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Case Report
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 45/Nov. 05, 2015 Page 8208
A CASE STUDY OF ARTERIOVENOUS MALFORMATIONS OF PREGNANT UTERUS
Sravanthi Pathapati1, Mamatha Reddy2, Kudupudi Subba Rao3
1Post Graduate, Department of Obstetrics & Gynecology, Konaseema Institute of Medical Sciences & RF.
2Post Graduate, Department of Obstetrics & Gynecology, Konaseema Institute of Medical Sciences & RF.
3Professor, Department of Obstetrics & Gynecology, Konaseema Institute of Medical Sciences & RF.
ABSTRACT: Uterine arteriovenous malformation (AVM) is a rare but potentially life threatening condition with fewer than 100
cases reported in literature. With advent of Doppler ultrasonography many cases of uterine arteriovenous malformations have been diagnosed. We present a case of AVM uterus in 22 years old presented with pain abdomen and shock and trans abdominal ultrasound was done showing hemoperitonium. Exploratory laparotomy was done and hemostasis was controlled. Colour Doppler and angiography were used for diagnosis. Bilateral uterine arteries embolization was performed successfully.
HOW TO CITE THIS ARTICLE: Sravanthi Pathapati, Mamatha Reddy, Kudupudi Subba Rao. “A Case Study of Arteriovenous
Malformations of Pregnant Uterus”. Journal of Evidence based Medicine and Healthcare; Volume 2, Issue 45, November 05, 2015; Page: 8208-8209, DOI: 10.18410/jebmh/2015/1105
INTRODUCTION: Arteriovenous malformations (AVMs)
are vascular channels composed of admixture of arteries and veins without intervening capillaries. These AVMsconsist of numerous fragile low-resistant arteriovenous shunts. Uterine arteriovenous malformation (UAVM) is a rare condition that affects women of reproductive age and clinically presents with unexplained profuse bleeding par vagina. UAVM are abnormal vascular channels that involve the myometrium and occasionally the endometrium.1 The first case of uterine AVM was reported
by Dubreuil and Loubat in 1926.2 We report a case of
uterine AVM diagnosed during pregnancy during 36 weeks gestation treated with bilateral uterine arteries embolization.
CASE REPORT: A 22 years old G2P1 with history of
previous LSCSat 36 weeks gestational age was admitted with complaints of lower abdominal pain. After admission patient had hemodynamicallydetoriated. Patient was started on colloid infusion and trans abdominal ultrasound was done which showed hemoperitonium and intact uterine scar. An emergency laparotomy was performed and about 1.5 litres of hemoperitonium was seen and a bleeding vessel at posterior aspect of uterus was identified. Fine superficial hemostatic sutures around the bleeding site caused profuse bleeding from needle entry and exit points. So four vessel ligation was performed and hemostasis was controlled. LSCS was performed and baby was delivered.
Colour Doppler on 7th post operative day showed
serpigenous anechoic structures within the myometrium of
Submission 21-10-2015, Peer Review 22-10-2015, Acceptance 27-10-2015, Published 05-11-2015. Corresponding Author:
Sravanthi Pathapathi, Post Graduate, Department of Obstetrics & Gynecology, Konaseema Institute of Medical Sciences & RF. Amalapuram.
E-mail: drsravanthipathapati@gmail.com DOI: 10.18410/jebmh/2015/1105
posterior uterine wall with low resistance high flow pattern suggestive of arterio venous malformation. Patient was referred to higher centre where uterine artery angiogram confirmed the presence of arterio venous malformation. Embolization of AVM was done with embolization of both uterine arteries. Post embolization angiography showed complete embolization of AVM. No complications were encountered and the patient was eventually discharged.
DISCUSSION: Uterine AVMs are a rare cause of uterine
bleeding with fewer than 100 cases reported.3
Arteriovenousmal formations may be congenital or acquired, with the congenital form being rare, the result of anomalous differentiation or development of the capillary plexus, leading to multiple abnormal connections between arteries and veins. Acquired uterine AVMs are really multiple small arteriovenous fistulas between intramural arterial branches and the myometrial venousplexus and appear as a vascular tangle, mimicking congenital AVMs. Acquired uterine vascular malformations may be due to trauma, malignancy, or infection. Specific causes include miscarriage, termination, dilation and curettage, cesarean delivery, carcinoma of the cervix or endometrium, uterine infection, trophoblastic disease, fibromas, endometriosis, and uterine surgery.4
Gross specimen evaluation may reveal variable sized thin-walled, tubular channels filled with blood clots which appear as region of irregular blood spaces and congested blood vessels within the myometrial tissues that is devoid of specific lesion. Similarly, microscopic examination may demonstrate the gross pathologic findings as numerous dilated blood-filled (Estatic and congested) thick walled vessels of varying calibre in the myometrium that may extend into the endometrium.5Patients may present
variably from an asymptomatic case to life-threatening situation such that the patient may be in hypovolemic shock at the point of presentation. Most commonly the bleeding is intermittent and torrential. A surprising case of UAVM was reported by Das et al,6 in which the patient had
Jebmh.com
Case Report
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 45/Nov. 05, 2015 Page 8209
a history of recurrent par vagina bleeding of 18 years duration.
This case shows that patient presentation may be acute or chronic depending on the amount of blood loss, associated complicating features and clinical status. Angiography is the gold-standard in making a diagnosis of UAVM. The UAVM appears as a tangle of dilated vessels with early venous drainage which is seen during the angiographic arterial phase. Color Doppler features are more consistent and include intense juxtaposed signals with aliasing. Spectral Doppler sonography reveals high-velocity diastolic components with low-resistance flow (resistive index, 0.25–0.55; pulsatility index, 0.3–0.6) and high PSV greater than 96 cm/s that suggest arteriovenous shunting.7,8 Treatment of uterine AVMs remains
controversial, often with great concern for fertility. Hysterectomy remains the definitive treatment, especially in a symptomatic patient without desired fertility.9 A
minimally invasive approach through angiographic embolization of the AVM, which has potential to preserve fertility, is currently the preferred treatment.
CONCLUSION: AVM of uterus, although rare, must be
considered in unexpected, intermittent torrential bleeding after delivery or a procedure on the uterus. Gray scale morphology and Doppler US should be used for noninvasive diagnosis of uterine AVM. Angiography should be used both for diagnosis of AVM and treatment with embolization. Angiography and embolization should be performed in stable patients when the bleeding is not heavy. In patients with profuse bleeding hysterectomy should be the mainstay of treatment.
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