Key content
The incidence and prevalence of uterine arteriovenous malformations (AVMs) is difficult to determine because bleeding caused by uterine AVMs does respond to medical management
and several of these may go undiagnosed.
Fewer than 100 cases have been reported in the literature, but the increasing use of imaging modalities, particularly ultrasound, in acute gynaecology is likely to lead to identification of these lesions
more frequently.
Uterine AVMs are largely acquired lesions, with pregnancy playing an important role in their pathogenesis.
The most frequent clinical manifestation is abnormal uterine bleeding, which can often be episodic, torrential and can result in significant anaemia or even shock.
Hysterectomy remains the most definitive treatment, however, modern management of uterine AVMs varies from medical management (hormonal therapy), through minimally invasive uterine artery embolisation to more definitive surgical hysterectomy.
Learning objectives
To be aware of the existence of these lesions and to understand the risk factors and clinical presentation of women who should be suspected of having these lesions.
To learn the various conservative treatment options for the management of uterine AVMs.
To understand the implications for women’s future fertility.
Ethical issues
Should ultrasound Doppler be routinely performed in women who have persistent vaginal bleeding after management of miscarriage?
Since experience with interpreting angiography to diagnose uterine AVM is limited, should those women with suspecteduterine AVM requiring surgical management be referred to a tertiary centre?
Keywords: conservative treatment options / diagnosis / lesions /
uterine arteriovenous malformations / uterine bleeding
Introduction
Incidence and prevalence
Causes and risk factors
Pathophysiology and other differential diagnosis
Congenital AVMs
Iatrogenic acquired AVMs
Enhanced myometrial vascularity
Subinvolution of the uterus (placental bed)
Uterine AVM following gestational trophoblastic disease
Clinical manifestation
Investigations
Grey-scale ultrasound
Colour Doppler
Angiography
Magnetic resonance imaging
General principles of management
Management of uterine AVM depends on:
haemodynamic status
size and site of the lesion
degree of bleeding
age
desire for future fertility.
Specific therapeutic options
Surgical management
Internal iliac artery or uterine artery ligation and hysterectomy were the traditional treatment options for
uterine AVMs in the past.
Medical management
Transcatheter arterial embolisation
Balloon-occluded retrograde transvenous obliteration
Impact on subsequent fertility and pregnancy
Conclusion
Uterine AVMs are a rare cause of uterine haemorrhage. The vast majority resolve spontaneously or with medical treatment. The remaining cases normally respond to conservative management options. Uterine AVMs have the potential to cause life-threatening haemorrhage, despite which, with the availability of uterine artery embolisation, hysterectomy is rarely required to stem the bleeding. Normal menstrual cycle and fertility is restored in the vast majority of women with this condition.