Outcome in women undergoing uterine artery embolization for arterio-venous malformation diagnosed post-pregnancy-A retrospective study

Abstract

Objective: To analyse the outcome of patients with symptomatic arterio-venous malformation (AVM), formed following pregnancy and managed by uterine artery embolization (UAE).

Materials and methods: This retrospective study was conducted after ethical approval and included 15 patients presenting with abnormal uterine bleeding following pregnancy, who were suspected to have an AVM which later was confirmed by angiography and managed with UAE. Presenting symptoms, post-UAE complications and subsequent fertility outcomes were noted. Follow-up period ranged from 6 months to 2.5 years.

Results: The mean age was 28.4±3.82 years and mean parity was 1.3. Out of 15 cases, 9 (60%) presented after abortion, 4 (26.6%) after normal vaginal delivery and 2 (13.3%) after cesarean delivery; of these 10/15 (66.7%) patients had a history of curettage. The most common presenting symptom was continuous bleeding per-vaginum since the antecedent pregnancy in 9/15 (60%) patients and 6/15 (40%) patients had irregular bleeding. The mean duration of symptoms was 91±85.7 (30-360) days. For UAE, embolic agents used were polyvinyl alcohol (PVA) particles (300-500 μm) in 2 (13.3%), 30% glue injection in 3 (20%), the combination of PVA with glue injection in 4 (26.6%) and PVA with gelfoam in 6 (40%) patients. After UAE, bleeding responded within 3.6±0.97 (3-6) days in all but one patient who required repeat UAE one month later. All women resumed their normal menstrual cycle in 31.3±5.2 (24-42) days. Ten patients desired conception, of whom 5 (50%) conceived within 13.2±5.1 (6-19) months after UAE. Two women carried pregnancy to term, one underwent preterm cesarean for growth restriction with oligohydramnios. One patient had postpartum hemorrhage, which was managed medically. One had spontaneous abortion at 6 weeks gestation and the other is 13 weeks pregnant at present.

Conclusion: UAE is an effective treatment modality for the management of symptomatic post-pregnancy AVMs.

Keywords: Uterine artery embolization; arteriovenous malformation; outcomes; post-pregnancy.

Figure 1

Showing antecedent pregnancies and history of curettage in women included in study

Figure 2

Diagnostic subtraction angiography (DSA) spot images of UAE: A & D showing bilateral hypertrophied uterine arteries supplying the nidus of uterine AVM (curved arrow); B & E showing vessels being embolized sequentially using glue mixed with lipiodol (arrows); C &F showing post embolization angiograms showing non filling of the uterine AVM suggestive of successful embolization

Figure 3

(A) Pre-embolization ultrasound Doppler image (A) showing bunch of vascular channels within the uterine wall (arrow) suggestive of uterine AVM. (B) Post embolization Doppler image (B) showing complete obliteration of nidus of AVM