Women's health case of the day. Uterine arteriovenous malformation.

Uterine arteniovenous malformations (AVM5) are uncommon [1]. They have been reported in patients from 18 to 72 years old, but only rarely in nulliparous women [2]. AVMs have been referred to by many names, including arteriovenous f istula, arteriovenous aneurysm, cinsoid aneurysm, racemose aneurysm, pulsating angioma, and cavernous angioma [2-4]. AVMs consist of a “proliferation of arterial and venous channels with fistula formation and an admixture of small capillary-like channels” [4]. They can be congenital on acquired. Congenital AVMs may represent arrested embryonic development of vascular structures [5]. In contrast, acquired AVMs have been attributed to a variety of causes, including pelvic trauma, surgery, neoplasm, inflammation, and exposure to diethylstilbestrol (DES), or they may be idiopathic [3, 4, 6]. Associated tumors include endometnial or cervical carcinoma and tnophoblastic disease [2, 7]. Surgical procedures such as curettage and cesanean section may predispose to this entity [2]. Uterine AVMs grow slowly and symptoms may be delayed, although onset may be sudden [3]. The patient may note inreguIan vaginal bleeding, heavy menses, or abdominal pain. Bleeding occurs as a result of vascular erosion through the endometrium, which then can be exposed when the endometrium sheds [4]. Lange AVMs occasionally are complicated by the cardiovascular effects of blood shunting, such as dyspnea on exertion on fatigue [8]. Signs such as an audible bruit, a palpable thrill in the groin, or a pulsating mass on manual examination have been observed [7, 9]. Edematous lower extremities due to venous stasis may be seen [7]. Sonognaphy has recently been used to diagnose uterine AVM (Fig. 1). The first sonographic report in 1 979 described multiple serpentine, tubular anechoic structures in the pelvis [10]. The differential sonognaphic diagnosis includes fluidfilled bowel loops, multiloculated ovarian cysts, and hydnosalpinx [1 , 10]. More recently, colon Doppler imaging of uterme AVM has been described [8]. The abundant tangle of vessels with high-velocity flow is impressive, and the detection of such blood flow helps eliminate several of the differential diagnoses just listed. Colon Doppler imaging is an excellent noninvasive means of following up these patients after therapy. Contrast-enhanced CT, MR imaging, and hystenosalpingography have also been used in the diagnosis and management of pelvic AVMs [11-13]. Angiognaphy, which in the past has been used for diagnosis, is still essential to determine the vascular supply and is used to guide embolization therapy. Although hysterectomy had been the therapy for uterine AVM, embolization is now often used, particularly in patients of child-beaning age, because pregnancy is possible after embolization therapy [ii , 14]. Various embolization materials have been used, including gelatin sponge, coils, isobutyl-2-cyanoacrylate, detachable balloons, thrombin, and polyvinyl alcohol sponge (Ivalon) [9, 14]. Awareness of the uncommon diagnosis of uterine AVM will help prevent inappropriate procedures such as curettage in these patients, who almost always have vaginal bleeding. Color Doppler imaging combined with angiognaphic embolization will provide accurate diagnosis and optimize treatment. Jon W. Meilstrup Mary Ellen Fisher