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      Uterine arteriovenous malformation leading to postpartum hemorrhage: A case report

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          Abstract

          Uterine arteriovenous malformation (AVM) is an uncommon but potentially life-threatening cause of postpartum hemorrhage (PPH). AVMs often present with intermittent or profuse vaginal bleeding in a woman with a history of uterine instrumentation. Transvaginal ultrasound is the initial imaging method used for diagnosis. Management depends on the patient's hemodynamic stability and desire for future pregnancy. Uterine artery embolization (UAE) is the initial treatment option for women of reproductive age. Due to limited evidence, there are no guidelines for the management of failed UAE. Here we report a case of uterine AVM following a cesarean section that failed initial management with UAE and required emergency hysterectomy.

          Highlights

          • •

            Uterine arteriovenous malformation (AVM) is a rare cause of postpartum hemorrhage.

          • •

            Acquired uterine arteriovenous malformations are associated with a history of surgical instrumentation of the uterus.

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            Transvaginal ultrasound is the initial imaging method used for diagnosis.

          • •

            Uterine artery embolization is the first-line treatment for uterine arteriovenous malformations.

          • •

            Hysterectomy is a definitive treatment for uterine arteriovenous malformations refractory to embolization.

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          Color Doppler imaging is a valuable tool for the diagnosis and management of uterine vascular malformations.

          D Timmerman, Robrecht van der Wel, S Linden … (2003)
          The aim of this study was to assess the spontaneous outcome of uterine vascular malformations detected with ultrasonography and color Doppler, and to investigate the predictive value of color Doppler imaging as to which patients require invasive treatment. This was a prospective observational study conducted between January 1999 and February 2001 comprising all consecutive patients diagnosed with a uterine vascular malformation by ultrasonography and color Doppler imaging. Spectral analysis included measurement of flow velocities, pulsatility index (PI) and resistance index (RI). Close follow-up was arranged in all cases and the outcomes were recorded. A total of 30 consecutive patients with uterine vascular malformations were included in the study. Spectral analysis of the vessels in the vascular malformations within the myometrium and endometrium revealed the presence of a low-impedance and high-velocity flow. The average values for PI, RI, peak systolic velocity (PSV) and time-averaged maximum velocity (TAMXV) were 0.50, 0.38, 0.63 m/s and 0.46 m/s, respectively. Eight patients (27%) eventually required embolization of the uterine arteries and three of them had true arteriovenous malformations confirmed at angiography. PSV values of >/= 0.83 m/s were associated with higher probabilities of further treatment, such as an embolization, whereas no vascular malformation with a PSV value < 0.39 m/s required embolization. Conservative management is possible in more than two-thirds of patients presenting with uterine vascular malformations diagnosed by color Doppler sonography. Despite considerable overlap, PSV values appear to be useful in distinguishing between low- and high-risk patients. Copyright 2003 ISUOG. Published by John Wiley & Sons, Ltd.
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            A Systematic Review of Acquired Uterine Arteriovenous Malformations: Pathophysiology, Diagnosis, and Transcatheter Treatment

            Daniel J. Yoon, Megan E.B. Jones, Jamal Taani … (2015)
            Objective An acquired uterine arteriovenous malformation (AVM) is a rare cause of vaginal bleeding and, although hysterectomy is the definitive therapy, transcatheter embolization (TCE) provides an alternative treatment option. This systematic review presents the indications, technique, and outcomes for transcatheter treatment of the acquired uterine AVMs. Study Design Literature databases were searched from 2003 to 2013 for eligible clinical studies, including the patient characteristics, procedural indication, results, complications, as well as descriptions on laterality and embolic agents utilized. Results A total of 40 studies were included comprising of 54 patients (average age of 33.4 years). TCE had a primary success rate with symptomatic control of 61% (31 patients) and secondary success rate of 91% after repeated embolization. When combined with medical therapy, symptom resolution was noted in 48 (85%) patients without more invasive surgical procedures. Conclusion Low-level evidence supports the role of TCE, including in the event of persistent bleeding following initial embolization, for the treatment of acquired uterine AVMs. The variety of embolic agents and laterality of approach delineate the importance of refining procedural protocols in the treatment of the acquired uterine AVM. Condensation A review on the management of patients with acquired uterine AVMs.
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              Arteriovenous malformation of the uterus associated with secondary postpartum hemorrhage.

              S M Kelly, A. Belli, S. Campbell (2003)
              We present the case of a young woman with persistent secondary postpartum hemorrhage. Transvaginal imaging demonstrated an irregular pulsatile lesion in the anterior myometrium. Color Doppler analysis revealed the presence of abnormal vessels consistent with an arteriovenous malformation. Typically this vascular abnormality had a turbulent pattern of arterial and venous flow with high peak velocities and low resistance. The patient was treated with selective arterial embolization leading to a full recovery.
              Article 0 comments Cited 11 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Nathaniel Gallagher
                Journal
                Journal ID (nlm-ta): Case Rep Womens Health
                Journal ID (iso-abbrev): Case Rep Womens Health
                Title: Case Reports in Women's Health
                Publisher: Elsevier
                ISSN (Electronic): 2214-9112
                Publication date PMC-release: 03 October 2020
                Publication date Collection: October 2020
                Publication date (Electronic): 03 October 2020
                Volume: 28
                Electronic Location Identifier: e00260
                Affiliations
                [a ]Medical Student, Marshall University Joan C. Edwards School of Medicine, Huntington, WV, United States of America
                [b ]Department of Obstetrics & Gynecology, Marshall University Joan C. Edwards School of Medicine Huntington, WV, United States of America
                [c ]Department of Radiology, Marshall University Joan C. Edwards School of Medicine Huntington, WV, United States of America
                Author notes
                [* ]Corresponding author at: Marshall University Joan C. Edwards School of Medicine, 1600 Medical Center Drive, Huntington, WV 25701, United States of America. gallagher16@ 123456marshall.edu
                Article
                Publisher Item ID: S2214-9112(20)30090-4 Publisher ID: e00260
                DOI: 10.1016/j.crwh.2020.e00260
                PMC ID: 7559227
                PubMed ID: 33088725
                SO-VID: 62e383ca-8263-46cd-897a-21af634f50e1
                Copyright © © 2020 The Authors
                License:

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                Date received : 24 September 2020
                Date revision received : 26 September 2020
                Date accepted : 30 September 2020
                Categories
                Subject: Article

                Keywords: uterine arteriovenous malformation,uterine artery embolization,postpartum hemorrhage,avm, arteriovenous malformation,uae, uterine artery embolization,pph, postpartum hemorrhage
                Data availability:
                Keywords: uterine arteriovenous malformation, uterine artery embolization, postpartum hemorrhage, avm, arteriovenous malformation, uae, uterine artery embolization, pph, postpartum hemorrhage

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