Uterine Vascular Anomalies: Management and Treatment Overview

Enhanced Myometrial Vascularity, a Little-Known Complication of Pregnancy: Filling the Knowledge-Gap

In the last decades, clinicians reported that patients, after failed or terminated intrauterine or cesarean scar pregnancies, demonstrated increased vascularization of the adjacent uterine muscle layers by ultrasound (US). These "earned" the incorrect diagnosis: uterine arterio-venous malformation (AVM). This misnomer was used without etiologic scrutiny by clinicians and repeated in scientific articles and textbooks. Despite the articles written during the same 10-20 years which tried to encourage caretakers of patients to relinquish the term AVM and use the correct term of enhanced myometrial vascularity (EMV). There still is a degree of ignorance as well as a knowledge gap in the obstetrical and radiological community as to the etiology, pathophysiology, and management of the above clinical entity. This article contains previously published, relevant ultrasound-based data on the subject along with our clinical experience highlighted by examples. We aim to fill this gap by providing illustrative clinical cases of the tools we consider relevant to the clinical diagnosis and management of EMV. We emphasize, that in the majority of cases expectant approach, avoids complications resulting from misdiagnosis and unnecessary treatment as well as pointing out the diagnostic importance of determining the parameters in guiding their treatment.

Embolisation of an acquired uterine arteriovenous malformation

A G5P2+2 woman in her 30s presented to hospital with per vaginum (PV) bleeding, approximately 2 weeks post electric vacuum aspiration (EVA) for retained products of conception. Ultrasound and MRI demonstrated a large vascular myometrial lesion, suggestive of a uterine arteriovenous malformation (UAVM). She underwent digital subtraction angiography (DSA) with interventional radiology and simultaneous uterine artery embolisation (UAE). She represented 2 weeks later with recurrent PV bleeding and anaemia. She underwent repeat DSA, demonstrating persistent UAVM, and a repeat embolisation was performed. Symptoms resolved following the second embolisation, and a repeat MRI performed 12 weeks later demonstrated complete resolution of the UAVM.Although UAVMs are rare lesions, they can cause significant haemorrhage and morbidity. The presence of UAVM should particularly be considered after uterine intervention such as EVA or caesarean section.UAE is a safe and effective therapy, which preserves fertility.

Postabortal Bleeding: A Diagnostic Dilemma Resolved As Arteriovenous Malformation and Successfully Managed With Uterine Artery Embolization

Uterine arteriovenous malformations (AVM) are rare and may be missed in routine clinical practice, often concealing their existence until dire consequences emerge. This potentially lethal condition can manifest abruptly, with torrential postabortal bleeding, as a grim reminder of its risky nature. Here, we present a rare case of para 1, living 1, abortion 2, initially subjected to dilatation and evacuation due to a missed abortion at a peripheral healthcare facility, subsequently developing torrential bleeding despite all the conservative measures. So she was referred to our hospital in view of heavy vaginal bleeding following the earlier instrumentation; the differential diagnosis of molar pregnancy and AVM was made clinically. As per speculum examination, the presence of remnants of abortion was seen, and the possibility of an invasive mole was suspected. Ultrasonography with color Doppler showed uterine AVM, which was further confirmed by magnetic resonance imaging (MRI). In order to save her life while preserving the uterus, a multidisciplinary approach was involved in managing this patient, consisting of interventional radiologists to perform uterine artery embolization (UAE).