the parametrium.

CONCLUSION

The prevalence of uterine AVMs has increased with the rise in surgical obstetrics. In patients with a failed prior interventional procedure, surgical management is necessary to prevent life-threatening hemorrhage. The location of the AVM within the abnormal uterine scar tissue requires familiarity with radical pelvic surgical techniques that are normally used in cancer surgery in order to definitively treat this delayed obstetrical complication.