Uterine arteriovenous malformation: A retrospective study from a tertiary center in southern Karnataka

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The basic pathology is an abnormal arteriovenous connection in the uterine myometrium, which is observed as an entangled serpentine vascular architecture on ultrasound. Color Doppler and higher imaging modalities with angiography are usually used to confirm a diagnosis. Materials and methods An electronic database of Obstetrics and Gynecology departments was searched for cases of arteriovenous malformation (AVM) between 2021 and 2025. Only cases of AVM confirmed by ultrasound or higher imaging were considered. Results We comprehensively reported 15 cases of arteriovenous malformations. All patients had acquired AVMs, with abnormal uterine bleeding as the main symptom in 93% of cases. The treatment provided was medical management in 26% of patients, conservative management by transcatheter embolization in 66%, and hysterectomy in 6.6%. Conclusion AVMs are rare in clinical practice, and an understanding of their pathophysiology and prompt diagnosis are highly important for managing this emergency. Fertility-preserving treatments include medical therapy and uterine artery embolization. Hysterectomy is the definitive treatment for this condition. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-554/v1", "name": "Uterine arteriovenous malformation: A retrospective study from a tertiary..." } } ] } Home Browse Uterine arteriovenous malformation: A retrospective study from a tertiary... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Hebbar S, Kramadhari H, Sharma R et al. Uterine arteriovenous malformation: A retrospective study from a tertiary center in southern Karnataka [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :554 ( https://doi.org/10.12688/f1000research.164989.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Uterine arteriovenous malformation: A retrospective study from a tertiary center in southern Karnataka [version 1; peer review: 1 approved, 1 approved with reservations] Shripad Hebbar 1 , Harshith Kramadhari 2 , Richa Sharma 3 , Rajeshwari Bhat 1 , Krupa Shah https://orcid.org/0000-0001-8445-4170 1 Shripad Hebbar 1 , Harshith Kramadhari 2 , [...] Richa Sharma 3 , Rajeshwari Bhat 1 , Krupa Shah https://orcid.org/0000-0001-8445-4170 1 PUBLISHED 03 Jun 2025 Author details Author details 1 Obstetric and Gynecology, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India 2 Department of Radiodiagnostics and Imaging, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India 3 Obstetrics and Gynecology, University College of Medical science, Guru Tej Bahadur Hospital, Delhi, Delhi, 110095, India Shripad Hebbar Roles: Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Harshith Kramadhari Roles: Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Richa Sharma Roles: Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Rajeshwari Bhat Roles: Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Krupa Shah Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Manipal Academy of Higher Education gateway. This article is included in the Médecins Sans Frontières gateway. This article is included in the Global Public Health gateway. Abstract Introduction Uterine arteriovenous malformation (AVM) is a rare cause of chronic to catastrophic vaginal bleeding. The basic pathology is an abnormal arteriovenous connection in the uterine myometrium, which is observed as an entangled serpentine vascular architecture on ultrasound. Color Doppler and higher imaging modalities with angiography are usually used to confirm a diagnosis. Materials and methods An electronic database of Obstetrics and Gynecology departments was searched for cases of arteriovenous malformation (AVM) between 2021 and 2025. Only cases of AVM confirmed by ultrasound or higher imaging were considered. Results We comprehensively reported 15 cases of arteriovenous malformations. All patients had acquired AVMs, with abnormal uterine bleeding as the main symptom in 93% of cases. The treatment provided was medical management in 26% of patients, conservative management by transcatheter embolization in 66%, and hysterectomy in 6.6%. Conclusion AVMs are rare in clinical practice, and an understanding of their pathophysiology and prompt diagnosis are highly important for managing this emergency. Fertility-preserving treatments include medical therapy and uterine artery embolization. Hysterectomy is the definitive treatment for this condition. READ ALL READ LESS Keywords Arterio-venous malformation, enhanced myometrial vascularity, uterine artery embolization, Progesterone Corresponding Author(s) Krupa Shah ( [email protected] ) Close Corresponding author: Krupa Shah Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Hebbar S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Hebbar S, Kramadhari H, Sharma R et al. Uterine arteriovenous malformation: A retrospective study from a tertiary center in southern Karnataka [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :554 ( https://doi.org/10.12688/f1000research.164989.1 ) First published: 03 Jun 2025, 14 :554 ( https://doi.org/10.12688/f1000research.164989.1 ) Latest published: 16 Sep 2025, 14 :554 ( https://doi.org/10.12688/f1000research.164989.2 )  There is a newer version of this article available. Suppress this message for one day. Introduction Uterine arteriovenous malformation (AVM) is a rare, life-threatening condition. It is characterized by abnormal connections between the arteries and veins of the uterine myometrium. However, the exact prevalence of this condition remains unknown. These can be congenital or acquired. Acquired uterine AVMs are sometimes recognized as having enhanced myometrial vascularity (EVM). It refers to any uterine pathology resulting in increased myometrial vascularity regardless of residual tissue at conception. 1 , 2 Uterine acquired AVMs are typically noticed in a multipara woman in her thirties. 3 The common manifestations are menorrhagia, symptoms of anemia and catastrophic hemorrhage, which can lead to significant morbidity and, rarely, mortality. Ultrasound and CT angiography were the main diagnostic tests used. Treatment is generally multidisciplinary and involves obstetricians, radiologists, transfusion medicine professionals, and interventional radiologists. Medical, interventional (uterine artery embolization) and surgical methods are the different management modalities. The objective of this study was to systematically study cases of acquired arteriovenous malformation and their impact on health. The article has followed strobe guidelines for the reporting of data. Materials and methods First, this was a retrospective study. Ethical committee clearance was also obtained in 23 rd April 2025. (IEC1-166/2025). The search was performed from January 2021 to February 2025 for all patients admitted with an AVM diagnosis. Details of the AVM cases were obtained from the electronic database system or from the medical records section of the Kasturba Medical College, Manipal, Karnataka. Patient enrollment was performed only after confirmation of the diagnosis by uterine power Doppler or after imaging with angiography. Informed written consent was obtained. Data concerning the patient’s age, presenting symptoms, obstetric history, comorbid conditions, detection modality, and treatment provided were obtained. Patients with inconclusive diagnoses were excluded from the study. Results During the abovementioned time frame, a total of 19 cases of AV malformation were found, and 15 cases had appropriate doppler or higher imaging diagnosis. Patient characteristics are summarized in Table 1 . The age range of the patients was 24–40 years. The presenting symptom was bleeding or spotting per vagina in 93.3% of patients. A total of 86.8% of patients were referred, and a referral was observed 4 days to 10 weeks after the trigger event. A total of 13.2% of patients had severe multiple system involvement. The distribution of gravidae was as follows: primary (33.3%), second (26.6%), third (19.9%), fourth (13.2%), and fifth (6.6%) gravidae. A total of 46.2% had previous cesarean sections and 19% had undergone vaginal delivery. A total of 19.98% of women had a history of previous pregnancy mishaps in the form of first-trimester abortions. A total of 93.34% of women had early pregnancy loss or MTP as an inciting event between 5 and 14 weeks. A total of 79.9% of patients required dilatation and curettage (D&C) or MVA before or after AVM diagnosis. One patient presented with normal delivery. The reported hemoglobin level was between 4.2 and 11 during treatment, and 46.2% of the patients received blood ± blood product transfusions. hCG observed at the time of admission varied between 0.1 and 109 mIU/ml, which became negative during follow-up visits. Two patients delivered after treatment (Uterine Artery Embolization), one of whom had stage 1 gestational trophoblastic neoplasia. Table 1. Demographic information of AV malformation cases. Age Presenting symptom Referral or booked Diagnosis after primary event Gravidae para Previous abortion Previous delivery route Inciting event Surgical event 1=D&C 2=MVA Hb changes (gram%) PRBC transfusion in pints B hCG at presentation (mIU/ml) 40 Bleeding, abdominal pain R 3 weeks 4 2 1 SA 2 CD SA: 11 weeks 1* 6.2 1 17 28 Altered sensorium x 1 day, Fever R 6 weeks 1 0 ------ ------ SA: 8 weeks 1* 4.9 2 9.4 30 Prolonged bleeding R 2 weeks 2 1 -------- 1 CD MTP*: 15 weeks 1* 5.7 3 109 24 Asymptomatic R 3 weeks 1 0 -------- ------ MTP*: 10.4 weeks No 11.7 None 39 35 Secondary PPH R 6 weeks 2 2 -------- 2 CD Postpartum 44 days No 4 5 0.1 28 Sudden loss of consciousness and breathless R 5 weeks 4 2 1 MTP 2CD MTP for MA at 7 weeks 1* and 1 (3 months later) 11 None 0.2 38 Giddiness, bleeding palpitation R 1 weeks 2 1 ------ VD MTP for BO at 7 weeks 1* (1.5 months later) 4.9 3 PRBC a 1.5 30 Bleeding P/v R 2 weeks 5 2 2 MTPs 2 CD MTP* at 10 weeks 1*, 2 (later) 12 None 10.3 31 abdominal pain, bleeding PV R 4 days 3 2 2 CD MTP* at 6 weeks 2 later 8 None 34 25 Persistent bleeding PV B 4 weeks 1 0 ----- ----- MA at 8 weeks 2* 10 None 20 27 On and off bleeding P/V R 10 weeks 3 2 ----- 2 VD MA at 10 weeks 1* 4.6 3 7.23 35 Continuous bleeding PV R 4 weeks 2 1 ------- VD MA at 10 weeks 1* 10.2 None 0.6 31 Menorrhagia R 8 weeks 1 0 -------- ------ SA at 4 MA 1 6.4 5 1.3 33 Spotting B 25 days 3 2 ----- 2 CD MA at 14 weeks 2 8 None 0.1 27 Bleeding PV B 4 weeks 1 0 ------ ----- MA at 13 weeks 2 9.6 None 61 The diagnostic modalities and treatments are summarized in Table 2 . All patients underwent transvaginal ultrasound, and confirmation was provided by CT angiography in 59.4%, MRI angiography in 19.9%, digital subtraction angiography (DSA) in 13.3%, and contrast-enhanced computed tomography (CECT) in 6.6%. We observed that posterior uterine wall lesions were more common than anterior uterine wall lesions. The final treatment options included uterine artery embolization/transcatheter embolization (TCE) (66%), surgical hysterectomy (6.6%), and conservative management (26.6%). Failure of conservative management was observed in 2 patients (one after treatment with OC pills and one after treatment with progesterone). Injectable leuprolide (2 patients) and progesterone (2 patients) treatment resulted in satisfactory control of bleeding. One patient with medical management required an additional balloon tamponade for symptom control. Four procedures involved the use of PVA exclusively as embolization material (500–710 μm), one involved the use of glue, and five procedures involved the combination of both as embolization materials. The glue used was NCBA with a concentration between 20 and 40% and 2–3 cc used for a single artery, and is often used with a lipiodol emulsion. All the patients underwent bilateral uterine artery embolization (UAE). Figure 1 shows an ultrasound depiction of the AVM. MRI and Angiography findings of the AVM are depicted in Figures 2 and 3 , respectively. Figure 4 illustrates the UAE procedure. Table 2. Diagnosis and management of the cases with AVMs. Cases Location of lesion MRI/CT/DSA Procedure Definitive treatment ICU admission Hospital stay Follow up Other remarks 1 Anterior -Left lateral uterine wall MRI** Multiple serpentine flow voids with early draining veins 2x2 cm Nidus occlusion by 33% NBCA glue, 2 cc B/L UAE HDU 7 days 3 months Fertility not desired 2 Anterior uterine wall * Dilated vessels within myometrium of 2.5x2.5 cm 3 cc NBCA glue, right UA: PVA particle 350-500 microns Progesterone & DMPA failure B/L UAE ICU 17 days 4 months Fertility desired Infection 3 Antero-lateral uterine wall * 7x5x4.7 cm predominantly cystic area, aneurysmal dilation 40% NCBA glue, 2cc. additional PVA particles B/L UAE HDU 5 days 5 months Fertility not desired 4 Fundal and Right lateral wall MRI**3.4x2.5x2.2 cm, arterial enhancement with early drainage conservative Leuprolide for 3 months Na 5 days 6 months Fertility desired 5 Fundal and anterior wall DSA 3x2.5 cm hypervascular area with turbulent flow in fundal and anterior wall PVA 500-710 microns Primolute failure B/L UAE HDU 10 days 36 months Fertility not desired MTP for subsequent pregnancy 6 Right entire posterolateral wall CECT: nidus of vessels involving full thickness of myometrium, 5x4.5 cm conservative Norethisterone Tapering doses Na 6 days 29 months Sterilization done infection and PID 7 Posterior wall of myometrium * 2x2.3 cm nidus Deferred UAE TAH, BS, Na 6 days 28 months fertility not desired detected with chocolate cyst 8 Posterior endometrial/8 * hypervascular area at endomyometial wall PVA particles and gel foams B/L UAE Na 5 days 29 months Fertility not desired afterwards MVA for irregular bleeding 9 Left fundal posterior wall * 2x2.3 cm nidus at posterior wall PVA particles B/L UAE HDU 4 days 36 months Fertility not desired 10 Posterior fundal myometrium * left lateral wall and draining to LUA B/L UAE with NBCA glue, 20% glue:lipiodol B/L UAE Na 5 days 12 months Delivered, had GDM 11 Fundal myometrium * multiple tortuous vascular channels 20% glue-lipodol emulsion B/L UAE ICU 3 days 24 months Fertility not desired Had hematometra evacuation after a month 12 Outer fundal left myometrium MRI**: nidus at fundus 2x2.1 cm, vascular malformation in B /L adnexa and outer uterine wall 33%, 3 cc NBCA glue and lipidol emulsion B/L UAE OC pills failure no 3 days 12 months One live child and fertility desired 13 Posterior uterine wall CECT, DSA Nidus of 3x2.5 cm PVA particles B/L UAE no 7 days 42 months Delivered twice, had HDP and one GTT stage 1 14 Right posterior lower body myometrium * right posterior wall nidus of 2x2 cm conservative Progesterone, cervical tamponade no 6 days 3months Fertility not desired past history of recent infection 15 Left posterior myometrial wall * hyper vascular lesion 3x2.2 cm, Conservative/ Leuprolide and aromatase inhibitors No 10 days 3 months Fertility desired Past history of infection * CT angiogram; PVA, polyvinyl alcohol; NCBA, N-butyl cyanoacrylate. Figure 1. a, b: Ultrasound diagnosis of AVM suggests convoluted vascular structure (red color) in the myometrium with color signals. Figure 2. a, b, c: MRI depicting highly vascular structure (Blue arrow) suggestive of AVM in uterine myometrium. Figure 3. a, b, c: Angiography suggestive of uterine AVM. Figure 4. Uterine artery embolization procedure depicting pre-procedure, selection process and post-procedure arterial tree. The hospital stay was 3–17 days, and nearly 19% of the patients had repeated admissions due to hematometra (n=1) and bleeding per vagina (n=2). ICU admissions were observed in two patients: one for temporal mesial sclerosis and another for multisystem dysfunction. 26% the infected patients had infections in the last 3 months, including hepatitis (n=1), endometritis (n=2), endocarditis, and pancreatitis (n=1). Discussion AVMs are rare entities, and two varieties of uterine AVMs have been identified. Congenital AVMs are present from birth and develop during erroneous angiogenesis at the fetal stage, leading to aberrant formation of the primitive capillary plexus with the absence of muscular and collagen tissue. 4 , 5 Congenital or true AVMs are diagnosed either as isolated uterine entities or as a part of extensive pelvic AVMs. Only a few hundred cases have been reported because of the rarity of the condition, and the first case was reported in 1926. 4 , 6 The incidence of AVMs is 0.63 following abortion or parturition. 7 The acquired AVMs can be secondary to surgical procedures or pathologies. The most common reason is dilation and curettage (D&C) after abortion or MTP (medical termination of pregnancy). 8 Uterine surgeries, such as myomectomy or cesarean delivery, can be iatrogenic. It can occur even after a normal delivery. Certain neoplastic conditions, such as gestational trophoblastic neoplasia and endometrial or cervical carcinoma, can even result in AVM. 8 It has been reported following infection, hysteroscopy, intrauterine device placement, and cesarean site pregnancy in offspring exposed to diethylstilbosterone. 1 The number of acquired AVMs has increased due to both improved diagnosis and increased number of uterine surgeries in recent years. 9 In 2015, the international society of ultrasound in obstetrics and gynecology coined the term enhanced myometrial vascularity (EMV) for RPOC-related AVMs. 2 , 10 , 11 It was almost exclusively meant in the context of recent pregnancy and hence in women of reproductive age. 12 In the literature, traumatic AVMs, arteriovenous shunts, EVMs and arteriovenous fistulas are the terms used interchangeably and are difficult to differentiate. RPOC-related AVMs are formed between necrotic chorionic villi and venous sinuses of scar tissue. Histologically, a uterine AVM is an arteriovenous fistula between the intramural arterial branches of the uterine arteries and the myometrial venous plexus, bypassing the normal capillary system, which has an interrupted or absent elastic membrane and completely absent muscular tunica media. 13 The spectrum of presenting symptoms varies from asymptomatic detection to catastrophic hemorrhage. 14 True AVMs can have additional varicosities in the pelvic or perineal area. 15 The usual symptoms are abnormal vaginal bleeding leading to anemia and, sometimes, life-threatening hemorrhagic shock. Other symptoms include pelvic pain, urinary frequency and dyspareunia. 16 If not diagnosed and treated in a timely and proper manner, secondary cardiorespiratory or cerebrovascular complications may occur, which can rarely progress to multiple organ failure. The primary complaint was bleeding in 93% (14/15) of patients. Atypical symptoms such as fainting episodes, giddiness, breathlessness, and altered sensorium were present in three patients. One patient had acute kidney injury and another patient had mesial temporal sclerosis. The relationship between AVM and neuronal symptoms, such as temporal sclerosis, is not well established. However, we suggest utmost vigilance during medical therapy for patients with vaginal bleeding to prevent multisystem damage. A referral delay was observed, which needed to be curtailed by appropriate measures to achieve better outcomes. A transvaginal scan is a primary, cost-effective, and simple screening modality, and AVMs are suspected on grayscale as enlarged anechoic vessels in the myometrium/parametrium or as myoendometrial masses with myometrial thickening. 6 , 17 Doppler interrogation is often diagnostic, and AVMs are depicted as enlarged, entangled, hypervascular masses with high turbulence and aliasing. It exhibits a multidirectional flow. On power Doppler, it has a high velocity and low resistance flow. It has a high peak velocity and a low RI. It has prognostic ability, as it can stratify patients at high or low risk. 4 Thus, ultrasound and color Doppler are valuable tools for identifying AVMs. 18 3D color Doppler provides better delineation of feeding and draining vessels. We performed grayscale and color Doppler in all patients; however, power Doppler values were not consistently followed in our study. MRI or CT is indicated when USG is unsatisfactory. 6 It helps with pre-procedure planning. MRI/CT angiography is a better diagnostic modality for determining the lesion outlines. Uterine artery angiography (UAA), a specific application of digital subtraction angiography, is the gold standard test. 4 , 6 AVMs are characterized by tangled vessels containing nests, feeding arteries, draining veins, and brisk venous depletion. The utility of UAA is generally restricted for patients who would benefit from UAE because of the invasive nature of the test. 17 UAA helps in differentiating AVMs from pseudoaneurysms and other vascular lesions. Overdiagnosis can occur if the disease is diagnosed using ultrasonography alone. Angiography is not always needed for diagnosis, but is essential before planning operative management or arterial embolization. Hysteroscopy may be used to diagnose and manage AVMs. 13 We used DSA or CT/MRI angiograms as diagnostic or pretreatment tests in 93.4% of the patients. Treatment The treatment is based on the severity of symptoms and ranges from conservative to uterine artery embolization. 8 , 19 Owing to the rarity of this condition, there is a paucity of high-level evidence guiding clinicians with respect to its management. 19 Spontaneous resolution has been mentioned in asymptomatic women, with a wait-and-watch policy for postpartum/postabortion cases. 20 The medications used in the literature vary across the studies and for variable times. Progestins and gonadotropin-releasing hormone analogs are the most frequently used medications. Chemotherapeutic agents such as methotraxate, combined oral contraceptive pills, uterotonic (methyl ergonovine), danazol, ulliprtistol, and aromatase inhibitors, either in combination or alone, are less frequently prescribed. 19 The success rate varies between 42% and 100% across the studies. Medical management is prescribed either as primary treatment or after failure of transcatheter embolization (TCE). 8 , 19 A systematic review by Rosen evaluated 32 studies, irrespective of study design; 121 patients were managed with medical treatment, with a success rate of 88%. Progestins, GnRH analogs, and methotrexate are more efficacious than other medical agents are. 19 Medical management has the advantage of universal accessibility and is less expensive. It also has a higher fertility-sparing capacity. However, for patients with significant bleeding, medical management failure, and hemodynamic instability, UAE/TCE, internal iliac ligation, or other surgical procedures such as hysterectomy are alternative treatments. We reported 33% failures with medical management in patients who were managed with TCE. The success rate of UAE/TCE is reported to be 71–91%. 8 , 21 No TCE failure was observed. Importantly, repeat embolization, medical management, or surgery are secondary options for patients with UAE failure. 8 Mild pelvic pain was observed in 20% of the patients in the present study after TCE, which was controlled by analgesics. Postprocedural fever is another complication of post-embolization syndrome. Iatrogenic vessel dissection, contrast-induced nephrotoxicity, and puncture site hematoma are procedure-related complications. 8 The decision for unilateral or bilateral TCE was made by an interventional radiologist in our case. Hysterectomy is indicated only if future fertility is not desired and if immediate medical facilities are not available. It should be performed by experienced pelvic surgeons. 22 It is the final treatment if conservative medical treatment or UAE fails, leading to life-threatening hemorrhage. Minimally invasive surgical techniques through the laparoscopic uterine artery or internal iliac occlusion through nonabsorbable clips have also been mentioned in the literature, either following failure of UAE or as primary procedures. 23 Bipolar coagulation of the uterine arteries is a modality of treatment. 24 The resection of myometrial lesions by laparoscopy or hysteroscopy has been advocated in the literature. 13 , 25 Successful pregnancy and delivery have been described in the literature, 26 and we achieved a total of three successful pregnancies after TCE in two patients. The complications observed were mild preeclampsia (one patient) and gestational diabetes (one patient); however, all three neonates were normal. One pregnancy was diagnosed as gestational trophoblastic tumor stage I. There are few studies on fertility outcomes after TCE, but a higher risk of placental abnormalities has been described in the literature. The main limitations of this study are its retrospective nature and the small sample size. The diagnostic method varies across patients; hence, it cannot provide exclusive power Doppler data for diagnosis. Few patients were lost to follow-up; hence, data on the recurrence of symptoms requiring alternate/definitive therapy are not available. However, considering the rarity of this condition, we presented the exclusive details of patients with AVMs, which is the main strength of this study. Conclusion AVMs are rare; however, their incidence is increasing owing to the increase in the number of uterine surgeries and improvements in diagnosis. The primary investigating modality is ultrasound with color and power Doppler imaging. Uterine artery angiography is a diagnostic method used for the detection of AVMs. Owing to these rare conditions, no treatment guidelines are available. Each case must be individualized. Conservative treatment is an option in mild cases. It also helps retain fertility. Surgical management is the treatment of choice in severe cases without reproductive desire. Ethical approval The study was approved by Kasturba Medical College and Kasturba Hospital, Institutional Ethical Committee, IEC 1: 166/2025. Date: 23 April 2025. Ethical standards and research involving human participants: The study involving human participants followed the ethical standards of the institute’s ethical and research committee and the 1964 Helsinki Declaration and its later amendments. Consent Written informed consent was obtained from patients. Data availability The data generated for the article are depicted in a table format and uploaded to data repository. Relevant images are deposited for data availability. All author agreed to make all data freely available. The dataset can be accessed. Data file 1 Repository name: AVM repository PP. Power point containing images of AVM cases. https://figshare.com/articles/figure/AVM_repository_PP/29091842?file=54615845 DOI: 10.6084/m9.figshare.29091842 . 27 Data file 2 Repository name: case data in table format. Table format data of AVM cases is available in the repository. https://figshare.com/articles/dataset/case_data_in_table_format/29066567?file=54541703 DOI: 10.6084/m9.figshare.29066567 . 28 Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). References 1. Moradi B, Banihashemian M, Sadighi N, et al. : Enhanced myometrial vascularity and AVM: A review on diagnosis and management. J. Clin. Ultrasound. 2023; 51 (6): 1051–1058. PubMed Abstract | Publisher Full Text 2. Fleischer AC, Manning FA: Fleischer’s Sonography in Obstetrics & Gynecology. McGraw-Hill Education; 2018. 3. Giurazza F, Corvino F, Silvestre M, et al. : Uterine arteriovenous malformations. Seminars in Ultrasound, CT and MRI. Elsevier; 2021. 4. 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Yoon DJ, Jones M, Al Taani J, et al. : A systematic review of acquired uterine arteriovenous malformations: pathophysiology, diagnosis, and transcatheter treatment. Am. J. Perinatol. Rep. 2016; 06 (01): e6–e14. Publisher Full Text 9. Clavero Bertomeu L, Castro Portillo L, Fernández-Conde de Paz C: Uterine Arteriovenous Malformation: Diagnostic and Therapeutic Challenges. Diagnostics. 2024; 14 (11): 1084. PubMed Abstract | Publisher Full Text | Free Full Text 10. Dewilde K, Groszmann Y, Van Schoubroeck D, et al. : Enhanced myometrial vascularity secondary to retained pregnancy tissue: time to stop misusing the term arteriovenous malformation. Ultrasound Obstet. Gynecol. 2024; 63 (1): 5–8. PubMed Abstract | Publisher Full Text 11. Grewal K, Al-Memar M, Fourie H, et al. : Natural history of pregnancy-related enhanced myometrial vascularity following miscarriage. Ultrasound Obstet. Gynecol. 2020; 55 (5): 676–682. PubMed Abstract | Publisher Full Text 12. Groszmann YS, Healy Murphy AL, Benacerraf BR: Diagnosis and management of patients with enhanced myometrial vascularity associated with retained products of conception. Ultrasound Obstet. Gynecol. 2018; 52 (3): 396–399. PubMed Abstract | Publisher Full Text 13. Calzolari S, Cozzolino M, Castellacci E, et al. : Hysteroscopic Management of Uterine Arteriovenous Malformation. JSLS. 2017; 21 (2): e2016.00109. PubMed Abstract | Publisher Full Text | Free Full Text 14. Sridhar D, Vogelzang RL: Diagnosis and treatment of uterine and pelvic arteriovenous malformations. Endovasc. Today. 2018; 17 (1): 73. 15. Manabe Y, Uegaki M, Asazuma A, et al. : Two cases of congenital pelvic arteriovenous malformation in male. Hinyokika kiyo Acta Urologica Japonica. 2011; 57 (1): 25–28. PubMed Abstract 16. Molvi SN, Dash K, Rastogi H, et al. : Transcatheter embolization of uterine arteriovenous malformation: report of 2 cases and review of literature. J. Minim. Invasive Gynecol. 2011; 18 (6): 812–819. PubMed Abstract | Publisher Full Text 17. García-Mejido JA, García-Jiménez R, Rodriguez-Cruz L, et al. : Ultrasound Diagnosis of Uterine Arteriovenous Malformations: A Systematic Review. Clin. Exp. Obstet. Gynecol. 2023; 50 (8): 167. Publisher Full Text 18. Clavero Bertomeu L, Castro Portillo L, Fernández-Conde de Paz C: Uterine Arteriovenous Malformation: Diagnostic and Therapeutic Challenges. Diagnostics (Basel). 2024; 14 (11). Publisher Full Text 19. Rosen A, Chan WV, Matelski J, et al. : Medical treatment of uterine arteriovenous malformation: a systematic review and meta-analysis. Fertil. Steril. 2021; 116 (4): 1107–1116. PubMed Abstract | Publisher Full Text 20. Ghizzoni V, Gabbrielli S, Mannini L, et al. : Spontaneous Resolution of an Acquired Uterine Arteriovenous Malformation in an Elderly Primigravida. Am. J. Case Rep. 2018; 19 : 1140–1145. PubMed Abstract | Publisher Full Text | Free Full Text 21. Peitsidis P, Manolakos E, Tsekoura V, et al. : Uterine arteriovenous malformations induced after diagnostic curettage: a systematic review. Arch. Gynecol. Obstet. 2011; 284 : 1137–1151. PubMed Abstract | Publisher Full Text 22. Moulder JK, Garrett LA, Salazar GM, et al. : The role of radical surgery in the management of acquired uterine arteriovenous malformation. Case Rep. Oncol. 2013; 6 (2): 303–310. PubMed Abstract | Publisher Full Text | Free Full Text 23. Yokomine D, Yoshinaga M, Baba Y, et al. : Successful management of uterine arteriovenous malformation by ligation of feeding artery after unsuccessful uterine artery embolization. J. Obstet. Gynaecol. Res. 2009; 35 (1): 183–188. PubMed Abstract | Publisher Full Text 24. Chen S-Q, Jiang H-Y, Li J-B, et al. : Treatment of uterine arteriovenous malformation by myometrial lesion resection combined with artery occlusion under laparoscopy: a case report and literature review. Eur. J. Obstet. Gynecol. Reprod. Biol. 2013; 169 (2): 172–176. 25. Patton EW, Moy I, Milad MP, et al. : Fertility-preserving management of a uterine arteriovenous malformation: a case report of uterine artery embolization (UAE) followed by laparoscopic resection. J. Minim. Invasive Gynecol. 2015; 22 (1): 137–141. PubMed Abstract | Publisher Full Text 26. Chia Y, Yap C, Tan B: Pregnancy Following Embolisation of Uterine Arteriovenous Malformation. Ann. Acad. Med. Singap. 2003; 32 : 658–660. Publisher Full Text 27. Shah K: AVM repository PP. figshare. 2025. Publisher Full Text 28. Shah K: case data in table format. figshare. 2025. Publisher Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 03 Jun 2025 ADD YOUR COMMENT Comment Author details Author details 1 Obstetric and Gynecology, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India 2 Department of Radiodiagnostics and Imaging, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India 3 Obstetrics and Gynecology, University College of Medical science, Guru Tej Bahadur Hospital, Delhi, Delhi, 110095, India Shripad Hebbar Roles: Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Harshith Kramadhari Roles: Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Richa Sharma Roles: Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Rajeshwari Bhat Roles: Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Krupa Shah Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 16 Sep 2025, 14:554 https://doi.org/10.12688/f1000research.164989.2 version 1 Published: 03 Jun 2025, 14:554 https://doi.org/10.12688/f1000research.164989.1 Copyright © 2025 Hebbar S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Hebbar S, Kramadhari H, Sharma R et al. Uterine arteriovenous malformation: A retrospective study from a tertiary center in southern Karnataka [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :554 ( https://doi.org/10.12688/f1000research.164989.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 03 Jun 2025 Views 0 Cite How to cite this report: Vimercati A. Reviewer Report For: Uterine arteriovenous malformation: A retrospective study from a tertiary center in southern Karnataka [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :554 ( https://doi.org/10.5256/f1000research.181583.r396028 ) The direct URL for this report is: https://f1000research.com/articles/14-554/v1#referee-response-396028 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 23 Aug 2025 Antonella Vimercati , University of Bari “Aldo Moro", Bari, Italy Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.181583.r396028 Differentiation between AVM and enhanced myometrial vascularity (EMV) and retained products of conception is relevant in clinical practice, and it currently represents a challenge. An increasing number of studies describe the enhanced myometrial vascularity associated with retained products of ... Continue reading READ ALL Differentiation between AVM and enhanced myometrial vascularity (EMV) and retained products of conception is relevant in clinical practice, and it currently represents a challenge. An increasing number of studies describe the enhanced myometrial vascularity associated with retained products of conception as ‘acquired arteriovenous malformation’, with some recommending management with uterine-artery embolization. On the contrary true uterine AVMs are extremely rare and probably have a different pathogenesis; moreover, AVMs may require different treatment protocols from enhanced myometrial vascularity resulting from recent pregnancy. You should better describe the ultrasound characteristics of the AVM and the differential diagnosis with uterine enhanced myometrial vascularity (EVM) and retained products of conception (RPOC) and, although rare, degeneration in trophoblastic tumor (you should insert 2 bibliographic entries on this subject: Vimercati A, Crupano FM, Del Vecchio V, Cicinelli E. A Rare Case Of An Arteriovenous Malformation Scar Pregnancy Treated With A Combined And Conservative Approach. J Ultrasound Med. 2019; 38:1921-24, Doi: 10.1002/Jum.14876 and Vimercati A, De Gennaro AC, Resta L, Cormio G, Cicinelli E. Sonographic And Power Doppler Evaluation Of An Invasive Mole Located In A Cesarean Scar Pregnancy. J U Ltras Med 2016; 35(7):1608-12 ) Do you consider a specific cut off for the spectral evaluation of the vessels within the AVM lesion? What peak systolic velocity or resistance index ? There still is a degree of ignorance in the obstetrical and radiological community as to the etiology, pathophysiology, and management of avm/emv In case of ultrasound diagnosis only on what basis do you choose between waiting, medical or surgical treatment? Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Not applicable Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Yes References 1. Vimercati A, Crupano F, Del Vecchio V, Cicinelli E: A Rare Case of an Arteriovenous Malformation Scar Pregnancy Treated With a Combined and Conservative Approach. Journal of Ultrasound in Medicine . 2019; 38 (7): 1921-1924 Publisher Full Text 2. Vimercati A, De Gennaro AC, Resta L, Cormio G, Cicinelli E. Sonographic And Power Doppler Evaluation Of An Invasive Mole Located In A Cesarean Scar Pregnancy. J ULtras Med 2016; 35(7):1608-12. Competing Interests: No competing interests were disclosed. Reviewer Expertise: perinatal medicine I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Vimercati A. Reviewer Report For: Uterine arteriovenous malformation: A retrospective study from a tertiary center in southern Karnataka [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :554 ( https://doi.org/10.5256/f1000research.181583.r396028 ) The direct URL for this report is: https://f1000research.com/articles/14-554/v1#referee-response-396028 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 25 Nov 2025 Krupa Shah , Obstetric and Gynecology, Manipal Academy of Higher Education, Manipal, 576104, India 25 Nov 2025 Author Response Comment 1 : Differentiation between AVM and enhanced myometrial vascularity (EMV) and retained products of conception is relevant in clinical practice, and it currently represents a challenge. An increasing number ... Continue reading Comment 1 : Differentiation between AVM and enhanced myometrial vascularity (EMV) and retained products of conception is relevant in clinical practice, and it currently represents a challenge. An increasing number of studies describe the enhanced myometrial vascularity associated with retained products of conception as ‘acquired arteriovenous malformation’, with some recommending management with uterine-artery embolization. On the contrary true uterine AVMs are extremely rare and probably have a different pathogenesis; moreover, AVMs may require different treatment protocols from enhanced myometrial vascularity resulting from recent pregnancy. Response: Thanks for the review. We totally agree with you. The same points have been elaborated and added in the discussion. comment 2: You should better describe the ultrasound characteristics of the AVM and the differential diagnosis with uterine enhanced myometrial vascularity (EVM) and retained products of conception (RPOC) and, although rare, degeneration in trophoblastic tumour. Response: It has been added. Comment 3: Do you consider a specific cut off for the spectral evaluation of the vessels within the AVM lesion? What peak systolic velocity or resistance index? Response: There is no consensus in the literature, however, literature has been added regarding PSV and RI. comment 4: There still is a degree of ignorance in the obstetrical and radiological community as to the etiology, pathophysiology, and management of avm/emv. Response: ​​​​​​​Thank you for the insightful comment. The same observation might be true for some of the health care providers. However, in tertiary care centres with advanced facility, expert obstetrician and interventional radiologist would utilize different modalities of intervention on case-to-case basis. comment 5: In case of ultrasound diagnosis only on what basis do you choose between waiting, medical or surgical treatment? Response: Multiple variables are considered when only ultrasound as a diagnostic facility is available. We recommend with empty uterine cavity, and normal B hcg value, the ultrasound findings should be supported with higher imaging in cases of acquired AVMs. Dear Dr. Antonella Vimmercati, kindly check the responses and version 2 available online, https://f1000research.com/articles/14-554/v2 , is a link for the access. thank you again for your valuable opinion hope to hear soon. thanking you Krupa Shah. Comment 1 : Differentiation between AVM and enhanced myometrial vascularity (EMV) and retained products of conception is relevant in clinical practice, and it currently represents a challenge. An increasing number of studies describe the enhanced myometrial vascularity associated with retained products of conception as ‘acquired arteriovenous malformation’, with some recommending management with uterine-artery embolization. On the contrary true uterine AVMs are extremely rare and probably have a different pathogenesis; moreover, AVMs may require different treatment protocols from enhanced myometrial vascularity resulting from recent pregnancy. Response: Thanks for the review. We totally agree with you. The same points have been elaborated and added in the discussion. comment 2: You should better describe the ultrasound characteristics of the AVM and the differential diagnosis with uterine enhanced myometrial vascularity (EVM) and retained products of conception (RPOC) and, although rare, degeneration in trophoblastic tumour. Response: It has been added. Comment 3: Do you consider a specific cut off for the spectral evaluation of the vessels within the AVM lesion? What peak systolic velocity or resistance index? Response: There is no consensus in the literature, however, literature has been added regarding PSV and RI. comment 4: There still is a degree of ignorance in the obstetrical and radiological community as to the etiology, pathophysiology, and management of avm/emv. Response: ​​​​​​​Thank you for the insightful comment. The same observation might be true for some of the health care providers. However, in tertiary care centres with advanced facility, expert obstetrician and interventional radiologist would utilize different modalities of intervention on case-to-case basis. comment 5: In case of ultrasound diagnosis only on what basis do you choose between waiting, medical or surgical treatment? Response: Multiple variables are considered when only ultrasound as a diagnostic facility is available. We recommend with empty uterine cavity, and normal B hcg value, the ultrasound findings should be supported with higher imaging in cases of acquired AVMs. Dear Dr. Antonella Vimmercati, kindly check the responses and version 2 available online, https://f1000research.com/articles/14-554/v2 , is a link for the access. thank you again for your valuable opinion hope to hear soon. thanking you Krupa Shah. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 25 Nov 2025 Krupa Shah , Obstetric and Gynecology, Manipal Academy of Higher Education, Manipal, 576104, India 25 Nov 2025 Author Response Comment 1 : Differentiation between AVM and enhanced myometrial vascularity (EMV) and retained products of conception is relevant in clinical practice, and it currently represents a challenge. An increasing number ... Continue reading Comment 1 : Differentiation between AVM and enhanced myometrial vascularity (EMV) and retained products of conception is relevant in clinical practice, and it currently represents a challenge. An increasing number of studies describe the enhanced myometrial vascularity associated with retained products of conception as ‘acquired arteriovenous malformation’, with some recommending management with uterine-artery embolization. On the contrary true uterine AVMs are extremely rare and probably have a different pathogenesis; moreover, AVMs may require different treatment protocols from enhanced myometrial vascularity resulting from recent pregnancy. Response: Thanks for the review. We totally agree with you. The same points have been elaborated and added in the discussion. comment 2: You should better describe the ultrasound characteristics of the AVM and the differential diagnosis with uterine enhanced myometrial vascularity (EVM) and retained products of conception (RPOC) and, although rare, degeneration in trophoblastic tumour. Response: It has been added. Comment 3: Do you consider a specific cut off for the spectral evaluation of the vessels within the AVM lesion? What peak systolic velocity or resistance index? Response: There is no consensus in the literature, however, literature has been added regarding PSV and RI. comment 4: There still is a degree of ignorance in the obstetrical and radiological community as to the etiology, pathophysiology, and management of avm/emv. Response: ​​​​​​​Thank you for the insightful comment. The same observation might be true for some of the health care providers. However, in tertiary care centres with advanced facility, expert obstetrician and interventional radiologist would utilize different modalities of intervention on case-to-case basis. comment 5: In case of ultrasound diagnosis only on what basis do you choose between waiting, medical or surgical treatment? Response: Multiple variables are considered when only ultrasound as a diagnostic facility is available. We recommend with empty uterine cavity, and normal B hcg value, the ultrasound findings should be supported with higher imaging in cases of acquired AVMs. Dear Dr. Antonella Vimmercati, kindly check the responses and version 2 available online, https://f1000research.com/articles/14-554/v2 , is a link for the access. thank you again for your valuable opinion hope to hear soon. thanking you Krupa Shah. Comment 1 : Differentiation between AVM and enhanced myometrial vascularity (EMV) and retained products of conception is relevant in clinical practice, and it currently represents a challenge. An increasing number of studies describe the enhanced myometrial vascularity associated with retained products of conception as ‘acquired arteriovenous malformation’, with some recommending management with uterine-artery embolization. On the contrary true uterine AVMs are extremely rare and probably have a different pathogenesis; moreover, AVMs may require different treatment protocols from enhanced myometrial vascularity resulting from recent pregnancy. Response: Thanks for the review. We totally agree with you. The same points have been elaborated and added in the discussion. comment 2: You should better describe the ultrasound characteristics of the AVM and the differential diagnosis with uterine enhanced myometrial vascularity (EVM) and retained products of conception (RPOC) and, although rare, degeneration in trophoblastic tumour. Response: It has been added. Comment 3: Do you consider a specific cut off for the spectral evaluation of the vessels within the AVM lesion? What peak systolic velocity or resistance index? Response: There is no consensus in the literature, however, literature has been added regarding PSV and RI. comment 4: There still is a degree of ignorance in the obstetrical and radiological community as to the etiology, pathophysiology, and management of avm/emv. Response: ​​​​​​​Thank you for the insightful comment. The same observation might be true for some of the health care providers. However, in tertiary care centres with advanced facility, expert obstetrician and interventional radiologist would utilize different modalities of intervention on case-to-case basis. comment 5: In case of ultrasound diagnosis only on what basis do you choose between waiting, medical or surgical treatment? Response: Multiple variables are considered when only ultrasound as a diagnostic facility is available. We recommend with empty uterine cavity, and normal B hcg value, the ultrasound findings should be supported with higher imaging in cases of acquired AVMs. Dear Dr. Antonella Vimmercati, kindly check the responses and version 2 available online, https://f1000research.com/articles/14-554/v2 , is a link for the access. thank you again for your valuable opinion hope to hear soon. thanking you Krupa Shah. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Cavoretto PI. Reviewer Report For: Uterine arteriovenous malformation: A retrospective study from a tertiary center in southern Karnataka [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :554 ( https://doi.org/10.5256/f1000research.181583.r394304 ) The direct URL for this report is: https://f1000research.com/articles/14-554/v1#referee-response-394304 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 28 Jul 2025 Paolo Ivo Cavoretto , IRCCS San Raffaele Scientific Institute, Milan, Italy Approved VIEWS 0 https://doi.org/10.5256/f1000research.181583.r394304 This is a nice study with interesting results. The pictorial essay by Cavoretto and Cioffi on gestational trophoblastic neoplasia illustrates key imaging features of the disease. Notably, it highlights the early precursors of arteriovenous malformations associated with ... Continue reading READ ALL This is a nice study with interesting results. The pictorial essay by Cavoretto and Cioffi on gestational trophoblastic neoplasia illustrates key imaging features of the disease. Notably, it highlights the early precursors of arteriovenous malformations associated with this condition. These findings offer important diagnostic insights. The work is well worth mentioning in the context of vascular complications, there are no similar comprehensive work in the literature as far as I am concerned.. (refer 1) Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes References 1. Cavoretto P, Cioffi R, Mangili G, Petrone M, et al.: A Pictorial Ultrasound Essay of Gestational Trophoblastic Disease. Journal of Ultrasound in Medicine . 2020; 39 (3): 597-613 Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Obstetrics and gynaecology, prenatal medicine, ultrasound and imaging I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Cavoretto PI. Reviewer Report For: Uterine arteriovenous malformation: A retrospective study from a tertiary center in southern Karnataka [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :554 ( https://doi.org/10.5256/f1000research.181583.r394304 ) The direct URL for this report is: https://f1000research.com/articles/14-554/v1#referee-response-394304 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 03 Jun 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 16 Sep 25 Version 1 03 Jun 25 read read Paolo Ivo Cavoretto , IRCCS San Raffaele Scientific Institute, Milan, Italy Antonella Vimercati , University of Bari “Aldo Moro", Bari, Italy Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Vimercati A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 23 Aug 2025 | for Version 1 Antonella Vimercati , University of Bari “Aldo Moro", Bari, Italy 0 Views copyright © 2025 Vimercati A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Differentiation between AVM and enhanced myometrial vascularity (EMV) and retained products of conception is relevant in clinical practice, and it currently represents a challenge. An increasing number of studies describe the enhanced myometrial vascularity associated with retained products of conception as ‘acquired arteriovenous malformation’, with some recommending management with uterine-artery embolization. On the contrary true uterine AVMs are extremely rare and probably have a different pathogenesis; moreover, AVMs may require different treatment protocols from enhanced myometrial vascularity resulting from recent pregnancy. You should better describe the ultrasound characteristics of the AVM and the differential diagnosis with uterine enhanced myometrial vascularity (EVM) and retained products of conception (RPOC) and, although rare, degeneration in trophoblastic tumor (you should insert 2 bibliographic entries on this subject: Vimercati A, Crupano FM, Del Vecchio V, Cicinelli E. A Rare Case Of An Arteriovenous Malformation Scar Pregnancy Treated With A Combined And Conservative Approach. J Ultrasound Med. 2019; 38:1921-24, Doi: 10.1002/Jum.14876 and Vimercati A, De Gennaro AC, Resta L, Cormio G, Cicinelli E. Sonographic And Power Doppler Evaluation Of An Invasive Mole Located In A Cesarean Scar Pregnancy. J U Ltras Med 2016; 35(7):1608-12 ) Do you consider a specific cut off for the spectral evaluation of the vessels within the AVM lesion? What peak systolic velocity or resistance index ? There still is a degree of ignorance in the obstetrical and radiological community as to the etiology, pathophysiology, and management of avm/emv In case of ultrasound diagnosis only on what basis do you choose between waiting, medical or surgical treatment? Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Not applicable Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Yes References 1. Vimercati A, Crupano F, Del Vecchio V, Cicinelli E: A Rare Case of an Arteriovenous Malformation Scar Pregnancy Treated With a Combined and Conservative Approach. Journal of Ultrasound in Medicine . 2019; 38 (7): 1921-1924 Publisher Full Text 2. Vimercati A, De Gennaro AC, Resta L, Cormio G, Cicinelli E. Sonographic And Power Doppler Evaluation Of An Invasive Mole Located In A Cesarean Scar Pregnancy. J ULtras Med 2016; 35(7):1608-12. Competing Interests No competing interests were disclosed. Reviewer Expertise perinatal medicine I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 25 Nov 2025 Krupa Shah, Obstetric and Gynecology, Manipal Academy of Higher Education, Manipal, 576104, India Comment 1 : Differentiation between AVM and enhanced myometrial vascularity (EMV) and retained products of conception is relevant in clinical practice, and it currently represents a challenge. An increasing number of studies describe the enhanced myometrial vascularity associated with retained products of conception as ‘acquired arteriovenous malformation’, with some recommending management with uterine-artery embolization. On the contrary true uterine AVMs are extremely rare and probably have a different pathogenesis; moreover, AVMs may require different treatment protocols from enhanced myometrial vascularity resulting from recent pregnancy. Response: Thanks for the review. We totally agree with you. The same points have been elaborated and added in the discussion. comment 2: You should better describe the ultrasound characteristics of the AVM and the differential diagnosis with uterine enhanced myometrial vascularity (EVM) and retained products of conception (RPOC) and, although rare, degeneration in trophoblastic tumour. Response: It has been added. Comment 3: Do you consider a specific cut off for the spectral evaluation of the vessels within the AVM lesion? What peak systolic velocity or resistance index? Response: There is no consensus in the literature, however, literature has been added regarding PSV and RI. comment 4: There still is a degree of ignorance in the obstetrical and radiological community as to the etiology, pathophysiology, and management of avm/emv. Response: ​​​​​​​Thank you for the insightful comment. The same observation might be true for some of the health care providers. However, in tertiary care centres with advanced facility, expert obstetrician and interventional radiologist would utilize different modalities of intervention on case-to-case basis. comment 5: In case of ultrasound diagnosis only on what basis do you choose between waiting, medical or surgical treatment? Response: Multiple variables are considered when only ultrasound as a diagnostic facility is available. We recommend with empty uterine cavity, and normal B hcg value, the ultrasound findings should be supported with higher imaging in cases of acquired AVMs. Dear Dr. Antonella Vimmercati, kindly check the responses and version 2 available online, https://f1000research.com/articles/14-554/v2 , is a link for the access. thank you again for your valuable opinion hope to hear soon. thanking you Krupa Shah. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Vimercati A. Peer Review Report For: Uterine arteriovenous malformation: A retrospective study from a tertiary center in southern Karnataka [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :554 ( https://doi.org/10.5256/f1000research.181583.r396028) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-554/v1#referee-response-396028 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Cavoretto P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 28 Jul 2025 | for Version 1 Paolo Ivo Cavoretto , IRCCS San Raffaele Scientific Institute, Milan, Italy 0 Views copyright © 2025 Cavoretto P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This is a nice study with interesting results. The pictorial essay by Cavoretto and Cioffi on gestational trophoblastic neoplasia illustrates key imaging features of the disease. Notably, it highlights the early precursors of arteriovenous malformations associated with this condition. These findings offer important diagnostic insights. The work is well worth mentioning in the context of vascular complications, there are no similar comprehensive work in the literature as far as I am concerned.. (refer 1) Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes References 1. Cavoretto P, Cioffi R, Mangili G, Petrone M, et al.: A Pictorial Ultrasound Essay of Gestational Trophoblastic Disease. Journal of Ultrasound in Medicine . 2020; 39 (3): 597-613 Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Obstetrics and gynaecology, prenatal medicine, ultrasound and imaging I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Cavoretto PI. Peer Review Report For: Uterine arteriovenous malformation: A retrospective study from a tertiary center in southern Karnataka [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :554 ( https://doi.org/10.5256/f1000research.181583.r394304) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-554/v1#referee-response-394304 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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