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.     

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.     

Successful term pregnancy after selective arterial embolization of symptomatic arteriovenous malformation in the setting of gestational trophoblastic tumor

BACKGROUND: Patients with arteriovenous malformations (AVMs) are at risk for significant vaginal hemorrhage, and are traditionally managed surgically. In the patient desiring future fertility, conservative management via selective arterial embolization is a reasonable option. Only a few cases have been previously reported of successful pregnancy after this procedure in the setting of gestational trophoblastic disease (GTD). CASE: A 31-year-old gravida 1 para 0 was treated for persistent gestational trophoblastic tumor after a complete mole in 1997. She presented with heavy vaginal bleeding, and arteriogram demonstrated a large uterine AVM. The patient underwent selective uterine artery embolization with complete resolution of bleeding, as well as arteriographic cessation of flow through the AVM. After two first-trimester spontaneous abortions, the patient successfully completed a normal pregnancy, resulting in the forceps-assisted delivery of a healthy female infant. CONCLUSION: Successful term pregnancy can occur after selective uterine artery embolization in women hemorrhaging from symptomatic GTD-associated AVM.     

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.     

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.     

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.     

An arteriovenous malformation in pregnancy: a case report and review of the literature

A case is described of a young woman with progression of a macrofistulous arteriovenous malformation during pregnancy. This resulted in severe symptoms necessitating cesarean section, following which there was a dramatic postpartum recovery. The arteriovenous malformation was confirmed by angiography. The literature related to arteriovenous malformations in pregnancy is reviewed.     

Clinical Conundrum: A 39-Year-Old With Chronic Retained Products of Conception and Concurrent Uterine Arteriovenous Malformation

A 39-year-old woman presented with bleeding 4 months after a surgical termination of pregnancy. Persistent beta-human chorionic gonadotropin levels were suggestive of retained products of conception (RPOC). However, multimodal imaging revealed a concurrent uterine arteriovenous malformation (AVM). Although most stable AVMs can be managed conservatively, the need for surgical management of chronic RPOC and consequential hemorrhage risk complicates this approach. Patient-determined management prioritized blood conservation while minimizing risks to fertility. This case is discussed with respect to the rare concurrent existence of RPOC and AVM. Little is known regarding the optimal tandem therapeutic approach. As depicted, successful treatment requires careful diagnostic workup and a multidisciplinary approach.     

The counselling of patient with prior C-section

A trial of labor after prior cesarean delivery is associated with a greater perinatal risk than is elective repeated cesarean delivery without labor, although absolute risks are low. Information and counselling aim to estimate specific risks and to balance these risks according to individual factors. Therefore, the physician has to answer two questions: (i) which would be the probability of successful vaginal delivery? (ii) which would be the risk of uterine rupture with a trial of labor? The risk factors for failure of trial of labor are: increased maternal age, obesity, and fetal macrosomia. The risk factors for uterine rupture are: increased maternal age, postpartum fever after the previous cesarean delivery, short interdelivery interval, history of at least two previous cesarean deliveries, and a history of classical incision. Conversely, other factors are of good prognosis: a prior vaginal delivery and, particularly, a prior VBAC (Vaginal Birth After Caesarean) are associated with a higher rate of successful trial of labor compared with patients with no prior vaginal delivery; ultrasonographic measurement of the lower uterine segment thickness>3.5 mm has an excellent negative predictive value for the risk of uterine defect. Finally, the wish for additional pregnancies following a cesarean section must be considered as an argument in favour of a trial of labor after accounting for the increasing risks correlated with repeated elective cesarean deliveries.     

Uterine inversion due to a leiomyoma on postpartum day 41: a case report

Uterine leiomyomas are common tumors in women of reproductive age and are frequently detected during pregnancy. The major complications during pregnancy include abortion, preterm delivery, abruptio placentae, intrauterine growth retardation, dystocia, and postpartum hemorrhage. Little attention is given to uterine leiomyomas postpartum compared to leiomyomas prior to childbirth. In the present case, a 27-year-old woman, gravida 1 para 1, presented with massive vaginal bleeding, urinary retention and lower abdominal pain on postpartum day 41. She was diagnosed with uterine inversion due to leiomyoma. After a vaginal myomectomy, the uterus was re-placed with a combined vaginal and abdominal approach. Because of timely medical intervention, the patient managed to overcome the crisis and her reproductive organs were successfully preserved.     

Cerebral vascular malformations and pregnancy: obstetrical and anesthetic management

Obstetrical management of women known to have a cerebral vascular malformation is controversial. The risk of cerebral hemorrhage during pregnancy is difficult to assess. We report thirteen cases of pregnancy in women with known cerebral vascular malformations who had or had not undergone surgical treatment. The effect of pregnancy on these malformations and corresponding obstetrical care described in the literature were studied. Our conclusion is that the risk of bleeding from cerebral arteriovenous malformations is not significantly increased during pregnancy whereas the risk of cerebral hemorrhage is slightly increased at the end of pregnancy, but unchanged during labor and delivery, in women with arterial aneurysms. There is no reason to advise against pregnancy in most cases and vaginal delivery is often possible unless there is a risk of dystocia.     

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 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.     

Uterine arteriovenous malformations induced after diagnostic curettage: a systematic review

Purpose  

To perform an extensive systematic review to examine all the available literature reporting iatrogenic acquired arteriovenous malformation (AVM) induced after diagnostic curettage and to describe a further case of a 34-year-old woman presenting with acute vaginal bleeding due to AVM induced after uterine curettage for termination of pregnancy.     

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.     

Symptomatic arteriovenous malformation of Bartholin's gland. A case report

BACKGROUND: Arteriovenous malformations are composed of large, tortuous arteries and misshapen, veinlike structures. They are extremely uncommon in the genital tract. CASE: An arteriovenous malformation in a Bartholin gland presented as intermittent vaginal bleeding in a 43-year-old woman. CONCLUSION: Persistent unexplained bleeding from Bartholin's gland requires surgical excision.     

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.     

A trial of labor after cesarean section in patients with or without a prior vaginal delivery.

OBJECTIVE: To determine the outcome of labor in women with a previous cesarean section, with or without prior vaginal delivery. METHOD: Records were reviewed for 1065 women with a previous cesarean section at 'Virgen Macarena' Hospital who were attended for a subsequent labor. RESULTS: Chi-squared tests demonstrated that women with previous vaginal delivery (n = 346) had a significantly higher rate of vaginal delivery after a trial of labor (95.24%) than those without previous vaginal delivery (n = 719) (82.95%). All the ruptures of uterine scar (n = 4) were found in women without previous vaginal delivery. CONCLUSION: It appears that a cesarean section in a multiparous woman is not a determinant fact in her reproductive history and the risk of rupture of uterine scar did not appear to be present.