True pelvic congenital arteriovenous malformation in a patient seeking pregnancy

To describe the diagnostic challenges and management options of a rare case with congenital pelvic arteriovenous malformation (AVM) desiring pregnancy. AVMs are rare vascular anomalies which must be distinguished from acquired lesions associated with pregnancy-related events or uterine instrumentation. These malformations result from abnormal vessel development during embryogenesis, leading to direct arteriovenous connections without an interconnecting capillary bed. Their preoperative diagnosis is complex, particularly in women of reproductive age desiring fertility preservation, and can range from asymptomatic incidental findings to life-threatening hemorrhage. A delayed or missed diagnosis poses serious risks to patient survival and reproductive potential; therefore, it is important to recognize them and reserve individualized, multidisciplinary management, including advanced imaging, embolization, and potentially surgical intervention, if necessary.

A step-by-step narrated video of a rare clinical case and description of the diagnostic and management process.

A 25-year-old nulligravid woman with congenital pelvic AVM presenting to the emergency department with abnormal uterine bleeding and subsequent desire for pregnancy.

Initial expectant management with counseling regarding pregnancy risks. Serial transvaginal ultrasound surveillance throughout pregnancy. Prophylactic uterine artery embolization performed immediately prior to planned cesarean delivery to minimize hemorrhagic risk.

Successful ultrasound-based diagnosis of purely congenital pelvic AVM, careful management throughout pregnancy including hemodynamic surveillance, and maternal and perinatal outcomes following delivery.

Transvaginal ultrasound with color and power Doppler identified a high-flow vascular lesion adjacent to the left uterine margin, confirmed by angio-CT. After counseling, the patient declined immediate embolization and opted for expectant management. She later conceived spontaneously and had an uncomplicated pregnancy. Because of the anticipated hemorrhagic risk, planned cesarean delivery with preoperative uterine artery embolization was performed. The intraoperative and postoperative courses were uneventful, with no hemorrhage or fetal complications. Postpartum angio-CT confirmed resolution of the lesion.

This case underscores the complexities in managing congenital pelvic AVMs in women seeking pregnancy, emphasizing the need for a multidisciplinary approach to optimize maternal and fetal outcomes. Future research with multicenter registries or prospective design are needed to better understand the long-term implications of congenital AVMs on reproductive health and to refine management strategies.