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Radiology - Diagnostic
Resident PGY 4
Henry Ford Hospital
Background: PPH can occur in up to 6% of deliveries and is a major cause of maternal mortality. UAE is preferred for PPH after failure of conservative treatment, as UAE can be performed in an emergent manner and can be repeated if necessary. UAE is effective for multiple types of PPH, and 24 hours after delivery, AVMs are the most common type to require UAE. Sub-involution of the placenta bed (SIPB) as an etiology for PPH is a relatively underrecognized etiology in both diagnostic and interventional radiology. SIPB describes a persistence of large placental vessels within the myometrium greater than 24 hours after delivery. We present a pictorial review of ultrasound and angiographic cases to illustrate the differences between uterine AVM and SIP. Clinical Findings/Procedure Details: The appearance of uterine AVM and SIPB in the setting of PPH can be nearly identical on ultrasound with both showing enlarged myometrial vessels with low-resistance on Doppler. However, uterine vessel angiography can clearly diagnose a uterine AVM with tortuous and hypertrophied uterine vessels and an early draining vein. We present several cases of PPH with uterine AVM diagnosed on ultrasound that were confirmed with angiography and embolized successfully. We contrast those cases to patients with PPH and features that were consistent with AVM on ultrasound, whom had no evidence of AVM on angiography, thus suggestive of SIPB. Despite the lack of AVM found on angiography, these cases were embolized via gelatin foam with successful hemostasis of the PPH. Conclusion/Teaching Points: PPH is a significant factor of maternal mortality and can be successfully treated with UAE. Uterine AVM and SIPB can have nearly identical features on ultrasound but can be distinguished during angiography, however, the lack of an AVM on angiography should not preclude embolization.
Hillman, Daniel; Mitchell, Giordano; Craig, Brian; and Fallucca, John, "Tangled: A Pictorial Review of Ultrasound and Angiography of Postpartum Hemorrhage due to Uterine Arteriovenous Malformations and Sub-Involution of the Placental Bed" (2019). Clinical Research. 1.