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

Modified compression sutures for treatment of asymptomatic uterine arteriovenous malformation in a low-resource setting: A case report

INTRODUCTION AND IMPORTANCE

Uterine arteriovenous malformation (UAVM) can be present at birth or acquired later, often after trauma like cesarean delivery. It can cause severe vaginal bleeding but may have no symptoms. What makes our case special, other than being a rare condition, is the surgical technique used.

CASE PRESENTATION

A 24-year-old woman came in with abdominal pain at 38 weeks pregnant. She had a cesarean delivery 13 months before. She had an uncomplicated repeat cesarean but bled heavily after from uterine atony. A 5 × 7 cm asymptomatic uterine AVM was found incidentally in the right uterine horn. After the transfusion, B-Lynch sutures were used to treat the atony and AVM. The patient recovered well after the sutures. Follow-up ultrasound showed the AVM got much smaller and no more bleeding.

CLINICAL DISCUSSION

While conventional approaches advocate hysterectomy or uterine artery embolization (UAE), our case, situated in a low-income setting, necessitated innovative strategies. With embolization unavailable, and surgery carrying inherent risks, the B-lynch Procedure emerged as a pragmatic choice.

CONCLUSION

Uterine AVM with no symptoms can happen after cesarean delivery. In low-resource settings, modified compression sutures can effectively treat heavy bleeding after delivery and shrink AVM size, avoiding hysterectomy.

Abnormal uterine bleeding due to uterine arteriovenous malformation in an early adolescent with intrauterine contraceptive device in situ

We report a case of uterine arteriovenous malformation in an early adolescent who presented with heavy vaginal bleeding 2 months after termination of pregnancy with copper intrauterine contraceptive device (IUCD) insertion. The patient was admitted and had medical treatment, including blood transfusion and subsequently transcatheter embolisation of the arteriovenous malformation to control her bleeding. The IUCD was left in situ. Her symptoms completely resolved by 4 months post-procedure.

Acquired uterine arteriovenous malformation-Does it really exist? A case report

Acquired arteriovenous malformations (AVM) of the uterus can cause life-threatening vaginal bleeding and are associated with previous pregnancy, abortion or pelvic trauma. The pathophysiology is not well understood and the diagnosis is usually made by greyscale ultrasound often with nonspecific imaging findings, hence making it difficult to establish a correct diagnosis and therefore also the true incidence. However, case reports have previously described a connection between AVM formation and placental invasive disorders. In this report we demonstrate a case of a woman diagnosed with an AVM by ultrasound, presenting with menorrhagia after a termination of pregnancy, resulting in an emergency hysterectomy where subsequently a vascular malformation was found in conjunction with a remnant of a placenta increta and a placental site nodule. We hence suggest the hypothesis that these conditions are part of the same pathological process in the spectrum of abnormal invasive placental disorders, and that in the setting of previous trophoblastic processes, vascular malformations may mimic AVMs and ought not in fact to be considered as true AVMs.

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 Vascular Anomalies: Management and Treatment Overview

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.

Acquired uterine arteriovenous malformation treated with superselective embolization: Case report

Acquired uterine arteriovenous malformation is a rare condition, sometimes provoking abnormal life-threatening uterine hemorrhage. Here, we present the case of a 30-year-old healthy woman who developed heavy vaginal bleeding after dilatation and suctioning of the placenta 1 month after the delivery of a nonviable fetus. An ultrasound was performed which showed the appearance of a large exacerbation of a vessel with positive fetal sounds, normal cardiac movement, and normal morphological analysis. The patient was successfully treated with unilateral superselective embolization, distal to the ovarian supply, maintaining normal supply to the uterus and ovaries restoring normal menstruation, and showed complete resolution of the arteriovenous malformation.

A successful bilateral iliac arteries ligation as an emergency management to a life-threatening AVM bleeding: A case report and literature review

INTRODUCTION AND IMPORTANCE

Uterine arteriovenous malformation (AVM) is a defect due to direct connection between uterine arteries and veins, it has wide range of symptoms and severity, usually causes vaginal bleeding which may be mild or severe and may cause death in some rare cases. Diagnostic methods may include ultrasound, MRI, CT and/or angiography which reveal a high blood flow hypoechoic mass. Many options have been applied as management procedures, including invasive and noninvasive procedures, aiming to save patient life and stop bleeding or preserve fertility in the less severe cases.

CASE PRESENTATION

21 years old primigravida patient developed episodes of severe vaginal bleeding due to AVM after complete molar pregnancy evacuation and chemotherapy, managed successfully by bilateral internal iliac artery ligation and applying compression sutures on the uterus and continuing with compound medical treatment, trying to preserve fertility and ability to get pregnant in the future.

CLINICAL DISCUSSION

We point out AVM types, its sings, symptoms and the diagnostic procedures. We discuss the bilateral iliac artery ligation and applying modified compression sutures on uterus as possible emergency managements to AVM when there is a threatening on life due to huge bleeding. We also mentioned the other surgical and medical treatments.

CONCLUSION

We confirm the importance of keeping AVM in mind as a possible diagnose when there is unknown cause vaginal bleeding. Consider doing bilateral iliac artery ligation and applying the modified compression sutures as emergency procedures to stop or reduce AVM bleeding.

Evidences in Uterine Artery Embolization: A Radiologist's Primer

Uterine artery embolization is an established minimally invasive therapy for symptomatic fibroids. It has also been used for other diseases of the uterus, including adenomyosis, uterine arteriovenous malformation, ectopic pregnancy, abnormal invasive placenta, and postpartum hemorrhage. In this review, we provide an updated and comprehensive review of uterine artery embolization based on the evidence published. We review the indications, the role of MRI, technical aspects, and complications of the procedure. The issues with a future pregnancy, risk of infertility, and fetal radiation are discussed as well.

Uterine Artery Embolization of Uterine Arteriovenous Malformation: A Systematic Review of Success Rate, Complications, and Posterior Pregnancy Outcomes

Uterine Arteriovenous Malformation (UAVM) is a rare but life-threating cause of uterine bleeding. The clinical management of this condition is challenging, and there is a need to describe the most adequate approach for these patients. Uterine artery embolization (UAE) is the most widely-published treatment in the literature in recent years, although there is a need to update the evidence on this treatment and to compare it with other available therapies. Thus, the objective of this systematic review is to quantify the efficacy of UAE of UAVM. In addition, we evaluated the clinical context of the patients included, the treatment complications, and the pregnancy outcomes after UAE. With this goal in mind, we finally included 371 patients spread over all continents who were included in 95 studies. Our results show that, similar to other medical therapies, the global success rate after embolization treatment was 88.4%, presenting a low risk of adverse outcomes (1.8%), even in women with later pregnancy (77% had no complications). To date, this is the largest systematic review conducted in this field, although there are still some points to address in future studies. The results obtained in our study should be outlined in UAE protocols and guidelines to aid in clinical decision-making in patients with UAVM.

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.

Severe hemorrhage due to acquired uterine arteriovenous malformation/fistula following first-trimester aspiration abortion: A case report

Uterine arteriovenous malformation/arteriovenous fistula is a rare, but potentially life-threatening, cause of severe hemorrhage. A case of uterine arteriovenous malformation/fistula causing severe hemorrhage following a first-trimester aspiration abortion procedure in a patient with a history of prior cesarean sections is presented. In this case, the patient was promptly diagnosed and effectively treated with uterine artery embolization. Consideration of uterine arteriovenous malformation/fistula in the differential diagnosis of severe hemorrhage following first-trimester aspiration abortion, especially in women with risk factors, can lead to timely recognition and appropriate treatment.

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Uterine arteriovenous malformation/arteriovenous fistula is a vascular anomaly that can cause life-threatening hemorrhage.

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Acquired uterine arteriovenous malformation/arteriovenous fistula is a rare cause of hemorrhage following aspiration abortion.

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The diagnosis should be considered when hemorrhage fails to resolve with additional suction curettage and uterotonic administration.

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Uterine artery embolization is the treatment of choice for hemodynamically stable patients who want to preserve fertility.

Arteriovenous Malformation of the Uterus in a 41-Year-Old Woman Presenting as Uterine Bleeding

An arteriovenous malformation (AVM) is a vascular lesion most frequently encountered in the brain, lungs, colon, and soft tissues of the extremities. However, rarely, an AVM may develop in the uterus, where it can cause abnormal and even life-threatening uterine bleeding. Here, we present the case of a 41-year-old G6P6 woman with abnormal uterine bleeding which resulted in a hemoglobin level of 10.2 g/dL. On gross examination, the uterus was enlarged measuring 17.5 cm x 12.0 cm x 10.0 cm, with a pronounced globoid appearance and bogginess on palpation. The cut surface was hemorrhagic and notable for numerous tortuous dilated spaces of variable sizes. These hemorrhagic, cavernous spaces were grossly apparent throughout the entire myometrium, but were found to be most prominent in the lower uterine segment of the anterior wall. Microscopic examination revealed an admixture of malformed vasculature comprising arteries, venules, and capillaries. The vessels showed prominent dilation and tortuosity with abrupt variation in the thickness of the media and elastic lamina, as highlighted by Von Gieson stain. Unlike in many other organ systems where AVMs are often considered congenital lesions, uterine AVMs are more often acquired lesions that develop following iatrogenic uterine trauma, namely cesarean section or curettage. Upon review of our patient’s history, her final delivery was via cesarean section, after which she developed abnormal uterine bleeding. We present this case as a reminder to consider uterine AVM in cases of abnormal uterine bleeding, as it may be easily overlooked by even the most experienced pathologist.

[Uterine vascular abnormalities]

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

Postpartum hemorrhage - what the interventional radiologist should know

Postpartum hemorrhage is a leading cause of maternal morbidity and mortality around the world and can be caused by multiple etiologies. Distinguishing between the various etiologies that lead to PPH and identifying high risk features are crucial to implementing effective clinical management. In this review, the diagnostic imaging features and management principles of some of the most important causes of postpartum hemorrhage are discussed, with an emphasis on the pearls and pitfalls when minimally invasive treatment via interventional radiologic techniques are employed.

Heavy uterine bleeding in adolescent caused by uterine vascular lesion: A case report

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.

A case of a large leiomyomatous uterus with multiple arteriovenous malformations and subsequent high cardiac output state with severe four chamber cardiac enlargement

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Uterine arteriovenous malformations (AVMs) may be associated with leiomyomas.

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Uterine AVMs can lead to a high cardiac output state and cardiac dysfunction.

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Multidisciplinary management of uterine AVMs may prevent high output cardiac failure.

Uterine arteriovenous malformations (AVMs) are rare and potentially life-threatening. They can be congenital or acquired. Uterine artery embolization or hysterectomy are considered mainstays of management. AVMs can be associated with leiomyomas, and patients may require both procedures. We present a case of a 42-year-old woman with a massively enlarged leiomyomatous uterus supplied and drained by multiple large AVMs, leading to high cardiac output state with severe four chamber cardiac dilation. Management required a multidisciplinary team of interventional radiology, gynecologic oncology surgery, vascular surgery, cardiac anesthesiology, cardiology, and urology and a 2-day interventional approach of preoperative arterial embolization followed by hysterectomy.

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

Arteriovenous malformations (AVM) are abnormal connections between arteries and veins without a capillary bed, creating high- and low-flow areas that are prone to bleeding. Uterine AVMs can be congenital or acquired with an incidence of 0.1%. Acquired cases are usually caused by uterine instrumentation, trauma, infection, or gestational trophoblastic disease. Patients typically present with sudden onset of heavy vaginal bleeding. Diagnosis is made using angiography, ultrasound, computerized tomography, or magnetic resonance imaging. After patients are stabilized, management depends on their desire for future fertility and may include hysterectomy or endovascular embolization.

We present the case of a 16-year-old G1P0010 female with recurrent vaginal bleeding caused by a uterine AVM. To preserve the patient’s fertility, a selective embolization approach was employed using microcoils and gel foam. This case highlights a unique treatment option for uterine AVMs in patients who desire fertility preservation. Additionally, we review the diagnostic imaging and treatment options for uterine AVMs.

Successful transvenous embbolization for type II uterine arteriovenous malformation: A case report

A 40-year-old female (gravida 3 para 1) presented with menstrual, urinary, and anal pain. Computed tomography revealed type II acquired uterine arteriovenous malformation, a common dilated venous sac with bilateral uterine arteries, and multiple branches of iliac arteries draining to the bilateral ovarian veins. Venous sac transvenous embolization via the left ovarian vein of dominant outflow was planned, since complete arteriovenous malformation occlusion was difficult with super-selective transarterial embolization of multiple feeders. Therefore, transarterial embolization of the minor feeder was performed before completing transvenous embolization using coils and 50% glue under left iliac artery flow control. Immediately thereafter, angiography confirmed the complete disappearance of the uterine arteriovenous malformation, and all pain symptoms remitted. In conclusion, transvenous embolization combined with adjunctive transarterial embolization can be an effective and radical treatment for type II uterine arteriovenous malformations.

Uterine Arteriovenous Malformation: A Pictorial Review of Diagnosis and Management

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

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.

Incidental Ovarian and Uterine Findings on Cross-sectional Imaging

Incidental adnexal masses and uterine findings occur with a high frequency on cross-sectional imaging examinations, particularly in postmenopausal women in whom imaging is performed for a different reason. These incidentalomas encompass a gamut of potential pelvic gynecologic disorders. Most are benign ovarian cysts; however, other less commonly encountered disorders and improperly positioned gynecologic devices may be seen. A knowledge of the management recommendations for such pelvic incidental findings is critical to avoid unnecessary imaging and surgical interventions, as well as to avoid failure in diagnosis and management of some of these conditions.

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

Uterine arteriovenous malformation (AVM) is a very rare gynaecological condition, which can potentially lead to life-threatening abnormal uterine bleeding. In most cases uterine AVM is associated with prior pregnancy or pelvic surgery. We present the case of young woman seven weeks after medical termination of pregnancy diagnosed with heavy uterine bleeding due to uterine AVM, which was successfully treated with selective embolisation of uterine arteries.

Emergent postpartum pelvic sonography

This article describes the variable appearance of the normal postpartum uterus and reviews complications which can occur in the postpartum period, with particular emphasis on the sonographic findings. Postpartum complications are a common presentation to the emergency department. The majority of these patients present with secondary postpartum hemorrhage. Additional symptoms of pain or clinical findings of pyrexia and leukocytosis confound the clinical scenario and necessitate further evaluation with imaging. Ultrasonography is the mainstay in the initial imaging evaluation of the postpartum patient, with occasional progression to CT, MR, or angiography. We sought to provide a brief review of the literature, with pictorial review of key imaging findings, with a focus on ultrasonography. We provide a pictorial and brief literature review, with case examples from our institution, of key postpartum complications. Ultrasonography is an important component of evaluation in postpartum patients, particularly those with hemorrhage or other complication.

Successful transcatheter arterial embolization for massive hemorrhage from acquired uterine arteriovenous malformation which occurred as a complication of hysterectomy: A case report

RATIONALE

Uterine arteriovenous malformation (UVM), which can be congenital or acquired, is a relatively rare disorder that can cause life-threatening hemorrhage. Acquired UVM occurs predominantly after previous uterine procedures; rarely, it may occur after a hysterectomy. Although the best treatment option for UVM remains controversial, transcatheter arterial embolization (TAE) has recently been introduced as a safe and effective treatment.

PATIENT CONCERNS

A 34-year-old woman who underwent hysterectomy for uncontrolled postpartum bleeding continued to have hemoperitoneum.

DIAGNOSIS

Two days after surgery, massive hemoperitoneum was identified on computed tomography scan, and acquired UVM was diagnosed by angiography.

INTERVENTIONS

The patient was successfully treated using TAE with an n-Butyl cyanoacrylate.

OUTCOMES

After embolization, hemodynamic stability was achieved. A day after embolization, hemoglobin was 10.2 g/dL, and the patient was discharged from the hospital 4 days thereafter.

LESSONS

Although the overall incidence of acquired UVM after hysterectomy is low, bleeding from acquired UVM should be considered as one of the differential diagnoses in the immediate postpartum period, especially when the clinical symptoms do not correlate with the amount of blood loss. A high index of suspicion, prompt diagnosis and intervention, and a multidisciplinary approach in the management were the elements of a successful outcome in this case.

[Stage wise treatment of uterine arteriovenous malformation complicated by recurrent haemorrhage]

Uterine arteriovenous malformation is a rarely encountered disease threatening with massive haemorrhage. The article describes a clinical case report regarding a 37-year-old woman presenting with this pathology and previously hospitalized twice with severe posthaemorrhagic complications at a 5-month interval due to refusal from timely hysterectomy. A vascular formation in the womb was detected at ultrasonography, however its pattern was identified only by computed tomography of small pelvis organs with intravenous contrasting. However, the complete picture of the architectonics of uterine arteriovenous malformation and extension of the pathology was obtained by selective subtraction angiography, making it possible not only to perform diagnosis but also, if necessary, to immediately perform selective embolization of the supplying vessels. Due to massive uterine bleeding on the background of womb malformation, the woman was twice subjected to roentgenoendovascular embolization of afferent vessels, with the achievement of persistent haemostasis. Hysterectomy was performed after stabilization of the state. Thus, an extensive angiomatous uterine lesion accompanied by recurrent bleedings, along with roentgenoendovascular methods of treatment there is a need of additional surgical resection with the removal of the angiodysplasia focus.

Angiographic findings and outcomes after embolization of patients with suspected postabortion uterine arteriovenous fistula

INTRODUCTION

The purpose of this study is to assess the angiographic incidence of uterine arteriovenous fistula (UAVF) in women referred for a high ultrasonographic suspicion in a postabortion setting and to evaluate the safety, efficacy and impact on further fertility of uterine artery embolization (UAE) in this indication.

MATERIALS AND METHODS

A monocentric retrospective study of 31patients managed by uterine artery embolization for suspected UAVF after spontaneous or induced first trimester abortion. The diagnosis of UAVF was confirmed when an early venous drainage was identified on the angiogram. Technical success was defined as complete exclusion of the vascular lesion. Clinical success was defined as the absence of bleeding during the clinical follow-up and during the surgery in case of hysteroscopic resection. Information about further fertility was gathered by phone calls to the patients.

RESULTS

The mean age of the patients was 30.8 (±6.0) years. The diagnosis of UAVF was angiographically confirmed in 6 patients (19.4 %). Angiographic findings of retained product of conception (RPOC) with varying degrees of vascularity were observed in remaining patients. The technical success rate of UAE was 100 %, mostly through a proximal and bilateral embolization using a resorbable agent (27/31 patients, 87.1 %). The clinical success rate of UAE was 100 % in the group treated by a single UAE. We did not notice any bleeding during the surgery in the group of patients who needed a further hysteroscopic resection. 14 patients led at least one subsequent pregnancy to term without any difficulty.

CONCLUSION

UAVF is a rare condition. We supposed it may constitute the ultimate stage in the natural history of the retained products of conception with "marked vascularity". UAE seems to be an effective and safe first-line treatment.

Uterine arteriovenous malformation leading to postpartum hemorrhage: A case report

Uterine arteriovenous malformation (AVM) is an uncommon but potentially life-threatening cause of postpartum hemorrhage (PPH). AVMs often present with intermittent or profuse vaginal bleeding in a woman with a history of uterine instrumentation. Transvaginal ultrasound is the initial imaging method used for diagnosis. Management depends on the patient's hemodynamic stability and desire for future pregnancy. Uterine artery embolization (UAE) is the initial treatment option for women of reproductive age. Due to limited evidence, there are no guidelines for the management of failed UAE. Here we report a case of uterine AVM following a cesarean section that failed initial management with UAE and required emergency hysterectomy.

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Uterine arteriovenous malformation (AVM) is a rare cause of postpartum hemorrhage.

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Acquired uterine arteriovenous malformations are associated with a history of surgical instrumentation of the uterus.

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Transvaginal ultrasound is the initial imaging method used for diagnosis.

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Uterine artery embolization is the first-line treatment for uterine arteriovenous malformations.

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Hysterectomy is a definitive treatment for uterine arteriovenous malformations refractory to embolization.

Uterine arteriovenous malformation mimicking retained products Of conception - treated with embolization

Uterine arteriovenous malformations are uncommon but pose the risk of potentially life-threatening hemorrhage. A 29-year-old pregnant female presented with vaginal spotting, after which ultrasound diagnosis of missed miscarriage was made and medical management undertaken. Vaginal spotting continued post-treatment which led to repeat pelvic ultrasound and subsequent magnetic resonance imaging which confirmed a uterine arteriovenous malformation masquerading as retained products of conception. Uterine instrumentation with dilatation and curettage could have been potentially devastating. The patient was successfully treated with uterine artery embolization.

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.

Rare occurrence of uterine arteriovenous malformation clinically mimicking a malignant growth: A critical reminder for pathologists

Arteriovenous malformation (AVM) is a rare lesion in the uterus, which can lead to abnormal uterine bleeding. While AVM has been described in other organs in the literature, there is a paucity of pathology reports of the AVM in uterus. On gross examination, the uterus was markedly enlarged and partly distorted with a pedunculated solid mass, which on the cut surface showed multiple well-circumscribed hemorrhagic cysts ranging from 0.1 to 4.0 cm in size. Microscopically, they were malformed dilated vascular structures containing organized thrombi. We present this case of uterine AVM with gross and microscopic findings, which can serve as a crucial reminder for pathologists to keep in the differential diagnoses as a potential cause of abnormal uterine bleeding.

Systematic retrospective analysis of 13 cases of uterine arteriovenous fistula: Pathogeny, diagnosis, treatment and follow-up

AIM

To analyze the causes, clinical manifestations, diagnosis and treatment of uterine arteriovenous fistula (UAVF).

METHODS

We retrospectively analyzed 13 patients with UAVF admitted to our hospital from October 2016 to April 2019.

RESULTS

All patients had a history of intrauterine surgery (curettage for abortion, artificial removal of placenta, hysteroscopy, diagnostic curettage and intrauterine device removal). The main clinical manifestation of UAVF is paroxysmal massive vaginal bleeding; this involved a massive gush of vaginal blood that stopped suddenly. Sonographic images with typical features of UAVF were observed for 12 patients. Pelvic contrast-enhanced magnetic resonance imaging was performed as a noninvasive adjuvant examination method for diagnosis. Twelve patients underwent uterine arteriography and a diagnosis of UAVF was confirmed. Then, bilateral uterine artery embolization (UAE) was performed. One patient underwent laparoscopic hysterectomy directly instead of uterine arteriography because of unstable vital signs and one patient underwent laparoscopic hysterectomy 25 weeks after the second UAE. The median time until menstrual recovery was 33 days (range, 20-70 days) after UAE. The median time until normal ultrasound examination results was 10 weeks (range, 2-35 weeks).

CONCLUSION

Acquired UAVF was associated with a history of previous intrauterine surgery. The ultrasound examination and pelvic contrast-enhanced MRI were noninvasive adjuvant examination method to effectively assist in diagnosis. Uterine arteriography is considered the gold standard for the diagnosis of UAVF, and UAE is considered an effective intervention for treating UAVF and maintaining reproductive function with less damage. Hysterectomy is an appropriate option when conservative measures have failed to prevent a life-threatening hemorrhage.

Biomarkers in abnormal uterine bleeding†

Abnormal uterine bleeding (AUB) is an extremely common problem and represents a clinical area of unmet need. It has clinical implications and a high cost for the healthcare system. The PALM-COEIN acronym proposed by FIGO may be used as a foundation of care; it improves the understanding of the causes of AUB, and in doing so facilitates effective history taking, examination, investigations, and management. Heavy menstrual bleeding, a subset of AUB, is a subjective diagnosis and should be managed in the context of improving the woman's quality of life. Available evidence suggests that there is poor satisfaction with standard treatment options often resulting in women opting for major surgery such as hysterectomy. Such women would benefit from a tailored approach, both for diagnosis and treatment, highlighting the deficiency of biomarkers in this area. This article focuses on the causes of AUB as per the PALM-COEIN acronym, the researched biomarkers in this area, and the potential pathogenetic mechanisms. In the future, these approaches may improve our understanding of AUB, thereby enabling us to direct women to most suitable current treatments and tailor investigative and treatment strategies to ensure best outcomes, in keeping with the principles of personalized or precision medicine.

Arteriovenous uterine malformation developed from an interstitial pregnancy on residual tubal stump: A critical managment in a fertile woman

Uterine arteriovenous malformations are rare conditions with diverse clinical presentation that range from asymptomatic patients to different degrees of menorrhagia, commonly associated with previous pregnancy or uterine trauma. This case report describes a 36-year-old woman who presented with ultrasound diagnosis of interstitial pregnancy on residual right tube stump 4 months after a laparoscopic salpingectomy for extrauterine pregnancy. She started treatment with methotrexate; afterwards serum human chorionic gonadotropin levels and ultrasound follow-ups were scheduled. While serum human chorionic gonadotropin levels were progressively reducing, transvaginal ultrasound follow-ups showed a persistent anechoic mass on right rube stump, with increased peripheral high flow vascularity: highly suspicious for a uterine arteriovenous malformation. A laparoscopy was performed with a tumorectomy of the mass. The histopathological exam of the specimen confirmed uterine arteriovenous malformation. Patient successfully became pregnant 2 years later, with an eventless pregnancy and a vaginal delivery without complications.

Precipitating hydrophobic injectable liquid (PHIL) embolic for the treatment of a uterine arteriovenous malformation: a technical report

OBJECTIVE

Uterine arteriovenous malformations (AVM) are unusual causes of vaginal bleeding. Although hysterectomy is the definitive treatment; uterine artery embolization (UAE) provides an alternative therapeutic option. This case presents a technical report of a uterine AVM treated successfully with transcatheter UAE using precipitating hydrophobic injectable liquid (PHIL) embolic agent.

CASE REPORT

A 41-year-old female, gravida 6, para 4, miscarriage 2, including a molar pregnancy 15 years prior, presented with massive per vaginal bleeding. Pelvic ultrasound demonstrated an acquired AVM as the underlying aetiology for her presentation. 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 8 weeks after the procedure.

CONCLUSION

Uterine AVM can be treated safely and effectively with UAE using PHIL.

Ultrasound-guided high-intensity focused ultrasound ablation for treating uterine arteriovenous malformation

OBJECTIVE

To explore HIFU treatment for uterine arteriovenous malformation.

DESIGN

A case report.

SETTING

Gynaecological department in a university teaching hospital of China.

POPULATION

A patient with uterine arteriovenous malformation.

METHODS

The diagnosis of uterine arteriovenous malformation was made through MRI. Ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation was performed.

MAIN OUTCOMES MEASURES

HIFU is effective in treating uterine arteriovenous malformation.

RESULTS

The patient had reduction of the lesion volume and obvious symptom relief, without significant adverse effects.

CONCLUSIONS

HIFU can be used as a new treatment option for uterine arteriovenous malformation.

TWEETABLE ABSTRACT

Ultrasound-guided high-intensity focused ultrasound ablation is effective in treating uterine arteriovenous malformation.

Trans-arterial embolization of acquired uterine arteriovenous malformation after Cesarean section: A case series

Background

Acquired uterine arteriovenous malformation (AVM) is a rare condition due to traumatic episodes in cesarean section. The patient can suffer from life-threatening hemorrhage or recurrent vaginal bleeding. Establishing this diagnosis is difficult, often misdiagnosed due to lack of information and number of cases. Trans-Arterial Embolization (TAE) procedure is rarely performed in our center. All of the cases were found with history of massive bleeding and diagnosed lately after recurrent bleeding history. Even though promising, one of our cases failed to be managed with TAE. It is important to diagnose early symptoms of AVM in order to prevent the life threatening event.

Case presentation

In these case series, four cases of AVMs after cesarean procedures will be reviewed. One could be diagnosed in less than a month but the other three took several months. The symptom of vaginal bleeding might occur a few weeks after the procedure is done, and most patients need transfusion and hospitalization. Three out of four patients were initially sent to the hospital in order to recover from shock condition, and one patient was sent for a diagnostic procedure. AVMs diagnostic was established with ultrasound with or without angiography. Three of our cases were succeeded by performing TAE procedure without further severe vaginal bleeding. One case failed to be treated with embolization and had to proceed with hysterectomy.

Conclusion

AVM should be considered early-on in patient with abnormal uterine bleeding and history of cesarean section. Embolization is still the first-choice treatment of AVMs, otherwise definitive treatment is hysterectomy in a patient without fertility need, or impossible to perform TAE.

Transcatheter embolization with Squid, combined with other embolic agents or alone, in different abdominal diseases: a single-center experience in 30 patients

Background

Squid, as Onyx, is an ethylene-vinyl alcohol copolymer (EVOH)-based liquid embolic agent developed for neuroradiologic interventions with poor application in abdominal district. Our aim was to evaluate safety, complications, and efficacy of transcatheter embolization using the two available formulations Squid-18 and 12, in 30 patients affected by different abdominal diseases.

Results

Transcatheter embolization with Squid, combined with other embolic agents, as poly vinyl alcohol (PVA) particles, coils and amplatzer plugs, or alone (type 2 endoleak), was performed in 30 patients, as follows: 10 portal vein embolizations (PVEs), 6 arteriovenous malformations (AVMs), 5 visceral artery aneurysms (VAAs), 4 type 2 endoleaks, 3 preoperative embolizations, 1 acute arterial bleeding, 1 female varicocele. Squid was always administered using dimethyl sulfoxide (DMSO) compatible microcatheters. Technical success, 30-day clinical success and complications were assessed.

Technical success was 90%. 3 patients (2 AVMs, 1 VAA) required re-intervention successfully performed in all cases. Major complications, cases of microcatheter entrapment and DMSO-related poor pain control were not recorded. 30-day clinical success was 93.3%: in 2 patients submitted to PVE a sufficient future liver remnant (FLR) hypertrophy was not achieved.

Conclusion

Squid was successfully used with low complication rate in many abdominal diseases showing a valid embolic action either combined with other embolic agents or alone in type 2 endoleak. The availability of different formulations (Squid-18 and Squid-12) variable for viscosity makes Squid preferable to Onyx as EVOH-based liquid embolic agent, even though comparable studies in different abdominal districts with a larger cohort of patients will be necessary.

The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions

BACKGROUND

The International Federation of Gynecology and Obstetrics (FIGO) systems for nomenclature of symptoms of normal and abnormal uterine bleeding (AUB) in the reproductive years (FIGO AUB System 1) and for classification of causes of AUB (FIGO AUB System 2; PALM-COEIN) were first published together in 2011. The purpose was to harmonize the definitions of normal and abnormal bleeding symptoms and to classify and subclassify underlying potential causes of AUB in the reproductive years to facilitate research, education, and clinical care. The systems were designed to be flexible and to be periodically reviewed and modified as appropriate.

OBJECTIVES

To review, clarify, and, where appropriate, revise the previously published systems.

METHODOLOGY AND OUTCOME

To a large extent, the process has been an iterative one involving the FIGO Menstrual Disorders Committee, as well as a number of invited contributions from epidemiologists, gynecologists, and other experts in the field from around the world between 2012 and 2017. Face-to-face meetings have been held in Rome, Vancouver, and Singapore, and have been augmented by a number of teleconferences and other communications designed to evaluate various aspects of the systems. Where substantial change was considered, anonymous voting, in some instances using a modified RAND Delphi technique, was utilized.

Spontaneous Resolution of an Acquired Uterine Arteriovenous Malformation in an Elderly Primigravida

BACKGROUND Uterine arteriovenous malformation (AVM) is an uncommon lesion characterized by an abnormal connection between arterial and venous circulation that can be congenital or acquired. Acquired uterine AVMs are generally traumatic and follow delivery, abortion, curettage, or uterine surgery. CASE REPORT A 45-year-old female who was gravida 1 para 0 presented to our hospital with severe vaginal bleeding. Two weeks before, the patient underwent therapeutic abortion. At admission, a transvaginal ultrasound showed an unclear intrauterine lesion that spread out to the myometrium. Color Doppler evaluation demonstrated an elevated color score. Beta human chorionic gonadotropin (beta-hCG) levels were measured at admission and daily repeated, with a progressive decrease of values up to a negative level. A pelvic magnetic resonance imaging described an area of tubular and tortuous structures involving the myometrium. A computed tomography angiography confirmed the presence of a lesion infiltrating the endometrium and myometrium containing arteriovenous structures with a highly enhanced effect. Despite these findings, the patient was clinically stable. A diagnosis of uterine AVM was made and, after accurate counselling with the patient, she was discharged and underwent "watch and wait" management. After 35 days, the patient had a follow-up ultrasound that showed a complete resolution of the uterine lesion. CONCLUSIONS AVM should be considered in the presence of heavy and sudden vaginal bleeding in a patient with risk factors for acquired AVM. A color Doppler ultrasound scan should be performed as the first approach and an expectant management should be taken into account especially with a patient of childbearing age and hemodynamic instability.