Enhanced myometrial vascularity and persistence of beta hCG: grey area between retained products of conception, AV-malformation and gestational trophoblastic disease

Uterine vascular lesions with enhanced myometrial vascularity pose diagnostic and management dilemmas. They can represent arteriovenous malformation (AVM), retained products of conception or gestational trophoblastic disease/neoplasia (GTD/GTN). Because of their life threatening potential and due to a grey zone in diagnosis management is challenging. We present a case series, describe diagnostic findings and therapeutic options, which included observation, methotrexate (MTX), D&C, uterine artery embolization (UAE) and hysterectomy.

There was one case with cesarean scar pregnancy who had prior therapy with D&C, Cytotec and MTX. She opted for hysterectomy after follow up. The second case presented after D&C after missed abortion, received repeat D&C plus intraoperative embolization due to massive vaginal bleeding. Postoperatively she had tumor staging due to suspected GTD. The third case presented with six months amenorrhoea after D&C for missed abortion. She first received MTX with minimally decreasing levels and resectoscopy without excessive blood loss. The forth case presented 6 weeks after CS with negative hCG with pain and massive vaginal bleeding. She was treated with uterine artery embolization.

Management of vascularized myometrial lesions ranges from an observational approach to demanding surgeries with the risk of high blood loss. They might stem from placenta accreta or residual tissue, caesarean scar pregnancy or GTD. D&C seems to carry a high risk of excessive bleeding and should be carried out with the stand-by option of uterine artery embolization. Preoperative awareness of this condition by ultrasound is crucial and follow-up by gynecological oncologists in cases of suspected GTD is required.