Medical Treatment of a Uterine Arteriovenous Malformation

EDITORIAL COMMENT: A certain degree of scepticism in medicine is to be encouraged if for no other reason than to promote thought about aetiology and different methods of treatment. We have published 3 previous case reports in our journal on the successful management of so called arteriovenous malformations of the uterus (A, B, C). Since the new technology has become available that allows precise diagnosis of arteriovenous fistulas there have been numerous case reports on such lesions in the uterus in the gynaecological literature. One wonders what happened to these patients previously. Surely many must have had curettage performed for menorrhagia and yet how often was it necessary to perform hysterectomy for uncontrollable uterine haemorrhage after such a procedure? The only patient the editor can remember treating who required an emergency hysterectomy for torrential haemorrhage following curettage was a 17-year-old woman with an unsuspected choriocarcinoma, who had a preoperative diagnosis of incomplete abortion (D). From the point of view of aetiology, surely these lesions should be called arteriovenous fistulas rather than malformations because the patients often have had previous uterine surgery or complications that could have been causal. We accepted this case for publication because it suggests that trial of hormone therapy is a reasonable method of treatment in patients with uterine arteriovenous fistulas who have not got intractable haemorrhage and who wish to preserve their uterus.     

Acquired uterine arteriovenous malformations

Uterine arteriovenous malformations (AVM) may be responsible for vaginal bleeding potentially life-threatening. They are most often acquired following uterine trauma (curettage, cesarean section, artificial delivery/uterus examination) in association with pregnancy or gestational trophoblastic disease. We report three cases of patients having uterine AVM after curettage. The diagnostic management is important to avoid differential diagnoses (intra-uterine retention, hemangioma, gestational trophoblastic disease). It is based on serum hCG measurement and Doppler ultrasound, then confirmed on dynamic angio-MRI, which tends to replace angiography as first-line. The therapeutic management in cases of symptomatic AVMs is mostly embolization which offers the possibility for childbearing. Current data on subsequent pregnancies is reassuring even if they remain limited.     

Intussusception and incarceration of a fallopian tube: report of 2 atypical cases, with differential considerations, clinical evaluation, and current management strategies

Herein are presented 2 cases from the last 5 years. In case 1, a fallopian tube intussusception without perforation, misdiagnosed as a myoma, was observed at hysteroscopy of the uterine cavity 18 months after last vacuum aspiration. In case 2, a fallopian tube incarceration, misdiagnosed as a placental polyp, was observed 3 months after last suction curettage. Although uterine perforation caused by suction curettage after abortion or of afterbirth occurs rarely, it is a complication that must be taken into account because after this procedure there may be painful symptoms such as the typical triad of abdominal pain, vaginal discharge, and dyspareunia. In some situations, as in case 2, amenorrhea occurs alone, without other distressing symptoms. In both cases, a hysteroscopic approach was used; laparoscopy was necessary only in case 2.     

Uterine arteriovenous malformations: diagnosis and treatment in 2011

Uterine arteriovenous malformations (UAVM) are rare. They mostly occur after endo-uterine trauma, or are less often congenital. When symptomatic, they may be a cause of uterine recurrent and massive bleeding. Diagnosis should be evoked in these cases, to avoid haemostatic curettage which will be useless and injurious. UAVM is often suspected by Doppler ultrasound, but pelvic MRI seems to be also relevant. Angiography confirms the diagnosis and allows concomitant embolization. Uterine embolization seems to be currently the best treatment, however surgery should still be performed in case of failure or hemodynamic instability. In this work, we aim to evaluate diagnosis and therapeutic modalities for UAVM.     

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.     

Uterine arteriovenous malformation

Introduction Uterine arteriovenous malformations are very rare and potentially life-threatening. They can present with menorrhagia, postpartum bleeding, postmenopausal bleeding, an asymptomatic mass, or congestive heart failure.Case report We present a 37-year-old woman with massive uterine bleeding that started abruptly 3 weeks after D and C and was found to be due to arteriovenous malformations.     

Uterine artery embolization and hysteroscopic resection to treat retained placenta accreta: A case report

Retained placenta is a serious cause of postpartum hemorrhage. Compounding this problem is the rare finding of a retained placenta accreta. Different authors have presented management options for retained placenta accreta that include methotrexate, uterine artery embolization, dilation and curettage, hysteroscopic loop resection, and hysterectomy. We report here on a patient who was diagnosed with a retained placenta accreta and underwent successful conservative treatment with uterine artery embolization followed by hysteroscopic morcellation. Whereas other methods have failed due to bleeding and/or infection, this case illustrates a potential new means of addressing this challenging obstetrical complication.     

Prospective Evaluation of the Incidence of Uterine Vascular Malformations Developing After Abortion or Delivery

Study ObjectiveTo describe the incidence of uterine vascular malformations (UVMs) including uterine arteriovenous malformations (AVMs) in patients after abortion or delivery and in outpatients.DesignProspective study (Canadian Task Force classification II-3).SettingFukushima Red Cross Hospital.PatientsSix patients with a UVM including 1 with an AVM.InterventionsClinical screening of patients using transvaginal color Doppler ultrasonography between April 2010 and March 2012.Measurements and Main ResultsThe incidence of UVM developing after abortion or delivery or in outpatients was prospectively evaluated using transvaginal color Doppler ultrasonography. From 959 patients, we identified 6 (0.63%) with UVMs, including 1 (0.10%) with a uterine AVM. Specifically, we detected UVMs in 4 of 77 patients (5.2%) after abortion, 1 of 458 patients (0.22%) after delivery, and 1 of 424 outpatients (0.24%). Four patients after abortion and 1 after delivery reported mild symptoms, which were treated conservatively; however, the outpatient had a severe uterine AVM, which was confirmed via 3-dimensional computed tomography angiography.ConclusionThe incidence of UVMs was relatively higher, in particular in the patients after abortion, and was significantly higher than that in postpartum or outpatient groups. Therefore, it is important to consider the possibility of UVMs in any patient with episodes of unexplained uterine bleeding and to perform follow-up analysis using color Doppler ultrasonography. Such an approach will facilitate accurate diagnosis and lead to appropriate clinical management to prevent unnecessary dangerous repeat curettage, which might induce profuse uterine bleeding.     

Resolution of Uterine Arteriovenous Malformation and Maintenance of Reproduction in 20 Women Treated with a GnRH Agonist Concomitantly with an Aromatase Inhibitor and Tranexamic Acid

ObjectiveThis study investigated the efficacy of GnRH agonists concomitantly with transient aromatase inhibitor and tranexamic acid to treat women with uterine arteriovenous malformations (AVMs) associated with abnormal uterine bleeding (AUB) to preserve fertility and determine reproductive outcome.MethodsThis was a prospective cohort study in a tertiary centre. Doppler ultrasound demonstrated AVM in 19 women with AUB 1–28 weeks following spontaneous or therapeutic abortion and in one woman 4 years after normal pregnancy while taking an oral contraceptive. On the basis of experience from the first three cases, 17 women were treated with tranexamic acid (1 g three times daily orally for 5 days), a GnRH agonist (3.75–11.25 mg, for 1–3 months), plus an aromatase inhibitor (letrozole 2.5 mg once daily for 5days) with the initial injection of GnRH agonist. Two women required blood transfusion, and one required uterine tamponade with Foley catheter balloon in the first 48 hours to control heavy bleeding (Canadian Task Force Classification II-2).ResultsAll 20 AVMs resolved within 1–3 months of treatment. Of 16 women who attempted pregnancy, all (100%), including two who had uterine artery embolization (one after hysteroscopic septoplasty), conceived spontaneously with 18 live births. Two women are using contraception (one taking an oral contraceptive, one using a levonorgestrel intrauterine system), and one 40-year-old is not using contraception. One woman had hysteroscopic endometrial ablation followed by vaginal hysterectomy for AUB at 1 and 2 years later.ConclusionA GnRH agonist in combination with transient aromatase inhibitor and tranexamic acid is an effective management strategy to treat and maintain reproduction in women with AVMs associated with AUB.     

Do hysteroscopic metroplasties really improve really reproductive outcome?

The aim of metroplasties is to restore a normal uterine anatomy to improve obstetrical outcomes in some uterine malformations. The hysteroscopic septoplasty cures the septate uterus. It is an effective procedure in the case of recurrent abortion losses. It probably improves the rate of live birth in women without obstetrical antecedent. For some authors, it could be considered at the time of the diagnosis, because of the simplicity of the gesture and the low complication rate. The enlarging hysteroscopic metroplasty has certainly a positive impact on the obstetrical outcome in patients presenting a uterine hypotrophy or dysmorphy, in particular in women exposed in utero to DES. However, the proofs are poor to propose this procedure as first-line treatment, apart from specific cases such as old null gravid patient or before inclusion in an Assisted Reproductive Techniques (ART) program.     

Diagnosis and management of uterine arteriovenous fistulas with massive vaginal bleeding.

OBJECTIVE: To study the clinical manifestations, diagnosis, management, and prognosis of uterine arteriovenous fistulas with massive vaginal bleeding. METHODS: The clinical records of 15 patients who satisfied the diagnostic criteria were retrospectively analyzed. RESULTS: All patients had massive vaginal bleeding and a history of cesarean section, curettage, or gynecologic carcinoma. The disease was diagnosed by angiography or color Doppler ultrasonography. Vaginal bleeding can be aggravated by dilation and curettage. No complications occurred in the 14 patients who were treated with uterine artery embolization. Of the 11 patients who underwent successful embolizations, all returned to a normal menstrual cycle and 5 later became pregnant. CONCLUSION: Uterine arteriovenous fistula is a rare and potentially life-threatening condition. Uterine artery embolization is a safe and effective choice of treatment for this condition, and it can preserve both uterus and ovary function.     

应用宫腔镜诊断和处理难以取出的宫内节育器

本文介绍35例常规取节育器困难或失败的病例,经国产XG-3型宫腔镜检查定位,35例中有27例病人的宫内节育器或其碎片在宫腔内(其中1例不锈钢节育器恰套在粘膜下肌瘤蒂部、1例的节育器完全碎裂、1例断裂的T 形节育器横臂断段大部嵌入宫壁),8例未见宫内节育器(其中4例剖腹取出,另4例估计脱落而未作处理)。27例中,19例在宫腔镜直视下用蟹爪钳取出;2例用微钩取出;6例用长弯血管钳取出,效果均良好。由此认为应用宫腔镜诊断和处理断裂或嵌顿的难以取出的宫内节育器是极好的办法。     

Laparoscopic Management of Uterine Arteriovenous Malformation Via Occlusion of Internal Iliac Arteries

Uterine arteriovenous malformation (AVM) can be congenital or acquired. When acquired (e.g., fistula), it results from abnormal arteriovenous communication between one or more uterine arteries and a myometrial and/or endometrial venous plexus, without the interposition of a vascular nidus. Arteriovenous malformation is composed of a tortuous net of fragile low-resistant arteriovenous shunts. Other arteries can be involved in fistulas, including ovarian arteries or those from the round ligaments of the uterus, in particular in congenital AVMs, which develop from failure in embryologic differentiation that leads to multiple abnormal vascular connections. In these cases, extension to pelvic vessels other than uterine arteries is frequent. Acquired AVMs often result in trauma to the uterus such as dilation and curettage in 85% of cases, gestational trophoblastic disease, or endometrial carcinoma.     

Dysfunctional uterine bleeding: advances in diagnosis and treatment

Dysfunctional uterine bleeding occurs during the reproductive years unrelated to structural uterine abnormalities. Ovulatory dysfunctional uterine bleeding occurs secondary to defects in local endometrial hemostasis; while anovulatory dysfunctional uterine bleeding is a systemic disorder, occurring secondary to endocrinologic, neurochemical, or pharmacologic mechanisms. Evaluation of patients with abnormal uterine bleeding and identifying those with dysfunctional uterine bleeding is achieved with a combination of the following: history; physical examination; and judicious use of laboratory evaluation, endometrial sampling and uterine imaging, with sonographic techniques and/or hysteroscopy. Coagulopathies should be considered as should the notion that intramural and subserosal myomas are unlikely to contribute to AUB. High-quality evidence suggests that medical therapy is frequently successful, and newer approaches, such as local delivery of progestins via intrauterine devices, appear to be particularly promising and devoid of systemic side effects. For those intolerant of medical therapy, and/or for whom fertility is no longer desired, a number of minimally invasive surgical options for hysterectomy now exist and are collectively termed endometrial ablation. Endometrial ablation may be performed with or without hysteroscopic guidance. There is an increasing body of evidence that suggests that nonhysteroscopic endometrial ablation may be at least as effective as hysteroscopic endometrial ablation, even when the hysteroscopic procedure is performed by experts.     

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 artery malformation as a hidden cause of severe uterine bleeding. A case report

BACKGROUND: Uterine artery malformations are rare, life-threatening conditions. Clinical suspicion is essential for a prompt diagnosis and treatment. CASE: A 29-year-old woman was evaluated for severe uterine bleeding that started abruptly two weeks after elective termination of pregnancy. She underwent dilatation and curettage of the uterine cavity for retained products of conception. The patient presented to the emergency room two weeks later with abrupt onset of profuse vaginal bleeding that would spontaneously subside. Magnetic resonance angiography revealed a left uterine artery malformation that was successfully embolized. CONCLUSION: Uterine artery malformations should be suspected when heavy vaginal bleeding occurs in spite of medical or surgical treatment.     

Asherman��s syndrome after removal of placenta remnants: a serious clinical problem

Intrauterine adhesions (IUA) or Asherman’s syndrome is thought to develop after trauma to the uterine cavity by destruction of the basal layer of the endometrium. IUA can result in menstrual disorders, infertility, and complication during pregnancy and delivery. IUA formation is multifactorial, with pregnancy being an important etiologic factor. Performing a postpartum exploration/evacuation or curettage can lead to adhesion formation. We present three patients who presented with a menstrual disorder after postpartum surgical intervention on suspicion of placental remnants. Hysteroscopic evaluation revealed severe intrauterine adhesions with complete obliteration of the uterine cavity. Repeated and extensive hysteroscopic adhesiolysis is performed to acquire a cavity with a normal appearance. Besides the puerperal uterus, the time of surgical performance is crucial in the risk for adhesion formation. Performing a late surgical intervention, as from 24–48 h after delivery, leads to an increased risk for adhesion formation. Prevention of IUA can be established by an accurate indication for late postpartum surgical interventions. When performing a late surgical intervention, hysteroscopic surgery is preferable. Firstly, hysteroscopy allows the possibility for identification of placental remnants, and secondly, the possibility for selective removal, thus avoiding unnecessary trauma to the endometrium compared to blindly curettage. Caution is advised when performing a late puerperal surgical intervention. An accurate indication is essential, and when needed, hysteroscopic surgery is preferable, minimizing trauma to the endometrium.     

Cervical pregnancy: a case report of hysteroscopic resection and balloon compression combined with systematic methotrexate treatment

ObjectiveCervical pregnancy is a rare type of ectopic pregnancy. When the pregnancy is terminated, it will sometimes lead to persistent bleeding. In some cases, hysterectomy is inevitable and the patient loses fertility. Therefore, early diagnosis and targeted management with systemic or local injection of methotrexate is the first-line treatment. Multiple interventions of cervical pregnancy were used to prevent massive hemorrhage, including dilatation and curettage, laparoscopic resection, hysteroscopic resection combined with uterine artery embolization, or uterine artery clip.Case reportWe report a case of cervical pregnancy with a high beta-hCG level accompanied by a visible fetal heartbeat that was successfully treated with hysteroscopic cervical tissue resection and balloon compression combined with systemic administration of methotrexate.ConclusionEfficacy and safety with preserved fertility were important issues in the management of cervical pregnancy. We provide a safe, simple and effective treatment of cervical pregnancy.     

Cerebral arteriovenous malformation in pregnancy: presentation and neurologic, obstetric, and ethical significance.

Cerebral arteriovenous malformations infrequently complicate pregnancy. We sought to determine the neurologic, obstetric, and ethical significance of such malformations. We present the clinical course of 2 pregnant women with arteriovenous malformations who experienced cerebral hemorrhage and a loss of capacity for decision making. We also review the neurologic and obstetric significance of arteriovenous malformations in pregnancy. Various treatment options with concern for pregnancy and the prognosis for arteriovenous malformations are outlined. The ethical issues involved for pregnant patients whose decisional capacity is compromised as a result of cerebral injury are explored. A review of persistent vegetative state and brain death (death by neurologic criteria) occurring in pregnancy allows us to explore many issues that are applicable to decisionally incapacitated but physiologically functioning pregnant women. We outline a document, the purpose of which is to obtain advance directives from pregnant women regarding end-of-life decisions and to appoint a surrogate decision maker. We believe that evaluation and treatment of the arteriovenous malformation may be undertaken without regard for the pregnancy and that the pregnancy should progress without concern for the arteriovenous malformation.