Enhanced Myometrial Vascularity: Case Presentation and Review

Study Objective To describe the etiology of arteriovenous malformations (AVM) and enhanced myometrial vascularity (EMV) and review updates in management for patients with retained products of conception (RPOC) associated with EMV through a case presentation. Design The etiology, symptoms, imaging findings/interpretation, and updates in management based on symptoms are reviewed in detail. Setting Tertiary referral center. Patients or Participants Eight weeks following suction dilation and curettage (D&C) for an incomplete abortion, a 28-year-old G1P0 patient presented with RPOC, menorrhagia and an acute drop in hemoglobin to an outside facility. After a diagnosis of a uterine AVM was made, she was transferred to our facility for further care. Interventions After transfer to our center, ultrasound demonstrated RPOC, with prominent internal vasculature containing peak systolic velocity (PSV)>20 cm/sec. A diagnosis of EMV was made. An MRI confirmed prominent serpentine vessel at the endometrium and in the RPOC. Due to her anemia, she underwent a uterine artery embolization (UAE) followed by suction D&C. Hysteroscopy was performed before and after suction D&C and following curettage, a large vascular bundle was appreciated at the surface of the endometrium. Measurements and Main Results The patient presented to clinic 2 weeks post operatively with resolution of AUB symptoms and a negative Beta hCG. Conclusion The management of patients with EMV is dependent on the extent of their symptoms. If significant bleeding is present, surgical management is required. Previous reports suggested that patients with EMV and RPOC should undergo UAE prior to D&C, but more recent studies suggest that D&C may be initiated without UAE, as EMV associated with RPOC may be a normal transient placentation phenomenon and have less risk of hemorrhage than previously suspected. Each patient requires individualized management based on symptoms, signs, imaging, and plans for future fertility. The ideal management of patients with RPOC and EMV remains to be determined.