Uterine arteriovenous malformation: a case report with proposal for pathogenesis.

Uterine arteriovenous malformation (UAM) is a rare medical condition. Even though UAM can cause abnormal and life-threatening uterine hemorrhage, there is no consensus on the clinical guideline on its treatments, most likely due to its low incidence, unknown etiology, and distinct fertility demands by different patients. Here, we present one elderly woman with uncommon UAM. We first discuss our experience regarding the diagnoses and treatments of UAM and then propose a hypothesis for the pathogenesis of UAM.

Emergency and prophylactic uterine artery embolization in gynecology and obstetrics - a retrospective analysis.

BACKGROUND: This study aimed to evaluate the safety and efficacy of emergency and prophylactic uterine artery embolization (UAE) in our clinical practice, including technical success, clinical success, and associated complications. PATIENTS AND METHODS: In this retrospective study, we analyzed 64 women who underwent emergency (n =18) and prophylactic (n = 46) UAE. Indications for emergency UAE included postpartum hemorrhage or severe hemorrhage during pregnancy termination, while prophylactic UAE was performed prior to surgical removal of retained products of conception (RPOC), delivery with abnormal placental implantation, or pregnancy termination (cervical pregnancy or fetal anomalies accompanied by abnormal placental implantation). Technical success of UAE was defined as complete exclusion of the vascular lesion and contrast stasis on the final angiogram, while clinical success was defined as cessation of bleeding after UAE Termination without a hysterectomy. RESULTS: The overall clinical success of UAE in our study was 97% (62/64). All embolization procedures were technically and clinically successful in the prophylactic group without life-threatening hemorrhages or hysterectomies (100% success rate, 46/46). However, while 100% technical success was similarly attained in the emergency group, bleeding was successfully controlled in 89% of cases (16/18). In two patients with significant blood loss (over 2000 mL), embolization failed to achieve hemostasis, resulting in persistent bleeding and subsequent hysterectomy. CONCLUSIONS: UAE is a safe and effective procedure for managing primary postpartum hemorrhage or severe hemorrhage during pregnancy termination and for decreasing the risk of severe hemorrhage during surgical removal of RPOC, delivery with abnormal placental implantation, or pregnancy.

In vivo revascularization and tissue effects of uterine artery embolization with starch microspheres in sheep.

OBJECTIVE: In uterine artery embolization (UAE) for the treatment of fibroids, nondegradable particles permanently occlude the uterine artery (UA). These particles remain in the vessels and can cause secondary undesirable effects, such as severe pain after embolization and fertility issues. In this prospective experimental study, we aimed to evaluate the angiographic recanalization, local and systemic reactions, and uterine damage occurring after performing UAE with newly developed degradable starch microspheres (DSMs) in sheep. MATERIALS AND METHODS: Under general anesthesia, eight nonpregnant sheep underwent bilateral UAE using DSMs to achieve stasis. Angiographic evaluation was performed on days 1, 3 and 7 after embolization to assess in vivo recanalization. In addition, the angiographic series were scored via a modified embolization score. A postmortem tissue examination was performed to determine whether DSMs and foreign body inflammatory reactions were present and to assess uterine necrosis. RESULTS: Complete bilateral embolization of the UA and cervicovaginal branches was achieved in all treated animals. Recanalization of the occluded arteries was evident in 25 of 27 arteries during the angiographic evaluation. In all sheep, there were multifocal areas of uterine necrosis, and some uterine vessels contained intraluminal material consistent with DSMs. The average weight of both uterine horns was significantly correlated with both the number of microspheres needed for complete embolization (r = 0.69, ρ<0.01) and the average percentage of necrosis in both uterine horns (r = 0.64, ρ<0.05). CONCLUSIONS: Our findings demonstrated the efficacy of vascular embolization with DSM by inducing ischemic changes in the uterus and subsequent recanalization of previously occluded arteries.

Uterine artery pseudoaneurysm caused by hysteroscopic surgery: A case report.

BACKGROUND: We report a case of uterine artery pseudoaneurysm (UAP) occurrence during hysteroscopic endometrial polypectomy and its treatment via uterine artery embolization (UAE). CASE SUMMARY: A 48-year-old primigravid, primiparous patient was incidentally found to have an endometrial polyp during a health checkup, and underwent a hysteroscopic polypectomy at another hospital. Her cervix was dilated with a Laminken-R® device. After the Laminken-R® was withdrawn, a large amount of genital bleeding was observed. This bleeding persisted after the hysteroscopic polypectomy, and, as hemostasis became impossible, the patient was transferred to our hospital by ambulance. On arrival, transvaginal ultrasonography revealed a 3-cm hypoechoic mass with a swirling internal pulse on the right side of the uterus, and color Doppler ultrasonography showed feeder vessels penetrating the mass. Pelvic contrast-enhanced computed tomography (CT) confirmed the presence of a mass at this site, and vascular proliferation was observed within the uterine cavity. Consequently, UAP was diagnosed, and UAE was performed. The patient's postoperative course was uneventful, and 6 mo post-UAE, no recurrence of blood flow to the UAP was observed. CONCLUSION: When abnormal genital bleeding occurs during hysteroscopic surgery, ultrasonography and contrast-enhanced CT can assist in the detection of early UAPs.

Uterine Artery Embolization: A Case Report on Primary Postpartum Hemorrhage Management.

When traditional therapies fail to control obstetric emergencies such as postpartum hemorrhage (PPH), uterine artery embolization (UAE) has become an essential intervention. This case study demonstrates the effective use of UAE in a 32-year-old patient who had an elective cesarean section and was experiencing refractory PPH. Despite initial attempts at controlling bleeding with uterotonic agents and surgical intervention, the hemorrhage persisted, necessitating packed red blood cell transfusion. A multidisciplinary team opted for UAE due to the patient's deteriorating condition. Gelatin sponge particles were utilized as embolic agents, resulting in the immediate cessation of uterine blood flow and the stabilization of the patient. This case underscores the importance of early detection, collaborative decision-making, and prompt intervention in managing PPH. UAE offers several advantages, including targeted vascular occlusion, rapid bleeding control, and the preservation of fertility. Further research and practice are warranted to optimize UAE techniques and enhance outcomes in obstetric emergencies. The primary cause of severe maternal morbidity and death is postpartum hemorrhage. For successful uterine artery embolization (UAE), prompt management is essential. UAE is widely acknowledged as a dependable and safe process.

Progression of Uterine Artery Pseudoaneurysm Documented by Ultrasonography: A Case Report.

Introduction: Uterine artery pseudoaneurysm (UAP) is a rare cause of late postpartum hemorrhage. Insufficient understanding of this condition among clinicians may result in delayed diagnosis and treatment, potentially leading to incorrect interventions and poor prognosis, including fatal hemorrhage and even necessitating hysterectomy in severe cases. Case Report: The patient, a 41-year-old woman with a history of three pregnancies and two deliveries, underwent cesarean section and subsequently experienced persistent small amounts of vaginal bleeding for a duration of two months. Transvaginal ultrasonography revealed a hypoechoic mass in the cervix that was initially misdiagnosed as a cervical fibroid. Approximately 12 h prior to admission, she experienced an episode of acute vaginal bleeding of significant intensity. Emergency transvaginal ultrasound demonstrated an intrauterine mass located in the posterior wall of the cervix with swirling blood flow, exhibiting a to-and-fro pattern. The mass was connected to the left uterine artery adjacent to the cervix through a tear measuring approximately 0.5 cm in diameter. Emergency bilateral uterine artery embolization was performed. After a follow-up period of ten months, there was no recurrence of abnormal vaginal bleeding, and subsequent ultrasound examination confirmed the complete resolution of the cervical lesions. Conclusion: The findings of this case suggest that the UAP undergoes a dynamic process. In the early stages, the lesion may manifest as a small hypoechoic or anechoic area within the myometrium. Color Doppler imaging might not reveal blood flow signals within the lesion, potentially leading to misdiagnosis as other common uterine lesions such as fibroids or cysts. However, considering the close association between UAP and the uterine artery, meticulous observation of the relationship between the uterine artery and its branches is crucial for identifying myometrial lesions to facilitate early detection of UAP and minimize misdiagnosis.

Outcomes and prognosis of postpartum hemorrhage according to management protocol: an 11-year retrospective study from two referral centers.

BACKGROUND: No standard treatment guidelines have been established for postpartum hemorrhage (PPH). We aimed to assess the differences in outcomes and prognoses between patients with PPH who underwent surgical and non-surgical treatment. METHODS: This retrospective study included 230 patients diagnosed with PPH at two referral hospitals between August 2013 and October 2023. The patients were divided into non-surgical (group 1, n = 159) and surgical intervention groups (group 2, n = 71). A subgroup analysis was performed by dividing the surgical intervention group into immediate (n = 45) and delayed surgical intervention groups (n = 26). RESULTS: Initial lactic acid levels and shock index were significantly higher in group 2 (2.85 ± 1.37 vs. 4.54 ± 3.63 mmol/L, p = 0.001, and 0.83 ± 0.26 vs. 1.10 ± 0.51, p < 0.001, respectively). Conversely, initial heart rate and body temperature were significantly lower in group 2 (92.5 ± 21.0 vs. 109.0 ± 28.1 beat/min, p < 0.001, and 37.3 ± 0.8 °C vs. 37.0 ± 0.9 °C, p = 0.011, respectively). Logistic regression analysis identified low initial body temperature, high lactic acid level, and shock index as independent predictors of surgical intervention (p = 0.029, p = 0.027, and p = 0.049, respectively). Regarding the causes of PPH, tone was significantly more prevalent in group 1 (57.2% vs. 35.2%, p = 0.002), whereas trauma was significantly more prevalent in group 2 (24.5% vs. 39.4%, p = 0.030). Group 2 had worse overall outcomes and prognoses than group 1. The subgroup analysis showed significantly higher rates of uterine atony combined with other causes, hysterectomy, and disseminated intravascular coagulopathy in the delayed surgical intervention group than the immediate surgical intervention group (42.2% vs. 69.2%, p = 0.027; 51.1% vs. 73.1%, p = 0.049; and 17.8% vs. 46.2%, p = 0.018, respectively). CONCLUSIONS: Patients with PPH presenting with increased lactic acid levels and shock index and decreased body temperature may be surgical candidates. Additionally, immediate surgical intervention in patients with uterine atony combined with other causes of PPH could improve prognosis and reduce postoperative complications.

The role of VEGF and TGF-ß blood levels for fibroid shrinkage, menorrhagia score, and quality of life improvement after uterine artery embolization for uterine fibroids: a study protocol.

Uterine leiomyoma is a common condition affecting women that occurs in more than 70% of females. Women with leiomyomas overall have lower quality of life and deficiency in many specific spheres of life including work-related productivity, sexuality, relationships, social-emotional health, and physical well-being that might be present even in pre-and extended throughout early postmenopausal life. Choices for symptomatic fibroid management include medical, interventional radiology procedures, surgical, and expectant management. The uterine artery embolization (UAE) procedure has gained justified popularity for myoma management. Growth factors, vascular endothelial growth factor (VEGF) and tumor growth factor ß (TGF-ß), hold an important role in leiomyoma progression. However, blood levels of VEGF and TGF-ß in patients before and after UAE are not fully investigated and the possible relationship with myoma shrinkage has not been evaluated. Therefore, this study aims to assess menorrhagia score and quality of life improvement after UAE for uterine fibroids and compare blood levels of VEGF and TGF-ß in patients with uterine leiomyoma before and after UAE. This cross-sectional study will be performed at the University Medical Center, Astana, Kazakhstan. Women undergoing the UAE procedure for uterine leiomyoma will be involved in the study following the precisely defined inclusion/exclusion criteria. Uterine leiomyoma nodules' structural changes after UAE will be assessed along with the blood levels of growth factors (VEGF and TGF-ß), menorrhagia score, and quality of life. An important outcome of this project will be an investigation of the blood levels of growth factors (VEGF and TGF-ß) before and after the procedure and their association with leiomyoma shrinkage in correlation with the menorrhagia score and quality of life alterations among patients undergoing UAE.

Cervical ectopic pregnancy: A case report of a massive pregnancy with a minimally invasive blood-free treatment and a review of the literature.

Cervical ectopic pregnancy is one of the rarest types of pregnancy, representing less than 1 % of ectopic pregnancies. We report the case of minimally invasive management of a voluminous cervical ectopic pregnancy at 9 weeks gestation using uterine artery embolization and in situ methotrexate. During follow-up, we encountered no hemorrhagic complications, while ß-hCG values returned to normal by Day 104 and the uterine cavity fully recovered within 6 months. Additionally, we present a review of the literature on this topic.

Systematic review and meta-analysis of current evidence in uterine artery embolization vs myomectomy for symptomatic uterine fibroids.

This review compares the efficacy of Uterine Artery Embolization (UAE) and Myomectomy (MYO) in managing symptomatic Uterine Fibroids (UFs) in women who do not want hysterectomy. A meta-analysis was performed on all available studies that evaluated the relative benefits and harms of MYO and UEA for the management of patients suffering from UFs. Outcomes evaluated reintervention, UFs scores for quality of life (QOL) and symptom severity, and other complications. To determine mean differences (MDs) or odds ratios (ORs) with 95% confidence intervals (CIs), a random or fixed-effects model was utilized. A meta-analysis of 13 studies (9 observational and 4 randomized controlled trials) was conducted. The results indicated that UAE had a higher reintervention rate (OR 1.84; 95% CI 1.62-2.10; P < 0.01; I2 = 39%), hysterectomy rate (OR 4.04; 95% CI 3.45-4.72; P < 0.01; I2 = 59%), and symptom-severity score (OR - 4.02; 95% CI 0.82, 7.22; P = 0.01; I2 = 0%) compared to MYO at a four-year follow-up. However, UAE was associated with a lower rate of early complications (OR 0.44; 95% CI 0.20-0.95; P = 0.04; I2 = 25%), and readmission rate (OR 1.16; 95% CI 1.01-1.33; P = 0.04; I2 = 0%) compared to MYO. Furthermore, both procedures had comparable improvement in pregnancy rates and abnormal uterine bleeding. In conclusion, UAE and MYO are effective in treating symptomatic UFs but they have different outcomes. The decision on which procedure to choose should be made based on individual preferences and the physician's expertise.

Uterine Arteriovenous Malformation With Raised Serum Beta-Human Chorionic Gonadotropin (ß-hCG) Levels: A Diagnostic and Therapeutic Dilemma.

Uterine arteriovenous malformations (AVM) are rare and usually present in women of reproductive age. Clinical presentation may overlap with early pregnancy, retained products of conception (RPOC), or gestational trophoblastic disease (GTD) if it occurs in a pregnant patient or the immediate postpartum period and becomes challenging to manage. Here, we present two cases of uterine AVM that presented with vaginal bleeding after miscarriages. In these cases, the presentation was vaginal bleeding with raised serum beta-human chorionic gonadotropin (ß-hCG) levels. The uterine AVM was diagnosed with ultrasound and contrast-enhanced CT and subsequently managed with uterine artery embolization. Although rare, uterine AVM should be kept in the differentials in a premenopausal patient with abnormal vaginal bleeding and positive serum ß-hCG levels. It should be differentiated from other common causes of vaginal bleeding with raised serum ß-hCG levels, such as early pregnancy, GTD, and RPOC, as early diagnosis and proper treatment are crucial for favorable outcomes.

Minimally Invasive Endovascular Management of Uterine Arteriovenous Malformations: A Single Center Experience and Case Series.

Uterine arteriovenous malformations (UAVMs) are rare and abnormal entanglements of uterine arteries and veins that are potentially fatal, requiring blood transfusions in about a third of cases. Although the optimal management of the condition is not well established in the literature, surgical hysterectomy is believed to be the only definitive treatment for arteriovenous malformations. We present three cases of UAVMs treated by a minimally invasive endovascular approach. Chief complaints were heavy menstrual bleeding and sudden onset heavy bleeding. The diagnosis was confirmed by computed tomography imaging and angiography of the pelvic vessels. Uterine artery embolization (UAE) was performed in all patients. The follow-up period was uneventful. In our experience, the UAE provides satisfactory results in terms of success rates, complications, and short hospital stays.

Uterine artery embolization versus hysterectomy for uterine myoma: a meta-analysis of postoperative ovarian function.

Introduction: Uterine artery embolization (UAE) and hysterectomy are often used to treat uterine myoma. Nevertheless, the impact of these two treatments on postoperative ovarian function remains uncertain. Aim: To compare the postoperative ovarian function in individuals with uterine myoma who had UAE against hysterectomy. Material and methods: Searches were conducted in the Wanfang, Web of Science, and PubMed databases to find qualifying studies. The data were combined and analyzed. Results: Seven publications were included in this meta-analysis. Uterus and uterine myoma volume were dramatically decreased by UAE (p < 0.00001 for both). The combined preoperative levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) were similar in both groups. Three months postoperatively, the combined FSH (p = 0.28) and LH (p = 0.64) levels were similar in both groups, while the combined E2 level was notably higher in the UAE group compared to the hysterectomy group (p < 0.00001). Six months postoperatively, the combined postoperative FSH and LH levels were considerably lower in the UAE group compared to the hysterectomy group (p = 0.002 for both). However, the combined E2 levels were similar between the two groups (p = 0.07). Also, 12 months after surgery, the combined postoperative FSH and LH levels were remarkably lower in the UAE group compared to the hysterectomy group (p = 0.02 and p < 0.00001, respectively). However, the combined E2 levels were similar in both groups (p = 0.15). Conclusions: UAE may provide superior preservation of postoperative ovarian function compared to hysterectomy in individuals with uterine myoma.

Evolving Referral Patterns and Management Following Implementation of a Multidisciplinary Fibroid Center: A Retrospective Cohort Study.

Background/Objectives: Our objective was to evaluate changes in the management of symptomatic fibroids after establishing a multidisciplinary fibroid center with minimally invasive gynecologic surgery (MIGS) and interventional radiology (IR). Methods: A retrospective cohort study was conducted at the fibroid center created in September 2020. Patients were offered same-day consults with both MIGS and IR providers. Data were collected for patients with initial consultations from January to June 2019 (pre-fibroid center) and from January to June 2021 (post-fibroid center). Results: Among 615 patients meeting inclusion criteria, 273 had consultations pre-center and 342 post-center. More patients seen post-center had previously attempted medical management (30.1% vs. 20.2%), with a significant proportion having no prior medical or surgical treatment (53.2% vs. 61.5%). Post-center, there were more MIGS consultations (65.5% vs. 53.1%) and a decrease in general gynecology (GYN) consultations (19.0% vs. 25.6%). More patients sought additional opinions post-center (83.6% vs. 67.0%), particularly with MIGS (58.8% vs. 37.0%). General GYNs referred to MIGS (79.3% vs. 73.1%) and IR specialists (16.0% vs. 13.0%) more often in 2021. In 2021, use of MRI increased (66.5% vs. 52.4%), and more patients underwent uterine artery embolization (UAE) within 1 year of consultation compared to the pre-center period (13.8% vs. 6.9%). Conclusions: Patients with symptomatic fibroids often seek the expertise of specialists to explore treatment options. A multidisciplinary fibroid center that integrates efforts of MIGS and IR enables thorough counseling and a rise in the utilization of minimally invasive procedures, including UAE.

Association between uterine artery embolization for postpartum hemorrhage and second delivery on maternal and offspring outcomes: a nationwide cohort study.

STUDY QUESTION: What are the maternal and neonatal outcomes of second delivery in women who underwent uterine artery embolization (UAE) during their first delivery? SUMMARY ANSWER: Women who underwent UAE during their first delivery exhibited higher risks of placental problems, preterm births, and postpartum hemorrhage (PPH) in second delivery and the second offspring also showed increased risk of major congenital malformations, admission to the neonatal intensive care units (NICU), necrotizing enterocolitis, intraventricular hemorrhage, and bronchopulmonary dysplasia. WHAT IS KNOWN ALREADY: UAE is a minimally invasive procedure used as an alternative to hysterectomy for managing severe PPH. However, recent studies have raised concerns about potential obstetric complications, including recurrent PPH, placenta accreta spectrum (PAS), and fetal growth restriction in subsequent delivery following UAE. STUDY DESIGN SIZE DURATION: This was a nationwide retrospective cohort study using the Korean National Health Insurance Service (K-NHIS) database, covering 50 million individuals from 2004 to 2020. The cohort included 3 616 923 women with live births between 1 January 2005 and 31 December 2019 with follow-up data extending to 31 December 2020. PARTICIPANTS/MATERIALS SETTING METHODS: The study included women who had their first live birth between 2005 and 2019, excluding those who underwent hysterectomy (without UAE = 3 612 389, UAE = 4534). Among them, we selected women who had single gestation secondary delivery (without UAE = 1 694 600, UAE = 1146). Propensity score matching was used to control for confounding factors, resulting in 11 184 women without UAE and 1119 women with UAE for subsequent analysis. MAIN RESULTS AND THE ROLE OF CHANCE: Women in the UAE group had significantly higher risks of PAS (odds ratio (OR) = 38.91, 95% CI = 18.61-81.34), placenta previa (OR = 6.98, 95% CI = 5.57-8.75), and preterm birth (OR = 2.23, 95% CI = 1.71-2.90) during their second delivery. The risk of recurrent PPH was also significantly higher (OR = 8.94, 95% CI = 7.19-11.12). Their second offspring were more likely to have major congenital malformations (OR = 1.62, 95% CI = 1.25-2.11) and adverse neonatal outcomes, including NICU admissions (OR = 1.83, 95% CI = 1.48-2.25). Long-term outcomes showed a higher risk of attention-deficit/hyperactivity disorder (hazard ratio = 1.64, 95% CI = 1.03-2.63) but were otherwise comparable to those in the without UAE group. LIMITATIONS REASONS FOR CAUTION: Retrospective nature of the study may have introduced exposure and outcome misclassifications, despite the reliability of the K-NHIS database. Unmeasured confounders and selection bias due to only including live births could also have influenced the results. WIDER IMPLICATIONS OF THE FINDINGS: Women with a history of UAE require meticulous prenatal care and close monitoring during subsequent deliveries due to increased risks of complications. Counseling and referral to high-risk medical centers may improve outcomes. Further research is needed to understand the mechanisms of complications in both mothers and offspring at sequential delivery, as well as to refine UAE procedures. STUDY FUNDING/COMPETING INTERESTS: This study supported by Patient-Centered Clinical Research Coordinating Center (PACEN) funded by the Ministry of Health & Welfare, Republic of Korea (HC21C0123). This study was funded by S.-Y.O. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. TRIAL REGISTRATION NUMBER: N/A.

ACR Appropriateness Criteria® Management of Uterine Fibroids: 2023 Update.

Uterine fibroids are the most common benign tumor in women of reproductive age and can present with symptoms including bleeding, bulk related symptoms, and infertility. Several treatment options are available for the management of uterine fibroids, including medical management, minimally invasive therapies such as uterine artery embolization and MR-guided focused ultrasound ablation, and surgical interventions ranging from laparoscopic myomectomy to open hysterectomy. Given this wide range of therapeutic interventions, it is important to understand the data supporting these interventions and to be able to apply it in different clinical settings. This document provides a summary of recent trials supporting various therapies for uterine fibroids, including recent evidence for MR-guided focused ultrasound ablation and a detailed discussion of fertility outcomes in myomectomy and uterine fibroid embolization. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Management of uterine fibroids: 2023 update

Uterine fibroids are the most common benign tumor in women of reproductive age and can present with symptoms including bleeding, bulk related symptoms, and infertility. Several treatment options are available for the management of uterine fibroids, including medical management, minimally invasive therapies such as uterine artery embolization and MR-guided focused ultrasound ablation, and surgical interventions ranging from laparoscopic myomectomy to open hysterectomy. Given this wide range of therapeutic interventions, it is important to understand the data supporting these interventions and to be able to apply it in different clinical settings. This document provides a summary of recent trials supporting various therapies for uterine fibroids, including recent evidence for MR-guided focused ultrasound ablation and a detailed discussion of fertility outcomes in myomectomy and uterine fibroid embolization. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Symptomatic Calcified Uterine Fibroids Refractory to Repeat Uterine Artery Embolization: A Case Report.

Uterine leiomyomas, also known as uterine fibroids, are a commonly encountered condition with a diverse clinical presentation. Uterine fibroids are benign, smooth muscle tumors of the uterus arising from a single myometrial cell. The presentation can vary from asymptomatic incidental findings to causing a wide array of gynecological symptoms, including abnormal uterine bleeding, infertility, chronic pelvic pain, and bulk-related symptoms. There are several management approaches depending on the patient's clinical manifestations and goals. This is a unique case of a patient with symptomatic calcified uterine fibroids refractory to medical management and two uterine artery embolizations presenting with persistent abnormal uterine bleeding and chronic pelvic pain. Preservation of the uterus was desired, so an open myomectomy was subsequently performed. The patient was asymptomatic at two weeks follow-up, and further follow-up was unable to be obtained.  When considering interventions for symptomatic uterine fibroids, it is essential to consider the patient's preference for uterine-sparing methods and desire to preserve fertility. It is necessary that all modes of treatment and their potential future implications be discussed so that patients can make well-informed decisions regarding all aspects of their care. Further studies are needed comparing the outcomes of uterine-sparing interventions for symptomatic uterine fibroids so that the best possible shared decision-making can take place.

Challenges in Diagnosis and Management of Recurrent Uterine Arteriovenous Malformation: A Case Report.

Uterine arteriovenous malformation (AVM) is a potentially life-threatening condition. The vast majority of cases are acquired. Uterine artery embolization (UAE) is currently the treatment of choice for symptomatic women desiring future childbearing. However, there is no consensus on the number of UAE procedures that can be performed on an individual woman. We report a case of recurrent uterine AVM and discuss the challenges in diagnosis and management. A 35-year-old multiparous woman presented with heavy menstrual bleeding (HMB). She had been diagnosed with uterine AVM six years ago and had undergone two previous UAE procedures. Her abdominal examination revealed a healthy Pfannensteil scar. Bimanual examination revealed a normal-sized uterus that was firm, mobile, and fornices were free. Her haemoglobin was 10.2 g/dl. Greyscale two-dimensional ultrasound revealed a normal-sized uterus with multiple hypoechoic lesions in the myometrium. Colour Doppler ultrasound showed intense vascularity with multidirectional flow in the myometrium, suggestive of uterine AVM. In view of previous failed UAE procedures, she opted for a hysterectomy. A total abdominal hysterectomy with a bilateral salpingectomy was performed. Blood loss during the procedure was greater than average, and she was transfused with a unit of packed cells. Her post-operative course was uneventful. Histopathology confirmed the diagnosis of a uterine AVM. To conclude, the UAE is considered the treatment of choice for symptomatic women with uterine AVM desiring future childbearing. In cases of failure of UAE procedures, hysterectomy is therapeutic but may be associated with more than average blood loss.