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AJR Teaching File: Profuse Vaginal Bleeding Seven Weeks Following Induced Abortion

¹ All authors: Department of Radiology, Medical Sciences Campus, University of Puerto Rico, PO Box 365067, San Juan, PR 00936-5067.

Received September 30, 2007; accepted after revision February 12, 2008.

 
Address correspondence to J. Maldonado (maldonadojose{at}email.com).

Keywords: angiography • arteriovenous malformation • sonography • uterus • vascular system

Case History

Top Case History Radiologic Description Differential Diagnosis Diagnosis Commentary Objective Conclusion References

 
A 21-year-old woman who underwent an induced abortion 7 weeks earlier presented to an outside clinic with a 3-week history of profuse vaginal bleeding and symptomatic anemia. Serum β-hCG measurements were negative. The patient was transferred to our institution for definitive management.

Radiologic Description

Top Case History Radiologic Description Differential Diagnosis Diagnosis Commentary Objective Conclusion References

 
Endovaginal sagittal gray-scale sonography of the uterus (Fig. 1A) shows parenchymal inhomogeneity by the fundus with several interspersed sonolucent spaces of varying size. Color Doppler sonography (Fig. 1B) reveals the hypervascular nature of the latter. A transverse image (Fig. 1C) better shows the extent of the vascular lesion.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —21-year-old woman who underwent induced abortion 7 weeks earlier. Patient presented to outside clinic with 3-week history of profuse vaginal bleeding and symptomatic anemia. Endovaginal sagittal gray-scale sonogram of uterus shows parenchymal inhomogeneity next to fundus and several interspersed sonolucent spaces of varying sizes.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —21-year-old woman who underwent induced abortion 7 weeks earlier. Patient presented to outside clinic with 3-week history of profuse vaginal bleeding and symptomatic anemia. Endovaginal color Doppler sonogram (shown here in black and white) reveals hypervascular nature of sonolucent spaces.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —21-year-old woman who underwent induced abortion 7 weeks earlier. Patient presented to outside clinic with 3-week history of profuse vaginal bleeding and symptomatic anemia. Endovaginal transverse color Doppler sonogram (shown here in black and white) better shows extent of vascular lesion.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D —21-year-old woman who underwent induced abortion 7 weeks earlier. Patient presented to outside clinic with 3-week history of profuse vaginal bleeding and symptomatic anemia. Follow-up endovaginal sagittal gray-scale sonogram shows rather unremarkable and homogeneous uterine parenchyma.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1E —21-year-old woman who underwent induced abortion 7 weeks earlier. Patient presented to outside clinic with 3-week history of profuse vaginal bleeding and symptomatic anemia. Transabdominal color Doppler sonogram at same level as D also shows persistent hypervascularity and turbulent flow in myometrium.

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1F —21-year-old woman who underwent induced abortion 7 weeks earlier. Patient presented to outside clinic with 3-week history of profuse vaginal bleeding and symptomatic anemia. Endovaginal transverse oblique duplex Doppler sonogram shows low-resistance, high-velocity flow with resistive index of 0.43, pulsatility index of 0.68, and peak systolic velocity of 35 cm/s.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1G —21-year-old woman who underwent induced abortion 7 weeks earlier. Patient presented to outside clinic with 3-week history of profuse vaginal bleeding and symptomatic anemia. Coronal fat-suppressed fast spin-echo T2-weighted (TR/TE, 5,250/67.6) image shows multiple serpiginous flow-related signal voids in myometrium, corresponding to sonographic findings.

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1H —21-year-old woman who underwent induced abortion 7 weeks earlier. Patient presented to outside clinic with 3-week history of profuse vaginal bleeding and symptomatic anemia. Contrast-enhanced fat-suppressed coronal fast spin-echo T1-weighted (417/10.8) image during arterial phase also shows multiple serpiginous flow-related signal voids in myometrium, corresponding to sonographic findings.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1I —21-year-old woman who underwent induced abortion 7 weeks earlier. Patient presented to outside clinic with 3-week history of profuse vaginal bleeding and symptomatic anemia. Fluid-sensitive coronal STIR (3,250/57.4; inversion time, 150 milliseconds) image better shows associated asymmetric prominence of contiguous parametrial vessels on right.

View larger version (161K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1J —21-year-old woman who underwent induced abortion 7 weeks earlier. Patient presented to outside clinic with 3-week history of profuse vaginal bleeding and symptomatic anemia. Frontal digital subtraction angiography of selective catheterization of anterior division of right internal iliac artery shows hypertrophied uterine artery end branches opacifying hypervascular tangle of vessels.

Top Case History Radiologic Description Differential Diagnosis Diagnosis Commentary Objective Conclusion References

Diagnosis

Top Case History Radiologic Description Differential Diagnosis Diagnosis Commentary Objective Conclusion References

 
The diagnosis is acquired uterine AVM.

Commentary

Top Case History Radiologic Description Differential Diagnosis Diagnosis Commentary Objective Conclusion References

 
In the clinical setting of vaginal bleeding, one can use clinical history and laboratory data to narrow the diagnosis and determine the best course of management before initiating imaging studies. For example, GTD and retained products of conception are conditions known to produce arteriovenous shunting that can be difficult to distinguish from uterine AVMs by imaging studies alone. However, these pregnancy-related entities can be diagnosed with the help of serum hCG measurements. Distinguishing between these conditions and uterine AVMs is critical because the latter can be treated safely and effectively with percutaneous transcatheter embolization but may be complicated by surgical intervention and curettage with heavy, even life-threatening, bleeding [1, 2].

An AVM can be defined as a tangle of abnormal arteriovenous connections lacking an intervening capillary network on histopathologic examination. Congenital AVMs arise as a result of a defect in embryonic vascular differentiation or of developmental arrest. They may extend beyond the uterus and can grow as pregnancy progresses. Acquired AVMs, on the other hand, are usually secondary to uterine trauma (e.g., D&C, therapeutic abortion, uterine surgery, intrauterine devices) or GTD [3, 4].

Uterine AVMs are usually evaluated initially with sonography. Gray-scale sonography may show an inhomogeneous myometrium with hypoechogenic tubular structures. These findings are nonspecific and in some cases can be inconspicuous and difficult to appreciate. Color Doppler sonographic features are invariably more extensive than those of gray-scale sonography and are essential for the complete radiologic evaluation of uterine AVMs. Hypervascular areas with a color mosaic of aliasing and flow reversal are characteristic. Spectral sonographic analysis provides additional information, showing a low-resistance, high-velocity flow, with RI values ranging from 0.25 to 0.55 and PI values from 0.3 to 0.6. These spectral sonographic findings are similar for AVMs found elsewhere in the body [1, 5].

MRI serves to support the radiologic impression of AVM obtained by sonography. It is helpful in determining the magnitude of the vascular malformation, particularly if extrauterine extension is suspected. MR angiographic sequences are well suited for these purposes, allowing preinterventional planning. Moreover, additional pelvic disorders may be identified and better characterized with MRI. Serpiginous flow-related signal voids corresponding to the myometrial hypervascular areas on color Doppler sonography are characteristic of uterine AVMs. Prominent parametrial vessels and disruption of the junctional zones may also be present [1].

Angiography is considered the reference standard for the definitive diagnosis of AVMs, which appear as a markedly opacified vascular tangle, typically with early venous filling. However, angiography is an invasive procedure that should be reserved for patients in whom surgical intervention or therapeutic transcatheter embolization is contemplated. The angiographic goals are to define the vascular anatomy, assess the extent of the vascular malformation, and identify the feeding vessels. As in the management of other gynecologic disorders, the typical interventional approach starts with initial pelvic angiography using the Seldinger technique through the common femoral artery. Selective internal iliac angiography on the side affected is then performed. Some small AVMs are shown only by superselective catheterization of the uterine arteries. This can be accomplished with an angled 5-French catheter; however, 4-French hydrophilic microcatheters or 3-French microcatheters may be necessary to prevent spasm. Even after unilateral uterine artery embolization, we routinely reexamine the contralateral arteries. In some cases, previously inconspicuous feeding arteries may then be identified to advantage.

Patients with AVMs commonly present with vaginal bleeding after a miscarriage, uterine surgery, or curettage. Other symptoms include abdominal pain, dyspareunia, and anemia secondary to blood loss, which can be intermittent or profuse. Traditionally, the treatment of AVMs had been hysterectomy and uterine artery ligation. Intrauterine tamponade with a Foley bulb can be used as a temporizing measure. More recently, percutaneous transcatheter embolization has gained wide acceptance as a safe and effective alternate treatment. This procedure preserves uterine function and the possibility of future childbearing. Its clinical success rate after one to two embolization procedures is 93–96%, and its complication rate is 4% [3, 6, 7].

Several potential embolic agents are available to the interventional radiologist, including absorbable gelatin sponge, glue, microparticles, coils, or a combination of these agents. As previously stated, our patient was observed for 2 days and later discharged after an uneventful recovery. Nonetheless, adverse events after uterine artery percutaneous transcatheter embolization may be observed, most of which are minor. Patients often experience pelvic pain and nausea for 12–24 hours after the procedure, which gradually decreases in the next 5–7 days. Severe complications are rare and include uterine necrosis, sepsis, and lethal pulmonary embolism [8].

Clearly, in a patient presenting with vaginal bleeding and negative results of hCG, the diagnosis of AVM should be considered, particularly if a history of uterine instrumentation is elicited. Other uterine vascular abnormalities, including pseudoaneurysm and direct arterial branch injury, may have a similar clinical history and presentation. Imaging studies can reliably distinguish these traumatic vascular abnormalities from AVMs. A uterine pseudoaneurysm is characterized sonographically by a cystic structure that on duplex Doppler sonography shows turbulent arterial flow in a blood-filled sac and to-and-fro flow in the neck. In direct arterial branch injury, a heterogeneous intraparenchymal or cavitary hematoma may be shown, with slowly moving blood in the endometrial canal. Evidence of contrast extravasation in angiography is confirmatory. Both of these conditions are also amenable to percutaneous transcatheter embolization and could likewise be complicated by surgical intervention [8].

In addition to aiding in the diagnosis of AVMs, duplex Doppler sonography may be useful in distinguishing between low- and high-risk patients. After studying 30 patients with uterine vascular malformations, Timmerman et al. [4] noted that peak systolic velocity of 83 cm/s was associated with an increased likelihood of further treatment such as embolization, whereas no vascular malformation with a peak systolic velocity value < 39 cm/s required embolization. Maleux et al. [6], on the other hand, used the sonographic findings in patients with AVMs to plan the radiologic interventional approach. Specifically, uni- or bilateral embolization was performed, depending on whether the hypervascular area was unilateral, bilateral, or extended over the midline, as shown on sonography. By virtue of its lack of ionizing radiation, low cost, and availability, sonography is the preferred imaging technique for following up patients after treatment. Therefore, as in many other gynecologic conditions, the role of sonography in the management of uterine AVMs is often pivotal.

Objective

Top Case History Radiologic Description Differential Diagnosis Diagnosis Commentary Objective Conclusion References

 
The educational objective of this article is to describe the imaging features and therapeutic options in a patient with acquired uterine vascular malformation presenting with profuse vaginal bleeding.

Conclusion

Top Case History Radiologic Description Differential Diagnosis Diagnosis Commentary Objective Conclusion References

 
In a patient presenting with vaginal bleeding, it is important for radiologists to evaluate the possibility of a uterine AVM before surgical intervention is considered. Color Doppler sonography is essential for the diagnosis of uterine AVMs. Angiography confirms the diagnosis and allows percutaneous transcatheter embolotherapy, which is a safe and highly effective treatment option.

References

Top Case History Radiologic Description Differential Diagnosis Diagnosis Commentary Objective Conclusion References

 

1. Huang MW, Muradali D, Thurston WA, Burns PN, Wilson SR. Uterine arteriovenous malformations: gray-scale and Doppler US features with MR imaging correlation. Radiology 1998;206 : 115–123[Abstract/Free Full Text]
2. Jain K, Fogata M. Retained products of conception mimicking a large endometrial AVM: complete resolution following spontaneous abortion. J Clin Ultrasound 2007;35 : 42–47[Medline]
3. Ghai S, Rajan DK, Asch MR, Muradali D, Simons ME, TerBrugge KG. Efficacy of embolization in traumatic uterine vascular malformations. J Vasc Interv Radiol 2003;14 :1401 –1408[Medline]
4. Timmerman D, Wauters J, Van Calenbergh S, et al. Color Doppler imaging is a valuable tool for the diagnosis and management of uterine vascular malformations. Ultrasound Obstet Gynecol2003; 21:570 –577[Medline]
5. Polat P, Suma S, Kantarcy M, Alper F, Levent A. Color Doppler US in the evaluation of uterine vascular abnormalities. RadioGraphics 2002;22 : 47–53[Abstract/Free Full Text]
6. Maleux G, Timmerman D, Heye S, Wilms G. Acquired uterine vascular malformations: radiological and clinical outcome after transcatheter embolotherapy. Eur Radiol 2006;16 : 299–306. Epub 2005Jun 24[Medline]
7. Kim D, Baer SD. Interventional radiology in management of obstetrical and gynecological disorders. UpToDate online (15.1). www.uptodate.com/online/content/topic.do?topicKey=gyn_proc/7850. Accessed August 24, 2008
8. Kwon JH, Kim GS. Obstetric iatrogenic arterial injuries of the uterus: diagnosis with US and treatment with transcatheter arterial embolization. RadioGraphics 2002;22 : 35–46[Abstract/Free Full Text]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Maldonado, J. Articles by Rodriguez, W. Search for Related Content PubMed PubMed Citation Articles by Maldonado, J. Articles by Rodriguez, W. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?