Uterine Arteriovenous Malformation with Sudden Heavy Vaginal Hemmorhage
A 24-year-old female, G3P0030 with a history of depression presented to the emergency department (ED) for evaluation of abrupt heavy vaginal bleeding. The patient noticed a sudden gush of blood between her thighs, prompting her visit to the ED. She had 2 days of light spotting preceding this sudden heavy bleeding, as well as irregular menses ever since a missed abortion 4 months prior. She had 2 elective terminations of pregnancies in the preceding year secondary to severe hyperemesis gravidarum. During this episode of sudden heavy vaginal bleeding, she also complained of mild suprapubic cramping, but no associated nausea, vomiting, dizziness, chest pain, or shortness of breath.\nUpon presentation to the ED, approximately 30 minutes after the bleeding began, the patient’s triage vital signs showed a blood pressure of 123/81 mmHg, pulse of 102, respiratory rate of 20, pulse oximetry of 100% on room air, oral temperature of 98.7°F, and a negative rapid urine pregnancy. Intravenous access was obtained and blood was drawn for laboratory analysis. Upon evaluation, she was awake, alert and oriented ×3, and she was neither pale nor diaphoretic. She was bleeding through her sanitary napkins onto her clothes, but walked with ease to the exam table without any shortness of breath. Her abdomen had normoactive bowel sounds and was soft and non-tender. She had normal external genitalia with no signs of trauma. Her vaginal exam revealed copious dark blood and clots, with no trauma noted. There was approximately 300 mL of blood on the exam room floor. Her cervix had no lesions and clots were noted in the os. On bimanual exam, she had a closed cervical os, no cervical motion tenderness, and no adnexal tenderness.\nHer laboratory studies, including a complete blood count (CBC), electrolyte panel, coagulation studies, and thyroid function tests ,were unremarkable. She had a hemoglobin (Hgb) of 12.1 g/dL and hematocrit (Hct) of 37.1%. A point-of-care ED transvaginal ultrasound showed an enlarged endometrial cavity containing irregularities with an area of pulsatile flow via Doppler, no free fluid, and normal ovaries. Despite receiving an initial 2-liter bolus of intravenous crystalloid, the patient developed symptoms of postural hypotension with average blood pressures at approximately 100/60 mmHg. Her heart rate remained in the nineties; however, she continued to have persistent heavy vaginal bleeding. The decision was made to admit the patient to the gynecology service for possible surgical intervention of massive dysfunctional uterine bleeding, and further evaluation of an enlarged endometrial cavity.\nDuring her admission, and 9 hours after presentation, a repeat CBC due to heavy vaginal bleeding showed a 3-point drop in Hgb to 8.8 g/dL and Hct to 26.6%. She was transfused 4 units of packed red blood cells. On hospital day 2, her formal sonogram showed an enlarged endometrial cavity measuring 26 mm transversely with multiple hypertrophied vessels within the myometrium at the endometrial junction showing low resistance arterial flow, but no active flow within the endometrial cavity, suggesting a diagnosis of uterine arteriovenous malformation (AVM) ( and ). A magnetic resonance imaging angiogram (MRI/A) of the pelvis showed an amorphous collection of vessels arising from the pelvic arterial branches confirming the ultrasound diagnosis of multiple parametrial AVM or pseudoaneurysms ().\nOn hospital day 3, she had minimal vaginal bleeding, normal vitals, and stable blood counts (Hgb 9 g/dL and Hct 27%). After a multidisiciplinary discussion involving gynecology and interventional radiology, the patient declined surgical intervention, including uterine embolization of the AVM, and preferred to try medical management in an attempt to preserve her fertility. A hormonal intrauterine device (IUD) was placed and the patient was discharged with strict instructions on when to return to the hospital if the bleeding returned.