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

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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.

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Funding

The authors did not receive any funding to assist with preparation of this manuscript.

Author information

Authors and Affiliations

  1. Reproductive Genomics Program, The Fertility Center, 3230 Eagle Park Dr. NE, Suite 100, Grand Rapids, MI, 49525, USA

    Mili Thakur

  2. Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, MI, USA

    Mili Thakur, Michael R. Strug & Jessica Garcia De Paredes

  3. Department of Obstetrics, Gynecology and Women’s Health, Spectrum Health Medical Group, Grand Rapids, MI, USA

    Mili Thakur, Michael R. Strug, Jessica Garcia De Paredes & Marcos I. Cordoba Munoz

  4. Center for Minimally Invasive & Robotic Surgery, Camran Nezhat Institute, Palo Alto, CA, USA

    Anupama Rambhatla

  5. Stanford University Medical Center, Palo Alto, CA, USA

    Anupama Rambhatla

  6. Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Women’s Health, Spectrum Health Medical Group, Grand Rapids, MI, USA

    Marcos I. Cordoba Munoz

Authors
  1. Mili Thakur
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  2. Michael R. Strug
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  3. Jessica Garcia De Paredes
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  4. Anupama Rambhatla
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  5. Marcos I. Cordoba Munoz
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Contributions

All authors of this paper made substantial contribution to the conception of the study, collection of the data, and drafting of this manuscript. The authors approve this manuscript in the current form and are accountable for the accuracy of this work.

Corresponding author

Correspondence to Mili Thakur.

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Conflict of interest

The authors have no conflict of interest to declare that are relevant to the content of this article.

Ethical approval

The study was approved by the institutional review board SH IRB#: 2019-549.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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Thakur, M., Strug, M.R., De Paredes, J.G. et al. Ultrasonographic technique to differentiate enhanced myometrial vascularity/arteriovenous malformation from retained products of conception. J Ultrasound 25, 379–386 (2022). https://doi.org/10.1007/s40477-021-00574-y

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  • DOI: https://doi.org/10.1007/s40477-021-00574-y

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