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Reproductive/Endocrine Imaging

E1025. Imaging and Management of Uterine Arteriovenous Malformation

Koethe Y,  Poder L,  Maureen K. University of California, San Francisco, San Francisco, CA

Address correspondence to Y. Koethe (yilun.koethe@ucsf.edu)

Background Information: Uterine arteriovenous malformation (AVM) is a rare postpartum complication. When present, it can cause massive and often delayed postpartum hemorrhage, with high morbidity and mortality. Both diagnostic and interventional radiologists play concerted and essential roles in the rapid diagnosis and treatment of this rare but dangerous entity.

Educational Goals/Teaching Points: Through five cases of uterine AVM with contrasting and accompanying cases of retained placenta of conception (RPOC) and uterine pseudoaneurysm, this educational review demonstrates the distinguishing sonographic, angiographic, and MRI findings of uterine AVM. It also discusses the full clinical course and expected management of uterine AVM, including triage, emergent and not emergent embolization, and follow-up imaging.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: Uterine AVM has nearly indistinguishable clinical presentation and appearance on gray-scale ultrasound (US) from the more common cause of postpartum bleeding, RPOC. However, in cases where RPOC is removed via curettage, any disruption of AVM may lead to catastrophic hemorrhage. Doppler analysis when combined with ß-human chorionic gonadotropin can help differentiate uterine AVM from RPOC. This exhibit will discuss the imaging appearance of AVM on color Doppler (i.e., aliasing color patterns) and confirmation via spectral Doppler (i.e., high-velocity, low-resistance waveforms). In addition, in patients who are hemodynamically stable, peak systolic velocity can be applied during triaging according to most recent literature. The above concepts will be exemplified by five different cases of uterine AVM from our institution, including a case with coexistent RPOC and AVM. Subsequent emergent and urgent uterine artery embolization will be reviewed with discussion on how to find the bleeding nidus, choices in embolization materials based on clinical situations, and our institutional experience in the efficacy of embolization. It will demonstrate expected appearances on US and MRI in both successful and initially unsuccessful embolization cases. Finally, this exhibit will discuss imaging findings of pseudoaneurysm, another potential vascular postpartum complication, which also requires uterine artery embolization.

Conclusion: Both diagnostic and interventional radiologists must maintain high clinical suspicion for traumatic uterine AVM in postpartum bleeding, incidence of which is likely on the rise with increasing cesarean sections. As such, it is important for both radiology staff and trainees to know how to diagnose and manage this pathology.