Post Embolectomy Uterine AV Malformation Pregnancy and its Outcome – a case Report

 

Objective:

Pregnancy after embolization of uterine AV malformation is a rare event. Only few cases have been reported so far. Here we report a case of successful pregnancy following embolization for uterine AV malformation.

Case report:

31-year-old female, Gravida 3 para 0, known case of Rheumatic heart disease post double valve replacement done in 2014 for severe MS, severe TR, Severe PAH, with one previous history of MTP. Her 2^nd pregnancy was expulsion of preterm female at 21 weeks gestation due to cervical insufficiency. She was on Warfarin. She had two severe episodes of bleeding 1 month post expulsion which was managed with blood transfusion. Ultrasound abdomen showed an area of increased doppler vascularity in left posterior myometrium and parametrium- likely vascular malformation right uterine artery, which was confirmed with CT Abdominal Angiography. Bilateral uterine arteries were embolised with PVC and Gelfoam. Post embolization she had fever which was manged conservatively, and repeat ultrasound showed no abnormal doppler vascularity.

2 years later she conceived after ovulation induction with letrazole while on Warfarin, which wasstopped at 6 weeks gestation and started on clexane therapeutic dose. At 7 weeks, she had Covid infection which was managed conservatively. Her First Trimester Screening was low risk for aneuploidies . She was on cervical length surveillance in view of previous cervical insufficiency and was  detected to have short cervix and encerclage was done at 16 weeks. Clexane was changed back to warf at 16 weeks gestation after encerclage. Targetted anomaly scan and Fetal echo was done which were normal. Gestational Diabetes was detected at 20  weeks gestation which was managed with diet control. At 36 weeks warfarin was switched over to clexane again and was induced at 37 weeks gestation. She had vaginal delivery- female baby of 2.57kg. Post natally she was shifted back to warfarin.

Discussion:

Uterine arteriovenous malformation can be either acquired or congenital in nature. It may present as severe uterine bleeding which can be sometimes even fatal if not managed properly and in time. Previously definitive treatment was considered hysterectomy however, it may not be feasible option for women of child bearing age group. For such cases, uterine artery embolization should be offered wherever available. Several studies have shown pregnancy after UAE as similar to pregnancy after myomectomy for fibroid uterus.

Conclusion:

Successful pregnancies following UAE can be achieved and embolization should be first line option for AV malformation in child bearing women who wish to preserve uterus.