European Journal of Obstetrics & Gynecology and Reproductive Biology
Vascular malformations in the uterus: ultrasonographic diagnosis and conservative management
Introduction
Uterine arteriovenous malformations (AVM) are considered to be rare entities, with in 1997 only 73 cases reported in the literature [1]. However, the true incidence of AVM is unknown. These lesions may be congenital or acquired [2], [3]. Congenital AVM result from a failure in the embryological vascular differentiation [4], leading to multiple vascular connections. AVM are isolated anomalies in otherwise healthy persons [2]. They are extremely variable in size and anatomical location, leading to different clinical presentations. AVM have been reported in head, neck, extremities, but also in bowel, lung, spleen, stomach, pancreas, bladder, uterus or vagina [3], [5]. Congenital uterine AVM tend to invest the surrounding tissues, and constitute a very difficult therapeutical challenge. If asymptomatic no treatment is required. Since proliferation during pregnancy has been reported [2], [6], some authors consider it an absolute contraindication for pregnancy [2]. Most cases, however, are acquired and have resulted from previous uterine surgery or curettage, gestational trophoblast disease, exposure to diethylstilbestrol, infection, endometrial or cervical cancer [7], [8], [9], [10], [11], [12], [13].
Historically the diagnosis of uterine AVM was made only at laparotomy or upon pathological examination of the uterine specimen after hysterectomy had been performed. Subsequently, angiography became the gold standard for diagnosis of this condition [14]. More recently, color Doppler ultrasonography [15], [16] and hysteroscopy [3], [14], [17] have been proposed for obtaining a reliable diagnosis. More recent reports [5], [13], [15], [16], [18] suggest that color Doppler ultrasonography is the preferred method of diagnosing AVM, and that angiography should be reserved for cases in which surgical intervention and therapeutic embolization of the lesion are planned [15]. The ultrasonographic diagnosis of AVM is based on the presence of hypoechoic tortuous spaces in the myometrium demonstrating vascular flow as evidenced by color Doppler [1]. Spectral analysis of the vessels shows low impedance, and high velocity flow. To date it is not known how specific these criteria are to detect true uterine AVM.
Most reported cases so far have been treated with either hysterectomy [2], [3], [7], [13], [14], [15] or embolization of the uterine arteries [12], [20], [21], [22], [23], [24]. Using the published ultrasonographic criteria of AVM, we were surprised by the number of cases of uterine vascular malformations that had been diagnosed in the department of Obstetrics and Gynecology of our institution. We therefore have undertaken present observational study. The aims of the present study were, first, to estimate the proportion of premenopausal women with abnormal vaginal bleeding in whom uterine AVM or vascular malformation was considered to be the cause of abnormal bleeding; second, to analyze the outcome of patients diagnosed with uterine AVM at color Doppler imaging.
Section snippets
Methods
We studied all consecutive cases with abnormal premenopausal vaginal bleeding referred for transvaginal ultrasonography with color Doppler imaging to the University Hospitals Leuven between December 1994 and January 1999. All women were scanned by the same ultrasonographer (DT) with either an Acuson 128 XP/10 Acoustic Response Technology (ART) ultrasound system or an Acuson Sequoia ultrasound system (Acuson Inc., Mountain View, CA, USA), both equipped for color Doppler imaging. A 5 MHz or a
Results
A total of 265 consecutive patients were enrolled. The mean age of these women was 39 years (range 11–57 years). A total of 88 patients (33%) presented with intermenstrual bleeding, 91 (34%) with menorrhagia and 65 (25%) with menometrorraghia. Among them 14 (5%) patients complained of persistent postpartum bleeding, 4 (2%) patients had abnormal uterine bleeding after a miscarriage and 3 (1%) patients had bleeding under continuous progestogen treatment. The presenting symptoms and final
Case 1
A 27-year-old woman, gravida 1, para 0, presented with persistent vaginal blood loss 6 weeks after an uncomplicated therapeutic abortion at 18 weeks’ gestation. She had first presented a week after the procedure complaining of heavy, vaginal bleeding, requiring intravenous oxytocin for 24 h and afterwards ergometrin. After 6 days she reported a similar complaint and curettage was performed. Histological examination was negative. The next day she was discharged from hospital. Four weeks later,
Discussion
Arteriovenous malformations are considered to be very rare. However, the true incidence of AVM is unknown. The case reports published to date may represent only the tip of the iceberg of this poorly understood phenomenon, and very probably a strong bias exists in the literature towards the most severe and life-threatening cases [6], [25], [26], [27]. Manolitsas and colleagues [14] predicted that the more widespread use of the appropriate investigations, coupled with an increasing awareness of
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