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.

OBJECTIVE: Symptomatic 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 REPORT: A 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. CONCLUSION: This 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.

The RPOC long axis is a simple indicator for predicting the need of invasive strategies for secondary postpartum hemorrhage in either post-abortion or post-partum women: a retrospective case control study.

BACKGROUND: The retained products of conception (RPOC) and related conditions (RPOC-ARC) are the main cause of secondary postpartum hemorrhage (sPPH), but there is no clear consensus for their management. The purpose of this study was to characterize those RPOC-ARC that require invasive treatment and those that could be managed more conservatively. METHODS: We retrospectively analyzed 96 cases of RPOC-ARC that occurred after miscarriage, abortion, or delivery at a gestational age between 12 and 42 completed weeks, that were managed within our institution from May 2015 to August 2020. We reviewed the associations between the occurrence of sPPH requiring invasive treatment with clinical factors such as the maternal background and the characteristics of the lesions. RESULTS: The range of gestational age at delivery in our study was 12-21 weeks in 61 cases, 22-36 in 5, and 37 or later in 30. Among them, nine cases required invasive procedures for treatment. The onset of sPPH was within one month of delivery in all but two cases, with a median of 24 days (range 9-47). We found significant differences between requirements for invasive versus non-invasive strategies according to gestational age at delivery, assisted reproductive technology (ART) pregnancy, amount of blood loss at delivery, and the long axis of the RPOC-ARC lesion (p = 0.028, p = 0.009, p = 0.004, and p = 0.002, respectively). Multivariate analysis showed that only the long axis of the lesion showed a significant difference (p = 0.029). The Receiver Operating Characteristic (ROC) curve for predicting the need for invasive strategies using the long axis of the lesion showed that with a cutoff of 4.4 cm, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) was 87.5, 90.0, 43.8, and 98.7%, respectively. CONCLUSION: The long axis of the RPOC-ARC is a simple indicator for predicting which sPPH will require invasive procedures, which use is rare in cases with lesions less than 4.4 cm or those occurring after the first postpartum month. Conservative management should be considered in such cases.

Medical treatment of uterine arteriovenous malformation: a systematic review and meta-analysis.

OBJECTIVE: To quantify the efficacy of medical management of uterine arteriovenous malformation (AVM) and compare efficacy between different classes of medication. In addition, we evaluated for factors associated with treatment success and pregnancy outcomes after medical management. DESIGN: Systematic review and meta-analysis. SETTING: Not applicable. PATIENT(S): Thirty-two studies representing 121 premenopausal women with medically-treated uterine AVM were identified via database searches of MEDLINE, Embase, Web of Science, and cited references. INTERVENTION(S): Medical treatment with progestins, gonadotropin-releasing hormone agonists (GnRH-a), methotrexate, combined hormonal contraception , uterotonics, danazol, or combination of the above. MAIN OUTCOME MEASURE(S): Primary outcome of treatment success was defined as AVM resolution without subsequent procedural interventions. Secondary outcome was treatment complication (readmission or transfusion). RESULT(S): The overall success rate of medical management was 88% (106/121). After adjusting for clustering effects, success rates for progestin (82.5%; 95% confidence interval [CI], 70.1%-90.4%), GnRH-a (89.3%; 99% CI, 71.4%-96.5%) and methotrexate (90.0%; 99% CI, 55.8%-98.8%) were significantly different from the null hypothesis of 50% success. The agents with the lowest adjusted proportion of complications were progestins (10.0%; 99% CI, 3.3%-26.8%) and GnRH-a (10.7%; 99% CI, 3.5%-28.4%). No clinical factors were found to predict treatment success. Twenty-six subsequent pregnancies are described, with no reported recurrences of AVM. CONCLUSION(S): Medical management for uterine AVM is a reasonable approach in a well selected patient. These data should be interpreted in the context of significant publication bias.

Successful transcatheter arterial embolization for massive hemorrhage from acquired uterine arteriovenous malformation which occurred as a complication of hysterectomy: A case report.

RATIONALE: Uterine arteriovenous malformation (UVM), which can be congenital or acquired, is a relatively rare disorder that can cause life-threatening hemorrhage. Acquired UVM occurs predominantly after previous uterine procedures; rarely, it may occur after a hysterectomy. Although the best treatment option for UVM remains controversial, transcatheter arterial embolization (TAE) has recently been introduced as a safe and effective treatment. PATIENT CONCERNS: A 34-year-old woman who underwent hysterectomy for uncontrolled postpartum bleeding continued to have hemoperitoneum. DIAGNOSIS: Two days after surgery, massive hemoperitoneum was identified on computed tomography scan, and acquired UVM was diagnosed by angiography. INTERVENTIONS: The patient was successfully treated using TAE with an n-Butyl cyanoacrylate. OUTCOMES: After embolization, hemodynamic stability was achieved. A day after embolization, hemoglobin was 10.2 g/dL, and the patient was discharged from the hospital 4 days thereafter. LESSONS: Although the overall incidence of acquired UVM after hysterectomy is low, bleeding from acquired UVM should be considered as one of the differential diagnoses in the immediate postpartum period, especially when the clinical symptoms do not correlate with the amount of blood loss. A high index of suspicion, prompt diagnosis and intervention, and a multidisciplinary approach in the management were the elements of a successful outcome in this case.

Uterine arterio-venous malformation, an uncommon life-threatening condition: a case report.

Uterine Arteriovenous Malformation is a rare gynaecological disorder which commonly presents with profuse vaginal bleeding. This case report presents a patient referred to the Military Hospital, Rawalpindi from Pakistan Aeronautical Complex Hospital Kamra, a peripheral secondary care hospital. Patient was diagnosed as a case of Uterine Arteriovenous Malformation at the Military Hospital and was successfully treated with uterine artery embolization..

Evidence for uteroplacental malperfusion in fetuses with major congenital heart defects.

AIMS: Fetuses affected by congenital heart defects (CHD) are considered to be at increased risk of fetal growth restriction and intrauterine demise. Whether these risks are a direct consequence of fetal CHD or a result of associated uteroplacental dysfunction is not evident from the data of recent studies. The aim of this study was to investigate the prevalence of uteroplacental dysfunction reflected by abnormal uterine artery Doppler indices and reduced fetal growth in CHD pregnancies. METHODS: This is a retrospective case-control study including singleton pregnancies referred for detailed fetal cardiac assessment subsequently diagnosed with or without CHD. Mid-trimester uterine artery Doppler assessment at 20-24 weeks as well as third trimester fetal biometry and arterial Doppler pulsatility indices (PI) were performed. All fetal biometry were converted into centiles and Doppler values to multiples of median (MoM) to adjust for physiological changes with gestation. RESULTS: The study included 811 pregnancies including 153 cases where the fetus was diagnosed with CHD. Mid-pregnancy uterine artery PI was significantly higher in women with fetal CHD compared to controls (0.90MoM vs 0.83MoM; p = 0.006). In the third trimester, median centiles for fetal head circumference (45.4 vs 57.07; p<0.001), abdominal circumference (51.17 vs 55.71; p = 0.014), estimated fetal weight (33.6 vs 56.7; p<0.001) and cerebroplacental ratio (CPR: 0.84MoM vs 0.95MoM; p<0.001) were significantly lower in fetuses with CHD compared to controls. The percentage of small for gestational age births <10th centile (24.0% vs 10.7%; <0.001) and low CPR <0.6MoM (11.7% vs 2.5%; p<0.001) were significantly higher in the fetal CHD cohort. CONCLUSIONS: Mid-pregnancy uterine artery resistance is increased and subsequent fetal biometry reduced in pregnancies with CHD fetuses. These findings suggest that fetal CHD are associated with uteroplacental dysfunction, secondary to impaired maternal uteroplacental perfusion resulting in relative fetal hypoxaemia and reduced fetal growth.

Arteriovenous uterine malformation developed from an interstitial pregnancy on residual tubal stump: A critical managment in a fertile woman.

Uterine arteriovenous malformations are rare conditions with diverse clinical presentation that range from asymptomatic patients to different degrees of menorrhagia, commonly associated with previous pregnancy or uterine trauma. This case report describes a 36-year-old woman who presented with ultrasound diagnosis of interstitial pregnancy on residual right tube stump 4 months after a laparoscopic salpingectomy for extrauterine pregnancy. She started treatment with methotrexate; afterwards serum human chorionic gonadotropin levels and ultrasound follow-ups were scheduled. While serum human chorionic gonadotropin levels were progressively reducing, transvaginal ultrasound follow-ups showed a persistent anechoic mass on right rube stump, with increased peripheral high flow vascularity: highly suspicious for a uterine arteriovenous malformation. A laparoscopy was performed with a tumorectomy of the mass. The histopathological exam of the specimen confirmed uterine arteriovenous malformation. Patient successfully became pregnant 2 years later, with an eventless pregnancy and a vaginal delivery without complications.

Intraoperative transradial angiography augments safe hysterectomy for uterine fibroids in the setting of ambiguous arterial anatomy: a case report.

BACKGROUND: Transfemoral access is the traditional gold standard for uterine artery angiography; however, transradial access is gaining in popularity because of its decreased complication profile and patient preference. We present a case of a patient who underwent successful total abdominal hysterectomy for symptomatic uterine fibroids with ambiguous pelvic vasculature that would have been otherwise aborted if it were not for intraoperative transradial access angiography. CASE PRESENTATION: A 52-year-old Caucasian woman presented to her gynecologist for an elective total abdominal hysterectomy and bilateral salpingo-oophorectomy. During preoperative imaging, a 15-cm mass consistent with a uterine fibroid was identified, and the patient's gynecologist decided to treat her with surgical resection, given the fibroid's size. The procedure was halted upon discovery of a complicated vascular plexus at the fundus of the uterus, and an intraoperative vascular consult was requested. The vascular operator used a transradial access to perform pelvic angiography in real time to identify the complicated pelvic vasculature, which allowed the gynecologist to surgically resect the uterine fibroid. The patient was discharged on postoperative day 4 without any complications. CONCLUSIONS: Intraoperative imaging is a useful technique for the identification of complicated anatomical structures during surgical procedures. The successful outcome of this case demonstrates an additional unique benefit of transradial access and highlights an opportunity for interdisciplinary collaboration for management of complicated surgical interventions.

Successful management of abnormal uterine bleeding from uterine arteriovenous malformations with progesterone in postabortal patients.

AIM: To study the feasibility of conservative management with progesterone as a treatment option for postabortal patients with uterine arterio-venous malformations (AVMs). METHODS: This prospective observational study was conducted in the tertiary care teaching hospital over a period of 2 years. Postabortal patients with abnormal uterine bleeding were enrolled. Diagnosis was made by history, clinical and radiological examinations. Oral norethisterone was used (10 mg twice daily for 3 weeks, maximum of three cycles). Descriptive statistics was used to present the data. RESULTS: A total of 30 patients were included. Majority (n = 17) had complete resolution of symptoms after a single 3-week course of progesterone therapy. Rest (n = 13) remained symptomatic and required second course. Of the later, only three remained symptomatic after 2 months, and underwent CT angiography followed by embolization. There was no report of any serious adverse events. CONCLUSION: Oral norethisterone is a safe, effective and novel oral drug as an alternative to embolization or surgical therapy for patients with postabortal AVM bleed. Larger studies are required to confirm the findings of the present study.

Repeated pulmonary embolism with cardiac arrest after uterine artery embolization for uterine arteriovenous malformation: A case report and literature review.

OBJECTIVE: Uterine arteriovenous malformation (AVM) is an abnormal and nonfunctional communication between uterine arteries and veins, currently managed by uterine artery embolization (UAE). Pulmonary embolism (PE) is the most severe and life-threatening complication of this procedure. CASE REPORT: We report a case of 27 year-old woman with heavy vaginal bleeding and abdominal pain caused by AVM. UAE was performed uneventfully, but 2 h after the procedure the first attack of pulmonary embolism occurred, treated by anticoagulation therapy. Second attack happened on the third postinterventional day. Considering vaginal bleeding, continued extracorporeal membrane oxygenation (ECMO), and suspicion of embolic particles arising from uterus, a subtotal hysterectomy was done. Patient was discharged two weeks following surgery, after complete recovery. CONCLUSION: Although AVM is managed by UAE, clinicians must be aware of complications. To avoid PE, we suggest only large sized microspheres for carefully selected patients.

Successful management of acquired uterine arteriovenous malformation.

Uterine arteriovenous malformation (UAVM) is uncommon. They are usually acquired, due to previous intra uterine trauma. We report a case of acquired UAVM in a 28-years-old patient after a medical abortion, diagnosed with ultrasonography and successfully managed with uterine artery embolization.

Uterine arteriovenous malformation - diagnosis and management.

Uterine arteriovenous malformations are uncommon but potentially life-threatening conditions. They can be congenital or acquired and should be suspected in cases of severe or persistent uterine bleeding. In recent years, there has been an in-creasing number of reports of acquired vascular lesions of the uterus following pregnancy, abortion, caesarean delivery and curettage. This paper presents the review of the literature considered epidemiology, pathophysiology, diagnostic methods and treatment options. Unexplained uterine bleeding should be always an indication for colour Doppler ultrasonography and the presence of arteriovenous malformation should be always excluded.

Uterine Arteriovenous Malformations after Suction Evacuation of Missed Miscarriage.

Uterine arteriovenous malformation (AVM) is an uncommon but life-threating source of bleeding. AVM is an abnormal connection between uterine arteries and veins. Patients typically present with vaginal bleeding following miscarriage (medical/surgical) or cesarean section. The treatment of choice depends on the symptoms, age, desire of fertility, localization and size of the lesion. Uterine artery embolization is the first choice in symptomatic patients of reproductive age group. We report a case of AVM presenting after dilation and evacuation with extensive lesion, which was successfully treated with bilateral uterine artery embolization.

Extensive uterine arteriovenous malformation with hemodynamic instability: Embolization for whole myometrium affection.

Uterine arteriovenous malformation is abnormal and nonfunctional connections between the uterine arteries and veins. Patients typically present with vaginal bleeding which may be life-threatening. Treatment depends on the symptoms, age, desire for future fertility, localization and size of the lesion. Embolization of the uterine artery is the first choice in symptomatic AVM in patients in the reproductive age. We report a case of acquired AVM with an extensive lesion on ultrasound and MRI, which was successfully treated with uterine artery embolization for severe bleeding (UAE).