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Abstract

A 39 year-old woman, P2L2, presented to the emergency department with vaginal bleeding. She was diagnosed as having a molar pregnancy one and half months previously, for which surgical evacuation was performed at a private clinic. Beta-human chorionic gonadotropin ( β -hCG) level before evacuation was 40,738 mIU/mL and follow-up values followed a declining trend from 3,820 mIU/mL 48 hours after evacuation, to 1,342 mIU/mL after one week. Histopathological examination (HPE) ruled out any possibility of malignancy. During follow-up, she had an episode of severe vaginal bleeding on the fifteenth day after evacuation. Magnetic resonance imaging of the pelvis suggested uterine arteriovenous (A-V) malformation with the possibility of residual gestational trophoblastic disease (GTD), in view of medical history and raised β -hCG (1,083 mIU/mL) (Figure1a-c). She received a blood transfusion and single-agent chemotherapy (methotrexate) at her primary centre, however, her β -hCG values continued to fall. After one month, she had another episode of severe vaginal bleeding and was referred to our centre. Here, her vitals were stable and systemic examination showed no abnormality. Gynecological examination revealed normal vulva, vagina, cervix, and soft and enlarged uterus of 14 weeks size. β -hCG was 23.55 mIU/mL. Transvaginal sonography showed thin endometrium and a cystic lesion in the uterine fundus invading the anterior myometrium, which was hyper-vascular on colour Doppler, suggestive of A-V malformation (Figure 2a,b). Therefore, bilateral uterine artery embolization (UAE) was performed. The patient was then discharged in a stable condition. After one week of UAE, she again presented with severe vaginal bleeding. She had pallor, pulse rate of 110/