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HEAVY MENSTRUAL BLEEDING Resident(s): Adam Fang, MD Attending(s): Devang Butani, MD Program/Dept(s): University of Rochester Medical Center
HEAVY MENSTRUAL BLEEDING
Resident(s): Adam Fang, MD
Attending(s): Devang Butani, MD
Program/Dept(s): University of Rochester Medical Center
CHIEF COMPLAINT & HPI
Chief Complaint “Heavy period”
History of Present Illness
39 year-old, married, white female, G4/P2-0-2-2 noted a heavy period lasting for 16 days associated with irregular vaginal bleeding, abdominal cramps and heavy menses.
RELEVANT HISTORY
Past Medical History Bilateral tibial stress fractures.
Past Surgical History No significant past surgical history.
Family & Social History Family history of osteoporosis, hypertension, diabetes, dyslipidemia, anemia.
Does not smoke, drink alcohol, or use illicit drugs.
Medications Ibuprofen and vitamin D
Allergies NKDA
DIAGNOSTIC WORKUP
Physical Exam BP: 120/62, HR: 62, RR: 20, O2Sat: 99% RA
General: Oriented to person, place, and time. She appears well developed and well nourished.
Cardiac: RRR, no murmurs, rubs, or gallops.
Pulm: CTAB. No wheezes, rhonchi or rales.
Abd: Soft and nontender abdomen. No distention or mass. No rebound or guarding.
Pelvic: Uterus, vulva, and cervix were normal. No adnexal abnormality.
Lymphadenopathy: No lymphadenopathy
Laboratory Data Stool was guaiac negative.
Pregnancy test was negative.
INR 1.1, aPTT 28
7.3 20710.2
32
DIAGNOSTIC WORKUP
Ultrasound: Sagittal grey-scale (A) and color (B) trans-
vaginal ultrasound (US) with Doppler and spectral analysis (C) demonstrates an anteverted uterus measuring 9.4 x 5.5 x 4.8cm.
Multiple serpiginous and anechoic tubular structures (arrows) are seen within the myometrium of uterus (A), which demonstrate internal vascularity (B) on color Doppler US.
Spectral Doppler US of this area (C) reveals high peak velocity with low resistance arterial waveforms and spectral broadening (arrow).
A B
C
DIAGNOSTIC WORKUP
MRI: Sagittal (A) and axial (B) T1-weighted MRI images demonstrate multiple serpiginous flow-related signal voids (arrows) involving the
posterior uterine body bulging towards the endometrial cavity and bowing the endometrium anteriorly (A).
The lesion (arrow) crosses the midline posteriorly, and appears to receive vascular supply via internal iliac vessels (arrowheads) as depicted on contrast-enhanced magnetic resonance angiography (C).
B CA
DIAGNOSTIC QUESTION
1) Based on the US and MRI findings, what is the diagnosis?
A: Pelvic varicosities.
B: Uterine artery arteriovenous malformation.
C: Uterine hemangioma.
D: Retained products of conception.
CORRECT!
1) Based on the US and MRI findings, what is the diagnosis?
A: Pelvic varicosities.
B: Uterine artery arteriovenous malformation.
C: Uterine hemangioma.
D: Retained products of conception.
CONTINUE WITH CASE
SORRY, THAT’S INCORRECT.
1) Based on the US and MRI findings, what is the diagnosis?
A: Pelvic varicosities.
B: Uterine artery arteriovenous malformation.
C: Uterine hemangioma.
D: Retained products of conception.
CONTINUE WITH CASE
INTERVENTION
Right common femoral artery was accessed. A 5F glide Omni-SOS catheter® (Angiodynamics, Latham, NY, USA) was placed through a 5F sheath.
Aortogram was performed demonstrating a uterine AVM (arrows) fed mainly by the left (70% of supply) and the right (30% of supply) uterine arteries with small branches from the left internal iliac artery. Early venous drainage is noted on delayed images.
LINK TO VIDEO
INTERVENTION
A: Selective embolization of left uterine artery: Two 6 mm x 10 cm hydrocoils® (Terumo, Somerset, NJ, USA), several 8 mm Gore-Tex coils® (L.W. Gore & Associates, Flaggstaff, AZ, USA), and a small piece of surgical gelfoamsequentially deployed in the left uterine artery with the help of a renegade microcatheter® (Boston Scientific, Marlborough, MA, USA).
B: A repeat angiogram of the left internal iliac artery demonstrated the blood supply of the uterine AVM coming from the left uterine artery was almost completely shut down with very slow minimal flow from some small branches from the left internal iliac artery.
C: Selective embolization of right uterine artery: 4 mm and 6 mm Gore-Tex coils were deployed in the right uterine artery with the help of a renegade microcatheter.
D: Repeat arteriogram of the abdominal aorta demonstrated near-complete occlusion and reduced flow of the uterine AVM post-embolization.
A
D
B
C
LINK TO VIDEO
MANAGEMENT QUESTION
2) What other potential treatment options are available for patients who fail transcatheter arterial embolization?
A: Laparoscopic bipolar coagulation of uterine vessels.
B: Hysterectomy.
C: Unilateral uterine artery and ovarian artery ligament ligation.
D: All of the above.
CORRECT!
2) What other potential treatment options are available for patients who fail transcatheter arterial embolization?
A: Laparoscopic bipolar coagulation of uterine vessels.
B: Hysterectomy.
C: Unilateral uterine artery and ovarian artery ligament ligation.
D: All of the above.
CONTINUE WITH CASE
SORRY, THAT’S INCORRECT.
2) What other potential treatment options are available for patients who fail transcatheter arterial embolization?
A: Laparoscopic bipolar coagulation of uterine vessels.
B: Hysterectomy.
C: Unilateral uterine artery and ovarian artery ligament ligation.
D: All of the above.
CONTINUE WITH CASE
CLINICAL FOLLOW UP
Repeat pelvic US was performed 3 months after bilateral uterine artery coil embolization.
Uterine AVM was stable in size and involved the posterior and left side of uterus with pronounced color flow signal (A and B).
Patient continued to have cramps and sometimes heavy bleeding.
Multiple options were offered to the patient including surveillance, repeat embolization, and total hysterectomy with preservation of ovaries.
Patient decided to undergo laparoscopic total hysterectomy.
A
B
SUMMARY & TEACHING POINTS
Uterine arteriovenous malformations (AVMs) are rare, but can be a source of potentially life-threatening bleeding
Characterized by multiple communications between arteries and veins.
Classified as congenital or acquired
Clinical presentation: Signs and symptoms: Severe uterine bleeding, lower abdominal
pain, dyspareunia, anemia, and symptoms due to blood shunting (dyspnea, fatigue, and high-output heart failure)
Physical exam: Audible bruit, palpable thrill in groin, palpable mass on manual examination, venous stasis and lower extremity edema
Imaging: Doppler US, CT, MRI, and angiography (gold standard)
Classification
Congenital Acquired
Dilation and curettage
UterinesurgeryUterine
traumaEndometrialcarcinoma
SUMMARY & TEACHING POINTS
Treatment Options Indications Advantages Disadvantage
Surgical Management (ex: hysterectomy, uterine artery ligation, laparoscopic bipolar coagulation of uterine vessels)
Fertility preservation is not needed, limited access to medical facilities, or embolization therapy fails
Definitive treatment Potential loss of fertility
Expectant and Medical Management
Single episode of bleeding and hemodynamically stable
Avoidance of surgical risks and preservation of fertility
Unsuccessful in patients with severe or recurrent bleeding
Transcatheter Arterial Embolization
Recurrent bleeding, severe bleeding, or hemodynamically unstable
High success rates, low complications, avoidance of surgical risks, and preservation of fertility
Side effects include low-grade temperature, pelvic pain, infection, insufficient embolization, buttock and lower-limb claudication
SUMMARY & TEACHING POINTS
Transcatheter arterial embolization technique: Common femoral artery is accessed using Seldinger technique. Pelvic angiography followed by
selective internal iliac angiography and uterine angiography on the affected side. Embolization of feeding arteries to the point of stasis. Repeat ipsilateral internal iliac angiography to exclude additional feeding arteries.
Contralateral internal iliac artery and uterine artery angiography and embolization to prevent cross-filling. Repeat contralateral internal iliac angiography.
Ovarian artery, inferior epigastric artery, or middle sacral artery are evaluated if bleeding does not stop or the vascular abnormality does not disappear.
Treatment is usually successful after one or two sessions.
Embolization material used in previous cases include gelatin sponge, coils, isobutyl-2-cyanoacrylate, detachable balloons, thrombin, and polyvinyl alcohol sponge.
REFERENCES & FURTHER READING
Huang MW, Muradali D, Thurston WA, Burns PN, Wilson SR. Uterine arteriovenous malformations: gray-scale and Doppler US features with MR imaging correlation. Radiology. 1998;206:115–123.
Meilstrup JW, Fisher ME. Women's health case of the day Uterine arteriovenous malformation. AJR Am J Roentgenol. 1994;162:1457–1458.
Ghosh TK. Arteriovenous malformation of the uterus and pelvis. Obstet Gynecol. 1986;68:40S–43S.
Vogelzang RL, Nemcek AA, Jr , Skrtic Z, Gorrell J, Lurain JR. Uterine arteriovenous malformations: primary treatment with therapeutic embolization. J Vasc IntervRadiol. 1991;2:517–522.
