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Pelvis » Female Pelvis (Gynecology)
Uterine arteriovenous fistula
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Author(s) :
Vikram Dogra, MD
Presentation A 28 year old female presented to the ER with increased vaginal bleeding after spontaneous abortion. She was sent to the ultrasound department to assess for retained products of conception.
Caption: Transverse color Doppler image
Description: A focal area of increased vascularity is noted within the myometrium. There is marked aliasing as evidenced by the mosaic appearance.
Caption: Longitudinal color Doppler image
Description: This image demonstrates the focal area of vascularity in the myometrium in a different plane. The spectral Doppler wave form reveals arterialized venous waveform.
Caption: Transverse spectral waveform analysis
Description: The arterialized venous waveform is noted in the this transverse plane.
Differential Diagnosis Uterine arteriovenous fistula
Final Diagnosis Uterine arteriovenous fistula

Uterine arterio-venous fistulas are uncommon vascular malformations of the uterus. Some of the other uterine malformations include uterine artery aneurysm, pseudoaneurysms and chorioangiomas of the placenta. The uterine AV fistulae may be congenital or may be acquired due to pelvic surgery, gestational trophoblastic neoplasia and post-partum status.

Most of the women with uterine AV malformation and fistulae present in the reproductive age group with abnormal, unexplained vaginal bleeding. Some of these patients may have a pulsatile mass on examination, audible bruit and palpable thrills.

Ultrasound with color Doppler is a sensitive modality for diagnosing uterine vascular malformations [especially AV fistulae]. Gray scale ultrasound features may be non-specific, demonstrating a hypoechoic mass or multiple anechoic channels within the uterine myometrium. Color and spectral Doppler analysis can be diagnostic and shows -
1. A highly vascular mass which demonstrates a mosaic pattern of color, suggesting turbulence.
2. Intralesional spectral analysis of the artery reveals high velocity flow with a low resistive index.  High flow velocities are also noted in the intralesional veins [due to the abnormal communication with the arteries], resulting in an arterialized venous pattern [as is seen in the case demonstrated here]. 

Management includes conservative management in certain select cases of acquired uterine AV fistulas, selective uterine artery embolization and in severely affected cases hysterectomy may be performed.

Case References 1. Aziz N, Lenzi TA, Jeffrey RB Jr, Lyell DJ. Postpartum uterine arteriovenous fistula. Obstet Gynecol. 2004 May;103(5 Pt 2):1076-8.
2. Polat P, Suma S, Kantarcy M, Alper F, Levent A. Color Doppler US in the evaluation of uterine vascular abnormalities. Radiographics. 2002 Jan-Feb; 22(1):47-53.
3. Mungen E, Yergok YZ, et al. Color Doppler sonographic features of uterine arteriovenous malformations: report of two cases. Ultrasound Obstet Gynecol. 1997 Sep; 10(3):215-9.
4. Deckner C, Schiesser M, Bastert G. Diagnosis of uterine vascular malformation using Doppler ultrasound. Ultraschall Med. 2004 Apr; 25(2):141-3.
5. Timmerman D, et al. Vascular malformations in the uterus: ultrasonographic diagnosis and conservative management. Eur J Obstet Gynecol Reprod Biol. 2000 Sep; 92(1):171-8.
Follow Up A MRI scan confirmed the diagnosis of uterine arterio-venous fistula.
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