Successful management of uterine cervical arteriovenous malformation (Cervical AVM) by feeding vessel ligation

Successful management of uterine cervical arteriovenous malformation (Cervical AVM) by feeding vessel ligation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Successful management of uterine cervical arteriovenous malformation (Cervical AVM) by feeding vessel ligation Amany A. Makroum, Abdelhady Abdelhady Zayed, Tarek Shokeir, Maged El-Shamy, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7586315/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 17 You are reading this latest preprint version Abstract Background: Uterine arterio-venous malformation (AVM) is a serious condition, usually presented by abnormal vaginal bleeding, which may be life-threatening. It may be either corporeal or cervical. The commonly reported type was uterine corporeal AVM. Different methods of fertility-preserving techniques were used for their management. However, cases of uterine cervical AVM are scarce. Case presentation: Herein, a 27-year-old patient was diagnosed to have cervical AVM by using transvaginal color Doppler and CT angiography. A novel minimally invasive technique of feeding vessel ligation was used for her treatment, with a satisfactory outcome. Conclusions: T he vaginal approach of ligation of the descending vaginal branch of the uterine artery is a simple, feasible, safe, and cost-effective method. It could be considered a suitable therapeutic alternative for women of childbearing age desiring fertility preservation. Arterio-venous malformation Feeding vessel ligation Treatment Uterine-cervix AVM Figures Figure 1 Figure 2 Figure 3 Background Arteriovenous malformation (AVM) is an abnormal communication between the arterial and venous systems with an absent functional intervening capillary bed. The uterus is one of the body parts that could be affected by this condition. Corporal types are more frequent than cervical ones [ 1 ]. The cause of uterine cervical AVM (Cervical AVM) can be congenital or acquired. The exact pathogenesis is unknown; however, operative trauma or hormonal disturbances are suggested [ 2 ]. It commonly presents as menstrual, antenatal, postpartum, or post-abortive abnormal vaginal bleeding. The attack of bleeding may be life-threatening, which is usually refractory to conventional therapies[ 3 ]. Different treatment options were reported, including conservative follow-up, hormonal therapy, uterine arterial embolization, high-intensity focused ultrasound, hysteroscopic resection, and hysterectomy [ 1 , 2 ]. Nevertheless, there are also a few cases of cervical AVM that are addressed [ 4 – 6 ]. Herein, we describe a case of cervical AVM treated successfully by a novel minimally invasive technique of feeding vessel ligation with a satisfactory outcome. Case presentation A 27-year-old patient, booked G2P1 + 1 , referred to our emergency unit with a severe attack of vaginal bleeding. She had an unremarkable past medical and surgical history apart from a cesarean delivery 4.5 years ago and surgical evacuation for a missed miscarriage 4 months before admission. The event of the surgical evacuation was associated with a history of significant blood loss necessitating transfusion of one unit of packed RBCs. She developed recurrent attacks of post-abortive bleeding. The last attack was severe enough to be referred to our emergency unit. On admission, her vital data were markedly compromised. The blood pressure was 80/50 mmHg, and the heart rate was 120 beats/min. She was sweaty with cold extremities. The abdomen was lax, and there was significant vaginal bleeding. Her hemoglobin level was 7.2 gm/dl. Intravenous fluids, 2 units of packed RBCs, and 1 gm of tranexamic acid were used for initial management. After stabilization of her general condition, local vaginal examination revealed a normal appearance of the portio-vaginalis of the cervix with visible bright-red bleeding coming out of the external os. The uterus was normal-sized, and cervical motion was not associated with any tenderness. Serum β-hCG was negative. Coagulation profile and all other basic blood investigations were normal. Transvaginal ultrasound (TVS) showed that the posterior lip of the cervix was the seat of a cervical mass about 15 x 16 mm containing multiple tortuous hypoechoic structures at the level of the internal os (Fig. 1 a). Doppler examination revealed a mosaic pattern of increased vascularity, characterized by the expansion of numerous arterial and venous blood vessels, accompanied by rapid and turbulent vascular signals inside (Fig. 1 b). CT-angiography (Fig. 2 ) showed a complex mass of abnormal blood vessels referred to as a nidus, where arterial and venous structures are seen to connect directly without an intervening capillary bed, and MRI (Fig. 3 ) showed a low-signal-intensity lesion in the posterior cervical lip. It was an ill-defined, heterogeneous, enhanced soft tissue mass with multiple signal void vascular sinuses inside. Therefore, a likely diagnosis of cervical AVM was made. After the patient’s counselling and taking informed written consent, we decided to do bilateral ligation of the feeding blood vessel, which is the descending vaginal branch of the uterine artery at 3 and 9 o’clock. Under general anesthesia, the patient was placed in the lithotomy position, sterilization of vagina and perineum by povidone-iodine 10% and then draping was done. The urinary bladder was evacuated, and the portio vaginalis of the cervix was properly exposed using vaginal retractors. Stabilization and traction on the anterior and posterior cervical lips were done using two single-toothed tenacula. The anterior vaginal mucosa was transversely incised at the level of the bladder neck sulcus. After proper mobilization of the urinary bladder, the pulsation of the descending vaginal branch of the uterine artery was palpated. Then, gentle traction of the cervix to the contralateral side was done, followed by applying a delayed absorbable suture ligation (VICRYL® 0, Ethicon, Johnson & Johnson Spreitenbach, Switzerland) at the level of the cervico-vaginal junction. The same procedure was repeated on the other side. Finally, the vaginal mucosa was closed using absorbable sutures (VICRYL® 2/0, Ethicon, Johnson & Johnson Spreitenbach, Switzerland), and a vaginal pack was left for 12 hours. The postoperative course had passed uneventfully. The patient was discharged after 48 hours with a hemoglobin level of 9.8 gm/dl. Oral iron therapy and non-specific haemostatics were prescribed on discharge. Following surgery, the subsequent bleeding pattern showed marked improvements. To some extent, the first postoperative menstruation was associated with heavier blood loss for the first 2 days, for which the patient received oral non-specific haemostatics. During that cycle, TVS examination demonstrated a marked reduction in the size of the cervical mass (> 50%) with a definite decrease in the vascularity. Her second menstrual pattern was normal. The cervical mass disappeared completely on the follow-up TVUS scan. Discussion and Conclusions Cervical AVM is an extremely rare condition and may be life-threatening [ 3 ]. The exact etiology of this pathology is unknown. It could be either congenital or acquired. Traumas during cesarean delivery or surgical curettage are the more frequent causes [ 7 ]. Other etiologic factors include endometritis, retained products of conception, abnormal trophoblastic growth as in molar pregnancy, and gynecologic malignancies[ 7 ]. In our case, a recent history of surgical evacuation for a missed abortion is hypothesized to be the possible etiology. Diagnosis of cervical AVM is mainly radiological. Grey-scale ultrasound and color Doppler examination are the first highly sensitive diagnostic tools [ 8 ]. Color Doppler imaging confirms the presence of multiple swollen vessels, feeding arteries, and draining veins with a mosaic pattern. Furthermore, the presence of pulsatility in the arterial component using pulsed Doppler scanning differentiates it from cervical varix, which contains no pulsating waves. These findings should be supported by an MRI evaluation. The serpiginous appearance of signal voids and the enhancement on rapid acquisition of data are important in MRI examination. Also, the high flow in the arterial side and rapid filling of the venous side are important findings when using CT-angiography to confirm the diagnosis [ 1 , 2 , 8 ]. We used TVS with Doppler imaging for the initial assessment of our case. Also, CT and MRI were done to confirm the final diagnosis. Multiple fertility-preserving treatment options have been utilized to manage uterine AVM. Being a possible estrogen-dependent lesion, AVM was tried to be treated using gestagens, placement of hormonal IUDs [ 9 ], GnRH analogues, danazol [ 1 ]. Bilateral or unilateral trans-catheter embolization of feeding uterine blood vessels, ovarian or internal iliac arteries [ 10 – 14 ] was performed by placing metal coils [ 15 ], gel foam [ 16 ], or polyvinyl alcohol (PVA) [ 17 ]. High-intensity focused ultrasound mass ablation was described as an alternative to surgical treatment options [ 2 , 3 ]. Endoscopic management via hysteroscopic endometrial mass excision[ 18 ], or laparoscopic bipolar coagulation of the feeding uterine or ovarian arteries, and surgical excision of the mass were also successfully reported[ 19 ]. Hysterectomy was performed when fertility is no longer required [ 6 , 20 ]. The rationale of our surgical therapeutic choice is to attack directly the feeding blood vessels of the cervical AVM through a minimally invasive vaginal approach. We bilaterally ligated the descending vaginal branch of the uterine artery at 3 and 9 o’clock, using a delayed absorbable suture from outside the cervical canal. Ligation of the feeding vessels of the cervical AVM from inside the cervical canal was tried during the cesarean delivery of a patient diagnosed to have cervical AVM in the third trimester [ 5 ]. In conclusion, we found that the vaginal approach of bilateral ligation of the descending vaginal branch of the uterine artery is a successful treatment option for cervical AVM. It is simple, feasible, safe, and cost-effective. It could be considered a suitable therapeutic alternative for women of childbearing age desiring fertility preservation. Declarations Ethics approval The study protocol was approved by the institutional review board of the Faculty of Medicine, Mansoura University, with the number R.19.12.684.R1. Declaration of patient consent for participation and publication The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Availability of data and materials Please contact the authors for data requests. Competing interests None to declare Funding None to declare Author contributions: CRediT Amany A. Makroum: Writing – review and editing, Abdelhady Abdelhady Zayed: Investigation, Tarek Shokeir: Project administration, Maged El-Shamy: Supervision, Rawan Abo Asy: Data curation, Mohamed Taman: Conceptualization & Writing – original draft. Acknowledgement We are sincerely grateful to the study participant for her kind cooperation. Statement of prior presentation or publication and/or abstract/poster presentation The manuscript has no prior presentation or publication and/or abstract/poster presentation. References Peitsidis P, Manolakos E, Tsekoura V, Kreienberg R, Schwentner L. Uterine arteriovenous malformations induced after diagnostic curettage: a systematic review. Arch Gynecol Obstet [Internet]. 2011;284(5):1137–51. Available from: http://link.springer.com/ 10.1007/s00404-011-2067-7 Yoon D, Jones M, Taani J, Buhimschi C, Dowell J. A Systematic Review of Acquired Uterine Arteriovenous Malformations: Pathophysiology, Diagnosis, and Transcatheter Treatment. Am J Perinatol Reports [Internet]. 2015;06(01):e6–14. Available from: http://www.thieme-connect.de/DOI/DOI?10.1055/s-0035-1563721 Lowenstein L, Solt I, Deutsch M, Kerner H, Amit A. A Life-Threatening Event: Uterine Cervical Arteriovenous Malformation. Obstet Gynecol [Internet]. 2004;103(5):1073–5. 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As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7586315","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":514791286,"identity":"37f923fa-833a-41a5-9496-5278ecd97971","order_by":0,"name":"Amany A. 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07:17:44","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":61049,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7586315/v1/14bb29e4df8b7d9ce39297ad.html"},{"id":91956612,"identity":"da95c8db-6c35-43d7-b6e7-aee51f5164bf","added_by":"auto","created_at":"2025-09-23 07:17:44","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1200944,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(a):\u003c/strong\u003e 2-Dimensional grey-scale TVS showing a heterogeneous cervical mass 15X16 mm (Arrow) containing multiple tortuous hypoechoic structures at the level of the internal os. (\u003cstrong\u003eb):\u003c/strong\u003e Doppler examination demonstrating a mosaic pattern of increased vascularity with expansion of numerous arterial and venous vessels with high vascular signals.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7586315/v1/a3f3884a72db11f3c1bd7fb0.jpeg"},{"id":91955504,"identity":"d18b902f-8b62-46ac-8fd2-0cb521c020be","added_by":"auto","created_at":"2025-09-23 07:09:44","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":338715,"visible":true,"origin":"","legend":"\u003cp\u003eMRI showing an ill-defined heterogeneous enhanced soft tissue mass with multiple vascular structures inside, suggestive of cervical AVM.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7586315/v1/27781184a02839dd431c73de.jpeg"},{"id":91956614,"identity":"38a5baf6-d137-425d-bde0-897b4a5d72a2","added_by":"auto","created_at":"2025-09-23 07:17:44","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":498287,"visible":true,"origin":"","legend":"\u003cp\u003e3D Volume Rendered image from a Computed Tomography Angiography (CTA) scan showing the complex mass of abnormal blood vessels referred to as a nidus (cervical AVM).\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7586315/v1/3a7550795410471ebc4bfaa9.jpeg"},{"id":91956632,"identity":"c7c04190-b48d-4fb8-9e3c-2db72a342cbe","added_by":"auto","created_at":"2025-09-23 07:17:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2526255,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7586315/v1/a72d30ed-dae6-4a45-a91c-75a5a4824d69.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Successful management of uterine cervical arteriovenous malformation (Cervical AVM) by feeding vessel ligation","fulltext":[{"header":"Background","content":"\u003cp\u003eArteriovenous malformation (AVM) is an abnormal communication between the arterial and venous systems with an absent functional intervening capillary bed. The uterus is one of the body parts that could be affected by this condition. Corporal types are more frequent than cervical ones [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe cause of uterine cervical AVM (Cervical AVM) can be congenital or acquired. The exact pathogenesis is unknown; however, operative trauma or hormonal disturbances are suggested [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It commonly presents as menstrual, antenatal, postpartum, or post-abortive abnormal vaginal bleeding. The attack of bleeding may be life-threatening, which is usually refractory to conventional therapies[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDifferent treatment options were reported, including conservative follow-up, hormonal therapy, uterine arterial embolization, high-intensity focused ultrasound, hysteroscopic resection, and hysterectomy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Nevertheless, there are also a few cases of cervical AVM that are addressed [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHerein, we describe a case of cervical AVM treated successfully by a novel minimally invasive technique of feeding vessel ligation with a satisfactory outcome.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 27-year-old patient, booked G2P1\u003csup\u003e+ 1\u003c/sup\u003e, referred to our emergency unit with a severe attack of vaginal bleeding. She had an unremarkable past medical and surgical history apart from a cesarean delivery 4.5 years ago and surgical evacuation for a missed miscarriage 4 months before admission. The event of the surgical evacuation was associated with a history of significant blood loss necessitating transfusion of one unit of packed RBCs. She developed recurrent attacks of post-abortive bleeding. The last attack was severe enough to be referred to our emergency unit.\u003c/p\u003e\u003cp\u003eOn admission, her vital data were markedly compromised. The blood pressure was 80/50 mmHg, and the heart rate was 120 beats/min. She was sweaty with cold extremities. The abdomen was lax, and there was significant vaginal bleeding. Her hemoglobin level was 7.2 gm/dl. Intravenous fluids, 2 units of packed RBCs, and 1 gm of tranexamic acid were used for initial management. After stabilization of her general condition, local vaginal examination revealed a normal appearance of the portio-vaginalis of the cervix with visible bright-red bleeding coming out of the external os. The uterus was normal-sized, and cervical motion was not associated with any tenderness. Serum β-hCG was negative. Coagulation profile and all other basic blood investigations were normal. Transvaginal ultrasound (TVS) showed that the posterior lip of the cervix was the seat of a cervical mass about 15 x 16 mm containing multiple tortuous hypoechoic structures at the level of the internal os (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). Doppler examination revealed a mosaic pattern of increased vascularity, characterized by the expansion of numerous arterial and venous blood vessels, accompanied by rapid and turbulent vascular signals inside (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). CT-angiography (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e) showed a complex mass of abnormal blood vessels referred to as a nidus, where arterial and venous structures are seen to connect directly without an intervening capillary bed, and MRI (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e3\u003c/span\u003e) showed a low-signal-intensity lesion in the posterior cervical lip. It was an ill-defined, heterogeneous, enhanced soft tissue mass with multiple signal void vascular sinuses inside. Therefore, a likely diagnosis of cervical AVM was made.\u003c/p\u003e\u003cp\u003eAfter the patient’s counselling and taking informed written consent, we decided to do bilateral ligation of the feeding blood vessel, which is the descending vaginal branch of the uterine artery at 3 and 9 o’clock. Under general anesthesia, the patient was placed in the lithotomy position, sterilization of vagina and perineum by povidone-iodine 10% and then draping was done. The urinary bladder was evacuated, and the portio vaginalis of the cervix was properly exposed using vaginal retractors. Stabilization and traction on the anterior and posterior cervical lips were done using two single-toothed tenacula. The anterior vaginal mucosa was transversely incised at the level of the bladder neck sulcus. After proper mobilization of the urinary bladder, the pulsation of the descending vaginal branch of the uterine artery was palpated. Then, gentle traction of the cervix to the contralateral side was done, followed by applying a delayed absorbable suture ligation (VICRYL® 0, Ethicon, Johnson \u0026amp; Johnson Spreitenbach, Switzerland) at the level of the cervico-vaginal junction. The same procedure was repeated on the other side. Finally, the vaginal mucosa was closed using absorbable sutures (VICRYL® 2/0, Ethicon, Johnson \u0026amp; Johnson Spreitenbach, Switzerland), and a vaginal pack was left for 12 hours.\u003c/p\u003e\u003cp\u003eThe postoperative course had passed uneventfully. The patient was discharged after 48 hours with a hemoglobin level of 9.8 gm/dl. Oral iron therapy and non-specific haemostatics were prescribed on discharge.\u003c/p\u003e\u003cp\u003eFollowing surgery, the subsequent bleeding pattern showed marked improvements. To some extent, the first postoperative menstruation was associated with heavier blood loss for the first 2 days, for which the patient received oral non-specific haemostatics. During that cycle, TVS examination demonstrated a marked reduction in the size of the cervical mass (\u0026gt; 50%) with a definite decrease in the vascularity. Her second menstrual pattern was normal. The cervical mass disappeared completely on the follow-up TVUS scan.\u003c/p\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eCervical AVM is an extremely rare condition and may be life-threatening [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The exact etiology of this pathology is unknown. It could be either congenital or acquired. Traumas during cesarean delivery or surgical curettage are the more frequent causes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Other etiologic factors include endometritis, retained products of conception, abnormal trophoblastic growth as in molar pregnancy, and gynecologic malignancies[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In our case, a recent history of surgical evacuation for a missed abortion is hypothesized to be the possible etiology.\u003c/p\u003e\u003cp\u003eDiagnosis of cervical AVM is mainly radiological. Grey-scale ultrasound and color Doppler examination are the first highly sensitive diagnostic tools [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Color Doppler imaging confirms the presence of multiple swollen vessels, feeding arteries, and draining veins with a mosaic pattern. Furthermore, the presence of pulsatility in the arterial component using pulsed Doppler scanning differentiates it from cervical varix, which contains no pulsating waves. These findings should be supported by an MRI evaluation. The serpiginous appearance of signal voids and the enhancement on rapid acquisition of data are important in MRI examination. Also, the high flow in the arterial side and rapid filling of the venous side are important findings when using CT-angiography to confirm the diagnosis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. We used TVS with Doppler imaging for the initial assessment of our case. Also, CT and MRI were done to confirm the final diagnosis.\u003c/p\u003e\u003cp\u003eMultiple fertility-preserving treatment options have been utilized to manage uterine AVM. Being a possible estrogen-dependent lesion, AVM was tried to be treated using gestagens, placement of hormonal IUDs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], GnRH analogues, danazol [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Bilateral or unilateral trans-catheter embolization of feeding uterine blood vessels, ovarian or internal iliac arteries [\u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e–\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] was performed by placing metal coils [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], gel foam [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], or polyvinyl alcohol (PVA) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. High-intensity focused ultrasound mass ablation was described as an alternative to surgical treatment options [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Endoscopic management via hysteroscopic endometrial mass excision[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], or laparoscopic bipolar coagulation of the feeding uterine or ovarian arteries, and surgical excision of the mass were also successfully reported[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Hysterectomy was performed when fertility is no longer required [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe rationale of our surgical therapeutic choice is to attack directly the feeding blood vessels of the cervical AVM through a minimally invasive vaginal approach. We bilaterally ligated the descending vaginal branch of the uterine artery at 3 and 9 o’clock, using a delayed absorbable suture from outside the cervical canal. Ligation of the feeding vessels of the cervical AVM from inside the cervical canal was tried during the cesarean delivery of a patient diagnosed to have cervical AVM in the third trimester [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn conclusion, we found that the vaginal approach of bilateral ligation of the descending vaginal branch of the uterine artery is a successful treatment option for cervical AVM. It is simple, feasible, safe, and cost-effective. It could be considered a suitable therapeutic alternative for women of childbearing age desiring fertility preservation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the institutional review board of the Faculty of Medicine, Mansoura University, with the number R.19.12.684.R1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of patient consent for participation and publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePlease contact the authors for data requests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone to declare\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eNone to declare\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions: CRediT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAmany A. Makroum:\u003c/strong\u003e Writing \u0026ndash; review and editing,\u0026nbsp;\u003cstrong\u003eAbdelhady Abdelhady Zayed:\u003c/strong\u003e Investigation, \u003cstrong\u003eTarek Shokeir:\u003c/strong\u003e Project administration, \u003cstrong\u003eMaged El-Shamy:\u003c/strong\u003e Supervision, \u003cstrong\u003eRawan Abo Asy:\u0026nbsp;\u003c/strong\u003eData curation, \u003cstrong\u003eMohamed Taman:\u003c/strong\u003e Conceptualization \u0026amp; Writing \u0026ndash; original draft.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are sincerely grateful to the study participant for her kind cooperation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatement of prior presentation or publication and/or abstract/poster presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe manuscript has no prior presentation or publication and/or abstract/poster presentation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePeitsidis P, Manolakos E, Tsekoura V, Kreienberg R, Schwentner L. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://bmcwomenshealth.biomedcentral.com/articles/\u003c/span\u003e\u003cspan address=\"https://bmcwomenshealth.biomedcentral.com/articles/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12905-024-03313-7\u003c/span\u003e\u003cspan address=\"10.1186/s12905-024-03313-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Arterio-venous malformation, Feeding vessel ligation, Treatment, Uterine-cervix, AVM","lastPublishedDoi":"10.21203/rs.3.rs-7586315/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7586315/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eUterine arterio-venous malformation (AVM) is a serious condition, usually presented by abnormal vaginal bleeding, which may be life-threatening. It may be either corporeal or cervical. The commonly reported type was uterine corporeal AVM. Different methods of fertility-preserving techniques were used for their management. However, cases of uterine cervical AVM are scarce.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation: \u003c/strong\u003eHerein, a 27-year-old patient was diagnosed to have cervical AVM by using transvaginal color Doppler and CT angiography. A novel minimally invasive technique of feeding vessel ligation was used for her treatment, with a satisfactory outcome.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: T\u003c/strong\u003ehe vaginal approach of ligation of the descending vaginal branch of the uterine artery is a simple, feasible, safe, and cost-effective method. It could be considered a suitable therapeutic alternative for women of childbearing age desiring fertility preservation.\u003c/p\u003e","manuscriptTitle":"Successful management of uterine cervical arteriovenous malformation (Cervical AVM) by feeding vessel ligation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 07:09:39","doi":"10.21203/rs.3.rs-7586315/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-21T16:24:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-18T09:33:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-13T12:20:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50567426082882119895057286893896277295","date":"2025-12-05T08:30:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294502898450212789011248376114062605643","date":"2025-12-05T05:07:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"30651736578154031670530199094666070473","date":"2025-11-19T06:20:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"99369395472428796417713757716129597372","date":"2025-11-16T16:13:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-08T22:03:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143489547527664136461341576715046707364","date":"2025-10-28T20:29:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-11T06:59:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"128722402400877872595265723930025434658","date":"2025-09-30T11:21:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"335364674759159043485445071123175882568","date":"2025-09-25T08:19:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-14T10:23:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-11T08:59:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-11T06:30:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-11T06:29:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-09-10T23:00:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aba6b22c-efde-4f9e-a5a4-34a6734dfb81","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-23T07:09:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-23 07:09:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7586315","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7586315","identity":"rs-7586315","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}