Successful pregnancy after selective embolization of a post-molar vascular malformation

Near-fatal uterine hemorrhage during induction chemotherapy for acute myeloid leukemia: a case report of bilateral uterine artery embolization

Severe transfusion-dependent uterine hemorrhage is a relatively uncommon complication of induction chemotherapy for acute myeloid leukemia (AML). Even less common is the failure of systemic conjugated estrogens in this setting. We report a case of life-threatening uterine hemorrhage in a 38-year-old woman in the setting of transfusion-refractory thrombocytopenia after completing induction chemotherapy for AML. She experienced dramatic breakthrough uterine hemorrhage despite multiple platelet transfusions, conjugated estrogens, recombinant factor VIIa, epsilon-aminocaproic acid, and intracavitary thrombin-soaked gauze tamponade. At the point of near-exsanguination in the setting of hypotension, hematocrit of 14%, and a platelet count of 3,000/microL, she underwent bilateral uterine artery embolization which proved immediately successful. We review the literature and indications for this procedure in the oncologic patient care setting.

Color Doppler imaging is a valuable tool for the diagnosis and management of uterine vascular malformations

OBJECTIVE

The aim of this study was to assess the spontaneous outcome of uterine vascular malformations detected with ultrasonography and color Doppler, and to investigate the predictive value of color Doppler imaging as to which patients require invasive treatment.

METHODS

This was a prospective observational study conducted between January 1999 and February 2001 comprising all consecutive patients diagnosed with a uterine vascular malformation by ultrasonography and color Doppler imaging. Spectral analysis included measurement of flow velocities, pulsatility index (PI) and resistance index (RI). Close follow-up was arranged in all cases and the outcomes were recorded.

RESULTS

A total of 30 consecutive patients with uterine vascular malformations were included in the study. Spectral analysis of the vessels in the vascular malformations within the myometrium and endometrium revealed the presence of a low-impedance and high-velocity flow. The average values for PI, RI, peak systolic velocity (PSV) and time-averaged maximum velocity (TAMXV) were 0.50, 0.38, 0.63 m/s and 0.46 m/s, respectively. Eight patients (27%) eventually required embolization of the uterine arteries and three of them had true arteriovenous malformations confirmed at angiography. PSV values of >/= 0.83 m/s were associated with higher probabilities of further treatment, such as an embolization, whereas no vascular malformation with a PSV value < 0.39 m/s required embolization.

CONCLUSION

Conservative management is possible in more than two-thirds of patients presenting with uterine vascular malformations diagnosed by color Doppler sonography. Despite considerable overlap, PSV values appear to be useful in distinguishing between low- and high-risk patients.

Color Doppler and gray-scale ultrasound evaluation of the postpartum uterus

OBJECTIVES

To evaluate the color Doppler and gray-scale sonographic appearance of the uterus after pregnancy, with special attention to the occurrence of areas of enhanced vascularity and placental remnants.

PATIENTS AND METHODS

Cross-sectional observational study involving 385 consecutive women presenting at their first visit after pregnancy. The uterus was evaluated using ultrasound with color Doppler. In the presence of placental remnants, blood was sampled for measurement of beta human chorionic gonadotropin (beta hCG), hemoglobin (Hb) and infectious parameters. If indicated, a dilatation and curettage was performed.

RESULTS

In 8.3% of women, areas of enhanced vascularity were detected with color Doppler examination. Most cases (68.9%) were focal areas of one or more vessels. In 2.6% of patients abnormal vascularity extended over a large area of the whole myometrium. In 6.75% of cases, placental remnants were detected. In 46% of these, blood sampling revealed beta hCG levels below 30 mIU/mL; serological infection parameters and Hb concentration were within the normal range.

CONCLUSIONS

Areas of enhanced vascularity of the uterus, ranging from a focal vascular pedicle to a larger area of the myometrium, are relatively common after pregnancy. They are predominantly seen in the presence of placental remnants, in the early postpartum period and after instrumental or manual delivery of the placenta. There are no clear risk factors for retained placental tissue, besides the history of blood transfusion in the early postpartum, and perhaps multigravidity. Serology is of little help in the diagnosis of retained gestational products. The knowledge of the ultrasound and color Doppler features of the uterus after pregnancy may prove of practical value for the management of abnormal uterine bleeding in the postpartum period.

Vascular malformations in the uterus: ultrasonographic diagnosis and conservative management

OBJECTIVE

To investigate the presence and outcome of uterine vascular malformations in women with abnormal premenopausal bleeding.

STUDY DESIGN

In this observational study 265 consecutive patients with abnormal premenopausal bleeding were examined by the same ultrasonographer with transvaginal gray-scale ultrasonography and color Doppler imaging. A final diagnosis of uterine vascular malformation was based on ultrasonographic findings, hysteroscopy or histological findings. Patients suspected of uterine vascular malformations at ultrasonography were closely monitored.

RESULTS

In nine patients (3.4%) we found ultrasonographic features of uterine vascular malformations. Color Doppler imaging showed hypervascularity, marked turbulence, and low-impedance, high-velocity flow. In six patients the condition resolved spontaneously. Two patients with hydatiform mole needed chemotherapy and their condition normalized. One patient underwent a selective embolization of the uterine artery. Subsequently, five patients had uncomplicated pregnancies after resolution of the vascular malformation.

CONCLUSION

Uterine vascular malformations are more common than previously thought. We conclude that conservative management is a valuable option in many of the acquired pregnancy-related cases that are diagnosed with color Doppler imaging.