August 22nd, 2019

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Management of Symptomatic Uterine Arteriovenous Malformations After Gestational Trophoblastic Disease: The Brazilian Experience and Possible Role for Depot Medroxyprogesterone Acetate and Tranexamic Acid Treatment
Authors:  Antonio Braga, M.D., Lana Lima, M.D., Raphael Câmara Medeiros Parente, M.D., Roger Keller Celeste, Ph.D., Jorge de Rezende Filho, M.D., Joffre Amim Junior, M.D., Izildinha Maestá, M.D., Sue Yazaki Sun, M.D., Elza Uberti, M.D., Lawrence Lin, M.D., José Mauro Madi, M.D., Maurício Viggiano, M.D., Kevin M. Elias, M.D., Neil S. Horowitz, M.D., and Ross S. Berkowitz, M.D.
  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 was not 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). Patients 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.
Keywords:  Brazil, depot medroxyprogesterone acetate, gestational trophoblastic disease, tranexamic acid, uterine artery embolization, uterine arteriovenous malformation
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