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AIUM Practice Parameter for the Performance of Ultrasound of the Female Pelvis, 2024 Revision. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:E56-E64. [PMID: 39158217 DOI: 10.1002/jum.16556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Accepted: 08/07/2024] [Indexed: 08/20/2024]
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2
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Whitesell RT, Nordman CR, Johnston SK, Sheafor DH. Clinical management of active bleeding: what the emergency radiologist needs to know. Emerg Radiol 2024:10.1007/s10140-024-02289-z. [PMID: 39400642 DOI: 10.1007/s10140-024-02289-z] [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: 08/05/2024] [Accepted: 10/04/2024] [Indexed: 10/15/2024]
Abstract
Active bleeding is a clinical emergency that often requires swift action driven by efficient communication. Extravasation of intravenous (IV) contrast on computed tomography (CT) is a hallmark of active hemorrhage. This can be seen on exams performed for a variety of indications and can occur anywhere in the body. As both traumatic and non-traumatic etiologies of significant blood loss are clinical emergencies, exams demonstrating active bleeding are often performed in emergency departments and read by emergency radiologists. Prompt communication of these findings to the appropriate emergency medicine and surgical providers is crucial. Although many types of active hemorrhage can be managed by interventional radiology techniques, endoscopic and surgical management or clinical observation may be appropriate in certain cases. To facilitate optimal care, it is important for emergency radiologists to understand the scope of indications for embolization of bleeding by interventional radiologists (IR) and when an IR consultation is warranted. Similarly, timely comprehensive diagnostic radiology reporting including pertinent positive and negative findings tailored for IR colleagues can expedite the appropriate intervention.
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Affiliation(s)
- Ryan T Whitesell
- Division of Emergency Radiology, Midwest Radiology, 2355 Highway 36 West, Roseville, MN, USA.
| | - Cory R Nordman
- Division of Interventional Radiology, Midwest Radiology, 2355 Highway 36 West, Roseville, MN, USA.
| | - Sean K Johnston
- Division of Emergency Radiology, Midwest Radiology, 2355 Highway 36 West, Roseville, MN, USA.
| | - Douglas H Sheafor
- Division of Emergency Radiology, Midwest Radiology, 2355 Highway 36 West, Roseville, MN, USA.
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Frikha H, Aloui H, Karoui A, Hamami R, Menjli S, Abouda HS, Chanoufi MB. Uterine artery pseudoaneurysm presenting with subcutaneous hematoma and vaginal bleeding following cesarean delivery. AJOG GLOBAL REPORTS 2024; 4:100382. [PMID: 39253026 PMCID: PMC11382309 DOI: 10.1016/j.xagr.2024.100382] [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] [Indexed: 09/11/2024] Open
Abstract
We present a rare case of uterine artery pseudoaneurysm (UAP) following an emergency cesarean section, which led to severe vaginal bleeding and subcutaneous hematoma. The patient, a 40-year-old woman with no history of hemophilia or hemostasis disorders, presented with sudden profuse vaginal bleeding and multiple subcutaneous hematomas at the site of the cesarean scar ten days postoperation. Ultrasound and CT scan confirmed the presence of a pseudoaneurysm in the right uterine artery. Due to the unavailability of radiological embolization, surgical ligation of the right internal iliac artery was performed. Postoperative follow-up showed successful resolution of the pseudoaneurysm and cessation of bleeding. This case highlights the importance of considering UAP in the differential diagnosis of postpartum hemorrhage and demonstrates the efficacy of surgical intervention when embolization is not available.
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Affiliation(s)
- Hatem Frikha
- Faculty of Medicine of Tunis, Tunis Maternity and Neonatology Center, Department 'C' of Gynecology and Obstetrics, University of Tunis El Manar, Tunis, Tunisia (Frikha, Aloui, Karoui, Hamami, Menjli, Abouda, and Chanoufi)
| | - Haithem Aloui
- Faculty of Medicine of Tunis, Tunis Maternity and Neonatology Center, Department 'C' of Gynecology and Obstetrics, University of Tunis El Manar, Tunis, Tunisia (Frikha, Aloui, Karoui, Hamami, Menjli, Abouda, and Chanoufi)
| | - Abir Karoui
- Faculty of Medicine of Tunis, Tunis Maternity and Neonatology Center, Department 'C' of Gynecology and Obstetrics, University of Tunis El Manar, Tunis, Tunisia (Frikha, Aloui, Karoui, Hamami, Menjli, Abouda, and Chanoufi)
| | - Rami Hamami
- Faculty of Medicine of Tunis, Tunis Maternity and Neonatology Center, Department 'C' of Gynecology and Obstetrics, University of Tunis El Manar, Tunis, Tunisia (Frikha, Aloui, Karoui, Hamami, Menjli, Abouda, and Chanoufi)
| | - Sana Menjli
- Faculty of Medicine of Tunis, Tunis Maternity and Neonatology Center, Department 'C' of Gynecology and Obstetrics, University of Tunis El Manar, Tunis, Tunisia (Frikha, Aloui, Karoui, Hamami, Menjli, Abouda, and Chanoufi)
| | - Hassine Saber Abouda
- Faculty of Medicine of Tunis, Tunis Maternity and Neonatology Center, Department 'C' of Gynecology and Obstetrics, University of Tunis El Manar, Tunis, Tunisia (Frikha, Aloui, Karoui, Hamami, Menjli, Abouda, and Chanoufi)
| | - Mohamed Badis Chanoufi
- Faculty of Medicine of Tunis, Tunis Maternity and Neonatology Center, Department 'C' of Gynecology and Obstetrics, University of Tunis El Manar, Tunis, Tunisia (Frikha, Aloui, Karoui, Hamami, Menjli, Abouda, and Chanoufi)
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Bartolone M, Saluzzi E, Mazzeo A, D’Ambrosio V, Corno S, Mascio DD, Manganaro L, Giancotti A. Uterine Arteriovenous Malformations. J Med Ultrasound 2024; 32:266-270. [PMID: 39310860 PMCID: PMC11414961 DOI: 10.4103/jmu.jmu_103_22] [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: 10/11/2022] [Revised: 01/22/2023] [Accepted: 02/21/2023] [Indexed: 09/25/2024] Open
Abstract
Uterine arteriovenous malformations (AVMs) are an abnormal presence of shunts between myometrial arteries and veins within the myometrium that usually occurs after a traumatic event on the uterus and it is often diagnosed after a miscarriage. In this case report, we propone the case of a woman, gravida 3 para 2, admitted at the emergency department presenting deep vaginal bleeding and suspicion of incomplete miscarriage at 11 weeks of pregnancy. The suspect of AVM was made with noninvasive procedure; transvaginal ultrasound examination with the advantage of color Doppler showed a myometrial hypervascular lesion of the posterior wall. Pulsed Doppler permitted the waveform analysis of uterine arteries and three-dimensional sonography with color Doppler and reconstructions clearly showed dilated ad tortuous blood vessels within the contest of the myometrium. Magnetic resonance angiography showed multiple tubular structures with tortuous appearance that confirmed the suspicion of AVM. Uterine artery embolization was performed of the right uterine artery. One month after uterine embolization, the ultrasound control confirmed the complete resolution of the AVM.
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Affiliation(s)
- Martina Bartolone
- Department of Maternal and Child Health and Urologynecological Sciences, Sapienza University of Rome, Umberto I Hospital, Rome, Italy
| | - Enrica Saluzzi
- Department of Maternal and Child Health and Urologynecological Sciences, Sapienza University of Rome, Umberto I Hospital, Rome, Italy
| | - Allegra Mazzeo
- Department of Maternal and Child Health and Urologynecological Sciences, Sapienza University of Rome, Umberto I Hospital, Rome, Italy
| | - Valentina D’Ambrosio
- Department of Maternal and Child Health and Urologynecological Sciences, Sapienza University of Rome, Umberto I Hospital, Rome, Italy
| | - Sara Corno
- Department of Maternal and Child Health and Urologynecological Sciences, Sapienza University of Rome, Umberto I Hospital, Rome, Italy
| | - Daniele Di Mascio
- Department of Maternal and Child Health and Urologynecological Sciences, Sapienza University of Rome, Umberto I Hospital, Rome, Italy
| | - Lucia Manganaro
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Antonella Giancotti
- Department of Maternal and Child Health and Urologynecological Sciences, Sapienza University of Rome, Umberto I Hospital, Rome, Italy
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Damiani GR, Dellino M, Cascardi E, Xuamin H, Di Gennaro D, Vimercati A, Vitagliano A, Malvasi A, loizzi V, Paniga C, Lanteri L, Alfonso R, Cicinelli E, Pellegrino A. Uterine venous malformations in the puerperium: 2 Atypical cases and literature review. Eur J Obstet Gynecol Reprod Biol X 2023; 19:100220. [PMID: 37636521 PMCID: PMC10450833 DOI: 10.1016/j.eurox.2023.100220] [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: 05/13/2023] [Accepted: 07/29/2023] [Indexed: 08/29/2023] Open
Abstract
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.
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Affiliation(s)
- Gianluca Raffaello Damiani
- Obstetrics and Gynecology Unit, Department of Biomedical Sciences and Human Oncology, University of "Aldo Moro", 70124 Bari, Italy
| | - Miriam Dellino
- Obstetrics and Gynecology Unit, Department of Biomedical Sciences and Human Oncology, University of "Aldo Moro", 70124 Bari, Italy
| | - Eliano Cascardi
- Department of Medical Sciences, University of Turin, 10124 Turin, Italy
- Pathology Unit, FPO-IRCCS Candiolo Cancer Institute, 10060 Candiolo, Italy
| | - He Xuamin
- Obstetrics and Gynecology Unit, Department of Biomedical Sciences and Human Oncology, University of "Aldo Moro", 70124 Bari, Italy
- San Raffaele Hospital, Milan,Italy
| | - Daniele Di Gennaro
- Obstetrics and Gynecology Unit, Department of Biomedical Sciences and Human Oncology, University of "Aldo Moro", 70124 Bari, Italy
| | - Antonella Vimercati
- Obstetrics and Gynecology Unit, Department of Biomedical Sciences and Human Oncology, University of "Aldo Moro", 70124 Bari, Italy
| | - Amerigo Vitagliano
- Obstetrics and Gynecology Unit, Department of Biomedical Sciences and Human Oncology, University of "Aldo Moro", 70124 Bari, Italy
| | - Antonio Malvasi
- Obstetrics and Gynecology Unit, Department of Biomedical Sciences and Human Oncology, University of "Aldo Moro", 70124 Bari, Italy
| | - Vera loizzi
- Department of Interdisciplinary Medicine (DIM), University of Bari "Aldo Moro", 70124 Bari, Italy
- Oncology Unit IRCSS Istituto Tumori "Giovanni Paolo II", 70124 Bari, Italy
| | - Cristiana Paniga
- University of Milan-Biccocca,Department of Medicine and Surgery, Milan, Italy
| | - Laura Lanteri
- University of Milan-Biccocca,Department of Medicine and Surgery, Milan, Italy
| | - Raffaello Alfonso
- Obstetrics and Gynecology Unit, Department of Biomedical Sciences and Human Oncology, University of "Aldo Moro", 70124 Bari, Italy
| | - Ettore Cicinelli
- Obstetrics and Gynecology Unit, Department of Biomedical Sciences and Human Oncology, University of "Aldo Moro", 70124 Bari, Italy
| | - Antonio Pellegrino
- Department of Obstetrics and Gynecology, ASTT LECCO, Alessandro Manzoni Hospital, Dell'Eremo Street 11, Lecco, Italy
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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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Inampudi V, Nimmalapudi S. Efficacy of Embolization in Acquired Uterine Vascular Malformations: An Experience in Tertiary Care Centre in India. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:325-332. [PMID: 37494575 PMCID: PMC10371068 DOI: 10.1055/s-0043-1770092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
OBJECTIVE To determine the efficacy of Uterine Artery Embolization in patients with bleeding acquired uterine arteriovenous malformations (AVMs). METHODS A prospective review of all patients who underwent Uterine Artery Embolization at our institution between July 2015 and April 2022 was performed. 225 patients were diagnosed with a uterine vascular malformation on doppler and corresponding MRI imaging. All patients underwent transcatheter embolization of the uterine arteries. Embolic agents in the 375 procedures included Histoacryl glue only (n = 326), polyvinyl alcohol (PVA) particles and Histoacryl glue (n = 29), PVA particles (n = 5), Gelfoam (n = 5), coils (n = 4), PVA particles and coils (n = 3), Histoacryl glue and Gelfoam (n = 2), and Histoacryl glue and coils (n = 1). RESULTS A total of 375 embolization procedures were performed in 225 patients. 90 patients required repeat embolization for recurrence of bleeding. The technical success rate of embolization was 100%. The clinical success rate was 92%: bleeding was controlled in 222 of 225 patients and three patients underwent a hysterectomy. 60 of the 225 patients had uneventful intrauterine pregnancies carried to term. The 210 patients who underwent successful embolization had no recurrence of bleeding at a median follow-up of 53 months (range, 5-122 months) after treatment. 15 patients were eventually lost to follow-up. One minor complication (0.4%) of non-flow-limiting dissection of the internal iliac artery occurred. CONCLUSION Uterine Artery Embolization is a safe, effective, minimally invasive method to treat uterine AVMs with long-term efficacy, which can provide the preservation of fertility.
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Affiliation(s)
- Vineel Inampudi
- Department of Radiodiagnosis, Sri Venkateswara Medical College, Tirupati, Andhra Pradesh, India
| | - Sunanda Nimmalapudi
- Department of Radiodiagnosis, Sri Venkateswara Medical College, Tirupati, Andhra Pradesh, India
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Khurana NK, Gangwani G, Thiyagarajan K, Chaurasia A, Thakre A. Interstitial Ectopic Pregnancy with Enhanced Myometrial Vascularity: A Rare Case Successfully Treated with Uterine Artery Embolization. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2023. [DOI: 10.1055/s-0043-1761621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
AbstractEnhanced myometrial vascularity (EMV) is a rare disorder associated with various obstetrical and gynecological pathologies. We describe a unique case of interstitial ectopic pregnancy associated with EMV successfully managed with bilateral uterine artery embolization.
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Affiliation(s)
- Navpreet Kaur Khurana
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Gaurav Gangwani
- Department of Interventional Radiology, Bhaktivedanta Hospital & Research Institute, Mira Bhayandar, Maharashtra, India
| | - Kamalapriya Thiyagarajan
- Department of Obstetrics & Gynaecology, Bhaktivedanta Hospital & Research Institute, Mira Bhayandar, Maharashtra, India
| | - Aditi Chaurasia
- Department of Radiology, National Institute of Health, India
| | - Akanksha Thakre
- Indira Gandhi Government Medical College, Nagpur, Maharashtra, India
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Fatima K, Zubairi MB, Azeemuddin M, Sayani R. Acquired Uterine Vascular Anomaly: Experience from a tertiary care centre in Pakistan. Sultan Qaboos Univ Med J 2023; 23:48-54. [PMID: 36865433 PMCID: PMC9974042 DOI: 10.18295/squmj.1.2022.006] [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: 06/16/2021] [Revised: 10/10/2021] [Accepted: 11/07/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives This study aimed to retrospectively review imaging findings and the outcomes of uterine artery embolisation (UAE) in symptomatic uterine vascular anomalies (UVA). Methods This study included a total of 15 patients with acquired UVA admitted to the Aga Khan University Hospital in Karachi, Pakistan, from 2010 to 2020. These patients were evaluated using ultrasound, computed tomography and magnetic resonance imaging, either alone or in combination. All patients had a history of dilatation and curettage or uterine instrumentation and underwent angiography and embolisation of the uterine arteries. The primary outcome post embolisation was assessed clinically and/or in combination with ultrasound. Post-procedure pregnancies were also recorded. Results Non-invasive imaging was abnormal in all patients; however, this pre-intervention imaging was unable to accurately classify the type of vascular anomaly, except in the case of a pseudoaneurysm. Conventional angiography showed uterine artery hyperaemia in six patients, arteriovenous malformation in seven patients and pseudoaneurysm in two patients. The technical success rate was 100% and no repeat embolisation was needed. The follow-up ultrasound in 12 patients revealed a resolution of the abnormal findings, while the remaining three were found to be normal on clinical follow-up. Seven patients (46.7%) had a normal pregnancy 15.7 months after the procedure (range: 4-28 months). Conclusions UAE is a safe and effective management option for intractable severe bleeding in patients with UVA post instrumentation and it was found that the procedure does not impair future pregnancy.
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Affiliation(s)
- Kulsoom Fatima
- Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Muhammad Azeemuddin
- Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan,Corresponding Author’s e-mail:
| | - Raza Sayani
- Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan
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Lawrenz B, Markova D, Melado L, Vitorino RL, Digma S, Samir S, Fatemi HM. Prospective observational comparison of arteria uterina blood flow between two frozen embryo transfer cycle regimens: natural cycle versus hormonal replacement cycle. Arch Gynecol Obstet 2022; 306:2177-2185. [PMID: 36123426 DOI: 10.1007/s00404-022-06789-6] [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: 05/26/2022] [Accepted: 09/07/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Is there a difference in the blood flow of the Arteria uterina in frozen embryo transfer (FET) cycles between a Natural Cycle (NC) and a Hormonal Replacement Therapy (HRT) cycle? METHODS Prospective observational study with measurement of the pulsatility index (PI) and resistance index (RI) throughout the ovarian stimulation cycle for IVF/ICSI, the FET cycle and at 12 weeks of gestation. RESULTS A total of 124 ovarian stimulation cycles with preimplantation genetic testing for aneuploidy (PGT-A) and "freeze-all" strategy due to PGT-A were included. Mean patient's age was 31.4 years, mean BMI 26.47 kg/m2, mean AMH 3.62 ng/ml and a mean AFC of 13. FET cycles were performed in 77 patients (NC protocol: 37.7%, HRT protocol: 62.2%). The overall pregnancy rate was 75%, (NC group: 79%, HRT-group 73%; not significant). No significant change of PI and RI was seen during hormonal stimulation. In FET cycles, there was a significant increase between cycle day 2/3 and ovulation/P4-start in the HRT-cycle, followed by a significant decrease until 12 weeks of gestation. The slope of the decrease in patients with a pregnancy in an HRT-approach was a bit steeper than in the NC-approach for both PI and RI, however, without a significant difference. CONCLUSIONS Early measurements of the blood flow parameters during the FET cycle do not reveal a difference between the NC- and the HRT-approach for FET, which could be predictive for development of pre-eclampsia.
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Affiliation(s)
- Barbara Lawrenz
- IVF Department, ART Fertility Clinics, P.O. Box 60202, Abu Dhabi, UAE. .,Women's University Hospital Tuebingen, Tuebingen, Germany.
| | | | - Laura Melado
- IVF Department, ART Fertility Clinics, P.O. Box 60202, Abu Dhabi, UAE
| | | | - Shieryl Digma
- IVF Department, ART Fertility Clinics, P.O. Box 60202, Abu Dhabi, UAE
| | - Suzan Samir
- IVF Department, ART Fertility Clinics, P.O. Box 60202, Abu Dhabi, UAE
| | - Human M Fatemi
- IVF Department, ART Fertility Clinics, P.O. Box 60202, Abu Dhabi, UAE
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Mule PM, Nair SS, Bhargava RN. Imaging in Uterine Artery Pseudoaneurysm: A Rare, Potentially Fatal Cause of Secondary Post-partum Hemorrhage. Indian J Radiol Imaging 2022; 32:611-614. [DOI: 10.1055/s-0042-1755246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
AbstractSecondary postpartum hemorrhage is one of the important cause of postpartum morbidity and mortality. Uterine artery pseudoaneurysm is a rare, potentially fatal but treatable cause of secondary post-partum hemorrhage. If not diagnosed timely, it can lead to life-threatening hemorrhage. We report the case of a 41-year-old woman who presented with profuse vaginal bleeding on 32nd day of cesarean section. On imaging a left uterine artery pseudoaneurysm was found in the uterine wall with blood clots in the uterine cavity. Patient was managed with aggressive fluid resuscitation and immediate interventional radiology procedure of selective embolization of pseudoaneurysm. High index of suspicion is needed to search for rare vascular causes like pseudoaneurysm.
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Affiliation(s)
- Prajakta M. Mule
- Department of Radiology, Fortis Hospitals, DMRD, Grant Medical College, J.J. Hospital, Mumbai, Maharashtra, India
| | - Sanjota Satish Nair
- Department of Radiodiagnosis, Seth G.S. Medical College and KEMH, Fortis Hospitals, Mumbai, Maharashtra, India
| | - Rajat N. Bhargava
- Department of Radiology, Fortis Hospitals, Mumbai, Maharashtra, India
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12
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Ghanaati H, Firouznia K, Moradi B, Behestani S. Fertility Outcomes After Uterine Artery Embolization for Symptomatic Uterine Arteriovenous Malformations: A Single-Center Retrospective Study in 33 Women. Cardiovasc Intervent Radiol 2022; 45:983-991. [PMID: 35296933 DOI: 10.1007/s00270-022-03105-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/21/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE To describe the clinical and fertility outcomes after uterine artery embolization (UAE) for symptomatic uterine arteriovenous malformations (AVMs). MATERIALS AND METHODS This single-center retrospective study included 33 patients with uterine AVMs who underwent UAE at our institution between May 2013 and May 2021. The inclusion criteria were diagnostic features of uterine AVM as detection of the nidus and early venous drainage on angiography. The exclusion criteria were high levels of beta-human chorionic gonadotropin indicative of gestational trophoblastic neoplasia. Polyvinyl alcohol (PVA) with a diameter of 500-700 µm (with or without Gelfoam/Glue) was used in 32 procedures and, Glue (with lipiodol) was used in one. The patients were followed up for 31 months (range, 6-90 months). Angiograms, medical records, and phone interviews were used to describe the technical and clinical success, complications, and pregnancy outcomes. RESULTS Thirty-three patients with a mean age of 31.2 ± 5.4 years (range, 21-42 years) were included in this case series. Technical success was reported in all patients (100%). Bleeding control was also achieved in 32 (96%) patients. Pelvic and puncture site pain and groin hematoma were reported as minor complications (grade 1 according to CIRSE classification). Six pregnancies (33%) occurred after uterine artery embolization. Four women had full-term pregnancies without complications and delivered healthy newborns. Another two women were in the second trimester of pregnancy with a favorable fetal condition. No post-embolization miscarriage was reported. CONCLUSION The UAE is safe and effective in controlling vaginal bleeding caused by uterine AVMs, allowing successful future pregnancies.
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Affiliation(s)
- Hossein Ghanaati
- Department of Radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Kavous Firouznia
- Department of Radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Behnaz Moradi
- Department of Radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Department of Radiology, Yas Complex Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Selda Behestani
- Department of Radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
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Khera PS, Garg PK, Yadav T, Tiwari S, Ghosh TS, Sureka B, Rajagopal R. Emergency Uterine Bleeding: A Pictorial Essay of Imaging and Endovascular Management. Curr Probl Diagn Radiol 2022; 51:858-867. [DOI: 10.1067/j.cpradiol.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 03/16/2022] [Accepted: 04/18/2022] [Indexed: 11/22/2022]
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14
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Uterine arteriovenous malformation (UAVM) as a rare cause of postpartum hemorrhage (PPH): a literature review. Arch Gynecol Obstet 2022; 306:1873-1884. [DOI: 10.1007/s00404-022-06498-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 02/26/2022] [Indexed: 11/02/2022]
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15
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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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16
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Ultrasound Imaging of Acquired Myometrial Pseudoaneurysm: The Role of Manipulators as an Unusual Cause during Laparoscopic Surgery. Diagnostics (Basel) 2022; 12:diagnostics12010164. [PMID: 35054332 PMCID: PMC8774433 DOI: 10.3390/diagnostics12010164] [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: 11/25/2021] [Revised: 01/07/2022] [Accepted: 01/07/2022] [Indexed: 11/17/2022] Open
Abstract
An acquired uterine artery myometrial pseudoaneurysm can occur due to inflammation, trauma, or iatrogenic causes, such as surgical procedures, and can lead to profuse bleeding. The efficacy of uterine manipulators in gynecological surgery, particularly as a cause of a pseudoaneurysm, has been poorly discussed in the literature. In this paper, we discuss a case of a 39-year-old woman with profuse uterine bleeding that occurred seven days after operative laparoscopic surgery for endometriosis. The color Doppler ultrasound better evoked the arterial-like turbulent blood flow inside this cavity. These sonographic features were highly suggestive of uterine artery pseudoaneurysm, presumably related to a secondary trauma caused by the manipulator. The diagnosis was subsequently re-confirmed by angiography, and the patient was treated conservatively with uterine artery embolization. Ultrasound has been shown to be a valuable and safe tool for imaging pseudoaneurysm and guiding subsequent interventional procedures. Accordingly, we briefly review the most suitable manipulators used in benign gynecological surgeries to verify if the different types in use can guide the surgeon towards the correct choice according to surgical needs and thus prevent potentially dangerous trauma.
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17
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Masood L, Rana AI, Khan ZA, Nosheen S, Ali H, Anwar J. Imaging spectrum of acquired uterine vascular abnormalities with angiographic correlates, a pictorial review. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2022. [DOI: 10.1186/s43055-021-00683-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Acquired uterine arterial anomalies, including uterine artery pseudoaneurysms (UAP), arteriovenous malformations (AVMs) and arteriovenous fistulae (AFVs), are rare presenting causes of abnormal uterine bleeding. Timely diagnosis is essential for safe and effective treatment, avoiding life-threatening haemorrhage resulting from erroneous uterine curettage due to misdiagnosing these as other more common differentials.
Main text
This pictorial review discusses the ultrasound (USG), CT and MRI features of various acquired uterine vascular abnormalities with angiographic correlates.
Conclusion
Acquired uterine arteriovenous injuries are a fundamental cause of dysfunctional intractable bleeding recalcitrant to traditional conservative management. Endovascular transcatheter uterine artery embolisation is an increasingly popular and safe mode of treatment, especially in young patients desiring to have the option of future pregnancies, with lesser morbidity and in-hospital stay duration.
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18
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Le DTA, Nguyen AD, Phan GH, Pham NB, Vuong TT, Nguyen TQ. Heavy uterine bleeding in adolescent caused by uterine vascular lesion: A case report. Int J Gynaecol Obstet 2021; 158:325-329. [PMID: 34735727 DOI: 10.1002/ijgo.14004] [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: 08/13/2021] [Revised: 10/22/2021] [Accepted: 11/02/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To analyze a case of heavy uterine bleeding in adolescence caused by an arteriovenous malformation (AVM) in Hanoi Obstetrics and Gynecology Hospital, Vietnam. METHODS We observed a case of a 14-year-old girl, without vaginal sexual intercourse experience, having heavy uterine bleeding caused by AVM. She underwent a laparoscopic operation at the hospital for vascular lesions in the uterine anterior wall, which caused an internal hemorrhage of 1500 ml blood loss into the peritoneal cavity. Three years later, this patient was hospitalized twice for massive vaginal bleeding. RESULTS Results of ultrasound and magnetic resonance imaging indicated a uterine intramural mass with enlarged vessels connecting to the endometrial cavity. A pelvic digital subtraction angiography was performed and showed profuse bleeding from a ruptured branch of the left uterine artery. This artery was embolized at Bach Mai hospital and the bleeding was stopped. The patient had stable health and normal menstrual periods after 4 months of follow up. CONCLUSION Abnormal mass with dilated vessels in the myometrium in a patient experiencing heavy uterine bleeding is an exclusive sign of uterine vascular malformation and can be treated by angioembolization.
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Affiliation(s)
- Dao Thi Anh Le
- Gynecology Department, Hanoi Obstetrics & Gynecology Hospital, Hanoi, Vietnam
| | - Anh Duy Nguyen
- Labor Department, Hanoi Obstetrics & Gynecology Hospital, Hanoi, Vietnam
| | | | - Nha Ba Pham
- Obstetric Department, Bach Mai Hospital, Hanoi, Vietnam
| | - Thang Toan Vuong
- Labor Department, Hanoi Obstetrics & Gynecology Hospital, Hanoi, Vietnam
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19
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Hoang VT, Van HAT, Trinh CT, Pham NTT, Huynh C, Ha TN, Huynh PH, Nguyen HQ, Vo UG, Nguyen TT. Uterine Arteriovenous Malformation: A Pictorial Review of Diagnosis and Management. J Endovasc Ther 2021; 28:659-675. [PMID: 34142901 DOI: 10.1177/15266028211025022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Van Trung Hoang
- Department of Radiology, Thien Hanh Hospital, Buon Ma Thuot, Vietnam
| | - Hoang Anh Thi Van
- Department of Radiology, Thien Hanh Hospital, Buon Ma Thuot, Vietnam
| | | | | | - Chinh Huynh
- Department of Radiology, Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - To Nguyen Ha
- Department of Radiology, Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Phuong Hai Huynh
- Department of Radiology, University Medical Center at Ho Chi Minh City, Vietnam
| | - Hoang Quan Nguyen
- Department of Radiology, Da Nang Oncology Hospital, Da Nang, Vietnam
| | - Uyen Giao Vo
- Department of Vascular Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Thanh Thao Nguyen
- Department of Radiology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
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20
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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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21
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Huynh C, Ha TN, Hoang VT, Huynh PH. Acquired life-threatening uterine arteriovenous malformation treated by endovascular embolization. Radiol Case Rep 2021; 16:241-245. [PMID: 33304434 PMCID: PMC7708760 DOI: 10.1016/j.radcr.2020.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/05/2020] [Accepted: 11/05/2020] [Indexed: 11/22/2022] Open
Abstract
Uterine arteriovenous malformation (AVM) is a rare condition that may lead to a life-threatening state. The urgency of diagnosis and treatment for uterine AVM should be emphasized. This case report describes a 42-year-old woman with a vaginal hemorrhage. In the previous month, the patient also had a hemorrhage after induced abortion that required a bilateral artery suture hemostasis of the uterus. On ultrasound, there was a lesion suspected by acquired AVM. Magnetic Resonance Angiography and Digital Subtraction Angiography was indicated to confirm the diagnosis. The patient was successfully treated by uterine artery embolization. After 6 months, the re-examined result showed no lesion of AVM.
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Affiliation(s)
- Chinh Huynh
- Department of Radiology, Tu Du Hospital, Ho Chi Minh, Viet Nam
| | - To-Nguyen Ha
- Department of Radiology, Tu Du Hospital, Ho Chi Minh, Viet Nam
| | - Van-Trung Hoang
- Department of Radiology, Thien Hanh Hospital, Buon Ma Thuot, Viet Nam
| | - Phuong-Hai Huynh
- Department of Radiology, University Medical Center, Ho Chi Minh, Viet Nam
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22
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Naik S, Singh S, Mohakud S, Jena S. Uterine artery pseudoaneurysm: A rare complication of cesarean section. J Postgrad Med 2020; 66:174-175. [PMID: 32675457 PMCID: PMC7542062 DOI: 10.4103/jpgm.jpgm_625_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- S Naik
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - S Singh
- Department of Obstetrics and Gyaenacology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - S Mohakud
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - S Jena
- Department of Obstetrics and Gyaenacology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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23
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Prisca Gabrielle Andrianah E, Ony Narindra Lova Hasina Rajaonarison N, Rasolohery H, Dina Ranoharison H, Andriamiarintsoa H, Blangy S, Ahmad A. Fistule artérioveineuse intra-utérine secondaire : à propos de deux cas. IMAGERIE DE LA FEMME 2020. [DOI: 10.1016/j.femme.2020.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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24
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Hammad R, Nausheen S, Malik M. A Case Series on Uterine Arteriovenous Malformations: A Life-Threatening Emergency in Young Women. Cureus 2020; 12:e9410. [PMID: 32864239 PMCID: PMC7449621 DOI: 10.7759/cureus.9410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 07/27/2020] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Rabia Hammad
- Obstetrics and Gynaecology, Aga Khan University Hospital, Karachi, PAK
| | - Sidrah Nausheen
- Obstetrics and Gynecology, Aga Khan University Hospital, Karachi, PAK
| | - Mumtaz Malik
- Radiology, Aga Khan University Hospital, Karachi, PAK
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25
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Rossard L, Body G, Ouldamer L. Uterine pseudoaneurysm after abdominal myomectomy: A case report. J Gynecol Obstet Hum Reprod 2020; 50:101877. [PMID: 32717332 DOI: 10.1016/j.jogoh.2020.101877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/14/2020] [Accepted: 07/21/2020] [Indexed: 10/23/2022]
Abstract
We present the case of a young woman with abnormal vaginal bleeding two weeks after an abdominal myomectomy. The intervention was initially considered uncomplicated. Transvaginal sonography detected a pulsatile cystic area, just above the endometrium in the anterior wall of the lower uterine segment. Color Doppler analysis revealed the communication between an artery and a vein. Although, the ultrasound was completely sufficient for diagnosis, computed tomographic angiography was performed and confirmed the diagnosis of uterine pseudoanevrysm within the uterine myometrium. Selective arterial embolization was performed with complete recovery.
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Affiliation(s)
- Lauranne Rossard
- Department of Gynecology. Centre Hospitalier Régional Universitaire de Tours. Hôpital Bretonneau. 2 Boulevard Tonnellé. 37044 Tours. France; François-Rabelais University, Tours. France
| | - Gilles Body
- Department of Gynecology. Centre Hospitalier Régional Universitaire de Tours. Hôpital Bretonneau. 2 Boulevard Tonnellé. 37044 Tours. France; François-Rabelais University, Tours. France; INSERM Unit 1069, Tours. France
| | - Lobna Ouldamer
- Department of Gynecology. Centre Hospitalier Régional Universitaire de Tours. Hôpital Bretonneau. 2 Boulevard Tonnellé. 37044 Tours. France; François-Rabelais University, Tours. France; INSERM Unit 1069, Tours. France.
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26
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AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Female Pelvis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:E17-E23. [PMID: 32150295 DOI: 10.1002/jum.15205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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27
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Grewal K, Al-Memar M, Fourie H, Stalder C, Timmerman D, Bourne T. Natural history of pregnancy-related enhanced myometrial vascularity following miscarriage. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:676-682. [PMID: 31503383 DOI: 10.1002/uog.21872] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Our primary aim was to report the incidence of enhanced myometrial vascularity (EMV) in consecutive women attending our early pregnancy assessment unit, following first-trimester miscarriage. We aimed further to evaluate the clinical presentation and complications associated with expectant and surgical management of EMV in these women. METHODS This was a prospective cohort study conducted in a London teaching hospital between June 2015 and June 2018, including consecutive patients with an observation of EMV on transvaginal ultrasonography following first-trimester miscarriage. The diagnosis was made following the subjective identification of EMV using color Doppler ultrasonography and a peak systolic velocity (PSV) ≥ 20 cm/s within the collection of vessels. Women were followed up with repeat scans every 14 days. Management was expectant unless intervention was indicated because of excessive or prolonged bleeding, persistent presence of retained tissue in the endometrial cavity or patient choice. The final clinical outcome was recorded. Time to resolution of EMV was defined as the interval from detection of EMV until resolution. RESULTS During the study period, there were 2627 first-trimester fetal losses in the department and, of these, 40 patients were diagnosed with EMV, hence the incidence of EMV following miscarriage was 1.52%. All cases were associated with ultrasound evidence of retained products of conception (RPOC) at presentation (mean dimensions, 22 × 20 × 20 mm). Thirty-one patients opted initially for expectant management, of which 18 had successful resolution without intervention, five were lost to follow-up and eight subsequently had surgical evacuation due to patient choice. No expectantly managed case required emergency intervention. Nine patients chose surgical evacuation as primary treatment. No significant correlation was seen between PSV within the EMV at presentation and blood loss at surgery. Median PSV was 47 (range, 20-148) cm/s. The estimated blood loss in all cases managed surgically ranged from 20-300 mL. Presence of RPOC was confirmed in all specimens that were sent for analysis following surgery. For cases successfully managed expectantly, the mean time to resolution was 48 (range, 21-84) days. In the nine cases managed surgically from the beginning, the mean time to resolution of EMV was 10.6 (range, 3-29) days. CONCLUSIONS This study suggests that EMV is an uncommon finding following miscarriage and is associated with the presence of RPOC. Expectant management was a safe option in our cohort, with minimal bleeding, although it was associated with protracted time to resolution. In patients who opted for surgery, the maximum blood loss was 300 mL and no patient required blood transfusion or embolization. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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MESH Headings
- Abortion, Spontaneous/diagnostic imaging
- Adult
- Female
- Humans
- Incidence
- London
- Myometrium/blood supply
- Myometrium/diagnostic imaging
- Neovascularization, Pathologic/diagnostic imaging
- Neovascularization, Pathologic/epidemiology
- Neovascularization, Pathologic/etiology
- Placenta, Retained/diagnostic imaging
- Placenta, Retained/etiology
- Pregnancy
- Pregnancy Trimester, First
- Prospective Studies
- Ultrasonography, Doppler, Color
- Ultrasonography, Prenatal
- Watchful Waiting
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Affiliation(s)
- K Grewal
- Tommy's National Centre for Miscarriage Research, Institute of Reproductive & Developmental Biology, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - M Al-Memar
- Tommy's National Centre for Miscarriage Research, Institute of Reproductive & Developmental Biology, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - H Fourie
- Tommy's National Centre for Miscarriage Research, Institute of Reproductive & Developmental Biology, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - C Stalder
- Queen Charlotte's Hospital, Hammersmith Hospital Campus, Imperial College London, London, UK
| | - D Timmerman
- Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Leuven, Belgium
| | - T Bourne
- Tommy's National Centre for Miscarriage Research, Institute of Reproductive & Developmental Biology, Imperial College London, Hammersmith Hospital Campus, London, UK
- Queen Charlotte's Hospital, Hammersmith Hospital Campus, Imperial College London, London, UK
- Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Leuven, Belgium
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28
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Timor-Tritsch IE, Monteagudo A, Calì G, D'Antonio F, Agten AK. Cesarean Scar Pregnancy: Patient Counseling and Management. Obstet Gynecol Clin North Am 2020; 46:813-828. [PMID: 31677756 DOI: 10.1016/j.ogc.2019.07.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
There is no universally agreed upon and adopted management protocol supported by professional societies in the United States or around the world for the treatment of cesarean scar pregnancy. There is a wide range of management options in the literature, and many of them can to lead to severe bleeding complications, which can result in loss of fertility or even maternal death. If inadequately managed, it can lead to untoward complications throughout all 3 trimesters of the pregnancy. Early detection of CSP has a paramount clinical importance.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, NYU School of Medicine, NYU Langone Health, 550 1st Avenue, New York, NY 10016, USA.
| | - Ana Monteagudo
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Giuseppe Calì
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - Francesco D'Antonio
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Andrea Kaelin Agten
- Nottingham University Hospitals NHS, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
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29
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Ohliger MA, Choi HH, Coutier J. Imaging Safety and Technical Considerations in the Reproductive Age Female. Radiol Clin North Am 2020; 58:199-213. [DOI: 10.1016/j.rcl.2019.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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30
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Revels JW, Dey CB, Aggarwal A, London SS, Katz D, Menias C, Moshiri M. More Than Just 2 Layers: A Comprehensive Multimodality Imaging Review of Endometrial Abnormalities. Curr Probl Diagn Radiol 2019; 49:431-446. [PMID: 31307863 DOI: 10.1067/j.cpradiol.2019.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/06/2019] [Accepted: 06/25/2019] [Indexed: 11/22/2022]
Abstract
Endometrial abnormalities develop in female patients of all ages. Symptoms related to endometrial pathologies are among the most common causes of gynecologist office visits, with the radiologists playing an important role in endometrial evaluation. In some instances, the radiologist may be the first physician to note endometrial pathology. In this article, we will provide a comprehensive review of radiologic modalities utilized in the evaluation of the endometrium, as well as the imaging appearance of various endometrial disease processes.
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Affiliation(s)
| | - Courtney B Dey
- Department of Radiology, Eastern Virginia Medical School, Sentara Norfolk General Hospital, Norfolk, VA
| | - Abhi Aggarwal
- Department of Radiology, Eastern Virginia Medical School, Sentara Norfolk General Hospital, Norfolk, VA
| | - Sean S London
- Department of Radiology, University of Washington, Seattle, WA
| | - Douglas Katz
- Department of Radiology, NYU Winthrop Hospital, Mineola, NY
| | | | - Mariam Moshiri
- Department of Radiology, University of Washington, Seattle, WA
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31
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Khan S, Saud S, Khan I, Achakzai B. Acquired Uterine Arteriovenous Malformation Following Dilatation and Curettage Treated with Bilateral Uterine Artery Embolization: A Case Report. Cureus 2019; 11:e4250. [PMID: 31131173 PMCID: PMC6516630 DOI: 10.7759/cureus.4250] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Uterine arteriovenous malformations (AVMs) are a rare, potentially life-threatening cause of abnormal uterine bleeding that can be acquired following uterine instrumentation. We herein report a case of acquired uterine AVM following dilatation and curettage (D&C) that was successfully treated with bilateral embolization using Gelfoam (Pfizer, New York, USA) pledgets.
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Affiliation(s)
- Salman Khan
- Internal Medicine, Guthrie Clinic/Robert Packer Hospital, Sayre, USA
| | - Shakir Saud
- Family Medicine, Rutgers New Jersey Medical School, Newark, USA
| | - Imran Khan
- Internal Medicine, North Shore University Hospital, Hempstead, USA
| | - Basit Achakzai
- Interventional Radiology, Guthrie Clinic/Robert Packer Hospital, Sayre, USA
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32
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Shim DJ, Choi SJ, Jung JM, Choi JH. Uterine arteriovenous malformation with repeated vaginal bleeding after dilatation and curettage. Obstet Gynecol Sci 2019; 62:142-145. [PMID: 30918884 PMCID: PMC6422849 DOI: 10.5468/ogs.2019.62.2.142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/13/2018] [Accepted: 12/26/2018] [Indexed: 12/30/2022] Open
Abstract
Uterine arteriovenous vascular malformation (UAVM) is a disease that causes excessive bleeding. The symptoms do not subside without proper treatment and this can lead to life-threatening situations. The correct diagnosis of UAVM can be complicated if the patient's uterus did not completely discharge everything during abortion (in broader terms, retaining remnants of the products of conception). In this case, Doppler ultrasonography and computed tomography angiography with 3-dimensional rendering were used to analyze the cause of bleeding and provide proper treatment of this patient. Then, uterine artery embolization, dilatation, and curettage were performed safely and successfully. The patient no longer had symptoms of vaginal spotting during the planned follow up care. UAVM is uncommon; however, if reproductive-age women show repeated abnormal vaginal bleeding after dilatation and curettage, a diagnosis of UAVM must be considered based on the medical history and examination.
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Affiliation(s)
- Da Joung Shim
- Department of Obstetrics and Gynecology, Chosun University Hospital, Chosun University College of Medicine, Gwangju, Korea
| | - Sang Joon Choi
- Department of Obstetrics and Gynecology, Chosun University Hospital, Chosun University College of Medicine, Gwangju, Korea
| | - Ji Min Jung
- Department of Obstetrics and Gynecology, Chosun University Hospital, Chosun University College of Medicine, Gwangju, Korea
| | - Ji Hyun Choi
- Department of Obstetrics and Gynecology, Chosun University Hospital, Chosun University College of Medicine, Gwangju, Korea
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Jennings L, Presley B, Krywko D. Uterine Artery Pseudoaneurysm: A Life-Threatening Cause of Vaginal Bleeding in the Emergency Department. J Emerg Med 2019; 56:327-331. [PMID: 30685218 DOI: 10.1016/j.jemermed.2018.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/02/2018] [Accepted: 12/08/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Vaginal bleeding is a common presenting complaint in the emergency department (ED); life-threatening hemorrhage is rare. Uterine artery pseudoaneurysm (UAP) is an uncommon but potentially life-threatening cause of vaginal bleeding that is most likely to present primarily to EDs, given its delayed postpartum or postoperative presentation. CASE REPORT A 25-year-old female gravida two, para one, who was 19 days post dilation and evacuation for an elective termination of a pregnancy at 20 weeks, presented to the ED with profuse vaginal bleeding. She was hypotensive and tachycardic at presentation, requiring resuscitation with 0.9% normal saline and transfusions of packed red blood cells. Transvaginal ultrasound completed in the ED demonstrated a pulsatile mass in the cervix with internal "ying-yang" flow on Doppler images, suggestive of a uterine artery pseudoaneurysm within the cervix. The patient underwent emergent uterine artery embolization with resolution of bleeding and improvement in her hemodynamic status. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: UAP is an uncommon cause of vaginal bleeding, but UAP rupture can be life-threatening. UAP is an important differential diagnosis for vaginal bleeding, particularly in the postpartum or postoperative setting. Delaying diagnosis may worsen bleeding in the setting of a ruptured UAP if treatment is pursued for alternative diagnosis; for example, treating retained products of conception with a dilation and curettage. Being aware of UAP and how to diagnose it will allow early proper treatment and more favorable patient outcomes.
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Affiliation(s)
- Lindsey Jennings
- Department of Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Brad Presley
- Department of Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Diann Krywko
- Department of Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina
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Cunningham RK, Horrow MM, Smith RJ, Springer J. Adenomyosis: A Sonographic Diagnosis. Radiographics 2018; 38:1576-1589. [PMID: 30207945 DOI: 10.1148/rg.2018180080] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Adenomyosis is a common benign uterine condition and a frequent cause of pelvic pain in premenopausal women. Transvaginal US is now considered the primary imaging modality for the diagnosis of adenomyosis, and thus radiologists should be familiar with its sonographic appearance. US findings can be divided into three categories, which parallel the histology of adenomyosis: (a) ectopic endometrial glands and stroma, (b) muscular hyperplasia/hypertrophy, and (c) increased vascularity. Ectopic endometrial glands manifest as echogenic nodules and striations, radiating from the endometrium into the myometrium. When the glands contain fluid, myometrial cysts and fluid-filled striations may be visible at US. Muscular hyperplasia and hypertrophy cause focal or diffuse myometrial thickening and globular uterine enlargement, often with thin "venetian blind" shadows. The combination of these findings results in a heterogeneous myometrium, with blurring of the endometrial border. Adenomyosis increases uterine vascularity, depicted as a pattern of penetrating vessels at color Doppler US. Other US techniques that are helpful in the diagnosis of adenomyosis include obtaining cine clips and coronal reformatted images, both of which can survey the entire endometrial-myometrial border, and performing saline-infusion sonohysterography, during which ectopic glands frequently fill with either air or fluid. While most cases of adenomyosis develop spontaneously, there are specific inciting causes that include tamoxifen use, postendometrial ablation syndrome, and deep-infiltrating endometriosis. Mimics of adenomyosis include leiomyomas, uterine contractions, neoplasms, and vascular malformations. This article reviews the pathophysiology of adenomyosis and correlates it with the US findings, highlights specific causes of adenomyosis, and describes how to distinguish this common diagnosis from a variety of mimics. Online supplemental material is available for this article. ©RSNA, 2018.
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Affiliation(s)
- Ryan K Cunningham
- From the Department of Radiology, Einstein Healthcare Network, 5501 Old York Rd, Philadelphia, PA 19141
| | - Mindy M Horrow
- From the Department of Radiology, Einstein Healthcare Network, 5501 Old York Rd, Philadelphia, PA 19141
| | - Ryan J Smith
- From the Department of Radiology, Einstein Healthcare Network, 5501 Old York Rd, Philadelphia, PA 19141
| | - Joseph Springer
- From the Department of Radiology, Einstein Healthcare Network, 5501 Old York Rd, Philadelphia, PA 19141
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El Agwany AS, Elshafei M. Extensive uterine arteriovenous malformation with hemodynamic instability: Embolization for whole myometrium affection. Eur J Obstet Gynecol Reprod Biol 2018; 222:188-191. [PMID: 29395294 DOI: 10.1016/j.ejogrb.2018.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 12/27/2017] [Accepted: 01/16/2018] [Indexed: 11/30/2022]
Abstract
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).
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Affiliation(s)
- Ahmed Samy El Agwany
- Women imaging unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Alexandria University, Egypt.
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Kassam Z, Petkovska I, Wang CL, Trinh AM, Kamaya A. Benign Gynecologic Conditions of the Uterus. Magn Reson Imaging Clin N Am 2017; 25:577-600. [DOI: 10.1016/j.mric.2017.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Reimnitz L, Sanchez-Migallon Guzman D, Alex C, Summa N, Gleeson M, Cissell DD. Multiple endometrial venous aneurysms in a domestic rabbit ( Oryctolagus cuniculus ). J Exot Pet Med 2017. [DOI: 10.1053/j.jepm.2017.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Dunham GM, Ingraham CR, Maki JH, Vaidya SS. Finding the Nidus: Detection and Workup of Non-Central Nervous System Arteriovenous Malformations. Radiographics 2017; 36:891-903. [PMID: 27163597 DOI: 10.1148/rg.2016150177] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Vascular anomalies are a diverse group of pathologic conditions. They have different manifestations, natural histories, and treatments. Compared with other vascular malformations, arteriovenous malformations (AVMs) are considered the most symptomatic and difficult to manage. AVMs inherently progress and have a high rate of recurrence after treatment. Imaging helps provide an accurate and early diagnosis, which can then be used to direct appropriate management, with embolization evolving as the primary therapy. Thus, radiology plays a crucial role in the detection, workup, and management of AVMs. Ultrasonography (US) is a useful initial imaging modality, particularly when AVMs involve the extremities or a superficial or accessible location. Limitations include poor identification of soft-tissue and bone components, as well as suboptimal evaluation of deep or complex AVMs. Magnetic resonance (MR) angiography is the preferred imaging modality for AVMs and should be considered in any symptomatic patient or in the initial evaluation of vascular anomalies that are equivocal at US. Computed tomographic angiography should be reserved for those patients who are unable to undergo MR angiography or for evaluation of acute symptoms, such as bleeding or airway compromise. Conventional catheter-based angiography is useful for real-time depiction and evaluation of AVMs, particularly in the planning and execution of endovascular treatment and in the diagnosis of an AVM when findings from noninvasive imaging are equivocal for a high-flow component. As with the diagnostic workup, MR angiography is the preferred posttreatment modality. (©)RSNA, 2016.
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Affiliation(s)
- Gregor M Dunham
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Box 357115, Seattle, WA 98195
| | - Christopher R Ingraham
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Box 357115, Seattle, WA 98195
| | - Jeffrey H Maki
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Box 357115, Seattle, WA 98195
| | - Sandeep S Vaidya
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Box 357115, Seattle, WA 98195
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Agarwal N, Chopra S, Aggarwal N, Gorsi U. Congenital Uterine Arteriovenous Malformation Presenting as Postcoital bleeding: A Rare Presentation of a Rare Clinical Condition. J Clin Imaging Sci 2017; 7:11. [PMID: 28400997 PMCID: PMC5359997 DOI: 10.4103/jcis.jcis_95_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 12/24/2016] [Indexed: 11/11/2022] Open
Abstract
Congenital uterine arteriovenous malformation (AVM) is an extremely rare condition with <100 cases documented in literature. We report multiparous women presenting to us with a history of postcoital bleed. Initial Doppler ultrasonography was consistent with features suggestive of AVM. Subsequently, computed tomography (CT) angiography confirmed the diagnosis. Embolization was chosen as the treatment because of the large extension of AVM and the risk of hemorrhage during hysterectomy. The patient was discharged in a stable condition with a plan of repeat embolization in the next setting. At 6 and 12 weeks of follow-up, she did not experience any further episodes of bleed. The purpose of this case report is to highlight the salient clinical features, diagnosis, and the management options available for this rare clinical condition.
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Affiliation(s)
- Neha Agarwal
- Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Seema Chopra
- Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Neelam Aggarwal
- Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Evans A, Gazaille RE, McKenzie R, Musser M, Lemming R, Curry J, Meyers W, Austin N. Acquired uterine arteriovenous fistula following dilatation and curettage: an uncommon cause of vaginal bleeding. Radiol Case Rep 2017; 12:287-291. [PMID: 28491172 PMCID: PMC5417766 DOI: 10.1016/j.radcr.2017.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 12/20/2016] [Accepted: 01/02/2017] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Adam Evans
- Department of Diagnostic Radiology, Grandview Medical Center-Kettering Health Network, 405 W Grand Avenue, Dayton, OH 45405, USA
| | - Roland E Gazaille
- Department of Diagnostic Radiology, Grandview Medical Center-Kettering Health Network, 405 W Grand Avenue, Dayton, OH 45405, USA
| | - Richard McKenzie
- Department of Diagnostic Radiology, Grandview Medical Center-Kettering Health Network, 405 W Grand Avenue, Dayton, OH 45405, USA
| | - Meghan Musser
- Department of Diagnostic Radiology, Grandview Medical Center-Kettering Health Network, 405 W Grand Avenue, Dayton, OH 45405, USA
| | - Robert Lemming
- Department of Diagnostic Radiology, Grandview Medical Center-Kettering Health Network, 405 W Grand Avenue, Dayton, OH 45405, USA
| | - Jarrod Curry
- Department of Diagnostic Radiology, Grandview Medical Center-Kettering Health Network, 405 W Grand Avenue, Dayton, OH 45405, USA
| | - William Meyers
- Department of Diagnostic Radiology, Grandview Medical Center-Kettering Health Network, 405 W Grand Avenue, Dayton, OH 45405, USA
| | - Nicholas Austin
- College of Osteopathic Medicine, Kansas City University of Medicine and Biosciences, Kansas City, MO, USA
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Bucha A, Chawla SK, Sethi N. Uterine arteriovenous malformation: A rare cause of abnormal uterine bleeding in a post-menopausal female. Med J Armed Forces India 2016; 72:S210-S212. [DOI: 10.1016/j.mjafi.2016.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 08/25/2016] [Indexed: 10/20/2022] Open
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Successful Treatment of Uterine Arteriovenous Malformation due to Uterine Trauma. Case Rep Obstet Gynecol 2016; 2016:1890650. [PMID: 27699074 PMCID: PMC5028872 DOI: 10.1155/2016/1890650] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 08/17/2016] [Indexed: 12/28/2022] Open
Abstract
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).
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Timor-Tritsch IE, Haynes MC, Monteagudo A, Khatib N, Kovács S. Ultrasound diagnosis and management of acquired uterine enhanced myometrial vascularity/arteriovenous malformations. Am J Obstet Gynecol 2016; 214:731.e1-731.e10. [PMID: 26873276 DOI: 10.1016/j.ajog.2015.12.024] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/12/2015] [Accepted: 12/15/2015] [Indexed: 10/22/2022]
Abstract
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.
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Transcatheter Arterial Embolization with n-Butyl Cyanoacrylate for the Treatment of Acquired Uterine Vascular Malformations. Cardiovasc Intervent Radiol 2016; 39:1170-6. [DOI: 10.1007/s00270-016-1328-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 03/13/2016] [Indexed: 10/22/2022]
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Eling R, Kent A, Robertson M. Pregnancy after uterine arteriovenous malformation-case series and literature review. Australas J Ultrasound Med 2015; 15:87-96. [PMID: 28191151 PMCID: PMC5025090 DOI: 10.1002/j.2205-0140.2012.tb00012.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Rebeka Eling
- Australian National University Medical School Canberra Australian Capital Territory Australia
| | - Alison Kent
- Australian National UniversityMedical SchoolCanberraAustralian Capital TerritoryAustralia; Dept of NeonatologyCanberra HospitalWodenAustralian Capital TerritoryAustralia
| | - Meiri Robertson
- Australian National UniversityMedical SchoolCanberraAustralian Capital TerritoryAustralia; Fetal Medicine UnitCanberra HospitalWodenAustralian Capital TerritoryAustralia
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Venturini M, Cristel G, Marzoli SB, Simionato F, Agostini G, Barboni P, De Cobelli F, Falini A, Bandello F, Del Maschio A. Orbital color Doppler ultrasound as noninvasive tool in the diagnosis of anterior-draining carotid-cavernous fistula. Radiol Med 2015; 121:301-7. [PMID: 26639150 DOI: 10.1007/s11547-015-0607-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 11/09/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE To investigate the role of orbital color Doppler ultrasound (OCDUS) in the diagnosis of carotid-cavernous fistula (CCF) with anterior drainage and particularly whether a negative OCDUS could avoid an invasive diagnostic cerebral angiography (DSA). MATERIALS AND METHODS Twenty-two consecutive patients with ophthalmic signs suspecting CCF were submitted to ophthalmologic examination, OCDUS and DSA. CCF diagnosis with OCDUS was based on the finding of a reversed, arterialized and low-resistive-index (RI <0.5) blood flow in the superior ophthalmic vein (SOV). Sensibility, specificity, PPV, NPV, and accuracy of OCDUS were calculated considering both patients and eyes, using DSA as gold standard. RESULTS DSA demonstrated 20 CCFs in 18 patients. Considering the patients, in 18/22 CCF diagnosis was positive at OCDUS and DSA while 4/22 were negative at both. Considering the eyes, in 24/43 CCF diagnosis was positive at both DSA and OCDUS (total eyes = 43, due to one case of SOV thrombosis). In 19/43 eyes diagnosis was negative at both OCDUS and DSA. So sensitivity, specificity, PPV, NPV, and accuracy of OCDUS in the patients and eyes analysis were all 100 %. CONCLUSIONS OCDUS is a reliable, noninvasive tool in the diagnosis of CCF; a negative OCDUS could avoid an invasive DSA in patients suspected for anterior-draining CCF.
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Affiliation(s)
- Massimo Venturini
- Department of Radiology, San Raffaele Scientific Institute - Vita Salute University, Via Olgettina, 60, 20132, Milan, Italy.
| | - Giulia Cristel
- Department of Radiology, San Raffaele Scientific Institute - Vita Salute University, Via Olgettina, 60, 20132, Milan, Italy
| | | | - Franco Simionato
- Department of Neuroradiology, San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Agostini
- Department of Radiology, San Raffaele Scientific Institute - Vita Salute University, Via Olgettina, 60, 20132, Milan, Italy
| | - Piero Barboni
- Department of Ophthalmology, San Raffaele Scientific Institute, Milan, Italy
| | - Francesco De Cobelli
- Department of Radiology, San Raffaele Scientific Institute - Vita Salute University, Via Olgettina, 60, 20132, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Falini
- Department of Neuroradiology, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Bandello
- Department of Ophthalmology, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Del Maschio
- Department of Radiology, San Raffaele Scientific Institute - Vita Salute University, Via Olgettina, 60, 20132, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
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Ahmed Y, Davidson J, Azar N. Ultrasound-guided Transcutaneous Embolization of Uterine Arteriovenous Fistula Performed for Treatment of Symptomatic, Heavy Vaginal Bleeding: Case Report with Brief Review of Literature. J Med Ultrasound 2015. [DOI: 10.1016/j.jmu.2015.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Youssef AT. Endosonography of benign myometrium cysts and cyst-like lesions. J Ultrasound 2015; 18:213-22. [PMID: 26261463 DOI: 10.1007/s40477-014-0142-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 10/20/2014] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION Many pathological causes are responsible for the sonographic presentation of myometrium cysts and cyst-like lesions, where the distinction between these etiologies is required. THE AIM OF THE WORK The current work is aimed at discerning between different etiologies of myometrium cysts and cyst-like lesions for an optimum management. METHODOLOGY In the course of daily practice of gynecological transvaginal ultrasound, 66 cases of myometrium cysts and cyst-like lesions have been discerned, where all were examined with endovaginal ultrasound using a multifrequency endocavitary probe having color Doppler capability. RESULTS Adenomyosis uteri detected in 15 cases, invasive mole in 4 cases, congested arcuate veins in 20 cases, incidental cysts in 4 cases, cystic degeneration of myoma in 3 cases, C-section scar cysts and cyst-like lesions in 13 cases, interstitial ectopic pregnancy in 2 cases, incomplete abortion with congested myometrium vessels in 4 cases, and arteriovenous malformation in 1 case. The number of cases with cervical nabothian cysts was not considered since they were too frequent. CONCLUSION Endosonography is an important tool in differentiating between the various diseases that are responsible for benign myometrium cysts and cyst-like lesions, which are all important since some of them are visualized as serious clinical situations and others turn out to be of little clinical significance.
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Raherinantenaina F, Rajaonanahary TMA, Randriamandrato TAV, Rakoto Ratsimba HN. [Successful management of an acquired uterine arteriovenous malformation by selective ligation of the internal iliac artery]. ACTA ACUST UNITED AC 2015; 40:182-6. [PMID: 25778842 DOI: 10.1016/j.jmv.2015.02.001] [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: 05/27/2014] [Accepted: 01/08/2015] [Indexed: 10/23/2022]
Abstract
Uterine arteriovenous malformations can be congenital or acquired. When acquired, they result from abnormal arteriovenous communication between one or more uterine arteries and a myometrial and/or endometrial venous plexus, without the interposition of a vascular nidus. Arteriovenous malformations are composed of a tortuous net of fragile low-resistant arteriovenous shunts. Uterine arteriovenous malformations create a rare and potentially life-threatening condition. The method of treatment is determined by symptoms, desire for future fertility, extent, and location of the malformation. The first treatment option for uterine arteriovenous malformation is hysterectomy, and the second option is uterine artery embolization. Selective ligation of the vessels supplying the malformation is an effective treatment option when conservative methods have failed. The present report describes a patient whose uterine arteriovenous malformation was successfully managed by selective ligation of the internal iliac artery.
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Affiliation(s)
- F Raherinantenaina
- Service de chirurgie générale et vasculaire, CHU/HUJRA, BP 4150, Antananarivo, Madagascar.
| | - T M A Rajaonanahary
- Service de chirurgie générale et vasculaire, CHU/HUJRA, BP 4150, Antananarivo, Madagascar
| | | | - H N Rakoto Ratsimba
- Service de chirurgie générale et vasculaire, CHU/HUJRA, BP 4150, Antananarivo, Madagascar
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Lee TY, Kim SH, Lee HJ, Kim MJ, Lee SK, Kim YH, Cho SH. Ultrasonographic indications for conservative treatment in pregnancy-related uterine arteriovenous malformations. Acta Radiol 2014; 55:1145-52. [PMID: 24338371 DOI: 10.1177/0284185113514222] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Tae Young Lee
- Keimyung University, Dongsan Hospital, Department of Radiology, Republic of Korea
| | - See Hyung Kim
- Keimyung University, Dongsan Hospital, Department of Radiology, Republic of Korea
| | - Hee Jung Lee
- Keimyung University, Dongsan Hospital, Department of Radiology, Republic of Korea
| | - Mi Jeong Kim
- Keimyung University, Dongsan Hospital, Department of Radiology, Republic of Korea
| | - Sang Kwon Lee
- Keimyung University, Dongsan Hospital, Department of Radiology, Republic of Korea
| | - Young Hwan Kim
- Keimyung University, Dongsan Hospital, Department of Radiology, Republic of Korea
| | - Seung Hyun Cho
- Kyungbook National University Hospital, Department of Radiology, Republic of Korea
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