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

Uterine arteriovenous malformation or uterine artery pseudoaneurysm secondary to uterine aspiration in cesarean scar ectopic pregnancy: a case report and review of the literature

INTRODUCTION

Uterine arteriovenous malformation or uterine artery pseudoaneurysm after the treatment of cesarean scar ectopic pregnancy is a scarce entity, leading to potentially life-threatening conditions due to the massive bleeding. The management remains significantly crucial. Herein, we report an uncommon case with surgical management of such a rare condition at our center.

PRESENTATION CASE

A 31-year-old Vietnamese female patient (gravida 2, para 1) was hospitalized for cesarean scar pregnancy. The uterine aspiration was well performed. However, the woman was readmitted for an abnormally persistent hypervascularity at the site of cesarean scar ectopic pregnancy under repeated ultrasound scans. After counseling, arteriovenous malformation was suspected more, whereas uterine pseudoaneurysm was incompletely ruled out. Initially, gonadotropin-releasing hormone agonist was administered, with two doses of 37.5 mg. Later, the patient underwent laparoscopic intervention to suture the vascular proliferation mass to prevent spontaneous rupture. The surgery was achieved successfully. One more dose of gonadotropin-releasing hormone agonist was added. The ultrasound detected no existing lesion compared with previous ultrasonic imaging and serum beta-human chorionic gonadotropin declined to a negative value. The patient was monitored in 1 month uneventfully.

CONCLUSION

A high index of suspicion of uterine arteriovenous malformation or uterine artery pseudoaneurysm should be raised after uterine curettage of cesarean scar ectopic pregnancy. Ultrasound scan is still a pivotal first-line tool in assessing this abnormality. Laparoscopic surgery with compressing suture of the enhanced myometrial vascularity/arteriovenous malformation combined with administration of gonadotropin-releasing hormone agonist may be applied. This surgical approach has not been reported before, which makes our case report unique. Further cases are required for this rare entity so as to ensure patient safety.

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

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

Imaging in Acute Obstetric Conditions: A Pictorial Essay

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

Imaging of Antepartum and Postpartum Hemorrhage

Severe obstetric hemorrhage is a leading cause of maternal mortality and morbidity worldwide. Major hemorrhage in the antepartum period presents potential risks for both the mother and the fetus. Similarly, postpartum hemorrhage (PPH) accounts for up to a quarter of maternal deaths worldwide. Potential causes of severe antepartum hemorrhage that radiologists should be familiar with include placental abruption, placenta previa, placenta accreta spectrum disorders, and vasa previa. Common causes of PPH that the authors discuss include uterine atony, puerperal genital hematomas, uterine rupture and dehiscence, retained products of conception, and vascular anomalies. Bleeding complications unique to or most frequently encountered after cesarean delivery are also enumerated, including entities such as bladder flap hematomas, rectus sheath and subfascial hemorrhage, and infectious complications of endometritis and uterine dehiscence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Javitt and Madrazo in this issue.

Uterine arteriovenous malformation: a case of challenges in diagnosis and management of a patient with a history of misdiagnosed hemorrhage

Introduction

Uterine arteriovenous malformations (AVMs) are a rare cause of obstetrical hemorrhage. It can be congenital due to a defect during embryogenesis or acquired. Uterine AVMs can cause life threatening postpartum hemorrhage, and is most frequently misdiagnosed. This case highlights the diagnostic challenges posed by uterine arteriovenous malformation, a rare vascular anomaly that poses significant challenges in diagnosis and management.

Case presentation

This case report details the clinical presentation, diagnostic challenges, and treatment approach for a 39-year-old woman. In the absence of a medical history indicative of pre-existing ailments, the individual in question has undergone two emergency cesarean sections as documented in her surgical history, in addition to two previous dilation and curettage D&C operations. The patient presented with heavy vaginal bleeding 6 months after a cesarean section. The patient's clinical presentation, imaging findings, and intraoperative observations collectively substantiate the diagnosis of uterine AVMs.

Discussion

Women who have had uterine instrumentatio surgery, such as a cesarean section or dilatation and curettage (D&C) are more likely to develop acquired uterine AVMs. The absence of uterine artery embolism options compelled the use of alternative diagnostic methods, including contrast MRI, which successfully detected abnormal vascular lesions. The choice for hysterectomy was influenced by the patient's completion of childbearing and the presence of large vessels in proximity to critical regions.

Conclusion

This case emphasizes the significance of adapting treatment plans based on local resource constraints and the need for ongoing efforts to enhance diagnostic capabilities in undeserved regions.

Retained Products of Conception (RPOC): Diagnosis, Complication & Management

Introduction

Retained products of conception (RPOC) generally result after first half of pregnancy termination and also may occur after vaginal or cesarean delivery. It frequently presents with irregular or continuous vaginal bleeding, lower abdominal and pelvic pain, and discharge per vaginum due to infection; it can also cause late complications like formation of intrauterine adhesions and subfertility. The diagnosis of the RPOC along with the symptoms is generally supported by ultrasonography with or without colour Doppler. The patient also undergoes uterine vasculature assessment to diagnose arteriovenous malformation (AVM). The management of RPOC has been conventionally done with blind dilation and suction curettage (D and C); however, expectant management, uterine artery embolization, and hysteroscopic resection of RPOC are safe and efficient alternatives.

Materials and methods

In this review, we analyse the current available evidence regarding the clinical presentation, diagnosis and treatment of RPOC comparing the sensitivity, specificity, outcomes, pros and cons of various methods.

Conclusion

RPOC is a common complication associated with early and late complications. The judicious use of antibiotics along with interventional radiology and hysteroscopy forms the backbone for the treatment of this condition.

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

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

Retained Placenta Percreta with Acquired Uterine Arteriovenous Malformation—Case Report and Short Review of the Literature

Placenta accreta spectrum disorder (PAS) has an increased frequency due to the high number of cesarean sections. The abnormal placentation associated with a retained placenta can cause persistent uterine bleeding, with ultrasound Doppler examination being the main choice to assess the uterine hemorrhage. An acquired uterine arteriovenous malformation (AVM) may occur because of uterine trauma, spontaneous abortion, dilation and curettage, endometrial carcinoma or gestational trophoblastic disease. The treatment for abnormal placentation associated with AVM can be conservative, represented by methotrexate therapy, arterial embolization, uterine curettage, hysteroscopic loop resection or radical, which takes into consideration total hysterectomy. Therapeutic management always considers the degree of placental invasion, the patient hemodynamic state and fertility preservation. Considering the aspects described, we present a case of retained placenta percreta associated with acquired uterine AVM, with imagistic and clinical features suggestive of a gestational trophoblastic disease, successfully treated by hysterectomy, along with a small review of the literature, as only a few publications have reported a similar association of diagnostics and therapy.