Pregnancy and delivery in moyamoya vasculopathy: experience of a single European institution

Hypertensive disorders of pregnancy in moyamoya disease: A single institution experience

OBJECTIVE

The characteristics of pregnancy and delivery in patients with moyamoya disease (MMD) remain unclear. We retrospectively investigated perinatal outcomes in patients with MMD to evaluate the risks associated to this condition.

MATERIALS AND METHODS

Clinical data of women with MMD who delivered at the University of Tokyo Hospital between 2000 and 2021 were collected. Maternal characteristics including genetic data, obstetric complications, method of delivery and anesthesia, neonatal outcomes, neurological events during pregnancy, delivery, and postpartum course, were reviewed.

RESULTS

Thirteen pregnancies with MMD were identified. The median maternal age was 30 years. The initial clinical symptoms were identified as transient ischemic attack, infarction, and headache. Eight patients had a history of bypass surgery. The median gestational age at delivery was 37 weeks. DNA samples were collected from five patients, responsible for six pregnancies. Of these six cases, five had the RNF213 c.14429G > A (p.Arg4810Lys) heterozygous variant. Of the 13 pregnancies, seven had hypertensive disorder of pregnancy (HDP). Additionally, three of five pregnancy cases with RNF213 p.Arg4810Lys heterozygous variant presented with HDP. Nine patients underwent cesarean section, and four delivered vaginally with epidural anesthesia. One case of ischemic stroke was confirmed during the postpartum period. Regarding newborns, neither Apgar scores lower than 7 nor neonatal intensive care unit admissions were reported.

CONCLUSIONS

This study suggests that the frequency of HDP is higher in patients with MMD compared to those with normal pregnancies. Strict blood pressure control should be performed in patients with MMD during pregnancy and postpartum period.

Safe delivery planning of patients with moyamoya disease in pregnancy: Case series of a single center

OBJECTIVE

Moyamoya disease (MMD) is a rare cerebral vascular disease and there is limited clinical experience for pregnant women. Cerebrovascular condition might deteriorated during pregnancy. Management and mode of delivery is challenging for obstetrics specialist.

CASE REPORT

Three cases of parturients with moyamoya disease delivered in National Taiwan University Hospital are presented. All were previously diagnosed and one had stroke incidence before current pregnancy course. Two delivered with Cesarean section and one with vaginal delivery, and all delivered at term without maternal or neonatal complication.

CONCLUSION

Although delivery method of parturients with MMD has been debating, vaginal delivery may be suitable for certain cases under adequate monitoring and case selection.

Pregnancy after direct cerebral bypass for moyamoya disease

OBJECTIVE

Moyamoya disease (MMD) disproportionately affects young to middle-aged women. The main treatment for this challenging disease is cerebral bypass surgery. Vascular neurosurgeons often need to counsel women regarding pregnancy following bypass for MMD, but there is a paucity of data. The authors set out to examine neurological and obstetric outcomes in an extensive cohort of MMD patients who had pregnancies following cerebral revascularization at the Stanford Medical Center.

METHODS

The authors identified all patients at their institution who underwent cerebral bypass for MMD from 1990 through 2018 and who later became pregnant. Some of these patients also had pregnancies prior to undergoing bypass surgery, and the authors examined these pregnancies as well. They performed a chart review and brief telephone survey to identify obstetric complications, transient ischemic attacks (TIAs), and strokes. Neurological and obstetric outcomes were compared to published rates. They also compared pre- and post-bypass pregnancy complication rates using logistic regression techniques.

RESULTS

There were 71 pregnancies among 56 women whose mean age was 30.5 years. Among 59 post-bypass pregnancies, there were 5 (8%) perinatal TIAs. There were no MRI-confirmed strokes or strokes with residual deficits. Among 12 pre-bypass pregnancies, there were 3 (25%) TIAs and 2 (17%) MRI-confirmed strokes. There were no hemorrhagic complications in either group. In the generalized estimating equations analysis, performing cerebral revascularization prior to pregnancy versus after pregnancy was associated with lower odds of perinatal stroke or TIA (OR 0.15, p = 0.0061). Nine pregnancies (13%) were complicated by preeclampsia, and there was one (1%) instance of eclampsia. The overall rate of cesarean delivery was 39%. There were 2 miscarriages, both occurring in the first trimester. There were no maternal deaths.

CONCLUSIONS

The authors present neurological and obstetric outcomes data in a large cohort of MMD patients. These data indicate that post-bypass pregnancy is accompanied by low complication rates. There were no ischemic or hemorrhagic strokes among post-bypass pregnant MMD patients. The rate of obstetric complications was low overall. The authors recommend close collaboration between the vascular neurosurgeon and the obstetrician regarding medical management, including blood pressure goals and continuation of low-dose aspirin.

Indirect bypass for maternal symptomatic moyamoya in the first trimester of pregnancy: case report

There are no practice guidelines for the treatment of moyamoya disease in pregnant women. The need for such guidelines, however, is evidenced by the numerous case reports, case series, and systematic reviews in the literature highlighting an at-risk period for female moyamoya patients of childbearing age. Here the authors review and interpret the existing literature as it applies to their index patient and expand the literature in support of treating select patients during pregnancy. The authors describe what is to their knowledge the first case reported in the literature of a patient successfully treated with indirect surgical revascularization during the first trimester, who went on to deliver a healthy term baby without complications.

Epidemiology of neurologic disease in pregnancy

Many neurologic diseases in women are influenced by the physiologic and hormonal changes of pregnancy, and pregnancy itself poses challenges in both treatment and evaluation of these conditions. Some diseases, such as epilepsy and multiple sclerosis, have a high enough prevalence in the young female population to support robust epidemiologic data while many other neurologic diseases, such as specific myopathies and muscular dystrophies, have a low prevalence, with data limited to case reports and small case series. This chapter features epidemiologic information regarding a breadth of neurologic conditions, including stroke, epilepsy, demyelinating disease, peripheral neuropathies, migraine, sleep-disordered breathing, and meningioma, in women in the preconception, pregnancy, and postpartum stages.

Moyamoya-Related Stroke Risk During Pregnancy: An Evidence-Based Reappraisal

BACKGROUND

Moyamoya is a rare, yet classic etiology of stroke in young adults, affecting predominately women of childbearing age. The impact of pregnancy on the natural history of symptomatic moyamoya remains a matter of extensive debate, however.

METHODS

In October 2017, a MEDLINE search was performed using 14 keywords. A total of 12 original articles reporting on cohorts of at least 5 patients were retrieved and reviewed. Individual study data were extracted, pooled, and analyzed.

RESULTS

A total of 736 pregnancies in 483 patients were included in our analysis. The mean age at delivery was 31 years, and the mean age at diagnosis (before pregnancy) was 22.6 years. Clinical presentation was ischemic stroke in 50.8%, hemorrhagic stroke in 45.9%, headaches in 2.1%, and ischemic-hemorrhagic stroke in 1.2%. After excluding patients first diagnosed during or after pregnancy (n = 283) and those who had been revascularized before pregnancy (n = 183), a total of 270 pregnancies in 188 patients were analyzed. During 224.6 patient-years of follow-up, 22 moyamoya-related neurologic events occurred (annual event rate 9.8%), more than two-thirds of which were transient (12 transient ischemic attacks and 3 seizures). Seven strokes occurred (6 hemorrhagic and 1 ischemic), yielding an annual stroke risk of 3.1%. As a result, 1 patient died and 2 were permanently disabled (annual death/disability rate 1.3%). All remaining patients experienced favorable functional outcomes.

CONCLUSIONS

The risk of moyamoya-related stroke during pregnancy, delivery, and the postpartum period appears to be similar to or lower than that suggested by published natural history studies in symptomatic patients. A neuroprotective effect of pregnancy in moyamoya patients cannot be excluded.

Moyamoya disease in pregnancy: a systematic review

BACKGROUND

Moyamoya disease (MMD) management during pregnancy poses a challenge to health care providers, and recommendations are outdated, vague, and controversial. We conducted a systematic review to investigate and present the available evidence.

METHOD

We searched five online databases and bibliographies of relevant published original studies to identify case reports, case series, cohort studies, and reviews reporting on patients diagnosed with MMD before, during, or shortly after pregnancy. We report and analyze the respective data.

RESULTS

Fifty-four relevant articles were identified. In the group of patients with MMD diagnosed prior to pregnancy, 68.7% had previously undergone bypass surgery, 64.5% delivered via cesarean section, 95.2% of mothers had good outcomes, and no bad fetal outcomes were reported. In patients first diagnosed with MMD due to a cerebrovascular accident during pregnancy, the mean gestational age on symptom onset was 28.7 weeks and 69.5% presented with cerebral hemorrhage. In this group, 57.2% received neurosurgical operative management, and 80% underwent cesarean section with 13.6% maternal mortality and 23.5% fetal demise. In patients diagnosed with MMD immediately postpartum, 46.6% suffered a cerebrovascular event within 3 days of delivery, 78.3% of which were ischemic. Only 15.3% underwent surgical hematoma evacuation and one patient (9%) expired.

CONCLUSIONS

MMD may coincide with pregnancy, but there is paucity of high-quality data. It appears that MMD is not a contraindication to pregnancy, if blood pressure and ventilation are properly managed. There is no clear evidence that bypass surgery before pregnancy or cesarean mode of delivery improve outcomes.