Postpartum Haemorrhage and Pelvic AVM

Postpartum haemorrhage (PPH) is excessive bleeding after childbirth and remains a leading cause of maternal morbidity and mortality. While common causes include uterine atony, retained products, and genital tract trauma, a pelvic arteriovenous malformation (AVM) is a rare but important cause—especially in cases of recurrent, unexplained, or delayed PPH.

Postpartum Haemorrhage (PPH)

Definition

  • Primary PPH: ≥500 mL blood loss after vaginal delivery or ≥1000 mL after cesarean section within 24 hours.

  • Secondary (Delayed) PPH: Abnormal bleeding occurring 24 hours to 6 weeks postpartum.

Common Causes (4 Ts)

  1. Tone: Uterine atony

  2. Tissue: Retained placental tissue

  3. Trauma: Lacerations/uterine rupture

  4. Thrombin: Coagulation disorders

When bleeding persists despite routine management, vascular causes such as pelvic AVM should be suspected.

Pelvic Arteriovenous Malformation (AVM)

What is a Pelvic AVM?

A pelvic AVM is an abnormal direct connection between arteries and veins without a capillary bed, leading to high-flow vascular shunting and potential severe bleeding.

Types

  • Congenital AVM: Rare, present from birth.

  • Acquired AVM (more common): Occurs after uterine surgery or trauma such as:

    • Cesarean section

    • Dilatation & curettage (D&C)

    • Myomectomy

    • Previous pelvic surgery

Link Between PPH & Pelvic AVM

  • Pelvic AVM can cause profuse, recurrent, or delayed postpartum bleeding.

  • Often misdiagnosed as retained products or subinvolution.

  • Curettage in undiagnosed AVM can worsen bleeding and be life-threatening.

Clinical Presentation

  • Heavy or intermittent vaginal bleeding postpartum

  • Failure to respond to uterotonics

  • Pelvic bruit (occasionally)

  • Anemia or hemodynamic instability in severe cases

Diagnosis

Imaging Modalities

  1. Color Doppler Ultrasound

    • First-line

    • Shows high-velocity, low-resistance flow

  2. CT Angiography / MR Angiography

    • Defines anatomy and extent

  3. Digital Subtraction Angiography (DSA)

    • Gold standard

    • Allows simultaneous diagnosis and treatment

Management

Conservative

  • For small, asymptomatic AVMs

  • Close monitoring

Interventional Radiology (Preferred Treatment)

Uterine Artery / Pelvic Artery Embolization

  • Minimally invasive

  • Preserves uterus and fertility

  • Rapid control of bleeding

  • High success rate (>90%)

Embolic agents may include:

  • Polyvinyl alcohol (PVA) particles

  • Coils

  • Glue (NBCA)

  • Onyx

Surgical (Rarely Needed)

  • Hysterectomy (only if embolization fails or in life-threatening situations)

Advantages of Embolization in PPH due to AVM

  • Avoids major surgery

  • Short hospital stay

  • Less blood loss

  • Fertility preservation

  • Can be repeated if necessary

Key Clinical Points

  • Always consider pelvic AVM in unexplained or recurrent PPH.

  • Avoid blind curettage if AVM is suspected.

  • Early involvement of an Interventional Radiologist can be life-saving.

Book an Appointment / Consultation

If you have been advised for aspiration, drainage, or biopsy—our expert interventional radiology team can provide safe, accurate, and minimally invasive treatment options.

📞 Contact / WhatsApp: 0370-7353445 , 0326-4053417 , 0323-0825571

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Farooq Hospital :

Avenue Mall, Main Ghazi Rd, DHA, Lahore, Punjab 54000, Pakistan
Mian Muree Expressway, Bahria Golf City Rawalpindi.

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