Ultrasonographic technique to differentiate enhanced myometrial vascularity/arteriovenous malformation from retained products of conception

Abstract

Purpose: To objective of this study is to discuss the ultrasonographic technique to diagnose uterine enhanced myometrial vascularity/arteriovenous malformation (EMV/AVM) and differentiate it from retained products of conception. The study also reviews the management and outcome of EMV/AVM.

Methods: We present a series of three women who developed EMV after early pregnancy loss and a control case of incomplete abortion, where colour Doppler ultrasound was used to distinguish retained products of conception from features of EMV. Clinical status and imaging findings, including peak systolic velocity (PSV), were used for the initial risk stratification of the patients. All cases with EMV/AVM were managed expectantly with serial ultrasound imaging and trending human chorionic gonadotropin levels. The patient with retained products of conception was managed by hysteroscopy and curettage.

Results: In all cases, presentation was suggestive of incomplete abortion with retained products of conception. However, colour Doppler ultrasound demonstrated hypoechoic areas within the endometrium extending into the myometrium with a high maximum PSV. In the control case, colour Doppler ultrasound noted a heterogeneous area in the left uterine cavity; however, vascular flow in this area was distinct from the endometrium, suggesting retained products of conception. All three women with EMV were managed expectantly with close monitoring and good outcomes.

Conclusion: In patients with early pregnancy loss and bleeding or persistently elevated human chorionic gonadotropin levels, clinical status and appropriate use of ultrasound imaging with colour Doppler, including PSV measurement, can assist in recognition of EMV/AVM. Expectant management with serial ultrasound evaluation is a safe treatment option for EMV/AVM with low PSV and can minimise complications such as need for blood transfusion, uterine artery embolization, and hysterectomy.

Keywords: Arteriovenous malformation; Colour Doppler ultrasound; Enhanced myometrial vascularity; Peak systolic velocity; Uterine artery embolization; hysteroscopy.