Malformação arteriovenosa uterina: um relato de caso / Uterine arteriovenous malformation: a case report

O presente estudo tem como objetivo relatar o caso de uma paciente com malformação arteriovenosa uterina, efetivamente tratada com embolização seletiva e com fertilidade preservada. A malformação arteriovenosa uterina é uma alteração vascular rara até então pouco descrita na literatura. A paciente do sexo feminino apresentou quadro de sangramento uterino anormal, com início 30 dias após um abortamento, sem realização de curetagem, de uma gestação resultante de fertilização in vitro. Foram, então, realizados exames de imagem, que levaram ao diagnóstico de malformação arteriovenosa uterina. O tratamento de escolha foi a embolização arterial seletiva, com resolução do caso. Após sete meses, nova fertilização in vitro foi realizada, encontrando-se na 36a semana de gestação. São necessários mais estudos sobre essa malformação a fim de que sejam estabelecidos os métodos mais eficazes para o manejo de casos futuros, especialmente quando há desejo de gestar.

The present study aims to report the case of a patient with uterine arteriovenous malformation, effectively treated with selective embolization and with preserved fertility. Uterine arteriovenous malformation is a rare vascular disorder that has so far been rarely described in the literature. Female patient presented with abnormal uterine bleeding, starting 30 days after an abortion without subsequent curettage, of a pregnancy resulting from in vitro fertilization. Imaging tests were then performed that led to the diagnosis of uterine arteriovenous malformation. The treatment of choice was selective arterial embolization, with successful results. After seven months, a new in vitro fertilization was performed, being in the 36th week of pregnancy. Further studies on this pathology are needed in order to establish the most effective methods for the management of future cases, especially when there is a desire to become pregnant.

Efficacy of Embolization in Acquired Uterine Vascular Malformations: An Experience in Tertiary Care Centre in India / Eficácia da embolização em malformações vasculares uterinas adquiridas: uma experiência em centro de atendimento terciário na Índia

Abstract Objective: To determine the efficacy of Uterine Artery Embolization in patients with bleeding acquired uterine arteriovenous malformations (AVMs). Methods: A prospective review of all patients who underwent Uterine Artery Embolization at our institution between July 2015 and April 2022 was performed. 225 patients were diagnosed with a uterine vascular malformation on doppler and corresponding MRI imaging. All patients underwent transcatheter embolization of the uterine arteries. Embolic agents in the 375 procedures included Histoacryl glue only (n = 326), polyvinyl alcohol (PVA) particles and Histoacryl glue (n = 29), PVA particles (n = 5), Gelfoam (n = 5), coils (n = 4), PVA particles and coils (n = 3), Histoacryl glue and Gelfoam (n = 2), and Histoacryl glue and coils (n = 1). Results: A total of 375 embolization procedures were performed in 225 patients. 90 patients required repeat embolization for recurrence of bleeding. The technical success rate of embolization was 100%. The clinical success rate was 92%: bleeding was controlled in 222 of 225 patients and three patients underwent a hysterectomy. 60 of the 225 patients had uneventful intrauterine pregnancies carried to term. The 210 patients who underwent successful embolization had no recurrence of bleeding at a median follow-up of 53 months (range, 5-122 months) after treatment. 15 patients were eventually lost to follow-up. One minor complication (0.4%) of non-flow-limiting dissection of the internal iliac artery occurred. Conclusion: Uterine Artery Embolization is a safe, effective, minimally invasive method to treat uterine AVMs with long-term efficacy, which can provide the preservation of fertility.

The use of uterine artery Doppler studies as predictors for postmolar gestational trophoblastic neoplasia / Philippine Journal of Obstetrics and Gynecology

Background@#Gestational trophoblastic neoplasia (GTN) is considered one of the most curable malignancies, especially when diagnosis and treatment are commenced early. Identifying predictors for the development of GTN will enable prompt management equating to an excellent prognosis.@*Objectives@#The objectives of this study were to determine the validity of uterine artery Doppler parameters (UADPs) as predictors for postmolar GTN, compare UADP values before and after evacuation, determine cutoff values and relationship with beta‑human chorionic gonadotropin (hCG) levels.@*Materials and methods@#This was a prospective cohort study, which included histopathologically confirmed hydatidiform mole (HM) patients who underwent suction curettage. UADPs (pulsatility index (PI), resistive index, and systolic/diastolic [S/D] ratio) were measured preevacuation, 4 weeks postevacuation, and 6 weeks postevacuation. Patients were followed up to determine whether they will develop postmolar GTN or not.@*Results@#A total of 31 HM patients were admitted during the study period, 84% (26/31) of whom underwent suction curettage. Of these, 92% (24/26) had histopathology of complete HM and were recruited. However, only 17 patients followed up and completed the study. Results showed that there was an increasing trend of the UADP from preevacuation to 6 weeks postevacuation and the trend between those with and without postmolar GTN was statistically significant. There was also an inverse relationship between the UADP and baseline β‑hCG values. UADP showed lower values among patients who developed postmolar GTN compared to those who did not. The cutoff values recommended by the area under curve (AUC) that can be a possible predictor were 4th‑week right PI of 2.14 (AUC = 0.71) and right S/D ratio of 2.60 (AUC = 0.73) and 6th‑week left PI of 2.80 (AUC = 0.70) and right PI of 2.53 (AUC = 0.74).@*Conclusion@#Neoangiogenesis, a hallmark of malignancy, is correlated with invasive disease and will show increased myometrial vascularization with lower uterine artery indices. Doppler ultrasound may be a useful tool for postmolar follow‑up and GTN diagnosis. However, the small sample size in this study is a limitation and a larger multicenter study is recommended.

Malformación arteriovenosa uterina como causa de hemorragia puerperal tardía / Uterine arteriovenous malformation as a cause of late puerperal hemorrhage

Resumen ANTECEDENTES: Las malformaciones arteriovenosas uterinas constituyen una causa infrecuente de hemorragia puerperal, en la bibliografía solo se encontraron 150 casos. Su conocimiento es importante porque son potencialmente mortales y porque se ha registrado un aumento en los últimos años. Suelen estar relacionadas con intervenciones en el útero: legrados, cesáreas o miomectomías o asociadas con neoplasias (enfermedad trofoblástica gestacional o adenocarcinoma endometrial), aunque otras son congénitas. CASO CLÍNICO: Paciente de 32 años, con una conización cervical y ablación de un mioma uterino mediante radiofrecuencia como únicos antecedentes de interés. A los 15 días posteriores a un parto eutócico, que fue el primero en su historial, tuvo un episodio de abundante metrorragia. En el puerperio inmediato tuvo una hemorragia abundante que requirió la transfusión de dos concentrados de hematíes. En la ecografía transvaginal el útero se observó de 22 x 44 mm, que podría corresponder a un cotiledón retenido. Ante la persistencia del sangrado se colocó un taponamiento intracavitario con una sonda de Foley con lo que se consiguió el cese del sangrado. Luego de descartar la embolización de las arterias uterinas debido al gran tamaño de la malformación arteriovenosa, se procedió a la histerectomía total simple por vía laparotómica. CONCLUSIÓN: Las malformaciones arteriovenosas uterinas, aunque son una causa infrecuente de hemorragia puerperal, deben ser sospechadas en virtud de ser potencialmente mortales.

Abstract BACKGROUND: Uterine arteriovenous malformations are a rare cause of puerperal hemorrhage, with only 150 cases reported in the literature. Their knowledge is important because they are life-threatening and because there has been an increase in recent years. They are usually related to interventions in the uterus: curettage, caesarean section or myomectomy or associated with neoplasms (gestational trophoblastic disease or endometrial adenocarcinoma), although others are congenital. CLINICAL CASE: A 32-year-old patient with a cervical conization and ablation of a uterine myoma by radiofrequency as the only history of interest. Fifteen days after a euthecological delivery, which was the first in her history, she had an episode of abundant metrorrhagia. In the immediate postpartum period, she had a heavy hemorrhage that required the transfusion of two red blood cell concentrates. Transvaginal ultrasound showed a uterus measuring 22 x 44 mm, which could correspond to a retained cotyledon. In view of the persistent bleeding, intracavitary tamponade was placed with a Foley catheter, which led to cessation of bleeding. After ruling out embolization of the uterine arteries due to the large size of the arteriovenous malformation, a simple total hysterectomy by laparotomy was performed. CONCLUSION: Uterine arteriovenous malformations, although an infrequent cause of puerperal hemorrhage, should be suspected because they are potentially fatal.

Pelvic arteriovenous malformation involving the uterine and internal iliac vessels with concomitant true aneurysm of uterine artery diagnosed through color Doppler ultrasound / Philippine Journal of Obstetrics and Gynecology

Background@#Pelvic arteriovenous malformations (AVMs) are rare but carries life-threatening consequences.@*Case Report@#A 47-year-old multipara who had previously undergone four cesarean sections came for re-evaluation of a malignant ovarian new growth. She was asymptomatic. Repeat ultrasound revealed normal ovaries, and a cystic structure at the left adnexa with abundant mixing of colors, turbulent flow and pulsative waveforms on spectral Doppler. It arises from serpentine tubular structures from the uterine isthmus. Uterine artery aneurysm was considered. Magnetic resonance angiography confirmed the findings of aneurysm and pelvic arteriovenous malformation. The patient underwent a hysterectomy with ligation and excision of aneurysm. Histopathologic findings showed pelvic AVM and a true aneurysm of the uterine artery.@*Conclusion@#Ultrasound with color Doppler is a low-cost and readily available tool for gynecologists for the diagnosis and management of pelvic AVM.

Progress in application of placental and intraplacental circulation Doppler in obstetrics / 中华围产医学杂志

Placental and maternal-fetal circulation Doppler ultrasound are the main noninvasive means for maternal-fetal monitoring. However, Doppler studies on placental abnormalities are not well studied yet. Doppler monitoring of the maternal-fetal circulation, involving uterine arteries, umbilical arteries, and fetal vessels, is still used to screen diseases related to placental dysfunction (such as preeclampsia and fetal growth restriction) and to guide clinical management. This article reviews the advances in the clinical application of placental and maternal-fetal circulation Doppler in obstetrics to optimize the clinical management of disorders associated with abnormal placental structure and function.

Efficacy of transcatheter uterine artery embolization in scar pregnancy patients of different ages based on random walk model / 中国医师杂志

Objective:To explore the efficacy and safety of cesarean scar pregnancy (CSP) in different ages treated by uterine artery embolization (UAE).Methods:120 patients with CSP admitted to Jiangyin Hospital of Traditional Chinese Medicine from July 2016 to July 2019 were selected as the research objects. They were divided into observation group (≤35 years, 75 cases) and control group (>35 years, 45 cases) according to age. Clinical data of all patients were collected and followed up for 6 months. The clinical observation indicators, surgical efficacy, Visual Analogue Scale (VAS) score, ovarian recovery, postoperative complications and adverse reactions, and quality of life score at 6 months after surgery were compared between the two groups. A random walk model was used to evaluate the improvement of ovarian function in the two groups.Results:In the observation group, the blood loss, operation time, postoperative β-human chorionic gonadotropin (β-HCG) value, β-HCG value turning negative and menstrual recovery time were significantly less than those in the control group (all P<0.05). The total effective rate was above 90% in the two groups, and no significant difference was observed (96.00% vs 91.11%, P>0.05). There was no statistical significance in VAS score of the two groups before surgery, 48 h and 72 h after surgery (all P>0.05), and VAS score of the observation group at 12 h and 24 h after surgery were significantly higher than those of the control group (all P<0.05). The levels of serum follicle stimulating hormone (FSH), estradiol (E 2), testosterone (T) and luteinizing hormone (LH) in observation group were better than those in control group after treatment (all P<0.05). There was no significant difference in the incidence of secondary uterine clearance, massive bleeding, hysterectomy, incision infection, vaginal bleeding and vaginal hematoma between the two groups (all P>0.05), but the total incidence of complications in observation group was significantly lower than that in control group ( P<0.05). Diarrhea, fever, nausea and vomiting, abdominal pain and other adverse reactions were significantly improved after symptomatic treatment, and there was no significant difference in the incidence of adverse reactions between the two groups ( P>0.05). There was no significant difference in the quality of life score 6 months after surgery between the two groups ( P>0.05). The results of random walk model evaluation showed that the improvement coefficients of the observation group were 0.147 6, 0.135 9, 0.180 2 and 0.206 3, while those of the control group were 0.142 2, 0.098 9, 0.152 4 and 0.197 4, respectively. Conclusions:UAE treatment for CSP patients of different ages showed no significant difference in clinical efficacy, and postoperative complications were not easy to occur, and the prognosis was good.

Application of uterine artery blood flow ultrasonic parameters in prognosis evaluation of threatened abortion during early pregnancy / 中国基层医药

Objective:To explore the application value of uterine artery blood flow ultrasound parameters in evaluating the prognosis of threatened abortion during early pregnancy.Methods:In this non-randomized controlled prospective clinical study, 108 women with threatened abortion during early pregnancy (6-12 weeks of pregnancy) who received treatment in the Health Community Group of Yuhuan Second People's Hospital from July 2021 to December 2022 were included in the observation group. An additional 108 healthy women who were at the early stage of pregnancy were selected for the control group. Color Doppler ultrasound was performed in both groups to measure the ultrasonic parameters of uterine artery blood flow (peak systolic/end diastolic flow velocity, resistance index, pulsatility index) and compare their differences. The pregnant women in the observation group were followed up until 28 weeks of gestation, and their prognosis was analyzed. The pregnant women who had successfully insured their babies were included in the good prognosis group, and the pregnant women who had aborted their babies were included in the poor prognosis group. The ultrasonic parameters of uterine artery blood flow in the two groups were compared. Logistic regression analysis was used to analyze the correlation between ultrasound parameters of uterine artery blood flow and poor prognosis.Results:In the observation group, the systolic peak/end diastolic flow velocity, resistance index, and pulsatility index on the left side were (6.46 ± 1.71), (0.97 ± 0.30), (2.72 ± 0.89), respectively, and they were (6.49 ± 1.70), (0.96 ± 0.32), (2.70 ± 0.91) respectively on the right side, which were significantly greater than (3.90 ± 1.02), (0.64 ± 0.17), (1.36 ± 0.54), (3.91 ± 1.04), (0.62 ± 0.18), (1.35 ± 0.52) in the control group ( t = 13.36, 9.95, 13.58, 13.45, 9.62, 13.39, all P < 0.001). Twenty-eight-week follow-up results showed that 72 women (66.67%) in the observation group had successfully insured their babies and 36 women (33.33%) had aborted their babies. In the good prognosis group, the systolic peak/end diastolic flow velocity, resistance index, and pulsatile index were (7.95 ± 1.89), (1.22 ± 0.36), (3.06 ± 0.95) on the left side, and they were (7.45 ± 1.94), (1.24 ± 0.37), and (3.03 ± 0.96) on the right side, which were significantly greater than (4.72 ± 1.27), (0.77 ± 0.24), (1.74 ± 0.69), (4.74 ± 1.32), (0.75 ± 0.25), (1.77 ± 0.70) in the poor prognosis group ( t = 10.53, 7.73, 8.23, 8.55, 8.14, 7.76, all P < 0.001). Logistic regression analysis showed that peak systolic/end diastolic flow velocity and resistance index were risk factors for poor prognosis of threatened abortion during early pregnancy, while the pulsatility index had no significant correlation with poor prognosis of threatened abortion during early pregnancy. Conclusion:Uterine artery blood flow ultrasound parameters have a certain predictive value for the prognosis evaluation of threatened abortion during early pregnancy, which can provide an important reference for clinical fetal protection treatment and benefit the prognosis of pregnant women.

Analgesic effect and safety of using an epidural analgesia pump versus an intravenous analgesia pump for uterine artery embolization in the treatment of uterine fibroids / 中国基层医药

Objective:To investigate the analgesic effect and safety of using an epidural analgesia pump versus an intravenous analgesia pump for uterine artery embolization in the treatment of uterine fibroids. Methods:Fifty patients with uterine fibroids undergoing uterine artery embolization admitted to The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University from January 2019 to December 2021 were included in this study. They were divided into an observation group and a control group ( n = 25/group). Patients in the observation group used an epidural analgesia pump for pain relief, while patients in the control group used an intravenous analgesia pump for pain relief. At 1, 6, 12, and 24 hours after surgery, pain severity was compared between the two groups using the Visual Analogue Scale. Comfort level was compared between the two groups using the Bruggemann Comfort scale. Before and after surgery, respiratory rate, heart rate, blood pressure, and adverse reactions were compared between the two groups. Results:At 1 hour after surgery, the Visual Analogue Scale score in the observation group was significantly lower than that in the control group [3.00 (2.00, 5.50) vs. 7.00 (6.00, 8.00), Z = -3.84, P < 0.05]. At 6, 12, and 24 hours after surgery, there was a significant difference in the Visual Analogue Scale score between the two groups (all P > 0.05). Within 24 hours after surgery, the use of opioid analgesics in the observation group was less than that in the control group [16.00% (4/25) vs. 88.00% (22/25), χ2 = 25.96, P < 0.001]. At 1 hour after surgery, the Bruggemann Comfort Scale score in the observation group was significantly higher than that in the control group [0.00 (0.00, 0.50) vs. 0.00 (0.00, 0.00), Z = 2.08, P < 0.05]. At 6, 12, and 24 hours after surgery, there was no significant difference in the Bruggemann Comfort Scale score between the two groups (all P > 0.05). After surgery, heart rate was significantly decreased in each group compared with before surgery (both P < 0.05). There were no significant differences in respiratory rate and mean arterial pressure between the two groups before and after surgery (both P > 0.05). There were no significant differences in the incidences of postoperative nausea, vomiting, and fever between the two groups (all P > 0.05). Conclusion:The epidural analgesia pump used for uterine artery embolization in the treatment of uterine fibroids has a better analgesic effect and provides more comfort and is safer than the intravenous analgesia pump. The former is worthy of clinical promotion.

Uterine artery embolization with highly compressible calibrated microspheres for the treatment of uterine fibroids / Embolização de miomas uterinos com microesferas calibradas de alta compressibilidade

Abstract Objective: To evaluate the safety and efficacy of using highly compressible calibrated microspheres in uterine artery embolization (UAE) for the treatment of uterine fibroids. Materials and Methods: This was a prospective multicenter study. Thirty-two women with symptomatic uterine fibroids were selected for UAE between January 2019 and March 2020. The participants completed the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire, underwent contrast-enhanced pelvic magnetic resonance imaging (MRI), and were submitted to anti-Müllerian hormone measurement, subsequently undergoing UAE with Embosoft microspheres. After six months, the patients again completed the UFS-QOL questionnaire and underwent pelvic MRI. Results: The most common symptoms were abnormal uterine bleeding (in 81.3% of the cases), pelvic pain (in 81.3%), and compression (in 46.9%). Of the 32 patients evaluated, 12 (37.5%) had anemia due to abnormal uterine bleeding. Thirty patients completed the study. Among those patients, we observed median reductions of 21.4% in uterine volume and 15.9% in dominant fibroid volume. We identified no adverse events that could be attributed to the material itself, although there were events attributed to the UAE procedure in general. Conclusion: For the treatment of uterine fibroids, UAE using Embosoft microspheres shows satisfactory results, providing reductions in uterine and dominant fibroid volumes, with a low rate of adverse events, and improving patient quality of life, as well as demonstrating safety and efficacy.

Resumo Objetivo: Avaliar a eficácia e segurança da embolização da artéria uterina (EAU) com microesferas calibradas de alta compressibilidade no tratamento de miomas uterinos. Materiais e Métodos: Este foi um estudo prospectivo e multicêntrico. Foram selecionadas 32 mulheres com miomas uterinos sintomáticos para EAU de janeiro de 2019 a março de 2020. As participantes preencheram o questionário Uterine Fibroid Symptom and Quality of Life (UFS-QOL), realizaram ressonância magnética (RM) pélvica com contraste e teste para medição dos hormônios antimüllerianos, seguido de embolização de miomas com microesferas Embosoft. Após seis meses, as pacientes novamente preencheram o UFS-QOL e realizaram RM pélvica. Resultados: Os sintomas mais relatados foram sangramento uterino anormal (81,3%), dor pélvica (81,3%) e compressão (46,9%). Doze pacientes (37,5%) apresentaram anemia consequente a sangramento uterino anormal. Nas 30 pacientes que completaram o estudo, observou-se redução mediana de 21,4% no volume uterino e 15,9% no volume do mioma dominante. Não foram identificados eventos adversos possivelmente relacionados ao material utilizado, apenas em relação ao procedimento de EAU. Conclusão: EAU com microesferas Embrosoft mostrou resultados satisfatórios no tratamento de miomas uterinos, com redução dos volumes uterino e do mioma dominante, baixa taxa de eventos adversos e melhora na qualidade de vida, demonstrando segurança e eficácia.

Could Aspirin Treatment Modify the Assessment of the Uterine Arteries? / O tratamento com aspirina pode modificar a avaliação das artérias uterinas?

Abstract Objective To analyze whether acetylsalicylic (ASA) intake modifies the mean uterine arteries pulsatility index (UtA-PI) at the 2nd or 3rd trimester in a cohort of pregnant women with abnormal mean UtA-PI at between 11 and 14 weeks of gestation. Methods This is a retrospective cohort study. Singleton pregnancies with abnormal mean UtA-PI at between 11 and 14 weeks of gestation were studied. The participants were divided into 3 groups: 1) If the participant did not take ASA during pregnancy; 2) If the participant took ASA before 14 weeks of gestation; and 3) If the participant took ASA after 14 weeks of gestation. The mean UtA-PI was evaluated at the 2nd and 3rd trimesters, and it was considered to improve when it decreased below the 95th percentile. The prevalence ratio (PR) and the number needed to treat (NNT) werecalculated. Results A total of 72 participants with a mean UtA-PI>95th percentile at the 1st trimester of gestation were evaluated. Out of the 18 participants who took ASA, 8 participants started it before 14 weeks of gestation and 10 after. A total of 33.3% of these participants had improved the mean UtA-PI at the 2nd and 3rd trimesters of gestation, although it was not statistically significant (p=0.154). The prevalence ratio was 0.95 (95% confidence interval [CI]: 0.31-1.89), but between the 1st and 2nd trimesters of gestation, the PR was 0.92 (95%CI: 0.21-0.99) and it was statistically significant. Conclusion The present work demonstrates a modification of the mean UtA-PI in participants who took ASA compared with those who did not. It is important to check if ASA can modify the normal limits of uterine arteries because this could have an impact on surveillance.

Resumo Objetivo Analisar se a ingestão de acetilsalicílico (ASA) modifica o índice médio de pulsatilidade das artérias uterinas (UtA-PI) no 2° ou 3° trimestre em uma coorte de gestantes com média anormal de UtA-PI entre 11 e 14 semanas. Métodos Este é um estudo de coorte retrospectivo. Gravidezes únicas com média anormal de UtA-PI entre 11 e 14 semanas foram estudadas. As participantes foram divididas em 3 grupos: 1) Se a participante não tomou ASA durante a gravidez, 2) Se a participante tomou AAS antes das 14 semanas e 3) Se a participante tomou ASA após 14 semanas. A média do UtA-PI foi avaliada nos 2° e 3° trimestres e considerou-se que melhorava quando diminuía<95° percentil. Foram calculados a razão de prevalência (RP) e o número necessário para tratar (NNT). Resultados Foram avaliadas 72 participantes com média de UtA-PI>95° percentil no 1° trimestre de gravidez. Das 18 participantes que tomaram ASA, 8 participantes começaram antes de 14 semanas e 10 depois. Um total de 33,3% desses participantes melhoraram a média de UtA-PI nos 2° e 3° trimestres, embora não tenha sido estatisticamente significante (p=0,154). A razão de prevalência foi de 0,95 (intervalo de confiança [IC95%]: 0,31-1,89), mas entre os 1° e o 2° trimestres, a RP foi de 0,92 (IC95%: 0,21-0,99) e foi estatisticamente significativa. Conclusão O presente trabalho demonstra uma modificação da média de UtA-PI em participantes que faziam uso de ASA em comparação com aqueles que não faziam. É importante verificar se o ASA pode modificar os limites normais das artérias uterinas porque isso pode ter um impacto na vigilância.

Correlation analysis between phonographic cardiac function and uterine artery resistance index in pregnant women with hypertension of different conditions during pregnancy / 中国医师进修杂志

Objective:To analyze the correlation between phonographic cardiac function and uterine artery resistance index (RI) in pregnant women with hypertension of different conditions during pregnancy by color Doppler ultrasonically.Methods:A total of 100 pregnant women with gestational hypertension admitted to Lishui People′s Hospital from January 2020 to February 2021 were selected and divided into gestational hypertension group (40 cases), mild pre-eclampsia group (30 cases) and severe pre-eclampsia group (30 cases) according to the severity of their disease. Another 30 normal pregnant women who underwent physical examination during the same period were selected as the control group. The left ventricular function parameters isovolumetric relaxation time (IVRT), left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume(LVESV), left atrial volume index (LAVI) and uterine arter RI in 4 groups were quantitatively analyzed by ultrasound during 28 to 38 weeks of gestation. The correlation between cardiac ultrasound parameters and of pregnant women RI were analyzed.Results:As the severity of the disease, the levels of IVRT, LVEDV, LVESV, LAVI were gradually rised, and the level of LVEF was gradually decreased, there were significant differences among the 4 groups ( P<0.05). The uterine arter RI in the control group, gestational hypertension group, mild pre-eclampsia group and severe pre-eclampsia group was 0.42 ± 0.04, 0.50 ± 0.05, 0.54 ± 0.11, 0.58 ± 0.06, there was significant difference ( F = 34.11, P<0.001), and as the severity of the disease , the level of uterine arter RI was gradually rised, there were significant differences among the 4 groups ( P<0.05). Pearson correlation analysis showed that IVRT had certain correlation with RI in the 4 groups ( r = 0.331, 0.450, 0.531, 0.582; P<0.05). In mild and severe pre-eclampsia group, there were a certain correlation between LVEDV, LVESV and RI (in mild pre-eclampsia group: r = 0.360 and 0.411, P<0.05; in severe pre-eclampsia group: r = 0.383 and 0.451, P<0.05). Conclusions:The left heart function of pregnant women with different conditions evaluated by ultrasound showed a downward trend, and the uterine artery RI increased gradually in pregnant women with severe pre-eclampsia, and RI was closely related to the cardiac ultrasound parameter IVRT.

Clinical value of laparoscopic reversible uterine artery occlusion in treatment of cesarean section scar pregnancy / 中华内分泌外科杂志

Objective:To explore the clinical value of laparoscopic reversible uterine artery occlusion in the treatment of cesarean section scar pregnancy.Methods:A total of 112 patients who were hospitalized in our hospital from Sep. 2018 to Jun. 2020 in the First Affiliated Hospital of Bengbu Medical College and diagnosed with type II and type III cesarean section scars were selected. The patients were divided into groups according to the randomization method, the control group ( n=58) and the study group ( n=54) . The control group used uterine artery embolization combined with laparoscopic removal of pregnancy and uterine scar repair, while the study group used laparoscopic reversible uterine artery occlusion, pregnancy removal surgery and uterine scar repair surgery. The clinical treatment effects of the two groups of patients were compared. Results:The intraoperative blood loss of the control group (21.26±9.64) ml was significantly less than that of the study group (75.25±8.25) ml ( P<0.05) ; the treatment success rate of the study group was 98.15% (53/54) , which was significantly higher than the control group 86.21% (50/58) ( P<0.05) ; the time of vaginal bleeding in the study group (7.26±0.94) d, postoperative menstrual regain time (31.25±1.26) d, and hospital stay (3.14±0.25) d were significantly less than those in the control group ( (9.54±0.94) 0.86) d, (47.25±2.15) d, (9.26±0.94) d) ] ( P<0.05) ; 24 h β-hCG level and β-hCG negative time study group [ (1015.11±325.05) IU/L, (14.25±3.21) d] was significantly less than the control group [ (2654.25±284.25) IU/L, (27.16±5.14) d] ( P<0.05) ; there was no difference in the scores of the modified SF-36 scale before treatment between the two groups ( P>0.05) . The modified SF-36 scale score (63.22±4.25) of the study group after treatment was significantly higher than that of the control group (55.25±3.83) ( P<0.05) . Conclusions:Laparoscopic reversible uterine artery occlusion is effective in treating cesarean section scar pregnancy. After treatment, the β-hCG level of the patient is significantly reduced and the quality of life is significantly improved.

Clinical characteristics of 16 cases of acquired uterine arteriovenous malformation / 中国综合临床

Objective:To analyze the clinical characteristics, diagnosis and treatment of acquired uterine arteriovenous malformation (UAVM).Methods:The clinical data of 16 patients with diagnosis of UAVM from January 2014 to March 2021 in Beijing Friendship Hospital, Capital Medical University were enrolled in this retrospective study. The general data of patients were observed and analyzed: age, pregnancy and childbirth, etc. Auxiliary examinations: human chorionic gonadotropin (hCG), B-ultrasound, CT angiography (CTA), magnetic resonance (MRI), digital subtraction angiography (DSA), lesion diameter, resistance index (RI), peak systolic velocity (PSV), treatment and postoperative pathology.Result:Among the 16 patients, hCG was negative in 10 cases and positive in 6 cases. The first abnormal bleeding time was (43.4±36.4) days and (16.0±9.0) days, respectively. The rehospitalization time was (63.3±54.4) days and (48.3±54.0) days. Six patients with massive bleeding were HCG negative. Ultrasound in 16 cases showed mixed echo light mass with rich blood flow in the uterine cavity, and magnetic resonance examination in 14 cases also showed abnormal signals in the uterine cavity or uterine wall. Mass staining was seen in 6 cases by DSA, vein development in advance, contrast medium overflow was seen in 2 cases, and the conclusion of CTA was consistent with DSA in 5 cases. Uterine artery embolization was performed in 5 cases, including 2 cases of massive bleeding, emergency bilateral uterine artery embolization and 3 cases of preventive embolization. Hysteroscopy was performed in 4 cases after embolization, and balloon compression was performed in 1 case because there was no obvious tissue in the uterine cavity. Hysteroscopy were performed in 10 cases without UAE. Mifepristone combined with misoprostol was used in 1 case. Among the 15 patients treated by surgery, 14 cases showed degenerative trophoblasts or villi. During the follow-up, one patient after uterine artery embolization complained of decreased menstruation, and ultrasound considered the possibility of intrauterine adhesion.Conclusion:After termination of pregnancy, imaging examination should be strengthened to guard against the occurrence of UAVM. Once diagnosed, medical intervention should be started as soon as possible to reduce bleeding. There is no standardized treatment for UAVM related to pregnancy. Comprehensive consideration should be given to the clinical manifestations, bleeding situation, lesion location and fertility requirements of the patients.

Utilidad de la evaluación USG Doppler de las arterias uterinas entre las semanas 11 y 13+6 y su aplicación en las calculadoras de riesgo para predecir preeclampsia / Usefulness of the USG Doppler evaluation of the uterine arteries between weeks 11 and 13+6 and its application in risk calculators to predict preeclampsia / Utilidade da avaliação USG Doppler das artérias uterinas entre as semanas 11 e 13+6 e sua aplicação em calculadoras de risco para prever pré-eclâmpsia

Introducción. La preeclampsia es la primera causa de muerte materna directa en Colombia y la segunda a nivel mundial. El desarrollo de estrategias de predicción y prevención puede disminuir las complicaciones y secuelas ocasionadas por dicha enfermedad. El Doppler de arterias uterinas entre las semanas 11 y 13+6 como prueba independiente o en combinación con factores maternos o pruebas bioquímicas permite tasas de detección de preeclampsia temprana ≥ 90% a partir de la implementación de distintos cribados. La validez de dicha prueba diagnóstica presenta una sensibilidad del 47.8% y especificidad del 92.1% para la detección de preeclampsia temprana; con una sensibilidad del 26.4% y especificidad del 93.4% para predecir preeclampsia en cualquier etapa. División de los temas tratados. En esta revisión de tema se aborda la utilidad de esta medición, se habla de la realización de la técnica en cuestión y, por último, se revisan las herramientas estandarizadas que están disponibles en la actualidad junto con su accesibilidad y precisión. Conclusiones. La evidencia empírica que respalda la validez de las herramientas disponibles hoy en día para el tamizaje de preeclampsia a través de la evaluación por ultrasonografía Doppler de las arterias uterinas es significativa. Al ser Colombia un país que presenta una prevalencia alta de preeclampsia, conocer la utilidad de esta medición favorece una vigilancia temprana y oportuna, lo que disminuye los posibles desenlaces desfavorables para las maternas.

Introduction. Preeclampsia is the primary cause of direct maternal death in Colombia and the second globally. The development of prediction and prevention strategies can reduce complications and consequences caused by this disease. The uterine arteries Doppler between weeks 11 and 13+6 as an independent test or in combination with maternal factors or biochemical tests allows for early detection rates for preeclampsia of ≥90% from the implementation of different sieving. The validity of this diagnostic test has a sensitivity of 47.8% and specificity of 92.1% for the early detection of preeclampsia; with a sensitivity of 26.4% and specificity of 93.4% to predict preeclampsia at any stage. Division of Covered Topics. This topic review covers the usefulness of this measurement. It discusses the performance of the technique in question and, lastly, the standardized tools currently available are reviewed together with the accessibility and accuracy. Conclusions. The empirical evidence that supports the validity of the tools available today for the screening of preeclampsia via Doppler ultrasound evaluation of the uterine arteries is significant. As Colombia is a country with a high prevalence of preeclampsia, knowing the usefulness of this measurement favors early and timely surveillance, which reduces possible unfavorable outcomes for mothers.

Introdução. A pré-eclâmpsia é a principal causa de morte materna direta na Colômbia e a segunda no mundo. O desenvolvimento de estratégias de predição e prevenção pode reduzir as complicações e sequelas causadas pela doença. O Doppler da artéria uterina entre as semanas 11 e 13+6 como um teste independente ou em combinação com fatores maternos ou testes bioquímicos permite taxas de detecção de pré-eclâmpsia precoce≥90% a partir da implementação de diferentes exames. A validade desse teste diagnóstico tem sensibilidade de 47,8% e especificidade de 92,1% para a detecção de pré-eclâmpsia precoce; com uma sensibilidade de 26,4% e especificidade de 93,4% para prever pré-eclâmpsia em qualquer fase. Divisão dos tópicos abordados. Esta revisão de tópicos aborda a utilidade desta medição, discute a realização da técnica em questão e, por fim, são revisadas as ferramentas padronizadas que estão disponíveis atualmente, juntamente com sua acessibilidade e precisão. Conclusões. A evidência empírica que apoia a validade das ferramentas disponíveis atualmente para rastreamento de pré-eclâmpsia por meio da avaliação de ultrassom Doppler das artérias uterinas é significativa. Como a Colômbia é um país com alta prevalência de pré-eclâmpsia, conhecer a utilidade dessa medição favorece a vigilância precoce e oportuna, o que reduz possíveis resultados desfavoráveis para mulheres maternas.

Uterine Artery Pulsatility Index as a Pre-eclampsia Predictor in the 3 Trimesters in Women with Singleton Pregnancies / Índice de pulsatilidade da artéria uterina como preditor de pré-eclâmpsia nos 3 trimestres em mulheres com gestações únicas

Abstract Objective To evaluate the mean uterine artery pulsatility index (UtAPI) in each trimester of pregnancy as a predictor of early or late pre-eclampsia (PE) in Colombian pregnant women. Methods The UtAPI was measured in singleton pregnancies in each trimester. Uterine artery pulsatility index as predictor of PE was evaluated by odds ratio (OR), receiver operating characteristic (ROC) curves, and Kaplan-Meier diagram. Results Analysis in the 1st and 3rd trimester showed that abnormal UtAPI was associated with early PE (OR: 5.99: 95% confidence interval [CI]: 1.64-21.13; and OR: 10.32; 95%CI: 2.75-42.49, respectively). Sensitivity and specificity were 71.4 and 79.6%, respectively, for developing PE (area under the curve [AUC]: 0.922). The Kaplan-Meier curve showed that a UtAPI of 0.76 (95%CI: 0.58-1.0) in the 1st trimester was associated with early PE, and a UtAPI of 0.73 (95%CI: 0.55-0.97) in the 3rd trimester was associated with late PE. Conclusion Uterine arteries proved to be a useful predictor tool in the 1st and 3rd trimesters for early PE and in the 3rd trimester for late PE in a pregnant population with high prevalence of PE.

Resumo Objetivo Avaliar o índice médio de pulsatilidade da artéria uterina (UtAPI) em cada trimestre da gravidez como preditor de pré-eclâmpsia (PE) precoce ou tardia em gestantes colombianas. Métodos O UtAPI foi medido em gestações únicas em cada trimestre. O UtAPI como preditor de PE foi avaliado por odds ratio (OR), curvas receiver operating characteristic (ROC) e diagrama de Kaplan-Meier. Resultados A análise no 1° e 3° trimestres mostrou que um UtAPI anormal foi associado com PE inicial (OR: 5,99; intervalo de confiança [IC] 95%: 1,64-21,13; OR: 10,32; IC95%: 2,75-42,49, respectivamente). A sensibilidade e a especificidade foram de 71,4 e 79,6%, respectivamente, para o desenvolvimento de PE (area under the curve [AUC]: 0,922). A curva de Kaplan-Meier mostrou que um UtAPI de 0,76 (IC95%: 0,58- 1,0) no 1° trimestre foi associado com PE precoce, e que um UtAPI de 0,73 (IC95%: 0,55-0,97) no 3° trimestre foi associado com PE tardia. Conclusão As artérias uterinas mostraram ser uma ferramenta preditora útil no 1° e 3° trimestres para PE inicial e no 3° trimestre para PE tardia em uma população de gestantes com alta prevalência de PE.

Uterine rescue in high-risk gestational trophoblastic neoplasia treated with ema-co by uterine arteries embolization due to arteriovenous malformations / Resgate uterino em neoplasia trofoblástica gestacional de alto risco tratada com EMA-CO por embolização de artérias uterinas devido a malformações arteriovenosas

Abstract Complete hydatidiform mole (CHM) is a rare type of pregnancy, in which 15 to 20% of the cases may develop into gestational trophoblastic neoplasia (GTN). The diagnostic of GTN must be done as early as possible through weekly surveillance of serum hCG after uterine evacuation.We report the case of 23-year-old primigravida, with CHM but without surveillance of hCG after uterine evacuation. Two months later, the patient presented to the emergency with vaginal bleeding and was referred to the Centro de Doenças Trofoblásticas do Hospital São Paulo. She was diagnosed with high risk GTN stage/score III:7 as per The International Federation of Gynecology and Obstetrics/World Health Organization (FIGO/WHO). The sonographic examination revealed enlarged uterus with a heterogeneous mass constituted of multiple large vessels invading and causing disarrangement of the myometrium. The patient evolved with progressive worsening of vaginal bleeding after chemotherapy with etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO) regimen. She underwent blood transfusion and embolization of uterine arteries due to severe vaginal hemorrhage episodes, with complete control of bleeding. The hCG reached a negative value after the third cycle, and there was a complete regression of the anomalous vascularization of the uterus as well as full recovery of the uterine anatomy. The treatment in a reference center was essential for the appropriate management, especially regarding the uterine arteries embolization trough percutaneous femoral

Resumo Mola hidatiforme completa (MHC) é um tipo raro de gravidez, na qual 15 a 20% dos casos podem desenvolver neoplasia trofoblástica gestacional (NTG). O diagnóstico de NTG deve ser feito o mais cedo possível, pelo monitoramento semanal do hCG sérico após esvaziamento uterino. Relatamos o caso de uma paciente primigesta, de 23 anos de idade, com MHC, sem vigilância de hCG após esvaziamento uterino. Dois meses depois, a paciente compareceu na emergência com sangramento vaginal, sendo encaminhada ao Centro de Doenças Trofoblásticas do Hospital São Paulo, onde foi diagnosticada com NTG de alto risco, estádio e score de risco III:7 de acordo com a The International Federation of Gynecology and Obstetrics/Organização Mundial de Saúde (FIGO/OMS). O exame ultrassonográfico revelou útero aumentado com uma massa heterogênea constituída pormúltiplos vasos volumosos invadindo e desestruturando o miométrio. A paciente evoluiu com piora progressiva do sangramento vaginal após quimioterapia com o regime etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO). Ela foi submetida a transfusão de sangue e embolização das artérias uterinas devido aos episódios graves de hemorragia vaginal, com completo controle do sangramento. O hCG atingiu valor negativo após o terceiro ciclo, havendo regressão completa da vascularização uterina anômala, assim como recuperação da anatomia uterina. O tratamento em um centro de referência permitiu o manejo adequado, principalmente no que se refere à embolização das artérias uterinas através da punção percutânea da artéria femoral, que foi crucial para evitar a histerectomia, permitindo a cura da NTG e a manutenção da vida reprodutiva.

Validación de la calculadora de la Fundación de Medicina Fetal para tamiz de preeclampsia adaptada a población mexicana / Validation of the Fetal Medicine Foundation calculator for pre-eclampsia screening test adapted to a Mexican population

Resumen OBJETIVO: Validar el rendimiento de la calculadora de la Fundación de Medicina Fetal 4.0 adaptada a población mexicana. MATERIALES Y MÉTODOS: Estudio de cohorte efectuado en embarazos con feto único, según el modelo de riesgos en competencia para preeclampsia en un centro de medicina fetal de la Ciudad de México. El riesgo a priori se calculó de acuerdo con la historia clínica. La presión arterial media, el índice de pulsatilidad medio de la arteria uterina y la proteína plasmática A asociada al embarazo se midieron a las 11 a 14 semanas de gestación con metodología estandarizada. El valor de cada marcador se transformó en múltiplos de la mediana adaptados a la población local. Se aplicaron la distribución normal multivariante y el teorema de Bayes para obtener las probabilidades posprueba individuales, que se utilizaron como clasificadores para el área bajo la curva de característica receptor-operador. RESULTADOS: La incidencia de preeclampsia fue del 5.0% (54/1078). El área bajo la curva de característica receptor-operador fue de 0.784 (0.712; 0.856) para preeclampsia a menos de 37 semanas y de 0.807 (0.762; 0.852) para preeclampsia global. CONCLUSIONES: La calculadora FMF 4.0 adaptada a población mexicana resultó válida. Si bien tuvo menor rendimiento al esperado para preeclampsia a menos de 37 semanas, el rendimiento para preeclampsia global fue satisfactorio. Se justifica desarrollar la calculadora local.

Abstract OBJECTIVE: To validate the performance of the Fetal Medicine Foundation 4.0 calculator adapted to the Mexican population. MATERIALS AND METHODS: Cohort study performed in singleton pregnancies, according to the competing risk model for preeclampsia in a fetal medicine center in Mexico City. The a priori risk was calculated according to the clinical history. Mean arterial pressure, mean uterine artery pulsatility index and pregnancy-associated plasma protein A were measured at 11 to 14 weeks of gestation with standardized methodology. The value of each marker was transformed into multiples of the median adapted to the local population. Multivariate normal distribution and Bayes' theorem were applied to obtain individual posttest probabilities, which were used as classifiers for the area under the receiver-operator characteristic curve. RESULTS: The incidence of preeclampsia was 5.0% (54/1078). The area under the receiver-operator characteristic curve was 0.784 (0.712; 0.856) for preeclampsia at less than 37 weeks and 0.807 (0.762; 0.852) for global preeclampsia. CONCLUSIONS: The FMF 4.0 calculator adapted to Mexican population proved valid. Although it had lower performance than expected for preeclampsia at less than 37 weeks, the performance for global preeclampsia was satisfactory. The development of the local calculator is justified.

Complicaciones maternas durante la cesárea en pacientes con preeclampsia severa / Maternal complications during cesarean section in patients with severe preeclampsia

Resumen OBJETIVO: Identificar las complicaciones maternas durante la cesárea en pacientes con preeclampsia severa. MATERIALES Y MÉTODOS: Estudio retrospectivo, transversal y descriptivo efectuado en pacientes embarazadas con preeclampsia severa atendidas en la Unidad Médica de Alta Especialidad del Hospital de Gineco-Obstetricia 3 del Centro Médico Nacional La Raza entre el 1 de septiembre de 2020 y el 31 de mayo del año 2021. Se registraron: la indicación de la cirugía (materna o feto-placentaria), las complicaciones y su desenlace, el tiempo de estancia en la unidad de cuidados intensivos y en hospitalización y la muerte materna. Se utilizó estadística descriptiva con el programa estadístico SPSS v 20. RESULTADOS: Se estudiaron 100 pacientes con media de edad de 30.5 ± 5.85 años (límites 17 y 43), mediana de la paridad 2 (límites 1 y 6), semanas de embarazo 33.08 ± 3.9 (límites 26 y 39.4), peso 77.98 ± 15.87 kg (límites 42 y 120), talla 1.57 ± 0.07 m (límites 1.36 y 1.73) e IMC 31.46 ± 5.54 (límites 22.15 y 48.44). 90 de ellas finalizaron el embarazo por cesárea indicada por: crisis hipertensiva (81%), síndrome HELLP (17%), eclampsia (2%) y feto-placentaria en 10% (estado fetal no confiable 5%, ruptura prematura de las membranas 2%, anhidramnios 2%, restricción del crecimiento 1%). Se registraron 12% de complicaciones (atonía uterina (6%), lesión de una arteria uterina (2%), desgarro de la comisura de la histerorrafia (1%), hematoma de la histerorrafia (1%), hematoma del ligamento ancho (1%) y sangrado en capa (1%). Todas las complicaciones se corrigieron en el mismo tiempo quirúrgico. La media del tiempo entre el ingreso a hospitalización hasta la finalización del embarazo fue de 6.26 ± 2.26 horas, estancia en cuidados intensivos 1.36 ± 0.69 días y muerte materna 0%. CONCLUSIÓN: La frecuencia de complicaciones fue baja, quizá por tratarse de pacientes intervenidas en un hospital de alta especialidad.

Abstract OBJECTIVE: To identify maternal complications during cesarean section in patients with severe preeclampsia. MATERIALS AND METHODS: Retrospective, cross-sectional, descriptive study carried out in pregnant patients with severe preeclampsia attended at the High Specialty Medical Unit of the Obstetrics and Gynecology Hospital 3 of the National Medical Center La Raza between September 1, 2020 and May 31, 2021. The following were recorded: indication for surgery (maternal or feto-placental), complications and their outcome, length of stay in the intensive care unit and hospitalization, and maternal death. Descriptive statistics were used with the statistical program SPSS v 20. RESULTS: 100 patients were studied with mean age 30.5 ± 5.85 years (limits 17 and 43), median parity 2 (limits 1 and 6), weeks of pregnancy 33.08 ± 3.9 (limits 26 and 39.4), weight 77.98 ± 15.87 kg (limits 42 and 120), height 1.57 ± 0.07 m (limits 1.36 and 1.73) and BMI 31.46 ± 5.54 (limits 22.15 and 48.44). Ninety of them terminated the pregnancy by cesarean section indicated by: hypertensive crisis (81%), HELLP syndrome (17%), eclampsia (2%) and feto-placental in 10% (unreliable fetal status 5%, premature rupture of membranes 2%, anhydramnios 2%, growth restriction 1%). There were 12% complications (uterine atony (6%), uterine artery injury (2%), hysterorrhaphy commissure tear (1%), hysterorrhaphy hematoma (1%), broad ligament hematoma (1%) and layer bleeding (1%). All complications were corrected within the same surgical time. The mean time from hospitalization to termination of pregnancy was 6.26 ± 2.26 hours, intensive care stay 1.36 ± 0.69 days and maternal death 0%. CONCLUSION: The frequency of complications was low, perhaps because these patients underwent surgery in a high specialty hospital.

Ligaduras vasculares no tratamento cirúrgico da hemorragia pós-parto / Vascular ligations in the surgical treatment of postpartum hemorrhage

Hemorragia pós-parto é a maior causa de histerectomia periparto. Esta revisão descreve e ilustra as técnicas de ligaduras vasculares utilizadas no tratamento cirúrgico da hemorragia pós-parto. São apresentados os detalhes técnicos da ligadura das artérias uterinas, da ligadura das conexões útero-ovarianas, da ligadura tríplice de Tsirulnikov, das ligaduras sequenciais de AbdRabbo e de Morel e da ligadura das artérias ilíacas internas. Também são revistos os fatores que dificultam o sucesso dessas técnicas. As ligaduras vasculares são estratégias eficientes para o controle hemorrágico durante cesarianas e devem integrar o conjunto de técnicas que preservam o útero no tratamento da hemorragia pós-parto.(AU)

Postpartum hemorrhage is the major cause of peripartum hysterectomy. This review describes and illustrates the techniques of vascular ligations used in the surgical treatment of postpartum hemorrhage. The technical details of the uterine arteries ligation, of the ligation of the utero-ovarian connections, of the Tsirulnikov triple ligation, of the AbdRabbo and Morel sequential ligations and of the internal iliac arteries ligation are presented. The factors that hinder the success of these techniques also are reviewed. Vascular ligations are efficient strategies for hemorrhagic control during cesarean sections and should integrate the set of techniques that preserve the uterus in the treatment of postpartum hemorrhage.(AU)