Uterine AVM After D&C

What It Is

• Dilation and curettage (D&C)
• Suction evacuation
• Caesarean section
• Endometrial biopsy
• Uterine surgery

Presentation

• Recurrent, sudden, heavy vaginal bleeding - the hallmark symptom - often unprovoked and profuse
• Bleeding typically occurs weeks to months after the D&C
• May follow a period of apparently normal recovery
• Can be life-threatening if a large AVM ruptures
• Importantly, if bleeding persists after D&C and beta-hCG has normalized, AVM should be suspected (rather than retained products of conception)

Diagnosis

• Turbulent, high-velocity, low-resistance flow on color Doppler
• Aliasing (color mosaic pattern) - a hallmark sign
• Dilated feeding vessels

• Arterial phase CT shows a hypervascular lesion with early venous opacification
• MRI shows tortuous vessels protruding into the endometrium, with signal voids on T1/T2 weighted sequences and enhancement with contrast
• Selective angiography: shows early venous return (pathognomonic) and can be used therapeutically

• RPOC typically resolves after b-hCG normalizes
• AVM persists even after b-hCG normalization
• Clinical context (ongoing bleeding, post-D&C) + imaging together guide the diagnosis

Management

1. Uterine Artery Embolization (UAE) - First-line for active/severe bleeding

• Selective angiographic embolization is the standard definitive treatment
• The lesion is identified on angiography by early venous return, then embolized with coils or particles
• Preserves fertility in most cases
• High success rate for stopping acute hemorrhage

2. Medical Management - For stable patients or fertility preservation

• No clinical factors reliably predicted success
• 26 subsequent pregnancies reported with no AVM recurrence
• Medical management is reasonable in hemodynamically stable, well-selected patients

3. Surgical Management

• Reserved for cases failing embolization or medical management
• Options: hysteroscopic resection (small AVMs), uterine artery ligation, or as a last resort - hysterectomy
• Blind curettage of a suspected AVM is contraindicated as it can precipitate catastrophic hemorrhage

Key Points Summary

Pituitary Microadenoma - 3.6mm x 2.8mm

Definition & Classification

• A microadenoma is a pituitary adenoma < 10mm in diameter
• Your lesion at 3.6 x 2.8mm is a small microadenoma, well within this category
• Pituitary adenomas make up 10-15% of all intracranial neoplasms
• They are either functioning (hormone-secreting) or non-functioning

Imaging Appearance

• Enhance later and/or less than normal pituitary tissue on dynamic contrast MRI
• Show as a hypointense/filling defect within the brightly enhancing gland
• Thin 3mm coronal and sagittal slices with gadolinium are standard
• Dynamic pituitary MRI (rapid sequential imaging every 10-15s post-contrast) increases sensitivity

Functional Classification - The Critical Step

• Serum prolactin (PRL)
• IGF-1 (screens for GH excess)
• ACTH + morning cortisol (± 24h urine cortisol, late night salivary cortisol)
• TSH + free T4
• LH, FSH, testosterone (men) / estradiol (women)

Management by Type

Prolactinoma (most likely for this size)

"Because microadenomas rarely progress to become macroadenomas, no treatment may be needed if patients are asymptomatic and fertility is not desired; these patients should be monitored by regular serial PRL measurements and MRI scans."

• First-line: Dopamine agonists - either cabergoline or bromocriptine
• Cabergoline (0.5-1.0 mg twice weekly): achieves normoprolactinemia in ~80% of microadenoma patients; improves/resolves galactorrhea in 90%. Preferred due to once/twice-weekly dosing and fewer side effects
• Bromocriptine: shorter-acting; preferred when pregnancy is desired (more safety data in pregnancy)
• After 2 years of normoprolactinemia, dopamine agonist may be carefully withdrawn with monitoring
• ~5% achieve permanent resolution after long-term treatment

Corticotropinoma (Cushing's disease)

• First-line: Transsphenoidal surgery - success rate >80% for microadenomas
• If microadenoma not found at surgery: hemihypophysectomy
• Requires precise lateralization pre-operatively - inferior petrosal sinus sampling if MRI inconclusive

Somatotropinoma (Acromegaly)

• First-line: Transsphenoidal surgery
• Adjuncts: somatostatin analogues (octreotide, lanreotide), pegvisomant, cabergoline

Non-functioning Microadenoma (Incidentaloma)

• No immediate treatment if asymptomatic and hormones are normal
• Serial MRI: repeat at 6 months, then annually for 3 years, then every 2 years
• Treat only if growth, new symptoms, or visual compromise develops

Prognosis & Natural History

• Only about 5% of microadenomas progress to macroadenomas over the long term
• PRL levels typically remain stable, reflecting slow tumor growth
• A 3.6mm lesion has a very low risk of mass effect on optic chiasm (which requires >10mm suprasellar extension)
• No hypopituitarism expected at this size
• Fertility outcomes are generally good with appropriate treatment

Key Points for This Size (3.6 x 2.8mm)

1. No mass effect expected at this size - no visual field testing needed unless symptoms arise
2. The most important immediate step is hormonal evaluation to determine if it is functioning
3. If prolactinoma with symptoms - start cabergoline
4. If asymptomatic and non-functioning - observe with serial MRI
5. Surgery (transsphenoidal) is first-line for ACTH/GH-secreting microadenomas, and for prolactinomas resistant to or intolerant of dopamine agonists