Successful pregnancy after the noninvasive management of uterine arteriovenous malformation

Medical treatment of uterine arteriovenous malformation: a systematic review and meta-analysis

OBJECTIVE

To quantify the efficacy of medical management of uterine arteriovenous malformation (AVM) and compare efficacy between different classes of medication. In addition, we evaluated for factors associated with treatment success and pregnancy outcomes after medical management.

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Thirty-two studies representing 121 premenopausal women with medically-treated uterine AVM were identified via database searches of MEDLINE, Embase, Web of Science, and cited references.

INTERVENTION(S)

Medical treatment with progestins, gonadotropin-releasing hormone agonists (GnRH-a), methotrexate, combined hormonal contraception , uterotonics, danazol, or combination of the above.

MAIN OUTCOME MEASURE(S)

Primary outcome of treatment success was defined as AVM resolution without subsequent procedural interventions. Secondary outcome was treatment complication (readmission or transfusion).

RESULT(S)

The overall success rate of medical management was 88% (106/121). After adjusting for clustering effects, success rates for progestin (82.5%; 95% confidence interval [CI], 70.1%-90.4%), GnRH-a (89.3%; 99% CI, 71.4%-96.5%) and methotrexate (90.0%; 99% CI, 55.8%-98.8%) were significantly different from the null hypothesis of 50% success. The agents with the lowest adjusted proportion of complications were progestins (10.0%; 99% CI, 3.3%-26.8%) and GnRH-a (10.7%; 99% CI, 3.5%-28.4%). No clinical factors were found to predict treatment success. Twenty-six subsequent pregnancies are described, with no reported recurrences of AVM.

CONCLUSION(S)

Medical management for uterine AVM is a reasonable approach in a well selected patient. These data should be interpreted in the context of significant publication bias.

Uterine Arteriovenous Malformations

Uterine arteriovenous malformations are rare but may represent a life-threatening cause of vaginal bleeding. The typical patient affected is a multiparous woman during her thirties. The origin can be congenital or acquired, with the latter being more common after uterine surgery and presenting mainly as arteriovenous fistulous connections into the myometrium supplied by uterine arteries. The correct diagnosis of uterine arteriovenous malformations requires imaging findings of tubular and tortuous structures with mixed signal from arterial and venous flows; transvaginal color-Doppler ultrasound is the initial technique applied, then integrated with contrast-enhanced magnetic resonance or computed tomography. Multiple treatment approaches are available, including conservative-medical, endovascular embolization and surgery. Transarterial embolization represents the most applied, preserving childbearing capacity with negligible procedural complications; clinical and technical success rates are elevated, up to 90%. The goal of embolization is to occlude the point of fistula or the nidus and the application of multiple embolizing agents has been reported: despite there is no clear superiority of one over the others, liquids, especially those related to the dymethil-sulfoxide family, present relevant technical advantages. Surgery is nowadays to be considered when the endovascular approach fails and in these cases hysterectomy remains the common recommendation.

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

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

Spontaneous Regression of Uterine Arteriovenous Malformations with Conservative Management

Uterine arteriovenous malformation (AVM) can cause massive hemorrhage and is often treated with uterine artery embolization (UAE), which may lead to ovarian insufficiency. Thus, avoiding UAE should be considered, particularly in women undergoing fertility treatments. We present three women diagnosed with postmiscarriage AVM on color Doppler by transvaginal ultrasound imaging. They had no genital bleeding and a small mass, measuring 16–22 mm. If estradiol was >300 pg/mL when AVM was diagnosed, then a gonadotropin-releasing hormone agonist was administered. All three women underwent follow-up observation, revealing spontaneous mass disappearance. To avoid ovarian insufficiency risk with UAE, conservative management and close follow-up observation should be considered in patients with AVM without bleeding, particularly during the fertility treatment.

Differential diagnosis and management of placental polyp and uterine arteriovenous malformation: Case reports and review of the literature

Postpartum uterine bleeding is not uncommon and is caused by a variety of obstetrical and gynecological disorders, such as retained placenta, dysfunctional bleeding, and endometrial polyps. Placental polyps and uterine arteriovenous malformation are disorders often encountered in cases of abnormal uterine bleeding in the late puerperal period. These patients may experience life-threatening bleeding and require prompt intervention based on the correct differential diagnosis. The optimal treatments for both diseases differ as follows: intrauterine curettage or transcervical resection are chosen for placental polyps, while total abdominal hysterectomy or uterine artery embolization is preferred for uterine arteriovenous malformation since intrauterine curettage or transcervical resection has the risk of massive bleeding. However, since placental polyp and uterine arteriovenous malformation have similar clinical characteristics, it is important to accurately identify and differentiate between them to ensure optimal therapy. We report here cases that were suggestive of placental polyp or uterine arteriovenous malformation. We discuss the differential diagnoses and treatments for both diseases based on a literature review and propose a novel algorithm for managing such patients.

Successful Treatment of Uterine Arteriovenous Malformation due to Uterine Trauma

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

Successful Transarterial Embolization of Uterine Arteriovenous Malformation: Report of Three Cases

Uterine arteriovenous malformations (AVMs) are relatively rare disorders that can cause life-threatening vaginal bleeding. We describe three childbearing-age females, who had abdominal pain and heavy vaginal bleeding, and were diagnosed as uterine AVM by color Doppler and angiography. The patients received successful superselective transarterial embolization (TAE) with N-butyl cyanoacrylate (NBCA). Three years after treatment, one of them was admitted to our hospital for vaginal delivery at 39 weeks of gestation, and the baby was healthy.

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.

[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.

Successful Treatment of Uterine Arteriovenous Malformation with Percutaneous Embolization

OBJECTIVE

Uterine arteriovenous malformation (AVM) is a rare condition and can be life-threatening if not managed properly. We report a case that was diagnosed by typical ultrasound imaging and treated successfully with uterine arterial embolization.

CASE REPORT

A 28-year-old female, gravida 4, para 3, abortus 1, presented with massive vaginal bleeding 19 days after a termination of pregnancy due to fetal anomaly. After a dilatation and curettage 3 years previously, typical ultrasound image findings and a declining pattern of serum beta-hCG (human chorionic gonadotrophin), acquired AVM was highly suspected. The patient underwent bilateral uterine arterial embolization. Four weeks later, there was nearly complete resolution of the AVM and the patient's menstrual cycle was restored 6 weeks after embolization.

CONCLUSION

AVM can be diagnosed at an early stage with the aid of history taking and ultrasound. Percutaneous embolotherapy is a safe and effective treatment for AVM, especially when fertility preservation is desired.

Pregnancy after embolization therapy for uterine arteriovenous malformation

OBJECTIVE

To describe childbearing prognosis following embolization therapy for uterine arteriovenous malformation (AVM).

DESIGN

Case report and review.

SETTING

University hospital.

PATIENT(S)

Thirteen patients, including our case, who underwent pregnancy after embolization therapy for arteriovenous malformation.

INTERVENTION(S)

Two successive embolization procedures.

MAIN OUTCOME MEASURE(S)

Childbearing prognosis following embolization therapy for uterine AVM.

RESULT(S)

Bilateral embolization was performed in seven patients. In four cases, including ours, two successive embolization procedures were required to treat the uterine AVM. The longest delay between embolization and pregnancy was 5 years and the shortest was six weeks. Two patients presented with postpartum hemorrhage which was treated medically. One neonate required resuscitation after delivery in the context of Listeria infection.

CONCLUSION(S)

Conservative management of uterine AVMs using embolization therapy is being increasingly developed. New embolization agents and hyperselective technical procedures aim at reducing morbidity related to such treatments and preserving reproductive capacity in women of childbearing age.

Successful term pregnancy after selective embolization of a large postmolar uterine arteriovenous malformation

Uterine arteriovenous malformations (AVM) are very uncommon disorders. Successful conservative treatment with subsequently conceived is rarely reported. We describe a 31-year-old woman with a complex and large postmolar AVM; she was successfully treated with transarterial selective embolization for a long history of repeated excessive vaginal bleeding and anemia. She resumed normal menstrual periods soon after treatment, and she subsequently conceived about 2 years later. A healthy male baby was delivered at 39 weeks of gestation via vaginal route. Selective embolization of a complex and large uterine AVM seems to be feasible for the treatment of uterine bleeding and preservation of reproductive capability.

Uterine arteriovenous malformations: a review of the current literature

Uterine arteriovenous malformation (AVM) is a rare but potentially life-threatening condition. AVMs often present with intractable bleeding and commonly are seen in association with pregnancy and uterine trauma. Ultrasound is the most common form of initial investigation, and computed tomography and magnetic resonance imaging are being used with greater frequency. Despite this, angiography remains the gold standard for diagnostic evaluation. Embolization has become a more acceptable form of treatment and allows more invasive forms of treatment, particularly hysterectomy, to be avoided. Numerous medical therapies have also been used in the management of patients with uterine AVM. Reports of successful pregnancies after diagnosis and treatment of a uterine AVM are still uncommon, but increasingly good outcomes are being reported after successful treatment of a confirmed uterine AVM.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to describe the many and varied clinical manifestations of a uterine arteriovenous malformation (AVM), summarize the best ways to manage an acute hemorrhage from an AVM, and identify the current best way to diagnose an AVM.

Uterine arteriovenous malformation

INTRODUCTION

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

CASE REPORT

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

Efficacy of Embolization in Traumatic Uterine Vascular Malformations

PURPOSE

To evaluate the efficacy of embolotherapy in patients with bleeding traumatic uterine arteriovenous malformations (AVMs).

MATERIALS AND METHODS

A retrospective review of all patients who underwent pelvic arterial embolization at our institution between July 1992 and September 2002 was performed. Fifteen patients were diagnosed with a uterine vascular malformation on duplex ultrasonography and correlative MR imaging. Serial beta-human chorionic gonadotropin levels were measured to exclude gestational trophoblastic neoplasia. All patients underwent transcatheter embolization of the uterine arteries. Embolizations were performed with use of standard 4-5-F catheters and microcatheters when necessary. Embolic agents in the 25 procedures included glue only (n = 13), polyvinyl alcohol (PVA) particles and glue (n = 4), PVA particles (n = 2), Gelfoam (n = 2), coils (n = 1), PVA particles and coils (n = 1), glue and Gelfoam (n = 1), and glue and coils (n = 1). PVA particle size ranged from 350 to 1,000 micro m. Outcomes assessed were cessation of bleeding, persistence or resolution of the AVM, complications, and pregnancy after embolization. These were assessed by chart, laboratory, and imaging reviews.

RESULTS

A total of 25 embolization procedures were performed in 15 patients. Six patients required repeat embolization (one patient underwent embolization on six occasions; five patients had two embolization procedures each) for recurrence of bleeding. Sixteen procedures were performed on an elective basis and nine were performed on an emergent basis. The technical success rate of embolization was 100%. The clinical success rate was 93%: bleeding was controlled in 14 of 15 patients and one patient underwent a hysterectomy. Four of the 15 patients subsequently had a total of five uneventful intrauterine pregnancies carried to term. The 14 patients who underwent successful embolization had no recurrence of bleeding at a median follow-up of 53 months (range, 3-124 months) after treatment. Three patients were eventually lost to follow-up. One minor complication (0.4%) of non-flow-limiting dissection of the internal iliac artery occurred.

CONCLUSION

Percutaneous embolotherapy is a safe and effective treatment for traumatic AVMs. This procedure allows for preservation of uterine function with the possibility of future pregnancy and should be considered as a primary treatment option.