Fístulas arteriovenosas uterinas tras legrado. Manejo histeroscópico

Uterine arteriovenous malformations are uncommon entities that may lead to life-threatening genital bleeding. These malformations can be congenital or acquired. In this article, we review uterine arteriovenous malformations occurring after curettage, their incidence, and their hysteroscopic management. To our knowledge, the distinct therapeutic options are limited to expectant management with or without methylergometrine maleate, embolization and hysterectomy, without considering hysteroscopy. We believe that hysteroscopic management could be a new treatment option for uterine arteriovenous malformation occurring after curettage.     

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.     

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.     

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.     

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 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.     

Congenital uterine malformations are associated to increased blood pressure in pregnancy.

OBJECTIVE: To assess the relationship between congenital uterine malformations and blood pressure in pregnancy. STUDY DESIGN: Twenty-four-hour automated ambulatory blood pressure monitoring (readings every 30 min) was performed in 16 normotensive, nonproteinuric, primigravidae with congenital uterine malformations (5 uterus septus, 9 uterus bicornis, 2 uterine didelphys) between 20 and 30 weeks. From the 24-hr blood pressure report, we calculated 24-hr mean, daytime and nighttime means. The results were compared with 16 primigravidae, matched for age and gestation, who were and remained normotensive throughout pregnancy, and tested for statistics with t-test; significance assessed at p < 0.001. RESULTS: Although they were within the normotensive range, all blood pressure measurements considered were significantly higher in pregnant women with congenital uterine malformations, compared to normal pregnant women. Namely, 24-hr, daytime, and nighttime systolic (mean +/- SD) were 121.1 +/- 8.4, 124.4 +/- 8.8, 114.0 +/- 7.7 mmHg, respectively, in women with uterine malformations and 108.0 +/- 7.4, 109.2 +/- 7.3, 102.1 +/- 8.5 mmHg, respectively, in normal pregnant women. Twenty-four-hour diastolic, daytime, and nighttime diastolic (mean +/- SD) 74.1 +/- 10.2, 77.1 +/- 10.6, 68.1 +/- 9.2 mmHg, in women with uterine malformations and 64.1 +/- 5.7, 66.0 +/- 5.7, 58.2 +/- 6.3 mmHg, in normal pregnant women (all differences p < 0.001). Fifteen of the fetuses from women with congenital uterine malformations showed intrauterine growth retardation. No differences were found 6 months after delivery. CONCLUSIONS: Although the blood pressure levels remained within the normotensive range, pregnant women with congenital uterine anomalies have a higher blood pressure than normal women. Elevated blood pressure can result from altered uterine circulation and reduced blood supply to the placenta. This pathogenesis or the poor placentation may result in a foetal growth retardation.     

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.     

Conservative correction of uterine anomalies in cases of congenital and posttraumatic infertility.

Uterine anomalies are due either to primary congenital malformations, or to secondary traumatic lesions of the intrauterine cavity as well as to pathology of the endometrium. The latter two etiologic factors create difficulties in the correct diagnosis of a congenital malformation and despite the convincing hysterosalpingographic findings a false diagnosis of a congenital malformation and despite the convincing hysterosalpingographic findings a false diagnosis is frequent. On the other hand the various degrees of uterine anomalies cannot always convince the gynecologist to undertake a plastic operation where the results for future fertility are doubtful. In our experience the extensive beneficial use of a variety of selected IUDs for the correction of intrauterine lesions also resulted in the correction of the size and shape of the uteri, previously diagnosed as malformed. The preliminary results of treatment in 110 cases of uterine anomalies after the application of a selected IUD combined with the administration of high doses of gestagens, showed an overall satisfactory improvement or complete reconstruction to a normal uterus in 86 (78%) of the cases. Higher fertility rate, better pregnancy outcome, correct diagnosis of the existing malformation, and safer decisions for further correction have also been attributed to the beneficial effects of the above treatment.     

Hereditary hemorrhagic telangiectasia with pulmonary arteriovenous malformations

Background: Most congenital pulmonary arteriovenous malformations are associated with hereditary hemorrhagic telangiectasia. During pregnancy, pulmonary hemorrhage can occur, compromising maternal and fetal health.Cases: We studied three pregnancies in two women with hemorrhagic telangiectasia complicated by pulmonary arteriovenous malformations. A 28-year-old primigravida’s fetus died at 25 weeks’ gestation, and she had embolotherapy with coil springs, which corrected the hypoxemic state. In a subsequent pregnancy she delivered a healthy 2315-g infant at 38 weeks’ gestation. A 19-year-old primigravida had spontaneous hemothorax at 26 weeks’ gestation with severe hypoxemia and a growth-restricted fetus without umbilical artery diastolic flow. Pulmonary arteriovenous malformation was diagnosed by computed tomography of the maternal lung. She had continued pulmonary bleeding, so emergency lung lobectomy was done. Maternal hypoxemia and umbilical diastolic flow improved, and she had term delivery of a healthy 2250-g infant.Conclusion: Antenatal diagnosis and treatment of women with hereditary hemorrhagic telangectasia and pulmonary arteriovenous malformations might prevent potentially life-threatening fetomaternal complications.     

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.     

Anatomische Ursachen habitueller Aborte

Recurrent miscarriage can be caused by multiple factors. This review focuses on uterine conditions responsible for recurrent miscarriage. Such anomalies can be either congenital or acquired. Among the former are septate, bicornuate, and unicornuate uterus and uterus didelphys, whereas arcuate uterus does not seem to be responsible for miscarriage. Acquired uterine malformations include intrauterine adhesions, endometrial polyps, and myomas. Some of these malformations can be treated surgically, improving the prognosis for future pregnancies in patients with histories of recurrent abortion.     

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.     

Perinatal management of fetal malformations amenable to surgical correction

Advances in prenatal imaging modalities such as ultrasound and magnetic resonance imaging have permitted the more frequent and accurate diagnosis of congenital malformations. Fetal surgical intervention has been reserved for those malformations that lead to fetal demise or are life-threatening in the neonatal period. We review the current indications for intervention in fetuses diagnosed with congenital lung lesions, congenital diaphragmatic hernia, sacrococcygeal teratoma, and obstructing airway lesions. A discussion of the recent interest in the fetal repair of severe myelomeningocele is also included.     

An unusual case of rupture of a pregnant rudimentary horn of a bicornuate uterus

Relatively few comprehensive studies^1–4 comprising a significant number of cases of congenital malformations of the female reproductive tract associated with pregnancy have appeared in the obstetrical literature.Among congenital uterine malformations the most frequently encountered is the bicornuate uterus. The report presented is a case of rupture of a pregnant rudimentary horn of a bicornuate uterus.     

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.     

Anatomic factors in recurrent pregnancy loss

Anatomic uterine defects are present in 15% of women evaluated for three or more consecutive spontaneous abortions. These anatomic abnormalities can be classified as congenital or acquired. In addition to pregnancy loss, uterine malformations appear to predispose women to other reproductive difficulties including infertility, preterm labor, and abnormal presentation. These poor reproductive outcomes resulting from uterine septum, intrauterine adhesions, polyps, and fibroids are amenable to surgical correction. Therefore, it is essential to make an accurate diagnosis to offer an adequate treatment. In this article, we review the common congenital and acquired uterine anomalies associated with recurrent pregnancy losses, and discuss contemporary diagnosis and treatment options.     

Expectant management of pregnancy-related high-velocity uterine arteriovenous shunt diagnosed after abortion

Objective

To assess sonographic and clinical outcome in women with pregnancy-related uterine arteriovenous malformations (AVMs) diagnosed after abortion.

Method

Twelve patients diagnosed as having AVMs after abortion were followed-up until resolution of the lesions.

Results

The 9 asymptomatic patients were managed expectantly for 4 to 10 weeks without further complications. None of the 12 required aggressive interventions such as transcatheter arterial embolization, and 6 had uncomplicated pregnancies after resolution of the lesions.

Conclusion

Expectant management is an option in many women with pregnancy-related uterine AVMs.     

经阴道超声诊断不孕症常见宫腔病变的分析——300例与宫腔镜检查结果的比较

目的:探讨经阴道超声检查不孕症患者常见宫腔内疾病的发生率准确性。方法:分析300例同时接受阴道超声及宫腔镜检查的不孕症患者常见宫腔内病变,比较2种方法的各项指标。结果:所占比例最高的宫腔内病变为子宫内膜息肉,其次为宫腔粘连、宫腔畸形,最低的是子宫内膜结核;对各种常见宫腔内病变的诊断,2种检查方法符合率比较无统计学差异(P0.05)。结论:阴道超声在诊断不孕症患者中最常见的宫腔内病变是子宫内膜息肉、宫腔粘连、宫腔畸形,黏膜下肌瘤、内膜结核较少见;子宫内膜息肉、宫腔粘连中各项指标均高,最有利于开展临床工作;对诊断子宫异常增生、慢性非特异性子宫内膜炎,宫腔镜可以定位取材,明显优于阴道超声。