A life threatening secondary postpartum haemorrhage due to AV malformation of uterus: a missed diagnosis

Authors

  • Sanjay Mathuriya Department of Surgery, ESI Model Hospital, Indore, Madhya Pradesh, India
  • Gayatri Mathuriya Department of Obstetrics and Gynecology, MGM Medical College, Indore, Madhya Pradesh, India
  • Ayushi Jaiswal Department of Obstetrics and Gynecology, MGM Medical College, Indore, Madhya Pradesh, India
  • Devyani Tiwari Department of Obstetrics and Gynecology, MGM Medical College, Indore, Madhya Pradesh, India

DOI:

https://doi.org/10.18203/2320-1770.ijrcog20231248

Keywords:

Caesarean section, RPOC, Arteriovenous malformation

Abstract

In current practice, the incidence of c section and other pelvic surgeries has been risen steadily worldwide, so is the complications of surgeries one such rare complication is "AV malformation". The classical presentation of uterine AVM is recurrent profuse vaginal bleeding. Presence of retained product of conception can cause diagnostic dilemma and clinical presentation could be similar. We presented a case report of 19 year old primigravida with secondary post-partum hemorrhage, 1 month following caesarean section. USG shows RPOC so patient was managed conservatively and discharge. Again she had massive bleeding per vaginum on Post LSCS day 57, was re-admitted, as the patient was hemodynamically unstable to save her life hysterectomy was performed, patient  condition improved and was discharged successfully but at the cost of her fertility. HPR showed ‘vascular lesions in lower uterine segment’. Uterine AVM could present in a variety of ways from asymptomatic to periodic or episodic vaginal bleeding or secondary PPH to life threatening torrential vaginal bleeding. The proper diagnosis of AVM is crucial because the primary treatment modalities for the alternative diagnosis of RPOC is dilation and curettage that can worsen the condition. In past AVM were difficult to diagnose. However, availability of Doppler USG scanning has made diagnosis of AVM more feasible. Prompt resuscitation, a high index of suspicion and timely treatment is essential for avoiding a catastrophic outcome in this situation.

References

of the chorionic villi. In past AVMs were difficult to diagnose and were usually only confirmed retrospectively in post hysterectomy specimen. However, availability of Doppler USG scanning has made the diagnosis of AVM relatively more feasible though confirmation with angiography (gold standard) is usually required prior to intervening. Case reports have described the use of gonadotropin-releasing hormone (GnRH) agonists to treat uterine AVMs in stable patients. In one case, the AVM completely resolved after 6 months of GnRH agonist therapy (with subsequent successful pregnancy), and in another case, 6 months of GnRH therapy decreased the size of the AVM, which was subsequently embolized for definitive therapy.4,5 Ultrasound-guided high-intensity focused ultrasound was used in one case to treat an acquired uterine AVM in a stable patient; two treatments were required.6

CONCLUSION

Prompt resuscitation, a high index of suspicion and timely treatment is essential for avoiding a catastrophic outcome in this situation. It is recommended that a transvaginal scan and colour Doppler assessment should be performed on any women with moderate to severe secondary PPH to exclude this rare but dangerous abnormality.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

Ghosh TK. Arteriovenous malformation of the uterus and pelvis. Obstet Gynecol. 1986;68(3):40-3.

Musa A, Hata T, Hata K, Kitao M. Pelvic arteriovenous malformation diagnosed by color flow Doppler imaging. AJR Am J Roentgenol. 1989;152(6):1311-2.

Borell U, Fernström I. Arteriovenous Fistulae of the Uterus and Adnexa: An Arteriographic Study. Acta Radiologica. 1958;49(1).

Nonaka T, Yahata T, Kashima K, Tanaka K. Resolution of uterine arteriovenous malformation and successful pregnancy after treatment with a gonadotropin-releasing hormone agonist. Obstet Gynecol. 2011;117(2 Pt 2):452-5.

Morikawa M, Yamada T, Yamada H, Minakami H. Effect of gonadotropin-releasing hormone agonist on a uterine arteriovenous malformation. Obstet Gynecol. 2006;108(3 Pt 2):751-3.

Yan X, Zhao C, Tian C, Wen S, He X, Zhou Y. Ultrasound-guided high-intensity focused ultrasound ablation for treating uterine arteriovenous malformation. BJOG. 2017;124(3):9.

Downloads

Published

2023-04-28

Issue

Section

Case Reports