Uterine Arteriovenous Malformation: Diagnostic and Therapeutic Challenges

Abstract

Uterine arteriovenous malformations are a rare cause of puerperal haemorrhage, but their incidence is increasing due to both improved diagnosis and the more frequent use of uterine surgery in recent years. The use of ultrasound, both B-mode and Doppler, is recommended for diagnosis and follow-up, as it has been shown to be the simplest and most cost-effective method. Endometrial thickening associated with an anechoic and vascular intramiometrial structure is very useful for diagnosis and can help to exclude other causes of dysfunctional bleeding. Pulsed Doppler shows low-resistance vessels and high pulsatility indices with a high peak systolic velocity (PSV). In a healthy myometrium, the vessels have a peak systolic velocity of 9-40 cm/s and a resistance index between 0.6 and 0.8, whereas in the case of AVMs, the systolic and diastolic velocities are 4-6 times higher (PSV 25-110 cm/s with a mean of 60 cm/s and a resistance index of 0.27-0.75 with a mean of 0.41). For treatment, we must individualise each case, taking into account haemodynamic stability, the patient's reproductive wishes, and the severity of the AVM as assessed by its size and PSV.

Keywords: Doppler ultrasound; myometrial hypervascularisation; peak systolic velocity; uterine arteriovenous malformation.

Figure 1

Transvaginal ultrasound with suspected uterine arteriovenous malformation.

Figure 2

Colour and pulsed Doppler studies of the uterine arteriovenous malformation.

Figure 3

Cross-sectional pelvic CT angiography.

Figure 4

Coronal pelvic CT angiography.

Figure 5

Linear endometrium after conservative treatment for 4 months.

Figure 6

Absence of colour Doppler uptake.