Placental polyps with uterine vascular malformation mimics: Management dilemma

Purpose

Abnormal uterine bleeding after abortion or delivery requires special management. Sonography with clinical and laboratory findings are important to narrow the differential diagnoses. Presence of increased uterine vascularity and arteriovenous shunting can be detected in retained trophoblastic tissue, gestational trophoblastic disease, and placental polyps and uterine vascular malformation are mainly related to failure of detection of associated pathology in the uterus on ultrasound. Here we are describing to both as a same entity for simplicity.

Methods and results

We present two cases of placental polyp with uterine vascular malformation, one case after abortion and the other case after vaginal delivery. The first case was multiparous female complaining of abnormal uterine bleeding three month after delivery. Ultrasound revealed diffuse uterine vascularity with echogenic vascular mass with blood flow velocity less than 40 cm/s that was evacuated and packed using hysteroscopy. The second case was also multiparus female complaining of abnormal uterine bleeding two months after abortion. Ultrasound revealed abnormal vascularity from perimetrium to the endmometrial mass. Hysteroscopic removal of the mass was done. Both patients were discharged after two days with menses resumed regularly afterwards.

Conclusions

Uterine vascular malformations may be associated with heavy bleeding. They should be suspected on ultrasound with anechoic structures with positive Doppler signal. Dilatation and curettage is therapeutic for evacuation of placental polyps but can induce massive, life-threatening bleeding in cases with uterine arteriovenous shunting or malfomration (AVM), thus it should be done with caution in endometrial pathology with high velocity flow more than 40 cm/s as infection and adhesions are associated. Treatment of uterine AVM varies from medical management (hormonal therapy), minimally invasive uterine artery embolization to more definitive surgical hysterectomy, depending upon age of the patient, size, site of the lesion, and the desire to retain future fertility.