Management of symptomatic uterine arteriovenous malformations after gestational trophoblastic disease: The Brazilian experience and possible role for depot medroxyprogesterone acetate and tranexamic acid treatment

Abstract

OBJECTIVE: To identify predictive variables of heavy vaginal bleeding from uterine arteriovenous malformation (uAVM) after gestational trophoblastic disease (GTD) and review outcomes with different treatment strategies. STUDY DESIGN: This is a retrospective study of patients with uAVM presenting with vaginal bleeding after postmolar follow-up or treatment for postmolar gestational trophoblastic neoplasia, with normal hCG levels for at least 6 or 12 months, respectively, followed at 9 Brazilian GTD reference centers, from January 2004– January 2016. Patients were treated preferentially with uterine artery embolization (UAE), but when UAE wasnot available, depot medroxyprogesterone acetate and tranexamic acid (DMPA+TA) was offered. RESULTS: The incidence of symptomatic uAVM after GTD was 0.6% (39/6,129). Risk factors associated with class III–IV hemorrhage included number of previous curettages (aRR 4.23, 95% CI 1.36–13.1, p=0.013), uterine artery index of resistance ≤0.32 (aRR 35.2, 95% CI 3.58–347.5, p= 0.002), and uterine artery peak systolic velocity ≥78.7 cm/s (aRR 10.7, 95% CI 1.15–100.6, p=0.037). Patients with class I–II hemorrhage treated with DMPA+TA had a higher rate of uAVM resolution (N=14/16 [87.5%]) versus UAE (N=4/8 [50%], p=0.033). Pa-tients with class III–IV hemorrhage were 87% less likely to have successful treatment with DMPA+TA compared to class I–II hemorrhage (cRR 0.13, 95% CI 0.02–0.83, p=0.013). CONCLUSION: Although UAE is preferred for cases of heavy vaginal bleeding, there may be a role for DMPA+TA in the management of less severe bleeding complications.