Challenges in Diagnosis and Management of Recurrent Uterine Arteriovenous Malformation: A Case Report

Abstract

Uterine arteriovenous malformation (AVM) is a potentially life-threatening condition. The vast majority of cases are acquired. Uterine artery embolization (UAE) is currently the treatment of choice for symptomatic women desiring future childbearing. However, there is no consensus on the number of UAE procedures that can be performed on an individual woman. We report a case of recurrent uterine AVM and discuss the challenges in diagnosis and management. A 35-year-old multiparous woman presented with heavy menstrual bleeding (HMB). She had been diagnosed with uterine AVM six years ago and had undergone two previous UAE procedures. Her abdominal examination revealed a healthy Pfannensteil scar. Bimanual examination revealed a normal-sized uterus that was firm, mobile, and fornices were free. Her haemoglobin was 10.2 g/dl. Greyscale two-dimensional ultrasound revealed a normal-sized uterus with multiple hypoechoic lesions in the myometrium. Colour Doppler ultrasound showed intense vascularity with multidirectional flow in the myometrium, suggestive of uterine AVM. In view of previous failed UAE procedures, she opted for a hysterectomy. A total abdominal hysterectomy with a bilateral salpingectomy was performed. Blood loss during the procedure was greater than average, and she was transfused with a unit of packed cells. Her post-operative course was uneventful. Histopathology confirmed the diagnosis of a uterine AVM. To conclude, the UAE is considered the treatment of choice for symptomatic women with uterine AVM desiring future childbearing. In cases of failure of UAE procedures, hysterectomy is therapeutic but may be associated with more than average blood loss.

Keywords: color doppler ultrasound; s: uterine arteriovenous malformation; total abdominal hysterectomy; ultrasound (u/s); uterine artery embolization (uae).

Figure 1. Ultrasound showing

(A) Normal-size uterus with multiple hypoechoeic lesions in the myometrium (arrow) on greyscale. (B) Presence of intense vascularity in the myometrium with multidirectional flow, suggestive of uterine arterio-venous malformation (AVM) on colour Doppler.

Figure 2. Operative and histopathology imaging showing

(A) Multiple tortuous vessels (black arrow) over the right fallopian tube and parametrium. (B) Angulated thick and thin-walled vascular channels (arrow) within the myometrium (hematoxylin and eosin, 40×). (C) A dilated vessel containing extraneous thrombogenic agent with giant cell reaction and perivascular inflammation around it (hematoxylin and eosin, 200×).