Treating a recurrent uterine arteriovenous malformation with uterine artery embolization. A case report

BACKGROUND: Uterine arteriovenous malformation is a rare condition. Uterine artery embolization offers the possibility of conservative management as opposed to the traditional hysterectomy. We report a case with recurrent uterine arteriovenous malformation confirmed by angiography and successfully treated with a second embolization procedure. CASE: A 33-year-old woman presented with heavy vaginal bleeding. The diagnosis of uterine arteriovenous malformation was suspected on Doppler ultrasonography and confirmed by angiography. The first embolization procedure was performed using polyvinyl alcohol and steel coils. Recurrence was diagnosed 1 year later with the same imaging techniques. The second embolization procedure was performed using histoacryl. The patient remained asymptomatic at 1-year of follow-up. CONCLUSION: Minimally invasive management is an option in recurrent uterine arteriovenous malformation.     

Uterine arteriovenous malformation. A rare cause of recurrent metrorrhagia

Uterine arteriovenous malformation is a rare condition. We report a case with acquired arteriovenous malformation arising from the left uterine artery. She was diagnosed by color Doppler ultrasound and treated with a selective uterine artery embolization.     

Uterine arteriovenous malformation successfully embolized with a liquid polymer, isobutyl 2-cyanoacrylate

A uterine arteriovenous malformation was diagnosed angiographically in a 27-year-old woman presenting with recurrent menometrorrhagia. Bilateral hypogastric artery embolization with a liquid polymer, isobutyl 2-cyanoacrylate (Bucrylate), resulted in subsequent normal menses. Bucrylate offers a number of advantages over other agents previously used to embolize uterine arteriovenous malformations.     

A new fertility-preserving treatment modality for life-threatening bleeding caused by acquired uterine arteriovenous malformation (AVM): Combination laparoscopic ligation of uterine arteries and AVM suture

ObjectiveSymptomatic Uterine arteriovenous malformation (AVM) can result in sudden and massive vaginal bleeding that can be life-threatening. We report a new fertility-preserving treatment modality for disastrous bleeding caused by acquired uterine AVM: Combination laparoscopic ligation of uterine arteries and AVM suture.Case reportA 39-year-old female received Dilatation and Curettage due to missed abortion. However, she experienced heavy vaginal bleeding after surgery. Uterine arteriovenous malformation (AVM) was diagnosed by color Doppler ultrasonography, hysteroscopy, and angiography. She was successfully treated using laparoscopy bilateral uterine arteries ligation followed by application of uterine AVM suture with absorbable barbed wound closure device. After the laparoscopic surgery, vaginal bleeding stopped immediately. Complete regression of the AVM lesion on sonography was noted 8 months after laparoscopic surgery. Besides, this patient had normal menstruation after the operation.ConclusionThis case report describes for the first time a successful combination of bilateral uterine artery ligation and AVM suture to treat a patient with uterine arteriovenous malformation. We demonstrated the efficacy and safety of this fertility preserving method.     

Three-dimensional CT Angiography Is Useful for Diagnosis of Postabortion Uterine Hemorrhage: 3 Case Reports and Review of the Literature

Uterine hemorrhage is a major complication associated with abortion. There are various causes of postabortion uterine hemorrhage. The objective of this article is to estimate the efficacy of three-dimensional computed tomography (3D-CT) angiography in the diagnosis of this condition. We present 3 case reports of women with massive genital bleeding after abortion. 3D-CT angiography clearly demonstrated the 3-D features of the feeding artery, the draining vein, and the surrounding normal structures. The diagnosis in patient 1 was a uterine arteriovenous malformation, in patient 2 was a placental polyp mimicking a uterine arteriovenous malformation, and in patient 3 was a placental polyp. Patients were all successfully treated with uterine artery embolization or transcervical resection of the placental polyp. We conclude that 3D-CT angiography is useful for making a differential diagnosis and for preoperative planning in patients with postabortion uterine hemorrhage.     

Embolization of a uterine arteriovenous malformation followed by a twin pregnancy

BACKGROUND: Uterine arteriovenous malformation is a lesion that can cause recurrent pregnancy loss. Very few successful pregnancies have been reported after selective embolization of an arteriovenous malformation. CASE: A 42-year-old gravida 6 para 0 with a history of four first-trimester spontaneous abortions was found to have a uterine arteriovenous malformation by hysterosalpingogram, which was confirmed by magnetic resonance angiography. She underwent selective transcatheter embolization of the arteriovenous malformation. A twin gestation was later conceived via in vitro fertilization. The twins were delivered by cesarean at term. CONCLUSION: Uterine arteriovenous malformation can be successfully treated with selective embolization, with good obstetric outcome.     

Embolization of uterine arteriovenous malformation for treatment of menorrhagia

Background  Uterine arteriovenous malformations are rare but potentially life-threatening conditions that should be suspected in unexplained severe vaginal bleeding. Case  A 28-year-old gravida 7, para 3 presented to the emergency department with heavy vaginal bleeding and passage of blood clots. In the emergency room, her hemoglobin dropped from 11.2 to 7.4 gm%. Transvaginal ultrasonographic scan showed a large vascular mass in the uterus measuring 2.6 cm in diameter with low resistance of flow within, concerning for arteriovenous malformation or an arteriovenous fistula. Digital subtraction arteriography confirmed the lesion. She underwent angiography and bilateral uterine artery embolization. Conclusion  The diagnosis of uterine arteriovenous malformation requires a high index of suspicion in the scenario of unexplained severe vaginal bleeding. Digital subtraction angiography is the gold standard for definitive diagnosis and allows immediate treatment by embolization.     

Successful medical treatment with danazol after failed embolization of uterine arteriovenous malformation

BACKGROUND: Transcatheter arterial embolization has been the therapy of choice for uterine arteriovenous malformations, whereas medical therapy has not been popular because of patient propensity to bleed. CASE: A 29-year-old woman, gravida 3, para 0, was diagnosed with uterine arteriovenous malformation. Because initial treatment with uterine artery embolization was unsuccessful, she was ultimately treated with danazol. Resolution of the lesion after 2 weeks of danazol therapy was observed. As of follow-up at 16 months, she has remained free from further abnormal bleeding episodes and recurrence of the lesion. CONCLUSION: Danazol has the potential for medical management of uterine arteriovenous malformations in hemodynamically stable patients who do not respond to embolization.     

Fertility and pregnancy outcomes following uterine artery embolization (UAE) for uterine arteriovenous malformation (AVM)

A 19-year-old patient presented with intractable uterine bleeding, 11 weeks post-abortion. A pelvic ultrasound with Doppler and color imaging suggested a uterine arteriovenous malformation. Failing conservative therapies, the patient consented to uterine artery embolization (UAE). Two months later, she conceived and had an uneventful normal vaginal delivery at term. Since this is an extremely rare condition, allowing limited clinical exposure and experience, there may be an underlying reluctance by general practitioners to treat these cases with uterine artery embolization for fear of compromising future fertility and pregnancies. However, data from the 20 pregnancies embolized for uterine AVM cited in the present report and data from embolization for uterine fibroids indicate that such fears may be unfounded since pregnancy rates and outcomes may not be compromised after UAE.     

Pregnancy after medical management of a uterine arteriovenous malformation. A case report

BACKGROUND: The natural history of conservatively managed uterine arteriovenous malformations is largely unknown, and the risks associated with subsequent pregnancy and vaginal delivery have not been established. CASE: A multiparous woman with a previously reported history of uterine arteriovenous malformation was monitored throughout pregnancy and vaginal delivery. Serial ultrasound studies were performed prior to a successful induction of labor for severe preeclampsia at 34 weeks' gestation. CONCLUSION: To our knowledge, this is the first report of pregnancy and vaginal delivery in a woman with a prior history of a medically managed uterine arteriovenous malformation. Noninvasive treatment of uterine arteriovenous malformations is rare, and the potential long-term risks of this approach, including pregnancy, remain uncertain.     

Forceps delivery after molar malignancy in a woman with arteriovenous malformation. A case report.

BACKGROUND: An arteriovenous (AV) fistula in the female pelvis is a rare finding. This report describes a successful pregnancy after selective embolization of a postmolar vascular malformation. CASE: At 5 weeks of pregnancy, a 27-year-old, white female, gravida 3, para 0, was discovered on ultrasound examination to have an AV malformation along with a fetal pole. The patient was asymptomatic and had previously received two courses of chemotherapy for a previous nonmetastasized malignant molar pregnancy. Doppler ultrasonography uncovered a vascular malformation extending from the margin of the fetal pole to the margin of the uterus. The pregnancy ended at 8 weeks with a spontaneous abortion. The patient underwent angiography and embolization of extensive right-sided uterine vessels. She resumed normal menstrual periods six weeks after the embolization and became pregnant. The pregnancy concluded in low forceps vaginal delivery of a healthy, female infant at 34 weeks. CONCLUSION: Vaginal delivery following postmolar pregnancy and a uterine AV malformation may be considered a viable delivery option.     

Pregnancy after transcatheter embolization of a uterine arteriovenous malformation

A 25-year-old woman with a congenital uterine arteriovenous malformation had a long history of repeated excessive vaginal bleeding. She was successfully treated with transarterial embolization. She had normal menstrual periods for 6 months and subsequently conceived. She was delivered of a normally grown baby at 35 weeks. To the best of our knowledge, this is the third pregnancy described after successful embolization of an arteriovenous malformation.     

Arteriovenous malformation after uterine curettage: a report of 3 cases

BACKGROUND: Acquired uterine arteriovenous malformation is a rare but potentially life threatening condition and, as such, must be considered in the differential diagnosis of cases of abrupt, profuse vaginal bleeding following uterine curettage. The condition can easily be confused with retained products of conception and gestational trophoblastic disease. CASES: One case was managed surgically, while 2 others were treated with selective embolization. CONCLUSION: A positive medical history, the clinical presentation and features for the the ultrasonic appearance are the main features for the correct differential diagnosis and treatment of traumatic arteriovenous malformation resulting from uterine curettage.     

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.     

Acretismo placentario focal tratado mediante embolización de arterias uterinas

Placenta accreta can cause postpartum bleeding and has high maternal morbidity and mortality. Prenatal diagnosis is difficult. Selective embolisation of the uterine artery is a conservative technique that preserves the uterus and fertility.We present the case of a woman with puerperal bleeding, with a postulated differential diagnosis of focal placenta accreta and uterine arteriovenous malformation. Uterine artery embolisation and curettage successfully preserved fertility and the patient subsequently conceived again.We discuss the importance of image interpretation for correct diagnosis, the personalised adaptation of therapeutic methods and a multidisciplinary approach.     

Intra-arterial Chemotherapy with Cisplatin Followed by Radical Radiotherapy for Locally Advanced Cervical Cancer

Locally advanced cervical cancer has a dismal prognosis, with a high local failure rate and a poor survival rate. To improve the cure rate for advanced carcinoma of the cervix, we initiated a study of intra-arterial (I-A) chemotherapy with cisplatin via the uterine artery prior to definitive radiotherapy. I-A chemotherapy via the internal iliac artery has been used to treat advanced cervical cancer; however, access by way of the uterine artery has not been tested for this purpose. Thirty-four patients with central tumor ≥5 cm in anteroposterior diameter observed on CT scans were treated with I-A chemotherapy. I-A chemotherapy consisted of unilateral catheterization of the uterine artery using 120 mg/m²cisplatin. After assessment of I-A chemotherapy, all but 3 patients were treated with a combination of whole-pelvis external irradiation and intracavitary irradiation. The 3 patients underwent external radiotherapy alone. Twenty-seven of 34 patients treated were evaluable for response to I-A chemotherapy. Eleven patients (41%) experienced a partial response. Seventy-six percent of the 34 patients treated with I-A chemotherapy followed by radiotherapy exhibited a complete response by the end of treatment. Toxicity was well tolerated and no death due to treatment occurred. The 2- and 5-year actuarial survival rates were 64 and 55%, respectively. The crude incidences of pelvic recurrence and distant metastasis observed at a median follow-up of 54 months were both 47%. This study for locally advanced cervical cancer suggests there is benefit to be derived from our I-A chemotherapy followed by radical radiotherapy.     

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

Abstract.   Tsai C-C, Cheng Y-F, Changchien C-C, Lin H. Successful term pregnancy after selective embolization of a large postmolar uterine arteriovenous malformation. Int J Gynecol Cancer 2006; 16(Suppl. 1): 339–341.
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.     

Radiotherapy at a young age reduces uterine volume of childhood cancer survivors

BACKGROUND: In contrast to chemotherapy, previous irradiation of the uterus carries an increased risk of an adverse pregnancy outcome. Conflicting results exist as regards the ability of the uterus to increase in volume following radiotherapy-induced damage. We measured uterine volume in a cohort of childhood cancer survivors, and assessed uterine response to a high-dose estrogen replacement regimen. METHODS: Uterine volume was assessed by transvaginal sonography in 100 childhood cancer survivors. Three patients with ovarian failure and severely reduced uterine volume following abdominal or pelvic irradiation were treated with percutaneous estradiol 150 microg/24 h for three cycles, and transvaginal uterine sonography was repeated monthly. RESULTS: Uterine volume was significantly reduced in nulliparous patients who had received direct uterine irradiation (n = 13; median 13 mL, range 1-52 mL) compared with nulliparous patients who had received chemotherapy only (n = 37; 47 mL, 22-88), radiotherapy above the diaphragm (n = 17; 40 mL, 24-61), or radiotherapy below the diaphragm not directly involving the uterus (n = 13; 34 mL, 8-77) (p < 0.02 in all comparisons). Among nulliparous patients a significant correlation was found between age at direct uterine irradiation and uterine volume (r = 0.78, p = 0.002). No significant improvement in uterine volume, endometrial thickness or uterine artery blood flow was observed in three hypogonadal patients in response to high-dose estrogen replacement therapy. CONCLUSIONS: Our results indicate that cytotoxic treatment in childhood does not affect adult uterine size. In contrast, uterine irradiation at a young age reduces adult uterine volume. The radiotherapy-induced damage is probably irreversible.     

Uterine arteriovenous malformation: a case report diagnosed by sonohysterography

PURPOSE OF INVESTIGATION: The aim of this report is to describe a case of uterine arteriovenous malformation that occurred in a 54-year-old postmenopausal woman referring recurrent postmenopausal bleeding, after two years of tamoxifen therapy. METHODS: Medical therapy with GnRh agonists was unsuccessful. Ultrasound and Doppler flow ultrasound scanning were normal and the following hysteroscopy was normal as well. RESULTS: Hysterosonography performed on the patient made us suspect the presence of an intracavitary vascular lesion which was confirmed histologically after hysterectomy. CONCLUSION: In our case hysterosonography allowed us--by creating optimal contrast between the uterine wall and the uterine cavity--to suspect and identify the lesion and to recognize the typical ultrasound findings of this pathology not visualized with standard transvaginal ultrasound.     

Uterine Vascular Lesions

Vascular lesions of the uterus are rare; most reported in the literature are arteriovenous malformations (AVMs). Uterine AVMs can be congenital or acquired. In recent years, there has been an increasing number of reports of acquired vascular lesions of the uterus following pregnancy, abortion, cesarean delivery, and curettage. It can be seen from these reports that there is confusion concerning the terminology of uterine vascular lesions. There is also a lack of diagnostic criteria and management guidelines, which has led to an increased number of unnecessary invasive procedures (eg, angiography, uterine artery embolization, hysterectomy for abnormal vaginal bleeding). This article familiarizes readers with various vascular lesions of the uterus and their management.Key words: Uterine arteriovenous malformations, Uterine hemangioma, Placental chorioangioma, Uterine arteriovenous fistula, Uterine pseudoaneurysm, Acquired AVMVascular lesions of the uterus are very rare; most reported in the literature are arteriovenous malformations (AVMs). Uterine vascular malformations can be congenital or acquired. Recently, there has been a rise in the number of reported cases following pregnancy, abortion, and curettage. Many of these studies report spontaneous resolution of vascular lesions during follow-up; in addition, there is an increasing trend toward use of uterine artery embolization (UAE) to treat these lesions. In many of the reported studies, the diagnosis of uterine vascular malformation was made as early as the second day after a delivery or an abortion. In a study by Timmerman and colleagues,¹ out of 30 cases reported as uterine AVM based on Doppler study, only 3 were true AVMs. Rufener and associates² conducted a sonologic evaluation of postpartum and postabortion uterine vascular lesions that were reported as AVMs; the study revealed that, on pathologic examination, none turned out to be AVMs. Thus, we observe that there is confusion with regard to the terminology of vascular lesions such as uterine AVM, vascular malformation, arteriovenous fistula (AVF), and non-AVM vascular abnormalities of the uterus. The term malformation, however, is generally used to describe defects in the structure of an organ or region of the body resulting from an intrinsically abnormal process of development. Therefore, spontaneous resolution of a malformation in a short period of time is unlikely. An investigation by Mulliken and Glowacki,³ published in 1982, provided the groundwork for a proper identification of vascular lesions. Vascular tumors grow by cellular (mainly endothelial) hyperplasia: the very common hemangioma is, in reality, a benign vascular tumor. In contrast, vascular malformations have a quiescent endothelium and are considered to be localized defects of vascular morphogenesis, likely caused by dysfunction in pathways regulating embryogenesis and vasculogenesis. Therefore, the terms vascular abnormality or vascular lesion seem to best describe hypervascular areas within the uterus seen on color Doppler ultrasound, unless they are proven to be an AVM by angiography or pathologic examination. Many of these vascular lesions are increasingly being managed by UAE. Although there have been various reports of successful pregnancy following UAE, there have also been reports of ectopic pregnancy following UAE.⁴It is important to correctly identify various vascular lesions in the uterus to avoid unnecessary invasive intervention. This article aims to familiarize the reader with various vascular lesions of the uterus and their management.Uterine AVM is a rare condition, and the true incidence is not yet known. A study by O’Brien and associates⁵ showed an incidence of AVM of 4.5% in 464 pelvic sonographic examinations performed for pelvic bleeding. AVM has been described in patients between 18 and 72 years of age, and may be congenital or acquired pathologic conditions.⁶ The congenital form is very rare and is the result of a defect in embryonic vascular differentiation or a premature arrest in the development of the capillary plexus leading to multiple abnormal connections between arteries and veins.⁷ These congenital AVMs often penetrate the surrounding tissue and can cause an elaborate collateral vascular network. Furthermore, these congenital lesions can grow as pregnancy progresses.⁸The International Society for the Study of Vascular Anomalies classification system divides vascular anomalies into two primary biologic categories: (1) vasoproliferative or vascular neoplasms and (2) vascular malformations. The major distinction between the two categories is whether there is increased endothelial cell turnover, which is ultimately determined by the identification of mitoses seen on histopathology. Vasoproliferative neoplasms have increased endothelial cell turnover (ie, they proliferate and undergo mitosis) because they are neoplasms. Vascular malformations do not have increased endothelial cell turnover; rather, they are structural abnormalities of the capillary, venous, lymphatic, and arterial system, and can be congenital or acquired.