Ultrasound of enhanced myometrial vascularity after termination of pregnancy: A literature review with a clinical case analysis

The introduction of Doppler ultrasound into clinical practice has enabled the observation of changes in the uterine vasculature after termination of pregnancy. The phenomenon of enhanced myometrial vascularity (EMV) indicates delayed recovery of blood flow parameters and is often associated with retained products of conception (RPOC) in the uterine cavity. However, it shows similar ultrasound features with uterine arteriovenous malformations.

Differential diagnosis of uterine vascular malformations (UVM) from RPOC is important, as this can lead to overtreatment and, on the one hand, to iatrogenic profuse bleeding in the event of an attempted surgical evacuation of the uterine contents when the vascular anomaly is unrecognized. Although angiography is the gold standard for diagnosis, many specialists have favored Doppler ultrasound for detecting UVMs over the past two decades due to its noninvasive nature and usefulness in determining treatment strategies, including the need for uterine artery embolization. To date, differential diagnostics for the physiological and pathological characteristics of myometrial blood flow have not been developed, and signs indicating the likelihood of spontaneous regression or persistence of UVMs with the risk of profuse bleeding have not been established. The clinical significance of UVMs in asymptomatic patients is also unclear.

Mapping the vascular abnormality area using Doppler ultrasound allows for a clear determination of the extent of the process and the prevention of complications when choosing the optimal surgical method.

1. Cresswell J.A., Alexander M., Chong M.Y.C. et al. Global and regional causes of maternal deaths 2009-20: a WHO systematic analysis. Lancet Glob. Health. 2025; 13 (4): e626–e634. http://doi.org/10.1016/S2214-109X(24)00560-6

2. Kirsch A., Strachowski L., Poder L. et al. Secondary Postpregnancy Hemorrhage: Guide for Diagnosis and Management. Radiographics. 2025; 45 (5): e240098. http://doi.org/10.1148/rg.240098

3. Voloshchuk I.N., Barinova I.V., Chechneva M.A., Mar’yanova T.A. Uterine vascular abnormalities. Russian Journal of Archive of Pathology. 2022; 84 (1): 39–44. http://doi.org/10.17116/patol20228401139 (In Russian)

4. Thakur M., Strug M.R., De Paredes J.G. et al. Ultrasonographic technique to differentiate enhanced myometrial vascularity/arteriovenous malformation from retained products of conception. J. Ultrasound. 2022; 25 (2): 379–386. https://doi.org/10.1007/s40477-021-00574-y

5. 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. https://doi.org/10.1002/jcu.23495

6. Algeri P., Spazzini M.D., Seca M. et al. About uterine enhanced myometrial vascularity: Doppler ultrasound could reduce misdiagnosed life-threatening vaginal bleeding after pregnancy and guide the management. J. Ultrasound. 2023; 26 (3): 695–701. https://doi.org/10.1007/s40477-022-00734-8

7. O’Leary M., Sanders A.P. Enhanced myometrial vascularitythe time has come for individualized treatment of focal uterine pathology. Fertil. Steril. 2021; 116 (3): 691–692 https://doi.org/10.1016/j.fertnstert.2021.06.059

8. Youssef A.T. Uterine vascular abnormalities linked to pregnancy complications: color and power Doppler-assisted transvaginal ultrasound evaluation. J. Ultrason. 2024; 24 (96): 20240011. https://doi.org/10.15557/jou.2024.0011

9. Van den Bosch T., Van Schoubroeck D., Timmerman D. Maximum Peak Systolic Velocity and Management of Highly Vascularized Retained Products of Conception. J. Ultrasound. Med. 2015; 34 (9): 1577–1582. https://doi.org/10.7863/ultra.15.14.10050

10. Timor-Tritsch I.E., Haynes M.C., Monteagudo A. et al. Ultrasound diagnosis and management of acquired uterine enhanced myometrial vascularity/arteriovenous malformations. Am. J. Obstet. Gynecol. 2016; 214 (6): 731.e1–731.e10. https://doi.org/10.1016/j.ajog.2015.12.024

11. van Schoubroeck D., Van den Bosch T., Scharpe K. et al. Prospective evaluation of blood flow in the myometrium and uterine arteries in the puerperium. Ultrasound Obstet. Gynecol. 2004; 23 (4): 378–381. https://doi.org/10.1002/uog.963

12. 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. https://doi.org/10.1002/uog.27476

13. Cavoretto P., Cioffi R., Mangili G. et al. A pictorial ultrasound essay of gestational trophoblastic disease. J. Ultrasound Med. 2020; 39 (3): 597–613. https://doi.org/10.1002/jum.15119

14. Goyal S., Goyal A., Mahajan S. et al. Acquired uterine arteriovenous malformation developing in retained products of conception: a diagnostic dilemma. J. Obstet. Gynaecol. Res. 2014; 40 (1): 271–274. https://doi.org/10.1111/jog.12139

15. Hong W., Wang B.Y., Wu Z.P. et al. Systematic retrospective analysis of 13 cases of uterine arteriovenous fistula: Pathogeny, diagnosis, treatment and follow-up. J. Obstet. Gynaecol. Res. 2020; 46 (7): 1117–1127. https://doi.org/10.1111/jog.14264

16. Bedaiwy M.A. Unconventional treatment of uterine arteriovenous malformation: the challenge of generating evidence for a rare condition. Fertil. Steril. 2021; 116 (4): 1117–1118. https://doi.org/10.1016/j.fertnstert.2021.08.013

17. Ercolino C., Ferrazzi E., Ossola M.W. et al. A comprehensive diagnostic approach to differentiate intrauterine arteriovenous malformation in cases of enhanced myometrial vascularity. Arch. Gynecol. Obstet. 2024; 310 (5): 2523–2529. https://doi.org/10.1007/s00404-024-07754-1

18. Gingold J.A., Bradley L.D. Use of hysteroscopy in diagnosis and follow-up of acquired uterine enhanced myometrial vascularity. Fertil. Steril. 2020; 113 (2): 460–462. https://doi.org/10.1016/j.fertnstert.2019.11.006

19. Matsumoto M.M., Caridi T.M. Uterine Vascular Anomalies: Management and Treatment Overview. Semin. Interv. Radiol. 2023; 40 (4): 342–348. https://doi.org/10.1055/s-0043-1770714

20. Gao F., Ma X., Xu Y. et al. Management of Acquired Uterine Arteriovenous Malformations Associated with Retained Products of Conception. J. Vasc. Interv. Radiol. 2022; 33 (5): 547–553. https://doi.org/10.1016/j.jvir.2022.01.004

21. Sellmyer M.A., Desser T.S., Maturen K.E. et al. Physiologic, histologic, and imaging features of retained products of conception. Radiographics. 2013; 33 (3): 781–796. https://doi.org/10.1148/rg.333125177

22. Rufener S.L., Adusumilli S., Weadock W.J., Caoili E. Sonography of uterine abnormalities in postpartum and Postabortion patients-a potential pitfall of interpretation. J. Ultrasound Med. 2008; 27 (3): 343–348. https://doi.org/10.7863/jum.2008.27.3.343

23. Xholli A., Scovazzi U., Londero A.P. et al. Clinical and ultrasonographic characteristics of pregnancy-related enhanced myometrial vascularity: prospective cohort study. Ultrasound Obstet. Gynecol. 2024; 63 (5):672–682. https://doi.org/10.1002/uog.27537

24. Shahulhameed M.S. Chern B.S.M., Wright A.M. Role of Hysteroscopy in the Management of Uterine Vascular Malformations with a Focus on Enhanced Myometrial Vascularity – A Review of Diagnosis and Treatment with the Suggested Algorithm. Gynecol. Minim. Invasive Ther. 2024; 13 (4): 209–214. https://doi.org/10.4103/gmit.gmit_29_24

25. 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. https://doi.org/10.1002/uog.21872

26. Groszmann Y.S., Healy Murphy A.L., Benacerraf B.R. Diagnosis and management of patients with enhanced myometrial vascularity associated with retained products of conception. Ultrasound Obstet. Gynecol. 2018; 52 (3): 396–399. https://doi.org/10.1002/uog.18954

27. O'Rourke-Suchoff D., Benitez S., Higgins M.C.C.S., Stier E.A. Diagnosis and treatment of women with radiologic findings suspicious for uterine arteriovenous malformations. J. Obstet. Gynaecol. 2021; 41 (5): 769–773. https://doi.org/10.1080/01443615.2020.1798905

28. Chen J., Huang D., Yang J., Zhang S. Resection of uterine arteriovenous fistula with temporary occlusion of the internal iliac arteries: Case series and literature review. Medicine (Baltimore). 2024; 103 (35): e39442. https://doi.org/10.1097/MD.0000000000039442

29. Jeerakornpassawat D., Tantipalakorn C., Sirilert S., Tongsong T. Sonographic Features of Uterine Arteriovenous Malformation: A Case Series. Diagnostics (Basel). 2024; 14 (9): 873. https://doi.org/10.3390/diagnostics14090873

30. Ruiz Labarta F.J., Pintado Recarte M.P., González Leyte M. et al. Uterine Artery Embolization of Uterine Arteriovenous Malformation: A Systematic Review of Success Rate, Complications, and Posterior Pregnancy Outcomes. J. Pers. Med. 2022; 12 (7): 1098. https://doi.org/10.3390/jpm12071098

31. O'Brien P., Neyastani A., Buckley A.R. et al. Uterine arteriovenous malformations: from diagnosis to treatment. J. Ultrasound Med. 2006; 25 (11): 1387–1392; quiz. 1394–1395. https://doi.org/10.7863/jum.2006.25.11.1387

32. Müngen E. Vascular abnormalities of the uterus: have we recently over-diagnosed them? Ultrasound Obstet. Gynecol. 2003; 21 (6): 529–531. https://doi.org/10.1002/uog.163

33. Masood L., Rana A.I., Khan Z.A. et al. Imaging spectrum of acquired uterine vascular abnormalities with angiographies correlates, a pictorial review. Egypt J. Radiol. Nucl. Med. 2022; 53. https://doi.org/10.1186/s43055-021- 00683-y

34. Sahoo B., Jena S.K., Mishra S.K. et al. Uterine Arteriovenous Malformation With Raised Serum Beta-Human Chorionic Gonadotropin (β-hCG) Levels: A Diagnostic and Therapeutic Dilemma. Cureus. 2024; 16 (7): e64209. https://doi.org/10.7759/cureus.64209

35. Timor-Tritsch I.E., McDermott W.M., Monteagudo A. et al. Extreme enhanced myometrial vascularity following cesarean scar pregnancy: a new diagnostic entity. J. Matern. Fetal Neonatal Med. 2022; 35 (25): 5846–5857. https://doi.org/10.1080/14767058.2021.1897564

36. Timmerman D., Wauters J., Van Calenbergh S. et al. Color Doppler imaging is a valuable tool for the diagnosis and management of uterine vascular malformations. Ultrasound Obstet. Gynecol. 2003; 21 (6): 570–577. https://doi.org/10.1002/uog.159

37. Liu Q., Peng P., Chen W.L. et al. Analysis of clinical characteristics of pregnancy-related uterine arteriovenous malformation. Zhonghua Fu Chan Ke Za Zhi. 2025; 60 (5): 348–354. https://doi.org/10.3760/cma.j.cn112141-20241106-00592 (In Chinese)

38. Salmeri N., Papale M., Montresor C. et al. Uterine arteriovenous malformation (UAVM) as a rare cause of postpartum hemorrhage (PPH): a literature review. Arch. Gynecol. Obstet. 2022; 306 (6): 1873–1884. https://doi.org/10.1007/s00404-022-06498-0

39. Mishina M., Hasegawa J., Nakamura M. et al. Sonohysterography is a useful diagnostic approach for uterine arteriovenous malformation. J. Obstet. Gynaecol. Res. 2014; 40: 1811–1813. https://doi.org/10.1111/jog.12390

40. Rosen A., Chan W.V., Matelski J. et al. Medical treatment of uterine arteriovenous malformation: a systematic review and meta-analysis. Fertil. Steril. 2021; 116 (4): 1107–1116. https://doi.org/10.1016/j.fertnstert.2021.05.095

41. Li F., Tao H., Chen J. et al. Ultrasound-guided high-intensity focused ultrasound ablation for uterine arteriovenous fistula: a case series. Int. J. Hyperthermia. 2024; 41 (1): 2325478. https://doi.org/10.1080/02656736.2024.2325478

42. Xu L., Chen H., Xiao Y. et al. High-Intensity Focused Ultrasound Ablation Combined With Hysteroscopy for the Treatment of Uterine Arteriovenous Fistula Associated With Retained Products of Conception: A Prospective Cohort Study. J. Minim. Invasive Gynecol. 2025; 32 (1): 64–71. https://doi.org/10.1016/j.jmig.2024.09.010

43. Fu Y., Lei Z., Gong L., Wang X. New prospects for high-intensity focused ultrasound ablation in the treatment of uterine arteriovenous fistula associated with retained products of conception: A retrospective cohort study. Medicine (Baltimore). 2025; 104 (27): e43211. https://doi.org/10.1097/MD.0000000000043211

44. Memtsa M., Jamil A., Sebire N. et al. Diagnosis and management of intramural ectopic pregnancy. Ultrasound Obstet. Gynecol. 2013; 42 (3): 359–362. https://doi.org/10.1002/uog.12437