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Transabdominal two‐ and three‐dimensional color Doppler imaging of a uterine arteriovenous malformation

2011; Wiley; Volume: 37; Issue: 3 Linguagem: Inglês

10.1002/uog.8918

1469-0705

Blerim Syla, S. S. Fetiu, S. S. Tafarshiku,

Uterine Myomas and Treatments

Ultrasound in Obstetrics & GynecologyVolume 37, Issue 3 p. 376-378 Picture of the MonthFree Access Transabdominal two- and three-dimensional color Doppler imaging of a uterine arteriovenous malformation B. H. Syla, Corresponding Author B. H. Syla [email protected] Gynecologic Private Office 'Dr Bajrami'—Ferizaj, KosovoPrivate Clinic 'Dr Bajrami', rr Tajar Hatipi nr 5, Ferizaj, Kosovo 70000Search for more papers by this authorS. S. Fetiu, S. S. Fetiu University Clinical Center, Obstetric-Gynecologic Hospital, Prishtina, KosovoSearch for more papers by this authorS. S. Tafarshiku, S. S. Tafarshiku Gynecologic Private Office 'Dr Bajrami'—Ferizaj, KosovoSearch for more papers by this author B. H. Syla, Corresponding Author B. H. Syla [email protected] Gynecologic Private Office 'Dr Bajrami'—Ferizaj, KosovoPrivate Clinic 'Dr Bajrami', rr Tajar Hatipi nr 5, Ferizaj, Kosovo 70000Search for more papers by this authorS. S. Fetiu, S. S. Fetiu University Clinical Center, Obstetric-Gynecologic Hospital, Prishtina, KosovoSearch for more papers by this authorS. S. Tafarshiku, S. S. Tafarshiku Gynecologic Private Office 'Dr Bajrami'—Ferizaj, KosovoSearch for more papers by this author First published: 10 January 2011 https://doi.org/10.1002/uog.8918Citations: 10AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Uterine arteriovenous malformation (AVM) is a rare condition that has been reported in patients ranging in age between 18 and 72 years1. Several terms have been used for uterine AVM, including arteriovenous fistula, arteriovenous aneurysm, cirsoid aneurysm, racemose aneurysm, pulsatile angioma and cavernous angioma2. Arteriovenous malformations can be congenital or acquired and consist of a 'proliferation of arterial and venous channels with fistula formation and an admixture of small capillary-like channels'2. Congenital AVM is very rare and is the result of a defect in the embryonic development of vascular structures3, 4. Most uterine AVMs are acquired following damage to the uterine tissue. Cases of acquired AVM have been attributed to a variety of causes, including pelvic trauma, surgical interventions such as dilatation and curettage and Cesarean section, cervical and endometrial carcinoma, trophoblastic diseases, inflammation and diethylstilbestrol exposure, and can be idiopathic5-8. Uterine AVMs grow slowly and the appearance of symptoms may be delayed. However, the onset of symptoms can be sudden4. Patients may suffer from irregular vaginal bleeding, heavy menses and/or abdominal pain. Bleeding is thought to occur as a result of vessels of the AVM being exposed by shedding of the endometrium. There are several signs that can indicate the diagnosis of uterine AVM; an audible bruit or palpable thrill may be present and in some cases a pulsatile mass can be detected on manual examination7. A 40-year-old woman (gravida 6, para 3, abortus 3) presented at our hospital with heavy menstrual bleeding. The bleeding was reduced by intravenous administration of 10 IU oxytocin in physiological solution and methylergonovine maleate was then prescribed until bleeding ceased. An ultrasound scan was performed 3 days after this. The patient declined to undergo a transvaginal scan. On transabdominal gray-scale ultrasound, we observed multiple irregular hypoechoic spaces in the anterior wall and fundus of the uterus, which formed a mass that extended to the endometrium (Figure 1). On power Doppler imaging, color signals were observed within these hypoechoic spaces in the fundal region and lateral to the uterus (Figure 2). On color Doppler imaging, a mosaic pattern of flow was observed inside the mass (Figure 3). Spectral analysis of the arterial vessels showed high-velocity (peak systolic velocity (PSV) 64.4 cm/s), low-resistance (resistance index (RI), 0.46; pulsatility index (PI), 0.73) flow (Figure 4). Three-dimensional color Doppler rendering mode showed the presence of arteriovenous communications within the mass and lateral to it (Figure 5). On the same day, the patient had a new episode of profuse bleeding. On admission to hospital, the hemorrhage was stopped by insertion of a Foley catheter and a week later total abdominal hysterectomy was carried out. Diagnosis of uterine AVM was confirmed histologically. Figure 1Open in figure viewerPowerPoint Gray-scale transabdominal ultrasound image showing hypoechoic spaces in the anterior wall and fundal part of the uterus extending to the endometrium. Figure 2Open in figure viewerPowerPoint Power Doppler image showing signals in the fundal part of the uterus and lateral to it, following the path of the uterine vessels. Figure 3Open in figure viewerPowerPoint Color Doppler image showing mosaic pattern and turbulent flow. Figure 4Open in figure viewerPowerPoint Spectral analysis of the right uterine artery showing high-velocity flow with low resistance index and pulsatility index. Figure 5Open in figure viewerPowerPoint Three-dimensional color rendering mode showing the extent of the vascular mass. Angiography used to be the gold standard diagnostic method for uterine AVM. This invasive procedure not only allows confirmation of the diagnosis, but also helps in the identification of 'feeding' blood vessels and facilitates embolization in suitable cases9, 10. However, color Doppler sonography is noninvasive and seems to be a reliable diagnostic method, with uterine AVM presenting as a color mosaic with thickened vessels and turbulent flow11-14. Low-resistance flow with high maximal velocity and evidence of turbulence is found on pulsed Doppler. Angiography should be reserved for cases in which selective embolization of the feeding vessel can be performed15. In our case, the diagnosis of uterine AVM by color Doppler sonography allowed the correct management approach for the patient: hemostasis by Foley catheter followed by total abdominal hysterectomy (embolization is not available to us). Without an examination using color Doppler ultrasound, curettage would have been performed, which would have led to more profuse hemorrhage. We propose that color Doppler ultrasound examination should be performed for any patient with heavy bleeding before any invasive therapeutic procedure is begun, to avoid complications caused by this rare and potentially dangerous abnormality. SUPPORTING INFORMATION ON THE INTERNET The following supporting information may be found in the online version of this article: Videoclip S1 Gray-scale ultrasound imaging of the uterine arteriovenous malformation. Videoclip S2 Color Doppler imaging in sagittal view of the uterine arteriovenous malformation. Videoclip S3 Power Doppler imaging in sagittal view of the uterine arteriovenous malformation. Videoclip S4 Power Doppler imaging in transverse view of the uterine arteriovenous malformation. Videoclip S5 Three-dimensional color rendering mode imaging of the uterine arteriovenous malformation. Supporting Information Filename Description uog8918_suppinfoGrayscalevs1.mpg1.3 MB Supporting Information: Videoclip S1 Gray-scale ultrasound imaging of the uterine arteriovenous malformation. uog8918_suppinfoColorDopplervs2.mpg3.1 MB Supporting Information: Videoclip S2 Color Doppler imaging in sagittal view of the uterine arteriovenous malformation. uog8918_suppinfoPowerDopplersvvs3.mpg2.7 MB Supporting Information: Videoclip S3 Power Doppler imaging in sagittal view of the uterine arteriovenous malformation. uog8918_suppinfoPowerDopplertvvs4.mpg1.4 MB Supporting Information: Videoclip S4 Power Doppler imaging in transverse view of the uterine arteriovenous malformation. uog8918_suppinfocolorrenderingvs5.mpg1.9 MB Supporting Information: Videoclip S5 Three-dimensional color rendering mode imaging of the uterine arteriovenous malformation. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. References 1Timmerman D, Wauters J, Van Calenbergh S, Van Schoubroeck D, Maleux G, Van Den Bosch T, Spitz B. Color Doppler imaging is a valuable tool for the diagnosis and management of the uterine vascular malformation. Ultrasound Obstet Gynecol 2003; 21: 570– 575. 2Fleming H, Östör A, Pickel H, Fortune D. Arteriovenous malformations of the uterus. Obstet Gynecol 1989; 73: 209– 213. 3Kasznica J, Nisar N. Congenital vascular malformation of uterus in a stillborn: a case report. Hum Pathol 1995; 26: 240– 241. 4Jain KA, Jeffrey RB Jr, Sommer FG. Gynecologic vascular abnormalities: diagnosis with Doppler US. Radiology 1991; 178: 549– 551. 5Flynn MK, Levine D. The noninvasive diagnosis and management of a uterine arteriovenous malformation. Obstet Gynecol 1996; 88: 650– 652. 6McLachlan MSF, Bird CC, Naiem EA, Scott JS. Uterine cirsoid aneurysm. 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