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Published Quarterly
Mangalore, South India
ISSN 0972-5997
Volume 7, Issue ! "ul-Se# 200$
Uterine Arteriovenous Malformation As A Rare Cause Of Menorrhagia
Authors
Chandana Das,
Associate Professor, Department of Gynaecology and Obstetrics, N.R.S. Medical College, Kolata,
Snehamay Chaudhuri
Assistant Professor, Department of Gynaecology and Obstetrics, N.R.S. Medical College, Kolata,
Madan Karmakar,
Associate Professor, Department of Radiology ,N.R.S. Medical College, Kolata
Sudipta Chakraborty
Associate Professor, Department of Pat!ology, N.R.S. Medical College, Kolata
Address or Corresponden!e
Dr" Snehamay Chaudhuri,
Sopan K"tir, #lat No $G,
%& ', Dr S C 'aner(ee Road,
Kolata ) *+++$+
#$mail% sne!amay,c!a"d!"ri,dr-ya!oo.com
Citation
Das C, C!a"d!"ri S, Karmaar M, C!araborty S. .terine Arterio/eno"s Malformation As A Rare Ca"se Of
Menorr!agia Online J Health Allied Scs. 0++12*3&456
UR&
!ttp577888.o(!as.org7iss"e0*70++1)&)6.!tm
!ttp577o(!as.org
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OJHAS Vol 7 Issue 3(4) Das C, Chaudhuri S, Karmakar M, Chakrabor! S" #eri$e Arerio%e$ous Mal&ormaio$ As A 'are Cause O& Me$orrha(ia
Case Report
S"bmitted5 A"g"st 9, 0++12 S"ggested Re/ision5 No/ $6, 0++12 Res"bmitted5 No/ $9, 0++12 Accepted5 No/ $*,
0++12 P"blis!ed5 No/ 06, 0++1
Abstra!t%
.terine arterio /eno"s malformation is "ncommon ca"se of menorr!agia. :e report a rare case of
arterio/eno"s malformation diagnosed after $1 years of s"ffering from menorr!agia.
Key 'ords% .terine arterio/eno"s malformation, Menorr!agia
(ntrodu!tion%
.terine arterio/eno"s malformation 3A;M4 is a rare ca"se of menorr!agia. <t is important to eep in mind t!e possibility of
"terine A;M in refractory cases of menorr!agia not responding to con/entional meas"res. A;M can be diagnosed by color
Doppler "ltrasonograp!y, comp"ted tomograp!y, magnetic resonance imaging and angiograp!y. <n t!e past !ysterectomy
8as t!e only remedy. Recent reports !a/e mentioned s"ccessf"l conser/ati/e management s"c! as s"rgical remo/al of A;M,
laparoscopic bipolar coag"lation of t!e "terine arteries and long term medical t!erapy.
$
.terine artery emboli=ation is also
effecti/e in controlling !emorr!age.
0
:e report a case of "terine A;M, 8!ere !ysterectomy 8as performed
Case Report%
A 6+ years old lady, married for 00 years, 8as admitted in t!e department of Gynecology and Obstetrics in N.R.S Medical
College 8it! !istory of menorr!agia for $1years. Obstetric !istory re/ealed t!at s!e concei/ed 6 years after marriage 8!ic!
res"lted in spontaneo"s abortion for 8!ic! c"rettage 8as done. Since t!en s!e de/eloped menorr!agia. 'lood loss 8as so
!ea/y t!at s!e 8as compelled to be admitted in !ospital for se/eral times for blood transf"sion, in spite of taing different
!ormonal preparations.
S!e !ad been in/estigated for secondary infertility also and reports s!o8ed no abnormality in o/arian and t"bal factors.
On admission s!e 8as se/erely anemic. >emoglobin 8as 6gm?. S!e recei/ed 9 "nits of blood transf"sion. .ltra so"nd scan
3color Doppler4 s!o8ed grossly dilated and tort"o"s /essels in bot! adne@al regions, more prominent on t!e rig!t side.
A!ere 8as increased myometrial color flo8 !a/ing a mosaic pattern. #lo8 in t!e /essels of myometri"m and adne@al region
s!o8ed !ig! /elocity increased diastolic flo8, !a/ing lo8 resistance inde@, s"ggesti/e of arterio /eno"s malformation.

igure ) *&eft+% Doppler ultrasonography of uterus ,ith in!reased myometrial !olour flo, having mosai! pattern-
ig .% /rossly dilated and tortuous vessels in both adne0al regions,more prominent or right side

ig 1 *&eft+% 2art of uterus ,ith !ongested blood vessels in right adne0a during operation-
ig 3% Uterus and both adne0ae after operation
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OJHAS Vol 7 Issue 3(4) Das C, Chaudhuri S, Karmakar M, Chakrabor! S" #eri$e Arerio%e$ous Mal&ormaio$ As A 'are Cause O& Me$orrha(ia
igure 4% 5istologi!al se!tions of myometrium sho,ing dilated and !ongested vas!ular spa!es lined by endothelial
!ells in absen!e of any spe!ifi! lesion * 56#, 7)88+
Pel/ic angiograp!y and MR< 8ere not done as t!ese facilities 8ere not a/ailable in o"r !ospital.
Aotal !ysterectomy 8it! bilateral salpingo oop!orectomy 8as done after co"nselling t!e patient 3patient 8as not desiro"s
for c!ild and s!e 8anted to get rid of t!e "ter"s4.
>istopat!ological e@amination of "ter"s and o/aries s!o8ed plenty of congested blood /essels and irreg"lar blood spaces in
myometri"m 8it!o"t any specific lesion. A!ere 8ere feat"res of c!ronic cer/icits. <n t!e o/aries also t!ere 8ere fair n"mber
of congested blood /essels. No neoplastic lesion 8as seen.
Dis!ussion%
A!e first case of A;M 8as reported in $B09 by D"bre"il and Co"bat.
&
<t consists of proliferation of arterial and /eno"s c!an)
nels 8it! fist"la formation and admi@t"re of small capillary lie c!annels. <n many cases, distinction bet8een artery and /ein
becomes bl"rred d"e to secondary intimal t!icening in t!e /eins as a res"lt of increased intral"minal press"re.
.terine A;M may be congenital or acD"ired. Congenital "terine A;M may be isolated or may occ"r in association 8it! A;M
in ot!er organs. AcD"ired A;Ms may be d"e to pre/io"s "terine tra"ma 3s"c! as "terine c"rettage4, gestational trop!oblastic
disease, caesarean section, intra"terine contracepti/e de/ices, necrotic c!orionic /illi in/ading /eno"s sin"ses.
6
<n o"r case "terine A;M 8as acD"ired in nat"re as it started after post abortal c"rettage. .ter"s 8as normal in si=e. :e did
not get any a"dible br"its or p"lsatile masses at /aginal e@amination. A!o"g! angiograp!y remains t!e gold standard imaging
tec!niD"e for diagnosis of "terine A;M
%
, o"r case 8as diagnosed by colo"r doppler sonograp!y. :iebe and S8it=er report)
ed se/en cases of A;M diagnosed by colo"r Doppler sonograp!y.
9
Management depends on t!e age of t!e patient, !er desire for f"t"re fertility and se/erity of bleeding. <n t!e past, treatment
!ad been confined to !ysterectomy. <n t!e last decade, an increasing n"mber of 8omen !a/e been treated conser/ati/ely
8it! s"ccess and !ysterectomy is no longer considered essential. Ac"te management incl"des meas"res to stabili=e t!e pa)
tient, "terine tamponade 8it! #oleyEs cat!eter or rolled ga"=e pacing, and medical t!erapies lie estrogens, progestins,
met!ylergono/ine, dana=ol, and $%)met!yl)prostaglandin #0alp!a. <n stable 8omen, e@pectant management, s"rgical remo/al
of an A;M, laparoscopic bipolar coag"lation of t!e "terine blood /essels, and long)term medical t!erapy 8it! combined oral
contracepti/e pills are reported.
$
Recent reports !a/e described s"ccessf"l treatment of "terine artery emboli=ation 8it! dif)
ferent materials "sed singly or in combination s"c! as a"tologo"s blood clot, gelfoam, microfibrillar collagen, poly/inyl alco)
!ol, isob"tyl cyanoacrylate and steel coil spring occl"ders.
*
Gonadotropin)releasing !ormone agonists !a/e been "sed as an
ad("nct to emboli=ation and 9 mont!s of t!erapy red"ced t!e si=e of a "terine A;M from %.$ @ &.1 cm to $.6 @ $.+ cm.
1
S"b)
seD"ent "terine artery emboli=ation res"lted in complete disappearance of t!e A;M, and normal cycles 8ere res"med &
mont!s later. A!e a"t!ors concl"ded t!at gonadotropin)releasing !ormone agonist t!erapy may be "sef"l in sit"ations
8!ere emboli=ation needs to be postponed.
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OJHAS Vol 7 Issue 3(4) Das C, Chaudhuri S, Karmakar M, Chakrabor! S" #eri$e Arerio%e$ous Mal&ormaio$ As A 'are Cause O& Me$orrha(ia
O"r patient 8as 6+ years old and not desiro"s of !a/ing c!ild. Moreo/er s!e 8as so m"c! disg"sted 8it! t!e contin"ed s"f)
fering from menorr!agia, t!at s!e ref"sed any ind of conser/ati/e management and so !ysterectomy 8as planned for.
#leming et al reported si@ cases of A;M 8!o "nder8ent total abdominal !ysterectomy for life t!reatening bleeding.
*
S"c)
cessf"l "terine artery emboli=ation 8it! poly/inyl alco!ol particles in t!ree cases 8as reported by AA Nic!olson et al. All of
t!em res"med normal menstr"ation and one of t!em !ad s"ccessf"l pregnancy also.
0
Prab!" et al also reported a case of
"terine A;M treated 8it! spring coil, 8!o res"med normal menstr"ation 8it! t!e proced"re.
B

Con!lusion%
.terine A;Ms t!o"g! rare are potentially life t!reatening lesions. A!o"g! !ysterectomy 8as t!e only treatment for it in t!e
past, "terine artery emboli=ation is a safe and effecti/e met!od of treatment 8!en "terine f"nction is to be preser/ed. A!e
case is reported !ere not only for its rarity b"t also to !ig!lig!t t!e delay in its diagnosis. #or long eig!teen years s!e 8as
treated by different doctors 8it! /ario"s !ormonal preparations. >ad s!e been diagnosed earlier and treated by "terine
artery emboli=ation, !er "ter"s 8o"ld !a/e been sa/ed and s!e mig!t concei/e. So 8!ile dealing 8it! a case of refractory
type of menorr!agia one s!o"ld al8ays consider t!e possibility of "terine A;M.
Referen!es%
$. 'agga R, ;erma P, Agar8al N, S"ri ;, 'ap"ra( FR. #ailed angiograp!ic emboli=ation in "terine arterio /eno"s mal)
formation5 a case report and re/ie8 of literat"re. A/ailable at 888.medscape.com7/ie8article 7%9*%0&,print Ac)
cessed on 0B7*70++1.
0. Nic!olson AA, A"rnb"ll C:, Coady AM, G"t!rie K. Diagnosis and management of "trineaterio/eno"s malforma)
tions. Clin Radiol$BBB2%636409%)B
&. D"bre"il G, Co"bat G, Ane"rysme crisoide de lH "ter"s and Ann Anat Patho. $B092&59B*)*$1
6. G!os! AK. Arterio/eno"s malformation of t!e "ter"s and pel/is. Obstet Gynecol. $B1929156+)& .
%. 'ottomoley FP, :!ite!o"se G>. Congenital arterio/eno"s malformation of t!e "ter"s demonstrated by angiogra)
p!y. Acta Radiological Diagnostica $B*%2$956&)61 .
9. :iebe, GR S8it=er P. Arterio/eno"s malformation of "ter"s associated 8it! medical abortion. Int J obstet Gynecol.
0++*2*$5 $%%)1
*. #leming >, Ostor AI, Picel >, #or"ne D:. Artio/eno"s malformations of t!e "ler"s. Obstet gyneccol
$B1B2*&30450+B)$6 .
1. Moria8a M, Jamada A, Jamada >, Minaami >. Gffect of gonadotropin)releasing !ormone agonist on a "terine
arterio/eno"s malformation. Obstet Gynecol. 0++92$+15*%$)*%&
B. Prab!" A, G"pta A , Par"lear S. .lerene Arte/io/eno"es Malformation A rare case of .terine >aemorr!age. A/ail)
able at !ttp577888.b!(.org7(o"rnal7$BBB,6$+0,aprB*7case,&%%!tm Accessed on 0*)+*)+1
!ttp577o(!as.org
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OJHAS Vol 7 Issue 3(4) Das C, Chaudhuri S, Karmakar M, Chakrabor! S" #eri$e Arerio%e$ous Mal&ormaio$ As A 'are Cause O& Me$orrha(ia