Pregnancy after embolization therapy for uterine arteriovenous malformation

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

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

Uterine Arteriovenous Malformation Treated by Hysteroscopic Excision

Uterine arteriovenous malformation (AVM) is a vascular hamartoma of the myometrium that mostly results from uterine tissue damage. Herein, we report a case of uterine AVM managed successfully by hysteroscopy. The patient had an induced abortion and subsequent persistent vaginal spotting and irregular active vaginal bleeding. Ultrasonography showed a 3.5 cm × 2.9 cm heterogeneous lesion in the endometrial cavity with increased vascularity. Symptoms were monitored without uterine artery embolization to avoid complications that may affect a future pregnancy. However, 10 days later, she presented with active vaginal bleeding. Hysteroscopic endometrial mass excision was performed. Her postoperative hemoglobin level and vital signs were stable. Biopsy of the excised mass revealed AVM. Her postoperative vaginal bleeding decreased significantly, and outpatient ultrasonography 1 month later showed no abnormal findings. This case confirms the feasibility and safety of hysteroscopic management of uterine AVMs. The hysteroscopic technique should be prioritized for managing uterine AVMs.

Uterine arteriovenous malformation with repeated vaginal bleeding after dilatation and curettage

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.

Successful pregnancy after uterine artery embolization for uterine arterovenous malformation: a rare case report

Objective

This paper reports on a rare case of pregnancy after uterine artery embolization (UAE) for uterine arteriovenous malformation (AVM). Debate exists about persistence of fertility in women after UAE. Adverse effects of this technique can modify both uterine echostructure, inducing necrosis and infarction, endometrial atrophy and uterine artery rupture, and ovarian reserve, causing persistent amenorrhea. Ovarian reserve appears to be affected by UAE in pre-menopausal women. However, younger ovaries (according to biological ovarian age) exhibit a greater capacity for recovery after ovarian damage. Therefore, larger studies are needed for more conclusive results.

Case report

A 28-year-old woman was admitted to our department due to life-threatening uterine bleeding, resulting in tachycardia, pallor, and sweating. The patient came with a history of two spontaneous miscarriages. After sonography and computed tomography, AVMs were identified at uterine fundus and anterior wall.

Conclusion

The pathogenesis of infertility after UAE is not yet known. The peculiarity of this case was that, only few months later, the patient became pregnant and gave birth to a live fetus at 37 weeks with cesarean delivery.

Hysteroscopic Management of Uterine Arteriovenous Malformation

Background and Objectives:

Uterine arteriovenous malformation (AVM) is characterized by shunts between the myometrial arteries and veins. Treatment is based on the severity of uterine bleeding and ranges from conservative medical approaches to embolization of affected arteries. The aim of study was to evaluate the feasibility and safety of hysteroscopy for management of uterine AVM.

Methods:

This was a retrospective study of a cohort of 11 cases occurring between March 2012 and December 2015 in our Regional Center of Excellence in Hysteroscopy, University of Florence. The diagnosis of AVM was made by transvaginal ultrasonography with high-definition flow in patients with mild to moderate symptoms. In all cases, we used the hysteroscopic platform Gynecare VersaPoint II (Ethicon, Somerville, New Jersey, USA), equipped with a 4-mm electrosurgical loop and associated with the SPIES (Storz Professional Image Enhancement System) system (Karl Storz, Tuttlingen, Germany).

Results:

All patients were successfully treated with operative hysteroscopy with no reported complications. No patient had residual disease detected by ultrasonography performed after a month. At this writing, of the 11 patients treated with operative hysteroscopy, 4 had achieved a pregnancy that carried to term, 1 was pregnant at 20 wk, and 1 had a miscarriage in the first trimester.

Conclusions:

Hysteroscopy is a feasible and safe alternative treatment modality for AVM. Patients treated with surgical hysteroscopy have high fertility outcomes, a 100% success rate after the first treatment, no complications related to the surgical procedure, and a short hospital stay.

Management of uterine artery pseudoaneurysm: advanced ultrasonography imaging and laparoscopic surgery as an alternative method to angio-computed tomography and transarterial embolization

Uterine artery pseudoaneurysms (UAP) are rare but potentially life-threatening lesions. They may occur after traumatic deliveries, cesarean sections, and other interventions. We present a case of a 39-year-old woman with a UAP. The patient was accurately diagnosed using ultrasound imaging, with subsequent diagnostic hysteroscopy and laparoscopic excision of the UAP. In the present case, a ligation of the artery branch was performed to provide accurate hemostasis during UAP dissection. The vascular lesion was partially enucleated and removed, followed by recreation of the previous uterine shape. Power Doppler with HD flow and 3D ultrasound are accurate methods in the diagnosis of UAP. We are of the opinion that laparoscopic surgery can be on a par with transarterial embolization. During laparoscopy, the surgeon can either close the feeding vessel or remove the pathological tissue. In our opinion, this method solves the problem permanently and, after a successful case series with long-term follow-up, might be applied in other centers as well.

A Systematic Review of Acquired Uterine Arteriovenous Malformations: Pathophysiology, Diagnosis, and Transcatheter Treatment

Objective An acquired uterine arteriovenous malformation (AVM) is a rare cause of vaginal bleeding and, although hysterectomy is the definitive therapy, transcatheter embolization (TCE) provides an alternative treatment option. This systematic review presents the indications, technique, and outcomes for transcatheter treatment of the acquired uterine AVMs. Study Design Literature databases were searched from 2003 to 2013 for eligible clinical studies, including the patient characteristics, procedural indication, results, complications, as well as descriptions on laterality and embolic agents utilized. Results A total of 40 studies were included comprising of 54 patients (average age of 33.4 years). TCE had a primary success rate with symptomatic control of 61% (31 patients) and secondary success rate of 91% after repeated embolization. When combined with medical therapy, symptom resolution was noted in 48 (85%) patients without more invasive surgical procedures. Conclusion Low-level evidence supports the role of TCE, including in the event of persistent bleeding following initial embolization, for the treatment of acquired uterine AVMs. The variety of embolic agents and laterality of approach delineate the importance of refining procedural protocols in the treatment of the acquired uterine AVM. Condensation A review on the management of patients with acquired uterine AVMs.

Pregnancy after uterine arteriovenous malformation-case series and literature review

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

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

BACKGROUND

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

Ultrasonography can accurately predict selection of conservative management.

[Role of imaging in cases of bleeding after spontaneous or induced abortion]

Post-abortum hemorrhage is a common clinical situation and etiological diagnosis has to be made early to avoid further complications such as persistent bleeding, infection or adhesions that may compromise fertility. Retained products of conception are the most common cause of bleeding. The diagnosis is based on endovaginal color doppler ultrasound showing a thickened and hypervascular endometrial echo-complex extending partly to the myometrium. The main differential diagnosis is uterine arteriovenous malformation, mostly iatrogenic. Diagnosis is based on the presence of myometrial confluent cystic lesions filled with turbulent and high velocity arterial flow on endovaginal color doppler ultrasound. The distinction between these two etiologies of post-abortion bleeding is mandatory because of totally different treatment: typically medical and/or surgical in case of retained products of conception and by selective arterial embolization in case of vascular malformation.

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

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

Management of bleeding uterine arteriovenous malformation with bilateral uterine artery embolization

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Diagnosis and management of life-threatening hypermenorrhagia caused by uterine arteriovenous malformation secondary to surgical termination of pregnancy: video evidence!

A 23-year-old lady presented with a 10-month history of multiple episodes of prolonged and erratic menstrual bleeding having undergone a surgical termination of pregnancy. Initially, pelvic ultrasound and hysteroscopy were found to be normal and for many months she was treated pharmacologically for dysfunctional uterine bleeding. She also tried both a copper-coil and MIRENA intrauterine system, which were both expelled due to heavy bleeding characterised by 'a clot the size of two fists'. She required blood transfusions on multiple admissions, was forced to resign from her job and later became depressed. Under our care a transvaginal ultrasound scan showed a hypervascular region on the posterior uterine wall. An urgent hysteroscopy was performed due to her haemoglobin being 5.7 g/dl and revealed a pulsating lesion abutting the endometrium, which can be seen here on video. MR angiography confirmed an arteriovenous malformation and she was successfully treated with uterine artery embolisation.

[Case study of a severe hemorrhage during a dilatation and curettage: Arteriovenous malformation or first trimester placenta accreta?]

A 27-year-old woman had a uterine curettage that was complicated by a severe hemorrhage. Ultrasonography and MRI showed a vascular lesion of the uterine fundus suspected to be an atypical arteriovenous malformation. The lesion spontaneously disappeared 2months later. The two most likely diagnoses are an arteriovenous malformation or a placenta accreta. The aim is to discuss the etiology of this serious complication from a case report of a severe hemorrhage during a uterine curettage.

Traitement radiologique des malformations artérioveineuses périphériques

Management of high-flow arteriovenous malformation remain often problematic. Complete eradication of the nidus is the only potential cure, but this, however, is often difficult if not impossible. Frequently, a multidisciplinary approach is required. In these article, techniques and results of the endovascular management of MAV are discussed.