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Obstetric Iatrogenic Arterial Injuries of the Uterus: Diagnosis with US and Treatment with Transcatheter Arterial Embolization¹

¹ From the Department of Diagnostic Radiology, Dongkang General Hospital, 123-3 Taehwa-dong, Ulsan 681-320, Korea. Presented as an education exhibit at the 2000 RSNA scientific assembly. Received April 19, 2001; revision requested May 31 and received July 20; accepted July 23. Address correspondence to J.H.K. (e-mail: KJH2603@chollian.net).

View larger version (132K): [in a new window]   Figure 1a.   Pseudoaneurysm after D&C in a 28-year-old woman. The patient had intermittent vaginal bleeding after a spontaneous abortion followed by D&C 7 months earlier. At presentation, the serum ß-human chorionic gonadotropin (HCG) test was negative. (a) Longitudinal gray-scale US image shows a cystic lesion (between cursors) in the left wall of the lower uterus. (b) Longitudinal color Doppler US image shows that the cystic structure is filled with blood and has varying colors (arrow). (c) Longitudinal duplex Doppler US image shows turbulent arterial flow within the sac. (d) Left internal iliac angiogram shows the pseudoaneurysm (arrows), which is supplied by the left uterine artery (arrowhead). After embolization with a 3-mm-diameter coil, the pseudoaneurysm disappeared. Follow-up US showed no evidence of the pseudoaneurysm.

View larger version (119K): [in a new window]   Figure 1b.   Pseudoaneurysm after D&C in a 28-year-old woman. The patient had intermittent vaginal bleeding after a spontaneous abortion followed by D&C 7 months earlier. At presentation, the serum ß-human chorionic gonadotropin (HCG) test was negative. (a) Longitudinal gray-scale US image shows a cystic lesion (between cursors) in the left wall of the lower uterus. (b) Longitudinal color Doppler US image shows that the cystic structure is filled with blood and has varying colors (arrow). (c) Longitudinal duplex Doppler US image shows turbulent arterial flow within the sac. (d) Left internal iliac angiogram shows the pseudoaneurysm (arrows), which is supplied by the left uterine artery (arrowhead). After embolization with a 3-mm-diameter coil, the pseudoaneurysm disappeared. Follow-up US showed no evidence of the pseudoaneurysm.

View larger version (106K): [in a new window]   Figure 1c.   Pseudoaneurysm after D&C in a 28-year-old woman. The patient had intermittent vaginal bleeding after a spontaneous abortion followed by D&C 7 months earlier. At presentation, the serum ß-human chorionic gonadotropin (HCG) test was negative. (a) Longitudinal gray-scale US image shows a cystic lesion (between cursors) in the left wall of the lower uterus. (b) Longitudinal color Doppler US image shows that the cystic structure is filled with blood and has varying colors (arrow). (c) Longitudinal duplex Doppler US image shows turbulent arterial flow within the sac. (d) Left internal iliac angiogram shows the pseudoaneurysm (arrows), which is supplied by the left uterine artery (arrowhead). After embolization with a 3-mm-diameter coil, the pseudoaneurysm disappeared. Follow-up US showed no evidence of the pseudoaneurysm.

View larger version (173K): [in a new window]   Figure 1d.   Pseudoaneurysm after D&C in a 28-year-old woman. The patient had intermittent vaginal bleeding after a spontaneous abortion followed by D&C 7 months earlier. At presentation, the serum ß-human chorionic gonadotropin (HCG) test was negative. (a) Longitudinal gray-scale US image shows a cystic lesion (between cursors) in the left wall of the lower uterus. (b) Longitudinal color Doppler US image shows that the cystic structure is filled with blood and has varying colors (arrow). (c) Longitudinal duplex Doppler US image shows turbulent arterial flow within the sac. (d) Left internal iliac angiogram shows the pseudoaneurysm (arrows), which is supplied by the left uterine artery (arrowhead). After embolization with a 3-mm-diameter coil, the pseudoaneurysm disappeared. Follow-up US showed no evidence of the pseudoaneurysm.

View larger version (154K): [in a new window]   Figure 2a.   Recurrent pseudoaneurysm after embolization in a 35-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 9 weeks earlier. She had markedly aggravated, intractable vaginal bleeding after therapeutic D&C 2 weeks earlier for abnormal vaginal bleeding. (a) Longitudinal gray-scale US image shows a septate cystic lesion (arrows) at the left wall of the lower uterus. (b) Longitudinal color Doppler US image shows that the cystic structure is filled with blood and has varying colors (arrows). (c) Longitudinal duplex Doppler US image shows turbulent arterial flow within the sac. (d) Left internal iliac angiogram shows the pseudoaneurysm (arrow), which is supplied by the left uterine artery. Arterial embolization with a 3-mm-diameter coil was performed. (e) Follow-up longitudinal US image obtained 3 days later shows thrombosis of the pseudoaneurysm (arrows). Two weeks later, the bleeding recurred and Doppler US showed recanalization of the pseudoaneurysm. (f, g) Photograph of the pathologic specimen (f) and photomicrograph (original magnification, x100; hematoxylin-eosin stain) (g) show degenerating retained chorionic villi (arrowheads in g) against a background of hematoma in placenta accreta (arrows in f). Scale in f is in centimeters.

View larger version (155K): [in a new window]   Figure 2b.   Recurrent pseudoaneurysm after embolization in a 35-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 9 weeks earlier. She had markedly aggravated, intractable vaginal bleeding after therapeutic D&C 2 weeks earlier for abnormal vaginal bleeding. (a) Longitudinal gray-scale US image shows a septate cystic lesion (arrows) at the left wall of the lower uterus. (b) Longitudinal color Doppler US image shows that the cystic structure is filled with blood and has varying colors (arrows). (c) Longitudinal duplex Doppler US image shows turbulent arterial flow within the sac. (d) Left internal iliac angiogram shows the pseudoaneurysm (arrow), which is supplied by the left uterine artery. Arterial embolization with a 3-mm-diameter coil was performed. (e) Follow-up longitudinal US image obtained 3 days later shows thrombosis of the pseudoaneurysm (arrows). Two weeks later, the bleeding recurred and Doppler US showed recanalization of the pseudoaneurysm. (f, g) Photograph of the pathologic specimen (f) and photomicrograph (original magnification, x100; hematoxylin-eosin stain) (g) show degenerating retained chorionic villi (arrowheads in g) against a background of hematoma in placenta accreta (arrows in f). Scale in f is in centimeters.

View larger version (131K): [in a new window]   Figure 2c.   Recurrent pseudoaneurysm after embolization in a 35-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 9 weeks earlier. She had markedly aggravated, intractable vaginal bleeding after therapeutic D&C 2 weeks earlier for abnormal vaginal bleeding. (a) Longitudinal gray-scale US image shows a septate cystic lesion (arrows) at the left wall of the lower uterus. (b) Longitudinal color Doppler US image shows that the cystic structure is filled with blood and has varying colors (arrows). (c) Longitudinal duplex Doppler US image shows turbulent arterial flow within the sac. (d) Left internal iliac angiogram shows the pseudoaneurysm (arrow), which is supplied by the left uterine artery. Arterial embolization with a 3-mm-diameter coil was performed. (e) Follow-up longitudinal US image obtained 3 days later shows thrombosis of the pseudoaneurysm (arrows). Two weeks later, the bleeding recurred and Doppler US showed recanalization of the pseudoaneurysm. (f, g) Photograph of the pathologic specimen (f) and photomicrograph (original magnification, x100; hematoxylin-eosin stain) (g) show degenerating retained chorionic villi (arrowheads in g) against a background of hematoma in placenta accreta (arrows in f). Scale in f is in centimeters.

View larger version (170K): [in a new window]   Figure 2d.   Recurrent pseudoaneurysm after embolization in a 35-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 9 weeks earlier. She had markedly aggravated, intractable vaginal bleeding after therapeutic D&C 2 weeks earlier for abnormal vaginal bleeding. (a) Longitudinal gray-scale US image shows a septate cystic lesion (arrows) at the left wall of the lower uterus. (b) Longitudinal color Doppler US image shows that the cystic structure is filled with blood and has varying colors (arrows). (c) Longitudinal duplex Doppler US image shows turbulent arterial flow within the sac. (d) Left internal iliac angiogram shows the pseudoaneurysm (arrow), which is supplied by the left uterine artery. Arterial embolization with a 3-mm-diameter coil was performed. (e) Follow-up longitudinal US image obtained 3 days later shows thrombosis of the pseudoaneurysm (arrows). Two weeks later, the bleeding recurred and Doppler US showed recanalization of the pseudoaneurysm. (f, g) Photograph of the pathologic specimen (f) and photomicrograph (original magnification, x100; hematoxylin-eosin stain) (g) show degenerating retained chorionic villi (arrowheads in g) against a background of hematoma in placenta accreta (arrows in f). Scale in f is in centimeters.

View larger version (105K): [in a new window]   Figure 2e.   Recurrent pseudoaneurysm after embolization in a 35-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 9 weeks earlier. She had markedly aggravated, intractable vaginal bleeding after therapeutic D&C 2 weeks earlier for abnormal vaginal bleeding. (a) Longitudinal gray-scale US image shows a septate cystic lesion (arrows) at the left wall of the lower uterus. (b) Longitudinal color Doppler US image shows that the cystic structure is filled with blood and has varying colors (arrows). (c) Longitudinal duplex Doppler US image shows turbulent arterial flow within the sac. (d) Left internal iliac angiogram shows the pseudoaneurysm (arrow), which is supplied by the left uterine artery. Arterial embolization with a 3-mm-diameter coil was performed. (e) Follow-up longitudinal US image obtained 3 days later shows thrombosis of the pseudoaneurysm (arrows). Two weeks later, the bleeding recurred and Doppler US showed recanalization of the pseudoaneurysm. (f, g) Photograph of the pathologic specimen (f) and photomicrograph (original magnification, x100; hematoxylin-eosin stain) (g) show degenerating retained chorionic villi (arrowheads in g) against a background of hematoma in placenta accreta (arrows in f). Scale in f is in centimeters.

View larger version (117K): [in a new window]   Figure 2f.   Recurrent pseudoaneurysm after embolization in a 35-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 9 weeks earlier. She had markedly aggravated, intractable vaginal bleeding after therapeutic D&C 2 weeks earlier for abnormal vaginal bleeding. (a) Longitudinal gray-scale US image shows a septate cystic lesion (arrows) at the left wall of the lower uterus. (b) Longitudinal color Doppler US image shows that the cystic structure is filled with blood and has varying colors (arrows). (c) Longitudinal duplex Doppler US image shows turbulent arterial flow within the sac. (d) Left internal iliac angiogram shows the pseudoaneurysm (arrow), which is supplied by the left uterine artery. Arterial embolization with a 3-mm-diameter coil was performed. (e) Follow-up longitudinal US image obtained 3 days later shows thrombosis of the pseudoaneurysm (arrows). Two weeks later, the bleeding recurred and Doppler US showed recanalization of the pseudoaneurysm. (f, g) Photograph of the pathologic specimen (f) and photomicrograph (original magnification, x100; hematoxylin-eosin stain) (g) show degenerating retained chorionic villi (arrowheads in g) against a background of hematoma in placenta accreta (arrows in f). Scale in f is in centimeters.

View larger version (192K): [in a new window]   Figure 2g.   Recurrent pseudoaneurysm after embolization in a 35-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 9 weeks earlier. She had markedly aggravated, intractable vaginal bleeding after therapeutic D&C 2 weeks earlier for abnormal vaginal bleeding. (a) Longitudinal gray-scale US image shows a septate cystic lesion (arrows) at the left wall of the lower uterus. (b) Longitudinal color Doppler US image shows that the cystic structure is filled with blood and has varying colors (arrows). (c) Longitudinal duplex Doppler US image shows turbulent arterial flow within the sac. (d) Left internal iliac angiogram shows the pseudoaneurysm (arrow), which is supplied by the left uterine artery. Arterial embolization with a 3-mm-diameter coil was performed. (e) Follow-up longitudinal US image obtained 3 days later shows thrombosis of the pseudoaneurysm (arrows). Two weeks later, the bleeding recurred and Doppler US showed recanalization of the pseudoaneurysm. (f, g) Photograph of the pathologic specimen (f) and photomicrograph (original magnification, x100; hematoxylin-eosin stain) (g) show degenerating retained chorionic villi (arrowheads in g) against a background of hematoma in placenta accreta (arrows in f). Scale in f is in centimeters.

View larger version (147K): [in a new window]   Figure 3a.   Four pseudoaneurysms supplied by the right uterine artery and right internal pudendal artery in a 30-year-old woman who underwent embolization twice. The patient had massive vaginal bleeding during D&C for a therapeutic abortion. (a) Longitudinal gray-scale US image shows cystic lesions (arrows) in the right wall of the lower uterus. (b) Longitudinal color Doppler US image shows that the cystic structures are filled with blood (arrows). (c) Longitudinal duplex Doppler US image shows less disturbed, high-velocity, high-resistance arterial flow within the sacs (peak systolic velocity [PSV], 50 cm/sec; resistive index [RI], 0.98). (d) Right internal iliac angiogram shows four pseudoaneurysms (arrows). After bilateral embolization of the uterine arteries with pledgets of absorbable gelatin sponge (Gelfoam; Pharmacia & Upjohn, Kalamazoo, Mich), the bleeding decreased but was still present. (e) Subsequent repeat right internal iliac angiogram obtained during the late arterial phase shows cross-filling of a pseudoaneurysm (arrow) supplied by the right internal pudendal artery, which demonstrates proximal occlusion (arrowhead) of unknown origin. Follow-up US after embolization showed no evidence of pseudoaneurysms.

View larger version (115K): [in a new window]   Figure 3b.   Four pseudoaneurysms supplied by the right uterine artery and right internal pudendal artery in a 30-year-old woman who underwent embolization twice. The patient had massive vaginal bleeding during D&C for a therapeutic abortion. (a) Longitudinal gray-scale US image shows cystic lesions (arrows) in the right wall of the lower uterus. (b) Longitudinal color Doppler US image shows that the cystic structures are filled with blood (arrows). (c) Longitudinal duplex Doppler US image shows less disturbed, high-velocity, high-resistance arterial flow within the sacs (peak systolic velocity [PSV], 50 cm/sec; resistive index [RI], 0.98). (d) Right internal iliac angiogram shows four pseudoaneurysms (arrows). After bilateral embolization of the uterine arteries with pledgets of absorbable gelatin sponge (Gelfoam; Pharmacia & Upjohn, Kalamazoo, Mich), the bleeding decreased but was still present. (e) Subsequent repeat right internal iliac angiogram obtained during the late arterial phase shows cross-filling of a pseudoaneurysm (arrow) supplied by the right internal pudendal artery, which demonstrates proximal occlusion (arrowhead) of unknown origin. Follow-up US after embolization showed no evidence of pseudoaneurysms.

View larger version (89K): [in a new window]   Figure 3c.   Four pseudoaneurysms supplied by the right uterine artery and right internal pudendal artery in a 30-year-old woman who underwent embolization twice. The patient had massive vaginal bleeding during D&C for a therapeutic abortion. (a) Longitudinal gray-scale US image shows cystic lesions (arrows) in the right wall of the lower uterus. (b) Longitudinal color Doppler US image shows that the cystic structures are filled with blood (arrows). (c) Longitudinal duplex Doppler US image shows less disturbed, high-velocity, high-resistance arterial flow within the sacs (peak systolic velocity [PSV], 50 cm/sec; resistive index [RI], 0.98). (d) Right internal iliac angiogram shows four pseudoaneurysms (arrows). After bilateral embolization of the uterine arteries with pledgets of absorbable gelatin sponge (Gelfoam; Pharmacia & Upjohn, Kalamazoo, Mich), the bleeding decreased but was still present. (e) Subsequent repeat right internal iliac angiogram obtained during the late arterial phase shows cross-filling of a pseudoaneurysm (arrow) supplied by the right internal pudendal artery, which demonstrates proximal occlusion (arrowhead) of unknown origin. Follow-up US after embolization showed no evidence of pseudoaneurysms.

View larger version (73K): [in a new window]   Figure 3d.   Four pseudoaneurysms supplied by the right uterine artery and right internal pudendal artery in a 30-year-old woman who underwent embolization twice. The patient had massive vaginal bleeding during D&C for a therapeutic abortion. (a) Longitudinal gray-scale US image shows cystic lesions (arrows) in the right wall of the lower uterus. (b) Longitudinal color Doppler US image shows that the cystic structures are filled with blood (arrows). (c) Longitudinal duplex Doppler US image shows less disturbed, high-velocity, high-resistance arterial flow within the sacs (peak systolic velocity [PSV], 50 cm/sec; resistive index [RI], 0.98). (d) Right internal iliac angiogram shows four pseudoaneurysms (arrows). After bilateral embolization of the uterine arteries with pledgets of absorbable gelatin sponge (Gelfoam; Pharmacia & Upjohn, Kalamazoo, Mich), the bleeding decreased but was still present. (e) Subsequent repeat right internal iliac angiogram obtained during the late arterial phase shows cross-filling of a pseudoaneurysm (arrow) supplied by the right internal pudendal artery, which demonstrates proximal occlusion (arrowhead) of unknown origin. Follow-up US after embolization showed no evidence of pseudoaneurysms.

View larger version (54K): [in a new window]   Figure 3e.   Four pseudoaneurysms supplied by the right uterine artery and right internal pudendal artery in a 30-year-old woman who underwent embolization twice. The patient had massive vaginal bleeding during D&C for a therapeutic abortion. (a) Longitudinal gray-scale US image shows cystic lesions (arrows) in the right wall of the lower uterus. (b) Longitudinal color Doppler US image shows that the cystic structures are filled with blood (arrows). (c) Longitudinal duplex Doppler US image shows less disturbed, high-velocity, high-resistance arterial flow within the sacs (peak systolic velocity [PSV], 50 cm/sec; resistive index [RI], 0.98). (d) Right internal iliac angiogram shows four pseudoaneurysms (arrows). After bilateral embolization of the uterine arteries with pledgets of absorbable gelatin sponge (Gelfoam; Pharmacia & Upjohn, Kalamazoo, Mich), the bleeding decreased but was still present. (e) Subsequent repeat right internal iliac angiogram obtained during the late arterial phase shows cross-filling of a pseudoaneurysm (arrow) supplied by the right internal pudendal artery, which demonstrates proximal occlusion (arrowhead) of unknown origin. Follow-up US after embolization showed no evidence of pseudoaneurysms.

View larger version (137K): [in a new window]   Figure 4a.   Acquired AVM in a 26-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 9 weeks earlier. The serum ß-HCG test was negative at presentation. (a) Transverse gray-scale US image shows a thickened endometrium and myometrium with subtle inhomogeneity (arrows) in the left posterior aspect of the uterus. (b) Transverse color Doppler US image shows focally increased arterial vascularity in the corresponding area (arrows). (c) Transverse duplex Doppler US image shows arterial flow with a high diastolic component (PSV, 42 cm/sec; RI, 0.52). (d) Left internal iliac angiogram shows a markedly opacified vascular tangle (arrows) supplied by the left uterine artery (arrowhead). Follow-up Doppler US examinations after embolization with a 3-mm-diameter coil showed disappearance of the lesion.

View larger version (101K): [in a new window]   Figure 4b.   Acquired AVM in a 26-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 9 weeks earlier. The serum ß-HCG test was negative at presentation. (a) Transverse gray-scale US image shows a thickened endometrium and myometrium with subtle inhomogeneity (arrows) in the left posterior aspect of the uterus. (b) Transverse color Doppler US image shows focally increased arterial vascularity in the corresponding area (arrows). (c) Transverse duplex Doppler US image shows arterial flow with a high diastolic component (PSV, 42 cm/sec; RI, 0.52). (d) Left internal iliac angiogram shows a markedly opacified vascular tangle (arrows) supplied by the left uterine artery (arrowhead). Follow-up Doppler US examinations after embolization with a 3-mm-diameter coil showed disappearance of the lesion.

View larger version (145K): [in a new window]   Figure 4c.   Acquired AVM in a 26-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 9 weeks earlier. The serum ß-HCG test was negative at presentation. (a) Transverse gray-scale US image shows a thickened endometrium and myometrium with subtle inhomogeneity (arrows) in the left posterior aspect of the uterus. (b) Transverse color Doppler US image shows focally increased arterial vascularity in the corresponding area (arrows). (c) Transverse duplex Doppler US image shows arterial flow with a high diastolic component (PSV, 42 cm/sec; RI, 0.52). (d) Left internal iliac angiogram shows a markedly opacified vascular tangle (arrows) supplied by the left uterine artery (arrowhead). Follow-up Doppler US examinations after embolization with a 3-mm-diameter coil showed disappearance of the lesion.

View larger version (194K): [in a new window]   Figure 4d.   Acquired AVM in a 26-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 9 weeks earlier. The serum ß-HCG test was negative at presentation. (a) Transverse gray-scale US image shows a thickened endometrium and myometrium with subtle inhomogeneity (arrows) in the left posterior aspect of the uterus. (b) Transverse color Doppler US image shows focally increased arterial vascularity in the corresponding area (arrows). (c) Transverse duplex Doppler US image shows arterial flow with a high diastolic component (PSV, 42 cm/sec; RI, 0.52). (d) Left internal iliac angiogram shows a markedly opacified vascular tangle (arrows) supplied by the left uterine artery (arrowhead). Follow-up Doppler US examinations after embolization with a 3-mm-diameter coil showed disappearance of the lesion.

View larger version (133K): [in a new window]   Figure 5a.   Acquired AVM in a 30-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 110 days earlier. The serum ß-HCG test was negative at presentation. (a) Transverse gray-scale US image shows subtle myometrial inhomogeneity (arrows) with a small internal anechoic component in the right posterolateral wall of the uterus. (b) Transverse color Doppler US image shows a tangle of tortuous vessels (arrows) in the corresponding myometrium. (c) Transverse duplex Doppler US image shows high-velocity arterial flow with a high diastolic component (PSV, 63 cm/sec; RI, 0.19). (d) Selective angiogram of the right uterine artery obtained during the arterial phase shows a markedly opacified vascular tangle (arrows) and early venous drainage (arrowheads). After embolization with absorbable gelatin sponge pledgets, no bleeding recurred.

View larger version (118K): [in a new window]   Figure 5b.   Acquired AVM in a 30-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 110 days earlier. The serum ß-HCG test was negative at presentation. (a) Transverse gray-scale US image shows subtle myometrial inhomogeneity (arrows) with a small internal anechoic component in the right posterolateral wall of the uterus. (b) Transverse color Doppler US image shows a tangle of tortuous vessels (arrows) in the corresponding myometrium. (c) Transverse duplex Doppler US image shows high-velocity arterial flow with a high diastolic component (PSV, 63 cm/sec; RI, 0.19). (d) Selective angiogram of the right uterine artery obtained during the arterial phase shows a markedly opacified vascular tangle (arrows) and early venous drainage (arrowheads). After embolization with absorbable gelatin sponge pledgets, no bleeding recurred.

View larger version (89K): [in a new window]   Figure 5c.   Acquired AVM in a 30-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 110 days earlier. The serum ß-HCG test was negative at presentation. (a) Transverse gray-scale US image shows subtle myometrial inhomogeneity (arrows) with a small internal anechoic component in the right posterolateral wall of the uterus. (b) Transverse color Doppler US image shows a tangle of tortuous vessels (arrows) in the corresponding myometrium. (c) Transverse duplex Doppler US image shows high-velocity arterial flow with a high diastolic component (PSV, 63 cm/sec; RI, 0.19). (d) Selective angiogram of the right uterine artery obtained during the arterial phase shows a markedly opacified vascular tangle (arrows) and early venous drainage (arrowheads). After embolization with absorbable gelatin sponge pledgets, no bleeding recurred.

View larger version (114K): [in a new window]   Figure 5d.   Acquired AVM in a 30-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 110 days earlier. The serum ß-HCG test was negative at presentation. (a) Transverse gray-scale US image shows subtle myometrial inhomogeneity (arrows) with a small internal anechoic component in the right posterolateral wall of the uterus. (b) Transverse color Doppler US image shows a tangle of tortuous vessels (arrows) in the corresponding myometrium. (c) Transverse duplex Doppler US image shows high-velocity arterial flow with a high diastolic component (PSV, 63 cm/sec; RI, 0.19). (d) Selective angiogram of the right uterine artery obtained during the arterial phase shows a markedly opacified vascular tangle (arrows) and early venous drainage (arrowheads). After embolization with absorbable gelatin sponge pledgets, no bleeding recurred.

View larger version (143K): [in a new window]   Figure 6a.   AVM combined with a pseudoaneurysm in a 24-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 50 days earlier. The serum ß-HCG test was negative at presentation. (a) Transverse gray-scale US image shows subtle myometrial inhomogeneity (arrows) in the left lateral wall of the uterus and an anechoic sac (arrowhead) in the endometrium. (b) Transverse color Doppler US image shows a tangle of tortuous vessels (arrows) and a blood-filled cystic structure (arrowhead) in the corresponding area. (c) Transverse duplex Doppler US image shows fast arterial flow with low resistance in the myometrium (PSV, 67 cm/sec; RI, 0.43). (d) Left internal iliac angiogram obtained during the late arterial phase shows a markedly opacified vascular tangle (arrows) and a pseudoaneurysm (black arrowheads) supplied by the left uterine artery. Early draining veins (white arrowhead) are seen. After embolization with absorbable gelatin sponge pledgets, no bleeding recurred.

View larger version (122K): [in a new window]   Figure 6b.   AVM combined with a pseudoaneurysm in a 24-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 50 days earlier. The serum ß-HCG test was negative at presentation. (a) Transverse gray-scale US image shows subtle myometrial inhomogeneity (arrows) in the left lateral wall of the uterus and an anechoic sac (arrowhead) in the endometrium. (b) Transverse color Doppler US image shows a tangle of tortuous vessels (arrows) and a blood-filled cystic structure (arrowhead) in the corresponding area. (c) Transverse duplex Doppler US image shows fast arterial flow with low resistance in the myometrium (PSV, 67 cm/sec; RI, 0.43). (d) Left internal iliac angiogram obtained during the late arterial phase shows a markedly opacified vascular tangle (arrows) and a pseudoaneurysm (black arrowheads) supplied by the left uterine artery. Early draining veins (white arrowhead) are seen. After embolization with absorbable gelatin sponge pledgets, no bleeding recurred.

View larger version (129K): [in a new window]   Figure 6c.   AVM combined with a pseudoaneurysm in a 24-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 50 days earlier. The serum ß-HCG test was negative at presentation. (a) Transverse gray-scale US image shows subtle myometrial inhomogeneity (arrows) in the left lateral wall of the uterus and an anechoic sac (arrowhead) in the endometrium. (b) Transverse color Doppler US image shows a tangle of tortuous vessels (arrows) and a blood-filled cystic structure (arrowhead) in the corresponding area. (c) Transverse duplex Doppler US image shows fast arterial flow with low resistance in the myometrium (PSV, 67 cm/sec; RI, 0.43). (d) Left internal iliac angiogram obtained during the late arterial phase shows a markedly opacified vascular tangle (arrows) and a pseudoaneurysm (black arrowheads) supplied by the left uterine artery. Early draining veins (white arrowhead) are seen. After embolization with absorbable gelatin sponge pledgets, no bleeding recurred.

View larger version (165K): [in a new window]   Figure 6d.   AVM combined with a pseudoaneurysm in a 24-year-old woman. The patient had intermittent vaginal bleeding after D&C for a therapeutic abortion 50 days earlier. The serum ß-HCG test was negative at presentation. (a) Transverse gray-scale US image shows subtle myometrial inhomogeneity (arrows) in the left lateral wall of the uterus and an anechoic sac (arrowhead) in the endometrium. (b) Transverse color Doppler US image shows a tangle of tortuous vessels (arrows) and a blood-filled cystic structure (arrowhead) in the corresponding area. (c) Transverse duplex Doppler US image shows fast arterial flow with low resistance in the myometrium (PSV, 67 cm/sec; RI, 0.43). (d) Left internal iliac angiogram obtained during the late arterial phase shows a markedly opacified vascular tangle (arrows) and a pseudoaneurysm (black arrowheads) supplied by the left uterine artery. Early draining veins (white arrowhead) are seen. After embolization with absorbable gelatin sponge pledgets, no bleeding recurred.

View larger version (145K): [in a new window]   Figure 7a.   Direct rupture of an arterial branch in a 33-year-old woman. The patient had massive vaginal bleeding during D&C for a therapeutic abortion. (a) Transverse gray-scale US image shows a markedly enlarged uterus (arrowheads) with large, heterogeneous hematomas (arrows) in the uterine cavity. (b) Longitudinal color Doppler US image shows slowly moving blood without fluctuation (arrows) within the hematomas, a finding suggestive of extravascular blood. (c) Left internal iliac angiogram shows extravasation of contrast medium (arrows) from branches of the left uterine artery. The uterus (arrowheads) is markedly enlarged by the hematomas. After arterial embolization with absorbable gelatin sponge pledgets, the bleeding stopped and did not recur.

View larger version (110K): [in a new window]   Figure 7b.   Direct rupture of an arterial branch in a 33-year-old woman. The patient had massive vaginal bleeding during D&C for a therapeutic abortion. (a) Transverse gray-scale US image shows a markedly enlarged uterus (arrowheads) with large, heterogeneous hematomas (arrows) in the uterine cavity. (b) Longitudinal color Doppler US image shows slowly moving blood without fluctuation (arrows) within the hematomas, a finding suggestive of extravascular blood. (c) Left internal iliac angiogram shows extravasation of contrast medium (arrows) from branches of the left uterine artery. The uterus (arrowheads) is markedly enlarged by the hematomas. After arterial embolization with absorbable gelatin sponge pledgets, the bleeding stopped and did not recur.

View larger version (147K): [in a new window]   Figure 7c.   Direct rupture of an arterial branch in a 33-year-old woman. The patient had massive vaginal bleeding during D&C for a therapeutic abortion. (a) Transverse gray-scale US image shows a markedly enlarged uterus (arrowheads) with large, heterogeneous hematomas (arrows) in the uterine cavity. (b) Longitudinal color Doppler US image shows slowly moving blood without fluctuation (arrows) within the hematomas, a finding suggestive of extravascular blood. (c) Left internal iliac angiogram shows extravasation of contrast medium (arrows) from branches of the left uterine artery. The uterus (arrowheads) is markedly enlarged by the hematomas. After arterial embolization with absorbable gelatin sponge pledgets, the bleeding stopped and did not recur.