Arteriovenous malformation in uterine cervix during pregnancy
A 33-year-old pregnant woman, gravida 1 para 0, presented with vaginal spotting on her first visit to our hospital at the 32th gestational week. Cervical AVM had not been previously identified. Her past medical history was unremarkable, except that she was a hepatitis B carrier. She has have no pathological history on the uterine cervix. Obstetric sonography revealed a single active fetus in the cephalic position. The structural survey remained unremarkable, except an upper-normal amount of amniotic fluid (amniotic fluid index was 23 cm). The fetus was average in size (estimated body weight was 2,000 g). Ultrasonography revealed a 4.4 × 2.28 cm sized hypoechoic mass like lesion in the cervix and a suspected severe engorged vessel (). Placenta previa was not suspected. For the differential diagnosis of cervical varix and cervical AVM, Doppler velocimetry was performed. Color Doppler analysis demonstrated expanding of numerous vessels and rapid and turbulent blood flow in the cervix with a mosaic pattern. Pulsed Doppler evaluation revealed pulsed wave with high-velocity flow during both systole and diastole with the maximum systolic and diastolic velocity of 39 cm/sec and 22 cm/sec. Both the arterial and venous waveforms were mixed (). A presumptive diagnosis of uterine cervix AVM was made. The non-stress test showed a reactive pattern of fetal heart tone, but regular uterine contraction was noted. Subsequent speculum pelvic examination revealed an engorged vessel on the surface of the cervix which was suspicious for vessel disorder, but no bleeding was noted (). She was hospitalized for management of preterm labor and further evaluations of the engorged vessel on the cervix. After tocolytics, pain was subside. Pelvic magnetic resonance imaging (MRI) revealed about a 20 × 25 mm sized T2 high signal intensity lesion in the endocervix. This indicated the presence of an engorged vessel on the cervix; the possibilities of cervical AVM were considered ().\nAt 32 weeks and 6 days' gestation, active bleeding with a large amount of blood clot from AVM was detected by speculum pelvic examination. Hemoglobin measurement was dropped from 10.9 to 9.7 g/dL even after two units of packed red blood cells transfusion. Transvaginal sonography was performed, and there was no evidence of placental bleeding, for example, placenta abruption or placenta previa. To gain time for preparing emergency cesarean section, we performed clamping with ring forceps and ligation of bleeding points. Fetal cardiotocography showed reactive pattern of heart rate without any deceleration. After 20 minutes or so, there was no bleeding and we decided to maintain the pregnancy. At 34 weeks and 2 days' gestation, we performed emergent cesarean section under general anesthesia because of massive uterine bleeding which was uncontrolled with vaginal packing tamponade. A male infant weighing 2,700 g was delivered without difficulty; Apgar scores were 4 and 6 at 1 and 5 minutes, respectively.\nDuring the operation, we noticed a severe engorged vessel suspected as the venous sinus near to endocervix. Except that site, we could not find AVM or venous sinus on the whole uterine corpus. Massive active bleeding from the suspected uterine cervical AVM occurred. Direct suture ligation of the cervical AVM was performed inside of the uterus with ligations of both uterine arteries, and they were successful in arresting the bleeding. The operation was completed uneventfully, and the estimated blood loss during surgery was about 2,500 mL. We could maintain the hemoglobin level of 10.7 g/dL by transfusion with 7 units of packed red blood cells and 7 units of fresh frozen plasma. She was discharged in stable condition without vaginal bleeding associated uterine cervical AVM at postoperative day 7. Four weeks later, transvaginal sonography revealed remaining multiple AVM in the lower cervix (Peak systolic velocity 34 mm/sec) (). Eight weeks from delivery, AVM of the uterine cervix decreased dramatically and no visible vessel engorgement of the cervix was noted by speculum and transvaginal sonography.