Uterine arteriovenous malformation (AVM) is an uncommon but fatal condition and can cause bleeding from abnormal connection between artery and vein. Pregnancy after embolization of uterine AVM is very uncommon, and there are increased risks of spontaneous abortion and growth retardation. We report a case of pregnancy after bilateral uterine artery embolization for AVM and its successful outcome.

Javed, Arshia

Sheikh, Sana

English

eCommons@AKU

eCommons@AKU Department of Obstetrics & Gynaecology Division of Woman and Child Health 3-1-2021 Pregnancy after embolization for arteriovenous malformation: An uncommon successful outcome Arshia Javed Sana Sheikh Follow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_women_childhealth_obstet_gynaecol  Part of the Female Urogenital Diseases and Pregnancy Complications Commons, and the Obstetrics and Gynecology Commons 1020Vol. 71, No. 3, March 2021AbstractUterine arteriovenous malformation (AVM) is anuncommon but fatal condition and can cause bleedingfrom abnormal connection between artery and vein.Pregnancy after embolization of uterine AVM is veryuncommon, and there are increased risks of spontaneousabortion and growth retardation. We report a case ofpregnancy after bilateral uterine artery embolization forAVM and its successful outcome.Keywords: Uterine artery embolization, conception,pregnancy.DOI: https://doi.org/10.47391/JPMA.246IntroductionUterine arteriovenous malformation (AVM) is anuncommon but fatal condition responsible for bleedingfrom vessels which are connected abnormally, usuallyarteries and veins are connected by fistula.1 The AVM canbe congenital or acquired. Congenital uterine AVM arisesfrom embryological developmental abnormality in vascularstructure and abnormal communications between arteryand vein.2 Acquired AVM arises due to uterine curettage,trophoblastic disease, endometrial cancer and infection.3Angiography is the gold standard test for the diagnosis ofAVM.2 Angiography is an invasive technique that helps toconfirm the diagnosis by identifying the AVMs as complextangle of vessels supplied by large feeding vessels,2 butnowadays colour Doppler ultrasound provides reliablediagnosis. The treatment options for AVM are either surgicalwith hysterectomy or uterine artery ligation, which havebeen used previously. Currently uterine artery embolization(UAE) is becoming more acceptable because of its capacityto preserve the reproductive capability.4 Pregnancy afterembolization of uterine AVM is very uncommon.5 The firstsuccessful pregnancy case after embolization of uterineartery was reported by Chapman and Lutz in 1985.6 Thereare increased risks of spontaneous abortion and growthretardation due to poor vascularisation which disrupt theplacental development and maternal-foetal blood flow atthe treated area. Hyper selective embolization which onlyocclude feeding vessels of AVM and preserve other vessels,improves the pregnancy outcome. We report the case of apatient who became pregnant after bilateral uterine arteryembolization for AVM and her pregnancy outcome. To thebest of our knowledge no local case has been reportedregarding pregnancy after AVM treatment. The institutionalEthical review committee (ERC) approval was obtained. Thewritten consent of the patient was taken for the publicationCase ReportA 21-year-old primipara was admitted through the clinicwith a two-day history of heavy vaginal bleeding. She hadsuction evacuation at eight weeks of gestation due tomissed miscarriage on February 2017 and since then shehad multiple episodes of vaginal bleeding. Her Dopplerultrasound revealed loss of endometrial-myometrialinterface which confirmed the diagnosis of AVM. (Figure).Her bilateral uterine artery embolization was performed byinterventional radiologist at the Aga Khan UniversityHospital, Karachi in March 2017, the patient remainedstable after the procedure.7 The patient conceivedspontaneously 15 months after embolization. She had herfirst antenatal visit at 16th weeks of gestation in clinic atThe Aga Khan hospital for women Garden in December2018. Her routine antenatal screening tests were normalexcept for haemoglobin which was 7.8g/dl withhaematocrit (Hct) 25.6%. Her serum ferritin was 5.8ng/ml,which confirmed the diagnosis of iron deficiency anaemia.Iron infusions were given and the haemoglobin level roseCASE REPORT Pregnancy after embolization for arteriovenous malformation: An uncommon successful outcomeArshia Javed1, Sana Sheikh21Department of Obstetrics and Gynaecology, The Aga Khan Hospital forWomen, Karachi, Pakistan; 2Department of Obstetrics and Gynaecology, The Aga Khan University Hospital, Karachi, Pakistan.Correspondence: Arshia Javed. e-mail: drarshiajaved@yahoo.comFigure:  Coloured Doppler ultrasound imaging feature of uterine arteriovenousmalformation.1021J Pak Med Assocto 10.1g/dl. All her antenatal scans showed appropriatefoetal growth. At 39 weeks of gestation the patient camewith labour pains, she opted for spontaneous progress oflabour. After three hours of labour, spontaneous rupture ofthe membranes occurred and grade ii meconium stainedliquor was observed. Her foetal cardiotocographic trace(CTG) showed variable decelerations. Emergency caesareansection was performed in view of non-reassuring CTG trace.She delivered a male baby on May 2019 weighing 3.7kgwith Apgar score 8 in 1 minute and 9 in 5 minutes. Theplacenta was removed; estimated blood loss was 500ml.The patient was discharged on second post-operative dayin stable condition, and stitches were removed on seventhpost-operative day. To date the patient and her baby arewell.DiscussionUterine AVM are very uncommon lesions due toarteriovenous shunts between myometrial arteries andveins.2 Pregnancy after uterine artery embolization for AVMis very uncommon.5 A study by Barral et al showed that outof 12 women who had uterine artery embolization, onlythree conceived and only one pregnancy reached term.8The fertility rate is lower after embolization, which is dueto ovarian insufficiency or endometrial atrophy. TheNational Institute of Health and Care Excellence (UK)guideline 2010 states that patients who want to becomepregnant should be explained the uncertain effects of UAEon fertility.1 The Royal College of Obstetricians andGynaecologists guidelines 2013 state poor fertilityevidence after UAE, so it should be performed afterdiscussion with the women who wish to become pregnantin future.9 The risks of complications during pregnancyafter UAE are abortion, placenta previa and morbidadherence of placenta.10 There is also increased rate ofcaesarean section, postpartum bleeding and foetal growthrestriction.1ConclusionThe reported case demonstrated that uterine AVMembolization in symptomatic patient not only resolved thesymptoms but was also followed by spontaneousconception, pregnancy to term without any antenatal,intrapartum and post-natal risk to mother. Foetal outcomewas also favourable.Disclaimer: None.Conflict of Interest: None.Funding Sources: None.References 1. Guida M, Maffucci D, Iannuzzi G, Giordano M, Luciano G, DiBenedetto L, et al. Successful pregnancy after uterine artery em-bolization for uterine arterovenous malformation: a rare case report.Int J Womens Health 2018;10:745-50. doi: 10.2147/IJWH.S182131.2. Chen Y, Wang G, Xie F, Wang B, Tao G, Kong B. Embolization of uterinearteriovenous malformation. Iran J Reprod Med 2013;11:159-66.3. Calzolari S, Cozzolino M, Castellacci E, Dubini V, Farruggia A, Sisti G.Hysteroscopic Management of Uterine Arteriovenous Malformation.JSLS 2017;21:e2016.00109. doi: 10.4293/JSLS.2016.00109.4. Maleux G, Timmerman D, Heye S, Wilms G. Acquired uterine vascularmalformations: radiological and clinical outcome after transcatheterembolotherapy. Eur Radiol 2006;16:299-306. doi: 10.1007/s00330-005-2799-5.5. Delotte J, Chevallier P, Benoit B, Castillon JM, Bongain A. Pregnancyafter embolization therapy for uterine arteriovenous malformation.Fertil Steril 2006;85:228. doi: 10.1016/j.fertnstert.2005.06.058.6. Chapman DR, Lutz MH. Report of a successful delivery after nonsur-gical management of a choriocarcinoma-related pelvic arteriove-nous fistula. Am J Obstet Gynecol 1985;153:155-7. doi:10.1016/0002-9378(85)90102-4.7. Javed A, Chander R, Hoodbhoy Z. Uterine Arteriovenous Malforma-tions after Suction Evacuation of Missed Miscarriage. J Coll Physi-cians Surg Pak 2018;28:s33-4. doi: 10.29271/jcpsp.2018.03.S33.8. Barral PA, Saeed-Kilani M, Tradi F, Dabadie A, Izaaryene J, Soussan J,et al. Transcatheter arterial embolization with ethylene vinyl alcoholcopolymer (Onyx) for the treatment of hemorrhage due to uterinearteriovenous malformations. Diagn Interv Imaging 2017;98:415-21.doi: 10.1016/j.diii.2016.09.003.9. Karlsen K, Hrobjartsson A, Korsholm M, Mogensen O, Humaidan P,Ravn P. Fertility after uterine artery embolization of fibroids: a sys-tematic review. Arch Gynecol Obstet 2018;297:13-25. doi:10.1007/s00404-017-4566-7.10. Soeda S, Kyozuka H, Suzuki S, Yasuda S, Nomura Y, Fujimori K. Uterineartery embolization for uterine arteriovenous malformation is asso-ciated with placental abnormalities in the subsequent pregnancy:two cases report. Fukushima J Med Sci 2014;60:86-90. doi:10.5387/fms.2013-13.A. Javed, S. Sheikh

Pregnancy after embolization for arteriovenous malformation: An uncommon successful outcome

https://ecommons.aku.edu/cgi/viewcontent.cgi?article=1222&context=pakistan_fhs_mc_women_childhealth_obstet_gynaecol

Pregnancy after embolization for arteriovenous malformation: An uncommon successful outcome

Abstract

Similar works

Full text

Available Versions

eCommons@AKU