P14.14: Acquired uterine arteriovenous malformation (AVM): case series

Abstract

Uterine AVM although rare, may be acquired after myometrial damage by instrumentation. Pelvic Transvaginal Ultrasound (TVS), gray-scale with colour Doppler and spectral analysis are excellent diagnostics with AVM appearing as subtle heterogeneous hypoechoic myometrial masses with serpinginous mosaic hypervascularity, with low resistance, turbulent vascular flow on Doppler. PSV seems most accurate with a value below .39 m/sec being considered “safe area” and above 0.83 m/sec “dangerous area”. Between 0.40 m/sec and below 0.83 m/sec are “potentially dangerous” according to Timmerman D., Wauters J. et al, Colour Doppler imaging is a valuable tool for the diagnosis and management of UAVM Ultrasound Obstet Gynecol 2003; 21, 570-577. Gold Standard for diagnosis is Angiography, however invasive and reserved for cases needing embolisation, surgery, or both. Presented are 0.14 percent (4/2750 cases) of the total gynecologic cases in 5 years. All presented with profuse vaginal bleeding post curettage. Initial diagnoses were Incomplete Abortion, Endometritis, and Trophoblastic Disease. TVS Indices showed uterine AVM with PSV= 0.55 m/s to 0.7 m/s classified as “Potentially Dangerous”. Three warranted blood transfusion with two undergoing Total Abdominal Hysterectomy with Right Salpingoophorectomy and Bilateral Hypogastric Artery Ligation with endometrial mass excision. Two were stable and underwent Uterine Artery Embolisation (UAE). All repeat TVS with Doppler showed homogeneous myometrium. Clinical courses from time of uterine surgery to diagnosis lasted 1.5 to 8 weeks. Total time from prior obstetric procedure to resolution was 2.7 to 12 weeks. The potential danger of Uterine AVM necessitates careful evaluation and treatment. UAE as conservative therapy is recommended for urgent treatment prior to performing another curettage or surgical procedure, to avoid complications. Total clinical time, from prior obstetric surgical procedure to resolution of disease was 8.5 weeks to 12 weeks proving that UAE is a safe and effective option for conservative management.