Uterine arterio venous malformation is uncommon cause of menorrhagia. We report a rare case of arteriovenous malformation diagnosed after 18 years of suffering from menorrhagi

Chakraborty, Sudipta

Chaudhuri, Snehamay

Das, Chandana

Karmakar, Madan

English

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Published Quarterly
Mangalore, South India
ISSN 0972-5997
Volume 7, Issue 3; Jul-Sep 2008
Uterine Arteriovenous Malformation As A Rare Cause Of Menorrhagia  
Authors
Chandana Das,
Associate Professor, Department of Gynaecology and Obstetrics, N.R.S. Medical College, Kolkata,
Snehamay Chaudhuri
Assistant Professor, Department of Gynaecology and Obstetrics, N.R.S. Medical College, Kolkata,
Madan Karmakar,
Associate Professor, Department of Radiology ,N.R.S. Medical College, Kolkata 
Sudipta Chakraborty
Associate Professor, Department of Pathology, N.R.S. Medical College, Kolkata
Address For Correspondence
Dr. Snehamay Chaudhuri,
Sopan Kutir, Flat No 1G,
53 B, Dr S C Banerjee Road,
Kolkata - 700010
E-mail: snehamay_chaudhuri_dr@yahoo.com
Citation
Das C, Chaudhuri S, Karmakar M, Chakraborty S. Uterine Arteriovenous Malformation As A Rare Cause Of 
Menorrhagia Online J Health Allied Scs. 2008;7(3):4
URL
http://www.ojhas.org/issue27/2008-3-4.htm
http://ojhas.org 1
OJHAS Vol 7 Issue 3(4)   Das C, Chaudhuri S, Karmakar M, Chakraborty S. Uterine Arteriovenous Malformation As A Rare Cause Of Menorrhagia
 Case Report
Submitted: August 6, 2008; Suggested Revision: Nov 14, 2008; Resubmitted: Nov 16, 2008; Accepted: Nov 17, 
2008; Published: Nov 24, 2008
Abstract:
Uterine  arterio  venous  malformation  is  uncommon  cause  of  menorrhagia.  We  report  a  rare  case  of 
arteriovenous  malformation  diagnosed  after  18  years  of  suffering  from  menorrhagia.
 Key Words: Uterine arteriovenous malformation, Menorrhagia
Introduction:
Uterine arteriovenous malformation (AVM) is a rare cause of menorrhagia. It is important to keep in mind the possibility of 
uterine AVM in refractory cases of menorrhagia not responding to conventional measures. AVM can be diagnosed by color 
Doppler ultrasonography, computed tomography, magnetic resonance imaging and angiography. In the past hysterectomy 
was the only remedy. Recent reports have mentioned successful conservative management such as surgical removal of AVM, 
laparoscopic bipolar coagulation of the uterine arteries and long term medical therapy.1 Uterine artery embolization is also 
effective in controlling hemorrhage.2
We report a case of uterine AVM, where hysterectomy was performed
Case Report:
A 40 years old lady, married for 22 years, was admitted in the department of Gynecology and Obstetrics in N.R.S Medical 
College with history of menorrhagia for 18years. Obstetric history revealed that she conceived 4 years after marriage which 
resulted in spontaneous abortion for which curettage was done. Since then she developed menorrhagia. Blood loss was so 
heavy that she was compelled to be admitted in hospital for several times for blood transfusion, in spite of taking different 
hormonal preparations. 
She had been investigated for secondary infertility also and reports showed no abnormality in ovarian and tubal factors.
On admission she was severely anemic. Hemoglobin was 4gm%. She received 6 units of blood transfusion. Ultra sound scan 
(color Doppler) showed grossly dilated and tortuous vessels in both adnexal regions, more prominent on the right side. 
There was increased myometrial color flow having a mosaic pattern. Flow in the vessels of myometrium and adnexal region 
showed high velocity increased diastolic flow, having low resistance index, suggestive of arterio venous malformation.
 
Figure 1 (Left): Doppler ultrasonography of uterus with increased myometrial colour flow having mosaic pattern; 
Fig 2: Grossly dilated and tortuous vessels in both adnexal regions,more prominent or right side
 
Fig 3 (Left): Part of uterus with congested blood vessels in right adnexa during operation;
Fig 4: Uterus and both adnexae after operation
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OJHAS Vol 7 Issue 3(4)   Das C, Chaudhuri S, Karmakar M, Chakraborty S. Uterine Arteriovenous Malformation As A Rare Cause Of Menorrhagia
Figure V: Histological sections of myometrium showing dilated and congested vascular spaces lined by endothelial 
cells in absence of any specific lesion ( H&E, X100)
Pelvic angiography and MRI were not done as these facilities were not available in our hospital.
Total hysterectomy with bilateral salpingo oophorectomy was done after counselling the patient (patient was not desirous 
for child and she wanted to get rid of the uterus).
Histopathological examination of uterus and ovaries showed plenty of congested blood vessels and irregular blood spaces in 
myometrium without any specific lesion. There were features of chronic cervicits. In the ovaries also there were fair number 
of congested blood vessels. No neoplastic lesion was seen.
Discussion:
The first case of AVM was reported in 1926 by Dubreuil and Loubat.3 It consists of proliferation of arterial and venous chan-
nels with fistula formation and admixture of small capillary like channels. In many cases, distinction between artery and vein 
becomes blurred due to secondary intimal thickening in the veins as a result of increased intraluminal pressure.
Uterine AVM may be congenital or acquired. Congenital uterine AVM may be isolated or may occur in association with AVM 
in other organs. Acquired AVMs may be due to previous uterine trauma (such as uterine curettage), gestational trophoblastic 
disease, caesarean section, intrauterine contraceptive devices, necrotic chorionic villi invading venous sinuses. 4
In our case uterine AVM was acquired in nature as it started after post abortal curettage. Uterus was normal in size. We did 
not get any audible bruits or pulsatile masses at vaginal examination. Though angiography remains the gold standard imaging 
technique for diagnosis of uterine AVM 5, our case was diagnosed by colour doppler sonography. Wiebe and Switzer report-
ed seven cases of AVM diagnosed by colour Doppler sonography.6
Management depends on the age of the patient, her desire for future fertility and severity of bleeding. In the past, treatment 
had been confined to hysterectomy. In the last decade, an increasing number of women have been treated conservatively 
with success and hysterectomy is no longer considered essential. Acute management includes measures to stabilize the pa-
tient, uterine tamponade with Foley's catheter or rolled gauze packing, and medical therapies like estrogens, progestins, 
methylergonovine, danazol, and 15-methyl-prostaglandin F2alpha. In stable women, expectant management, surgical removal 
of an AVM, laparoscopic bipolar coagulation of the uterine blood vessels, and long-term medical therapy with combined oral 
contraceptive pills are reported.1 Recent reports have described successful treatment of uterine artery embolization with dif-
ferent materials used singly or in combination such as autologous blood clot, gelfoam, microfibrillar collagen, polyvinyl alco-
hol, isobutyl cyanoacrylate and steel coil spring occluders.7 Gonadotropin-releasing hormone agonists have been used as an 
adjunct to embolization and 6 months of therapy reduced the size of a uterine AVM from 5.1 x 3.8 cm to 1.4 x 1.0 cm.8 Sub-
sequent uterine artery embolization resulted in complete disappearance of the AVM, and normal cycles were resumed 3 
months  later.  The authors  concluded that  gonadotropin-releasing hormone agonist  therapy may be useful  in  situations 
where embolization needs to be postponed.
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OJHAS Vol 7 Issue 3(4)   Das C, Chaudhuri S, Karmakar M, Chakraborty S. Uterine Arteriovenous Malformation As A Rare Cause Of Menorrhagia
Our patient was 40 years old and not desirous of having child. Moreover she was so much disgusted with the continued suf-
fering from menorrhagia,  that she refused any kind of conservative management and so hysterectomy was planned for. 
Fleming et al reported six cases of AVM who underwent total abdominal hysterectomy for life threatening bleeding.7 Suc-
cessful uterine artery embolization with polyvinyl alcohol particles in three cases was reported by AA Nicholson et al. All of 
them resumed normal menstruation and one of them had successful pregnancy also.2 Prabhu et al also reported a case of 
uterine AVM treated with spring coil, who resumed normal menstruation with the procedure.9 
Conclusion:
Uterine AVMs though rare are potentially life threatening lesions. Though hysterectomy was the only treatment for it in the 
past, uterine artery embolization is a safe and effective method of treatment when uterine function is to be preserved. The 
case is reported here not only for its rarity but also to highlight the delay in its diagnosis. For long eighteen years she was 
treated by different doctors with various hormonal preparations. Had she been diagnosed earlier and treated by uterine 
artery embolization, her uterus would have been saved and she might conceive. So while dealing with a case of refractory 
type of menorrhagia one should always consider the possibility of uterine AVM.
References:
1. Bagga R, Verma P, Agarwal N, Suri V, Bapuraj JR. Failed angiographic embolization in uterine arterio venous mal-
formation: a case report and review of literature. Available at www.medscape.com/viewarticle  /567523_print    Ac-
cessed on 29/7/2008.
2. Nicholson AA, Turnbull LW, Coady AM, Guthrie K. Diagnosis and management of utrineateriovenous malforma-
tions. Clin Radiol1999;54(4)265-9
3. Dubreuil G, Loubat E, Aneurysme crisoide de l’ uterus and Ann Anat Patho. 1926;3:697-718
4. Ghosh TK. Arteriovenous malformation of the uterus and pelvis. Obstet Gynecol. 1986;68:40-3 .
5. Bottomoley JP, Whitehouse GH. Congenital arteriovenous malformation of the uterus demonstrated by angiogra-
phy. Acta Radiological Diagnostica 1975;16:43-48 .
6. Wiebe, ER Switzer P. Arteriovenous malformation of uterus associated with medical abortion. Int J  obstet Gynecol.  
2007;71: 155-8 
7. Fleming  H,  Ostor  AQ,  Pickel  H,  Forune  DW.  Artiovenous  malformations  of  the  ulerus.  Obstet  gyneccol 
1989;73(2):209-14 .
8. Morikawa M, Yamada T, Yamada H, Minakami H. Effect of gonadotropin-releasing hormone agonist on a uterine 
arteriovenous malformation. Obstet Gynecol. 2006;108:751-753
9. Prabhu A, Gupta A , Parulekar S. Ulerene Arteviovenoues Malformation A rare case of Uterine Haemorrhage. Avail-
able at http://www.bhj.org/journal/1999_4102_apr97/case_355htm Accessed on 27-07-08
http://ojhas.org 4
OJHAS Vol 7 Issue 3(4)   Das C, Chaudhuri S, Karmakar M, Chakraborty S. Uterine Arteriovenous Malformation As A Rare Cause Of Menorrhagia


Arteriovenous malformation of the uterus and pelvis. Obstet Gynecol.

Arteriovenous malformation of uterus associated with medical abortion.

Congenital arteriovenous malformation of the uterus demonstrated by angiography.

Diagnosis and management of utrineateriovenous malformations.

Effect of gonadotropin-releasing hormone agonist on a uterine arteriovenous malformation. Obstet Gynecol.

Failed angiographic embolization in uterine arterio venous malformation: a case report and review of literature. Available at www.medscape.com/viewarticle /567523_print Accessed on 29/7/2008.

Forune DW. Artiovenous malformations of the ulerus.

Loubat E, Aneurysme crisoide de l’ uterus and Ann Anat Patho.

Ulerene Arteviovenoues Malformation A rare case of Uterine Haemorrhage. Available at http://www.bhj.org/journal/1999_4102_apr97/case_355htm Accessed on 27-07-08 http://ojhas.org 4

Uterine Arteriovenous Malformation As A Rare Cause Of Menorrhagia

Chandana Das

Snehamay Chaudhuri

Madan Karmakar

Sudipta Chakraborty

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Uterine Arteriovenous Malformation As A Rare Cause Of Menorrhagia

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