Management of women presenting with vaginal bleeding with enhanced myometrial vascularity and suspected retained products of conception

Background: To describe the clinical course of women with acute vaginal bleeding and a finding of uterine enhanced myometrial vascularity (EVM) with suspected retained products of conception (RPOC) on vaginal ultrasound examination. Methods: A retrospective cohort study including women with EMV and suspected RPOC attending a single tertiary medical center between April 2018 to May 2020. Women with uterine EMV were identified from medical records of the ultrasound clinics. Demographic and clinical characteristics were retrieved from women's medical files. Results: During the study period nine women met inclusion criteria. The preceding event in seven and in two of the women was first and second trimester abortions, respectively. Of those who underwent first trimester abortion, three were surgical, two were medical and two were spontaneous. Suspected RPOC and EMV were observed by ultrasound in all cases. Six of nine women (67%) underwent uncomplicated operative hysteroscopy with removal of RPOC, and three (33%), who had severe active bleeding due to vascular malformations (arterio-venous malformation-1, pseudo-aneurysm of uterine artery-1, other vascular malformation-1) were treated with uterine artery embolization prior to operative hysteroscopy. Conclusions: Work-up of women with episodes of uterine bleeding following curettage or abortion should include color/power Doppler ultrasonography for the detection of EMV. Although in most cases EMV is a benign sonographic finding that accompany RPOC and disappear after the removal of RPOC, in women who present with acute vaginal bleeding it might hint for the presence of vascular malformations that might cause life-threatening bleeding during additional surgical interventions.