Recurrent severe uterine bleeding: uterine arteriovenous malformation (UAVM) managed with uterine artery embolization (UAE)
Alexandra Cameron¹, Elise Hayles², Kevin Hayes³
¹ 5th Year Medical Student, St. George’s University of London, United Kingdom. ² Senior Clinical Fellow, Acute Gynaecology Unit, St. George’s University Hospital, NHS Foundation Trust, London, United Kingdom. ³ Obstetrics and Gynaecology Consultant, St. George’s University Hospital, NHS Foundation Trust, London, United Kingdom
Introduction
UAVMs are rare
Uterine trauma is most common cause
Can cause severe uterine bleeding
Refractory bleeding formerly managed with hysterectomy
Objective
Patient diagnosed with large UAVM, successfully treated with UAE.
Significance: rarity of UAVM, potential life-threatening consequences.
Fertility-sparing definitive treatments now available
Case Report
20-year-old G1P0, 18 months irregular heavy PV bleeds
Multiple admissions for blood transfusions
20-months prior: SMM
Repeated TVUSs: thin endometrium
Hysteroscopy: normal endometrial cavity
Mirena IUS inserted but expelled by heavy bleeding.
On admission: Hb 50g/L.
MRI and contrast-CT: probable UAVM.
TVUS: 21x18x23mm fundal myometrial mass (fig. 1), mixed venous-arterial flow, apparent unilateral arterial feed, consistent with UAVM (fig. 2).
Figure 1: Cystic mass in anterior myometrium
Figure 2: Colour doppler in longitudinal view, mixed flow ‘colour mosaic’ with feeding vessel on right
Diagnosis: Angiography showing unilateral supply from right uterine artery. (fig. 3)
Management: right uterine artery selectively embolised
Post-procedure angiogram: complete exclusion of UAVM (fig. 4)
Figure 3: supply from multiple branches of right uterine artery and early venous drainage
Figure 4: post embolisation, complete exclusion of the UAVM
Post op: good recovery, discharged next day, follow-up in 2 months.
Discussion
Consider UAVM in acute heavy bleeding after uterine trauma/ instrumentation.
Delayed diagnosis: haemorrhage, multiple admissions, unnecessary investigations/intervention.
UAVM on TVUS: enhanced myometrial vascularity, tortuous vessels, high velocity flow.
Clinically stable patients: Expectant management
UAE indicated: minimally-invasive, fertility sparing, may avoid hysterectomy.
Post UAE uterine ischaemia: proven collateral reperfusion
Miscarriage risk unclear: conflicting results, most evaluated UAE for fibroids
Perinatal considerations: no UAVM recurrence, close placental monitoring
Future fertility often primary patient concern- effective counselling vital
Conclusion
Overlooking UAVM as recurrent PV bleed differential leads to repeat admissions and delayed diagnosis.
UAE is an effective treatment for UAVM
Further research: fertility/ perinatal impacts of UAE for UAVM.
Contact: Elise Hayles: elise.hayles@nhs.net
