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.     

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.     

Successful Laparoscopic Bipolar Coagulation of a Large Arteriovenous Malformation Due to Invasive Trophoblastic Disease: a Case Report

We report the case of an acquired large arteriovenous malformation due to invasive gestational trophoblastic tumor that was treated successfully with laparoscopic surgery. After 4 cycles of methotrexate chemotherapy, a vascular tangle (volume, 28 cm³) was noted that emerged from the right uterine horn, invading the broad ligament adjacent to the uterine artery. Doppler ultrasonography along with magnetic resonance arteriography confirmed the diagnosis. The location, size and relation of this arteriovenous malformation to the uterine vasculature demanded urgent intervention. Laparoscopy was performed, and bipolar coagulation of the ovarian and uterine artery feeding branches was achieved after surgical resection of the tumor. The defect in the uterine wall with an intact uterine cavity was reconstructed using sutures. There were no intraoperative or postoperative complications. The patient underwent chemotherapy, and at 2-month follow-up was cured and has since had regular menstrual cycles.     

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.     

Management of retained products of conception with marked vascularity

Cases of retained products of conception (RPOC) with marked vascularity present a clinical challenge because simple dilation and curettage (D&C) can lead to life-threatening hemorrhage. We describe here two cases of hypervascular RPOC that were successfully managed with two different approaches. Case 1: A 26-year-old woman with history of 3 D&Cs was transported to the emergency room for heavy vaginal bleeding 45 days after a spontaneous abortion. Diagnosis of RPOC with aneurysm-like structure was considered and uterine artery embolization was performed. Four days after the uterine artery embolization, reduction of the vascularity of RPOC was confirmed on color Doppler ultrasonography and D&C was successfully carried out. Case 2: A 37-year-old woman with history of one cesarean section became pregnant after the regular menses. She underwent D&C for missed abortion at 8 weeks' gestation. Seven days after the D&C, sonographically heterogenous mass emerged in the vicinity of the previous cesarean scar. Thereafter, the mass gradually grew larger and diagnosis of hypervascular placental polyp was considered. As the amount of vaginal bleeding was small, expectant management was instituted. Sixty-one days after the first D&C, reduction of the vascularity of RPOC was confirmed on color Doppler ultrasonography and D&C was successfully completed.     

Uterine artery embolization in postabortion hemorrhage

OBJECTIVE: To summarize the efficacy of postabortion uterine artery embolization in cases of refractory hemorrhage. METHODS: Forty-two women were identified who had postabortion uterine artery embolization at San Francisco General Hospital between January 2000 and August 2007. Seven underwent embolization for hemorrhage caused by abnormal placentation. RESULTS: Embolization was successful in 90% (38 of 42) of cases. All failures (n=4) were in patients who had confirmed abnormal placentation. However, three of seven women (43%) with probable accreta diagnosed by ultrasonography were treated successfully with uterine artery embolization. Two patients experienced complications of uterine artery embolization. These complications-one contrast reaction and one femoral artery embolus-were treated without further sequelae. CONCLUSION: Uterine artery embolization is an alternative to hysterectomy in patients with postabortion hemorrhage refractory to conservative measures, especially when hemorrhage is caused by uterine atony or cervical laceration.     

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.     

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.     

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.     

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.     

Malformación arteriovenosa uterina como causa de hemorragia puerperal tardía

Arteriovenous malformation (AVM) of the uterus should be included in the differential diagnosis of patients with postpartum hemorrhage that does not yield to routine measures and may even worsen after curettage. Color Doppler sonography can aid in the diagnosis and clinical management of this entity. Although the classical treatment has been hysterectomy, conservative treatment with uterine artery embolization should currently be considered the first therapeutic option for these lesions because of its safety and effectiveness. We report the case of a patient with delayed postpartum hemorrhage and AVM successfully resolved with selective embolization of the left uterine artery.     

子宫动静脉瘘引起晚期产后出血的诊疗进展

子宫动静脉瘘(uterine arteriovenous fistula,UAVF)是一种临床上较为罕见的子宫血管异常疾病,是导致女性晚期产后出血的原因之一.近年来随着我国二孩政策的放开以及人工流产率的增高,UAVF的发病率也随之上升,严重影响女性的生活质量,并增加了患者再次妊娠的难度和风险.由于UAVF病因和临床表现...     

Computed tomographic angiography in diagnosis and management of placental polyp with neovascularization

Objective  

To evaluate the neovascularization in placental polyp tissue by computed tomographic angiography and to determine the need for uterine artery embolization before hysteroscopic resection.     

A case of placental polyp treated with an intraoperative injection of prostaglandin F<Subscript>2α</Subscript> followed by hysteroscopic resection

A 27-year-old woman had massive genital bleeding after an artificial abortion. Color Doppler ultrasonography showed a hypervascular mass. Hysteroscopy revealed a placental polyp. Serum hemoglobin level was decreased to 7.7 g/dl. Although uterine artery embolization (UAE) followed by hysteroscopic resection has been used for treatment of a placental polyp, UAE may not be an ideal option for patients with intent for future pregnancy because of the risk of ovarian function failure. This report presents a case of a placental polyp managed successfully with intracervical injection of prostaglandin F_2α, as an alternative UAE, followed by hysteroscopic resection.     

子宫下段妊娠人工流产术中大出血临床分析--附四例报告

目的 探讨早期子宫下段妊娠人工流产术中大出血的病例特点和保守治疗的方法。方法 回顾性分析1994年5月至2002年7月我们收治的4例子宫下段妊娠行人工流产术中大出血的病例资料。结果 4例患者均有剖宫产史;其中3例停经后有阴道不规则出血;子宫动脉造影显示子宫下段供血区出血;4例均于人工流产术中发生大出血,采用子宫动脉栓塞治疗,止血效果好。无一例因子宫动脉栓塞而行全子宫切除者。结论 有剖宫产史的患者再受孕时,有发生子宫下段妊娠的危险,行人工流产术中易发生难以控制的大出血;子宫动脉栓塞是行之有效的治疗方法。严格剖宫产指征和重视产后避孕,是主要的预防办法。     

Uterine Arteriovenous Malformation - A Rare Cause of Uterine Haemorrhage

Summary: Uterine arteriovenous malformation (AVM) is a rare cause of massive uterine bleeding, with 70 cases reported in the English literature. Although uterine AVM is a rare cause of menorrhagia or postmenopausal bleeding, it is important to consider in the assessment of a patient with abnormal (especially heavy) uterine bleeding because accurate diagnosis can allow appropriate treatment to be planned and avoid hysterectomy in women who wish to retain their reproductive capacity. Until relatively recently this condition was difficult to diagnose and management almost always required hysterectomy. Special investigations (hysteroscopy, Doppler flow ultrasound and pelvic angiography) are important for diagnosis and assessment. Transcatheter embolization has replaced hysterectomy as the treatment of choice in women who wish to retain their fertility. Curettage may precipitate life-threatening haemorrhage and is therefore contraindicated when uterine AVM is suspected.     

选择性动脉栓塞治疗妇产科大出血的临床应用

目的 研究选择性髂内动脉栓塞或子宫动脉栓塞技术在妇产科大出血中的临床应用。方法 选择性双侧髂内动脉或子宫动脉栓塞术治疗19例妇产科大出血患者，其中产后出血12例，功血3例，人工流产术后宫内残留2例，侵蚀性葡萄胎1例，绒癌子宫穿孔1例。产后出血、功血、宫内残留患者用明胶海绵栓塞，肿瘤患者用化疗药物加碘油混悬液、明胶海绵栓塞。结果 19例妇产科大出血患者栓塞后立即止血或出血明显减少，除1例出现右髂外动脉血栓形成，行右股动脉切开取栓术后好转外，余无严重并发症。结论 髂内动脉或子宫动脉栓塞技术的开展既避免了开腹手术，又不影响患者脏器功能，保留了年轻患者的生育功能，对抢救妇产科大出血是安全有效的。     

Application of 3-D Angiography in the Management of Placenta Percreta Treated with Repeat Uterine Artery Embolization

BackgroundRising Caesarean section rates have increased rates of abnormally invasive placentation. In the management of such invasive placentation, hysterectomy may result in greater morbidity than more conservative measures. Non-surgical interventions such as uterine artery embolization (UAE) attempt to decrease placental perfusion and augment placental resorption. Repeat UAE may decrease the risk of unpredictable hemorrhage requiring emergency intervention. Three-dimensional angiography is a novel technology for assessing volume with objective measures of internal flow.CaseWe report a case of placenta previa percreta that was treated conservatively by repeat UAE for persistent densely perfused placenta. Three-dimensional angiography was used to objectively assess placental characterization and vascularization.ConclusionRepeat UAE may be beneficial in reducing the risk of delayed hemorrhage in women with placenta previa accreta or percreta managed conservatively. Objective assessment of placental volume and vascularity by 3-D angiography can provide data on patients at risk and allow case selection for repeat UAE.     

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.     

Transcatheter embolization of uterine arteriovenous malformation: report of 2 cases and review of literature

Arteriovenous malformation (AVM) of the uterus is a rare cause of menorrhagia and may at times lead to life-threatening hemorrhage. The clinical findings may not always be reliable in the diagnosis of uterine AVM, and a high index of suspicion is important because, unlike many other causes of menorrhagia, curettage may paradoxically aggravate the bleeding. Herein are described the cases of 2 patients with uterine AVM with abnormal vaginal bleeding. Both had a history of abortion followed by dilation and curettage. In both patients, the diagnosis of uterine AVM was established at Doppler flow ultrasonography. Treatment using transcatheter embolization was successful, and both patients had normal menstrual cycles at follow-up. One patient delivered a healthy baby 2? years after transcatheter embolization.